Angiogenesis and experimental hepatic fibrosis

Angiogenesis is a basic change occurring during repair by granulation tissue. This process seems to precede fibrosis formation in most types of chronic liver disease. To examine its presence and significance in different types of hepatic insults, this paper sought to identify the presence, evolution and peculiarities of angiogenesis in the most common experimental models of hepatic fibrosis. The characterization of cells, vessels and extracellular matrix and the identification of factors associated with endothelium (factor VIII RA), vascular basement membrane, other components of the vascular walls (actin, elastin) and the presence of the vascular-endothelial growth factor were investigated. The models examined included Capillaria hepatica septal fibrosis, whole pig serum injections, carbon tetrachloride administration, main bile duct ligation and Schistosoma mansoni infection. The first four models were performed in rats, while the last used mice. All models studied exhibited prominent angiogenesis. The most evident relationship between angiogenesis and fibrosis occurred with the C. hepatica model due to circumstances to be discussed. Special attention was paid to the presence of pericytes and to their tendency to become detached from the vascular wall and be transformed into myofibroblasts, which is a sequence of events that explains the decisive role angiogenesis plays in fibrosis.

Evaluation of local immune response to Fasciola hepatica experimental infection in the liver and hepatic lymph nodes of goats immunized with Sm14 vaccine antigen

Protection against Fasciola hepatica in goats immunized with a synthetic recombinant antigen from Schistosoma mansoni fatty acid-binding protein 14 (rSm14) was investigated by assessing worm burdens, serum levels of hepatic enzymes, faecal egg count and hepatic damage, which was evaluated using gross and microscopic morphometric observation. The nature of the local immune response was assessed by examining the distribution of CD2+, CD4+, CD8+ and γ´+ T lymphocytes along with IgG+, IL-4+ and IFN-γ+ cells in the liver and hepatic lymph nodes (HLN). The goats used consisted of group 1 (unimmunized and uninfected), group 2 [infected control - immunized with Quillaia A (Quil A)] and group 3 (immunized with rSm14 in Quil A and infected), each containing seven animals. Immunization with rSm14 in Quil A adjuvant induced a reduction in gross hepatic lesions of 56.6% (p < 0.001) and reduced hepatic and HLN infiltration of CD2+, CD4+, CD8+ and γ´+ T lymphocytes as well as IL-4+ and IFN-γ+ cells (p < 0.05). This is the first report of caprine immunization against F. hepatica using a complete rSm14 molecule derived from S. mansoni. Immunization reduced hepatic damage and local inflammatory infiltration into the liver and HLN. However, considering that Quil A is not the preferential/first choice adjuvant for Sm14 immunization, further studies will be undertaken using the monophosphoryl lipid A-based family of adjuvants during clinical trials to facilitate anti-Fasciolavaccine development.

Low transformation growth factor-β1 production and collagen synthesis correlate with the lack of hepatic periportal fibrosis development in undernourished mice infected with Schistosoma mansoni

Undernourished mice infected (UI) submitted to low and long-lasting infections by Schistosoma mansoni are unable to develop the hepatic periportal fibrosis that is equivalent to Symmers’ fibrosis in humans. In this report, the effects of the host’s nutritional status on parasite (worm load, egg viability and maturation) and host (growth curves, biology, collagen synthesis and characteristics of the immunological response) were studied and these are considered as interdependent factors influencing the amount and distribution of fibrous tissue in hepatic periovular granulomas and portal spaces. The nutritional status of the host influenced the low body weight and low parasite burden detected in UI mice as well as the number, viability and maturation of released eggs. The reduced oviposition and increased number of degenerated or dead eggs were associated with low protein synthesis detected in deficient hosts, which likely induced the observed decrease in transformation growth factor (TGF)-β1 and liver collagen. Despite the reduced number of mature eggs in UI mice, the activation of TGF-β1 and hepatic stellate cells occurred regardless of the unviability of most miracidia, due to stimulation by fibrogenic proteins and eggshell glycoproteins. However, changes in the repair mechanisms influenced by the nutritional status in deficient animals may account for the decreased liver collagen detected in the present study.

Impact of 18F-FDG PET scan on the prevalence of benign thoracic lesions at surgical resection

