Keisuke Inaba

Appraisal of surgical treatment for pT2 gallbladder carcinomas.

This retrospective study was designed to appraise the surgical procedures for pT2 gallbladder (GB) carcinomas. Twenty patients with pT2 GB carcinomas underwent surgical resection. Hepatectomy of segments 4b and 5 was performed in 19 patients, and an extended right hepatic lobectomy was performed in 1. The extrahepatic bile duct was preserved in 8 patients in whom the disease was limited to the GB fundus and/or body. Regional lymphadenectomy was performed in 18 patients. A separate radical second operation was performed in 8 patients after cholecystectomy. Final pathological staging was stage IB in 15 patients, IIB in 4, and IV in 1. Overall 5-year survival rate in those 20 patients was 77% without operative deaths. The 5-year survival rate in 5 patients with nodal metastasis and in 8 patients without extrahepatic biliary resection was 80% and 100%, respectively. A separate radical second operation in 8 patients yielded 75% survival after 5 years. Perineural invasion as a prognostic determinant was closely associated with tumor extending to the neck or the cystic duct. Partial hepatectomy, usually with extrahepatic biliary resection and regional lymphadenectomy, was appropriate as a standard radical operation for pT2 GB carcinoma, but preservation of extrahepatic bile duct is advocated for disease limited to the GB fundus and/or body. Radical second operation enhanced the chance for cure in patients with pT2 GB carcinoma.RésuméCette étude rétrospective évalue les procédés chirurgicaux dans le traitement des cancers de la vésicule biliaire pT2. Vingt patients porteurs de tumeur de la vésicule biliaire pT2 ont eu une résection chirurgicale. L’hépatectomie des segments 4b et 5 a été réalisée chez 19 patients et une lobectomie droite étendue chez un. La voie biliaire extrahépatique a pu être préservée chez huit patients lorsque la maladie était limitée au fundus et/ ou au corps de la vésicule. Une lymphadénectomie régionale a été réalisée chez 18 patients. Une intervention radicale a été réalisée chez huit patients à distance de leur cholécystectomie initiale. Le staging anatomopathologique final a été stade « IB » chez 15 patients, stade « I1B » chez quatre, et stade « IV » chez un. Le taux de survie globale à 5 ans chez les 20 patients a été de 77%, sans aucune mortalité opératoire. Les taux de survie à 5 ans chez les cinq patients porteurs de métastases ganglionnaires et chez les huit patients sans résection extrahépatique, ont été, respectivement, de 80% et de 100%. En cas de deuxième intervention radicale, à distance, chez huit patients s’est soldée par une survie à 5 ans de 75%. L’envahissement périneural a été le facteur pronostique déterminant pour les tumeurs s’étendant au col vésiculaire et au canal cystique. L’hépatectomie partielle avec résection extrahépatique et une lymphadénectomie régionale ont été considérées comme l’intervention standard radicale en cas de tumeur pT2 mais la préservation de la voie biliaire extra-hépatique est conseillée en cas de cancer limité au fundus et/ou corps. L’intervention à distance radicale augmente les chances de cure chez le patient porteur de cancer pT2 de la vésicule biliaire.ResumenSe efectúa un estudio retrospectivo para averiguar el tratamiento quirúrgico realizado en carcinomas pT2 de vesícula biliar (GB). 20 pacientes con carcinomas pT2 de vesícula biliar (GB) fueron tratados quirúrgicamente. En 19 pacientes se efectuaron hepatectomías de los segmentos 4b y 5 y en 1 una lobectomía hepática derecha ampliada. La vía biliar extrahepática se conservó en 8 pacientes en los que la lesión estaba localizada, exclusivamente, en el fundus o cuerpo de la vesícula biliar. Iinfadenectomía regional se realizó en 18 casos. Fueron reintervenidos con criterios más radicales 8 pacientes tras sufrir una colecistectomía previa. La estadificación registrada fue la siguiente: estadio IB (n = 15) IIB (n = 4) y IV (n = 1 ). En los 20 pacientes la supervivencia global a los 5 años fue del 77%, sin mortalidad intraoperatoria alguna. La tasa de supervivencia a los 5 años en 5 pacientes con nódulos metastásicos y 8 sin resección biliar extrahepática fue del 80% y 100%. Una segunda operación más radical en 8 pacientes proportionó una tasa de supervivencia a los 5 años del 75%. Un factor pronóstico determinante fue la invasión perineural que se asociaba a la extensión del tumor hacia el cuello o al conducto cístico. La hepatectomía parcial generalmente acompañada de resección de la vía biliar extrahepática y linfadenectomía regional parece constituir la técnica quirúrgica estándar para los carcinomas pT2 de vesícula biliar, pero en los cánceres limitados al fundus y cuerpo de la vesícula se puede respetar la vía biliar extrahepática. Una segunda operación más radical, aumenta la posibilidad de curación en pacientes con carcinomas pT2 de vesícula biliar.

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography

BACKGROUND It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography. METHODS Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery. RESULTS The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients. CONCLUSION Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.

