Left Lateral Lobe Research Articles

Quantitative Analysis of Hepatic Microcirculation in Rabbits After Liver Ischemia-Reperfusion Injury Using Contrast-Enhanced Ultrasound

Previous studies have shown that contrast-enhanced ultrasound (CEUS) can be used quantitatively to analyze microcirculation blood perfusion in hepatocellular carcinoma patients. However, limited data have described the application of CEUS in hepatic microcirculation after liver ischemic-reperfusion injury (IRI). The purpose of this study was to explore the use of CEUS quantitatively to assess liver microcirculation after liver IRI. We randomly sorted 45 New Zealand rabbits into 3 groups (15 in each). Group A was a control group in which the rabbits underwent laparotomy alone. In groups B and C, hepatic blood was blocked for 30 min. Simultaneously, rabbits in group C underwent left lateral lobe resection. After 30 min of ischemia, CEUS was conducted after 0 h, 1 h, 6 h and 24 h of reperfusion in the 3 groups. Time-intensity curves (TICs) for CEUS were constructed and quantitative parameters (maximum intensity [IMAX], rise time [RT], time to peak [TTP] and mean transit time [mTT]) were obtained. In addition, serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were computed to estimate liver function before the operation and at 0 h, 1 h, 6 h and 24 h after reperfusion, respectively. Pathologic changes in the liver after reperfusion were also observed. Simultaneously, the correlations between serum transaminase and a variety of quantitative analysis parameters were analyzed. In groups B and C, the IMAX value decreased; whereas RT, TTP, mTT and serum ALT and AST levels increased significantly in comparison with those in group A after 0 h and 1 h of reperfusion. The pathology revealed that erythrocytes were destroyed and microcirculation was disturbed. Then, at 6 h of reperfusion, the IMAX continued to decrease. Additionally, the levels of RT, TTP, mTT and serum ALT and AST increased in comparison with those at 1 h of reperfusion. The pathologic analysis revealed inflammatory cell aggregation and leukocyte infiltration. After 24 h of reperfusion, the IMAX was reduced in comparison with that of the 6-h group. The levels of RT, TTP, mTT and serum ALT and serum AST were increased in comparison with that of the 6-h group. These findings were in accordance with the pathologic analysis. In addition, serum transaminase had a negative correlation with IMAX (p < 0.001) and a positive correlation with RT, TTP and mTT (all p < 0.001). So, in conclusion, the quantitative analysis of CEUS can be used to assess hepatic microcirculation after liver IRI.

AMNESTIC AND NON-AMNESTIC PHENOTYPES OF ALZHEIMER'S DISEASE: AN MRI-BASED PHASING ANALYSIS

Typical amnestic Alzheimer's disease (AD) presents with memory difficulty, and pathology is first seen in the medial temporal lobe (MTL). Disease then spreads to cortex as language, visuospatial, and executive difficulties emerge. In contrast, these cognitive domains are the first impaired in non-amnestic AD. Pathologically, non-amnestic AD patients have relative sparing of MTL and selective distribution of pathology in the cortex. However, the temporal progression of disease is unclear. We used a novel MRI phasing algorithm, based on pathological staging studies, to test the hypothesis that non-amnestic AD has disease originating and spreading in neocortex. We inferred the anatomical origin and progression of disease in each AD variant based on the frequency of regional atrophy patterns in cross-sectional MRI from 131 patients with AD, confirmed through autopsy or CSF results. Disease progression models were computed separately for typical amnestic AD (aAD, 38 scans), logopenic variant primary progressive aphasia (lvPPA, 97 scans), posterior cortical atrophy (PCA, 54 scans), corticobasal syndrome (CBS, 31 scans), and behavioural/dysexecutive-variant AD (bvAD, 39 scans). For each AD variant, 4 phases of atrophy were defined in 120 anatomical regions-of-interest (ROIs) using a grey matter volume threshold of Z < -1.0 relative to elderly controls. The origin of disease (Phase 1) was inferred from the most frequently atrophied 10% of ROIs; similarly, Phases 2, 3, and 4 comprised ROIs in the 2nd, 3rd, and 4th deciles of atrophy frequency. We observed a unique distribution of atrophy for each phenotype. Phase 1 ROIs in our model represent the anatomical origin of disease, including: MTL for the aAD group (relatively spared in other phenotypes), left lateral temporal lobe for lvPPA, occipito-parietal cortex for PCA, temporo-parietal cortex for CBS, and fronto-temporal cortex for bvAD. Disease phase was significantly correlated with MMSE score and disease duration, independently of age.

