Syuuichi Tobinaga

Usefulness of intraoperative diagnosis of hepatic tumors located at the liver surface and hepatic segmental visualization using indocyanine green- photodynamic eye imaging

BACKGROUND To improve the diagnostic accuracy for hepatic tumors on the liver surface, we investigated the usefulness of an indocyanine green-photodynamic eye (ICG-PDE) system by comparison with Sonazoid intraoperative ultrasonography (IOUS) in 117 patients. Hepatic segmentation by ICG-PDE was also evaluated. METHODS ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. ICG was injected into portal veins to determine hepatic segmentation. RESULTS Accurate diagnosis of liver tumors was achieved with ICG-PDE in 75% of patients, lower than with IOUS (94%). False-positive and false-negative diagnosis rates for ICG-PDE were 24% and 9%, respectively. New small HCCs were detected in 3 patients. The ICG fluorescent pattern in tumors was strong staining in 41%, weak staining in 13%, rim staining in 20% and no staining in 26%. Hepatocellular carcinoma predominantly showed strong staining (61%), while rim staining predominated in cholangiocellular carcinoma (60%) and liver metastasis (55%). Hepatic segmental staining was performed in 28 patients, proving successful in 89%. CONCLUSION ICG-PDE is a useful tool for detecting the precise tumor location at the liver surface, identifying new small tumors, and determining liver segmentation for liver resection.

Usefulness of the combination procedure of crash clamping and vessel sealing for hepatic resection.

Minimization of blood loss during resection of the hepatic parenchyma in hepatectomy remains a major problem. The usefulness of the LigaSure sealing system has been reported.

Usefulness of sonazoid–ultrasonography during hepatectomy in patients with liver tumors: A preliminary study

To improve diagnostic accuracy of intraoperative ultrasonography (IOUS), we investigated the usefulness of new contrast medium of microbubble agent, Sonazoid as a preliminary study.

Postoperative changes in protein-induced vitamin K absence or antagonist II levels after hepatectomy in patients with hepatocellular carcinoma: relationship to prognosis

BACKGROUND alpha-Fetoprotein (AFP) has been used as a marker for hepatocellular carcinoma (HCC). However, AFP levels are often high in patients with chronic hepatitis or cirrhosis. Protein-induced vitamin K absence or antagonist II (PIVKA-II) is more sensitive for the diagnosis of HCC and prediction of patient survival. Changes in these markers after treatment may reflect treatment curability and patient outcome. METHODS We conducted a retrospective analysis of prognosis of 63 HCC patients with high preoperative levels of AFP and PIVKA-II who underwent hepatectomy and examined the relationship between postoperative changes in both markers at 1 month and patient survival. Subjects were divided into three groups according to changes in these tumour markers after hepatectomy: normalization (N) group, decreased but still above the normal level (D) group and unchanged (U) group. RESULTS There were no significant differences in the numbers of patients who developed tumour recurrence between changes in AFP and PIVKA-II. Survival analysis showed no significant differences in tumour-free and overall survivals between groups with respect to AFP level. The PIVKA-II-N group showed significantly better tumour-free and overall survival compared with the D and U groups (p<0.01). Multivariate analysis that included other prognostic factors identified changes in PIVKA-II level as a significant and independent prognostic factor associated with overall survival. DISCUSSION Although changes in AFP did not correlate with patient prognosis, normalization of PIVKA-II was significantly associated with good patient survival after hepatectomy. Normalization of PIVKA-II after hepatectomy reflected the efficacy of treatment and is a suitable predictor of prognosis in HCC patients.

Comparison of Results between Pylorus-Preserving Pancreaticoduodenectomy and Subtotal Stomach-Preserving Pancreaticoduodenectomy: Report at a Single Cancer Institute

BACKGROUND/AIMS Pylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD. METHODOLOGY PPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009. RESULTS Pancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01). CONCLUSIONS SSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

Relationship of Hepatic Functional Parameters with Changes of Functional Liver Volume Using Technetium-99m Galactosyl Serum Albumin Scintigraphy in Patients Undergoing Preoperative Portal Vein Embolization: A Follow-Up Report