Lysophosphatidylcholine acyltransferase 1 altered phospholipid composition and regulated hepatoma progression.

BACKGROUND & AIMS Several lipid synthesis pathways play important roles in the development and progression of hepatocellular carcinoma (HCC), although the precise molecular mechanisms remain to be elucidated. Here, we show the relationship between HCC progression and alteration of phospholipid composition regulated by lysophosphatidylcholine acyltransferase (LPCAT). METHODS Molecular lipidomic screening was performed by imaging mass spectrometry (IMS) in 37 resected HCC specimens. RT-PCR and Western blotting were carried out to examine the mRNA and protein levels of LPCATs, which catalyze the conversion of lysophosphatidylcholine (LPC) into phosphatidylcholine (PC) and have substrate specificity for some kinds of fatty acids. We examined the effect of LPCAT1 overexpression or knockdown on cell proliferation, migration, and invasion in HCC cell lines. RESULTS IMS revealed the increase of PC species with palmitoleic acid or oleic acid at the sn-2-position and the reduction of LPC with palmitic acid at the sn-1-position in HCC tissues. mRNA and protein of LPCAT1, responsible for LPC to PC conversion, were more abundant in HCCs than in the surrounding parenchyma. In cell line experiments, LPCAT1 overexpression enriched PCs observed in IMS and promoted cell proliferation, migration, and invasion. LPCAT1 knockdown did viceversa. CONCLUSIONS Enrichment or depletion of some specific PCs, was found in HCC by IMS. Alteration of phospholipid composition in HCC would affect tumor character. LPCAT1 modulates phospholipid composition to create favorable conditions to HCC cells. LPCAT1 is a potent target molecule to inhibit HCC progression.

Bile leak test by indocyanine green fluorescence images after hepatectomy

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.

A 5-year survivor after resection of peritoneal metastases from pedunculated-type hepatocellular carcinoma.

We report herein a 5-year survivor after the resection of peritoneal metastases from pedunculated hepatocellular carcinoma (HCC). A 42-year-old man underwent lateral segmentectomy of the liver, with a diagnosis of pedunculated HCC, on October 10, 1994. The lesion was associated with intratumoral hemorrhage and was covered by the greater omentum, but there were no peritoneal metastases. The patient was readmitted to our hospital 4 months later with right upper quadrant pain. His serum alpha-fetoprotein level was 3ng/dl. Hepatitis B virus surface antigen (HBsAg) and hepatitis C virus antibody (HCV-Ab) were both negative. Abdominal computed tomography (CT) revealed two nodular lesions in the right upper abdominal cavity. He was diagnosed with peritoneal metastases from HCC. Because there were no other distant metastases, laparotomy was performed to resect these tumors. We found two other tumors, located in the mesentery of the appendix and ileum. All four tumors were resected by partial transverse colectomy and appendectomy. The histopathology of the tumors showed poorly differentiated HCC (Edmondson-Steiners grade III). The patient has been doing well without recurrent disease for more than 5 years after the second operation. The prognosis of patients with pedunculated HCC is poor. Furthermore, resection for peritoneal metastases from HCC is rare because of the presence of multiple seeding in the abdominal cavity and distant organ metastases. To our knowledge, our patient is the longest survivor after resection of peritoneal metastases from pedunculated HCC.

Ischemic preconditioning in hepatic ischemia and reperfusion

Purpose of reviewIschemic preconditioning that consists of a short period of hepatic inflow occlusion followed by reperfusion has the potential to increase tolerance to a subsequent prolonged ischemic insult. This review outlines current insight into ischemic preconditioning for hepatic ischemia and reperfusion injury in experimental and clinical settings. Recent findingsExperimental evidence suggests that interleukin-6 signaling and increased phosphorylation of STAT3 (signal transducer and activator of transcription-3) are involved in the protective effects of ischemic preconditioning. The benefit of ischemic preconditioning is restricted, however, by old liver and prolonged ischemic time (>60 min). To overcome this, ascorbic acid or glucose administration combined with ischemic preconditioning potentially can maintain the integrity of hepatic mitochondrial function through signal transduction pathways. The influence of ischemic preconditioning on hepatic regeneration varies with partial hepatectomy or small-for-size liver graft models, and remains controversial. Clinically, ischemic preconditioning in deceased donors protects against ischemia and reperfusion injury, as demonstrated by lowered liver enzyme levels, reduced incidence of primary nonfunction, and increased hepatic hypoxia-induced factor-1α concentrations. SummaryEnhanced understanding of the mechanisms of organ tolerance induced by ischemic preconditioning would strengthen the significance of this potential therapeutic strategy in liver transplantation.

