Segment VII Research Articles

Adrenal rest tumour of the liver

A 58-year-old man with chronic hepatitis B and HIV co-infection nderwent abdominal ultrasound for liver cancer screening. A 5 mm focal hypoechoic lesion was discovered in segment VII. Liver unction tests and tumour markers levels ( -fetoprotein, CEA, ca 9.9) were normal. On contrast abdominal computed tomography he mass was enhanced heterogeneously in the arterial phase with inimal washout in the portal and delayed phases. On superparaagnetic iron oxide-enhanced magnetic resonance imaging the esion appeared to be slightly hypointense on T1 (Fig. 1A), hyperntense on T2 fat suppression and clearly hypervascular in the rterial phase (Fig. 1B). Based on the radiological findings and the linical history a diagnosis of hepatocellular carcinoma (HCC) was

Biliary Fistula Treated with Endoscopic Therapy in Amoebic Liver Abscess with Cirrhosis

Large amoebic liver abscess is treated with either needle aspiration or percutaneous catheter drainage. Biliary communication of amoebic liver abscess has been reported in up to 27% of cases. Biliary fistula suspected by presence of bile in percutaneous draining catheter and confirmed by endoscopic retrograde cholangiopancreatography. Endoscopic therapy with sphincterotomy and biliary stent placement appears to be an effective mode of treatment for biliary fistulas complicating liver abscesses. Liver abscess is rare in cirrhosis. Here we are reporting a case of amoebic liver abscess with biliary fistula in a chronic liver disease patient which was managed with biliary sphincterotomy and biliary stent placement. A 45 Year old male alcoholic presented with fever of 1 week duration, right hypochondriac pain, abdominal distention and breathlessness. Abdominal examination revealed tenderness over the intercostal region and right hypochondriac area with mild ascites and right-sided pleural effusion. Investigations revealed neutrophilic leukocytosis (43,900cells/mm3) with elevated liver enzymes (SGOT: 102 U/L, SGPT: 169 U/L), alkaline phosphatase (649 U/L), ultrasound abdomen suggestive of coarsened echo texture of liver with surface irregularity and also liver abscess of size about 9.8 × 8.7 cms in segment VII of liver. He was also incidentally detected HBsAg positive. Ascitic fluid analysis suggestive of high SAAG, culture showed no growth of organisms. Blood culture was sterile. Hence diagnosed as cirrhosis with liver abscess. Patient was started on intravenous metronidazole and pipercillin and tazobactum. In view of large abscess and persistent symptoms percutaneous pigtail catheter placed into the liver abscess, anchovy sauce colored pus drained out. After few days of pigtail placement, bile was draining out of the catheter. Suspected biliary fistula, tubogram revealed communication between abscess and biliary radicles. Patient was treated conservatively for 1 month, but still bile was draining out of the catheter. Biliary sphincterotomy done and common bile duct stent was placed. Drain from percutaneous catheter decreased <10 ml per day and percutaneous catheter removed. Patient was doing well and discharged. Follow up did not show any recurrence of abscess.

A Rare Finding on Liver Explant

A55-year-old man with nonalcoholic fatty liver disease, refractory ascites, and hepatic encephalopathy after placement of a transjugular intrahepatic portosystemic shunt was referred for liver transplantation. He was placed on the transplantation waiting list in October 2009. Magnetic resonance imaging performed in March 2010 identified a 2.0-cm lesion concerning for hepatocellular carcinoma (HCC) in segment VII. Transarterial chemoembolization (TACE) was performed. Recurrence at the periphery of the post-TACE cavity occurred 1 year after the initial TACE, which was treated with stereotactic body radiation therapy. Two years later, a new 3.0-cm lesion in the caudate lobe was identified. Because the patient was near the top of the transplant waiting list, treatment was differed. On October 4, 2013, the patient underwent orthotopic liver transplantation. The surface of the explanted liver was firm and micronodular. A 3.0-cm, well-circumscribed HCC was present in the caudate lobe. Inspection of the previously treated HCC in segment VII showed dense fibrosis and a 1.2-cm, firm, irregular, white nodule (Figure A). Microscopy showed spindle cells and multinucleated tumor adjacent to TACE microspheres, (Figure B) with frequent mitoses (Figure C). This lesion was consistent with sarcomatoid HCC. Conventional HCC with clear cell morphology was noted next to the sarcomatoid HCC at the region of previous TACE and stereotactic body radiation therapy (Figure D). Sarcomatoid HCC is a rare entity, found in approximately 2% of surgical cases and up to 9.4% of autopsy cases. The incidence of sarcomatoid HCC has increased over the past 3 decades coincident with increasing use of nonsurgical anticancer therapies such as TACE,

