Search

Background/aims: The liver hanging maneuver (LHM) is a widely used novel suspending technique for facilitating liver transection. However, little evidence is available to reveal its safety and true advantages in donor operations for living donor liver transplantation (LDLT)., Methodology: The medical records of 422 consecutive living donors at a single institute were reviewed. The feasibility and outcomes of the use of LHM in donor operation for LDLT were investigated., Results: Two types of hanging maneuvers, namely, Belghiti's conventional method and a modified approach where the sling is placed after full mobilization of the liver, have been routinely adopted selectively since 2000, and to date, 304 LHM have been carried out. Marked reduction in the liver transection time needed for harvesting a hemiliver graft has been obtained after the introduction of LHM (p<0.0001). No major complications associated with the LHM have been recorded. Comparison of the conventional and modified LHM revealed similar outcomes for the two, except that the modified approach required a longer liver dissection time (81 vs. 98 min; p=0.0004)., Conclusions: Considering its high feasibility and several advantages in facilitating liver transection, LHM might be worth attempting in donor operations where a major hepatectomy is required.

Complete resection for colorectal metastases is the only treatment that can provide long-term survival and may lead to cure. Recent reports have shown that liver resection following systemic chemotherapy in patients with initially unresectable metastases from colorectal cancer may also result in a good long-term survival, and rescue surgery after chemotherapy has become a strategy of choice. A 29-year-old male and a 35-year-old female with unresectable liver metastases from colorectal cancer underwent complete resection after administration of third-line combination therapy of cetuximab and irinotecan. Although systemic chemotherapy may decrease liver function, which may make liver resection unfeasible, in the two cases reported, liver function did not deteriorate after cetuximab plus irinotecan. The indocyanine green retention rate at 15 minutes, which is useful in deciding the safe limit of hepatectomy, was optimal after the administration of cetuximab plus irinotecan in both patients. Cetuximab plus irinotecan may be beneficial as neoadjuvant chemotherapy for metastatic colorectal cancer, not only because of its oncological efficacy but also for preservation of liver function.

The prognosis of pancreatic cancer is poor, even in resectable patients. The reason for this poor prognosis is partly due to local invasion of the tumor into the tissues around the pancreas. Pancreatic head cancer usually invades the mesentericoportal veins, so the combined venous resection is usually performed during pancreatoduodenectomy for the purpose of obtaining a negative surgical margin. We performed pancreatoduodenectomy for lower pancreatic head cancer together with superior mesenteric vein resection without reconstruction in two patients, after confirming adequate portal venous flow and small intestinal congestion, This is the first report of pancreatoduodenectomy combined with superior mesenteric vein resection without reconstruction for the purpose of obtaining a wide surgical margin.

Background/aims: KL-6 mucin is MUC1 bearing sialylated carbohydrate epitopes recognized by KL-6 antibody. This study aimed to assess subcellular localization of KL-6 mucin in liver metastatic tissues from colorectal carcinoma and hepatocellular carcinoma tissues., Methodology: Tissue samples were collected from 56 patients with liver metastasis of colorectal carcinoma and 92 patients with hepatocellular carcinoma who underwent a hepatectomy. Tissues were subjected to immunohistochemical analysis using KL-6 antibody., Results: All 56 cases with metastatic liver cancer showed positive staining for KL-6 mucin in cancer tissues but not in non-cancerous tissues. All staining was observed in the circumferential membrane and/or cytoplasm of the cancer cells. In contrast, no staining for KL-6 mucin was observed in either cancerous or non-cancerous tissues of the 92 patients with hepatocellular carcinoma., Conclusions: KL-6 mucin may be an indicator for liver metastasis of colorectal carcinoma. Additionally, detection of KL-6 mucin may be helpful in distinguishing hepatocellular carcinoma from metastatic liver cancer.

