Shuichi Ishiyama

Subcutaneous seeding of small hepatocellular carcinoma after fine needle aspiration biopsy

Ultrasonically guided fine needle (21 gauge) aspiration biopsy (FNAB) was performed on a patient with a hepatocellular carcinoma (HCC) measuring 1.5 × 1.5 cm in segment VI of the liver. The tumour was located just beneath the liver surface. Subsegmentectomy of segment VI was performed. Twelve months after the biopsy and 10 months after the operation, levels of alpha‐fetoprotein (AFP) and protein induced by Vitamin K absence or antagonist‐II (PIVKA‐II) increased gradually without any evidence of recurrence of HCC in the liver. Thirteen months after the biopsy, the patient palpated a hard subcutaneous nodule 1.5 cm in diameter in the right lower anterior chest wall at the insertion site of the biopsy needle. A subcutaneous tumour was excised and histological examination revealed moderately differentiated HCC. The levels of AFP and PIVKA‐II normalized thereafter. These tumour markers were therefore useful for diagnosing the subcutaneous nodule as a metastatic HCC. The patient is currently doing well without further recurrence of HCC or needle‐tract seeding 23 months after subsegmentectomy and 11 months after excision of the subcutaneous tumour.

Altered biliary bilirubin profile in patients with persistent hyperbilirubinaemia after hepatic resection: Analysis of bile bilirubin subfractions by high-performance liquid chromatography

Subfractions of bilirubin in bile, obtained via biliary drainage tubes from 23 patients who had undergone radical surgery for bile duct cancer, were analysed by high‐performance liquid chromatography for 14 days after surgery. Five principal conjugated bilirubins were resolved: bilirubin diglucuronide (BDG); bilirubin monoglucuronide monoglucoside (BGG); bilirubin monoglucuronide monoxyloside (BGX); and two isomers of bilirubin monoglucuronide. After surgery, depression in concentration of BDG and elevation of BGG and BGX were found. These alterations were of higher magnitude in patients who had undergone hepatectomy, and especially prolonged in patients with hyperbilirubinaemia. These results suggest that the alteration in proportions of bilirubin conjugates might be a cause of hyperbilirubinaemia after hepatectomy.

Microsurgical technique used in right anterior segmentectomy and pancreatoduodenectomy with reconstruction of the right posterior hepatic artery for widespread bile duct cancer involving the hepatic hilus

A microsurgical technique was used in performing anterior hepatic segmentectomy and pancreatoduodenectomy with reconstruction of the posterior hepatic artery in a 64-year-old man with widespread bile duct cancer from the intrapancreatic bile duct over the hepatic hilus. The anterior hepatic artery was obviously involved and the posterior hepatic artery just behind common hepatic duct was very close to the cancer. Microsurgical anastomosis between the remnant gastroduodenal artery and the posterior hepatic artery at the hepatic hilus made it possible to preserve the posterior segment of the liver and to perform a curative resection of the cancer. The patient had pyrexia because of suprahepatic abscess after the operation, but the abscess drained spontaneously. Postoperative arteriogram showed neither obstruction nor kinking of the reconstructed artery. He was discharged 2 months after surgery and has been enjoying a normal quality of life for 10 months since, with no signs of recurrence. It is suggested that a microsurgical technique is useful for performing an accurate anastomosis with good patency that allows not only a safe but also a highly curative operation for advanced bile duct cancer.

Clinical evaluation of porto-systemic collaterals in patients with portal hypertension.

門脈圧亢進症66例の側副血行路について検討した.遠肝性側副血行路のうち左胃静脈の発生頻度が最も高く, 次いで短胃, 脾-後腹膜, 下腸間膜, 傍臍, 脾-腎静脈の順であった.左胃静脈の直径が大きいと静脈瘤の程度も高度であったが, 門脈圧や有効肝血流量との間には相関がなかった.食道静脈瘤の形成に関与しない側副血行路が太くなると門脈圧は低下する傾向があり, 有効肝血流量は有意に低下した.これらの側副血行路の直径の和が10mm以上の症例で食道静脈瘤からの吐血歴があるものはなかったが, 猪瀬型肝性脳症を示すものがあった.門脈圧亢進症の治療においては側副血行路の状態を十分把握する必要があると考えられた.