Yasuji Seyama

Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate.

Objective To demonstrate our strategy for hilar bile duct cancer and to elucidate prognostic factors and the surgeons role in long-term survival. Summary Background Data Extended hemihepatectomy is recognized as a curative treatment of hilar bile duct cancer but is not always safe because of the risk of postoperative liver failure. A safe and beneficial strategy is required. Methods Fifty-eight consecutive major hepatectomies for hilar bile duct cancer were reviewed retrospectively. Appropriate preoperative treatments, biliary drainage, and portal embolization were performed before major hepatectomies. The short- and long-term results of our strategy are presented and analyzed. Results Biliary drainage and portal embolization were performed in 39 patients (67.2%) and 31 patients (53.4%), respectively. Major hepatectomies comprised 27 extended right and 22 extended left hemihepatectomies and 9 hepatoduodenopancreatectomies. Operative morbidity and mortality rates were 43% and 0%, respectively. There was no postoperative liver failure. The overall 5-year survival rate was 40%. Univariate analysis showed that residual tumor status, lymph node involvement, and perineural invasion were associated with patients’ long-term survival. A surgical margin over 5 mm resulted in better long-term survival. The delay resulting from preoperative treatment was not detrimental to long-term survival. Multivariate analysis showed that lymph node involvement was the only prognostic factor. Conclusions Our strategy, which includes preoperative biliary drainage and portal embolization, led to a reduction in the risks associated with major hepatectomy for hilar bile duct cancer, and resulted in zero mortality. Surgeons should aim at complete clearance of the tumor with an adequate surgical margin to ensure optimal long-term survival.

Assessment of liver function for safe hepatic resection.

The preoperative assessment of liver function is extremely important for preventing postoperative liver failure and mortality after hepatic resection. Liver function tests may be divided into three types; conventional liver function tests, general scores, and quantitative liver function tests. General scores are based on selected clinical symptoms and conventional test results. Child–Turcotte–Pugh score has been the gold standard for four decades, but the Child–Turcotte–Pugh score has difficulty discriminating a good risk from a poor risk in patients with mild to moderate liver dysfunction. The model for end‐stage liver disease score has also been applied to predict short‐term outcome after hepatectomy, but it is only useful in patients with advanced cirrhosis. Quantitative liver function tests overcome the drawbacks of general scores. The indocyanine green retention rate at 15 minutes (ICG R15) has been reported to be a significant predictor of postoperative liver failure and mortality. The safety limit of the hepatic parenchymal resection rate can be estimated using the ICG R15, and a decision tree (known as the Makuuchi criteria) for selecting patients and hepatectomy procedures has been proposed. Hepatic resection can be performed with a mortality rate of nearly zero using this decision tree. If the future remnant liver volume does not fulfill the Makuuchi criteria, preoperative portal vein embolization should be performed to prevent postoperative liver failure. Galactosyl human serum albumin‐diethylenetriamine‐pentaacetic acid scintigraphy also provides data that complement the ICG test. Other quantitative liver function tests, however, require further validation and simplification.

Cohort study of the survival benefit of resection for recurrent hepatic and/or pulmonary metastases after primary hepatectomy for colorectal metastases.

