A.-Hon Kwon

Functional hepatic volume measured by technetium-99m-galactosyl-human serum albumin liver scintigraphy: comparison between hepatocyte volume and liver volume by computed tomography.

OBJECTIVES:We investigated the usefulness of measuring the functional hepatic volume by single-photon emission CT with 99m-technetium galactosyl-human serum albumin scintigraphy (GSA-LV). We then compared this value to the total hepatocyte volume and the hepatic volume determined from CT (CT-LV) in the patients with hepatobiliary tumors.METHODS:Forty-seven patients were divided into two groups, the SM group (subsegmentectomy and monosegmentectomy) and the DT group (disegmentectomy and trisegmentectomy). These groups were further divided into subgroups with or without chronic hepatitis or cirrhosis. The GSA-LV, CT-LV, and the total hepatocyte volume were then calculated. The GSA-LV and CT-LV measurements were performed preoperatively, at 2 and 4 wk, and at 3 and 6 months after surgery.RESULTS:The preoperative GSA-LV values were significantly correlated with the hepatocyte volume and the 15-min retention rate of indocyanine green (ICGR15). Similarly, the hepatocyte volume correlated well with the CT-LV and ICGR15. However, the CT-LV was correlated only with the ICGR15. Recovery of the GSA-LV in the DT group was delayed, and about 90% of the volumetric and functional regeneration was observed within 6 months after the hepatectomy. In contrast, the CT-LV of DT group patients with normal liver remnants returned to approximately 90% of their initial volume within 1 month after the hepatectomy, whereas patients with injured livers regenerated gradually and regained approximately 80% of their preoperative value by 6 months after the hepatectomy.CONCLUSIONS:We conclude that the measurement of functional hepatic volume using the GSA-LV is useful in fully evaluating hepatic function based on hepatocyte volume.

Effects of medicinal mushroom (Sparassis crispa) on wound healing in streptozotocin-induced diabetic rats

BACKGROUND The impaired wound healing in diabetes mellitus is a major clinical problem. Sparassis crispa (SC) is a medicinal mushroom and its beta-glucan content is more than 40%. This study investigated whether oral administration of SC could improve the impaired wound healing in diabetic rats. METHODS Full-thickness skin wounds were created on the backs of streptozotocin (STZ)-induced diabetic rats. Diabetic rats were then divided into 2 groups: SC-treated group that was orally administered doses of 1,000 mg/kg body weight per day of SC for 4 weeks and a control group without SC administration. Moreover, collagen synthesis of purified beta-glucan from SC was estimated in vitro. RESULTS Wound closure was significantly accelerated by oral administration of SC. Furthermore, in SC-treated wounds there were significant increases in macrophage and fibroblast migration, collagen regeneration, and epithelialization compared with the control group. The levels of type I collagen synthesized by cultured human dermal fibroblasts for the SC group were significantly higher than those for the control group. CONCLUSIONS SC can improve the impaired healing of diabetic wounds. This effect might involve an increase in the migration of macrophages and fibroblasts, and beta-glucan from SC directly increases the synthesis of type I collagen. Therefore, the use of SC may be extended to the clinical setting and prove an effective promoter of wound healing in patients with diabetes.

Intraoperative indocyanine green fluorescent imaging for prevention of bile leakage after hepatic resection

BACKGROUND Bile leakage is a common complication of hepatectomy, and is associated with an increase in sepsis and liver failure. There are no standard preventive methods against bile leakage after hepatic surgery. The aim of the present randomized clinical trial was to evaluate the application of indocyanine green (ICG) fluorescent cholangiography for preventing postoperative bile leakage. METHODS 102 patients who underwent hepatic resection without biliary reconstruction were divided into 2 groups. The control group (n = 50) underwent a leak test with ICG dye alone, and the experimental group underwent a leak test with ICG dye, followed by ICG fluorescent cholangiography using the Photodynamic Eye (PDE group, n = 52). RESULTS Among 42 patients with fluorescence in the PDE group, 25 patients had insufficient closure of bile ducts on the cut surface of the liver, which were closed by suture or ligation. There were 5 patients who developed postoperative bile leakage in the control group versus no bile leakage in the PDE group (10% vs 0%, P = .019). CONCLUSION ICG fluorescent cholangiography could detect insufficiently closed bile ducts that could not be identified by a standard bile leak test. ICG fluorescent cholangiography may have useful potential for prevention of bile leakage after hepatic resection.

Risk factors and outcome of early recurrence after resection of small hepatocellular carcinomas

BACKGROUND This study aimed to clarify risk factors for early recurrence and examine the subsequent outcome in patients undergoing potentially R0 resection of small hepatocellular carcinomas (HCCs) (<or=2 cm in greatest dimension). METHODS Eighty-nine patients were divided into 2 groups as follows: 26 patients suffering from recurrence within 2 years of surgery (early recurrence group) and 63 patients who were disease-free for at least 2 years (disease-free 2Y group). RESULTS Only 7 of 63 patients (11%) from the group that was disease-free for at least 2 years died during the 5-year period after surgery, whereas 13 of 26 patients (50%) from the early recurrence group died. Multivariate analysis showed that the preoperative maximum removal rate of technetium-99m-diethylenetriamine pentaacetic acid-galactosyl human serum albumin and microscopic vascular invasion were independent predictors of the early recurrence of small HCC. CONCLUSIONS Early recurrence of small HCC is the leading cause of death within 5 years after R0 resection. The preoperative hepatic functional reserve influences early recurrence, even in patients with small tumors.

