Liver resection for hemoperitoneum caused by spontaneous rupture of unrecognized hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasingly common form of cancer. Although its spontaneous rupture is rare in Western countries, it constitutes a surgical emergency and is associated with high mortality. There is a lack of consensus as to the best approach and what parameters to use in choosing it. The three main approaches are conservative, endovascular and resection - the treatment of choice for acute abdominal bleeding. We report a case of hemoperitoneum following the spontaneous rupture of an unrecognized HCV-related HCC in a patient with no history of liver disease. The patient was successfully treated by emergency surgery, with resection of two segments of the left liver.

Laparoscopic-endoscopic rendez-vous resection of iuxta-cardial gastric GIST

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and they often require a surgical removal. Gastrointestinal stromal tumors can originate from any part of the gastrointestinal tract but gastric location is the most common. In the past the risk of rupture of pseudocapsula and peritoneal dissemination have discouraged surgeons from making a minimally invasive surgical treatment. Recently laparoscopic wedge resection has been proposed. Performance of this mini-invasive technique is however difficult in some gastric location of gastrointestinal stromal tumors, such as iuxta-cardial region. The Authors report and discuss a new technique they used to remove a gastrointestinal stromal tumor located just below the cardia, using a rendez-vous endoscopic and laparoscopic technique.

The ileum as a determinant organ of the functional liver cell mass in rats

PURPOSE: To evaluate if the ileum resection changes the functioning liver cell mass, the hepatic metabolism and the biodistribution of radiopharmaceutical in rats. METHODS: Twelve Wistar rats weighing 285g±34g were randomly divided into the ileum resection group (n = 6) and sham group rats (n = 6). After 30 days, they were anesthetized and 0.1mL of 99m-Tc-phytate(0.66MBq) was injected via femoral vein. After 30 minutes, blood samples were collected for red blood cells radioactive labeling and serum ALT, AST and gammaGT. Liver samples were used for 99m-Tc-phytatepercentage of radioactivity/gram of tissue and histopathology. Student’s t test was used with significance 0.05. RESULTS: There was a higher uptake of 99m-Tc-phytate in the liver of sham rats, compared to the ileum resection group (p<0.05). GammaGT, ALT and AST were increased in ileum resection rats compared to sham (p<0.05). The he patocytes count was significantly lower in ileum resection group than in sham (p<0.05). Liver: body mass ratio was lower in experimental animals than in sham group (p<0.05). CONCLUSION: These data support that the ileum has important role in liver function and liver mass regulation, and they have potential clinical implications regarding the pathogenesis of liver injury following lower bowel resection.

Negative regulation of the hepatic fibrogenic response by suppressor of cytokine signaling 1 (SOCS1)

Abstract: Suppressor of cytokine signaling 1 (SOCS1) is an indispensable regulator of IFN-γ signaling and has been implicated in the regulation of liver fibrosis. However, it is not known whether SOCS1 mediates its anti-fibrotic functions in the liver directly, or via modulating IFN-γ, which has been implicated in attenuating hepatic fibrosis. Additionally, it is possible that SOCS1 controls liver fibrosis by regulating hepatic stellate cells (HSC), a key player in fibrogenic response. While the activation pathways of HSCs have been well characterized, the regulatory mechanisms are not yet clear. The goals of this study were to dissociate IFN-γ-dependent and SOCS1-mediated regulation of hepatic fibrogenic response, and to elucidate the regulatory functions of SOCS1 in H SC activation. Liver fibrosis was induced in Socs1[superscript -/-]Ifng[superscript -/-] mice with dimethylnitrosamine or carbon tetrachloride. Ifng[superscript -/-] and C57BL/6 mice served as controls. Following fibrogenic treatments, Socs1[superscript -/-]Ifng[superscript -/-] mice showed elevated serum ALT levels and increased liver fibrosis com-pared to mice Ifng[superscript -/-]. The latter group showed higher alanine aminotransferase (ALT) levels and fibrosis than C57BL/6 controls. The livers of Socs1-deficient mice showed bridging fibrosis, which was associated with increased accumulation of myofibroblasts and abundant collagen deposition. Socs1-deficient livers showed increased expression of genes coding for smooth muscle actin, collagen, and enzymes involved in remodeling the extracellular matrix, namely matrix metalloproteinases and tissue inhibitor of metalloproteinases. Primary HSCs from Socs1-deficient mice showed increased proliferation in response to growth factors such as HGF, EGF and PDGF, and the fibrotic livers of Socs1-deficient mice showed increased expression of the Pdgfb gene. Taken together, these data indicate that SOCS1 controls liver fibrosis independently of IFN-γ and that part of this regulation may occur via regulating HSC proliferation and limiting growth factor availability.

