Shojiro Hata

Volume regeneration after right liver donation

After right hepatectomy with the middle hepatic vein trunk for a graft, the venous outflow in segment IV is disturbed. There are limited data, however, regarding the effect of middle hepatic vein deprivation on liver regeneration or functional recovery. Living donors who underwent right hepatectomy with preservation of the middle hepatic vein (Group A, n = 58) and those deprived of the middle hepatic vein (Group B, n = 13) were reviewed. When the donor was under 50 years old and the remnant left liver was estimated to be more than 35% of the whole liver, right liver graft harvesting with the middle hepatic vein trunk was considered. Volume regeneration of segments I–III, segment IV, and overall liver volume was assessed at the third postoperative month using computed tomography. The regeneration rate of segment IV was significantly impaired in Group B donors compared with that in Group A donors (125% vs. 45%, P = 0.008). In contrast, the regeneration rate of segments I –III was significantly higher than that in Group A (208% vs. 263%, P = 0.004). There was no significant difference in the regeneration rate of the whole left liver or functional recovery between groups. Multivariate analysis revealed that the resection type (group) was a significant predictive factor for the regeneration rate of segments I–III and segment IV. When deprived of the middle hepatic vein, liver regeneration of segment IV was impaired but was compensated for by the regeneration of segments I–III. In conclusion, extended right hepatectomy can be safely performed with careful preoperative consideration using these criteria. (Liver Transpl 2004;10:65–70.)

Usefulness of contrast-enhanced intraoperative ultrasound using Sonazoid in patients with hepatocellular carcinoma.

Objective:To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC). Background:Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs). Methods:Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period. Results:Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm). Conclusions:With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.

Contrast-enhanced intraoperative ultrasonography using perfluorobutane microbubbles for the enumeration of colorectal liver metastases.

Intraoperative ultrasonography (IOUS) is considered the standard for the identification of liver metastases. Use of lipid‐stabilized perfluorobutane microbubbles as an ultrasound contrast agent may improve this. The value of contrast‐enhanced IOUS (CE‐IOUS) in enumerating colorectal liver metastases was studied here.

Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions.

BackgroundDelayed gastric emptying (DGE) is one of the most troublesome complications after pancreaticoduodenectomy (PD).MethodsBetween 2004 and 2009, 387 patients underwent PD and of these, 302 patients (78%) underwent pylorus-preserving PD. The stapled reconstruction of duodeno- or gastrojejunostomy was introduced in 2006, and 70 patients (18%) underwent stapled Roux-en-Y reconstruction. Postoperative DGE was defined based on the International Study Group on Pancreatic Surgery classification, and grade B or C DGE was considered to be clinically relevant. Risk factors for DGE were evaluated using univariate and multivariate analyses.ResultsFour patients died in the hospital (1.0%). Postoperative DGE was found in 70 patients (18%). DGE was less frequently seen in stapled reconstruction than in hand-sewn reconstruction (7.2% vs. 21%, P < 0.001), and in single-layer anastomosis than in double-layer anastomosis (12% vs. 24%, P = 0.02). The multivariate logistic regression analysis revealed that the independent risk factors for DGE were postoperative pancreatic fistula (risk ratio [RR] 2.4, P = 0.002), hand-sewn reconstruction (RR 2.9, P = 0.03) and male (RR 2.2, P = 0.02).ConclusionThe method of alimentary reconstruction affected the occurrence of DGE. The incidence of DGE was less in stapled reconstruction than in hand-sewn reconstruction.

Correlation Between Contrast-Enhanced Intraoperative Ultrasound Using Sonazoid and Histologic Grade of Resected Hepatocellular Carcinoma

OBJECTIVE Our aim was to accurately assess the correlation between findings of contrast-enhanced intraoperative ultrasound using Sonazoid and histologic grade of hepatocellular carcinoma (HCC). SUBJECTS AND METHODS We enrolled 239 consecutive patients who were undergoing surgery for HCC for this study. Because 33 extensively necrotic HCCs were excluded, a total of 374 histologically proven HCCs were detected in all resected specimens and were the study subjects (71 well-differentiated, 239 moderately differentiated, and 64 poorly differentiated HCCs). After a laparotomy and liver mobilization, contrast-enhanced intraoperative ultrasound in the harmonic mode was performed after a Sonazoid injection. The first minute was defined as the vascular phase, in which the vascularity of the 239 HCCs was assessed. After an approximately 15-minute delay, a thorough liver exploration was performed (Kupffer phase). Preoperative dynamic CT was routinely performed, and the findings were assessed for reference. RESULTS The proportion of hypervascular tumors during the vascular phase tended to be lower among well-differentiated than among moderately and poorly differentiated HCCs (66% vs 80%, p = 0.058). The proportion of hypoechoic tumors during the Kupffer phase was significantly lower among well-differentiated than among moderately and poorly differentiated HCCs (54% vs 92%, p < 0.0001). In dynamic CT, the proportions of hypervascular tumors during the early phase and hypodense tumors during the late phase were significantly lower among well-differentiated HCCs than among moderately and poorly differentiated HCCs, respectively (early phase, 51% vs 87%, p < 0.0001; late phase, 59% vs 85%, p < 0.0001). CONCLUSION Contrast-enhanced intraoperative ultrasound using Sonazoid is useful for estimating the histologic grade of HCC.