The wax glands and wax secretion of Matsucoccus matsumurae at different development stages

In this paper, the wax secretions and wax glands of Matsucoccus matsumurae (Kuwana) at different instars were investigated using light microscopy, scanning electron microscopy and transmission electron microscopy. The first and second instar nymphs were found to secrete wax filaments via the wax glands located in the atrium of the abdominal spiracles, which have a center open and a series of outer ring pores. The wax gland of the abdominal spiracle possesses a large central wax reservoir and several wax-secreting cells. Third-instar male nymphs secreted long and translucent wax filaments from monolocular, biolocular, trilocular and quadrilocular pores to form twine into cocoons. The adult male secreted long and straight wax filaments in bundles from a group of 18–19 wax-secreting tubular ducts on the abdominal segment VII. Each tube duct contained five or six wax pores. The adult female has dorsal cicatrices distributed in rows, many biolocular tubular ducts and multilocular disc pores with 8–12 loculi secreting wax filaments that form the egg sac, and a rare type wax pores with 10 loculi secreting 10 straight, hollow wax filaments. The ultrastructure and cytological characteristics of the wax glands include wax-secreting cells with a large nucleus, multiple mitochondria and several rough endoplasmic reticulum. The functions of the wax glands and wax secretions are discussed.

Peritoneal carcinomatosis secondary to spread of hepatocellular carcinoma originated upon a healthy liver

This is a female, 34 years, who presented with pain at the right iliac fosse and pre-syncopal symptoms. As background, she has undergone a right ovarian cystectomy due to a serous cystadenoma several years ago and appendectomy. At physical examination she had signs of peritoneal irritation and heterogeneous free fl uid was detected on ultrasound, suggesting hemoperitoneum, so urgent laparotomy was decided. A peripheral liver tumor was seen in segment VII, it was partially removed and pathological diagnosis was hepatocellular carcinoma (HCC). At that time, liver function tests and alpha-fetoprotein were within normal limits and hepatitis B and C virus serology were negative. The patient was moved to a referral centre, where a triphasic liver CT and MR-angiography (Fig. 1) were performed. small remaining tumor was observed within segment VII of the liver, without distance disease, so a formal resection of segment VII was made. The specimen showed a grade II HCC, 20 mm of diameter, with a satellite 1 mm away, without vascular invasion (Fig. 3A). No systemic or local therapy as secondary prophylaxis was administered. The fourth-month follow-up control showed multiple peritoneal implants

