Hiroyuki Hamba

Outcomes of hepatic resection for hepatolithiasis

BACKGROUND Hepatic resection is main approach to treatment of hepatolithiasis, but the long-term follow-up results of hepatic resection for hepatolithiasis are rarely reported. METHODS A retrospective study was conducted of 87 patients with hepatolithiasis who underwent hepatic resection. RESULTS The final stone clearance rates were 95%. There was a significant difference in the incidence of recurrent stones between patients with and without remaining biliary strictures. On multivariate analysis, the presence of residual or recurrent stones was an independent risk factor associated with recurrent cholangitis. The 10-year overall survival rate was 80.3%. On multivariate analysis, the development of cholangiocarcinoma was an independent predictor of survival in patients who underwent hepatic resection for hepatolithiasis. CONCLUSIONS The long-term outcomes after hepatic resection were satisfactory in patients whose intrahepatic stones and strictures were completely removed. Cholangiocarcinoma associated with hepatolithiasis was an independent prognostic factor in patients with hepatolithiasis who underwent hepatic resection.

Histologic factors affecting prognosis following hepatectomy for intrahepatic cholangiocarcinoma

Long-term survival following hepatectomy for intrahepatic cholangiocarcinoma has been poor, and specific factors influencing survival are unclear. In a retrospective study we sought to determine prognostic factors related to survival in these patients. In 28 patients who underwent hepatic resection for intrahepatic cholangiocarcinoma, we investigated the relations of several histologic factors to patient survival by univariate and multivariate analyses. No deaths occurred during the first 30 days. Median and mean survival times following hepatectomy were 409 and 935 days, respectively. The respective survival rates at 1, 3, and 5 years were 57%, 27%, and 27%. Resection margin status, intrahepatic metastasis, lymph node involvement, and lymphatic invasion were significant predictors of outcome. In a multivariate analysis using the Cox proportional hazards model, only lymphatic invasion independently predicted survival. Curative resection with clear margins was found to prolong survival after surgery. Hepatectomy for intrahepatic cholangiocarcinoma without lymphatic invasion offers hope for long-term survival.RésuméAlors que la survie à long terme après hépatectomie pour cholangiocarcinome intrahépatique est médiocre, les facteurs spécifiques influençant la survie ne sont pas clairement connus. Dans une étude rétrospective, nous avons essayé de déterminer les facteurs pronostiques en rapport avec la survie chez ces patients. Chez 28 patients ayant eu une résection hépatique pour cholangiocarcinome intrahépatique, nous avons réalisé une analyse uni- et multifactorielle pour étudier les rapports entre plusieurs facteurs histologiques et la survie. Aucune mortalité n’a été enregistrée pendant les 30 premiers jours. La survie médiane et moyenne après hépatectomie ont été, respectivement, de 409 et de 935 jours. Le taux de survie à 1, 3 et 5 ans ont été, respectivement, de 57%, de 27% et de 27%. L’état des marges de résection, les métastases intrahépatiques et l’envahissement ganglionnaire étaient des facteurs pronostiques significatifs. D’après analyse multifactorielle selon Cox, seul l’envahissement ganglionnaire était un facteur indépendant de survie. La résection avec clairance d’une marge de sécurité prolonge la survie. L’hépatectomie pour cholangiocarcinome intrahépatique sans envahissement ganglionnaire offre un espoir de survie à long terme.es|ResumenAunque la supervivencia a largo plazo tras hepatectomía por colangiocarcinoma intrahepático es escasa, no están claros los factores capaces de influir en la misma. En este estudio retrospectivo intentamos determinar los factores pronósticos relacionados con la supervivencia de estos pacientes. En 28 enfermos que sufrieron una resección hepática por colangiocarcinoma intrahepático, investigamos mediante análisis uni y multivariable la relación de diversos hallazgos histológicos con su supervivencia. Ningún paciente falleció en los primeros 30 días. La mediana y la media del tiempo de supervivencia tras hepatectomía fueron 409 y 935 días. La tasa de supervivencia a 1, 3 y 5 años fue 57%, 27% y 27%. Factores predictives significativos para los resultados fueron la infiltración o no de los márgenes de resección, las metástasis intrahepáticas, la afectación de ganglios linfáticos y la invasión linfática. En el análisis multivariante, utilizando el modelo de Cox, sólo la invasión linfática resultó ser un factor predictivo independiente, por lo que a la supervivencia se refiere. Resecciones curativas con limpios márgenes prolongaron la supervivencia tras cirugía. La hepatectomía por colangiocarcinoma intrahepático sin invasión linfática constituye un pronóstico favorable, por lo que a una prolongada supervivencia se refiere.

