Masakazu Yamamoto

Glissonean pedicle approach in liver surgery

Glissons capsule was discovered by Johannis Walaeus in 1640 and described by Francis Glisson in 1654. The capsule wraps the hepatic artery, the portal vein and the bile duct in the liver and forms bundles at the hepatic hilus and in the liver as the Glissonean pedicle tree. Glissons capsule does not connect to the proper membrane of the liver, which was discovered by Laennec; therefore, the Glissonean pedicles can be detached from the liver parenchyma without liver dissection. Couinaud described three main approaches to control the inflow system at the hepatic hilus in liver surgery; the intrafascial approach, the extrafascial and transfissural approach, and the extrafascial approach. The intrafascial approach is the so‐called control method. The extrafascial and transfissural approach, and the extrafascial approach are recognized as the Glissonean pedicle approach. When the Glissonean pedicles are ligated before liver transection, various types of anatomical hepatectomy can be carried out. The Glissonean pedicle approach is, therefore, considered to be one of the most important procedures in liver surgery. We herein describe the historical aspects and procedures of the Glissonean pedicle approach in liver surgery.

Transumbilical portal venous catheterization: a useful adjunct in left lobe living donor liver transplantation

To improve the processes used for perfusion of the explanted graft and measuring the portal venous pressure (PVP) in adult living donor transplantation (LDLT), we performed transumbilical portal venous catheterization (TPVC) to reopen the umbilical vein and insert the catheter for seven adult patients undergoing left lobe LDLT. There were no major complications as a result of this procedure. This procedure prior to implanting the graft was derived from our experience and is a classic diagnostic technique used during liver surgery. It is a simple and effective procedure for perfusion and washout of the graft and for the safe monitoring of the intraoperative PVP. We hope that this technique for left lobe LDLT will be helpful to others using postoperative PVP monitoring, administration of therapeutic drugs through the portal vein, and temporal portal decompression by preparation of extracorporeal shunting in patients with a small‐for‐size graft.

Pancreaticobiliary Complication Biliary Cancer in Pancreaticobiliary Maljunction and Congenital Biliary Dilatation

Pancreaticobiliary maljunction (PBM) and congenital biliary dilatation (CBD) are important risk factors of biliary cancers. According to the nationwide survey in Japan, the biliary cancer incidence of PBM was 21.6% in patients with CBD and 42.4% in patients without CBD. In patients with PBM and CBD, resection and reconstruction of the extrahepatic bile duct (flow-diversion surgery) is a basic surgical procedure for preventing the high occurrence of bile duct and gallbladder cancer. On the contrary, in patients with PBM but without CBD, no consensus has been reached about whether it is better to perform cholecystectomy alone or flow-diversion surgery. After surgery, a reported 0.5–2.0% of patients who undergo cyst excision develop bile duct carcinoma. Although the incidence of cancer after surgery is lower than that before surgery, it is 120–200 times higher than that of the entire population. Therefore, long-term follow-up is needed in patients with PBM and/or CBD.

Complete clinical response of a patient with lymph node and pulmonary metastatic hepatocellular carcinoma to very low-dose sorafenib (Nexavar®) therapy

We present the case of a patient with metastatic hepatocellular carcinoma (HCC) who showed complete response (CR) to very low-dose sorafenib therapy. The patient was a 74-year-old woman who had previously undergone S7/8 hepatectomy for HCC in December 2002. Intrahepatic recurrence developed in August 2007, and transcatheter arterial chemoembolization was performed seven times. An increase in the level of the tumor marker alpha-fetoprotein (AFP) was observed, and thus positron emission tomography-computed tomography (PET-CT) was performed in June 2010. PET-CT showed an accumulation of metastatic cells resulted in a swollen periaortic lymph node. Based on the features of this lymph node metastasis, HCC was diagnosed. Oral sorafenib (Nexavar®) was started at an initial dose of 400xa0mg/day given three times a week. Sorafenib therapy was discontinued when adverse reactions such as bloody sputum and hand tremor were noted after 1xa0week of therapy. Following improvement of the adverse reactions, sorafenib therapy was resumed at 200xa0mg/day given three times a week. Two months after the reinitiation of sorafenib therapy, CT showed no change in the lymph node metastasis, and previously undetected pulmonary metastasis was diagnosed. At 5xa0months of therapy, CT showed no pulmonary and lymph node metastases. As the patient developed another adverse effect of sorafenib therapy, the frequency of sorafenib administration was reduced to two times a week at 200xa0mg/day. After 15xa0months of sorafenib therapy at 200xa0mg/day given two times a week, the patient showed CR and remains in CR at this writing.

Surgical Anatomy of the Liver in the Glissonean Pedicle Approach: What We Need to Know

The Glissonean pedicle approach in liver surgery provides new knowledge of the surgical anatomy and progresses the technique of liver surgery. The Glissonean pedicle is wrapped by the connective tissue referred to as the Walaeus sheath and includes the hepatic artery, the portal vein, the bile duct, the nerves, and the lymphatic vessels. This approach provides extrafascial access to the hepatic hilus, and the secondary Glissonean pedicles are taped and ligated at the hepatic hilus without liver dissection. The approaching point must be over the hilar plate; therefore, surgeons do not have to consider any variation of the artery or bile ducts. The tertiary branches can be approached through the hepatic hilus or in the liver on the borderlines between the segments. Any anatomical hepatectomy can be done using this technique which allows simple, safe, and easy liver surgery. Liver surgeons should, therefore, know the fundamental concept of the Glissonean pedicle approach.