OBJECTIVE: The main utility of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) lies in the staging of lung cancer. However, it can also be used to differentiate indeterminate pulmonary lesions, but its impact on the resection of benign lesions at surgery is unknown. The aim of this study was to compare the prevalence of benign lesions at thoracotomy carried out for suspected lung cancer, before and after the introduction of PET scanning in a large thoracic surgical centre. MATERIALS AND METHODS: We reviewed our prospectively recorded surgical database for all consecutive patients undergoing thoracotomy for suspected or proven lung cancer and compared the prevalence of benign lesions in 2 consecutive 2-year groups, before (group I) and after (group II) the introduction of FDG-PET scan respectively. RESULTS: Surgical resection was performed on 1233 patients during the study period. The prevalence of benign lesions at surgery in groups I and II was similar (44/626 and 41/607, both 7%), and also in group II between those who underwent FDG-PET scan and the remainder (21/301 and 20/306 respectively, both 7%). In group II, of the 21 patients with benign lesions, who underwent FDG-PET, 19 had a false positive scan (mean standardised uptake value 5.3 [range 2.6-12.7]). Of these, 13 and 4 patients respectively had non-diagnostic bronchoscopy and percutaneous transthoracic lung biopsy pre thoracotomy. There was no difference in the proportion of different benign lesions resected between group I and those with FDG-PET in group II. CONCLUSION: The introduction of FDG-PET scanning has not altered the proportion of patients undergoing thoracotomy for ultimately benign lesions, mainly due to the avidity for the isotope of some non-malignant lesions. Such false positive results need to be considered when patients with unconfirmed lung cancer are contemplated for surgical resection.

Diagnosis of hepatic steatosis by contrast-enhanced abdominal computed tomography

Objective To evaluate the diagnostic capacity of abdominal computed tomography in the assessment of hepatic steatosis using the portal phase with a simplified calculation method as compared with the non-contrast-enhanced phase. Materials and Methods In the present study, 150 patients were retrospectively evaluated by means of non-contrast-enhanced and contrast-enhanced computed tomography. One hundred patients had hepatic steatosis and 50 were control subjects. For the diagnosis of hepatic steatosis in the portal phase, the authors considered a result of < 104 HU calculated by the formula [L - 0.3 × (0.75 × P + 0.25 × A)] / 0.7, where L, P and A represent the attenuation of the liver, of the main portal vein and abdominal aorta, respectively. Sensitivity, specificity, positive and negative predictive values were calculated, using non-contrast-enhanced computed tomography as the reference standard. Results The simplified calculation method with portal phase for the diagnosis of hepatic steatosis showed 100% sensitivity, 36% specificity, negative predictive value of 100% and positive predictive value of 75.8%. The rate of false positive results was 64%. False negative results were not observed. Conclusion The portal phase presents an excellent sensitivity in the diagnosis of hepatic steatosis, as compared with the non-contrast-enhanced phase of abdominal computed tomography. However, the method has low specificity.

The role of ultrasonography in the measurement of subcutaneous and visceral fat and its correlation with hepatic steatosis

Objective To evaluate the sonographic measurement of subcutaneous and visceral fat in correlation with the grade of hepatic steatosis. Materials and Methods In the period from October 2012 to January 2013, 365 patients were evaluated. The subcutaneous and visceral fat thicknesses were measured with a convex, 3–4 MHz transducer transversely placed 1 cm above the umbilical scar. The distance between the internal aspect of the abdominal rectus muscle and the posterior aortic wall in the abdominal midline was considered for measurement of the visceral fat. Increased liver echogenicity, blurring of vascular margins and increased acoustic attenuation were the parameters considered in the quantification of hepatic steatosis. Results Steatosis was found in 38% of the study sample. In the detection of moderate to severe steatosis, the area under the ROC curve was 0.96 for women and 0.99 for men, indicating cut-off values for visceral fat thickness of 9 cm and 10 cm, respectively. Conclusion The present study evidenced the correlation between steatosis and visceral fat thickness and suggested values for visceral fat thickness to allow the differentiation of normality from risk for steatohepatitis.

Presence of air in the hepatic portal system in association with umbilical venous catheter malposition

The authors report a case of umbilical venous catheter malposition with air in the portal venous system in a preterm neonate. Initially, the hypothesis of necrotizing enterocolitis was considered, but the newborn progressed with no finding of disease and the air disappeared at follow-up radiography. The differential diagnosis of such a finding can avoid unnecessary clinical treatments.

Transcatheter arterial embolization for unresectable symptomatic giant hepatic hemangiomas: single-center experience using a lipiodol-ethanol mixture

AbstractObjective:The present article is aimed at reporting the author’s experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas.Materials and Methods:The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009–2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture.Results:Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure.Conclusion:Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.

Anatomical variations of the celiac trunk and hepatic arterial system: an analysis using multidetector computed tomography angiography

Abstract Objective: To analyze the prevalence of anatomical variations of celiac arterial trunk (CAT) branches and hepatic arterial system (HAS), as well as the CAT diameter, length and distance to the superior mesenteric artery. Materials and Methods: Retrospective, cross-sectional and predominantly descriptive study based on the analysis of multidetector computed tomography images of 60 patients. Results: The celiac trunk anatomy was normal in 90% of cases. Hepatosplenic trunk was found in 8.3% of patients, and hepatogastric trunk in 1.7%. Variation of the HAS was observed in 21.7% of cases, including anomalous location of the right hepatic artery in 8.3% of cases, and of the left hepatic artery, in 5%. Also, cases of joint relocation of right and left hepatic arteries, and trifurcation of the proper hepatic artery were observed, respectively, in 3 (5%) and 2 (3.3%) patients. Mean length and caliber of the CAT were 2.3 cm and 0.8 cm, respectively. Mean distance between CAT and superior mesenteric artery was 1.2 cm (standard deviation = 4.08). A significant correlation was observed between CAT diameter and length, and CAT diameter and distance to superior mesenteric artery. Conclusion: The pattern of CAT variations and diameter corroborate the majority of the literature data. However, this does not happen in relation to the HAS.