Timing of Resection for Synchronous Liver Metastases from Colorectal Cancer

BackgroundThis study aimed to compare the surgical outcome and long-term survival between simultaneous and delayed resection of liver metastases from colorectal cancer (LM), and to identify the factors influencing hepatic disease-free survival in patients with synchronous LM.MethodsSeventy-four patients with LM were divided into two groups, i.e., 32 patients who underwent hepatectomy at the time of colorectal surgery (simultaneous group) and 42 patients who underwent delayed liver resection (delayed group).ResultsThe hepatic disease-free survival rates of patients from the delayed group with either ≥3 or <3 liver metastases were significantly better than that of the simultaneous group. Multivariate analysis showed that simultaneous resection was one of three independent prognostic indicators with an influence on hepatic disease-free survival. In 13 of the 42 (31%) patients from the delayed group, new metastatic lesions were found in the same and/or different segments after re-evaluation during the interval between operations. These patients had a higher incidence of poorly differentiated or mucinous adenocarcinoma, shorter interval between procedures, and larger tumors than patients without tumor progression.ConclusionsTumor progression could be recognized and occult metastases were detected during the interval between operations. Delayed resection of synchronous LM may be useful to reduce the risk of rapid recurrence in the remnant liver. Patients with poorly differentiated or mucinous adenocarcinoma and those with larger tumors who undergo delayed liver resection should receive neoadjuvant chemotherapy during the interval between operations.

Laparoscopic treatment using an argon beam coagulator for nonparasitic liver cysts

BACKGROUND Laparoscopic deroofing has been shown to produce good patient satisfaction and to have results similar to those of open surgical techniques. We evaluated the feasibility and efficacy of laparoscopic deroofing using an argon beam coagulator (ABC) in the patients with nonparasitic liver cysts. METHODS Laparoscopic deroofing for the treatment of liver cysts was attempted on 14 patients. After the deroofing, the secreting epithelium within the residual cystic cavity wall was destroyed using the ABC. RESULTS Laparoscopic deroofing was successful in all patients. No deaths or surgical morbidity occurred, and no postoperative complications were recorded. The median postoperative hospital stay was 7 days. The median follow-up was 56 months for all patients, and all patients have remained completely asymptomatic for 6 months after the surgery, with no recurrence of the cysts. CONCLUSIONS Our results indicate that laparoscopic deroofing using the ABC method in patients with nonparasitic liver cysts was effective in preventing cyst recurrence.

Laparoscopic management of bile duct and bowel injury during laparoscopic cholecystectomy