Clinicopathological features of hepatocellular carcinomas (HCCs) arising in patients without chronic viral infection or alcohol abuse : a retrospective study of patients undergoing hepatic resection

BackgroundThis study was carried out to clarify the etiology and clinicopathological features of hepatocellular carcinomas (HCCs) arising in patients without chronic viral infection or alcohol abuse.MethodsHCC patients who underwent resection were divided into three groups: a non-B non-C (NBNC) group (n = 13), who were seronegative for hepatitis B surface antigen (HBs Ag) and anti-hepatitis C antibody (HCV Ab), excluding a history of alcohol abuse; a B group (n = 25), who were seropositive for HBs Ag only; and a C group (n = 116), who were seropositive for HCV Ab only. We analyzed the features of tumor- and host-related factors and the outcome of the NBNC group.ResultsHepatic inflammation and fibrosis were less severe in the NBNC group than in the other groups. There were no significant differences in tumor-related factors, except for higher serum levels of α-fetoprotein in the NBNC group. Recurrence rates and disease-free survivals were comparable among the three groups. The NBNC group comprised a greater population with one or two recurrent hepatic lesions (P < 0.05), and indocyanine green retention rates and fibrosis scores were preserved after the initial hepatectomy. The NBNC group had higher resection rates for intrahepatic recurrences (75.0%) than the other groups (21.1% and 22.2% in groups B and C, respectively; P < 0.05 and P < 0.05). The survival rate after the initial hepatectomy or detection of the recurrent lesions was significantly better in the NBNC group (both 100% at 5 years) than those in groups B and C (P < 0.05).ConclusionsNBNC patients maintained good liver function following the initial hepatectomy, and tended to have one or two recurrent lesions. These biological advantages provided NBNC patients more opportunities for repeat resection of intrahepatic recurrences, which may lead to a favorable outcome.

Hepatic inflammatory pseudotumor mimicking intrahepatic cholangiocarcinoma: report of a case.

Hepatic inflammatory pseudotumor (IPT) is a relatively rare lesion comprised of proliferating fibrovascular tissue infiltrated by inflammatory cells. IPT has a potential for recurrence and persistent local growth. We present a case of hepatic IPT mimicking a periductal-infiltrating type of intrahepatic cholangiocarcinoma (ICC) in a patient whose serum carbohydrate antigen 19-9 was slightly elevated. We performed a left hepatic lobectomy with resection of the extrahepatic bile duct and regional lymph node dissection under a preoperative diagnosis of ICC. However, histlogical examination of the resected tumor revealed granuloma tissue with lymphocyte infiltration, mainly by plasma cells, and proliferation into the surrounding connective tissue, and the lesion was ultimately diagnosed as hepatic IPT. This case points out the difficulties in differentiating between hepatic IPT extending along Glissons sheath and ICC, based on imaging findings alone.

Colonic Fistula Associated with Severe Acute Pancreatitis : Report of Two Cases

Colonic fistula is a rare and potentially critical sequela of severe acute pancreatitis, which requires surgical treatment. We report two cases that were successfully treated by a colectomy for colonic fistula associated with severe acute pancreatitis. Case 1 is a 71-year-old man infected with pseudocysts owing to severe acute pancreatitis that developed into a colonic fistula as an early complication with a resulting pancreatic abscess. This patient underwent a left hemicolectomy, a transverse colostomy, and drainage of the pancreatic abscess. He has done well without recurrent disease for 35 months following surgery. Case 2 is a 58-year-old woman who had a past history of drainage during a laparotomy for a pancreatic abscess induced by endoscopic retrograde cholangiopancreatography 10 years earlier. She was admitted to our hospital with left lateral abdominal pain and low-grade fever. Abdominal magnetic resonance imaging showed a retroperitoneal abscess and fistula to the descending colon. She underwent a left hemicolectomy and drainage of the retroperitoneal abscess. She has remained symptom-free for 20 months following surgery. The colonic fistula should therefore be recognized as a late complication during long-term follow-up as well as an early sequela associated with severe acute pancreatitis.

Impact of the preoperative des-gamma-carboxy prothrombin level on prognosis after hepatectomy for hepatocellular carcinoma meeting the Milan criteria

PurposeHepatectomy is feasible for patients with hepatocellular carcinoma (HCC) who are eligible for liver transplantation according to the Milan criteria if they have good hepatic function. This retrospective study investigates the prognostic factors of hepatectomy in HCC patients meeting the Milan criteria.MethodsBetween 1991 and 2005, 175 patients underwent hepatectomy for HCC at our institute; 111 met and 64 exceeded the Milan criteria. The prognostic factors for hepatectomy were investigated using a Cox regression model.ResultsOperative mortality and morbidity were significantly lower in the patients who met the criteria than in those who exceeded the criteria. After a median follow-up of 51.5 months, the 5-year survival rate was significantly better for the patients who met the criteria than for those who exceeded the criteria (77.8% vs 35.7%; P < 0.0001). The factors predictive of poor prognosis were poor differentiation, microscopic vasculobiliary invasion, and a high serum des-gamma-carboxy prothrombin (DCP) level (>100 mAU/ml) for the patients who met the Milan criteria; and only the presence of a microsatellite lesion for the patients who did not meet the Milan criteria.ConclusionsHepatectomy is safe and beneficial for HCC patients who meet the Milan criteria, but a high preoperative serum DCP level may be predictive of a poor prognosis.