Toshiaki Kurokawa

Outcomes and Indications of Segmental Pancreatectomy

Background/Aim: To preserve pancreatic function, segmental pancreatectomy has been proposed for benign or low-malignancy tumors in the pancreatic body. Indications for the procedure, however, are still controversial. Methods: In this study, we investigated the advantages and disadvantages of segmental pancreatectomy compared with distal pancreatectomy and subsequently determined indications for segmental pancreatectomy. Results: The distal pancreatectomy patients had shorter operation times, lower incidence of operative complications, and shorter hospital stays compared to segmental pancreatectomy patients. Endocrine function in distal pancreatectomy patients deteriorated compared to that of segmental pancreatectomy patients. The postoperative 75-gram oral glucose tolerance test showed a diabetic pattern in 3 of 7 distal pancreatectomy patients, whereas none of the segmental pancreatectomy patients became diabetic after surgery. The relation between the length of the removed pancreas and plasma glucose at 2 h after the 75-gram glucose intake showed a significant correlation. Conclusion: According to our results, if the length of removed pancreas is longer than 12 cm, the patients will have a risk of acquiring diabetes. In those cases, the segmental pancreatectomy should be considered.

Cholangiocarcinoma coincident with schistosomiasis japonica

The relationship of parasitic liver disease to cholangiocarcinoma has long been debated, and it has been reported that cholangiocarcinoma is associated with opisthorchiasis viverrini. We report herein a rare case of cholangiocarcinoma associated with schistosomiasis japonica. A 76-year-old Japanese man with jaundice was diagnosed with cholangiocarcinoma. Radical resection was not done because of hepatic arterial and portal vein invasion. Biliary microwave tissue coagulation therapy was performed with placement of a metallic stent endoprosthesis. Twenty-two months after the treatment, however, the patient died from hematemesis. Autopsy findings revealed that there was no distant metastasis, even in the area of regional lymph node metastasis. The primary tumor in the hepatic hilar region had been replaced by necrotic debris resulting from the microwave therapy, and an expandable metallic stent was located in the center of the debris. Histological findings showed schistosome eggs, which were old and microcalcified, in veins in the colonic submucosa. Glisson’s fibrosis around the cancer lesion suggested that schistosomiasis japonica and cholangiocarcinoma can occur together with severe chronic inflammation of the portal vein.

Resection of a solitary pancreatic metastasis from renal cell carcinoma with a gallbladder carcinoma: Report of a case

Most metastatic pancreatic tumors are detected at an advanced stage and are not considered suitable for surgery; however, resection is sometimes indicated for a solitary pancreatic metastasis from renal cell carcinoma (RCC) and improves the prognosis. We report such a case, in which the hilar liver was resected with lymph node dissection and distal pancreatectomy. Histological examination revealed regional lymph node metastasis of gallbladder carcinoma (GBC), but all the surgical margins were free of cancer. Postoperative extra-beam radiation therapy was delivered to the hepatic portal lesion to prevent GBC recurrence. The patient remains disease-free 14 months after the completion of radiation therapy. Thus, if all affected areas can be resected, the prognosis associated with pancreatic metastasis from RCC may be favorable.

Prostaglandin E1 Continuous Hepatic Arterial Infusion in the Treatment of Postoperative Acute Liver Failure

Aim: In the treatment of severe liver damage, it is of greater advantage to administer prostaglandin E1 (PGE1) directly to the liver compared with systemic intravenous infusion, because of its high inactivation rate in the lungs. In comparison with intraportal infusion, hepatic arterial infusion is more advantageous because of its easier and safer accessibility. This study was designed to prove the superiority of hepatic arterial infusion to intravenous infusion. Methods: Changes in hepatic hemodynamics and oxygen delivery accompanying PGE1 infusion using both methods were investigated in pigs. In addition, continuous hepatic arterial infusion was applied in 3 cases of postoperative acute liver failure, for patients in whom other conventional treatments like plasma exchange failed to improve the functioning of the liver. Results: Hepatic arterial flow increased significantly accompanying hepatic arterial infusion of PGE1 at a rate of 0.1 μg/kg/min compared with intravenous infusion at the same rate in pigs. Such an increase resulted in elevation of total hepatic blood flow and oxygen delivery to the liver. Correspondingly, bile flow significantly increased accompanying hepatic arterial infusion of PGE1. Continuous hepatic arterial infusion was applied in 3 cases of postoperative acute liver failure. The infusion was continued for 7–9 days at a rate of 0.01 μg/kg/min without any complications through heparin-coated catheters inserted via the femoral artery. Significant increase in bile flow was observed in 2 cases in whom bile was collected, serum total bilirubin began to decrease in all these 3 cases, and the patients recovered from acute liver failure. Conclusion: Hepatic arterial infusion of PGE1 is very useful and effective in the treatment of acute liver failure.

