Hisashi Nakayama

Criteria for drain removal following liver resection

Abdominal drains have been placed prophylactically and removed in liver resection without robust evidence. The present study was designed to establish the optimal time for removal of such drains.

Marginal survival benefit in the treatment of early hepatocellular carcinoma.

BACKGROUND & AIMS Early treatment has been recommended for hepatocellular carcinoma (HCC) due to its high cure rate. However, the reported survival benefits of treating early HCC may be affected by lead time. METHODS Early HCC was defined as a well-differentiated cancer containing Glissons triad (carcinoma in situ). We applied the concept of lead time to chronic liver disease, which is originally the length of time between screen-detected and symptom-detected disease. To evaluate prolongation of survival with treatment of early HCC, survivals of patients with early and overt HCCs smaller than 2.0 cm treated with liver resection were compared. To calculate lead time and survival benefit of liver resection, survivals of untreated early and overt HCC patients were compared. RESULTS After liver resection, median overall survival of 46 patients with early HCC (8.8 years; 95% CI, 7.2-11.2) was significantly longer than that of the 202 with overt HCC (6.8 years; 95% CI, 6.2-8.3, p = 0.0257). The prolongation in survival time with liver resection for early HCC was 34.7 (95% CI, 22.1-46.5) months. On the other hand, comparing liver resection and natural history, the survival benefits of surgery for 12 patients with early and 16 with overt HCC were 74.7 (95% CI, 51.9-97.4) and 73.4 (95% CI, 57.9-88.9) months, respectively. Consequently, the lead time and survival benefit with resection for early HCC were estimated as 33.4 (95% CI, 18.9-47.8) and 1.3 (95% CI, -22.1-24.7) months, respectively. CONCLUSIONS Survival benefit of resection for early HCC is marginal because of a long lead time, and early HCC is therefore not a target lesion for surgery.

Validation of perioperative steroids administration in liver resection: a randomized controlled trial.

Objective:We performed a randomized controlled trial to investigate the clinical benefits of perioperative treatment with steroids in patients undergoing liver resection. Background:Perioperative steroids are considered to reduce surgical stress, but evidence supporting proposed clinical benefits is largely anecdotal. Patients and Methods:The 210 patients scheduled to undergo liver resection were randomly assigned to a steroids group (n = 105) or a control group (n = 105). The steroids group received 500 mg hydrocortisone immediately before hepatic-pedicle clamping, followed by 300 mg hydrocortisone on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. Serum levels of total bilirubin, aminotransferases coagulation factors, and inflammatory-related cytokines, and the clinical course were compared between the 2 groups. The primary end point was the postoperative bilirubin level. Results:All 210 patients underwent radical liver resection with no operative mortality. The median bilirubin level on POD 2 was significantly lower in the steroids group [0.71 mg/dL (0.33–2.17)] than in the control group [1.03 mg/dl (0.39–3.57); P = 0.01]. The postoperative time courses of the bilirubin level (P = 0.01), the interleukin-6 level (P = 0.01) and the C-reactive protein level (P = 0.01) were significantly lower whereas the the prothrombin level (P = 0.01) and interleukin-10 level (P = 0.01) were significantly higher in the steroids group. There was no difference between the groups in the proportion of patients with complications (40% vs 43%; P = 0.66) or the length of the hospital stay (14 days vs 13 days; P = 0.68). Conclusions:Perioperative treatment with steroids has a positive impact on the liver function of patients who undergo liver resection, without increasing the risk of complications.

Ulcerative colitis associated with Takayasu's disease in two patients who received proctocolectomy.

*1502). Coronary angiography showed 90% narrowing of the right coronary artery (RCA). After alleviating the RCA narrowing by percutaneous transluminal coronary angioplasty (PTCA), we performed a total proctocolectomy and ileostomy. Patient 2, a 20-year-old woman, was first diagnosed with TD at the age of 13 years. Severe symptoms, indicating fulminant UC, started 1 month prior to hospitalization. She was judged as needing surgery because the symptoms were not alleviated even with high doses of prednisolone. HLA typing showed A2, A31(19), B52, B61(40), DR2(DRB1*1502), and DR4 (DRB1*0405). Aortography showed a narrowing of the right renal artery; however, her renal function was normal. Based on these findings, we performed a three-stage operation for total proctocolectomy. Previously, we have reported that the DRB1*1502 and DRw11 genes were closely related to the intractability of UC. To date, we have not determined whether or how the DRB1*1502 gene might be related to TD. As the number of cases of UC associated with TD increases, it will be necessary to examine their DR2 subtypes.