Biodistribution of the radiophamarceutical sodium pertechnetate (Na99mTcO4) after massive small bowel resection in rats

To evaluate the biodistribution of sodium pertecnetate (Na99mTcO4) in organs and tissues, the morphometry of remnant intestinal mucosa and ponderal evolution in rats subjected to massive resection of the small intestine. Methods: Twenty-one Wistar rats were randomly divided into three groups of 7 animals each. The short bowel (SB) group was subjected to massive resection of the small intestine; the control group (C) rats were not operated on, and soft intestinal handling was performed in sham rats. The animals were weighed weekly. On the 30th postoperative day, 0.l mL of Na99mTcO4, with mean activity of 0.66 MBq was injected intravenously into the orbital plexus. After 30 minutes, the rats were killed with an overdose of anesthetic, and fragments of the liver, spleen, pancreas, stomach, duodenum, small intestine, thyroid, lung, heart, kidney, bladder, muscle, femur and brain were harvested. The biopsies were washed with 0.9% NaCl.,The radioactivity was counted using Gama Counter WizardTM 1470, PerkinElmer. The percentage of radioactivity per gram of tissue (%ATI-g) was calculated. Biopsies of the remaining jejunum were analysed by HE staining to obtain mucosal thickness. Analysis of variance (ANOVA) and the Tukey test for multiple comparisons were used, considering p<0.05 as signifi cant. Results: There were no signifi cant differences in %ATI-g of the Na99mTcO4 in the organs of the groups studied (p>0.05). An increase in the weight of the SB rats was observed after the second postoperative week. The jejunal mucosal thickness of the SB rats was signifi cantly greater than that of C and sham rats (p<0.05). Conclusion: In rats with experimentally-produced short bowel syndrome, an adaptive response by the intestinal mucosa reduced weight loss. The biodistribution of Na99mTcO4 was not affected by massive intestinal resection, suggesting that short bowel syndrome is not the cause of misleading interpretation, if an examination using this radiopharmaceutical is indicated

Ontogeny and nutritional programming of the hepatic growth hormone-insulin-like growth factor-prolactin axis in the sheep

The liver is an important metabolic and endocrine organ in the fetus but the extent to which its hormone receptor (R) sensitivity is developmentally regulated in early life is not fully established. We, therefore, examined developmental changes in mRNA abundance for the growth hormone (GH) and prolactin (PRL) receptors (R) plus insulin-like growth factor (IGF)-I and –II and their receptors. Fetal and postnatal sheep were sampled at either 80, or 140 days gestation, 1, 30 days or six months of age. The effect of maternal nutrient restriction between early to mid (i.e. 28 to 80 days gestation, the time of early liver growth) gestation on gene expression was also examined in the fetus and juvenile offspring. Gene expression for the GHR, PRLR and IGF-IR increased through gestation peaking at birth, whereas IGF-I was maximal near to term. In contrast, IGF-II mRNA decreased between mid and late gestation to increase after birth whereas IGF-IIR remained unchanged. A substantial decline in mRNA abundance for GHR, PRLR and IGF-IR then occurred up to six months. Maternal nutrient restriction reduced GHR and IGF-IIR mRNA abundance in the fetus, but caused a precocious increase in the PRLR. Gene expression for IGF-I and –II were increased in juvenile offspring born to nutrient restricted mothers. In conclusion, there are marked differences in the developmental ontogeny and nutritional programming of specific hormones and their receptors involved in hepatic growth and development in the fetus. These could contribute to changes in liver function during adult life.

Species-specific kinetics and zonation of hepatic DNA synthesis induced by ligands of PPARα

PPARα ligands evoke a profound mitogenic response in rodent liver, and the aim of this study was to characterise the kinetics of induction of DNA synthesis. The CAR ligand, 1,4-bis[2-(3,5- dichoropyridyloxy)]benzene, caused induction of hepatocyte DNA synthesis within 48 hours in 129S4/SvJae mice, but the potent PPARα ligand, ciprofibrate, induced hepatocyte DNA synthesis only after 3 or 4 days dosing; higher or lower doses did not hasten the DNA synthesis response. This contrasted with the rapid induction (24 hours) reported by Styles et al. (Carcinogenesis 9:1647-1655). C57BL/6 and DBA/2J mice showed significant induction of DNA synthesis after 4, but not 2, days ciprofibrate treatment. Alderley Park and 129S4/SvJae mice dosed with methylclofenapate induced hepatocyte DNA synthesis at 4, but not 2, days after dosing, and proved that inconsistency with prior work was not due to a difference in mouse strain or PPARα ligand. Ciprofibrate-induced liver DNA synthesis and growth was absent in PPARα- null mice, and are PPARα-dependent. In the Fisher344 rat, hepatocyte DNA synthesis was induced at 24 hours after dosing, with a second peak at 48 hours. Lobular localisation of hepatocyte DNA synthesis showed preferential periportal induction of DNA synthesis in rat, but panlobular zonation of hepatocyte DNA synthesis in mouse. These results characterise a markedly later hepatic induction of panlobular DNA synthesis by PPARα ligands in mouse, compared to rapid induction of periportal DNA synthesis in rat.