Objective:To evaluate resection for hepatic and/or pulmonary recurrences in a cohort that underwent initial hepatectomy for colorectal liver metastases. Summary Background Data:The survival benefit of repeated resections for hepatic and/or pulmonary recurrences after initial hepatectomy for colorectal liver metastases has remained unclear. Methods:Recurrence occurred in 166 of the 216 patients after the first hepatectomy. Repeated resections were performed in 98 patients. We investigated the pattern of recurrence, the proportion of patients who underwent repeated resection, and the surgical outcome. Results:Of the 166 patients with recurrence, 71 had isolated hepatic recurrence, 25 had isolated pulmonary recurrence, 13 had hepatic plus pulmonary recurrence, and 57 had recurrence in other organs. Repeated resections were conducted in 60 (85%) patients with isolated hepatic recurrence, 21 (84%) with isolated pulmonary recurrence, and 9 (69%) with both hepatic and pulmonary recurrence. The 5-year survival rates after repeated resection were 39%, 37%, and 20% for isolated hepatic recurrence, isolated pulmonary recurrence, and hepatic plus pulmonary recurrence, respectively. Multivariate analysis revealed that the following variables contributed to poor prognosis (hazard ratio [95% confidence interval]): number of recurrent tumors (1.20 [1.11–1.29]), maximum size of recurrent tumors (1.26 [1.02–1.48]), pulmonary recurrence (2.36 [1.41–3.20]), and hepatic plus pulmonary recurrence (4.01 [2.86–.17]). Conclusions:Patients with pulmonary or hepatic plus pulmonary recurrence had poorer prognoses than those with isolated hepatic recurrence. Reresection is the only potentially curative treatment. Stricter indication criteria, especially regarding the number of tumor nodules, can lead to comparable long-term outcomes.

Intraoperative Blood Salvage During Liver Resection: A Randomized Controlled Trial

Objective:A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss. Background:Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established. Methods:Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patients body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed. Results:Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11–0.85, P = 0.025). Conclusion:Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.

Two-staged pancreatoduodenectomy with external drainage of pancreatic juice and omental graft technique

Although operative mortality after pancreatoduodenectomy (PD) has been reduced dramatically by improvements in surgical techniques and perioperative care and the indications for PD have been expanded to more risky cases such as the very aged or emergency patients, 1-3 pancreatic leakage, once it has occurred, may cause severe infection and subsequent fatal bleeding from the stumps of the major vessels, contributing to postoperative mortality. High-risk patients with severe chronic liver diseases such as liver cirrhosis (LC) have been excluded as candidates for PD. Here, we report a successful two-staged PD with external drainage of pancreatic juice and omental graft technique in a patient with LC receiving anticoagulant therapy after cardiac valve replacement. TECHNIQUE

Two-stage pancreatojejunostomy in pancreaticoduodenectomy: a retrospective analysis of short-term results

BACKGROUND The morbidity associated with pancreatic fistula formation after pancreaticoduodenectomy (PD) still remains high. While theoretically 2-stage pancreatojejunostomy (PJ) is effective for preventing pancreatic juice enzymes from becoming activated by enteric contents, its clinical usefulness remains unknown. The aim of this retrospective study was to evaluate the short-term results of two-stage PJ in PD. PATIENTS AND METHODS In PD cases with a narrow main pancreatic duct and/or soft texture of the pancreas, we performed 2-stage PJ; first an external tube pancreatostomy was performed, in which the tube was not passed through the jejunal loop, followed about 3 months later by second-stage reconstruction for PJ. Between 1998 and 2005, PDs with 1-stage and 2-stage PJ were performed in 53 and 99 patients, respectively, at our institution. Among the latter 99 patients, 13 (13%) also underwent concomitant right or extended right hemi-hepatectomy. In this study, the clinical records of these 152 patients were retrospectively analyzed. RESULTS After PD, a pancreatic fistula occurred in 58% of the patients undergoing 2-stage PJ; however, the fistula healed with conservative therapy in all but 2 patients who required surgical drainage for abdominal abscess. A second-stage pancreato-enteric reconstruction by PJ could be completed about 3 months after the PD in 89 of the 99 (90%) cases. Although the incidence of pancreatic fistula was 16% after the second-stage reconstruction for PJ, completion pancreatectomy was not needed in any of the cases. There were no deaths or other catastrophic events related to the procedure. CONCLUSIONS While it is difficult to completely prevent pancreatic fistula formation after PD, a 2-stage PJ appears to be effective for minimizing pancreatic juice-related adverse events, especially in high-risk patients with a narrow pancreatic duct or undergoing highly invasive surgery, such as hepato-pancreticoduodenectomy.

The pH modulator chloroquine blocks trypsinogen activation peptide generation in cerulein-induced pancreatitis.

