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We report a case of xanthogranulomatous cholecystitis (XGC) that was diagnosed preoperatively by means of ultrasonography (US) with the contrast-enhancement agent Sonazoid after a false-positive result had been obtained with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET). A 69-year-old woman was admitted because of right upper quadrant pain. Blood tests revealed a serum CA19-9 level of 749.8 IU/L. Computed tomography (CT), US, and magnetic resonance imaging of the abdomen showed abnormal thickening of the gallbladder wall but no stones. The border between the gallbladder and the liver was unclear. FDG-PET revealed a lesion with increased uptake of tracer in the gallbladder wall. The thickness of the lesion was similar to that on CT. We suspected gallbladder carcinoma with hepatic invasion. To confirm the tentative diagnosis, we performed US with the contrast-enhancement agent Sonazoid. The gallbladder wall was homogeneously enhanced in the early vascular phase and remained enhanced for 90 seconds. Enhancement of the gallbladder wall was smooth and regular. The border between the gallbladder and liver was clear and smooth. On the basis of these examinations, we diagnosed chronic cholecystitis (XGC suspected), not gallbladder carcinoma. At surgery, the gallbladder wall was observed to be extremely thick because of severe inflammation, and cholecystectomy was performed. XGC was diagnosed on intraoperative pathological examination. Histopathological examination showed XGC, severe proliferative fibrosis with formation of multiple yellow-brown intramural nodules, and foamy histiocytes without malignant cells. In conclusion, the present case of XGC was diagnosed preoperatively with contrast-enhanced US after a false-positive result had been obtained with FDG-PET. Contrast-enhanced US can thus play important roles in diagnosing gallbladder disease and selecting treatment.

Torsion of the gallbladder is a rare condition that most commonly affects the elderly. This condition is rarely diagnosed preoperatively despite advances in diagnostic imaging. We report a case of torsion of the gall bladder diagnosed preoperatively. An 81-year-old woman presented with right upper quadrant pain. Initial laboratory tests revealed elevation of the white blood cell count to 15,900/μL(normal, 4,000 to 8,000/μL) and mild liver dysfunction. Ultrasonography and computed tomography revealed swelling of the gall bladder with increased wall thickness, but neither examination showed any gallstones. Percutaneous transhepatic gall bladder drainage was performed, and bloody bile juice was obtained. Cholangiography via the drainage catheter of the gall bladder and endoscopic retrograde cholangiography revealed smooth tapering of the neck of the gall bladder. We diagnosed acute torsion of gallbladder and brought the patient to the operating theatre for laparoscopic cholecystectomy. Intraoperatively, we observed that the gallbladder had undergone complete torsion and appeared gangrenous. Routine cholecystectomy was then performed, and the patient recovered without incident.

A 60-year-old woman with primary sclerosing cholangitis (PSC) and high levels of ALP, gamma-GTP, and DUPAN-2 was admitted to our institution for examination. The patient did not have ulcerative colitis or pancreatic intraductal papillary mucinous neoplasm. Imaging studies revealed atypical dilation of bile ducts in the left lobe of the liver. Repeated cytologic examinations of the bile showed atypical cells consistent with adenocarcinoma. The patient underwent extended resection of the left lobe of the liver and was found to have intraductal papillary carcinoma with associated mucin-producing bile duct carcinoma. This carcinoma fills dilated bile duct lumens with mucin. This tumor differs morphologically from typical cholangiocarcinoma, which is usually seen in the late stages of PSC. Just one case of mucin-producing bile duct carcinoma arising from PSC has been reported worldwide. The patient has had no signs of recurrence after 27 months. Patients with mucin-producing bile duct carcinoma, as in the case of its pancreatic counterpart, may have a better prognosis and a higher survival rate than patients with typical cholangiocarcinomas.

