The threat of ischemic complications following massive resection, especially in living donor hepatectomy or split liver transplantation, has been haunting surgeons for many years. Postmortem dissections of 62 livers were performed to investigate anatomical variations of the principal artery for segment 4 (A4). The origin of A4 was examined separately in the liver with (n ϭ 46) or without (n ϭ 16) an aberrant left hepatic artery (abLHA). A4s were found to be extrahepatic or intrahepatic branches of the right hepatic artery (RHA), left hepatic artery, or proper hepatic artery and were categorized into 4 different types according to their origins. The RHA type, originating from the RHA or right anterior hepatic artery (RAHA), was the most common pattern in our series. The A4 roots had a strong tendency of stemming from the RHA (n ϭ 12) even in the livers with abLHA (n ϭ 16). Among the RHA-type A4s, the A4 arising from RAHA (n ϭ 2) is supposed to be the most dangerous variant because it can cause an ischemic change in the remaining part of the liver after right hepatectomy. In conclusion, in the era of living donor liver transplantation, paying particular attention to the point of origin of A4 is a prerequisite, especially when the lateral section is relatively small. Arterial injuries to A4 during split liver transplantation may also increase the risk of hepatic artery thrombosis and ischemic cholangiopathy. Liver Transpl 14:1180-1184, 2008. © 2008 AASLD. Received November 29, 2007 accepted February 22, 2008.The artery to segment 4 has been an area of debate in segmental liver anatomy. Unlike the other segments, segment 4 has a peculiar pattern of arterial supply (earlier branching for segment 4) in comparison with the portal vein supply.Embryologically, there are 3 lobes in the early stage of hepatic formation, each supplied by an embryonic artery of its own: the lateral sector (segment 2) by the embryonic left hepatic artery, the medial and anterior sectors (segments 3, 4, 5, and 8) by the embryonic middle hepatic artery, and the posterior sector (segments 6 and 7) by the embryonic right hepatic artery 1 (Fig. 1). In the adult liver, segment 4 is a part of the medial sector, and it has been called by various other names such as medial segment, left medial segment, and quadrate lobe. Likewise, the artery for segment 4Abbreviations: A2, segment 2 artery; A3, segment 3 artery; A4, segment 4 artery; A4*, dangerous type of segment 4 artery variation; abLHA, aberrant left hepatic artery; CA, celiac axis; CHA, common hepatic artery; eRHA, embryonic right hepatic artery; eLHA, embryonic left hepatic artery; eMHA, embryonic middle hepatic artery; LDLT, living donor liver transplantation; LGA, left gastric artery; LHA, left hepatic artery; LPV, left portal vein; MHV, middle hepatic vein; PHA, proper hepatic artery; RHA, right hepatic artery; RAHA, right anterior hepatic artery; PV, portal vein; SMA, superior mesenteric artery.