Reactivation of Viral Replication After Liver Resection in Patients Infected With Hepatitis B Virus

ObjectiveTo investigate the mechanisms and risk factors underlying postoperative reactivation of hepatitis after liver resection for hepatitis B virus-related hepatocellular carcinoma.Summary Background DataAlthough risk factors for acute hepatic failure after liver resection have been reported in patients with chronic liver disease, the issue of reactivation of hepatitis B virus replication after liver resection is unresolved.MethodsFifty-five patients with hepatocellular carcinoma and hepatitis B surface antigen underwent liver resection. In 25 of these 55 patients, serum levels of hepatitis B virus DNA and the type of hepatitis B virus were determined before and after surgery.ResultsPostoperative hepatitis occurred in 13 of the 55 patients (24%). Reactivation of viral replication occurred after liver resection in 7 of the 25 patients tested, and alanine aminotransferase activity increased in 6 of these 7 patients. High preoperative alanine aminotransferase activity, high levels of hepatitis B virus DNA, presence of wild-type DNA, and detection of hepatitis B core antigen in hepatocytes, all features of the immune clearance phase in the natural course of hepatitis B virus infection with no surgery, were more likely to be found in patients with reactivation than in patients without reactivation.ConclusionsDuring the immune clearance phase of hepatitis B virus infection, especially the period of acute exacerbation, changes in serum hepatitis B virus DNA level should be monitored for early warnings of reactivation of viral replication, likely to cause severe postoperative hepatitis and acute hepatic failure.

Delayed hepatic resection for ruptured hepatocellular carcinoma

BACKGROUND Although transcatheter arterial embolization is advocated as initial therapy for ruptured hepatocellular carcinoma (HCC), hepatic resection is necessary for cure. The effectiveness of delayed hepatic resection for ruptured HCC was determined. METHODS The records of 10 patients who underwent delayed hepatic resection for ruptured HCC were reviewed. RESULTS All patients were men, and the mean age was 63 years. For hemostasis, transcatheter arterial embolization was performed in three patients, whereas in the other patients bleeding stopped without special procedures. Mean interval from rupture to hepatic resection was 74 days. Liver function test results before hepatic resection were almost normal. Trisegmentectomy in one and bisegmentectomy in four patients were performed, whereas minor hepatic resection was performed for four extrahepatic HCCs. There were no operative or hospital deaths. Four patients had cirrhosis. The mean tumor diameter was 7.5 cm. Of seven patients with recurrence, two with dissemination had tumors that ruptured on the inferior aspect of the liver. The 1- and 3-year survival rates were 77% and 48%, respectively. CONCLUSIONS Because delayed hepatic resection for ruptured HCC was safe and compared similarly with that for other patients who underwent resection for HCC, it should be used. However, when HCC ruptures in an inferior location, recurrence of tumor as dissemination is likely.

Mirizzi Syndrome Caused by Xanthogranulomatous Cholecystitis: Report of a case

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. In severe cases, inflammation extends to adjacent structures, and XGC is sometimes confused with a malignant neoplasm. We recently diagnosed XGC as the preoperative cause of Mirizzi syndrome in a patient based on the clinical course. The patient was admitted because of obstructive jaundice, with gallbladder carcinoma as the suspected cause. The gallbladder was swollen with gallstones and the serum level of carbohydrate antigen 19-9 (CA19-9) was 3070 U/ml at admission. A percutaneous transhepatic cholangiodrainage (PTCD) was done, and the common hepatic duct as well as the right and left hepatic ducts were found to be obstructed. Later, the CA19-9 level and swelling of the gallbladder decreased and the obstruction of the bile ducts disappeared. A cholecystectomy was performed and the intraoperative pathohistological diagnosis of chronic cholecystitis was made from frozen sections. The pathohistological diagnosis of XGC was made from paraffin-embedded sections. Mirizzi syndrome such as that seen in our patient is a rare complication of XGC. XGC occassionally causes extensive inflammation; thus, performing a conventional cholecystectomy can be unsafe. However, in our opinion, a total, not subtotal, cholecystectomy should be done whenever possible because the incidence of gallbladder carcinoma accompanied with XGC is higher than that with ordinary cholecystitis or gallstones.

Influence of histological inflammatory activity on regenerative capacity of liver after percutaneous transhepatic portal vein embolization.