Eighty-four patients underwent laparoscopic cholecystectomy (LC) from January through August 2006. Of these patients, 4 (4.7%) were found to have occult gallbladder carcinoma (GC) either during or after the procedure. Two of the patients were women and 2 were men. The mean age was 75.0 years. One patient had mucosal tumors, 2 had subserosal tumors, and 1 had a serosal lesion. One of the 2 patients with subserosal tumors underwent radical surgery. In a previous study, 0.83% (10 of 1,195) of patients who had undergone LC were found to have occult GC, either during of after the procedure. The prevalence of gallbladder carcinoma has recently been increasing. GC has been reported in 0.3% to 1.5% of patients who have undergone cholecystectomy. Since the introduction of laparoscopic surgery, the number of cholecystectomies being performed has increased, which may explain why occult GC seems to be occurring more frequently. The prognosis for GC is poor, and surgical resection is the only potentially curative treatment. However, GC is difficult to diagnose at an early stage and difficult to recognize even in the advanced stages. Fifteen percent to 30% of patients show no preoperative or intraoperative evidence of malignancy. Occult GC is also increasing. Because flat infiltrating GC and GC with cholecystitis and numerous stones are difficult to diagnose preoperatively, we recommend taking frozen sections from patients who are of advanced age (older than 70 years), have a long history of stones, or have a thickened gallbladder wall.

Background: The current study presents the long-term results of multiple minocycline hydrochloride (MINO) injections for the treatment of symptomatic solitary hepatic cyst. Methods: From 1989 to 1998, nine patients were referred for the treatment of a symptomatic solitary hepatic cyst, comprising two males and seven females aged between 41–72 years (mean 58.2 years). The chief complaint in all cases was upper abdominal discomfort or pain. Mean cyst diameter was 14.1 ± 2.3 cm. After insertion of an 8 or 9-French catheter into the cyst, 200 mg of MINO in 10 mL saline was injected and the catheter was flushed with 10 mL saline, for a total of 20 mL saline. The catheter was then clamped for 30 min. MINO injection was performed daily for 7–8 days, after which time the catheter was removed. Results: One patient complained of moderate right subscapular pain immediately after the injection, and one patient complained of pain at the site of catheter insertion. Patients were followed for 42–153 months (mean 85 months). Cyst regression without recurrence was documented in all patients. Conclusions: Multiple injections of MINO are safe, definitive treatments for symptomatic solitary hepatic cyst. © 2003 Blackwell Publishing Asia Pty Ltd

石灰乳胆汁を伴った胆石,総胆管結石症を経験した.症例は61歳男性.右季肋部痛にて当科受診,腹部CTおよび超音波検査で胆嚢および総胆管内に結石を認めた.また腹部単純X線写真にて右季肋部に臥位では円形の,立位では鏡面形成のある石灰化像を認め,胆嚢内の石灰乳胆汁が確認された.術前にENBD tubeを挿入留置後,胆石に対しては腹腔鏡下胆嚢摘出術を施行,総胆管結石は術後EPBDを行い採石した.胆嚢および総胆管結石ともにコレステロール結石であり,また胆嚢内胆汁のph8.2と胆汁のアルカリ化を認めた.胆嚢内の石灰乳胆汁は炭酸カルシウムが98%以上を占めており,摘出後まもなく固形化した.石灰乳胆汁を有する症例では,炎症や結石などによる胆嚢管の閉塞や術中操作による石灰乳胆汁の総胆管内への流入の可能性があるため,術前にENBD tubeを留置,術中造影および術後にこれを利用できるようにしておく必要があると考えられた.

At our institute, laparoscopic hepatectomy for hepatocellular carcinoma has been successfully performed in two cases. Each tumor was located solitarily, one in segment IV of the liver and another in the segment VI. Introducing a minimum of four trocars, the exact location of the tumor and the distance from main vessels to the tumor were determined by laparoscopic intraoperative ultrasonography. Hepatic parenchymal resection was carried out using a laparoscopic coagulating shears in combination with a microwave tissue coagulator to minimize the blood loss. After the operation, these patients made a rapid recovery. Although this technique has been available for good quality of life to the patient, a longer time for observation of the clinical course will be necessary to determine the long-term effectiveness.

Although hilar cholangioma is the most common cause of stricture of the hilar bile duct, several diseases can contribute to stenosis. Here, we report on a patient with immunoglobulin (Ig) G4-related sclerosing cholangitis (IgG4-SC) of the hilar bile duct arising from obstructive jaundice. The patient had undergone laparoscopic cholecystectomy for the removal of gallstones. The differential diagnosis for icterus included hilar cholangiocarcinoma, primary sclerosing cholangitis, IgG4 sclerosing cholangitis, ischemic bile duct stenosis, a complication of cholecystitis, amputation neuroma, and iatrogenic stenosis. Numerous examinations were performed, but a definite diagnosis remained elusive. Because cholangiocarcinoma could not be ruled out, we proposed surgical resection. The patient subsequently underwent extended right liver lobectomy and intrahepatic cholangiojejunostomy. Pathological examination revealed numerous inflammatory cell infiltrates resembling IgG4-positive antibody plasma cells in the stromal layer of the stenotic bile duct walls. Hypertrophy of the nerve fiber fascicles was not observed. The serum IgG4 level of the patient was within the normal range. Few reports of IgG4-SC with a normal serum IgG4 level have been published. When this condition presents as it did in the present case, establishing a definite diagnosis can be difficult.

