Tadaaki Shiba

Laparoscopic partial hepatectomy and left lateral segmentectomy: Technique and results of a clinical series

BACKGROUND Technical difficulties have impeded the development of laparoscopic hepatectomy. This article describes a new technique for performing partial hepatectomy and left lateral segmentectomy by means of laparoscopy, and the results in a series of 11 consecutive patients are reported. METHODS A microwave tissue coagulator is used in combination with an ultrasonic surgical aspirator to divide hepatic parenchyma without pneumoperitoneum. Branched vessels and ducts are clipped and transected. The largest vessels were suture ligated in some cases. The endoscopic linear stapler was used to transect the left hepatic vein for left lateral segmentectomy. The resected liver was maneuvered into a specimen bag and removed. The argon beam coagulator was used to secure hemostasis of the plane of transection. RESULTS Eleven patients underwent laparoscopic hepatic resection. Indications included isolated metastatic lesion, hepatocellular carcinoma, hemangioma, Wilsons disease, and hemochromatosis. Three patients underwent left lateral segmentectomy, and eight underwent partial hepatectomy. Ten procedures were performed uneventfully; one patient required conversion to open hepatectomy because of excessive bleeding. Notable differences were seen in blood loss compared with open hepatectomy, and no operative complications occurred. Postoperative pain was minimal. CONCLUSIONS The laparoscopic hepatectomy, especially partial or left lateral segmentectomy, appears to be a viable surgical alternative in selected cases.

Laparoscopic hepatectomy for extrahepatic growing tumor. Surgical strategy based on extrahepatic growing index.

AbstractsBackground: This article describes the operative procedures, varying difficulties, and required instrumentation for performing laparoscopic hepatectomy (LH) on the basis of a lesions extrahepatic growing (EG) index, as calculated by computed tomography (CT). Methods: Laparoscopic partial hepatectomy cases were divided into the following two groups: an EG tumor group (n = 11) and an intrahepatic tumor group (n = 8). The surgical procedures, operative results, and laparoscopic instrumentation for these two groups were compared based on the EG index (/cm2; maximum diameter of tumor pedicle/maximum vertical diameter of tumor/area of the tumor). Results: The mean operative time was significantly shorter and the mean blood loss was significantly less in the EG tumor group than in the intrahepatic tumor group. In addition, in the EG tumor group, there were significant differences in mean operative time and mean blood loss related to the values associated with the EG index (p <0.05, P <0.01). THE SELECTION OF LAPAROSCOPIC INSTRUMENTS WAS BASED ON THE EG INDEX, AS FOLLOWS: (A) LESIONS WITH AN EG INDEX >5/cm2 underwent resection in combination with a microwave tissue coagulator and an ultrasonic surgical aspirator (13 cases, including intrahepatic tumor cases); (b) lesions with an EG index of 5–15/cm2 underwent resection in combination with a microwave tissue coagulator and laparosonic coagulating shears (four cases); (c) lesions with an EG index <%15/cm2 underwent resection with a laparoscopic linear stapler (two cases). Conclusion: Our preliminary experience leads us to believe that it is useful to calculate the EG index by CT scan before formulating the technical strategy for a subsequent LH procedure.

Protective Effect of Human Urinary Thrombomodulin on Ischemia- Reperfusion Injury in the Canine Liver

This study was performed to determine whether human urinary soluble thrombomodulin plays a role in liver ischemia-reperfusion injury. Liver ischemia was induced in two groups of dogs. Group 1 was exposed to 60 min ischemia, and group 2 was exposed to 60 min ischemia after preischemic administration of human urinary soluble thrombomodulin. In group 1, the thrombin-antithrombin complex and hyaluronic acid were significantly elevated after ischemia, compared with the preischemic values. While liver issue blood flow and the plasmin-α2-plasmin inhibitor complex significantly decreased, AST, ALT and m-AST dramatically increased after reperfusion. In group 2, the increase in the thrombin-antithrombin complex and hyaluronic acid was significantly suppressed, and AST, ALT and liver tissue blood flow significantly improved, compared with group 1. Histologically, in group 2, the hepatic tissue structure, including endothelial cells, was relatively intact. These findings suggest that administration of thrombomodulin inhibits endothelial cell injury and coagulopathy and offers protection from liver ischemia-reperfusion injury.