P 037 - Effect of Neutral Sphingomyelinase Inhibition on ER Stress and Apoptosis in Liver Ischemia–Reperfusion Injury

This study determined the role of selective neutral sphingomyelinase (N-SMase) inhibition on endoplasmic reticulum (ER) stress and apoptotic markers in a rat model of liver ischemia reperfusion (IR) injury. Liver IR injury was created by clamping blood vessels supplying the median and left lateral hepatic lobes for 60 min, followed by 60 min reperfusion. Sphingmyelin and ceramide levels in liver tissue were determined by tandem mass spectrometry. Spingomyelin levels were significantly increased in all IR groups compared to controls. Treatment with a specific N-SMase inhibitor significantly decreased all measured ceramides in IR injury. A significant increase was observed in ER stress markers C/EBP-homologous protein (CHOP) and 78 kDa glucose-regulated protein (GRP78) in IR injury, which was not significantly altered by N-SMase inhibition. Inhibition of N-SMase caused a significant reduction in phospho-NF-kB levels, hepatic TUNEL staining, cytosolic cytochrome c and caspase-3, -8 and -9 activities which were significantly increased in IR injury. Data herein confirm the role of ceramide in increased apoptotic cell death and highlight the protective effect of N-SMase inhibition in down-regulation of apoptotic stimuli responses occurring in hepatic IR injury.

Transection of the hepatic parenchyma associated or not with the contralateral portal vein branch ligature and its effect in liver regeneration.

ABSTRACTObjective To analyze the influence of portal vein ligation in hepatic regeneration by immunohistochemical criteria.Methods Ten pigs divided into two groups of five animals underwent hepatectomy in two stages, and the groups were differentiated by ligation or not of the left portal vein tributary, which is responsible for vascularization of the left lateral and medial lobes of the pig liver. Five days after the procedure, the animals underwent liver biopsies for further analysis of histological and immunohistochemical with marker Ki67.Results The group submitted to hepatectomy with vascular ligation showed an increase of approximately 4% of hepatocytes in regeneration status, as well as a greater presence of Kupffer and inflammatory cells as compared to control.Conclusion As a result of positive cell replication observed through the Ki67 marker, we can suspect that the ligation of a tributary of the portal vein associated with liver resection promoted a greater stimulus of liver regeneration when compared to liver resection alone.

Glutamate in dorsolateral prefrontal cortex and auditory verbal hallucinations in patients with schizophrenia: A 1H MRS study

PurposeGlutamatergic models of psychosis propose that dysfunction of N-methyl-d-aspartate (NMDA) receptors, and associated excess of glutamate, may underlie psychotic experiences in people with schizophrenia. However, little is known about the specific relation between glutamate and auditory verbal hallucinations (AVH) in patients with psychosis. In this study, levels of glutamate+glutamine (Glx) in the left lateral prefrontal lobe were determined using proton magnetic resonance spectroscopy (1H MRS) to calculate their association with AVH. MethodsSixty-seven patients with schizophrenia and thirty healthy control participants (HC) underwent magnetic resonance spectroscopy (MRS) to estimate levels of Glx in the white matter of the left prefrontal lobe. The spectrum was estimated from an 8mm3 voxel placed in the left lateral prefrontal region, belonging to both the cingulum and forceps minor. Patients with lifetime AVH (AVH group; n=45) and patients without lifetime AVH were compared (NoAVH group; n=22) to control participants. ResultsLevels of Glx were significantly different between the groups (F(2,94)=5.27, p=0.007). Planned comparisons showed that higher Glx levels were found in control participants than in the total patient group (p=0.010). However, patients with lifetime AVH had higher levels of Glx compared to patients without lifetime AVH (p=0.019). Creatin levels were similar in all three groups. We found no association between Glx and the severity of symptoms (item P3 of the PANSS or PANSS positive subscale). ConclusionThe higher Glx levels in patients with lifetime AVH as compared to patients without lifetime AVH suggest a mediating role for Glx in AVH. Our results are consistent with a previous study that found similar decreased levels of Glx in patients with schizophrenia, and increased levels in an AVH group as compared to a NoAVH group. The role of the glutamatergic system deserves further investigation, for example in different brain regions and in relation to clinical variables.