BACKGROUND To identify predictors of changes in functional hepatic volumes after portal vein embolization (PVE) before hepatectomy, we examined the relationship between hepatic functional parameters and changes in functional volume of the embolized and non-embolized liver based on a previous volumetric analysis. MATERIAL AND METHODS Subjects were 24 patients who underwent PVE, which was performed through the trans-ileocolic vein (n = 4) or by percutaneous transhepatic puncture (n = 20). The RI liver volume parameter was measured by liver scintigraphy with technetium-(99m) galactosyl human serum albumin ((99m)Tc-GSA). Computed tomography (CT) volume parameter was also measured. RESULTS Significant atrophy of the embolized liver and hypertrophy of the non-embolized liver (change of 72 ± 108 cm(3) and 111 ± 91 cm(3), respectively) (change of 7.8%) was observed after PVE. The change in these RI volume parameters (change of 173 ± 175 cm(3) and 145 ± 137 cm(3) , respectively) (16.5%) was significantly greater than CT volume parameters (P < 0.01). CT vol and RI vol in the embolized and non-embolized liver were well correlated (r = 0.75 and 0.69, respectively). However, the correlation between CT and RI volume parameters in the embolized and non-embolized liver after PVE was very weak (r = 0.17 and 0.03, respectively). Only alkaline phosphatase level correlated negatively with atrophic CT volume parameter of the embolized liver (r = -0.455, P < 0.05). When compared with CT volume parameter, more parameters were significantly correlated with changes of RI volume parameter in the embolized liver: pre-PVE pressure; ICGR15; and serum levels of hyaluronate, total bilirubin, albumin, and alkaline phosphatase. Only platelet count was significantly correlated with hypertrophy of the non-embolized liver. CONCLUSION RI volume parameter might more accurately reflect functional changes in the embolized liver and non-embolized liver than CT volume parameter. Correlated parameters might allow us to predict the functional effect of PVE.

Intraductal papillary growth of liver metastasis originating from colon carcinoma in the bile duct: Report of a case

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.

Left hepatectomy accompanied by a resection of the whole caudate lobe using the dorsally fixed liver-hanging maneuver

A resection of the caudate lobe often needs to be combined with a hemi-hepatectomy for hilar cholangiocarcinoma or a liver tumor in segment 1. To achieve complete resection of the whole caudate lobe, the cut line between the right edge of the paracaval portion and the right lateral sector should be precisely controlled. The liver-hanging maneuver (LHM) is a useful anterior approach that does not require mobilization of the remnant liver. However, the precise set-up of the cut line of the right edge has not been optimized in previous reports. We herein introduce a new modification of LHM that we named the “dorsally fixed liver-hanging maneuver” (DF-LHM) based on the results in five patients who underwent left hepatectomy combined with a total resection of segment 1. This technique provided adequate cut planes along the right edge of the caudate lobe, shortening the transection time and reducing intraoperative blood loss. The DF-LHM may represent a new key technique for this type of hepatectomy, and further applications for other anatomical resections can be modeled on the strategy.

Prediction of Indocyanine Green Retention Rate at 15 Minutes by Correlated Liver Function Parameters before Hepatectomy

BACKGROUND Indocyanine green retention rate at 15 min (ICGR15) is a useful marker of liver function in deciding on the extent of hepatectomy. To determine ICGR15 regardless of liver condition, we sought to establish a formula for converted ICGR15 based on conventional blood tests and technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy. MATERIALS AND METHODS We measured liver function parameters, including ICGR15, in 307 patients, including 265 liver cancer patients without biliary obstruction (no obstruction group) and 42 with biliary obstruction (obstruction group). RESULTS In the no obstruction group, multiple regression analysis identified blood pool clearance ratio (HH15), liver uptake ratio (LHL15) calculated by heart and liver activity between 3 and 15 min after injection of (99m)Tc-GSA, and serum hyaluronic acid as significant correlates (P < 0.05). The calculated converted ICGR15 was then equal to 0.02∗HA + 0.276∗(HH15∗100)-0.501∗(LHL15∗100) + 41.41. The mean difference between actual and converted ICGR15 was significantly lower in the obstruction than in the no obstruction group (P = 0.031). A significantly larger proportion of patients of the obstruction group had lower converted ICGR15 than those of the no obstruction group (P = 0.045). CONCLUSION The converted ICGR15 is useful for evaluating hepatic function in patients with biliary obstruction who plan to undergo major hepatectomy.

Strategy of treatment for hepatocellular Carcinomas with vascular infiltration in patients undergoing hepatectomy

Vascular infiltration (VI) is an important prognostic factor for hepatocellular carcinoma (HCC) and predictive parameters are necessary to preoperatively decide treatment strategies in patients with HCC.