Prognosis of patients undergoing hepatectomy for solitary hepatocellular carcinoma originating in the caudate lobe

BACKGROUND Operative and nonoperative treatment for hepatocellular carcinoma (HCC) originating in the caudate lobe is regarded as challenging because of its deep location in the liver and possibly worse prognosis than HCC in other sites in the liver. The objective of this study is to investigate the clinicopathologic factors and survival of patients who underwent hepatectomy for solitary HCC originating in the caudate lobe. METHODS A retrospective review of 783 patients who underwent curative hepatectomy for solitary HCC between 1988 was performed. Clinicopathologic factors and survival rate of 46 (5.9%) patients with HCC originating in the caudate lobe were compared with those of 737 (94%) patients with HCC arising in other sites. RESULTS The clinical backgrounds of patients with HCC in the caudate lobe and in other sites were comparable. Hepatectomy for HCC in the caudate lobe was associated with greater operative time and blood loss than for HCC in other sites of the liver. Pathologically, HCC in the caudate lobe was associated with less frequent intrahepatic metastasis, lesser operative margins, and more frequent tumor exposure than HCC in other sites. Overall and disease-free 5-year survival rates of the 46 patients with solitary HCC in the caudate lobe were 76% and 45%, respectively; no significant difference was observed in the overall or disease-free survival rates between the 2 groups (P = .07 and P = .77, respectively). Resection of HCC in the paracaval portion of the caudate lobe (n = 27) was associated with more frequent anatomic resection, greater operative time and blood loss, and a lesser operative margin than HCC in the Spiegel lobe or caudate process (n = 19). CONCLUSION Resection for HCC in the caudate lobe, especially in the paracaval portion, remains technically demanding. The prognosis of patients with solitary HCC in the caudate lobe, however, was as good as that of patients with solitary HCC in other sites in the liver.

Left liver grafts for patients with MELD score of less than 15.

Left liver grafts are now seldom used for adult recipients of living donor liver transplantations because the left liver is believed to be insufficient to meet patient metabolic demands. At the University of Tokyo Hospital, left liver grafts have been limited to patients with fulminant hepatic failure or chronic hepatic failure with a model for end-stage liver disease (MELD) score of less than 15. Since 2000 25 adult patients received left liver grafts. The mean graft weight to standard liver volume ratio was 44%. The rates of acute rejection, vascular, and biliary complications were 24%, 0%, and 25%, respectively. All patients survived the operation and are doing well with a mean follow-up of 17 months. The present results suggest that left liver grafts provide acceptable results among patients satisfying our criteria.

Clinicopathological subclassification of biliary cystic tumors: Report of 4 cases with a review of the literature.

Biliary cystic tumors are rare hepatic neoplasms, and knowledge regarding the origin and pathology of these tumors remains vague. They should be analyzed in more detail. In our institution, 4 biliary cystic tumor surgeries were performed between December 1999 and March 2010. Pathological evaluation of resected specimens was performed to evaluate the characteristics of the intracystic epithelium and to determine the presence or absence of interstitial infiltrate, ovarian mesenchymal stroma (OMS), luminal communication between the cystic tumor and the bile duct, and mucin (MUC) protein expression. We evaluated the following 4 cases: case 1, a 21-year-old woman with a biliary cystadenoma who underwent extended right hepatectomy; case 2, a 39-year-old woman with a biliary cystadenoma who underwent left hepatectomy; case 3, an 80-year-old man with a biliary cystadenoma who underwent left hepatectomy; and case 4, a 61-year-old man with a biliary cystadenocarcinoma revealing papillary proliferation of atypical epithelium and interstitial infiltrates who underwent left hepatectomy. Case 3 had papillary proliferation of the intracystic atypical epithelium but showed interstitial infiltrates. Luminal communication with the bile duct, centrally or peripherally, was found in all 4 cases. Only case 2 showed OMS. Immunohistochemical staining revealed the following findings: cases 1 and 2, MUC1-/MUC2-; case 3, MUC1+/MUC2-; and case 4, MUC1+/MUC2+. It is important to gather information on more cases of biliary cystic tumors because atypical cases were observed, where both OMS and luminal communication with the bile duct were present or absent.

Total pancreatectomy with en bloc celiac axis resection for a pancreatic adenocarcinoma involving both the gastroduodenal artery and the celiac artery.

A pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery is often considered to be unresectable because the simultaneous division of both arteries may result in an acute severe ischemia of the liver and the stomach. We report here a case of total pancreatectomy with en bloc celiac axis resection for a 61-year-old female with a pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery. The patient had a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery, which was directly arising from the aorta. Preserving these collateral arteries, neither hepatic artery reconstruction nor total gastrectomy was needed after resection. The reported incidence of similar arterial anatomy was only 0.2% but the precise evaluation of arterial anatomy is important to offer a chance of curative resection for patients with usually unresectable locally advanced pancreatic cancer.