Benefit of an implanted solid barrier for the feasibility of a sequence of three different hepato-biliary operations in a small animal model

Current liver surgery includes complex multi-stage procedures such as portal vein ligation (PVL) followed by extended liver resection, especially in patients with Klatskin tumours. The risk for severe adhesions increases with every procedure. Finally, this complex sequence could fail because of malignant adhesions. Therefore, we proved the hypothesis of reducing malignant adhesions and increasing feasibility of a sequence with three hepato-biliary operations by implantation of a solid barrier. We operated in male rats (n=40). Our sequence included as 1st operation bile duct ligation mimicking Klatskin III° or IV°, the 2nd operation was a selective portal vein ligation (sPVL) and 3rd procedure was a 70% liver resection. The mechanical barrier (part of a sterile glove) was implanted at the end of the first operation between the upper (median lobe+left lateral lobe [ML+LLL]) and lower (right lobe+caudate lobe [RL+CL]) rat liver lobes. We assessed the degree of adhesions and the feasibility of the 2nd and 3rd operation by using an established adhesion score (Zühlke) and a feasibility score. The severity of the adhesions and the pro-inflammatory cellular response were further evaluated by morphometry of thickness (HE) of the adhesion layer and quantification of infiltrating neutrophils (ASDCL) in the adhesion layer on the liver surface. The planned liver resection as the third procedure was only feasible when a mechanical barrier was placed. Extent of cholestasis or time interval between the operations had no significant impact on adhesions score or feasibility of the whole sequence. A sequence of three hepato-biliary operations in a small animal model (rat) is feasible. It should be considered to implant a mechanical barrier in a sequence of more than two surgical interventions in an experimental model in order to assure the feasibility of the final operation.

Method of Direct Segmental Intra-hepatic Delivery Using a Rat Liver Hilar Clamp Model

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ischemia/reperfusion (I/R) injury with myriad negative consequences. Potential I/R injury in marginal organs destined for liver transplantation contributes to the current donor shortage secondary to a decreased organ utilization rate. A significant need exists to explore hepatic I/R injury in order to mediate its impact on graft function in transplantation. Rat liver hilar clamp models are used to investigate the impact of different molecules on hepatic I/R injury. Depending on the model, these molecules have been delivered using inhalation, epidural infusion, intraperitoneal injection, intravenous administration or injection into the peripheral superior mesenteric vein. A rat liver hilar clamp model has been developed for use in studying the impact of pharmacologic molecules in ameliorating I/R injury. The described model for rat liver hilar clamp includes direct cannulation of the portal supply to the ischemic hepatic segment via a side branch of the portal vein, allowing for direct segmental hepatic delivery. Our approach is to induce ischemia in the left lateral and median lobes for 60 min, during which time the substance under study is infused. In this case, pegylated-superoxide dismutase (PEG-SOD), a free radical scavenger, is infused directly into the ischemic segment. This series of experiments demonstrates that infusion of PEG-SOD is protective against hepatic I/R injury. Advantages of this approach include direct injection of the molecule into the ischemic segment with consequent decrease in volume of distribution and reduction in systemic side effects.

Method of Direct Segmental Intra-hepatic Delivery Using a Rat Liver Hilar Clamp Model

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ischemia/reperfusion (I/R) injury with myriad negative consequences. Potential I/R injury in marginal organs destined for liver transplantation contributes to the current donor shortage secondary to a decreased organ utilization rate. A significant need exists to explore hepatic I/R injury in order to mediate its impact on graft function in transplantation. Rat liver hilar clamp models are used to investigate the impact of different molecules on hepatic I/R injury. Depending on the model, these molecules have been delivered using inhalation, epidural infusion, intraperitoneal injection, intravenous administration or injection into the peripheral superior mesenteric vein. A rat liver hilar clamp model has been developed for use in studying the impact of pharmacologic molecules in ameliorating I/R injury. The described model for rat liver hilar clamp includes direct cannulation of the portal supply to the ischemic hepatic segment via a side branch of the portal vein, allowing for direct segmental hepatic delivery. Our approach is to induce ischemia in the left lateral and median lobes for 60 min, during which time the substance under study is infused. In this case, pegylated-superoxide dismutase (PEG-SOD), a free radical scavenger, is infused directly into the ischemic segment. This series of experiments demonstrates that infusion of PEG-SOD is protective against hepatic I/R injury. Advantages of this approach include direct injection of the molecule into the ischemic segment with consequent decrease in volume of distribution and reduction in systemic side effects.