Background/aims: Hepatic resection in metastatic disease from colorectal cancer offers the best chance in selected cases for long-term survival. Neoadjuvant chemotherapy (NACT) has been advocated in some cases initially deemed irresectable with few reports of the efficacy of such a strategy and the influence of the response to chemotherapy on the outcome of radical hepatic resection., Methodology: Between December 1995 and May 2005, 88 patients with colorectal liver metastases underwent hepatic resection with curative intent. Twenty-five of these patients, (7 males, 18 females, mean age: 58+/-9 years; range: 40-75 years) deemed as resectable cases at the time of diagnosis were treated with neoadjuvant chemotherapy. A 7-year survival analysis was performed. Chemotherapy included mainly oxaliplatin or irinotecan containing regimens for a median of 6 courses., Results: Fifteen patients (60%) had synchronous and 10 (40%) metachronous metastases. During preoperative chemotherapy tumor regression occurred in 8 cases (32%); stable disease (SD) in a further 10 patients (40%) and progressive disease (PD) developed in 7 cases (28%). The 5-year overall survival for NACT responders was 71% and only 15% for non-responders (p=0.026)., Conclusions: The response to chemotherapy is likely to be a significant prognostic factor affecting overall survival after radical hepatic resection for colorectal metastases.

Background/aims: Pancreatoduodenectomy is associated with high morbidity rates, resulting primarily from the occurrence of pancreatic fistula at pancreatojejunostomy. We transect the pancreas using a manual clamp-crushing technique to prevent postoperative pancreatic fistula (POPF) formation. The aim of this study was to clarify the usefulness of this new technique., Methodology: Fifty patients with a normal soft pancreas who underwent pancreatoduodenectomy in the last 3 years were selected. During the last stage of the classic Whipple operation, the pancreas was transected using a clamp-crushing technique under blood-flow control. The pancreas parenchyma was crushed using forceps, and small pancreatic branch ducts were securely ligated and cut. The main pancreatic duct was identified, and pancreatojejunal reconstruction was done end-to-side with a duct-to-mucosa anastomosis, following approximation of the pancreatic stump to the jejunal wall using the one-layer suture technique., Results: According to ISGPF (please use the first abbreviation for subtotal stomach--preserving pancreaticoduodenectomy) grading, POPF Grade B occurred in 10 (20%) patients. There were no Grade C patients, no postoperative hemorrhage and no POPF associated mortality., Conclusion: The clamp-crushing technique appears to be a safe method for pancreatic transection that is feasible in cases with a normal soft pancreas.

Background/aims: KL-6 mucin is a type of MUC1 mucin. Previous immunohistochemical studies by the authors revealed that, in liver cancer tissues, KL-6 mucin expressed only in intrahepatic cholangiocarcinoma (CC) but not in hepatocellular carcinoma (HCC). The current study performed serological analysis to evaluate KL-6 mucin levels in sera from various liver cancer patients and healthy individuals., Methodology: Enzyme-linked immunosorbent assay was used to measure KL-6 mucin levels in sera from 8 CC patients, 27 HCC patients, 30 metastatic liver cancer (MC) patients, and 19 healthy individuals., Results: Serum KL-6 mucin levels were significantly higher in CC patients than in healthy individuals (p<0.0001), HCC patients (p<0.0001), and MC patients (p<0.001). Receiver operating characteristic analysis determined the cut-off level of serum KL-6 mucin levels to be 240 U/mL (CC vs. healthy, p<0.001) or 248 U/mL (CC vs. HCC, p<0.001). Using 248 U/mL as a cut-off value, the positive rate for CC patients, healthy individuals, and HCC patients was 100.0%, 15.8%, and 18.5%, respectively., Conclusions: Elevation of serum KL-6 levels was detectable in CC patients. Thus, KL-6 might be a useful serological marker to distinguish CC patients from HCC patients.