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Introduction: Transcatheter arterial chemoembolization (TACE) is commonly performed for postoperative recurrence of hepatocellular carcinoma (HCC). The most common extrahepatic collateral that feed HCC is the inferior phrenic artery and therefore is a common target for embolization. We report a case of acute respiratory failure secondary to ischemic diaphragmatic paralysis immediately following embolization of the phrenic artery. A 76-year-old man with recurrent HCC had an elective outpatient TACE. He was diagnosed with an enlarging lesion on the dome of the liver 6 years after a segment VII resection. Angiography demonstrated the phrenic artery feeding the lesion. Embolization was performed and the patient developed severe right shoulder pain, associated with tachycardia, diaphoresis and shortness of breath. On exam, the patient demonstrated use of accessory muscles, and thoraco-abdominal paradoxical movement. CXR showed right hemi-diaphragm elevation. ABG revealed a pH of 7.26 and PaCO2 of 66 mmHg. The patient was intubated secondary to acute respiratory failure. Due to his neurologic alertness and hemodynamic stability he was extubated to NIPPV. Bedside ultrasonography of the diaphragms revealed right diaphragm paralysis with minimal thickening on inspiration (Thickness at FRC = 3.36mm and at TLC = 3.62mm). NIMV with Bilevel positive pressure corrected his respiratory symptoms, but we were not able to wean him off due to severe respiratory distress. The patient was transitioned to a sip and puff ventilator for daytime ventilation and continued on NIV as needed at night. He rapidly recovered with the NIV, IPPV, and extensive physical therapy. A repeat ultrasound of the diaphragm 2 weeks after the initial insult demonstrated a 22% improvement in the right hemi-diaphragm excursion. TACE causing diaphragmatic paralysis leading to acute respiratory failure has never been reported. On review of the angiography, the inferior diaphragmatic artery branched from the phrenic artery, thus the TACE caused severe diaphragm ischemia. Our case highlights ischemia as a cause of diaphragm dysfunction and the use of ultrasonography for rapid diagnosis in the critical care setting.

Problème diagnostique posé par une lésion hépatique hypermétabolique en TEP à la fluorocholine (18F) : à propos d’un cas

IntroductionWe report a case of atypical fluorocholine (18F) PET/CT hypermetabolic hepatic lesion discovered during the staging of a prostate carcinoma. Case reportBecause of elevated PSA serum level, the patient had prostate biopsies which elicited an adenocarcinoma with a Gleason score of 8 (4+4). Pelvic MRI did not display any extracapsular disease extension. The PET/CT scan demonstrated a prostatic focal uptake and a liver increased uptake area matching with a segment VII hepatic nodule measuring 25mm within a fatty liver, which was hypometabolic on the PET scan and hypodense on the CT scan. The liver ultrasound study reported the lesion as a focal spared area of healthy liver tissue within steatosis, whereas MRI diagnostic conclusion was inflammatory hepatocellular adenoma. When asking the patient, it appeared that the hepatic nodule had been known for 7years, its size was unchanged, and, from previous radiologic imaging, it had been considered as an adenoma. However, there was no histological proof. DiscussionIn the interpretation of the PET/CT scan findings, we excluded a hepatocellular carcinoma and a prostate metastasis due to the long period of time during which the nodule had been followed up without significant change. We thought that focal nodular hyperplasia, which is fluorocholine avid, was the most likely diagnosis, knowing that hepatocellular adenomas, including the inflammatory type, have not been reported to display increased fluorocholine uptake. We noticed that the patient's fatty liver uptake was low, which could have accounted for a falsely increased uptake by the nodule. But, similarly to other authors, we could not find any relationship between CT density and fluorocholine uptake. ConclusionThis case shows a discrepancy between the radiologic and nuclear medicine findings. However, this hepatic nodule is likely to be benign because of the lesion characteristics and the patient medical history.

Description of a New Species ofTuberaleyrodes(Hemiptera: Aleyrodidae) from China

ABSTRACT Tuberaleyrodes lauri Dubey and Wang new species (Hemiptera: Aleyrodidae) is described from China on Cinnamomum subavenium (Laurales: Lauraceae). The puparium of the new species differs from that of all other Tuberaleyrodes species by the presence of 6 to 8 pairs of subdorsal setae placed on long elevated tubercles, 8 pairs of small submarginal setae, an operculum that completely covers the orifice and reduced median length of abdominal segment VII. An identification key to puparia of the Tuberaleyrodes species is provided.

