Kentaro Iwaki

A comparative study of the long-term outcomes after laparoscopy-assisted and open left lateral hepatectomy for hepatocellular carcinoma.

Background Laparoscopic hepatectomy was initially reported in 1992. However, the reported experiences are scarce, and this operation has not been a standard procedure until now. The aims of this study were to assess our results of laparoscopy-assisted left lateral hepatectomy for hepatocellular carcinoma (HCC) and to compare them with those of open conventional procedures. Methods From 1984 to 2002, left lateral hepatectomy for HCC less than 5 cm in diameter was carried out in 21 patients. Ten patients received a laparoscopy-assisted procedure, and remaining 11 patients received an open procedure. Results There were no significant differences in the operation time, blood loss, resected liver weight, and resection margin between the 2 groups. The total time that analgesics were given, body temperature on postoperative day 1, weight loss on postoperative day 7, and postoperative hospital stay in the laparoscopic group were significantly better than in the conventional group. With regard to the long-term prognosis, there were no differences in patient survival or disease-free survival rates between the 2 groups. Conclusions Laparoscopy-assisted left lateral hepatectomy for HCC is superior to the conventional open surgery in terms of its short-term results and does not cause the long-term survival to deteriorate. Therefore, laparoscopic hepatectomy may be an alternative choice for treatment of HCC.

Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study.

Although laparoscopic distal pancreatectomy (LDP) is technically feasible, its benefits remain uncertain. The purpose of this study was to compare the clinical results of LDP and open distal pancreatectomy (ODP). The medical records of 14 consecutive patients who underwent LDP were reviewed and compared with those of 19 patients who underwent ODP. All patients were treated for benign or borderline malignant disease of the pancreas. Operation time was longer for LDP than for ODP (290.7 vs. 213.8 min, P=0.0022), and postoperative analgesics were administered less frequently for patients who underwent LDP. Patients treated by LDP had earlier recovery of bowel function, shorter time to oral intake, and shorter postoperative hospital stay than those treated by ODP. No difference in morbidity or inflammatory response was observed between the 2 groups. LDP for benign or borderline malignant disease of the pancreas provides benefits without increasing morbidity.

Prognosis of patients with intrahepatic recurrence after hepatic resection for hepatocellular carcinoma: A retrospective study

AIMS Hepatic resection is the most effective therapy for hepatocellular carcinoma (HCC); however, intrahepatic recurrence is common. Predictors of survival after intrahepatic recurrence have not been fully investigated. To clarify the prognosis and choice of treatment of intrahepatic recurrence after hepatic resection, we conducted a comparative retrospective analysis of 147 patients with HCC who underwent hepatic resection. METHODS We retrospectively examined the relations between clinicopathologic factors, including the number of recurrent intrahepatic tumors and long-term prognosis after recurrence in 147 HCC patients who underwent resection. We also examined long-term survival after recurrence based on treatment types and recurrence pattern. RESULTS Patients with multiple tumors (n=83) showed less tumor differentiation, more frequent portal invasion, a higher alpha-fetoprotein level, and larger tumors than did patients with solitary tumor (n=64). In the solitary tumor group, local ablation therapy and repeat hepatic resection were performed in 25 and 10, respectively. In the multiple tumor group, 59 were treated by transarterial chemoembolization. Multivariate analysis showed intraoperative blood transfusion and multiple tumors to be independent risk factors for poor cancer-related survival after recurrence. By subset analysis based on treatment types and recurrence pattern, survival after recurrence was significantly better in patients treated by local ablation therapy than those treated by other therapies in both solitary and multiple tumor groups. CONCLUSIONS For patients with solitary recurrence, a good prognosis is predicted. Local ablation therapy is a best candidate for treatment of solitary and multiple intrahepatic recurrences after hepatic resection.

