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Low skeletal muscle, referred to as sarcopenia, has been shown to be an independent predictor of lower overall survival in various kinds of diseases. Several studies have evaluated the low skeletal muscle mass using computed tomography (CT) imaging. However, the cutoff values based on CT imaging remain undetermined in Asian populations. Preoperative plain CT imaging at the third lumbar vertebrae level was used to measure the psoas muscle mass index (PMI, cm2/m2) in 541 adult donors for living donor liver transplantation (LDLT). We analyzed PMI distribution according to sex or donor age, and determined the sex-specific cutoff values of PMI to define low skeletal muscle mass. PMI in men was significantly higher than observed in women (8.85 ± 1.61 cm2/m2 versus 5.77 ± 1.21 cm2/m2; P < 0.001). PMI was significantly lower in individuals ≥50 y than in younger donors in both men and women (P < 0.001 and P < 0.001, respectively). On the basis of the younger donor data, we determined the sex-specific cutoff values for the low skeletal muscle mass were 6.36 cm2/m2 for men and 3.92 cm2/m2 for women (mean − 2 SD). Data from healthy young Asian adults were used to establish new criteria for low skeletal muscle mass that would be applicable for defining sarcopenia in Asian populations. •Low muscle mass is an independent predictor of poor survival in various diseases.•We investigated the psoas muscle mass index (PMI) using computed tomography imaging in 541 healthy adults in Japan.•PMI was significantly lower in women and in individuals ≥50 y.•We established the sex-specific cutoff values of PMI to define low muscle mass.•This new criterion would be applicable for defining sarcopenia in Asia.

Sarcopenia is characterized by muscle mass depletion and decrease in muscle power or physical activity. We previously reported that low skeletal muscle mass (SMM) is closely involved with posttransplant mortality in patients undergoing living donor liver transplantation (LDLT). The aim of this study was to prospectively investigate the effects of pretransplant sarcopenia on survival and examine sequential changes in sarcopenic parameters after LDLT. Sarcopenia was defined by measuring SMM using a multifrequency body composition analyzer and assessing grip strength (GS) in 72 adults who underwent LDLT at Kyoto University Hospital between January 2013 and October 2015. The effects of pretransplant sarcopenia on short-term survival and sequential changes in SMM and GS were prospectively analyzed. Of 72 patients, 10 (14%) were defined as having pretransplant sarcopenia. Overall survival rates were significantly lower in patients with sarcopenia (n = 10) than those without sarcopenia (n = 62; P < 0.001). SMM worsened after LDLT and did not return to preoperative levels until 1 y after LDLT. In contrast, GS returned to preoperative levels at 6 mo after LDLT, following sharp decrease at 1 mo after LDLT. This prospective study confirmed that pretransplant sarcopenia is closely associated with short-term survival after LDLT and that GS recovers before SMM. •Sarcopenia is characterized by muscle mass depletion and decrease in muscle power or physical activity.•We prospectively investigated the effects of pretransplant sarcopenia, defined as low skeletal muscle mass (SMM), using a multifrequency body composition analyzer and low grip strength on survival and examined sequential changes in sarcopenic parameters after living donor liver transplantation (LDLT).•Overall survival rates were significantly lower in patients with sarcopenia (n = 10) than those without sarcopenia (n = 62; P < 0.001).•Grip strength recovers earlier compared with SMM after LDLT.

INTRODUCTION: The rupture of an umbilical hernia, which is known as Flood syndrome, is a rare and life-threatening complication of liver cirrhosis. Herein, we report the successful repair of a ruptured incisional hernia accompanied by liver cirrhosis.CASE PRESENTATION: A female in her 40s with a history of alcoholic cirrhosis and ruptured acute umbilical hernia treated by primary closure 6 months earlier presented with ascites leakage from abdominal skin. She was diagnosed with a ruptured incisional hernia accompanied by massive ascites. We started preoperative management with topical corticosteroids and oral diuretics. Nine months after the first visit, hybrid herniorrhaphy, extended totally extraperitoneal transversus abdominis release (eTEP-TAR) was performed. The patient has since been well without any sign of recurrence for 2 years.CONCLUSIONS: We experienced a successful treatment of a ruptured incisional hernia accompanied by liver cirrhosis. Preoperative management and surgical strategies are important for the treatment of ruptured incisional hernia and Flood syndrome.