Although microRNAs are known to be post-transcriptional regulators in physiological and pathological events in the liver, their role in the obstructive jaundice liver remains unclear.We sequenced the small RNA libraries of the bile duct ligation (BDL) mouse liver to detect the in vivo microRNA expression profiles of obstructive jaundice. We also validated the differential expression of microRNAs in the BDL liver using real-time PCR. Laser microdissection was performed to identify the origin of BDL-related microRNAs. An IL6-treated normal intrahepatic biliary epithelial cell line was used as an in vitro model of obstructive jaundice.We found microRNAs that were upregulated in the BDL liver (let-7a, let-7d, let-7f, let-7g, miR-21, miR-125a-5p, miR-125b-5p, miR-194, miR-199a-3p, miR-199a-5p, miR-214, miR-221, and miR-486). Furthermore, laser-microdissection analysis showed that miR-199a-5p was significantly upregulated in the intrahepatic bile duct of the BDL liver. The in vitro expression of miR-199a-5p was appreciably elevated in accordance with increased proliferation of IL6-treated cells.We revealed dynamic changes in microRNA expression during obstructive jaundice using the BDL model. MiR-199a-5p was likely associated with the proliferation of intrahepatic bile ducts. Our data will facilitate further study of the pathophysiological role(s) of microRNAs in the obstructive jaundice liver.

Biliary tract cancer (BTC) is often difficult to diagnose definitively, even through histological examination. MicroRNAs (miRNAs) regulate a variety of physiological processes. In recent years, it has been suggested that profiles for circulating miRNAs, as well as those for tissue miRNAs, have the potential to be used as diagnostic biomarkers for cancer. The aim of this study was to confirm the existence of miRNAs in human bile and to assess their potential as clinical biomarkers for BTC. We sampled bile from patients who underwent biliary drainage for biliary diseases such as BTC and choledocholithiasis. PCR-based miRNA detection and miRNA cloning were performed to identify bile miRNAs. Using high-throughput real-time PCR-based miRNA microarrays, the expression profiles of 667 miRNAs were compared in patients with malignant disease (n = 9) and age-matched patients with the benign disease choledocholithiasis (n = 9). We subsequently characterized bile miRNAs in terms of stability and localization. Through cloning and using PCR methods, we confirmed that miRNAs exist in bile. Differential analysis of bile miRNAs demonstrated that 10 of the 667 miRNAs were significantly more highly expressed in the malignant group than in the benign group at P

黄疸を主訴とし, Vater乳頭に異所性に発生した非機能性膵島腫瘍の1例を経験したので報告する. 症例は61歳の女性. 黄疸, 皮膚掻痒感を主訴に来院し, 精査目的にて当科入院. 超音波, computed tomography, endoscopic retrogade cholangiopancreatography検査にて下部胆管癌または乳頭部癌が疑われた. 術中, 乳頭部腫瘍を確認し術中迅速病理診断にて悪性腫瘍と診断されたため, 膵頭十二指腸切除術を施行した. 組織学的に, 腫瘍細胞は豊富な毛細血管を伴い索状に配列し, ラ島細胞に類似していた. さらに免疫組織化学的には, insulin, glucagon, somatostatin, pancreatic polypeptideのすべてに陰性を示したため, 非機能性膵島腫瘍と診断した. Vater乳頭部に発生する非機能性膵島腫瘍は本邦でもきわめてまれであるが, 本症の術前診断は諸検査によってもきわめて困難なものと考えられた.