Thyroid Papillary Carcinoma Recurring as Squamous Cell Carcinoma: Report of a Case

We report a case of local squamous cell carcinoma recurrence of thyroid papillary carcinoma, 4 years after subtotal thyroidectomy, in an 82-year-old woman. The papillary cancer of the right thyroid was histopathologically classified as T2a, N0, M0, Ex1; pT2a, pN1b, pEx1; Stage III. Fine-needle aspiration cytology of the recurrent tumor revealed atypical squamous epithelium-like cells with keratinization. The tumor was judged cytologically to be class III, defined as a suspicious malignancy and, after reoperation, it was diagnosed histopathologically as papillary carcinoma recurrence with extensive squamous metaplasia. The recurrent papillary carcinoma was thought to have changed to a squamous cell carcinoma because most of the tumor was occupied by atypical squamous cells, with a small amount of glandular tissue. The primary tumor was histologically diagnosed as a well-differentiated papillary carcinoma at the initial operation. It contained numerous tall neoplastic cells with eosinophilic granules and pseudostratified nuclei, indicating that it could potentially transform into squamous cell carcinoma. We report this case as an example of how squamous cell carcinoma of the thyroid can develop.

Reconstruction after Distal Gastrectomy by Interposition of a Double-jejunal Pouch Using a Triangulating Stapling Technique

Sustaining good nutrition and preventing postgastrectomy syndrome are important for increasing the quality of life after distal gastrectomy. Many surgeons have proposed surgical methods designed to enhance long-term patient quality of life. An immediate, safe method based on current physiologic reconstructive principles shown to reduce postoperative patient complaints is presented. A reconstructive method using a modified interpositioned double-jejunal pouch after distal gastrectomy in 18 cancer patients was reviewed. This method uses a triangulating stapling technique with wide end-to-side anastomosis between the residual stomach and the pouch. In all patients, the anastomosis site was without leakage or stenosis, and there were no episodes of severe reflux esophagitis, residual gastritis, or dumping syndrome. The mean pooling rate was 44.2%, and emptying half-time was 73.0 minutes. After 2 years the body weight was 91.3% of the preoperative weight, the food volume was 89.2% of normal intake, and meal frequency was 3.0 per day. This method of reconstruction is useful for immediate and safe creation of a wide anastomosis between the residual stomach and the double-jejunal pouch after distal gastrectomy and in the prevention of esophagitis and residual gastritis.

Double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver

A very rare case of a double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver in a 65‐year‐old‐man is discussed. The patient was hospitalized with epigastralgia in May 1997. Abdominal computed axial tomography revealed a tumor located in the left lobe of the liver and a left hepatic lobectomy was performed. The tumor recurred several months after surgery and the patient died on 4 June 1999. At autopsy, both a major tumor mass with extensive involvement, located in the surgical margin, and a small mass located in S7 were discovered. Microscopically, the major tumor was diagnosed as adenosquamous carcinoma and the small one in S7 as hepatocellular carcinoma. To our knowledge, this is the first case of a double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver. The pathological findings support the hypothesis that this tumor developed as a squamous transformation of adenocarcinoma.

Reassessment of monoethylglycinexylidide as preoperative liver function test in a rat model of liver cirrhosis and man.

Abstract It is known that lidocaine is rapidly metabolized by the hepatic cytochrome P-450 system to form monoethylglycinexylidide (MEGX), its primary metabolite. We analyzed serum MEGX levels experimentally and clinically by fluorescent polatization immunoassay to reassess preoperative liver microsome functions. Experimental study: Liver cirrhosis was produced in rats by intra-abdominal injection of thioacetamide. MEGX, indocyanine green test (ICG), and liver biochemical variables were measured periodically. Then, survival rates were assessed after the rats received a 70% hepatectomy. Clinical study: MEGX levels were measured in various human patients with chronic hepatitis or liver cirrhosis who underwent hepatectomy. Serum MEGX levels significantly dropped and ICG levels significantly rose with macroscopic and histologic progression of liver cirrhosis in rats. The MEGX levels correlated closely with albumin levels and ICG. Preoperative MEGX and ICG levels of the mortal group of rats differed significantly from those of the survival group with 70% hepatectomy. Furthermore, 100% of the rats with MEGX levels above 40 ng/ml and ICG levels below 1.0%. In the clinical study, MEGX levels were significantly lower in patients with chronic hepatitis or liver cirrhosis than in healthy volunteers and correlated significantly with liver function tests such as albumin, Fischers ratio, prothrombin time, hepaplastin and ICG. A significant difference was found in MEGX levels between patients receiving lobectomy and those receiving subsegmentectomy or partial hepatectomy. All patients tolerated their operations. Our data indicate that the MEGX test combined with ICG test and Child-Pugh classification is a better predictor of residual liver reserve capacity, and the analysis of hepatic MEGX formation might prove useful for rapid and reliable assessment liver function and choice of surgical treatment.