BackgroundPortal vein embolization (PVE) is a common procedure for preventing hepatic insufficiency after major hepatectomy. While evaluating the body composition of surgical patients is common, the impact of muscularity defined by both muscle quantity and quality on liver hypertrophy after PVE and associated outcomes after major hepatectomy in patients with hepatobiliary cancer remain unclear.MethodsThis retrospective review included 126 patients who had undergone hepatobiliary cancer resection after PVE. Muscularity was measured on preoperative computed tomography images by combining the skeletal mass index and intramuscular adipose content. Various factors including the degree of hypertrophy (DH) of the future liver remnant and post-hepatectomy outcomes were compared according to muscularity.ResultsDH did not differ by malignancy type. Patients with high muscularity had better DH after PVE (P = 0.028), and low muscularity was an independent predictor for poor liver hypertrophy after PVE [odds ratio (OR), 3.418; 95% confidence interval (CI), 1.129–10.352; P = 0.030]. In subgroup analyses in which patients were stratified into groups based on primary hepatobiliary tumors and metastases, low muscularity was associated with higher incidence of post-hepatectomy liver failure (PHLF) ≥ grade B (P = 0.018) and was identified as an independent predictor for high-grade PHLF (OR 3.931; 95% CI 1.113–13.885; P = 0.034) among the primary tumor group. In contrast, muscularity did not affect surgical outcomes in patients with metastases.ConclusionsLow muscularity leads to poor liver hypertrophy after PVE and is also a predictor of PHLF, particularly in primary hepatobiliary cancer.

Background Decrease in skeletal muscle mass and function, known as sarcopenia, is associated with poor prognosis. Visceral fat accumulation also is related to mortality. This study investigated the impact of preoperative skeletal muscle mass, muscle quality, and visceral adiposity on outcomes in patients undergoing resection of intrahepatic cholangiocarcinoma (ICC). Methods A retrospective analysis was performed of 109 patients undergoing resections of ICC between January 2004 and April 2015. Skeletal muscle mass [skeletal muscle index (SMI)], skeletal muscle quality [muscle attenuation (MA)], and visceral adiposity [visceral to subcutaneous adipose tissue area ratio (VSR)] were measured on preoperative computed tomography images. The impacts of these parameters on outcomes after ICC resections were analyzed. Results The overall survival rates were significantly lower in patients with low SMI ( P  = 0.002), low MA ( P  = 0.032), and high VSR ( P  = 0.026) compared with patients with high SMI, high MA, and low VSR, respectively. With multivariate analyses, in patients with stage I–III, low SMI (hazard ratio (HR) 3.29, P  = 0.003) and low MA (HR 2.86, P  = 0.010) were revealed as independent significant risk factors for mortality. In patients with stage IV, none of these parameters was identified as risk factors, with only the absence of adjuvant chemotherapy identified as an independent risk factor for mortality (HR 5.92, P  = 0.001). Conclusions Although stage was the most important factor, low skeletal muscle mass and quality were closely related to mortality after resection of ICC in patients with stage I–III.

BackgroundHepatocellular carcinoma (HCC) recurrently develops in cirrhotic liver containing a number of regenerative nodules (RNs). However, the biological tumorigenic potential of RNs is still unclear. To uncover the molecular bases of tumorigenesis in liver cirrhosis, we investigated the genetic aberrations in RNs of cirrhotic tissues using next-generation sequencing.MethodsWe isolated 205 RNs and 7 HCC tissues from the whole explanted livers of 10 randomly selected patients who had undergone living-donor liver transplantation. Whole-exome sequencing and additional targeted deep sequencing on 30 selected HCC-related genes were conducted to reveal the mutational landscape of RNs and HCCs.ResultsWhole-exome sequencing demonstrated that RNs frequently harbored relatively high-abundance genetic alterations, suggesting a clonal structure of each RN in cirrhotic liver. The mutation signature observed in RNs was similar to those determined in HCC, characterized by a predominance of C>T transitions, followed by T>C and C>A mutations. Targeted deep sequencing analyses of RNs identified nonsynonymous low-abundance mutations in various tumor-related genes, including TP53 and ARID1A. In contrast, TERT promoter mutations were not detected in any of the RNs examined. Consistently, TERT expression levels in RNs were comparable to those in normal livers, whereas every HCC tissue demonstrated an elevated level of TERT expression.ConclusionAnalyses of RNs constructing cirrhotic liver indicated that a variety of genetic aberrations accumulate in the cirrhotic liver before the development of clinically and histologically overt HCC. These aberrations in RNs could provide the basis of tumorigenesis in patients with liver cirrhosis.