Intrahepatic cholangiocarcinoma (ICC), which arises in the small bile ducts of the liver, is the second most common liver malignancy. Although modulation of microRNA (miRNA) expression has been shown to be a potent sign of malignant tumors, miRNA profiles of ICC remains unclear. We performed sequencing analysis of the small RNA libraries of 2 ICC cell lines (HuCCT1 and MEC) and one normal intrahepatic biliary epithelial cell line (HIBEpiC) to produce the miRNA profiles of ICC in vitro. Furthermore, by means of the real-time polymerase chain reaction (PCR) we validated the differential expression of miRNAs cloned exclusively or predominantly from each of the cell lines. A total of 35,759 small RNA clones were obtained from the 3 cell lines. We identified 27 miRNAs that were expressed exclusively or predominantly in each cell line. Subsequent validation with the real-time PCR confirmed that the miRNAs hsa-miR-22, -125a, -127, -199a, -199a*, -214, -376a, and -424 were expressed specifically in HIBEpiC but were downregulated in the ICC cell lines. Our study provides important information for facilitating studies of the functional role(s) of miRNAs in carcinogenesis of the hepatobiliary system. The biliary epithelial cell-specific miRNAs identified in this study may serve as potential biomarkers for ICC.

臨床的には比較的まれな疾患である大腸脂肪腫を経験したので報告する.症例は61歳女性.腹痛を主訴として来院.注腸造影で, 横行結腸に表面平滑な腫瘍陰影を認めた.大腸内視鏡検査では, 肛門縁より65cmに可動性に富む有茎性の腫瘍を認めた.腹部CTをfat densityの条件にしてみると, 横行結腸に一致して-80 Hounsfield unitの内部構造が均一な腫瘍が認められた.以上の所見より, 横行結腸の脂肪腫と診断した.全麻下に開腹し, 結腸部分切除術を行った.腫瘍は3×3×7cmの粘膜下腫瘍であり, 病理組織学的にも成熟した脂肪組織であり, 悪性細胞は認められなかった.

The effectiveness of the clinical pathway for laparoscopic cholecystectomy was evaluated, and the efficiency of medical care was analyzed. The duration of hospitalization and the number of National Health Insurance (NHI) points for medical service fees were compared between 86 patients treated after introduction of the clinical pathway (pathway group) and 56 patients treated before introduction of the clinical pathway (pre-pathway group). In the pathway group, variance from the pathway occurred in 24 patients (27.9%) due to postponement of discharge in 7 patients, to earlier discharge in 5 patients, and to insertion of a bile duct catheter in 5 patients. Total and postoperative hospitalization times were significantly shorter in the pathway group than in the pre-pathway group (8.0 +/- 1.6 vs 13.7 +/- 9.0 days, p

Background: The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors. Patients and Method: A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia at our hospital. Five patients who had received laparoscopic hepatectomy (Lap‑Hx group were compared with 5 patients who had undergone open hepatectomy (O‑Hx group in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision a microwave coagulation device and an ultrasonically activated scalpel were used. Results: Mean patient age was 55.6 ± 13.9 years in the Lap‑Hx group and 51.8 ± 14.1 years in the O‑Hx group. Four patients in the Lap‑Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O‑Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 ± 1.5 cm in the Lap‑Hx group and 3.0 ± 1.8 cm in the O‑Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap‑Hx t han in the O‑Hx groups(213 ± 82 vs 247 ± 97 min; 154 ± 128 vs 648 ± 468 ml p=0.05: and 10.4 ± 2.3 vs 18.0 ± 5.1 days p=0.017 but operating time did not differ significantly. Conclusions: Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors in particular hepatocellular carcinoma in the cirrhotic liver. (J Nippon Med Sch 2007; 74: 158―162

To elucidate the biological effects of transforming growth factor-beta1 (TGF-beta1) on intrahepatic cholan-giocarcinoma (ICC).We investigated the effects of TGF-beta1 on human ICC cell lines (HuCCT1, MEC, and HuH-28) by monitoring the influence of TGF-beta1 on tumor growth and interleukin-6 (IL-6) expression in ICC cells.All three human ICC cell lines produced TGF-beta1 and demonstrated accelerated growth in the presence of TGF-beta1 with no apoptotic effect. Studies on HuCCT1 revealed a TGF-beta1-induced stimulation of the expression of TGF-beta1, as well as a decrease in TGF-beta1 mRNA expression induced by neutralizing anti-TGF-beta1 antibody. These results indicate that TGF-beta1 stimulates the production and function of TGF-beta1 in an autocrine fashion. Further, IL-6 secretion was observed in all three cell lines and exhibited an inhibitory response to neutralizing anti-TGF-beta1 antibody. Experiments using HuCCT1 revealed a TGF-beta1-induced acceleration of IL-6 protein expression and mRNA levels. These findings demonstrate a functional interaction between TGF-beta1 and IL-6. All three cell lines proliferated in the presence of IL-6. In contrast, TGF-beta1 induced no growth effect in HuCCT1 in the presence of small interfering RNA against a specific cell surface receptor of IL-6 and signal transducer and activator of transcription-3.ICC cells produce TGF-beta1 and confer a TGF-beta1-induced growth effect in an autocrine fashion. TGF-beta1 activates IL-6 production, and the functional interaction between TGF-beta1 and IL-6 contributes to ICC cell growth by TGF-beta1.