Transfusion Criteria for Fresh Frozen Plasma in Liver Resection: A 3 + 3 Cohort Expansion Study

OBJECTIVE To establish transfusion criteria for use of fresh frozen plasma (FFP) in liver resection. BACKGROUND Fresh frozen plasma has been transfused in liver resection without adequate supporting evidence, leading to unnecessary use. DESIGN Prospective study using a phase 1 dose-escalation, 3 + 3 cohort expansion design, modified for FFP transfusion. We designated a serum albumin level of 3.0 g/dL (step 1) as the starting limit for no transfusion and reduced the level in 0.2-g/dL steps. Advancement to the next step was permitted when the albumin level equaled the target value for the previous step in 3 patients. If the albumin value on postoperative day 2 fell below the target value, 100 mL of albumin, 25%, was transfused on that day and on postoperative day 3. The study continued until high-grade postoperative complications occurred without transfusion. If 1 of 3 patients developed Clavien-Dindo grade II or higher complications, 3 more patients (3 + 3 cohort) were added to the same step. SETTING Hepatobiliary pancreatic surgery center of a university hospital. PATIENTS Patients with hepatocellular carcinoma who had had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL. INTERVENTION Transfusion or no transfusion of FFP. Main Outcome Measure Reduction of transfusion rate in liver resection. RESULTS Of the 213 consecutive patients with liver cancer enrolled, 172 patients (80.8%) fulfilled the inclusion criteria. Step progression proceeded until step 5 (albumin level, 2.2 g/dL) without high-grade complications, but step 2 (albumin level, 2.8 g/dL) required 63 patients to complete because 1 patient developed grade II complications (massive ascites). Step progression was broken off at step 5 in the 172nd patient because the postoperative day 2 albumin value did not fall below the step 4 level (2.4 g/dL), defined as the goal limit. The overall operative morbidity rate was 27.9%; the mortality rate was 0%. The FFP transfusion rate was significantly reduced from 48.6% in a previous series involving 222 patients (unpublished historical data from our institution) to 0.6% (1 of 172 patients) in the present study (P < .001). The postoperative hospital stay in the present study was significantly shorter than that in our previous series (13 vs 16 days; P = .01). Total medical costs were significantly reduced from a median of

Decreased blood loss reduces postoperative complications in resection for hepatocellular carcinoma

21 061 (range, 10 032-59 410) to

Role of surgical resection for hepatocellular carcinoma based on Japanese clinical guidelines for hepatocellular carcinoma

17 267 (11 823-35 785; P = .04). CONCLUSION In liver resection, FFP transfusion is not necessary in patients with serum albumin levels higher than 2.4 g/dL on postoperative day 2.

Early cancer-related death after resection of hepatocellular carcinoma

The correlation between blood loss and the risk of postoperative complications was unclear in patients undergoing resection of hepatocellular carcinoma (HCC).

HETEROTOPIC PANCREATIC TISSUE ASSOCIATED WITH INTRA- AND EXTRAHEPATIC CHOLEDOCHAL CYSTS

In the Algorithm for Diagnosis and Treatment in the Japanese Evidence-Based Clinical Practice Guidelines for Hepatocellular Carcinoma, the treatment strategy is determined by three major factors: liver function and the number and size of tumors. The algorithm is quite simple, consisting of fewer components than the Barcelona-Clinic Liver Cancer staging system. In this article, we describe the roles of the treatment algorithm in hepatectomy and perioperative management of hepatocellular carcinoma.

Phase I/II study of a fine-powder formulation of cisplatin for transcatheter arterial chemoembolization in hepatocellular carcinoma

BACKGROUND Surgeons have attempted to prevent early cancer-related death after resection of hepatocellular carcinoma to identify risk factors associated with early death from hepatocellular carcinoma recurrence after liver resection. METHODS The study group comprised 350 patients who had undergone liver resection for hepatocellular carcinoma between 1997 and 2007. The preoperative risk factors for early death from intrahepatic recurrence (within 1 year after resection) were evaluated. RESULTS Fourteen (4%) patients died of intrahepatic recurrence in the first year after resection. Multivariate analyses identified the following risk factors for early cancer-related death: multiple tumors (odds ratio 10.4; 95% confidence interval, 2.42-44.3; P = .002), vascular invasion (odds ratio 10.1; 95% confidence interval 2.07-50; P = .004), serum alpha-fetoprotein level >20 ng/mL (odds ratio 9.52; 95% confidence interval 1.0--84.2; P = .043), and tumor size ≥50 mm (odds ratio 4.80; 95% confidence interval 1.06-21.9; P = .042). Each of these factors was assigned a score of 1 point, and an algorithm was developed to predict the risk of early death. Outcomes did not differ significantly between patients with 3 or 4 points (P = .48) or between those with 1 or 2 points (P = .49). Patients who underwent liver resection could be stratified into the following distinct groups according to the point score and the associated 1-year survival rate and median survival (shown respectively): 0 points, 99%, and not yet; 1 or 2 points, 96%, and 68 months; and 3 or 4 points, 50%, and 12 months) (P < .0001). CONCLUSION Even if hepatocellular carcinoma is resectable, patients with a score of 3 or 4 points may not be good candidates for liver resection.