Abstract: Percutaneous transhepatic portal vein embolization (PTPE) produces regenerative hypertrophy in the nonembolized part of the liver, but the regenerative capacity after PTPE in patients with chronic hepatitis is unknown. We studied 34 patients with hepatocellular carcinoma and chronic hepatitis who underwent PTPE at the right portal vein. Hepatic lobular volumes were calculated by computed tomography before and 2 weeks after PTPE. The increase in left lobular volume was analyzed using a stepwise multiple regression method incorporating 11 factors: age; portal venous pressure; proportional volume of the right lobe; indocyanine green retention test; platelet count; serum levels of aspartate transaminase, alanine transaminase, total bilirubin, and albumin; and histological inflammatory grade and stage of fibrosis, according to the criteria of the International Association for the Study of the Liver recommended at their 1994 meeting. The median volume of the left lobe had increased from 405 to 554 cm3 (P < 0.0001) by 2 weeks after PTPE. Inflammatory grade was the only independent factor predicting regenerative hypertrophy (regeneration ratio (%) = 80.3 − 20.1 × grade; standard correlation coefficient = −0.566; P = 0.0014). Histological inflammatory activity was the essential factor regulating liver regeneration after PTPE in patients with chronic hepatitis.

ANALYSIS OF 69 PATIENTS WITH AMEBIC LIVER ABSCESS

All 69 patients with amebic liver abscess that we treated in 1981–1992 were studied retrospectively. Men predominated by a 10∶1 ratio. Of our 227 patients with amebiasis, some 30% yearly had liver involvement. The incidence peaked in 1988, decreasing later but increasing again in 1992. Most patients were 30–50 years old, the overall mean age being 45 years (range, 22–79), and decreasing with time. Patients with the related factors of travel abroad, positive results of a test forTreponema pallidum hemagglutination, and homosexuality have increased in number in recent years. Fever, abdominal pain, and hepatomegaly were the most frequent findings, and 39 patients had neither bloody stools nor diarrhea. Only 8 patients had had amebiasis previously. A solitary abscess in the right lobe of the liver was found in 40 patients.Eniamoeba histolytica was found in the stool of 31 patients and in the pus of 39 patients. Sixty-one patients had positive results for an amebic serological test(s). The abscesses ruptured into the peritoneal cavity in 4 patients. All patients received metronidazole. Percutaneous or surgical drainage (or both) was done in 62 patients. The outcome was good, with 1 exception, and only 2 patients had recurrences.

A pancreatic anaplastic carcinoma of spindle-cell form

SummaryA 56-yr-old man with complaint of abdominal pain and body weight loss was admitted to our hospital. Contrast-enhanced computed tomography on admission revealed a pancreatic tumor. Contrast-enhanced computed tomography 1 mo after admission revealed rapid growth of this tumor. We performed exploratory laparotomy with only a needle biopsy of the unresectable tumor because of extensive spread, including liver metastases. Further histological and immunohistochemical examination revealed that both the pancreatic tumor and the hepatic metastases featured malignant spindle-shaped cells. Despite radiotherapy, the patient died 40 d after laparotomy.

Clinicopathological analysis of nodules in cirrhotic liver after resection for hepatocellular carcinoma.

肝癌切除後の残肝再発には,転移再発ならびに多中心性再発の2種類の様式が考えられている.これら残肝再発の機序を解明する一助として,最近5年間に取り扱った切除肝癌161症例の非癌部肝内結節性病変を再検索した.その結果,161症例中31症例(19%)に術前術中に診断し得なかった結節性病変48結節が検出された.これらを病理組織学的に検討したところ,large regenerative noduleは19結節(40%),adenomatous hyperplasiaは10結節(21%), early HCCは8結節(17%), intrahepatic metas-tasisは8結節(17%)であった.したがって,最近精度の著しく向上した術前画像診断法によっても検出しえない結節性病変が残肝にかなり存在することが推測された.

The distribution of secretory immunoglobulin A in the intrahepatic biliary epithelium of patients with hepatolithiasis

In the treatment of hepatolithiasis, liver resection helps to prevent recurrence and may reduce the incidence of infection by removal of the atrophic tissue. This study was conducted to determine if the affected liver tissue in hepatolithiasis is inflamed or has lowered local immunity by examining the distribution of secretory immunoglobulin A (sIgA) and proliferating cell nuclear antigen (PCNA) in the intrahepatic biliary tracts of 27 patients with hepatolithiasis. Operative specimens were sectioned and stained with avidinbiotin complex, and the labeling index for both sIgA and PCNA was calculated as a percentage of the biliary epithelial cells stained. Cells stained for sIgA increased to a certain point as the cholangitis became more severe; however, in advanced cholangitis, with severe parenchymal atrophy or actively proliferating biliary epithelium, there were fewer cells stained for sIgA than in mild cholangitis. In hepatolithiasis, the decreased local immunity related to sIgA accompanied severe chronic proliferative cholangitis and parenchymal atrophy.