With the increasingly widespread acceptance of laparoscopic cholecystectomy (LC), the number of cases of incidental gallbladder carcinoma (GBC) has increased; however, management of incidental GBC is a difficult issue in the absence of established guidelines. The present study aims to evaluate the treatment of patients with incidental GBC diagnosed with LC. We performed a 14-year review of 10 patients with GBC discovered with LC. From April 1991 through March 2004, we performed LC for 1,195 patients at Nippon Medical School Main Hospital. Of these patients, 10 (0.83%) were found to have GBC. Seven patients were women and 3 were men, with a mean age of 61.4 years. Four patients had mucosal tumors (pT1a), 5 had subserosal tumors (pT2), and 1 had a serosal lesion (pT3). Eight of the 10 patients underwent radical surgery. Two patients with pT1a tumors underwent no additional surgery. All 4 patients with pT1a tumors are alive without recurrence. One patient with a pT2 tumor with metastases to the liver and pericholedochal lymph nodes found with additional resection died of recurrence of metastasis to the liver and lung 70 months after LC. One patient with a pT2 tumor died of primary lung cancer 35 months after LC. The remaining 3 patients with pT2 tumors are alive without recurrence 51 to 128 months after surgery. One patient with a pT3 tumor is alive with no recurrence for 9 months. For stage Tis or T1a tumors, LC is sufficient. Patients with T1b tumors should undergo liver-bed resection and lymphadenectomy, and patients with >pT2 tumors should undergo systematic liver resection with lymphadenectomy. Even when incidental GBC diagnosed with LC is advanced, adequate additional surgery may improve the prognosis.

We report our second case of fracture of a SMART self-expandable metallic stent (Cordis Endovascular, Warren, NJ) placed to treat biliary obstruction due to an unresectable common bile duct carcinoma. An 82-year-old man presented with jaundice. Computed tomography and ultrasonography on admission demonstrated a mass in the lower common bile duct. The mass was identified as a common bile duct obstruction. A SMART stent was inserted. Ten months after stent insertion, two additional SMART stents were inserted to relieve obstructive jaundice due to occlusion of the first stent. Fourteen months after insertion of the first stent, endoscopic examination revealed stenosis of the duodenum due to invasion of the common bile duct carcinoma, prompting us to perform a gastrojejunostomy 1 month later. Three months after gastrojejunostomy, the patient presented with obstructive jaundice and cholangitis. A fracture of one of the stents was then discovered on plain X-ray films and percutaneous transhepatic cholangiography. Two SMART stents were inserted simultaneously. In conclusion, we report the fracture of a SMART stent placed for common bile duct carcinoma. Fracture should be considered as a possible complication after metallic stent insertion.

A 58-year-old man with a chief complaint of epigastralgia was admitted to our hospital. Physical examination disclosed a large, firm mass in the right hypochondrium. Abdominal computed tomography confirmed thickening of the gallbladder wall and a 15 x 8 cm mass occupying almost all of the right lobe and medial segment of the liver. With a preoperative diagnosis of malignant gallbladder tumor infiltrating the liver, right hepatic trisegmentectomy was performed. Histopathologic examination showed atypical cells with small round to oval nuclei and sparse eosinophilic cytoplasm, proliferating in a solid and focal nesting pattern. Near this small cell proliferation was a focus of tubular adenocarcinoma that showed a zone of transition from the small cell neuroendocrine pattern. The small cells demonstrated immunohistochemical reactivity for chromogranin A. Electron microscopy disclosed neurosecretory granules 150 nm in diameter, representing dense round core vesicles, confirming a neuroendocrine cell lineage. The patient was diagnosed with neuroendocrine cell carcinoma combined with adenocarcinoma of the gallbladder. Tumor recurrence became evident 3 months after surgery, and he died 4 months after surgery.