Dicerapanorpa, a new genus of East Asian Panorpidae (Insecta: Mecoptera: Penorpidae) with descriptions of two new species

Dicerapanorpa gen. nov. is erected with Panorpa magna Chou as its type species. The genus is recognizable by the following characters: body yellowish with two blackish lateral longitudinal stripes on dorsum; tergum VI of males with two anal horns; abdominal segment VII of males much thinner at the basal half and abruptly thicker at apical half; parameres of males trifurcate; female genital plate with the axis not extending beyond the main plate. Six new combinations, Dicerapanorpa magna (Chou in Chou et al., 1981), D. diceras (MacLachlan, 1894), D. stotzneri (Esben-Petersen, 1934), D. tjederi (Carpenter, 1938), D. kimminsi (Carpenter, 1948) and D. triclada (Qian and Zhou, 2001) are transferred from Panorpa Linnaeus. Dicerapanorpa baiyunshana sp. nov. and Dicerapanorpa shennongensis sp. nov. are described and illustrated. A key to the genera of Panorpidae is updated to include the new genus. A key to the species of Dicerapanorpa gen. nov. is also presented.http://www.zoobank.org/urn:lsid:zoobank.org:pub:F50E44C3-7275-4EC8-B048-4C7B2C6D57EF

Normal liver anatomy.

Normal liver anatomy.

Two hepatic abscesses of biliary origin: interest of echography

The annual incidence of non-parasitic liver abscess is low with 2.3 per 100 000. The biliary abscesses are usually secondary to biliary obstruction; with gallstones is by far the most common. In ultrasound, the early phase: abscess may appear hyperechoic, the liquefaction phase: anechoic with internal echoes, contours are usually irregular. The treatment of abscess hepatic are based on the puncture echo guided, and by broad-spectrum antibiotics guided by susceptibility of germ, surgical treatment is reserved for failures puncture, if not endoscopic sphincterotomy. We report a woman aged 85 years, coronary heart disease followed for his five years with ejection fraction 35%, cholecystectomized seven years ago, admitted to the ICU for fever, pain right upper quadrant. Abdominal ultrasound showed a dilated principal bile duct to 1.7 cm diameter with gallstone a 1.8/1.7cm, two liver images: segment VII and V with 6.1/5cm and 6.3/5.6 cm diameter, fuzzy aspects, without clear boundary with the liver parenchyma, with an anechoic center associated with some hyperechoic image in favor of liquefaction abscess stage, of biliary origin. Amoebic serology was negative. The drainage echo guided was made with empirical antibiotic, and guided after by a susceptibility which the germ was a streptococcus. The patient was referred for possible endoscopic sphincterotomy after seven days, given the high anesthetic risk for surgical drainage of the bile duct.

Robotic Liver Resection for Colorectal Cancer Metastases: A Feasible and Safe Procedure

Introduction: This study employs a video on surgical techniques to present the author's experience in the use of the Da Vinci Surgical System in robotic hepatic resections.1 Description of the Video: 00:50—The patient is placed in a supine, reversed Trendelenburg position. A pneumoperitoneum is then created by introducing a Veress needle into the right hypochondrium. A 12-mm trocar, for the robotic camera, is positioned in the right paraumbilical region. The three 8-mm robotic ports are inserted, respectively, into the epigastrium, right hypochondrium, and left subcostal region. A 12-mm extra-port for accessory surgical instruments controlled by the assistant surgeon is placed at the umbilicus. 1:38—The exploration of the hepatic parenchyma reveals a repetitive hepatic lesion, approximately 40 mm in diameter, at segment VII protruding from the Glissonian. 2:40—The right lobe of the liver is mobilized by a section of the right coronary ligament. 3:05—The resection of hepatic segment VII can proceed, using ultrasonic scalpels, along the ischemic demarcation line, beginning at the anterior border of the liver. The exposure of the portion of parenchyma to be resectioned is obtained using polypropylene stitches placed at the left resection margins and used for traction by the instrument's fourth arm. 4:24—Hemostasis of any minor bleeding can be carried out using bipolar cautery, while major bleeds are dealt with using selective stitches of polypropylene 4/0. 6:12—A check is then carried out on the hemostasis and biliostasis. 6:30—Having completed the procedure, the operated section is extracted by means of an endocatch by slightly increasing the widening of the operational trocar access. 6:42—The Jackson drain will be positioned close to the slice of hepatic section. The disconnection of the robotic arms and deflation now take place. Finally, the mini-incisions are sutured. Materials and Methods: A 68-year-old man had previously undergone anterior rectal resection for cancer. During the oncology follow-up, computed tomography scan revealed the onset of a repetitive lesion in segment VII of the liver. A hepatic resection with the aid of the Da Vinci robotic surgical system was performed. The Da Vinci Surgical System is a telerobotic device controlled from a surgeon at remote console, while the surgical team is close to the operating table and follows the procedure through a service screen.2 Results and Conclusion: Estimated intraoperative bleeding was 90 mL, and no blood transfusions were necessary in the perioperative period. The operative time was 150 minutes. There was no postoperative morbidity, and the hospital stay was 3 days. The hystopathological examination of the portion of parenchyma removed (90 × 60 × 45 mm), perfectly contained the nodule measuring 45 × 31 mm with ample-free resection margins. This confirmed the radical solution of the robotic approach adopted. The follow-up was 18 months with disease-free survival. Even if comparative studies are necessary to demonstrate real advantages of the robotic approach with respect to classic laparoscopy, the Da Vinci Surgical System allows a large tridimensional field of view, a steady traction, tremor suppression, flexibility of the instruments, and offers improved dexterity with an internal articulated EndoWrist that permits seven degrees of freedom and therefore execution of precise and safe dissection of tissue and sutures.3,4 The authors state that none of the authors involved in the manuscript preparation has any conflicts of interest toward the manuscript itself, neither financial nor moral conflicts. Besides, none of the authors received support in the form of grants, equipment, and/or pharmaceutical items. Runtime of video: 7 mins

