Masato Nagino

Application of a Three-dimensional Print of a Liver in Hepatectomy for Small Tumors Invisible by Intraoperative Ultrasonography: Preliminary Experience

BackgroundHepatectomy for an invisible small tumor using intraoperative ultrasonography requires technical ingenuity. We used a 3D print of a liver to perform a hepatectomy on two patients with synchronous multiple liver metastases from colorectal cancer. Because of preoperative chemotherapy, one of the tumors became smaller and invisible to ultrasonography in each case. We present our procedure here.MethodsMultidetector-row computed tomography images of anatomical structures were digitally segmented using the original software “PLUTO,” which was developed at the Graduate School of Information Science, Nagoya University. After converting the final segmentation data to stereolithography files, a 3D printed liver at a 70xa0% scale was produced. The support material was washed and the mold charge was removed from the 3D-printed hepatic veins. The surface of the 3D-printed model was abraded and coated with urethane resin paint. After air-drying, the 3D-printed hepatic veins were colored by injecting a dye. The 3D printed portal veins were whitish because mold charge remained. All procedures after 3D printing were performed by hand.ResultsHepatectomy for the small tumor that is invisible to intraoperative ultrasonography was performed by referring to a 3D-printed model. The planned resections were successful with histologically negative surgical margins.ConclusionsThe application of a 3D-printed liver to perform a hepatectomy for a small tumor that is invisible to intraoperative ultrasonography is an easy and feasible procedure. Use of 3D-printing technology in hepatectomy requires further improvement and automation of hand work after the 3D print has been made.

Preoperative Sarcopenia Negatively Impacts Postoperative Outcomes Following Major Hepatectomy with Extrahepatic Bile Duct Resection

BackgroundMajor hepatectomy with extrahepatic bile duct resection for perihilar cholangiocarcinoma remains a highly morbid procedure. The association between preoperative sarcopenia and postoperative morbidity/mortality has been reported for various types of surgeries. The objective was to analyze the relationship between preoperative sarcopenia and postoperative morbidity/mortality in patients who underwent major hepatectomy with extrahepatic bile duct resection.MethodsThis study included 256 patients who underwent major hepatectomy with extrahepatic bile duct resection from 2008 to 2014. Preoperative sarcopenia was assessed by a measurement of the total psoas muscle area (TPA). The measured TPA was normalized by height. Preoperative sarcopenia was defined as the presence of a normalized TPA in the lowest sex-specific tertile.ResultsA total of 54 males and 31 females were determined to have preoperative sarcopenia. The length of the postoperative hospital stay for patients with sarcopenia was significantly longer than for those without sarcopenia (39 vs 30xa0days, pxa0<xa00.001). Patients with sarcopenia experienced a significantly higher rate of liver failure (ISGLS gradexa0≥xa0B) (33 vs 16xa0%), major complications with Clavien gradexa0≥xa03 (54 vs 37xa0%), and intra-abdominal abscess (29 vs 18xa0%) than those without sarcopenia (all pxa0<xa00.05). After a multivariate analysis, low normalized TPA (male <567xa0mm2/m2; female <395xa0mm2/m2) was identified as an independent risk factor for the development of liver failure (odds ratio 2.46).ConclusionsThis study demonstrated that preoperative sarcopenia increased the morbidity rate including the rate of liver failure, in patients who underwent major hepatectomy with extrahepatic bile duct resection.

Surgery for Recurrent Biliary Tract Cancer: A Single-center Experience With 74 Consecutive Resections.

OBJECTIVEnTo review our experiences with surgery for recurrent biliary tract cancer (BTC).nnnBACKGROUNDnFew studies have reported on surgical procedures for recurrent BTC; therefore, it is unclear whether this surgery has survival benefit.nnnMETHODSnBetween 1991 and 2010, 606 patients had recurrences after resection of BTC (gallbladder cancer, n = 135; cholangiocarcinoma, n = 471); 74 patients underwent resection for recurrence, whereas the remaining 532 did not. The medical records were retrospectively reviewed.nnnRESULTSnCompared with the 532 patients without surgery for recurrence, the 74 patients with surgery had less advanced cancer, and their time to recurrence was significantly longer (1.4 vs 0.8 years; P < 0.001). A total of 89 surgical procedures for recurrence were performed in the 74 patients (1 time in 63 and ≥2 times in 11). Survival after recurrence was significantly better in the 74 patients with surgery than in the 532 without (32% vs 3% at 3 years; P < 0.001). Survival after surgery for recurrence was (1) similar between gallbladder cancer and cholangiocarcinoma; (2) significantly better in patients with initial disease-free interval of 2 or more years; (3) significantly worse in patients with chest or abdominal wall recurrences; and (4) significantly better in patients with pN0 disease in their primary cancer. Nodal status of the primary tumor and the site of initial recurrence were identified as independent prognostic factors after surgery for recurrence.nnnCONCLUSIONSnSurgical resection for recurrent BTC can be performed safely and offers a better chance of long-term survival in selected patients.