A 59-year-old man with myelodysplastic syndrome who was hospitalized for evaluation of fever and generalized fatigue had elevated levels of C-reactive protein and pancytopenia. A search for a site of infection and empiric treatment with antibiotics were unsuccessful. Over 5 to 6 weeks right upper quadrant pain and rebound tenderness developed. Sonographic Murphys sign was present. Computed tomography showed thickening of the gallbladder wall, and repeated ultrasonography demonstrated changes consistent with cholecystitis. Open cholecystectomy was performed as an emergency procedure. Macroscopically the resected gallbladder showed an edematous and thickened wall. Histopathologic examination revealed transmural infiltration by atypical mononuclear cells with distinct nuclei. The cells showed immunohistochemical staining for CD15, indicating myeloid lineage. By 10 days after surgery, counts of leukocytes and leukoblasts had markedly increased, reaching 36,700/microL and 76.0%, respectively. The blast crisis was thought to indicate progression from myelodysplastic syndrome to leukemia. The patient died of progressive disease 12 days after surgery. We have described a rare case of acute cholecystitis caused by infiltration of immature myeloid cells to the gallbladder. An acute abdomen complicating hematologic disorders is life-threatening and requires prompt and appropriate treatment.

Increases in the serum extracellular matrix proteins (ECMPs) have been described in studies on cholestasis, therefore we investigated the serum levels of collagen IV, aminoterminal propeptide of type III procollagen, and hyaluronic acid prior to percutaneous transhepatic biliary drainage (PTBD) to evaluate its potential as a predictor for prolonged bilirubin clearance and clinical course in patients with malignant obstructive jaundice (MOJ).Serum levels of ECMPs were prospectively investigated in 42 patients with MOJ prior to PTBD. The study group was subdivided according to the bilirubin clearance, and was also subdivided according to the determined level of collagen IV (cut-off point of 260 ng/mL).Serum collagen IV was identified as an independent risk factor for prolonged bilirubin clearance (P=0.006). Receiver-operating-characteristic curve analysis revealed that serum collagen IV had a diagnostic accuracy of 79% at the cut-off point of 260 ng/mL. Furthermore, these results indicated that the level of collagen IV is a reliable marker of postoperative liver failure (P=0.029) and predictor of death from liver failure (P=0.02).Elevated serum collagen IV is a feature of MOJ commonly associated with prolonged bilirubin clearance, and a useful indicator of clinical course, postoperative morbidity, and mortality in patients with MOJ.

Background & Aims: Transforming growth factor β (TGF-β) receptor II (TGF-βRII), which is essential for TGF-β signaling and is involved in the causation or participates in the pathway of various human disorders, is consequently considered a key target for therapeutics and analysis of the pathophysiology associated with disruption of the TGF-β system. In the liver, TGF-β plays an essential role in hepatocyte apoptosis, growth inhibition, and progression of fibrogenesis. There is a critical need to introduce technology involving the TGF-β system, such as RNA interference (RNAi), which has high potential for in vivo therapeutics and analytical activities. Methods: Here, we investigated the effect of short hairpin RNA targeting TGF-βRII, using hepatocyte injury in human and mouse cell lines and liver injury mouse models. Results: We demonstrated that short hairpin RNA targeting TGF-βRII can be used to silence TGF-βRII genes in mouse and human cell lines, and physiologic and morphologic changes in hepatocytes suffering from acute injury are spared by RNAi-mediated gene silencing of the target gene and by suppressing downstream signal transduction. Furthermore, short hairpin RNA targeting TGF-βRII protected mice from life-threatening acute liver failure. Conclusions: Our study suggests the potential use of TGF-βRII silencing by RNAi as an analytical tool for TGF-β signaling and gene-specific therapy in human disorders.

Spontaneous perforation of a duodenal diverticulum is a rare but serious complication with significant mortality rates. Just over 100 cases have been reported in the world literature. One case of perforated duodenal diverticulum treated by simple closure is reported. An elderly female was admitted to our hospital with an acute abdomen. Computed tomography of the abdomen showed retroperitoneal air around the duodenum and right kidney. Laparotomy with a Kocher maneuver disclosed a perforated diverticulum in the second portion of the duodenum. Although diverticulectomy is the most common treatment, simple closure of the perforated duodenal diverticulum with drainage was performed to avoid injury to the distal common bile duct and ampulla of Vater, which were close to the diverticulum. The patient has fully recovered and has been asymptomatic with no signs of recurrence for 25 months.