Three-Dimensional Staining of Liver Segments with an Ultrasound Contrast Agent as an Aid to Anatomic Liver Resection

complex3-dimensional(3-D)shape. 11-13 Inaddition,there are no anatomic landmarks indicating the positions of the borders between segment V and segment VIII or between segment VI and segment VII. Therefore, some additional means of identifying the actual shapes and intrahepatic positions of the segmental borders is needed to facilitate precise anatomic resections of the liver. In this study, we assessed a simple, novel technique for visualizing the 3-D shapes of liver segments by using a second-generation ultrasound contrast agent, Sonazoid (Daiichi Sankyo Pharmaceutical Co Ltd).

All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation

ObjectivesThis paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT). MethodsA patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17mm); one segment VII HV (11mm); two segment VI HVs (6mm and 16mm), and three segment V HVs. The graft weighed 663g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6–0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch. ResultsOverall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs. ConclusionsAll-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.

Clinical application of laparoscopic hepatectomy

Objective To investigate the indications, techniques and results of laparoscopic hepatectomy. Methods The clinical data and follow-up results of 463 patients who received laparoscopic hepatectomy at our institute were retrospectively analyzed. Results From March 1, 2007 to March 31, 2011, 463 cases of laparoscopic hepatectomy were successfully carried out. Of the 463 patients,165 were with primary liver cancer, 29 with metastatic liver cancer, 143 with hepatic hemangioma, 81with hepatolithiasis and 45 with other benign liver diseases (including hepatic angiomyolipoma, hepatocellular adenoma, focal nodular hyperplasia and chronic liver abscess). The surgical approaches included laparoscopic left lateral lobectomy (93 cases), left hepatectomy (71 cases), extended left hepatectomy (4 cases), right hepatectomy (29 cases), right posterior lobectomy (24 cases), hepatectomy of segment Ⅵ (56 cases), extended right hepatectomy (2 cases), central hepatectomy (8 cases) and hepatectomy of segments Ⅶ/Ⅷ, Ⅳa, caudate lobe and the junction of segment Ⅵ and Ⅶ (41 case).Nonanntomic and wedge resection were performed on 121 patients, and combined resection on 14 patients. The mean operation time, blood loss, length of hospital stay and incidence of postoperative complications were (244.71 ± 105. 07) minutes, (460. 26±425.81) ml, (15.51 ±4.36) days and 9.29%, respectively. And no operative death occurred. In the 194 cases with malignant liver lesions,185 cases were followed up for 2 to 50 months. The 1 year and 3 year overall and disease free survival rate were 90. 8% and 87.9% , 84.2% and 73. 7% respectively. Conclusions As a means of minimally invasive surgical approach, laparoscopic hepatectomy can be selectively adopted for the treatment of all kinds of liver diseases which located at different parts of the liver, with the advantages of smaller trauma, quick recovery and cosmetic benefits. The short-term results of laparoscopic hepatectomy is superior to and its long-term results is equal to that of open surgery. Benign liver diseases, small hepatocellular carcinoma and metastatic liver cancer are the good indications for laparoscopic hepatectomy. Key words: Laparoscopy; Hepatectomy; Liver neoplasmas; Hepatolithiasis