Predictors and prognostic significance of operative complications in patients with hepatocellular carcinoma who underwent hepatic resection

AIMS The morbidity rate of hepatic resection for hepatocellular carcinoma (HCC) remains high. To clarify predictors and the prognostic significance of operative complications in patients with HCC, we conducted a comparative retrospective analysis of 291 patients with HCC who underwent hepatic resection. METHODS Operative complications included hyperbilirubinemia, ascites, hemorrhage, respiratory and cardiovascular diseases, bile leakage and abscess formation, renal failure, wound infection, and pleural effusion. Predictors of operative complications and their prognostic value for long-term survival were studied by univariate and multivariate analyses. RESULTS Mortality and morbidity rates were 7.2% and 42.6%. The main operative complications were ascites (n = 30), intraabdominal abscess (n = 25), hyperbilirubinemia (n = 19), wound infection (n = 16), pleural effusion (n = 10) and intraabdominal hemorrhage (n=9). By a multivariate logistic regression model, Child-Pugh class B and increased operative blood loss (> or = 1200ml) were independent predictors of postoperative complications. Among 243 patients without operative death, the 5-year overall survival rate was significantly lower in patients with operative complications (34.3%) than in those without these complications (48.7%). By the multivariate Cox proportional hazards model, the presence of operative complications was an independent predictor of poor overall survival as well as presence of portal invasion. CONCLUSIONS Child-Pugh class B and operative blood loss > or = 1200ml were independent predictors of complications after hepatic resection for HCC. Long-term survival is poorer in patients with postoperative complications. Decreasing operative blood loss may result in fewer postoperative complications and better long-term survival of HCC patients.

A small interfering RNA targeting proteinase‐activated receptor‐2 is effective in suppression of tumor growth in a Panc1 xenograft model

Proteinase‐activated receptor‐2 (PAR‐2), which is a G protein‐coupled receptor, is activated in inflammatory processes and cell proliferation. We previously demonstrated that an anti‐PAR‐2 antibody suppresses proliferation of human pancreatic cells in vitro. However, there have been no studies of PAR‐2 signaling pathways in vivo. The aim of this study was to determine whether blockade of PAR‐2 by RNA interference influences pancreatic tumor growth. We originally constructed small interfering RNAs (siRNAs) targeting human PAR‐2, and performed cell proliferation assays of Panc1 human pancreatic cancer cell line with these siRNAs. Intratumoral treatment with these PAR‐2 siRNAs and atelocollagen was also performed in a xenograft model with nude mice and Panc1 cells. siRNAs against human PAR‐2 inhibited proliferation of Panc1 cells, whereas control scramble siRNAs had no effect on proliferation. The PAR‐2 siRNAs dramatically suppressed tumor growth in the xenograft model. PAR‐2‐specific siRNA inhibited growth of human pancreatic cancer cells both in vitro and in vivo. Blockade of PAR‐2 signaling by siRNA may be a novel strategy to treat pancreatic cancer.

Ethanol injection therapy of an isolated bile duct associated with a biliary‐cutaneous fistula

Abstract  Bile leakage after hepatic resection often results in the formation of a biliary‐cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73‐year‐old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary‐cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary‐ cutaneous fistula was completely healed. The post‐treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct.

Lymphatic invasion: an important prognostic factor for stages T1b-T3 gallbladder cancer and an indication for additional radical resection of incidental gallbladder cancer.

BackgroundLaparoscopic cholecystectomy is being performed with increasing frequency worldwide. This has led to more frequent discovery of incidental gallbladder cancer (IGBC) and in turn to the need for an independent prognostic factor for stages T1b–T3 gallbladder cancer so that is can be determined clinically which cases of IGBC are indicated for additional radical resection (ARR).MethodsA retrospective study was conducted that included 72 patients who underwent macroscopically curative surgical resection (R0, R1) at our center for stages T1b–T3 GBC. Survival analysis was performed, and the usefulness of ARR was analyzed in 15 patients with IGBC.ResultsUnivariate analysis of disease-specific survival showed stage T3, histologic grade II–IV, lymphatic invasion, vessel invasion, perineural invasion, lymph node metastasis, and a positive resection margin to be factors indicative of poor prognosis. Independent predictors of poor disease-specific survival were stage T3 (hazard ratio, 2.33 [95% CI, 1.10–4.95]), lymphatic invasion (5.97 [1.29–27.6]), and a positive resection margin (3.17 [1.51–6.63]). Among the 15 IGBC patients, 4 of 5 patients without lymphatic invasion were cured, 2 of whom underwent cholecystectomy alone; 4 of 10 patients with lymphatic invasion did not undergo ARR, and the cancer recurred in all 4 patients; the other 6 patients underwent ARR, and 4 of them were cured by reoperation.ConclusionsLymphatic invasion well reflects the malignant phenotype of stages T1b–T3 GBC. We advocate ARR for IGBC patients with lymphatic invasion.