Treatment for postoperative liver failure after major hepatectomy under hepatic total vascular exclusion

Abstract Hepatic total vascular exclusion (HTVE) with clamping of the portal triad and the inferior vena cava below and above the liver is a useful technique in the resection of major hepatic lesions situated close to the hepatic veins and inferior vena cava. From 1996 to 2000, five patients underwent major hepatectomy under HTVE; among these, liver failure occurred in two patients because of liver cirrhosis or hepatic artery interruption. In the former case, apheresis therapy (plasma exchange: 9 times), continuous prostaglandin E1 (PGE1) infusion via the hepatic artery (0.01 μg/kg/min) for 7 days, and hyperbaric oxygen therapy (3 times: 2 ATA, 60 min) were applied. In the latter case, apheresis therapy (plasma exchange: 9 times, continuous hemodiafiltration: 12 days) and continuous PGE1 infusion via the superior mesenteric artery for 7 days were applied. With these treatment modalities, both cases were cured of postoperative liver failure.

Three cases of small hepatocellular carcinoma presenting as obstructive jaundice

BACKGROUND Despite improved diagnostic tools, it is often difficult to make a correct diagnosis of small hepatocellular carcinoma (HCC) in patients with obstructive jaundice. CASE OUTLINES Three cases of small HCC (<2 cm diameter) presenting as obstructive jaundice are reported. All tumours were initially diagnosed as hilar cholangiocarcinoma based on ultrasonography, computed tomography, cholangiography and angiography. Because of insufficient hepatic function, none of the patients underwent hepatic resection. One patient died 8 months after first admission to our hospital, another died of disseminated intravascular coagulation I month after admission, and the third was treated with hepatic arterial infusion chemotherapy and survived >36 months. CONCLUSION It is important to consider HCC in the diagnosis of obstructive jaundice in patients who are predisposed to HCC because of liver cirrhosis and/or chronic viral hepatitis, and have elevated serum alpha-fetoprotein.

Enhanced cytokine production in peripheral blood monocytes following hepatic resection

Abstract Inflammatory cytokines have recently proven to be one of the major mediators in the pathogenesis of postoperative organ failures. The authors investigated the cytokine production from monocytes following major hepatic resection for hepatic tumors. In six patients subjected to hemihepatectomy with normal liver function, peripheral blood monocytes were separated and incubated with 10 μ g/ml LPS preoperatively and on postoperative days (POD) 1, 3, 7 and 14. Tumor necrosis factor (TNF)- α , interleukin (IL)-1 β and granulocyte-colony stimulating factor (G-CSF) secreted in the culture were measured by enzyme-linked immunosorbent assay. The monocyte count in the peripheral blood was also measured. Results showed that this cytokine production was enhanced after hepatic resection. Compared with preoperative values, significant increases were observed on POD 1, 3 and 7 in TNF- α production and on POD 1, 7 and 14 in IL-1 β and G-CSF production. The number of monocytes increased for 7 days after hepatic resection. These results demonstrate that monocytes increase in number and are primed to carry a greater cytokine productivity following hepatic resection. Therefore, if there is any stimulus such as endotoxin or tissue ischemia to these cells to release cytokines after hepatic resection, organ dysfunction could develop as a result of hypercytokinemia.

Two cases of hepatic artery interruption after hepatopancreatobiliary surgery treated by prostaglandin E1 infusion via the superior mesenteric artery

In two cases of hepatic arterial flow interruption after hepatopancreatic surgery, continuous PGE(1) infusion from the superior mesenteric artery (SMA) was applied to oxygenate the liver through the portal vein. Case 1 was a 69-year-old woman with a non-functioning islet cell tumor of the pancreas. She underwent pancreatic resection following hepatic arterial infusion of anticancer drugs. Serum alanine aminotransferase (ALT) was elevated to 5500 IU/l on postoperative day (POD) 2; angiography revealed complete celiac artery obstruction. Continuous PGE(1) was administered from SMA at a rate of 0.01 &mgr;g/kg/min for 7 days. Serum ALT was normalized within 2 weeks and the peak level of serum total bilirubin (T. Bil) was 4.5 mg/dl. Case 2 was a 66-year-old man suffering from metastatic liver cancer. Complete obstruction of the proper hepatic artery was noted at the time of liver resection after hepatic arterial chemotherapy. Serum ALT was elevated to 2930 IU/l on POD 1, and PGE(1) infusion from SMA was done for the succeeding 7 days. Necrotic area was so vast that serum T. Bil rose to 19 mg/dl. However, it decreased with time. Both cases required 3 months for necrotic liver shrinkage. Doppler ultrasonography revealed that PGE(1) infusion actually increased portal blood flow. In conclusion, based on the preceding experimental backgrounds and clinical experiences, continuous PGE(1) infusion via the SMA can be a useful measure to prevent severe liver damage after hepatic arterial flow interruption through portal blood oxygenation.