Protective effect of intraportal infusion of hypothermic hydrogen-rich saline solution on hepatic warm ischemia/reperfusion injury in rat model

The aim of the present study was to investigate the effects of intraportal administration of hypothermic hydrogenrich saline solution (HRSS) on hepatic ischemia/reperfusion (I/R) injury. Thirty rats were divided equally into six groups; 1) sham, no I/R or transfusion, 2) I/R injury (60 minutes ischemia + 120 minutes reperfusion, 3) I/R injury + normal saline 24°C, 4) I/R injury + normal saline 4°C, 5) I/R injury + HRSS 24°C, 6) I/R injury + HRSS 4°C. In groups 3-6, 1 mg/kg normal saline (NS) and/or HRSS were administered into the vein of the left lateral and median lobes of the liver (upper the site of clumping) 10 minutes before finishing of ischemic period. The harvest time points were at 2 hours post reperfusion in all groups. Cell death, sinusoidal dilatation, congestion, hemorrhage, and neutrophil infiltration were observed in I/R group, while these histopathological changes were attenuated in the hypothermic HRSS administrated groups (P < 0.01). The level of alanine aminotransferase, aspartate aminotransferase, malondialdehyde, interleukin 6, tumor necrosis factor a, and caspase-3 were increased significantly by I/R injury and hypothermic HRSS administration reduced all these markers (P < 0.01). SOD level was low in I/R group whereas it tended to increase in the hypothermic HRSS administrated groups (P < 0.01). The present study demonstrated that hypothermic hydrogen-rich saline solution effectively protected the hepatic tissue against cellular injury and organ dysfunction through the mechanisms that decrease the effect of oxidative stress, inflammation, apoptosis and necrosis.

Ozone oxidative intervention protects against hepatic ischemia reperfusion injury in rats

Objective To explore the protective effect of ozone oxidative preconditioning on hepatic ischemia reperfusion injury in rats. Methods Eighteen 8-week-old SPF Sprague-Dawley male rats weighting 250~300 g were randomly divided into three groups (n=6 each): sham operation group (group S), ischemia/reperfusion group (group I/R) and ozone oxidative preconditioning group (group O3+ I/R). In Group O3+ I/R, rats received five-day preconditioning treatments by intraperitoneal injection of ozone and oxygen mixed gases (ozone concentration 50 mg/L, 1 mg·kg-1·d-1), and then experienced the procedure of hepatic ischemia/reperfusion injury. Model of hepatic ischemia/reperfusion injury was established by clamping the branches of hepatic artery and portal vein in the median and left lateral hepatic lobes for 45 min, followed by 3-h reperfusion. After reperfusion, blood samples were taken from the aorta abdominalis for detecting serum aminotransferases (ALT & AST). These rats were executed and the hepatic tissue samples were collec-ted for measuring hepatic malondialdehyde (MDA) and superoxide dismutase (SOD) level. Results Compared with group S, concentrations of serum ALT, AST and hepatic MDA were increased in group I/R and O3+ I/R; concentrations of hepatic SOD were decreased (P<0.05) in group I/R, but concentration of hepatic SOD was increased in group O3+ I/R. Compared with group IR, concentrations of serum ALT, AST and hepatic MDA were decreased, while concentration of hepatic SOD was increased in group O3+ I/R (P<0.05). Conclusion Ozone oxidative preconditioning could inhibit the lipid peroxidation to protect the rats against hepatic ischemia/reperfusion injury. Key words: Ozone oxidative preconditioning; Ischemia/reperfusion injury; Liver

Neutral sphingomyelinase inhibition alleviates apoptosis, but not ER stress, in liver ischemia–reperfusion injury