Multidetector computed tomography angiography of the celiac trunk and hepatic arterial system: normal anatomy and main variants

Abstract Although digital angiography remains as the gold standard for imaging the celiac arterial trunk and hepatic arteries, multidetector computed tomography in association with digital images processing by software resources represents a useful tool particularly attractive for its non invasiveness. Knowledge of normal anatomy as well as of its variations is helpful in images interpretation and to address surgical planning on a case-by-case basis. The present essay illustrates several types of anatomical variations of celiac trunk, hepatic artery and its main branches, by means of digitally reconstructed computed tomography images, correlating their prevalence in the population with surgical implications.

Descoberta simultânea de carcinomatose disseminada e carcinoma de cólon, após colecistectomia laparoscópica

A particularly rapid and fatal outcome has been noted in cases of malignant soft-tissue metastases occurring after cancer surgery. Abdominal wall metastases occurring in scars after laparotomy for cancer resection show a similar poor outcome. On the other hand, neoplasm seeding at trocar sites after laparoscopy has been reported with an increasing frequency. A case is presented of a 68-years-old woman with metastatic seeding of non-diagnosed colon cancer at the umbilical trocar site used for a laparoscopic cholecystectomy. The gallbladder was extracted through the umbilical incision. Pathological examination confirmed chronic cholecystitis. Eight months latter, the patient was seen with a tender umbilical mass protruded through a 4,5 cm the umbilical incision site. Biopsies of this tissue were taken and histopathological examination showed metastatic adenocarcinoma, probably of a gastrointestinal origin. A colonoscopy performed at the same time revealed a 2-cm lesion at the hepatic flexur which was shown to be a differentiated adenocarcinoma. An 8.0 x 6.0 x 6.0-cm pelvic mass without signs of liver metastases was identified by computerised tomography. Diagnostic laparoscopy showed a diffuse peritoneal carcinomatosis. The pelvis could not be approached, except for simple biopsy, and no surgical procedure was performed. It is presumed that the primary colon cancer existed prior to cholecystectomy. Laparoscopy is the procedure of choice to perform cholecystectomy and fundoplication. It has also been increasingly used to diagnose, resect and perform the staging of malignant tumours. As in any relatively new technique, questions arising about its safety and risk of complications must be extensively studied. Many questions about the specific features of laparoscopy promoting cancer growth remain unanswered.

Localização de insulinoma pela injeção seletiva intra-arterial de cálcio

Insulinomas are rare endocrine tumors with an estimated incidence of 1(one) per million. Optimal therapy for all islet tumors of the pancreas is curative surgical resection. However, previous reports have show that, in the absence of preoparative localization, insulinoma may not be found intraoperatively in about 20% of patients. With current imaging technology, including serial computed tomography (CT), magnetic resonance imaging (MRI) and ultrasonography, localization of insulinomas less than 2cm remains inadequate. This case report shows that selective intraarterial calcium injection with hepatic venous sampling for insulin levels measured is a efficient technique for the localization of insulinomas.

Leiomiossarcoma de veia cava inferior

We present a case of a 56-year-old woman with abdominal pain, normal laboratorial exams, normal carcinoembryonary antigen (CEA) and abdominal tomography exam with tumor formation in hepatic region. A tumor lesion was identified in a surgery in the medial segment of the inferior vena cava. A surgical resection was done, respecting the security limits, and reconstruction of the inferior vein with polytetrafluoroethylene (PTFE) graft was performed. The histological examination showed differentiated leiomyossarcoma of the inferior vena cava. This report points to the necessity of differential diagnoses with leiomyossarcoma in the presence of abdominal mass, supra-mesocolic, and non-specific abdominal symptoms, since its pre-surgical diagnoses occurs in only 5% to 10% of the cases.

Autotransplante de fígado em Testemunha de Jeová portador de hepatocarcinoma

Hepatocellular carcinoma is one of the most frequent entities worldwide and partial hepatectomy has been the preferred option for treatment. We report the case of a 28-year-old Jehovah's Witness who came to us complaining about an abdominal mass. Angio-MRI showed a large heterogeneous mass in the left hepatic lobe. Ex situ liver resection followed by right hepatic lobe autotransplantation was performed, using extra-corporeal venous-venous bypass. He had an uneventful postoperative outcome and was discharged on the 10th postoperative day. The histology revealed hepatocellular carcinoma.