Analysis of thromboxane B3 converted from eicosapentaenoic acid in human platelet rich plasma by gas chromatography/mass spectrometry

Gas chromatographic mass spectrometric determination of thromboxane B3 (TXB3) synthesized from platelet is described. Eicosapentaenoic acid (EPA) was added to human platelet rich plasma and after the reaction the exstraction was carried out. Plasma thromboxanes were run through an Amberlite XAD-2 and SEP-PAK silica cartridge, and then chromatographed using silicagel thin layer plate to remove interfering materials, such as 6-keto-prostaglandin F1 alpha. Extracted thromboxanes were converted into the methoxime-dimethylisopropylsilylmethyl ester derivatives and they were measured by gas chromatography/ammonia chemical ionization mass spectrometry. Three peaks were obtained on the gas chromatogram which were presumed to be 3-series metabolite product TXB3 and their related substances. Results indicates the human platelet may easily convert EPA to TXB3 by adding EPA to PRP without adding arachidonic acid.

Laparoscopic Hepatectomy for the Patients with Hepatocellular Carcinoma.

原発性肝癌に対し腹腔鏡下肝切除を施行し, その手術手技や適応について検討した. 手術手技: 肝実質切離にはマイクロ波凝固装置と高周波凝固機能内臓超音波吸引装置の併用やハーモニックスカルペルを使用する. 視野展開はCO2塞栓の危険性から気腹を避け腹壁つり上げ法にする. 脈管切離にはクリッピングを, グリソンや肝静脈などの太い脈管には腹腔鏡用自動縫合器を使用する. 結果: 肝部分切除術7例, 肝外側区域切除術2例に試み, 1例は止血のため開腹術に移行したが, 8例は安全に施行できた. 手術時間, 出血量は通常の開腹術と差がなかった. 術後疼痛は軽微で, 回復も早く, 経過も良好であった. 適応: 高度肝硬変は原則的に除外, 系統的肝切除は外側区域切除を除き適応外とし, 腫瘍径は5cm以下, 部位は肝下区域の表面や辺縁, 外側区域に局在するものが適応となる. 原発性肝細胞癌に対しても, 腹腔鏡下肝切除は根治性と低侵襲を兼ね備えた外科治療の1手段になるものと考える.

A Case of Laparoscopic Splenectomy for Blunt Splenic Rupture after Abdominal Trauma.

IIId型外傷性脾破裂に対して腹腔鏡下に保存的治療の可否を判断し, その後腹腔鏡下に脾臓摘出術を施行した症例を経験した. 症例は14歳の男児. サッカーの試合中に腹部を打撲し, 当院に救急搬送された. 腹部CT, 超音波検査から脾損傷の程度はIIIc型と診断した. 循環動態は安定していたが, その後の画像診断で進行性の腹腔内出血と貧血を認めたため腹腔鏡を施行した. 腹腔内は消化管を含め他臓器の損傷はなく, 約1,200mlの血液が貯留していた. 脾損傷の程度はIIId型で脾温存は不可能と判断し, そのまま腹腔鏡下に脾臓摘出術を施行した. 術後経過は順調で, 第14病日に退院した. 腹腔鏡による脾損傷診断は, 保存的加療が可能であるかどうかを正確かつ迅速に判断し, その後摘脾術に移行することも可能である. 腹腔鏡下のアプローチは, これからの外傷性脾破裂に対する診断・治療戦略の選択肢になりうると考えられた.