Yoshifumi Beck

Real‐time identification of liver cancers by using indocyanine green fluorescent imaging

We have often encountered difficulties in identifying small liver cancers during surgery. Fluorescent imaging using indocyanine green (ICG) has the potential to detect liver cancers through the visualization of the disordered biliary excretion of ICG in cancer tissues and noncancerous liver tissues compressed by the tumor.

Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery

F T i m k c 8 nlike blood vessels, the biliary tract lies in the Glissonian heath and is buried in the perivascular connective tissue, o it is difficult to clearly visualize and isolate it during epatobiliary surgery. Intraoperative cholangiography IOC), which was originally introduced by Mirizzi in 937, has been widely used to delineate the biliary tract natomy in this setting. For example, routine IOC was ecently recommended during cholecystectomy to prevent ile duct injury. IOC is also considered an essential proedure during donor hepatectomy because it enables the ile duct to be divided at the appropriate level to ensure ider and fewer residual orifices. But conventional raiographic IOC is disadvantageous in that it exposes the atient and the medical staff to radiation and usually reuires a large and expensive C-arm fluoroscopy machine nd the additional human resources involved. Recently, intraoperative angiography using a fluorescent maging technique with IV injection of indocyanine green ICG) has been used to assess coronary artery bypass graft atency. This technique is based on the principle that CG binds to plasma proteins and that protein-bound ICG mits light with a peak wavelength of about 830 nm when lluminated with near-infrared light. Because human ile also contains plasma proteins that bind with ICG, we ypothesized that fluorescent images of the biliary tract ould be obtained with intrabiliary injection of ICG. We lso hypothesized that IV injection of ICG would provide luorescent images of the biliary tract without necessitating

Risk Factors and Management of Ascites After Liver Resection to Treat Hepatocellular Carcinoma

OBJECTIVES To identify risk factors for a massive amount of ascites after liver resection to treat hepatocellular carcinoma and to evaluate our postoperative management strategy. DESIGN Case-control study. SETTING University hospital. PATIENTS Two hundred three patients who underwent liver resection to treat hepatocellular carcinoma between January 1, 2003, and December 31, 2004. MAIN OUTCOME MEASURES Presence or absence of a large number of ascites (LA), defined as postoperative daily ascitic fluid drainage exceeding 10 mL per kilogram of body weight, and operative morbidity, mortality, and treatment costs. RESULTS A large number of ascites developed in 31 patients (15%). Multivariate analysis revealed that blood loss greater than 1000 mL (relative risk, 6.38; 95% confidence interval, 2.19-20.7; P = .001) and preoperative platelet count less than 100 x 10(3)/microL (4.75; 1.75-13.1; P = .002) independently increased the risk of LA. In patients with LA, urinary output on postoperative days 1 to 3 was significantly lower than in patients without LA, and daily ascitic fluid volume tended to peak on postoperative day 7. No operative mortality was related to liver failure; however, patients with LA required a larger volume of fresh frozen plasma than those without LA (median [range], 1600 [0-16 800] mL vs 480 [0-5760] mL; P < .001), resulting in higher hospital costs. CONCLUSIONS Large blood loss and low platelet count were independent risk factors for LA. Although it was possible to safely manage postoperative ascites using routine administration of diuretic agents and fresh frozen plasma, step-by-step trials are required to reduce the need for transfusion of fresh frozen plasma.

The vessel sealing system (LigaSure) in hepatic resection: a randomized controlled trial.

Objective:The aim of this trial was to verify the new surgical device (the LigaSure vessels sealing system) decrease liver transection time. Summary Background Data:Among the major goals in hepatic resection are minimization of the operation time and of the blood loss. Preliminary reports have suggested that the vessel sealing system might decrease the liver transection time, which is directly associated with the amount of blood loss. Methods:Patients who were scheduled to undergo hepatic resection at the Tokyo University Hospital were assigned, by the minimization method, to either use of the new vessel sealing system (VS group) or the conventional clamp crushing method (CC group) for liver transection. The primary end point was the liver transection time, and the secondary endpoints were the amount of blood loss during the entire operation and during liver transection, length of hospital stay, postoperative liver function, and the incidence of various adverse events. An English-language summary of the protocol was submitted (registration ID: C000000337) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan, which can be accessed commission-free on the internet (Available at: http://www.umin.ac.jp/ctr/index.htm). Results:From February to December in 2006, a total of 165 patients underwent liver resection for some benign or malignant disease of the liver. Among these patients, 120 were randomly assigned to the CC (n = 60) or the VS (n = 60) group. There was no mortality in either of the 2 groups. The median liver transection time in the VS group was 57 minutes (range: 11–127), similar to that in the CC group (56 [range: 9–269] min, P = 0.64), while there was no difference in the transection speed between the 2 groups (1.16 [0.15–2.26] cm2/min vs. 1.10 [0.15–2.66] cm2/min, P = 0.95). The amount of blood loss and blood loss per transection area during liver transaction in the VS group was also similar to that in the CC group (median: 315 [25–2415] mL vs. 315 [10–1700] mL; P = 0.80) and (5.04 [1.01–44.2] mL/cm2 vs. 4.36 [0.15–50.5] mL/cm2; P = 0.14), respectively. Conclusions:This randomized controlled trial showed that while the vessel sealing system was safe, its use was not associated with any significant decrease of the operation time or blood loss during liver transaction as compared with that of the clamp crushing method.

