Hiroshi Imamura

Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery

F T i m k c 8 nlike blood vessels, the biliary tract lies in the Glissonian heath and is buried in the perivascular connective tissue, o it is difficult to clearly visualize and isolate it during epatobiliary surgery. Intraoperative cholangiography IOC), which was originally introduced by Mirizzi in 937, has been widely used to delineate the biliary tract natomy in this setting. For example, routine IOC was ecently recommended during cholecystectomy to prevent ile duct injury. IOC is also considered an essential proedure during donor hepatectomy because it enables the ile duct to be divided at the appropriate level to ensure ider and fewer residual orifices. But conventional raiographic IOC is disadvantageous in that it exposes the atient and the medical staff to radiation and usually reuires a large and expensive C-arm fluoroscopy machine nd the additional human resources involved. Recently, intraoperative angiography using a fluorescent maging technique with IV injection of indocyanine green ICG) has been used to assess coronary artery bypass graft atency. This technique is based on the principle that CG binds to plasma proteins and that protein-bound ICG mits light with a peak wavelength of about 830 nm when lluminated with near-infrared light. Because human ile also contains plasma proteins that bind with ICG, we ypothesized that fluorescent images of the biliary tract ould be obtained with intrabiliary injection of ICG. We lso hypothesized that IV injection of ICG would provide luorescent images of the biliary tract without necessitating

AFP, AFP-L3, DCP, and GP73 as markers for monitoring treatment response and recurrence and as surrogate markers of clinicopathological variables of HCC

BackgroundAlpha-fetoprotein (AFP), lens culinaris agglutinin-reactive fraction of AFP (AFP-L3), des-γ-carboxy prothrombin (DCP), and Golgi protein-73 (GP73) have been used or proposed as tumor markers for hepatocellular carcinoma (HCC).MethodsThey were measured in 96 patients undergoing hepatectomy for HCC to investigate their treatment response and association with variables linked with tumor invasiveness and/or prognosis. Values at 1xa0month post-surgery in the 77 patients without recurrence within 6 postoperative months were adopted as those after surgery.ResultsGP73 levels did not change after hepatectomy, but levels of other markers decreased and areas under receiver operating characteristic curves (95% CI) were: 0.64 (0.56–0.72), 0.63 (0.55–0.71), 0.79 (0.73–0.86), and 0.63 (0.55–0.71) for AFP, AFP-L3, DCP, and combination of AFP and AFP-L3, respectively. Cutoff points giving specificities of 96.1% (sensitivities at these points) were: 124xa0ng/mL (28.1%), 10% (21.9%), and 60xa0mAU/mL (52.1%), for AFP, AFP-L3, and DCP, respectively. The combination of AFP and AFP-L3 provided a sensitivity of 26.0% at a specificity of 96.1%. The increased DCP value was, or tended to be, associated with a larger tumor, vascular invasion, intrahepatic metastases, and a lower grade of tumor cell differentiation. Although similar associations were found between AFP and vascular invasion as well as a lower grade of tumor cell differentiation, no such relationship was found with AFP-L3.ConclusionsDCP is a more effective tumor marker than AFP and AFP-L3. AFP-L3 showed comparable accuracy to AFP but no benefit was found in their combination. GP73 did not play a significant role in this context. Indices of tumor invasiveness were most closely associated with DCP.

Detection of hepatocellular carcinoma by Gd-EOB-DTPA-enhanced liver MRI: comparison with triple phase 64 detector row helical CT.

PURPOSEnTo compare the diagnostic performance of Gd-EOB-DTPA-enhanced MRI with that of triple phase 64-MDCT in the detection of hepatocellular carcinoma (HCC).nnnPATIENTS AND METHODSnThirty-four patients with 52 surgically proven lesions underwent Gd-EOB-DTPA-enhanced MRI and triple phase 64-MDCT. Two observers independently evaluated MR and CT imaging on a lesion-by-lesion basis. Sensitivity, positive and negative predictive values and reproducibility were evaluated. The diagnostic accuracy of each modality was assessed with alternative-free response receiver operating characteristic (ROC) analysis.nnnRESULTSnBoth observers showed higher sensitivity in detecting lesions with MRI compared to CT, however, only the difference between the two imaging techniques for observer 2 was significant (P=0.034). For lesions 1cm or smaller, MRI and CT showed equal sensitivity (both 62.5%) with one observer, and MRI proved superior to CT with the other observer (MRI 75% vs. CT 56.3%), but the latter difference was not significant (P=0.083). The difference in positive and negative predictive value between the two imaging techniques for each observer was not significant (P>0.05). The areas under the ROC curve for each observer were 0.843 and 0.861 for MRI vs. 0.800 and 0.833 for CT and the differences were not significant. Reproducibility was higher using MRI for both observers, but the result was not significant (MRI 32/33 vs. CT 29/33, P=0.083).nnnCONCLUSIONnGd-EOB-DTPA-enhanced MRI tended to show higher diagnostic accuracy, sensitivity and reproducibility compared to triple phase 64-MDCT in the detection of hepatocellular carcinoma, however statistical significance was not achieved.