BackgroundOligometastatic recurrence involves relapsed tumors for which locoregional treatment (LT) may yield a survival benefit. However, there are no clear criteria for selecting patients for LT or determining the effects of LT in recurrent biliary tract cancer (BTC). The aim of this retrospective study is to assess the effects of LT on survival outcomes and to identify potential criteria for selecting LT in recurrent BTC.Patients and MethodsIn the present work, 232 consecutive patients with recurrent BTC who initially underwent curative surgery between 1996 and 2015 were evaluated. The primary outcome was length of survival after recurrence (SAR). Propensity score stratification with various tumor-related factors was used to identify patients who would likely benefit from LT.ResultsAmong the cohort, 60 (25.9%) patients underwent LT, whereas 172 (74.1%) patients did not. The multivariate Cox model identified carbohydrate antigen 19-9 levels of > 50 U/mL, multiorgan recurrence, tumor number > 3, tumor size > 30 mm, and early recurrence (≤ 1 year) as independent predictors of poor SAR (P < 0.001 for each factor). In the propensity-score-stratified analysis, LT was associated with survival benefits for patients representing single-organ recurrence with at most three tumors and late-onset recurrence (> 1 year) (median SAR: 48.6 vs. 14.2 months, n = 33 vs. n = 34, hazard ratio: 0.10, 95% confidence interval: 0.04–0.20, P < 0.001).ConclusionsPatients with recurrent BTC may benefit from LT if they have single-organ recurrence with at most three tumors and late-onset recurrence. We propose that these patients may have clinically relevant “oligometastatic recurrence” of BTC.

Background This study aimed to assess an oncologic setting where patients with hepatocellular carcinoma (HCC) could benefit from liver resection (LR) compared to living donor liver transplantation (LDLT) using 18 F-fluorodeoxyglucose (FDG) positron emission tomography. Methods The consecutive data of patients with HCC who underwent 18 F-FDG PET before LR (LR group, n  = 314) and LDLT (LDLT group, n  = 65) between 2003 and 2015 were retrospectively analyzed. Tumor 18 F-FDG avidity was quantified as the tumor to liver standardized uptake value ratio (TLR, cut-off value was defined at 2). Multivariate analysis was performed to assess significant preoperative tumor factors in the LR group. Survival outcomes between the two groups were stratified by these factors. Results The 5-year overall survival (OS: 56.9% vs. 73.8%, LR vs. LDLT,  p  < 0.001) and recurrence-free survival rate (RFS: 27.4% vs. 70.7%,  p  < 0.001) were significantly better in the LDLT group compared to the LR group. In the LR study, multivariate analysis identified TLR and tumor multiplicity as significant preoperative tumor factors for OS. In patients with solitary and TLR < 2 HCC, the 5-year OS rate was not significantly different between the LR and LDLT groups (70.3% vs. 71.8%,  p  = 0.352); meanwhile, RFS rate was better in the LDLT group (34.3% vs. 71.8%,  p  = 0.001). Conclusions LDLT is associated with better long-term outcomes than LR in patients with HCC; however, selected patients with solitary and TLR < 2 HCC may benefit from LR.

Objectives We have reported preoperative low skeletal muscularity as an independent risk factor for poor outcomes after liver transplantation, resection of hepatocellular carcinoma, pancreatic cancer and extrahepatic biliary malignancies. However, the impacts of visceral adiposity and muscularity on outcomes after liver resection for colorectal liver metastases (CLM) have not been fully investigated. Methods We retrospectively analyzed 124 patients undergoing primary liver resection for CLM between 2005 and 2014. Using preoperative computed tomography at the third lumbar vertebra level, skeletal muscle and abdominal adipose tissue were evaluated by skeletal muscle index (SMI), intramuscular adipose tissue content (IMAC) and visceral-to-subcutaneous adipose tissue area ratio (VSR), respectively. Impacts of preoperative SMI, IMAC and VSR on outcomes after liver resection for CLM were investigated. Results Low SMI and high VSR were not significantly associated with poor overall or recurrence-free survivals ( P  = 0.324 and P  = 0.106, P  = 0.964 and P  = 0.738, respectively). Overall survival rate tended to be lower in patients with high IMAC than in patients with normal IMAC ( P  = 0.054). Recurrence-free survival rate did not differ significantly between high and normal IMAC ( P  = 0.721). Multivariate analysis showed that low SMI, high IMAC and high VSR were not significant risk factors for death or recurrence after liver resection for CLM. Conclusion Neither preoperative visceral adiposity nor low muscularity were poor prognostic factors in patients undergoing liver resection for CLM.