A substrate translocation trajectory in a cytoplasm‐facing topological model of the monocarboxylate/H+ symporter Jen1p

Previous mutational analysis of Jen1p, a Saccharomyces cerevisiae monocarboxylate/H⁺ symporter of the Major Facilitator Superfamily, has suggested that the consensus sequence ³⁷⁹NXX[S/T]HX[S/T]QD³⁸⁷ in transmembrane segment VII (TMS-VII) is part of the substrate translocation pathway. Here, we rationally design, analyse and show that several novel mutations in TMS-V and TMS-XI directly modify Jen1p function. Among the residues studied, F270 (TMS-V) and Q498 (TMS-XI) are critical specificity determinants for the distinction of mono- from dicarboxylates, and N501 (TMS-XI) is a critical residue for function. Using a model created on the basis of Jen1p similarity with the GlpT permease, we show that all polar residues critical for function within TMS-VII and TMS-XI (N379, H383, D387, Q498, N501) are perfectly aligned in an imaginary axis that lies parallel to the protein pore. This model and subsequent mutational analysis further reveal that an additional polar residue facing the pore, R188 (TMS-II), is irreplaceable for function. Our model also justifies the role of F270 and Q498 in substrate specificity. Finally, docking calculations reveal a 'trajectory-like' substrate displacement within the Jen1p pore, where R188 plays a major dynamic role mediating the orderly relocation of the substrate by subsequent H-bond interactions involving itself and residues H383, N501 and Q498.

Cyst in the liver and cough with copious purulent sputum

A 40-year-old woman presented with a history of pain in the right lower chest, fever and cough with purulent sputum in the previous 20 days. She was treated for a presumed lower respiratory tract infection and her fever subsided, but she continued to produce 400-500 mL of purulent sputum daily, which was blood-tinged on two occasions. Her past medical history was unremarkable. On examination she was pale and afebrile; pulse and blood pressure were normal. Local examination of the chest with palpation and auscultation revealed reduced breath sounds in the right infrascapular region, with some crepitations. Abdominal examination found an enlarged liver. Blood investigations revealed a hemoglobin of 9 g/dL and a white blood cell count of 14×109/L with 10% eosinophils. Serum bilirubin, alkaline phosphatase and transaminase levels were normal. Chest x-ray showed an elevated right hemidiaphragm and right lower zone consolidation; no air fluid level or pleural effusion was seen. Abdominal ultrasonography revealed a right lobe liver cyst with internal echoes inside and wall calcification. The patient was further evaluated by contrast-enhanced multidetector-row CT (MDCT) on a 64-detector row CT. Transverse CT through the chest showed soft issue attenuation due to consolidation in the lower lobe of right lung involving lateral basal, medial basal and posterior basal segments with rounded and elongated fluid attenuation areas within it (Figure 1). CT images through the upper abdomen showed a cystic mass in segment VII of liver with a focus of air attenuation in it anteriorly (Figure 2). The cyst wall showed curvilinear calcification; bile ducts were not dilated.