Previous studies have revealed the activation of neutral sphingomyelinase (N-SMase)/ceramide pathway in hepatic tissue following warm liver ischemia reperfusion (IR) injury. Excessive ceramide accumulation is known to potentiate apoptotic stimuli and a link between apoptosis and endoplasmic reticulum (ER) stress has been established in hepatic IR injury. Thus, this study determined the role of selective N-SMase inhibition on ER stress and apoptotic markers in a rat model of liver IR injury. Selective N-SMase inhibitor was administered via intraperitoneal injections. Liver IR injury was created by clamping blood vessels supplying the median and left lateral hepatic lobes for 60 min, followed by 60 min reperfusion. Levels of sphingmyelin and ceramide in liver tissue were determined by an optimized multiple reactions monitoring (MRM) method using ultrafast-liquid chromatography (UFLC) coupled with tandem mass spectrometry (MS/MS). Spingomyelin levels were significantly increased in all IR groups compared with controls. Treatment with a specific N-SMase inhibitor significantly decreased all measured ceramides in IR injury. A significant increase was observed in ER stress markers C/EBP-homologous protein (CHOP) and 78 kDa glucose-regulated protein (GRP78) in IR injury, which was not significantly altered by N-SMase inhibition. Inhibition of N-SMase caused a significant reduction in phospho-NF-kB levels, hepatic TUNEL staining, cytosolic cytochrome c, and caspase-3, -8, and -9 activities which were significantly increased in IR injury. Data herein confirm the role of ceramide in increased apoptotic cell death and highlight the protective effect of N-SMase inhibition in down-regulation of apoptotic stimuli responses occurring in hepatic IR injury.

Intermittent ischemia enhances the uptake of indocyanine green to livers subject to ischemia and reperfusion

Intermittent ischemia is known to promote post perfusion bile flow, and hence recovery of liver function following ischemia reperfusion of the liver. However, the mechanisms involved are not well understood. The aim of this study was to identify the step(s) in the bile acid transport pathway altered by intermittent ischemia. Arat model of segmental hepatic ischemia in which the bilateral median and left lateral lobes were made ischemic by clamping the blood vessels was used. Indocyanine green (ICG), infrared spectroscopy, and compartmental kinetic analysis, were used to indirectly monitor the movement of bile acids across hepatocytes in situ. Rates of bile flow were measured gravimetrically. In control livers (not subjected to ischemia), the movement of ICG from the blood to bile fluid could be described by a three compartment model comprising the blood, a rapidly-exchangeable compartment, and the hepatocyte cytoplasmic space. In livers subjected to continuous clamping, the rates of ICG uptake to the liver, and outflow from the liver, were greatly reduced compared with those in control livers. Intermittent clamping (three episodes of 15 min clamping) compared with continuous clamping substantially increased the rate of ICG uptake from the blood but had less effect on the rate of ICG outflow from hepatocytes. It is concluded that intermittent ischemia promotes post reperfusion bile flow in the early phase of ischemia reperfusion injury principally by enhancing the movement of bile acids from the blood to hepatocytes.

Oral administration of cilostazol improves survival rate after rat liver ischemia/reperfusion injury

BackgroundCilostazol is a type III phosphodiesterase inhibitor used to treat the symptoms of intermittent claudication. Recent studies have shown that cilostazol decreases ischemia/reperfusion (I/R) injury in several organs. Materials and methodsWe evaluated the effects of cilostazol in a rat model of liver I/R injury. Thirty male Wistar rats with liver I/R injury were divided into a cilostazol or saline (control) group (n = 15 each). Each rat was orally administered cilostazol or saline for 3 d before I/R injury. Liver I/R injury was induced via 1 h of warm ischemia of the median and left lateral liver lobes, followed by 3 h of reperfusion. The rats were then euthanized. Serum aspartate aminotransferase, alanine aminotransferase, interleukin (IL)-1β, IL-6, and tumor necrosis factor-α levels were measured. The Mann–Whitney U test was used to compare the differences between the treatment groups. Histologic examination was performed on the liver tissues. We also conducted a survival study to confirm the effect of cilostazol on the mortality rate in rats. For the survival study, a liver I/R injury model with an ischemia time of 1.5 h was used, and the rats were observed for 1 wk. ResultsSerum aspartate aminotransferase, alanine aminotransferase, IL-1β, and IL-6 levels were significantly lower in the cilostazol group than in the saline group. Treatment with cilostazol significantly improved pathological findings associated with liver I/R injury and increased survival rate compared to that in controls. ConclusionsCilostazol reduced mortality and alleviated the effects of liver I/R injury in Wistar rats.