Peripheral or central nerve injury often leads to neuropathic pain. Although ketamine and pregabalin are first line options for the treatment of neuropathic pain, their clinical application is limited due to side effects such as sedation, dizziness and somnolence. We designed this study to determine whether the intrathecal (i.t.) co-treatment with ketamine and pregabalin at sub-effective low doses would elicit a sufficient pain relief without producing side effect in a neuropathic pain mouse model. At day 7 after chronic constriction injury (CCI) of sciatic nerve, dose dependent effects of i.t. ketamine (3, 10, 30, 100 µg) or i.t. pregabalin (10, 30, 100 µg) on mechanical allodynia and thermal hyperalgesia were measured. For combination treatment, 3 or 10 µg of ketamine and 30 µg of pregabalin were selected because these doses of drugs were not effective on neuropathic pain. Interestingly, combined i.t. treatment groups (ketamine 3 µg+pregabalin 30 µg and ketamine 10 µg+pregabalin 30 µg) produced strong analgesia on neuropathic pain although these doses of ketamine and pregabalin alone are not effective. Moreover, rota rod test revealed that normal motor function was not affected by combined treatment while i.t. ketamine at doses above 10 µg showed a significant motor dysfunction. Results of this study suggested that i.t. co-treatment with ketamine and pregabalin at sub-effect low doses may be a useful therapeutic method for the treatment of neuropathic pain patients.Key words neuropathic pain; intrathecal; combination drug therapy; ketamine; pregabalin; mouse Peripheral or central nerve injury by a cancer, trauma, and/ or metabolic disease condition may evoke chronic neuropathic pain which is characterized by a presence of spontaneous pain (pain sensation without any stimulation), allodynia (pain sensation by a non-noxious stimulation), and hyperalgesia (enhanced pain by a noxious stimulation).1-4) The development and maintenance of neuropathic pain have been known to be closely associated with a variety of pathophysiologic changes, including peripheral and central sensitization. 5,6) At the periphery, up-regulation of α2δ subunit of voltagedependent calcium channel in the dorsal root ganglion correlates with the onset of tactile allodynia in spinal nerve-injured rats.7) Recently marketed drugs, gabapentin and pregabalin are used as a first line option for the treatment of neuropathic pain and its pain relief effect is induced by a blockade of Ca 2+ influx of sensory neuron via binding with α2δ subunit of Ca 2+ channel. 8,9) In addition, these treatments inhibit the release of excitatory neurotransmitters including glutamate, substance P and calcitonin gene-related peptide at a rodent spinal cord. [10][11][12][13] However, use of α2δ subunit Ca 2+ channel blockers has been limited since relatively higher dose is needed to produce a sufficient pain relief and several adverse effects such as dizziness and somnolence have been reported. 14,15) The N-methyl-d-aspartate (NMDA) receptor is highly expressed in the cen...

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PurposeComputer-assisted three-dimensional reconstruction of the fetal human pancreas was prepared to reconsider topographical relation between the dorsal/ventral anlagen and the vascular supply.MethodsTissue sections from the upper abdominal viscera of three fetuses were examined. Sections were immunohistochemically stained to determine pancreatic polypeptide expression, a marker of the ventral pancreas.ResultsThe immunohistochemical findings were used to create three-dimensional computer-assisted reconstructions to identify pancreatic arteries. The narrowest part of the pancreas, or the neck, corresponding to a part of the dorsal pancreas, was located on the left side of the common bile duct, portal vein and gastroduodenal artery (GDA). The posterior arterial arcade accompanied the ventral pancreas, whereas the anterior arcade did not. In contrast to the GDA, the splenic artery was clearly separated from the neck in fetuses. The GDA appears to be the primary and stable arterial supply for the neck of the pancreas.ConclusionsThis observation may have implications for the preservation of the neck with the GDA during pancreaticoduodenectomy for benign and low-grade malignant diseases.

Background:In the Korean National Health Insurance Corporation (KNHIC), payment for inhaled anesthetics are made according to the simulated dose and not the consumed dose. We compare the consumption of inhaled anesthetics according to fresh gas flow (FGF) and anesthetic circuits to compare the consumption of anesthetics and the guidelines for KNHIC payments.Methods: 161 patients were randomized into six groups who received isoflurane using a closed circuit (group I-C), a semi-closed circuit with FGF 3 L/min (group I-3), or 4 L/min (group I-4), as for the sevoflurane group (group S-C, S-3, and S-4). Mean arterial pressure (MAP) and heart rate (HR) were maintained within ± 20% of baseline. Minimum alveolar concentration (MAC) and consumption of inhaled anesthetics were recorded by a new anesthetic machine.Results: There were no significant differences among the groups for MAP, HR, and MAC. During anesthesia maintenance, the mean consumption per 15 minutes of inhaled anesthetics was significantly lower in group I-C (1.0 ± 0.3 ml) than in group I-3 (3.5 ± 0.7 ml) and than group I-4 (4.9 ± 0.9 ml) and similar to the sevoflurane groups (group S-C [1.3 ± 0.4 ml] vs group S-3 [5.3 ± 1.0 ml] vs group S-4 [6.9 ± 1.3 ml], respectively; P ＜ 0.05).Conclusions: In sevoflurane groups, inhaled anesthetics were consumed more than in isoflurane groups. The KNHIC payment guidelines were close to the actual consumption of inhaled anesthetics under using a semi-closed circuit with FGF 3 L/min in sevoflurane and FGF 4 L/min in isoflurane.