This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors' institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

A 74-year-old woman with advanced carcinoma of the gall bladder underwent anterior and medial segmentectomies, extrahepatic bile duct resection, lymph node dissection, and hepaticojejunostomy with retrograde transhepatic biliary drainage. On the sixteenth postoperative day, bleeding was noted through the biliary drain, but it stopped spontaneously. Two days later, the biliary drain showed bleeding again. Ultrasonography revealed mild dilatation of the intrahepatic bile duct. Cholangiography via the drain disclosed a defect in the jejunal limb. Emergency angiography revealed an aneurysm, 2 cm in diameter, in the posterior branch of the right hepatic artery. Contrast medium demonstrated extravasation into the jejunal limb. The pseudoaneurysm was embolized with coils. No further hemorrhage was noted, and the patient was discharged 30 days after operation.

Small cell carcinoma (SCC) of the pancreas is a rare disease, with an extremely poor prognosis; only 24 cases have been reported in the literature. However, as some patients have been successfully treated with combination chemotherapy, it is important to obtain both a definite diagnosis and a precise evaluation of the effect of the treatment. A 69-year-old woman presented with an abdominal tumor and pain. She had been observed for sensory neuropathy and swelling of the pancreatic head by the referring doctor over the previous 9 months. The patient was diagnosed with SCC of the pancreas after surgery and had two courses of combination chemotherapy (cisplatin and etoposide). Initially, the tumor disappeared completely on computed tomography (CT) scans, but she died of disease recurrence 3 months after completing the chemotherapy. Changes in serum neuron-specific enolase (NSE) levels were monitored constantly during the progress of the disease. NSE levels had already increased above the upper limit of normal 8 months before the patient’s admission to our hospital, and levels changed concurrently not only with tumor growth but also subsequently with remission and then relapse of the disease after treatment. These results indicate that NSE is a good marker, both as a diagnostic indicator for SCC of the pancreas and as a means of evaluating response to treatment.

An unusual case of choledocholithiasis followed by gallstone ileus documented by serial computed tomography is reported. A 91-year-old woman underwent gastrostomy because she repeatedly developed aspiration pneumonia, and a common bile duct stone was detected. She and her family refused surgery once symptoms resolved. One year later, she presented with increasing, intermittent abdominal pain and nausea. Abdominal computed tomography revealed a common bile duct stone with inflammatory changes, but the patient still refused surgery. Three months later, she was admitted with abdominal pain and vomiting. On admission, plain abdominal radiographs demonstrated proximal small bowel obstruction. A long ileus tube was inserted through the gastric fistula. Two days after admission, gallstone ileus was diagnosed on abdominal computed tomography based on the presence of pneumobilia, disappearance of the common bile duct stone, fluid-filled bowel loops, and the discovery of an impacted stone in the small bowel. Ten and 15 days after admission, repeated computed tomography demonstrated the impacted stone in the terminal ileum. Seventeen days after admission, a laparotomy was performed, and a 5x3-cm gallstone was removed through an ileotomy.

Background: This report describes a one‑step insertion of an expandable metallic stent to treat obstructive jaundice due to unresectable common bile duct carcinoma. Methods: A percutaneous transhepatic cholangiogram is obtained and the bile duct obstruction is negotiated with a guide wire. After advancing the catheter into the duodenum contrast material is injected to measure the length of the stenosis. After an expandable metallic stent is positioned an external biliary drainage catheter is left in place to provide temporary drainage. The catheter is removed after stent patency is confirmed after 3 days. Conclusions: One‑step insertion of an expandable metallic stent for biliary obstruction is a useful method that shortens hospitalization. Once it has been decided to use stent palliation the stent should be inserted without undue delay to maximize symptomatic relief and cost benefits.(J Nippon Med Sch 2003; 70: 179―182)