Hepatic Encephalopathy . A 2016 perspective

Classification of Hepatic EncephalopathyPathogenesis of HEWhy may HE increase the risk of death of cirrhotic patients? Is HE truly reversible? Interorgan ammonia metabolism: The basis of novel therapies of HE

Endoscopic band ligation without resection in selected patients for small and superficial upper gastrointestinal tract lesions

Background and aim: The aim of this study was to evaluate the efficacy of endoscopic band ligation (EBL) in carefully selected patients who would benefit from this method of resection. Methods: Patients with early upper gastrointestinal and small (< 15 mm) lesions treated with EBL (Duette® Multi-Band Mucosectomy) were prospectively recruited and retrospectively analyzed between 2010 and 2015. All cases were discussed in a multidisciplinary cancer committee and it was concluded that, owing to patient conditions, surgery was not possible and that not conducting histology would not change the clinical management. A first endoscopic control with biopsies was planned at 4-8 weeks. If there was no persistence of the lesion, new controls were programmed at 6 and 12 months. Results: The group (n = 12) included 5 esophagus lesions (adenosquamous carcinoma, n = 1; carcinoma squamous, n = 2; adenocarcinoma, n = 2); 4 gastric lesions (high grade dysplasia, n = 1; adenocarcinoma, n = 2; neuroendocrine tumor [NET], n = 1), and 3 duodenal lesions (NETs) (n = 3). The mean tumor diameter was 9.6 ± 2.8 mm (range 4-15). Only one minor adverse event was described. At first follow-up (4-8 weeks), there was 91.6% and 75% of endoscopic and histological remission, respectively. At 6-month follow-up there was 70% of both endoscopic remission and negative biopsies. And at 12 months, there was 100% and 75% of endoscopic and histological remission, respectively. Persisting lesions were T1 cancers. The median follow-up was 30.6 months. Conclusion: EBL without resection is an easy and safe technique that should be considered in patients with multiple morbidities and small superficial UGI lesions.

Development of gene therapy to deliver the receptor-specific rhTRAIL DHER variant to induce apoptosis in activated hepatic stellate cells for the treatment of liver fibrosis

Dissertação de Mestrado, Engenharia Biológica, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2014

Early Adaptation of Small Intestine After Massive Small Bowel Resection in Rats

Background: It is important that the residual bowel adapts after massive resection. The necessary intestinal adaptation is a progressive recovery from intestinal failure through increase in absorptive surface area and functional capacity and includes both morphological and functional adaptations. Objectives: The aim of this study was to investigate intestinal morphological and functional adaptations of small bowel syndrome (SBS) model rats (SBS1W) 7 days after bowel resection. Materials and Methods: Male sprague–dawley rats (n = 20/group) underwent either a 75% proximal small bowel resection (SBS1W group) or a control operation (control group). Markers of morphological adaptation were revealed by TEM analysis of H&E-stained tissue samples. The intestinal barrier condition was assessed by BT, and sIgA concentration in intestinal mucus was measured by ELISA. Contractility and the slow wave rhythm of the entire intestinal remnant were measured and recorded. Results: The SBS1W group experienced more weight loss than control group and had a clearly different intestinal morphology as revealed in TEM images. Compared with control rats, the SBS1W group had a lower sIgA concentration in intestinal mucus and higher BT to lymph nodes (70% vs 40%; level I), portal blood (40% vs 10%; level II), and peripheral blood (60% vs 30%; level III). Disorder of spontaneous rhythmic contraction, irregular amplitude, and slow frequency were detected in the SBS1W group by a muscle strips test. Similarly, the slow wave of the entire intestinal remnant in the SBS1W group was irregular and uncoordinated. Conclusions: The finding of intestinal adaptation following massive SBR in SBS1W rats provides more understanding of the mechanisms of progressive recovery from the intestinal failure that underlies SBS. The mechanical, chemical, immunological, and biological barriers were all impaired at 7 days following bowel resection, indicating that the SBS model rats were still in the intestinal adaptation phase.