Hepatitis B Virus Infection Predicts Extrahepatic Metastasis After Hepatic Resection in Patients With Large Hepatocellular Carcinoma

BackgroundAlthough extrahepatic metastasis occurs rarely after hepatic resection for hepatocellular carcinoma (HCC), the prognosis of these patients is extremely poor. Predictors of extrahepatic metastasis have not been fully investigated.MethodsTo identify predictors of extrahepatic metastasis after resection, we retrospectively investigated 77 patients with HCC tumors >50 mm in diameter who underwent hepatic resection. We investigated correlations between postoperative extrahepatic metastasis and clinicopathologic factors as well as extrahepatic metastasis-free survival rate by log rank test and predictors of extrahepatic metastasis by univariate and multivariate logistic regression models.ResultsHepatitis B surface antigen (HBs-Ag) was found in 25 (32.5%) of 77 patients, and extrahepatic metastasis occurred in 26 (33.8%). Patients with extrahepatic metastasis showed better liver function and a high occurrence of HBs-Ag positivity than those without. The 5-year extrahepatic metastasis-free survival rate was worse in patients with HBs-Ag positivity, larger tumors (≥70 mm), higher alfa-fetoprotein level (≥300 ng/mL), and lower indocyanine green retention rate at 15 minutes (ICGR15) (<15%) than in those without. By univariate logistic regression analysis, HBs-Ag positivity, larger HCC tumor (≥70 mm), lower ICGR15 (<15%), and lower preoperative lymphocyte count (<1000/mm3) were predictors of extrahepatic metastasis (P < .1). By multivariate analysis, HBs-Ag positivity was an independent predictor of postoperative extrahepatic metastasis (P = .04).ConclusionsIn patients positive for HBs-Ag, radiologic examination of extrahepatic organs should be performed as a part of the postoperative surveillance. Hepatitis B virus infection may promote establishment of extrahepatic metastasis.

Laparoscopic splenectomy in patients with inflammatory pseudotumor of the spleen: Report of 2 cases and review of the literature.

We report 2 cases of splenic inflammatory pseudotumor treated by laparoscopic splenectomy. The first patient was a 58-year-old woman who complained of constipation. Computed tomography (CT) showed a well-demarcated mass that measured 4 cm in diameter and was not enhanced. She underwent laparoscopic splenectomy under a preoperative diagnosis of hemangioma. The final histopathologic diagnosis was inflammatory pseudotumor. The second patient was a 29-year-old man who complained of abdominal pain. Computed tomography revealed a demarcated splenic tumor that measured 3 cm in diameter and was not enhanced. Laparoscopic splenectomy was performed. The pathologic and operative diagnoses were both inflammatory pseudotumor. In both cases, the postoperative course was uneventful, and the postoperative hospital stays were 10 and 11 days. Preoperative diagnosis of a splenic inflammatory pseudotumor is very difficult. However, laparoscopic splenectomy is safe and beneficial treatment for this tumor and should be performed in cases in which it is diagnosed.

Increased heat‐shock protein 90 expression contributes to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rats

Background and Aims:  Portal hypertensive (PHT) gastropathy results in an increased susceptibility to damage. Adaptive cytoprotection against ethanol‐induced damage is impaired in the gastric mucosa of rats with portal hypertension. Excessive nitric oxide (NO) production occurs in portal hypertension and is mediated in part via heat‐shock protein (Hsp)90 production. The aim of this study was to investigate the relation between adaptive cytoprotection after exposure to ethanol and gastric expression of Hsp90 in PHT rats.