Relationship between liver function and liver signal intensity in hepatobiliary phase of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging.

Objective: To evaluate the effect of liver function on liver signal intensity in gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging in humans and to examine the biochemical factors related to signal intensity in the hepatobiliary phase. Methods: This study included 48 patients with suspected hepatocellular carcinoma or metachronous liver metastases from colorectal cancer. The patients were divided into 2 groups: the chronic liver dysfunction and the normal liver function. All the individuals of both groups had magnetic resonance imaging before injection and at 5, 10, 15, 20, 25, and 30 minutes after bolus administration of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid. The time point when the mean liver signal-to-noise ratio (SNR) reached a peak was determined for each group, and the mean liver SNR at the peak point was compared between the groups. In all the patients, stepwise multivariate analysis was used to evaluate the relationship between the liver SNR at the peak time point and the laboratory data, using the following biochemical factors: prothrombin time, total bilirubin level, cholinesterase level, albumin level, creatinine level, indocyanine green retention rate at 15 minutes, and Child-Pugh score. Results: The mean values of liver SNR increased gradually. The mean liver SNR reached peak at 30 minutes after contrast injection in both groups and was significantly lower in the chronic liver dysfunction group than in the normal liver function group. Indocyanine green retention rate at 15 minutes was the only significant contributor to the liver signal intensity at the peak time point (30 minutes). Conclusions: The degree of liver enhancement in the hepatobiliary phase may reflect liver cell function. The measurement of liver signal intensity in the hepatobiliary phase may be useful in predicting whole and regional hepatic functional reserves.

MR imaging of the biliary tract with Gd-EOB-DTPA: effect of liver function on signal intensity.

OBJECTIVEnTo quantitatively evaluate the signal intensity of the biliary tract in gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) imaging and to investigate the effect of liver function on the signal intensity of the biliary tract.nnnMATERIALS AND METHODSnA total of 32 patients with and without chronic liver disease (normal liver group, n = 15; chronic liver disease group, n = 17) were included in this study. All patients were prospectively enrolled for evaluation of known or suspected focal liver lesions. In the chronic liver disease group, the etiologies were chronic hepatitis C virus infection (n = 12) and chronic hepatitis B virus infection (n = 5). The median Child-Pugh score was 5 (range, 5-7). Each patient received the standard dose of Gd-EOB-DTPA (0.025 mmol/kg of body weight). Post-contrast T1-weighted MR images were obtained at 5, 10, 15, 20, 25, and 30 min after administration of Gd-EOB-DTPA. Maximum signal intensities (SIs) of the right and left hepatic ducts, common hepatic duct, and common bile duct were measured. Relative signal intensity was calculated as follows: relative SI = maximum SI(bileduct)/mean SI(muscle). Serum albumin level, serum total bilirubin level, prothrombin time, indocyanine green retention rate at 15 min (ICG-R15), and estimated glomerular filtration rate were entered into regression analysis.nnnRESULTSnThe signal intensity of the bile duct reached a peak 30 min after administration of Gd-EOB-DTPA. The mean relative signal intensity of the right and left hepatic ducts at the peak time point was not significantly different between the two groups, while increase in signal intensity was delayed in the chronic liver disease group. The mean relative signal intensity of the common hepatic duct and that of the common bile duct at the peak time point were significantly different between the two groups (Wilcoxon rank-sum test, P = 0.03, respectively). Stepwise regression analysis revealed that ICG-R15 was a significant predictor of the signal intensity of the bile duct (right and left hepatic ducts, P = 0.04; common hepatic duct, P = 0.008; common bile duct, P = 0.003).nnnCONCLUSIONSnThe results of our study demonstrate that the presence of chronic liver disease significantly affects the signal intensity of the bile duct in Gd-EOB-DTPA-enhanced MR imaging. ICG-R15 was only a significant predictor of the signal intensity of the bile duct. The signal intensity of the bile duct may reflect underlying liver function.

Left lobe adult‐to‐adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult‐to‐adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult‐to‐adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%‐54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft‐to‐recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9‐38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14‐27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP − central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3‐26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1‐21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small‐for‐size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1‐, 3‐, and 5‐year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long‐term results for adult patients with a minimal donor burden. Liver Transpl 18:305–314, 2012.

Cohort study of the survival benefit of resection for recurrent hepatic and/or pulmonary metastases after primary hepatectomy for colorectal metastases.

