Hiroaki Takeshita

Prognosis of patients with hepatocellular carcinoma after hepatic resection: Are elderly patients suitable for surgery?

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

Relationship Between CT Volumetry and Functional Liver Volume Using Technetium-99m Galactosyl Serum Albumin Scintigraphy in Patients Undergoing Preoperative Portal Vein Embolization Before Major Hepatectomy: A Preliminary Study

To clarify the relationship between morphological measurements of hepatic volume by computed tomography (CT-vol) and functional volume (RI-vol) by technetium-99m galactosyl human serum albumin (99mTc-GSA) scintigraphy, and its clinical significance, we examined 16 patients with a background liver status of either normal liver function (n = 4), chronic hepatitis or cirrhosis (n = 7), or obstructive jaundice (n = 5). In five patients who underwent preoperative portal vein embolization (PVE), volumetric measurement was performed 2 weeks after PVE. The mean values of CT-vol and RI-vol of the right lobe were 692± 147 cm3 (66.1 ± 10.7%) and 668 ± 159 cm3 (67.8 ± 13.2%), respectively, and those of the left lobe were 329 ± 138 cm3 (33.9 ± 10.6%) and 328± 170 cm3 (32.2 ± 13.2%), respectively. There were no significant differences in the volume measurements between the two volumetric techniques. Correlations between CT-vol and RI-vol in the right and left lobes were positive and significant (r = 0.912 and 0.903, respectively; both P′s < 0.001). The mean values of post-PVE CT-vol and RI-vol of the right lobe in five patients were significantly different (628 ± 149 and 456± 211 cm3, respectively; P = 0.033). However, the mean values of post-PVE CT-vol and RI-vol of the left lobe were not different (496 ± 124 and 483± 129 cm3, respectively). We propose that volumetric measurement by 99mTc-GSA scintigraphy is useful for detecting changes in functional volume of individual lobes of the liver and is a more dynamic method compared with detection of morphological changes by CT scan.

Relationship between pattern of tumor enhancement and clinicopathologic characteristics in intrahepatic cholangiocarcinoma

Common enhancement pattern of intrahepatic cholangiocarcinoma (ICC) on computed tomography (CT) is that of hypovascular enhancement; however, in some cases, tumor shows identical enhancement in the arterial phase to that in hepatocellular carcinoma. To identify the specific characteristics of different enhancement patterns, we examined the relationship between CT enhancement pattern and clinicopathological features or postoperative prognosis.

Modified Japan Integrated Staging is currently the best available staging system for hepatocellular carcinoma patients who have undergone hepatectomy

BackgroundWe previously reported the effectiveness of the modified Cancer of the Liver Italian Program (CLIP) score in hepatocellular carcinoma (HCC) staging. To determine the best predictive staging system for HCC patients, we conducted a comparative analysis of prognosis using multivariate analysis in 230 Japanese HCC patients following hepatic resection.MethodsWe compared overall survival as predicted by different staging systems: the tumor node metastasis (TNM) system by the Liver Cancer Study Group of Japan, the Japan Integrated Staging (JIS) score (Japanese TNM and Child-Pugh classification), the modified JIS score using liver damage grade, the CLIP score, and our modified CLIP score using protein induced by vitamin K absence or the antagonist II (PIVKA-II).ResultsBy a univariate analysis the PIVKA-II level (cut-off level, 400 mAU/ml) was significantly associated with patient survival (P = 0.031); however, alpha-fetoprotein level was not related to survival. Liver damage grade was significantly associated with patient survival (P = 0.039), although Child-Pugh classification was not related to survival. Univariate analysis showed that prediction of survival, according to disease stage, was better with the modified JIS score than with the TNM system, CLIP, modified CLIP, or JIS score. Multivariate analysis showed the modified JIS score showed the best ability to predict overall survival according to disease stage (Hazard ratio, 1.77; P = 0.002), and its Akaike information criteria statistic was the lowest (634.3).ConclusionsThe modified JIS score, a staging system that combines tumor factors and hepatic function, is a better predictor of prognosis than other systems in HCC patients who have undergone hepatic resection.