Is there any difference in survival according to the portal tumor thrombectomy method in patients with hepatocellular carcinoma

BACKGROUND Although portal venous tumor thrombus (PVTT) is regarded as an ominous prognostic factor in patients with hepatocellular carcinoma (HCC), the optimal treatment method for maximizing both safety and long-term outcome has not yet been discussed. We describe a surgical technique in which the venous wall is peeled off from the PVTT. METHODS In the peeling off (PO) technique, the portal venotomy was placed after adequate vascular control of portal flow. The PVTT was dissected from the portal venous wall and removed through the opening. Macroscopically residual PVTTs intruding into tiny branches were meticulously extracted. This procedure was compared with the en bloc resection of PVTT. Between 1995 and 2006, 49 patients underwent curative hepatic resections for HCC with macroscopic PVTT; these patients were classified according to whether the PO technique (n = 20) or the en bloc technique (n = 29) had been utilized. Both the short- and long-term results were compared between the 2 groups. RESULTS No mortalities occurred in either group. Both the 5-year overall survival and the recurrence-free survival rates of the PO group were comparable with those of the en bloc group (39% vs 41% [P = .90] and 23% vs 18% [P = .89], respectively). No local recurrences or regrowth of the PVTT occurred in either group. CONCLUSION Our procedure is useful for removing PVTT extending beyond the bifurcation or into other sectors that should be preserved in terms of liver function and enables a more conservative resection than an en bloc technique without sacrificing curability.

Hepatobiliary Surgery Guided by a Novel Fluorescent Imaging Technique for Visualizing Hepatic Arteries, Bile Ducts, and Liver Cancers on Color Images

t t i g A fluorescent imaging technique using indocyanine green (ICG) was first introduced for assessing coronary artery bypass graft patency; its use was subsequently extended o visualize lymphatic vessels that need to be anastomosed and to identify sentinel lymph nodes during breast and gastric cancer operations. Recently, the fluorescent imagng technique has also been applied to hepatobiliary opertions, enabling highly sensitive identification of liver ancers and extrahepatic bile ducts. Although the echnique is used by several surgeons in clinical settings in apan, one of the drawbacks of the conventional fluorescent imaging system is that it provides only monochromatic images, which makes it relatively difficult for surgeons to assess the spatial relationships between the fluorescing lesions and the surrounding organs. Here, we describe hepatobiliary procedures using a novel imaging technique that enables visualization of fluorescing liver cancers and/or bile ducts on color images of the surrounding structures in real-time during surgery.

Value of prophylactic abdominal drainage in 1269 consecutive cases of elective liver resection

BackgroundThe value of prophylactic abdominal drainage in patients undergoing hepatectomy is controversial. We carried out a retrospective study to clarify the value of this procedure.MethodsThe study subjects were 1269 consecutive patients who underwent elective hepatectomy with drain insertion for malignant tumors without associated gastrointestinal procedures or bilio-enteric anastomosis. Symptomatic abdominal fluid collections were treated by the drain salvage method, percutaneous puncture, and/or re-operation, in that order of preference.ResultsOne patient died (mortality rate, 0.07%) and 7 patients had postoperative bleeding (0.6%). Bile leakage, found in 111 (8.7%) patients, subsided with retention of the drain in 78 (70%) and use of the drain salvage technique in 8 (7.2%), whereas percutaneous puncture and re-operation were required in 11 (9.9%) and 14 (12.6%). Symptomatic fluid collection, observed in 65 (5.1%) patients, was treated by the drain salvage technique in 20 (31%) patients, while puncture and re-operation were required in 25 (38%) and 20 (31%).ConclusionsPlacement of drains was effective in a considerable proportion of patients undergoing hepatectomy, with regard to reducing the frequency of development of subphrenic fluid collections and biliary fistula/biloma formation.

Indocyanine green injection for detecting sentinel nodes using color fluorescence camera in the laparoscopy-assisted gastrectomy

Background and Aim:  We seek for the accurate and simple method for detecting sentinel nodes of gastric cancer which can be popularized in community hospitals. The indocyanine green (ICG) fluorescence‐guided method is reported to be sensitive. However, the ordinal fluorescence cameras have gray scale imaging and require a dark room. We have developed a new device, Hyper Eye Medical System (HEMS) which can simultaneously detect color and near‐infrared rays and can be used under room light. This study was planned to examine whether submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery.

Usefulness of contrast-enhanced intraoperative ultrasound using Sonazoid in patients with hepatocellular carcinoma.

Objective:To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC). Background:Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs). Methods:Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period. Results:Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm). Conclusions:With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.

Successful resection of a large hepatoblastoma in a young adult: Report of a case

Hepatoblastoma (HB) rarely occurs in adults, and very few cases of successful resection have been documented. We report herein the unusual case of a 22-year-old, otherwise healthy woman with no history of liver disease who presented with upper abdominal pain and hepatomegaly. Tests for hepatitis B virus (HBV) and hepatitis C virus (HCV) were negative, but the AFP was mildly elevated at 77 ng/ml, the normal being <20. There was no evidence of liver cirrhosis on either the laboratory or histologic examinations. A well-demarcated solid mass of 14cm in diameter, which was lobulated and partly necrotic, was detected in the liver by computed tomography (CT). The lesion was echogenic on ultrasound, slightly hypodense on CT, and mildly hyper-vascular on arteriogram. The entire tumor was resected by extensive hepatectomy preserving only the lateral segment and part of the posterior segment of the liver. Histologically, the neoplasm was diagnosed as a pure epithelial HB of the fetal type. Following the operation, the patient has been well and free of recurrence for 38 months, maintaining low alpha-fetoprotein (AFP) levels at around 5 ng/ml. To our knowledge, this is the longest reported survival of an adult following surgical resection of an epithelial HB.