Yasuhiro Mamada

Partial splenic embolization

Partial splenic embolization (PSE) is a non‐surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2‐mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal‐stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal‐vein flow and a rapid increase in the platelet count after excessive embolization may cause portal‐vein or splenic‐vein thrombosis.

Long-Term Results of Partial Splenic Artery Embolization as Supplemental Treatment for Portal-Systemic Encephalopathy

OBJECTIVES:To present long-term results of angiographic partial splenic artery embolization (PSE) as a supplemental treatment of portal-systemic encephalopathy.METHODS:Twenty-five patients with portal-systemic encephalopathy were divided into two groups: 14 patients underwent transportal obliteration and/or balloon-occluded retrograde transvenous obliteration (BRTO) of portal-systemic shunts (PSS), followed by PSE (PSE(+) group), and 11 patients underwent only transportal obliteration and/or BRTO of PSS (PSE(−) group).RESULTS:Portal venous pressures pretreatment was similar to posttreatment in the PSE(+) group, but lower than posttreatment in the PSE(−) group. Serum ammonia levels were higher at pretreatment than at 1 wk posttreatment in both groups, but the levels in the two groups were similar at pretreatment, 1 wk, 3 months, 3 yr, 4 yr, and 5 yr posttreatment. However, serum ammonia levels were lower in the PSE(+) group than in the PSE(−) group 6 months, 9 months, 1 yr, and 2 yr posttreatment. Grades of encephalopathy were higher at pretreatment than at 1 wk posttreatment in both groups, but the levels in the two groups were similar at pretreatment, 1 wk, 2 yr, 3 yr, 4 yr, and 5 yr posttreatment. However, grades of encephalopathy were lower in the PSE(+) group than in the PSE(−) group 3 months, 6 months, 9 months, and 1 yr posttreatment.CONCLUSIONS:Obliteration of PSS followed by PSE benefit patients with portal-systemic encephalopathy.

Long-term results of multiple minocycline hydrochloride injections for the treatment of symptomatic solitary hepatic cyst

Background: The current study presents the long‐term results of multiple minocycline hydrochloride (MINO) injections for the treatment of symptomatic solitary hepatic cyst.

Long‐term results of elective hepatectomy for the treatment of ruptured hepatocellular carcinoma

BACKGROUND/PURPOSE According to the General rules for the clinical and pathological study of primary liver cancer, compiled by the Liver Cancer Study Group of Japan, ruptured hepatocellular carcinoma (HCC) is classified as stage 4, even if the tumor is small and solitary. We examined the long-term results of elective hepatectomy for the treatment of ruptured HCC. METHODS A first hepatectomy was performed without operative death in 193 patients with HCC. Ten patients had ruptured HCC (ruptured group) and 183 patients had nonruptured HCC (nonruptured group). The extension of HCC was macroscopically classified as stage 1 in 23 patients, stage 2 in 71, stage 3 in 53, and stage 4 in 46. RESULTS Cumulative survival rates in the ruptured group at 1, 5, and 10 years were 90.0%, 67.5%, and 20.3%, respectively. The cumulative survival rate was lower in patients with stage 4 disease in the nonruptured group than that in patients in the ruptured group (P < 0.05). Cumulative survival rates did not differ significantly between patients in the ruptured group and those with stage 2 or stage 3 disease. CONCLUSIONS Survival rates after elective hepatectomy in patients with ruptured HCC are good, even if the disease is classified as stage 4.

Splenic artery embolization before laparoscopic splenectomy in children

BackgroundThis study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.MethodsFive young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors’ institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.ResultsThe mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.ConclusionThe authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

Reconstruction of the vena cava with the peritoneum.

BACKGROUND Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum. METHODS A 2.5 x 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol. RESULTS In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted. CONCLUSIONS The peritoneum is an accessible and safe substitute for reconstruction of the vena cava.

Spontaneous ruptured hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is rising worldwide. Spontaneous rupture of HCC occasionally occurs, and ruptured HCC with intraperitoneal hemorrhage is potentially life‐threatening. The most common symptom of ruptured HCC is acute abdominal pain. The tumor size in ruptured HCC is significantly greater than that in non‐ruptured HCC, and HCC protrudes beyond the original liver margin. In the acute phase, hemostasis is the primary concern and tumor treatment is secondary. Transcatheter arterial embolization (TAE) can effectively induce hemostasis. The hemostatic success rate of TAE ranges 53–100%. A one‐stage surgical operation is a treatment modality for selected patients. Conservative treatment is usually given to patients in a moribund state with inoperable tumors and thus has poor outcomes. Patients with severe ruptures of advanced HCC and poor liver function have high mortality rates. Liver failure occurs in 12–42% of patients during the acute phase. In the stable phase, tumor treatment, such as transarterial chemoembolization or hepatic resection should be concerned. The combination of acute hemorrhage and cancer in patients with ruptured HCC requires a two‐step therapeutic approach. TAE followed by elective hepatectomy is considered an effective strategy for patients with ruptured HCC.

New trends in surgical treatment for portal hypertension

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non‐shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices.

Hand-assisted laparoscopic hepatectomy after partial splenic embolization

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patient’s liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 × 104/µl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 × 104/µl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patient’s postoperative course was unremarkable, and he was discharged on postoperative day 12.

Modified Endoscopic Variceal Ligation

Endoscopic variceal ligation (EVL) has been widely adopted because it is technically easy to perform. However, it is not always possible to eradicate varices by the standard ligation method. Therefore, we examined the effectiveness of the intensive ligation method as an alternative for the eradication of varices. In applying this method, rubber bands are used to make ligations much closer to each other, than with the standard method, just above the esophago‐gastric junction (EG‐junction). We also compared the effectiveness of EVL in nine cases undergoing the standard ligation method with that in nine cases treated by the new intensive ligation method. With the standard ligation method, the average number of sessions was 2.2 per week, while the average number of rubber bands used was 9.6 per patient. Varices disappeared in three of nine cases. With the intensive ligation method, the number of sessions was two per week in all cases, while the average number of rubber bands was 19.9 per patient. Varices disappeared in all nine cases. Chest discomfort, as a complication, was experienced by three of nine cases in both groups. It is concluded that the intensive ligation method is a very effective means of achieving early, safe eradication of varices.