Usefulness of sonazoid–ultrasonography during hepatectomy in patients with liver tumors: A preliminary study

To improve diagnostic accuracy of intraoperative ultrasonography (IOUS), we investigated the usefulness of new contrast medium of microbubble agent, Sonazoid as a preliminary study.

Novel Powdered Anti-adhesion Material: Preventing Postoperative Intra-abdominal Adhesions in a Rat Model

Background: Although laparoscopic surgery has decreased postoperative adhesions, complications induced by adhesions are still of great concern. The aim of this study was to investigate the anti-adhesive effects of a novel powdered anti-adhesion material that can be applied during laparoscopic surgery in comparison with other anti-adhesion materials. Methods:Our novel powdered anti-adhesion material is composed of aldehyde dextran and ε-poly(L-lysine). In 40 male rats, a 2.5×2.0-cm abdominal wall resection and cecum abrasion were performed. The rats were randomized into four groups based on the anti-adhesion treatments: normal saline; Seprafilm®; Interceed®; and novel powdered anti-adhesion material. The animals were euthanized on days 7 and 28 to evaluate the adhesion severity, area of adhesion formation, gross appearance, and pathological changes. Results: The adhesion severities on both days 7 and 28 were significantly lower for all anti-adhesion material groups compared with the normal saline group (p<0.05). Pathologically, all groups showed inflammatory cell infiltration on day 7 and complete regeneration of the peritoneum on day 28. Conclusions:Our novel powdered anti-adhesion material was found to be effective for reducing postoperative intra-abdominal adhesions and showed equivalent efficacy to commercial anti-adhesion materials.

Usefulness of vessel-sealing devices combined with crush clamping method for hepatectomy: A retrospective cohort study

BACKGROUND Blood loss during resection of the hepatic parenchyma in hepatectomy can be minimized using vessel-sealing (VS) devices. Some sealing devices were retrospectively compared to evaluate the efficacy of each device for controlling blood loss, transection time and postoperative complications in hepatectomy as a cohort study. METHODS Between 2005 and September 2012, hepatectomy was underwent in 150 patients using one of three types of LigaSure™ (Dolphin Tip Laparoscopic Instrument, Precise or Small Jaw) or the Harmonic Focus or Ace ultrasonic dissecting sealer. Results were compared to crush-clamping alone as the control method by the historical study (n = 81). RESULTS Irrespective of the vessel-sealing device used for underlying chronic hepatitis, blood loss, blood transfusion rate, operating time and transection time were significantly reduced in the VS group compared with controls (p < 0.05). Rates of postoperative bile leakage and intra-abdominal abscess formation were significantly lower in the VS group than in controls (p < 0.05). Comparing devices, LigaSure Small Jaw and Harmonic Focus showed lower blood loss, shorter transection time and reduced rates of post-hepatectomy complications, in turn resulting in shorter hospital stays (p < 0.05). Tendencies toward uncontrolled ascites and bile leakage were only concern with the use of Harmonic Focus. Satisfactory surgical results were achieved using the sealing device for laparoscopic hepatectomy. CONCLUSIONS The use of energy sealing devices improves surgical results and avoids hepatectomy-related complications. Adequate use of vessel sealers is necessary for safe and rapid completion of hepatic resection.

Usefulness of measuring hepatic functional volume using Technetium-99m galactosyl serum albumin scintigraphy in bile duct carcinoma: report of two cases

We report the usefulness of measuring functional liver volume in two patients undergoing hepatectomy. Case 1 involved a 47-year-old man with hepatitis B virus infection. The indocyanine green test retention rate at 15 min (ICGR15) was 14%. Liver uptake ratio (LHL15) by technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) liver scintigraphy was 0.91. The patient displayed hilar bile duct carcinoma necessitating right hepatectomy. After preoperative portal vein embolization (PVE), future remnant liver volume became 54% and functional volume by (99m)Tc-GSA became 79%. Although the permitted resected liver volume was lower than the liver volume, scheduled hepatectomy was performed following the results of functional liver volume. Case 2 involved a 75-year-old man with diabetes. ICGR15 was 27.4% and LHL15 was 0.87. The patient displayed bile duct carcinoma located in the upper bile duct with biliary obstruction in the right lateral sector. The right hepatectomy was scheduled. After PVE, future remnant volume became 68% and functional volume became 88%. Although ICGR15 was worse as 31%, planned hepatectomy was performed due to the results of functional volume. In the liver with biliary obstruction or portal embolization, functional liver volume is decreased more than morphological volume. Measurement of functional volume provides useful information for deciding operative indication.

