Terumasa Noike

Results of Surgical Resection for Patients With Hilar Bile Duct Cancer: Application of Extended Hepatectomy After Biliary Drainage and Hemihepatic Portal Vein Embolization

Objective To evaluate the feasibility of an aggressive surgical approach incorporating major hepatic resection after biliary drainage and preoperative portal vein embolization for patients with hilar bile duct cancer. Summary Background Data Although many surgeons have emphasized the importance of major hepatectomy in terms of curative resection for patients with hilar bile duct cancer, this procedure results in a high incidence of postoperative morbidity and mortality in patients with cholestasis-induced impaired liver function. Methods A retrospective cohort study was conducted in 140 patients with hilar bile duct cancer treated from 1990 through 2001. Resectional surgery was performed in 79 patients, 69 of whom underwent major hepatic resection. Thirteen patients underwent concomitant pancreaticoduodenectomy. Preoperative biliary drainage was carried out in all 65 patients who had obstructive jaundice. Portal vein embolization was conducted in 41 of 51 patients undergoing extended right hepatectomy. Short- and long-term outcomes were evaluated. Results No patient experienced postoperative liver failure (maximum total bilirubin level, 5.4 mg/dL). The in-hospital mortality rate was 1.3% (1 in 79, resulting from cerebral infarction). A histologically negative resection margin was obtained more frequently when the scheduled extended hepatic resection was conducted (75% vs 44%, P = 0.0178). The estimated 5-year survival rate was 40% when histologically negative resection margins were obtained, but only 6% if the margins were positive. Multivariate analysis identified the resection margin and nodal status as independent factors predictive of survival. Conclusions Extensive resection, mainly extended right hemihepatectomy, after biliary drainage and preoperative portal vein embolization, when necessary, for patients with hilar bile duct cancer canbe performed safely and is more likely to result in histologically negative margins than other resection methods.

Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma.

BACKGROUND Staged hepatectomy after emergency transcatheter arterial embolization (TAE) has been advocated in ruptured hepatocellular carcinoma (HCC). However, there have been no reports of clinical series of this strategy. The purpose of this study was to evaluate the protocol of this therapeutic strategy. METHODS Sixteen patients with suspected rupture of HCC were included in the study. After emergency TAE, tumor resectability was assessed, followed by staged hepatectomy or repeated TAE. The patients were reevaluated with regard to rupture of HCCs. RESULTS Primary hemostasis was achieved successfully in all patients. Eleven patients were finally judged to have experienced HCC rupture. Seven of them underwent staged hepatectomy; the other four underwent repeated TAE because their tumors were considered unresectable. Survival time tended to be longer, but not to a significant extent, in patients who underwent hepatectomy (range, 139 to 1527 days; median, 375 days) than in those treated by TAE alone (range, 43 to 1317 days; median, 158 days). CONCLUSIONS Staged hepatectomy after TAE is a rational treatment for patients with ruptured HCC. Although TAE is highly effective for initial hemostasis, hepatectomy appears to provide better long-term survival.

Relationship between Doubling Time of Liver Metastases from Colorectal Carcinoma and Residual Primary Cancer

Background: The doubling times of liver metastases were calculated in order to clarify their usefulness in predicting the presence of residual cancer in the abdominal cavity in patients who had undergone curative resection of primary colorectal cancer. Patients and Methods: Tumor doubling times were calculated retrospectively in 22 patients by serial measurement of the size of their liver metastases. Results: Patients with a tumor doubling time of less than 92.4 days had a significantly poorer prognosis than those with a doubling time more than or equal to 92.4 days (p < 0.05). Local recurrence or peritoneal dissemination was significantly more likely to occur when the tumor doubling time was less than 92.4 days than when it was more than or equal to 92.4 days (p < 0.01). Conclusion: The doubling time of hepatic metastases in patients with colorectal carcinoma may be a useful prognostic indicator, with patients who have a shorter tumor doubling time carrying a greater risk of residual primary cancer in the abdominal cavity.

Plasma Concentration of Endothelin-1 Does Not Reflect Renal Vasoconstriction as Estimated by Duplex Ultrasonography in Cirrhosis

Endothelin, a potent vasoconstrictor, is thoughtto play a role in liver cirrhosis-related functionalkidney failure. Our aim was to investigate thecorrelation between renal vasoconstriction, as detected by a Doppler ultrasound technique, and plasmaconcentrations of endothelin in cirrhotic patients.Fifty cirrhotic patients underwent Doppler examinationsto detect renal vasoconstriction. The plasmaconcentration of endothelin was measured in 10 patients whoexhibited vasoconstriction of the renal microvesselsdiagnosed by Doppler waveform analysis and was comparedto that of patients in whom there was no sign of such vasoconstriction. No difference wasobserved in the plasma concentration of endothelinbetween patients in whom renal vasoconstriction wasdiagnosed and those in whom it was not. Our resultssuggested that the circulating endothelin does notreflect renal vasoconstriction, at least in the earlyphase of the functional renal failure associated withcirrhosis of the liver.