Adult-onset type II citrullinemia (CTLN2) is a rare disorder of the urea cycle resulting in hyperammonemia, with a poor prognosis. Here we report a 48-year-old Japanese man who showed abnormal nocturnal behavior. Laboratory data indicated raised plasma concentrations of ammonia and citrulline, and a definitive diagnosis of CTLN2 was made by DNA analysis. Hyperammonemia was not improved by oral intake of branched-chain amino acids (BCAA), whereas venous infusion of BCAA was effective. Western blotting revealed heterozygotic expression of citrin protein in a liver biopsy specimen from the patient's brother. However, as symptomatic CTLN2 is very unusual in a heterozygotic carrier, we considered the brother suitable as a living-donor liver transplantation (LDLT) donor. The recipient's entire liver was removed, and replaced with the left liver graft. The plasma ammonia level remained low without infusion of BCAA after liver transplantation. From this case we conclude that venous infusion, rather than oral administration, of BCAA is useful for conservative treatment of CTLN2. However, liver transplantation is the only effective therapeutic option for CTLN2, and should be performed before irreversible encephalopathy occurs. Use of a graft from heterozygotic donors is permissible treatment for CTLN2.

We report a 49-year-old man with unresectable intrahepatic cholangiocarcinoma (ICC) who was treated with oral tegafur-uracil (UFT) chemotherapy and survived for over a decade. In 1995, the patient was admitted to our institution after a large tumor in his left liver was detected using computed tomography (CT). The tumor was diagnosed as ICC, and a laparotomy was performed; however, the tumor was too advanced to perform a curative resection. The cancer had spread to the lymph nodes in the hepatoduodenal ligament and on the posterior surface of the pancreas head. A curative resection was abandoned, and oral UFT chemotherapy was started immediately after the laparotomy. The tumor remained almost unchanged until 2001 with only UFT administration; however, its size gradually increased to 7.8 cm in diameter. External-beam radiotherapy (50.4 Gy) was performed, and the tumor's size decreased to 6.3 cm in diameter. Eleven years have now passed since the laparotomy, and the patient continues to lead a normal daily life working as a banker. The cumulative dose of UFT has reached 2511 g without any significant adverse effects. This case suggests that oral UFT might suppress the progression of ICC, contributing to this patient's 11-year survival period.

Background/aims: Portal vein thrombosis (PVT) after liver transplantation is a fatal complication. The risk factors for PVT after LDLT remain to be clarified., Methodology: A total of 287 consecutive living donor liver transplantations have been performed. Some clinical parameters of the recipients with and without postoperative PVT were compared to analyze the risk factors for PVT., Results: A total of 20 recipients (7%) were complicated with PVT. Of these 20, 6 patients had late onset PVT (> or =3 months after LDLT). There were no significant risk factors for early onset PVT (<3 months after LDLT). In contrast, a venous conduit for interposition was a significant risk factor for late onset PVT (multivariate analysis, p=0.02)., Conclusions: Use of venous conduit for portal vein interposition might be limited for better results although longer term follow-up and further case accumulation are necessary for more definitive conclusions.

Intussusception occurs rarely in adults compared with children, and in the case of adults, some organic disease, such as a benign or malignant tumor, can be found at the leading edge of the intussusception in about 90% of adult cases. This study reports a case of adult intussusception in which the stump of the jejunal loop in a Roux-en-Y bilioenteric reconstruction acted as a leading tip of the intussusception.