Relationship of Hepatic Functional Parameters with Changes of Functional Liver Volume Using Technetium-99m Galactosyl Serum Albumin Scintigraphy in Patients Undergoing Preoperative Portal Vein Embolization: A Follow-Up Report

BACKGROUND To identify predictors of changes in functional hepatic volumes after portal vein embolization (PVE) before hepatectomy, we examined the relationship between hepatic functional parameters and changes in functional volume of the embolized and non-embolized liver based on a previous volumetric analysis. MATERIAL AND METHODS Subjects were 24 patients who underwent PVE, which was performed through the trans-ileocolic vein (n = 4) or by percutaneous transhepatic puncture (n = 20). The RI liver volume parameter was measured by liver scintigraphy with technetium-(99m) galactosyl human serum albumin ((99m)Tc-GSA). Computed tomography (CT) volume parameter was also measured. RESULTS Significant atrophy of the embolized liver and hypertrophy of the non-embolized liver (change of 72 ± 108 cm(3) and 111 ± 91 cm(3), respectively) (change of 7.8%) was observed after PVE. The change in these RI volume parameters (change of 173 ± 175 cm(3) and 145 ± 137 cm(3) , respectively) (16.5%) was significantly greater than CT volume parameters (P < 0.01). CT vol and RI vol in the embolized and non-embolized liver were well correlated (r = 0.75 and 0.69, respectively). However, the correlation between CT and RI volume parameters in the embolized and non-embolized liver after PVE was very weak (r = 0.17 and 0.03, respectively). Only alkaline phosphatase level correlated negatively with atrophic CT volume parameter of the embolized liver (r = -0.455, P < 0.05). When compared with CT volume parameter, more parameters were significantly correlated with changes of RI volume parameter in the embolized liver: pre-PVE pressure; ICGR15; and serum levels of hyaluronate, total bilirubin, albumin, and alkaline phosphatase. Only platelet count was significantly correlated with hypertrophy of the non-embolized liver. CONCLUSION RI volume parameter might more accurately reflect functional changes in the embolized liver and non-embolized liver than CT volume parameter. Correlated parameters might allow us to predict the functional effect of PVE.

Does the placement of a cystic duct tube after a hepatic resection help reduce the incidence of post-operative bile leak?

BACKGROUND In this retrospective study, the effects of cystic duct (C) tube use on the incidence of post-hepatectomy bile leak were assessed. METHODS The subjects were 550 patients who underwent a hepatectomy during 1990-2011, with (n = 83) and without (n = 467) C tube drainage. The use of a C tube was based on the surgeons choice. RESULTS Bile leakage was observed in 44 (8%) patients, and its incidence post-operatively correlated with intrahepatic cholangiocarcinoma, parenchymal transection with forceps fracture and tie, a major hepatectomy, prolonged surgery and excessive blood loss (P < 0.050) but not with the use of a C tube. The incidence of an intra-abdominal infection was higher and the hospital stay was longer in the leak (49 days) than non-leak group (21 days, P < 0.001). ISGLS grade B and C bile leak post-hemi-hepatectomy and extended-hepatectomy were more frequent in the non-C than C tube group (P = 0.016). The duration of hospitalization was not different between the two groups; however, 7 patients in the non-C tube group had prolonged hospitalization (> 60 days) compared with none in the C tube group (P = 0.454). CONCLUSION The usefulness of the C tube in preventing post-hepatectomy bile leak could not be confirmed; however, both bile leak requiring clinical management and long hospitalization after a major hepatectomy could be reduced with C tube use.