We describe an unusual case involving an infected hepatic cyst. An 88-year-old woman presented with acute onset of right upper quadrant abdominal pain, mild left lower abdominal pain, diarrhea, and fever. On admission, computed tomography revealed multiple hepatic cysts including an 8-cm cyst located in the left medial segment of the liver, which demonstrated a thickened wall enhanced with contrast media. Ultrasonography showed an 8-cm hypoechoic lesion which differed in appearance from the other, anechoic hepatic cysts. The serum concentration of C-reactive protein was 29.8 mg/dL; white blood cell count, 12,800/microL; CA19-9, 96 U/mL; and CEA, 2.2 ng/mL. Diagnosis of infected hepatic cyst was made by percutaneous transhepatic drainage of the cyst. Milky fluid was obtained and the patient's right upper quadrant abdominal pain resolved after drainage. The cyst fluid CA19-9 concentration was 18,000 U/mL. Cytology of the cyst fluid was negative. Serum CA19-9 (41 U/mL) and CEA (1.8 ng/mL) concentrations were improved 1 week after drainage. Escherichia coli was cultured from the drainage fluid. The patient was discharged 27 days after admission. Percutaneous transhepatic drainage is effective in the treatment of infected hepatic cysts.

An unusual case involving hemorrhage of a benign intrahepatic cyst in which the correct diagnosis was made preoperatively is reported. A 60-year-old man presented with acute onset of left upper quadrant abdominal pain. On admission, computed tomography and ultrasonography revealed an 8-cm hepatic cyst in the left lateral segment of the liver. Serum concentrations of CA19-9 (170 mu/mL), DUPAN2 (1600 mu/mL), and SPAN1 (94 mu/mL) were elevated. Twenty-three days after admission, magnetic resonance imaging revealed a hyperintense 13-cm lesion that appeared heterogeneous on T1-weighted sequences and relative hypointensity of the bottom on T2-weighted sequences. Percutaneous transhepatic drainage of the cyst was performed 27 days after admission, and serosanguineous fluid was obtained; abdominal pain resolved. Tumor marker concentrations decreased by 1 week after drainage. Six days after drainage, the drainage fluid became purulent. The infection persisted and a left lateral segmentectomy and cholecystectomy were performed 24 days after the cyst was drained. Pathology confirmed that the cyst was benign. The use of magnetic resonance imaging and tumor markers may allow the differentiation of benign hepatic cyst from malignant lesions and obviate the need for surgery.

A 39-year-old man hospitalized with upper abdominal pain had been found to have a 3mm polyp in the body of the gallbladder 3 years previously. Laboratory tests on admission showed mild liver dysfunction. Ultrasonography depicted a dilated gallbladder with increased wall thickness; the polyp could no longer be seen. Computed tomography with drip infusion cholangiography again showed a dilated gallbladder, and also stenosis of the distal cystic duct. The resected specimen obtained by laparoscopic cholecystectomy showed disappearance of the polyp from the body of the gallbladder. A cholesterol stone was incarcerated in the cystic duct, representing an impacted detached cholesterol polyp causing acute cholecystitis. Spontaneous detachment of a cholesterol polyp from the gallbladder mucosa, then, can result in acute cholecystitis.

The spontaneous disappearance of a hepatic cyst is described. A 62-year-old woman presented with symptoms of general fatigue in August 1992. Her past medical history was significant for chronic hepatitis, which was diagnosed in 1990 but not treated. Initial laboratory tests revealed mild liver dysfunction with a positive serologic test for hepatitis C. In August 1992, ultrasonography and computed tomography disclosed a cystic lesion along the middle hepatic vein in the right anterior segment of the liver, which was 40 mm in diameter. Repeat radiologic studies in June 1994 demonstrated that the size of the cyst was unchanged. In May 1995, the cyst was only 25 mm in diameter, and it continued to decrease in size thereafter, to 10 mm in September 1995 and 7 mm in September 1996. No hepatic cyst was visualized in December 1996, though the region in which the cyst existed was hyperechoic. Laboratory data were essentially unchanged from August 1992 to December 1996. Clinically the patient remained asymptomatic.

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage (RTBD) tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative management, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.

AIM: To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent (EMS) used in the treatment of obstructive jaundice caused by unresectable malignancies. METHODS: Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure. RESULTS: One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered. CONCLUSIONS: One-step percutaneous transhepatic insertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient’s quality of life.

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patients liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 x 10(4)/microl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 x 10(4)/microl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patients postoperative course was unremarkable, and he was discharged on postoperative day 12.

Rubrofusarin, a metabolic product of Fusarium culmorum Sacc. and its methyl ethers were synthesized by the Claisen condensation of 2-acetylnaphthalene derivatives (XIII, XV and XVIII), which were prepared starting from α-resorcylic acid. The structures of rubrofusarin monomethyl ether A and nor-rubrofusarin diacetate were established spectrometrically and synthetically.