The adverse effects of preoperative cholangitis on the outcome of portal vein embolization and subsequent major hepatectomies

BACKGROUNDnThe presence of cholangitis has been shown to impair liver regeneration capacity after major hepatectomy in a rat cholangitis model. It is unclear, however, whether the presence of cholangitis has any impact on liver generation in clinical settings.nnnOBJECTIVEnTo determine the effects of preoperative cholangitis on hepatic regeneration rates after preoperative portal vein embolizations (PVEs) and postoperative courses after major hepatectomies in humans.nnnMETHODSnFrom 1991 to 2012, 450 patients underwent preoperative PVEs and subsequent major hepatectomies. Among them, 72 patients (16.0%) had preoperative cholangitis. The volume change of the nonembolized lobe after PVE and the postoperative outcomes after a major hepatectomy were compared between cholangitis and noncholangitis groups.nnnRESULTSnThe average volume increase in the nonembolized lobe after PVE was almost identical in both the cholangitis (10.0%) and noncholangitis (9.5%) groups. The average term required to acquire institutional safety criteria, however, was longer in the cholangitis group (24.3 days) compared with the noncholangitis group (18.3 days) (P < .001). The postoperative maximum serum total bilirubin levels (5.7 mg/dL vs 8.1 mg/dL, P = .035), morbidity rate (56% vs 78%, P = .001), and postoperative hospital stay (44 days vs 53 days, P = .021) were all greater in the cholangitis group compared with the noncholangitis group. With multivariate logistic regression analyses, the presence of preoperative cholangitis was identified as one of the independent risk factors for postoperative morbidity.nnnCONCLUSIONnThese results indicate that patients with preoperative cholangitis should be carefully managed during their perioperative periods of PVE and after major hepatectomies.

A study of the right intersectional plane (right portal scissura) of the liver based on virtual left hepatic trisectionectomy

AbstractBackgroundLeft hepatic trisectionectomy is a challenging procedure.n For an anatomically correct resection, it is necessary to have understanding of the right intersectional plane; however, little is known on this issue. The purpose of this study was to investigate the 3D anatomy of the right intersectional plane and to enable safe and precise left trisectionectomy.MethodsA virtual left trisectionectomy was performed using 3D-processing software, in patients who underwent computed tomography. The reconstructed images were reviewed, and attention was paid to the extent of the right hepatic vein (RHV) exposure on the transected plane and the type of the inferior right hepatic vein (IRHV).ResultsOf the 200 study patients, 109 (54.5xa0%) patients showed complete exposure of the RHV on the transected plane, whereas the remaining 91 exhibited partial exposure. In the 109 patients with complete exposure, 58 (53.2xa0%) patients had no IRHV and the remaining 51 had a small IRHV. None of the patients had a large IRHV. In contrast, of the 91 patients with partial exposure, only 10 (11.0xa0%) patients had no IRHV, 35 (38.5xa0%) had a small IRHV, and 46 (50.5xa0%) patients had a large IRHV. The incidence of IRHV types was significantly different between the two groups (Pxa0<xa00.001).ConclusionsThe RHV does not always run along the right intersectional plane, i.e., the vein is not always fully exposed on the transected plane even after anatomically correct left trisectionectomy. The extent of the RHV exposure is closely related to the type of the IRHV.

The Pathologic Correlation Between Liver and Portal Vein Invasion in Perihilar Cholangiocarcinoma: Evaluating the Oncologic Rationale for the American Joint Committee on Cancer Definitions of T2 and T3 Tumors

BackgroundThe American Joint Committee on Cancer (AJCC) has recommended that cancers with liver involvement be graded T2b and those with portal vein involvement be graded T3, although the value of staging as prognostic factors remains unclear. We evaluated the current definition of the T2/3 tumors for perihilar cholangiocarcinoma.MethodsA total of 202 patients with perihilar cholangiocarcinoma who underwent hepatectomy without vascular resection were enrolled. Clinicopathologic data about invasion of the liver and the unilateral portal vein were evaluated.ResultsThe liver and the unilateral portal vein were involved in 100 (49.5xa0%) and 38 (18.8xa0%) patients, respectively. The survival rates were not significantly different between patients with and without liver invasion (48.6 vs. 52.2xa0%, respectively, at 5xa0years, Pxa0=xa00.157) and between patients with or without unilateral portal vein invasion (43.2 vs. 52.1xa0%, respectively, at 5xa0years, Pxa0=xa00.363). The survival rate of patients with tumors staged pT2b was not significantly different from the rate of patients with pT2a (63.4 vs. 55.6xa0% at 5xa0years, Pxa0=xa00.912), and the pT2b tumor patient survival rate was better than the rate of patients with pT3 (34.9xa0% at 5 years, Pxa0=xa00.011). Using multivariate analysis, nodal metastasis (Pxa0=xa00.003), positive surgical margin (Pxa0=xa00.010), and Bismuth type IV tumor (Pxa0=xa00.039) were identified as independent prognostic factors.ConclusionsThe liver and the unilateral portal vein are frequently involved in perihilar cholangiocarcinoma. The determinants of the current AJCC T2/3 tumor classifications are rational; however, subdivision of T2 tumors may be of less clinical value.