Objective:To evaluate resection for hepatic and/or pulmonary recurrences in a cohort that underwent initial hepatectomy for colorectal liver metastases. Summary Background Data:The survival benefit of repeated resections for hepatic and/or pulmonary recurrences after initial hepatectomy for colorectal liver metastases has remained unclear. Methods:Recurrence occurred in 166 of the 216 patients after the first hepatectomy. Repeated resections were performed in 98 patients. We investigated the pattern of recurrence, the proportion of patients who underwent repeated resection, and the surgical outcome. Results:Of the 166 patients with recurrence, 71 had isolated hepatic recurrence, 25 had isolated pulmonary recurrence, 13 had hepatic plus pulmonary recurrence, and 57 had recurrence in other organs. Repeated resections were conducted in 60 (85%) patients with isolated hepatic recurrence, 21 (84%) with isolated pulmonary recurrence, and 9 (69%) with both hepatic and pulmonary recurrence. The 5-year survival rates after repeated resection were 39%, 37%, and 20% for isolated hepatic recurrence, isolated pulmonary recurrence, and hepatic plus pulmonary recurrence, respectively. Multivariate analysis revealed that the following variables contributed to poor prognosis (hazard ratio [95% confidence interval]): number of recurrent tumors (1.20 [1.11–1.29]), maximum size of recurrent tumors (1.26 [1.02–1.48]), pulmonary recurrence (2.36 [1.41–3.20]), and hepatic plus pulmonary recurrence (4.01 [2.86–.17]). Conclusions:Patients with pulmonary or hepatic plus pulmonary recurrence had poorer prognoses than those with isolated hepatic recurrence. Reresection is the only potentially curative treatment. Stricter indication criteria, especially regarding the number of tumor nodules, can lead to comparable long-term outcomes.

Value of prophylactic abdominal drainage in 1269 consecutive cases of elective liver resection

BackgroundThe value of prophylactic abdominal drainage in patients undergoing hepatectomy is controversial. We carried out a retrospective study to clarify the value of this procedure.MethodsThe study subjects were 1269 consecutive patients who underwent elective hepatectomy with drain insertion for malignant tumors without associated gastrointestinal procedures or bilio-enteric anastomosis. Symptomatic abdominal fluid collections were treated by the drain salvage method, percutaneous puncture, and/or re-operation, in that order of preference.ResultsOne patient died (mortality rate, 0.07%) and 7 patients had postoperative bleeding (0.6%). Bile leakage, found in 111 (8.7%) patients, subsided with retention of the drain in 78 (70%) and use of the drain salvage technique in 8 (7.2%), whereas percutaneous puncture and re-operation were required in 11 (9.9%) and 14 (12.6%). Symptomatic fluid collection, observed in 65 (5.1%) patients, was treated by the drain salvage technique in 20 (31%) patients, while puncture and re-operation were required in 25 (38%) and 20 (31%).ConclusionsPlacement of drains was effective in a considerable proportion of patients undergoing hepatectomy, with regard to reducing the frequency of development of subphrenic fluid collections and biliary fistula/biloma formation.

Fate of hypointense lesions on Gd-EOB-DTPA-enhanced magnetic resonance imaging

PURPOSEnTo investigate the natural outcome and clinical implication of hypointense lesions in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI.nnnMATERIALS AND METHODSnForty patients underwent Gd-EOB-DTPA-enhanced MRI for preoperative evaluation of HCC. Hypointense lesions in the hepatobiliary phase that were hypovascular 5mm of more were extracted for follow-up. We performed a longitudinal study retrospectively for these lesions regardless of whether classical HCC developed or emerged in a different area from that of the lesions being followed.nnnRESULTSnThirty one patients displayed 130 hypointense lesions on MRI and only nine showed no hypointense lesions. In total, 17 (13.1%) of 130 hypointense lesions on MRI developed into classical HCC. The cumulative rates for these lesions to develop into classical HCC were 3.2% at 1 year, 11.1% at 2 years and 15.9% at 3 years. The total occurrence rates of classical HCC (25.8% at 1 year, 52.6% at 2 years and 76.4% at 3 years) were higher compared to those regarding only occurrence of classical HCC from hypointense lesions on MRI (10.0% at 1 year, 35.6% at 2 years and 44.6% at 3 years), although no significant difference was observed (p=0.073).nnnCONCLUSIONSnHypointense lesions that are detected in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI have some malignant potential, although treating these lesions aggressively in patients who already have HCC may be too severe.

Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver

Although patients with liver cirrhosis are supposed to tolerate ischaemia–reperfusion poorly, the exact impact of intermittent inflow clamping during hepatic resection of cirrhotic compared with normal liver remains unclear.