Deconstructing empathy: Neuroanatomical dissociations between affect sharing and prosocial motivation using a patient lesion model

Affect sharing and prosocial motivation are integral parts of empathy that are conceptually and mechanistically distinct. We used a neurodegenerative disease (NDG) lesion model to examine the neural correlates of these two aspects of real-world empathic responding. The study enrolled 275 participants, including 44 healthy older controls and 231 patients diagnosed with one of five neurodegenerative diseases (75 Alzheimer's disease, 58 behavioral variant frontotemporal dementia (bvFTD), 42 semantic variant primary progressive aphasia (svPPA), 28 progressive supranuclear palsy, and 28 non-fluent variant primary progressive aphasia (nfvPPA). Informants completed the Revised Self-Monitoring Scale's Sensitivity to the Expressive Behavior of Others (RSMS-EX) subscale and the Interpersonal Reactivity Index's Empathic Concern (IRI-EC) subscale describing the typical empathic behavior of the participants in daily life. Using regression modeling of the voxel based morphometry of T1 brain scans prepared using SPM8 DARTEL-based preprocessing, we isolated the variance independently contributed by the affect sharing and the prosocial motivation elements of empathy as differentially measured by the two scales. We found that the affect sharing component uniquely correlated with volume in right>left medial and lateral temporal lobe structures, including the amygdala and insula, that support emotion recognition, emotion generation, and emotional awareness. Prosocial motivation, in contrast, involved structures such as the nucleus accumbens (NaCC), caudate head, and inferior frontal gyrus (IFG), which suggests that an individual must maintain the capacity to experience reward, to resolve ambiguity, and to inhibit their own emotional experience in order to effectively engage in spontaneous altruism as a component of their empathic response to others.

Hepatic parenchymal transection increases liver volume but not function after portal vein embolization in rabbits

Associating liver partition with portal vein ligation for staged hepatectomy induces more extensive liver hypertrophy than ligation alone; however, the mechanisms underlying the accelerated liver regrowth and the functional quality of the hypertrophic liver are presently elusive. This study, therefore, investigated the effect of parenchymal transection on liver volume and function after portal vein embolization in a standardized rabbit model. Twelve rabbits were subjected to portal vein embolization of the cranial liver lobes and randomized between parenchymal transection of the left lateral liver lobe versus no transection (portal vein embolization only). Liver volume of the nonembolized liver lobe was assessed using computed tomography-volumetry, and liver uptake function was determined by 99mTc-mebrofenin hepatobiliary scintigraphy before and 3 and 7days after portal vein embolization. The increase in nonembolized liver volume 3days after portal vein embolization was 2.7-fold greater in the transected group compared with the portal vein embolization only group (56 ±16% vs 21 ±12%, respectively, P<.01) and 1.7-fold greater 7days after portal vein embolization (113 ±34% vs 68 ±24%, P<.01). Liver uptake function did not differ between groups before portal vein embolization (8.4 ±3.7%/min in the transection group vs 8.9 ±1.6%/min) on day 3 (33.2 ±4.7% after transection vs 30.3 ±4.6%/min, respectively) and day 7 after portal vein embolization (42.6 ±8.4% vs 39.1 ±5.3%/min, respectively). Parenchymal transection after portal vein embolization increases liver growth in terms of volume but not function. These results indicate that the rapid volume increase observed after associating liver partition with portal vein ligation for staged hepatectomy does not coincide with the clinically more relevant functional increase. Quantitative liver function tests might be essential in associating liver partition with portal vein ligation for staged hepatectomy to better assess the hypertrophy response and improve clinical decision-making.

An unusual case of adult-onset multi-systemic Langerhans cell histiocytosis with perianal and incident thyroid involvement.