Surgical and Radiological Studies on the Length of the Hepatic Ducts

BackgroundRight-sided hepatectomy is often selected for perihilar cholangiocarcinoma, due to the anatomic consideration that “the left hepatic duct is longer than that of the right hepatic duct”. However, only one study briefly mentioned the length of the hepatic ducts. Our aim is to investigate whether the consideration is correct.MethodsIn surgical study, the lengths of the resected bile duct were measured using pictures of the resected specimens in 475 hepatectomized patients with perihilar cholangiocarcinoma. In radiological study, the estimated lengths of the bile duct to be resected were measured using cholangiograms reconstructed from computed tomography images in 61 patients with distal bile duct obstruction.ResultsIn surgical study, the length of the resected left hepatic duct was 25.1xa0±xa06.4xa0mm in right trisectionectomy (nxa0=xa037) and 14.9xa0±xa05.7xa0mm in right hepatectomy (nxa0=xa0167). The length of the right hepatic duct was 14.1xa0±xa05.7xa0mm in left hepatectomy (nxa0=xa0149) and 21.3xa0±xa06.4xa0mm in left trisectionectomy (nxa0=xa0122). In radiological study, the lengths of the bile duct corresponding to the surgical study were 34.1xa0±xa07.8, 22.4xa0±xa07.1, 20.8xa0±xa04.8, and 31.6xa0±xa05.3xa0mm, respectively. Both studies determined that the lengths of the resected bile ducts were (1) similar between right and left hepatectomies, (2) significantly shorter in right hepatectomy than in left trisectionectomy, and (3) the longest in right trisectionectomy.ConclusionsThe aforementioned anatomical assumption is a surgeon’s biased view. Based on our observations, a flexible procedure selection is recommended.

Single-incision laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallbladder drainage

PurposeSingle-incision laparoscopic cholecystectomy (SILC) has been performed for patients with gallbladder stones but without acute cholecystitis. We report our experience of performing SILC for patients with cholecystitis requiring percutaneous transhepatic gallbladder drainage (PTGBD).MethodsWe performed SILC via an SILS-Port with additional 5-mm forceps through an umbilical incision in ten patients with cholecystitis requiring PTGBD.ResultsAll procedures were completed successfully. The mean operative time was 124xa0min (range 78–169xa0min) and there were no intraoperative or postoperative complications. The mean postoperative hospital stay was 2.7xa0days. All patients were satisfied with the cosmetic results.ConclusionsOur procedure may represent an alternative to conventional laparoscopic cholecystectomy (CLC) for patients who fervently demand the cosmetic advantages, despite cholecystitis requiring PTGBD. SILC should be performed carefully to avoid bile duct injury because the only advantage of SILC over CLC is cosmetic.

Management strategy for biliary stricture following laparoscopic cholecystectomy

Biliary strictures following laparoscopic cholecystectomy (Lap‐C), which are often associated with vascular injuries, remain a serious problem to manage. The aim of this study was to review our experiences with postoperative biliary stricture.

Clinicopathological Significance of Mucin Production in Patients with Papillary Cholangiocarcinoma

BackgroundThe clinicopathologic significance of mucin production in patients with papillary cholangiocarcinoma (PCC) is still controversial. We aimed at clarifying the similarities and differences between PCC cases with and without mucin secretion with regard to biological behavior and clinical course.MethodsAmong 644 patients with surgically resected cholangiocarcinoma (1998–2011), 184 (28xa0%) patients were considered to have PCC and were enrolled in the study. Those patients were divided into two groups based on whether their PCC was mucin-producing (PCC-M, nxa0=xa089) or not (PCC-NM, nxa0=xa095). The presence of mucin secretion was determined by the cut surface of the specimens and by pathologic examination.ResultsThe clinicopathological features of PCC-M and PCC-NM largely overlapped. No significant between-group differences in malignant potential characteristics, including the depth of invasion, pathological T classification, and regional/periaortic lymph node metastasis, were observed (Pxa0=xa00.193, 0.181, 0.083, and 0.674, respectively). However, a few clinicopathological differences existed between the two PCC types, i.e., the predominant histological type and epithelial subtype (Pxa0<xa00.001 and Pxa0=xa00.016, respectively). Immunohistochemically, MUC2, MUC5AC, MUC6, and HGM were more frequently expressed in PCC-M than PCC-NM (Pxa0<xa00.002 in all). The disease-specific survival values were not significantly different between the two PCC types (PCC-M; 60xa0% at 5xa0year, PCC-NM; 46xa0%, Pxa0=xa00.097).ConclusionPCC-M and PCC-NM were similar in morphology and prognosis. Although a few clinicopathological differences exist between them, their overlapping features and identical survival curves appear to justify the lack of a specific treatment modality for either type.