Laparoscopic liver resection for benign and malignant liver tumors

Laparoscopic liver resection is one of the most complex procedures in hepatobiliary surgery. In the last two decades, laparoscopic liver surgery has emerged as an option at major academic institutions. The purpose of this study is to describe the initial experience of minimally invasive liver resections at a non-academic institution. We retrospectively reviewed medical records of patients undergoing laparoscopic liver resections between June 2006 and December 2009 at our center. Indications, technical aspects, and outcomes of these patients are described. Laparoscopic liver resection was attempted in 28 patients. Of these, 27 patients underwent laparoscopic liver resection (22 total laparoscopic and 5 hand assisted) and one needed conversion to open surgery. Twenty patients had a benign lesion and 8 had malignant lesions. Three patients had multiple lesions in different segments requiring separate resections. The lesions were located in segments II-III (n=18), IV (n=3), V-VI (n=9), and VII (n=1). Tumor size ranged from 1.5 cm to 8.5 cm. The surgical procedures included left lateral sectionectomy (n=17), left hepatectomy (n=2), sectionectomy (n=8), and local resections (n=4). Median operative time was 110 minutes (range 55-210 minutes), and the median length of hospital stay was 2.5 days (range 1-7 days). There was no perioperative mortality. One patient developed hernia at the site of tumor extraction requiring repair at 3 months. Laparoscopic liver resections can be safely performed in selected patients with benign and malignant liver tumors. With increasing experience, laparoscopic liver resections are likely to become a favorable alternative to open resection.

Identification of a Substrate Translocation Trajectory in the Inward-Facing Conformation of the Monocarboxylate/H+ Symporter Jen1

Previous mutational analysis of Jen1p, a Saccharomyces cerevisiae monocarboxylate/H+ symporter of the Major Facilitator Superfamily, has suggested that the consensus sequence 379NXX[S/T]HX[S/T]QD387, located in transmembrane segment VII (TMS-VII), is part of the substrate translocation pathway. In this work, we rationally design and analyse novel mutations concerning residues in TMS-V and TMS-XI. Our analysis identifies several residues critical for Jen1p function. Among these, F270 (TMS-V) and Q498 (TMS-XI) function as specificity determinants for the distinction of mono- from di-carboxylates, whereas N501 is irreplaceable for function. Using a novel theoretical model created on the basis of Jen1p similarity with GlpT permease, we demonstrate that all polar residues in TMS-VII and TMS-XI, shown previously and herein to be critical for function and/or specificity (N379, H383, D387, Q498, N501), are perfectly aligned in a row along an imaginary axis that lies parallel to a protein pore. The model also predicts that the flexible side-chain of an additional polar residue, R188 in TMSII, faces the pore and subsequent mutational analysis showed that this aminoacid, similar to most polar residues of the pore, is irreplaceable for function. Finally, our model shows that the location of F270 and Q498 could justify their role in substrate specificity. Independent substrate docking approaches reveal a ‘trajectory-like’ displacement of the substrate within the Jen1p pore. In this inward-facing trajectory the flexible side-chain of R188 plays a major dynamic role mediating the orderly relocation of the substrate by subsequent H-bond interactions involving itself and residues H383, N501 and Q498.

Cowden syndrome complicated with hepatocellular carcinoma possibly originating from non‐alcoholic steatohepatitis (NASH)

There is currently no report that has documented hepatocellular carcinoma (HCC) in a case of Cowden syndrome. Here, we present the first reported case of HCC in a 60-year-old female patient with Cowden syndrome. We diagnosed the patient using a pathognomonic criterion of the International Cowden Consortium Operational Diagnostic Criteria and performed genetic analysis. Enhanced computed tomography demonstrated a hypervascular tumor in segment VII of the liver. The patient was diagnosed with Cowden syndrome because her mucocutaneous lesions met the pathognomonic criterion. Mutational analysis confirmed a heterozygous germ line TGT→TAT transition at nucleotide 407 in exon 5 of the phosphatase and tensin homolog detected on the chromosome 10 (PTEN) gene. Needle biopsy showed a poorly differentiated HCC. We also diagnosed non-alcoholic steatohepatitis (NASH) from hepatic histological findings of Mallory's bodies and ballooning cells. PTEN-deficient mice reportedly develop HCC through NASH. This is the first reported case of Cowden syndrome complicated with HCC possibly originating from NASH.