Accidentai injuries to the bile duct and bowel are significant risks of laparoscopic surgery and sometimes require conversion to open surgery. Although some of the injuries related to laparoscopic cholecystectomy can be managed by endoscopic techniques, laparoscopic surgery is not yet sufficiently perfected. We investigated the efficacy of laparoscopic management combined with endoscopic tube or stent insertion in cases of bile duct and bowel injuries during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted on 1,190 consecutive patients between April 1992 and June 1999. The first 70 patients underwent only preoperative intravenous infusion cholangiography (IVC), and the remaining 1,120 patients were subjected to both preoperative IVC and intraoperative cholangiography. We experienced 16 cases of bile duct injury (1.4%). Five patients with circumferential injuries of the bile duct were converted to open surgery for biliary reconstruction. The other 11 patients with partial laceration injuries of the bile duct and biliary leakage from the cystic duct underwent a laparoscopic simple closure technique. In 10 of these patients, an endoscopic tube or stent was inserted on the day after surgery to facilitate biliary decompression and drainage. Bowel injuries occurred in seven patients (0.6%). Three intestinal injuries were due to careless technique, and two duodenal injuries and two intestinal injuries were related to dense adhesions. All of these injuries were successfully repaired using laparoscopic techniques, auto-suturing devices, or extracorporeal suturing via the umbilical incision. No postoperative complications were identified. We concluded that the biliary injury site could be closed with a laparoscopic technique so long as the biliary injury was not circumferential. Bowel injuries also could be repaired laparoscopically.RésuméLe risque de lésions accidentelles des voies biliaires et des intestins n’est pas rare au cours de la chirurgie laparoscopique: de temps à autre, une conversion à la chirurgie ouverte est nécessaire. Si certaines lésions en rapport avec la cholécystectomie laparoscopique peuvent être traitée s par des méthodes endoscopiques, le traitement par laparoscopie de ces lésions n’est pas encore suffisamment perfectionné. Nous avons évalué l’efficacité du traitement laparoscopique combiné à l’endoscopie ou par insertion d’un stent en cas de lésion biliaire ou lésion des intestins secondaires à la laparoscopie. Une cholécystectomie a été réalisée par laparoscopie chez 1190 patients consécutifs entre avril 1992 et juin 1999. Les 70 premiers patients ont eu une cholangiographie intraveineuse préopératoire alors que les 1120 patients restants ont eu et une cholangiographie intraveineuse et une cholangiographie peropératoire. Nous avons observé 16 cas de lésions des voies biliaires (1,4%). Cinq patients atteints d’une lésion circonférentielle des voies biliaires ont été convertis en chirurgie ouverte pour reconstruction des voies biliaires. On a pu réaliser un traitement laparoscopique pour les 11 autres patients ayant une plaie partielle des voies biliaires ou une fuite à partir du canal cystique. Chez 10 de ces patients, on a inséré un tube ou un stent endoscopique le jour suivant la chirurgie laparoscopique pour décomprimer et faciliter le drainage biliaire. On a dénombré sept lésions intestinales (0,6%). Trois lésions intestinales étaient en rapport avec une erreur technique, deux lésions duodenales et deux lésions intestinales étaient en rapport avec des adhérences serrées. Toutes les lésions ont été réparées avec succès sous laparoscopie, en utilisant soit un appareil de suture mécanique soit des techniques de sutures extracorporéales à travers le trocart ombilical. On n’a observé aucune complication postopératoire. Nous concluons qu’une lésion biliaire iatrogène lors d’une cholécystectomie laparoscopique a toujours pu être réparée par une technique laparoscopique à condition que la lésion biliaire ne soit pas circonférentielle. Les lésions intestinales peuvent également être réparées sous laparoscopie.ResumenLa cirugia laparoscópica conlleva un riesgo significativo de lesiones accidentales del colédoco e intestino delgado. Aunque algunas de éstas, sobre todo las referidas a la colecistectomia laparoscópica, pueden tratarse mediante técnicas endoscópicas, es evidente que la cirugí laparoscópica no está todavía suficientemente perfeccionada por lo que al tratamiento de estas lesiones se refiere. Investigamos la eficacia del tratamiento laparoscópico en combinación con la inserción de tubos o “stent”, en las lesiones de vías biliares e intestino delgado producidas por colecistectomia laparoscópica. Entre abril 1992 y junio 1999, se realizaron 1,190 colecistectomias laparoscópicas. Sólo en los 70 primeros pacientes se efectuó una colangiografia intravenosa preoperatoria (IVC). En los restantes enfermos 1,120 se realizaron una IVC preoperatoria y una colangiografia intraoperatoria. Se detectaron 16 casos de lesiones de vias biliares (1.4%). 5 casos, con sección completa circunferencial del colédoco, se reconvirtieron realizándose la reconstrucción de la via biliar por cirugia abierta. Los otros 11 casos, con lesiones parciales o con fistulas del conducto cístico, fueron tratados mediante una simple sutura por vía laparoscópica. En 10 de estos pacientes y para descomprimir y facilitar el drenaje biliar se insertaron, al día siguiente de la reparación quirúrgica, por vía endoscópica, una sonda o un “stent”. En 7 pacientes (0.6%) se produjeron lesiones del intestino delgado. Tres de ellas se debieron a faltas técnicas; dos lesiones duodenales y otras dos intestinales fueron propiciadas por la existencia de densas adherencias. Todas estas lesiones se trataron con éxito por técnicas laparoscópicas bien con: autosutura o con suturas extracorpóreas, a través de la puerta umbilical. No se observó complicación postoperatoria alguna. Conclusión: excepción hecha de las secciones circunferenciales totales del colédoco, todas las otras lesiones tanto de las vías biliares como del intestino delgado pueden tratarse por vía laparoscópica.

A case of splenic low-grade mucinous cystadenocarcinoma resulting in pseudomyxoma peritonei.

Primary splenic mucinous cystadenocarcinoma (MCCa) is extremely rare, and only six cases appear to have been reported previously. We present herein a case of primary splenic MCCa resulting in pseudomyxoma peritonei (PMP). A 66-year-old Japanese woman presented to a hospital with a chief complaint of upper abdominal pain and a 7-year history of splenic cyst. Cyst rupture was noted on computed tomography, and splenectomy was performed. The abdominal cavity was filled with a large amount of gelatinous ascites, with the appearance of PMP. On the cut surface, multiple cysts containing mucinous material were found within and outside the spleen. Microscopically, splenic parenchyma was occupied by large mucinous pools focally lined with mucinous epithelial cells and mesothelial cell-like cells, which were considered benign. Outside the spleen, a low-grade MCCa component was found. No ectopic pancreatic or intestinal tissue was identified. Although most PMP cases are known to be caused by low-grade mucinous appendiceal tumor, the present case represents the first report of a splenic MCCa resulting in PMP.