Impaired reverse cholesterol transport and hepatic steatosis contribute to pathogenesis of high fat dietinduced hyperlipidemia in murine models

Purpose: To investigate the pathogenesis of high fat diet (HFD)-induced hyperlipidemia (HLP) in mice, rats and hamsters and to comparatively evaluate their sensitivity to HFD. Methods: Mice, rats and hamsters were fed with high-fat diet formulation (HFD, n = 8) or a control diet (control, n = 8) for 4 weeks. Changes in body weight, relative liver weight, serum lipid profile, expressions of hepatic marker gene of lipid metabolism and liver morphology were observed in three hyperlipidemic models. Results: Elevated total cholesterol (TC), triglyceride, low density lipoprotein-cholesterol (LDL-C) and high density lipoprotein-cholesterol (HDL-C) levels and body weight were observed in all hyperlipidemic animals (p < 0.05), while hepatic steatosis was manifested in rat and hamster HLP models, and increased hepatic TC level was only seen (p < 0.05) in hamster HLP model. Suppression of HMG-CoA reductase and up-regulation of lipoproteinlipase were observed in all HFD groups. Hepatic gene expression of LDLR, CYP7A1, LCAT, SR-B1, and ApoA I, which are a response to reverse cholesterol transport (RCT), were inhibited by HFD in the three models. Among these models, simultaneous suppression of HMG-CR, LCAT, LDLR and SR-BI and elevated LPL were features of the hamster model. Conclusion: As the results show, impaired RCT and excessive fat accumulation are major contributors to pathogenesis of HFD-induced murine HLP. Thus, the hamster model is more appropriate for hyperlipidemia research.

The use of expandable megaprostheses for reconstruction of the distal femur in pediatric patients after bone tumor resection

Expandable prostheses are becoming increasingly popular in the reconstruction of children with bone sarcomas of the lower limb. Since the introduction of effective chemotherapy in the treatment of these pathologies, in the 70s, there has been need for new limb salvage techniques. In children, limb salvage of the lower limbs is particularly challenging, not in the last place, because of the loss of growth potential. Therefore, expandable prostheses have been developed. However, the first experiences with these implants were not very successful. High complication rates and unpredictable outcomes raised major concerns on this innovative type of reconstruction. The rarity of the indication is one of the main reasons why there has been a relatively slow learning curve and implant development regarding this type of prosthesis. This PhD thesis, gives an overview of the introduction, the development, the current standards, and the future perspectives of expandable prostheses for the reconstruction of the distal femur in children.

Il trattamento riabilitativo e il recupero precoce dopo intervento di “wedge resection” polmonare per secondarismi da tumore osseo: uno studio osservazionale

Background. Il recupero funzionale precoce dopo intervento di wedge resection polmonare non è studiato in maniera approfondita, in particolare, sono carenti i dati relativi al recupero postoperatorio precoce dei pazienti sottoposti a tele procedura chirurgica in seguito a metastasi polmonari per tumore osseo primitivo. Obiettivo. Lo scopo di questo studio osservazionale è quello di descrivere il percorso fisioterapico dopo intervento di wedge resection polmonare, evidenziando il possibile recupero funzionale nel breve termine e ricercandone i possibili fattori prognostici. Metodi. Per valutare il recupero funzionale si è utilizzato il 1 minute sit to stand test (1MSTS), che è stato somministrato in sesta giornata postoperatoria. Per descrivere l’andamento del recupero il test è stato somministrato in fase preoperatoria e in tutte le giornate postoperatorie. Sono state condotte analisi di univariata per valutare l’associazione delle variabili demografiche, anamnestiche e cliniche con l’outcome primario. Risultati. Sono stati reclutati 13 pazienti, per un totale di 17 osservazioni poiché alcuni pazienti hanno ripetuto l’operazione. Nella sesta giornata il 41,2% dei pazienti aveva eseguito lo stesso o un numero maggiore di verticalizzazioni del 1MSTS fatte nella fase preoperatoria. Nella sesta giornata postoperatoria il 100% dei pazienti era riuscito ad eseguire il 1MSTS almeno una volta dopo l’intervento. All’outcome primario risultavano associarsi con una significatività statistica il livello di autonomia, misurato con la TESS, (p=0,01) e il 1MSTS (p=0,001) misurati nella fase preoperatoria. Conclusioni. Il recupero funzionale postoperatorio è possibile fin dalle prime giornate postoperatorie per i pazienti sottoposti a wedge resection. Il livello di autonomia e il numero di verticalizzazioni del 1MSTS eseguite in fase preoperatoria sono possibili fattori prognostici del recupero funzionale postoperatorio.