SummaryLangerhans cell histiocytosis (LCH) is a rare sporadic disease characterized by histiocytic neoplastic infiltration of various organ systems and a wide spectrum of clinical manifestations, ranging from benign and self-limiting to lethal. Herein, we report a rare case of adult-onset multi-systemic LCH in a 36-year-old male patient with an initial perianal presentation and incidental finding of subsequent thyroid gland involvement in the follow-up period. The patient with a history of perianal LCH treated with surgical excision and local radiotherapy was referred to our Endocrinology Department upon detection of hypermetabolic nodular lesions in the left lateral lobe of thyroid gland on positron emission tomography–computed tomography (PET/CT) scan in the nineth month of follow-up. Current evaluation revealed euthyroid status, a hypoechoic solid lesion of 13 × 9 mm in size with irregular borders in the left thyroid lobe on thyroid USG and cytologic assessment of thyroid nodule. The patient was diagnosed with suspected, oncocytic lesion, Hashimoto thyroiditis or LCH. The patient underwent total thyroidectomy and pathological assessment confirmed the diagnosis of Langerhans cell histiocytosis. Assessments in the sixth month of postoperative follow-up revealed euthyroid status with no thyroid tissue remnants or pathological lymph node on thyroid USG. In view of the multifocal lesions indicating multi-system disease, a systemic chemotherapy protocol with combination of prednisone (PRED) and vinblastine (VBL) has been planned by the hematology department.Learning points:Langerhans cell histiocytosis (LCH) shows a wide clinical spectrum and prognosis that ranges from benign and self-limiting single-system disease (with single or multifocal lesions) to a potentially lethal multi-system disease with severe organ dysfunction and death in some cases.It has been stated that the diagnosis is often delayed in perianal LCH unless LCH is specifically considered in the etiology, despite the fact that mucosal involvement may precede systemic involvement.Our findings support the statement that most of patients with LCH were PET positive at the time of initial diagnosis, while also emphasize the inclusion of this imaging modality as a part of the diagnostic workflow as well as in the setting of treatment response evaluation among adult LCH patients.

同期三镜、扩张导管、气囊鼻胆管治疗肝左外叶及胆总管结石26例

目的：探讨同期三镜(腹腔镜、胆管镜、十二指肠镜)、扩张导管(逐级扩张导管、球囊导管)、气囊鼻胆管(LCDND)治疗肝左外叶及胆总管结石的应用体会。方法：回顾性分析成都市第二人民医院2011年3月至2017年9月期间，符合入选标准的26例患者的临床资料。结果：腹腔镜下切除肝左外叶和探查胆总管胆管镜取石26例，切除胆囊15例。逐级导管扩张左肝管和乳头并留置气囊鼻胆管65.5% (17/26)，逐级导管扩张左肝管和推挤左肝管结石出总管切口并留置气囊鼻胆管11.5% (3/26)，逐级导管联合球囊导管扩张左肝管并留置气囊鼻胆管3.8% (1/26)，逐级导管扩张左肝管和乳头、十二指肠镜行乳头小切开或微切开并留置气囊鼻胆管11.5% (3/26)，逐级导管扩张左肝管后因肝内胆管残石并腹腔镜下留置T管7.7% (2/26)。鼻胆管引流术后无残石，胆汁漏2例(7.7%)，轻症胰腺炎1例(3.8%)。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症，无围手术期再次手术和死亡患者。术后总并发症发生率为11.5% (3/26)。结论：从本研究对本医院有限病例进行初步研究发现，只要病例选择合适，LCDND治疗肝左外叶及胆总管结石是可行、有效和安全的。 Objective: To explore the surgical technique and clinical effect of laparoscopy, choledochoscopy, duodenoscopy, dilatable catheter and balloon nasobiliary drainage (LCDND) of the corresponding period for the treatment of the left lateral lobe hepatic duct and common bile duct stones during the course of therapeutic laparoscopy. Methods: The clinical data of 26 cases of the left lateral lobe hepatic duct and common bile duct stones undergoing LCDND were analyzed retrospectively from March 2011 to September 2017 in the Second People’s Hospital of Chengdu. Results: It was in 26 cases removed the left hepatic lateral lobe and exploration of common bile duct and in 15 cases removed the gallbladder by laparoscopy. Through the duct incision with choledochoscopy to remove gallstones, step by step dilatable catheter expanded left hepatic duct and duodenal papilla and indwelling balloon nasobiliary was in 65.5% (17/26); push the stones into the common hepatic duct in 11.5% (3/26); step by step dilatable catheter combining balloon catheter expanded left hepatic duct and duodenal papilla and indwelling balloon nasobiliary was in and 3.8% (1/26); step by step dilatable catheter expanded left hepatic duct and duodenal papilla and duodenoscopic papillary sphincterotomy of micro incision or small incision, and indwelling balloon nasobiliary was in 11.5% (3/26); via choledochoscopic examination indwelling T shape tube drainage due to residual stone of the intrahepatic bile duct in 7.7% (2/26). Residual stone was not occurred after the nasobiliary drainage. Bile leakage was cured in two cases (7.7%). One patient (3.8%) was a slight pancreatitis. No cases had perforation of intestine and bile duct, bleeding, severe pancreatitis. No perioperative reoperation and death. Total postoperative complication formation rate was in 11.5% (3/26). Conclusion: From preliminary results of limited cases in this study in our hospital, if patients are suitable, LCDND for treatment of the left lateral lobe hepatic duct stones and common bile duct stones, it is safe and effective.