Introduction and Aims We examined the effects of a weak base, chloroquine, on the trypsinogen processing in cerulein-induced pancreatitis. Methodology Immunofluorescence studies were performed using newly generated affinity-purified antibodies to the trypsinogen activation peptide (TAP). Results The present study showed that chloroquine pretreatment blocked intracellular TAP generation in cerulein-induced pancreatitis. Conclusion These results indicate that intracellular trypsinogen activation, which plays an important role in acute pancreatitis, requires a low-pH compartment, as well as serine protease activity.

Sequential Transcatheter Arterial Chemoembolization and Portal Vein Embolization for Hepatocellular Carcinoma: The University of Tokyo Experience

When undertaking portal vein embolization (PVE) in patients with hepatocellular carcinoma (HCC), the following possibilities should be considered: (1) failure to induce hypertrophy of the nonembolized segments due to the underlying liver disease, (2) acceleration of tumor growth by occlusion of the portal venous flow because HCC is a hypervascular tumor fed exclusively by hepatic arterial flow, and (3) poor efficacy of PVE due to the presence of arterioportal shunts frequently observed in cases of liver cirrhosis and HCC. With these in mind, we performed sequential transcatheter arterial chemoembolization (TACE) and PVE in 45 patients with HCC undergoing major liver resection. This double preparation was well tolerated, enhanced the hypertrophy process in the nonembolized segments, and suppressed the tumor growth during the preparation period. Furthermore, PVE also functioned as a preoperative test to select patients for major liver resection. Sequential TACE and PVE is an effective preoperative intervention in patients with HCC scheduled for major liver resection.

Three-Dimensional Staining of Liver Segments with an Ultrasound Contrast Agent as an Aid to Anatomic Liver Resection

complex3-dimensional(3-D)shape. 11-13 Inaddition,there are no anatomic landmarks indicating the positions of the borders between segment V and segment VIII or between segment VI and segment VII. Therefore, some additional means of identifying the actual shapes and intrahepatic positions of the segmental borders is needed to facilitate precise anatomic resections of the liver. In this study, we assessed a simple, novel technique for visualizing the 3-D shapes of liver segments by using a second-generation ultrasound contrast agent, Sonazoid (Daiichi Sankyo Pharmaceutical Co Ltd).

Expression of KL-6 mucin, a human MUC1 mucin, in intrahepatic cholangiocarcinoma and its potential involvement in tumor cell adhesion and invasion

AIMS Aberrant expressions of KL-6 mucin were proved to be associated with worse tumor behaviors of many carcinomas. This study was to evaluate the expression KL-6 mucin, a human MUC1 mucin, in intrahepatic cholangiocarcinoma (CC) and its significance in tumor progression. MAIN METHODS KL-6 mucin expressions in 21 patients with CC, 12 with combined hepatocellular and cholangiocarcinoma (cHCC-CC), and 78 with hepatocellular carcinoma (HCC) were detected by immunohistochemical staining. The effects of two glycosylation inhibitors (tunicamycin and benzyl-alpha-N-acetylgalactosamine (BAG)) on CC cell proliferations were assessed by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide (MTT) assays. KL-6 mucin expressions were detected by immunocytochemical staining and western blotting after tunicamycin or BAG treatment. Cell adhesive and invasive properties were evaluated by adhesion tests and transwell chamber assays after tunicamycin or BAG treatment. KEY FINDINGS Positive KL-6 mucin staining was observed in all CC tissues and CC areas of cHCC-CC tissues. Immunocytochemical staining and western blotting showed that KL-6 mucin expressions were significantly reduced after both inhibitors treatment. Cell adhesive properties were significantly decreased after both inhibitors treatment, while cell invasive abilities were significantly decreased after BAG but not tunicamycin treatment. SIGNIFICANCE This study indicated that KL-6 mucin might be a specific tumor target for CC. Therapeutic strategies that target glycosylation of KL-6 mucin may be useful to control aggressive behaviors of CC.