Neuropsychiatric symptoms and PET imaging characteristics in patients with Parkinson-plus syndromes

Objective To explore the neuropsychiatric symptoms and 18 F-fluoro-2-deoxy-D-glucose ( 18 F-FDG) PET imaging features of Parkinson-plus syndromes. Methods There were 8 patients with probable Parkinson-plus syndromes, including one case of multiple system atrophy-cerebellar predominant (MSA-C), 4 cases of progressive supranuclear palsy (PSP), one case of corticobasal ganglionic degeneration (CBD) and 2 cases of dementia with Lewy bodies (DLB). Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to evaluate cognitive function, Neuropsychiatric Inventory (NPI) was used to evaluate neuropsychiatric behaviors, and Hamilton Depression Rating Scale-21 Items (HAMD-21) was used to evaluate the emotional state of patients. Results One MSA-C patient showed only anxiety. Four PSP patients showed different degrees of cognitive disorders, of whom 3 cases also presented obvious depression, anxiety, irritability and sleep disorders. One case of CBD showed dysfunction in executive function, visual spatial ability, verbal function, attention and orientation, as well as depression, anxiety, irritability and sleep disorders. Two cases of DLB were found unable to copy pentagon in MMSE chart or draw a circle in Clock Drawing Test (CDT), and they also presented hallucination, depression and indifference. As for the result of 18 F-FDG PET, one MSA-C patient showed cerebellarglucose hypometabolism; 4 PSP patients showed hypometabolism in bilateral symmetrical frontal lobes, anterior cingulate gyrus and parietal lobe, especially in thalamus, basal ganglia region and brain stem; one case of CBD showed hypometabolism in right lateral fronto-temporo-parieto-occipital lobes, left lateral parietal lobe, bilateral cingulate gyri and precuneus; 2 cases of DLB showed hypometabolism in bilateral temporo-occipital lobes. Conclusions Patients with early Parkinson-plus syndromes are easily misdiagnosed as mental illness and delayed treatment, in addition, their movement disorders and extrapyramidal symptoms would be aggravated due to misusage of sedative hypnotic drugs. Neuropsychological changes are found closely related to cognitive dysfunction. PET imaging has important clinical values to early diagnosis of Parkinson-plus syndromes. DOI: 10.3969/j.issn.1672-6731.2017.01.008

Immune and Inflammatory Responses of the Intestinal Mucosa following Extended Liver Radiofrequency Ablation.

Background and Aim Extended liver radiofrequency ablation (RFA) has been shown to disrupt gut barrier integrity with subsequent bacterial translocation. The aim of the present project was to study the immune and inflammatory responses of the intestinal mucosa after extended RFA of the liver. Methods Twelve Wistar rats were either subjected to RFA of the left lateral hepatic lobe (approximately 30% of the liver mass) after midline laparotomy (group RFA, n = 6) or sham operation (group Sham, n = 6). Forty-eight hours later, ileal tissue specimens were excised for immunohistochemical assessment of CD68+ macrophages, CD4+ T-lymphocytes, CD8+ T-lymphocytes, mucosal addressin cell adhesion molecule-1 (MAdCAM-1), tumor necrosis factor-α (TNFα), interleukin-6 (IL-6), and nuclear factor-κB (NFκB) expression. Results Immune response biomarkers were upregulated in the RFA group. Expression of CD4+ and CD8+ T-lymphocytes was moderate, while that of CD68+ macrophages and MAdCAM-1 was high. Inflammatory response biomarkers were also upregulated in the RFA group. TNFα, IL-6, and NFκB expression was low, moderate, and high, respectively. Conclusions Extended liver RFA evokes both immune and inflammatory responses of the gut mucosa.

Feasibility and Technique for Transvaginal Natural Orifice Transluminal Endoscopic Surgery Liver Resection: A Porcine Model.

Introduction:Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).Materials and Methods:Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.Results:Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.Conclusions:Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.