Background/aims: To describe and compare the demographic and clinical characteristics of hepatocellular carcinoma (HCC) patients subject to surgical operation at two referral centers in China and Japan., Methodology: Information on surgical HCC patients was retrieved from medical records. All patients were subjected to regular follow-up. The characteristics of HCC cases from two countries were described and compared., Results: A total of 353 newly diagnosed cases subject to surgical resection for HCC from 1995 to 1999 were analyzed in China and Japan. Differences were noted in the demographic and clinical characteristics of HCC patients between the two countries, such as average age of incidence, history of blood transfusion, serum examination, and history of hepatic viral infection. Statistical analysis also indicated differences in surgical systematic anatomical resection (p < 0.001), liver cirrhosis (p < 0.05), tumor diameter, and distant metastases (p < 0.001). The Chinese patients in early TNM stage I showed poorer outcomes in terms of cumulative survival in comparison with Japanese patients (p < 0.001)., Conclusions: HCC patients in Japan were diagnosed earlier, subject to more standard treatment, and had better prognosis. Examination with a larger population and more clinical data, including repeated treatment for recurrent HCC, will be required to provide a more accurate assessment of HCC in the two countries.

Background/aims: In extended left hepatectomy including venous resection of proximal portion of the MHV, a simple new venous reconstruction technique was attempted to bypass the long gap between the stump of peripheral portion of MHV and IVC., Methodology: One of the hepatic venous branches in resecting side of the liver was dissected during liver transection. The dissected vein was left attached to the IVC at its proximal portion and the distal end was directly anastomosed with the stump of MHV as an alternative venous drainage rout., Results: Of 282 hepatectomies performed for metastatic liver tumor in Tokyo University Hospital from 1995 to 2004, two patients were treated with the present technique. With the in situ hepatic vein graft method, postoperative venous congestion was successfully avoided in both of two cases and drainage areas of the reconstructed vein showed sufficient parenchymal regeneration., Conclusions: In situ hepatic vein graft might be useful and possibly superior to conventional free venous graft in reconstructing long venous gap in selected patients from the viewpoint of its safety, curative potential, and the long-term patency.

Background/aims: Limiting the backflow bleeding from the hepatic veins is a priority in liver resections. We describe an ultrasound-guided technique for backflow bleeding control from the right hepatic vein (RHV) during right-sided liver resection., Methodology: Right surface of the extrahepatic RHV is exposed to allow its compression by surgeon's finger-tips: the effectiveness of finger compression is checked by color-Doppler intraoperative ultrasonography., Results: This technique was adopted in 47 consecutive patients with tumors located in the right segments and not infiltrating the RHV close to its caval confluence. There was no hospital mortality or major morbidity. Mean blood loss was 310 mL, and 4 patients required blood transfusion. The maneuver here described was used 2.3 times per patients, and taping of the RHV was never needed., Conclusions: The technique here described allows easy and safe control of the RHV patency without its skeletonization and encirclement.

Background/aims: Reversed portal flow following liver transplantation is life-threatening complication. There are few reports, however, regarding reversed portal flow after liver transplantation., Methodology: We performed 180 living donor liver transplantations (LDLTs) over 8 years. Portal vein flow was routinely measured postoperatively two or three times a day during the first 2 weeks after LDLT. Surgical correction of reversed portal flow was attempted as soon as possible., Results: Five patients (2%) were complicated by postoperative hepatofugal portal flow. The reversed portal flow was corrected surgically in all the patients by splenectomy and/or ligation of the residual collateral veins. The revision operation was repeated in two patients. In three patients, the shunts responsible for hepatofugal flow were not detected in preoperative imaging, which must be approached under the guidance of intraoperative ultrasound or radiologic examination. All five patients survived the operation., Conclusions: Hepatofugal flow causes ischemic damage to the graft, which will not normalize spontaneously. Prompt treatment of the reversed portal flow salvaged the graft.

Background/aims: Aberrant cell surface glycosylation, and especially excessive sialylation, is thought to have great importance in tumor malignancy. To investigate the clinicopathological significance of sialylation in colorectal cancer, we performed histochemical analyses using sialic acid-binding lectins., Methodology: Primary colorectal cancer and lymph node tissues obtained from 80 cases were subjected to lectin-immunohistochemical staining using Maackia amurensis leukoagglutinin (MAL) and Sambucus nigra agglutinin (SNA). The relationship between the staining characteristics and the various clinicopathological parameters was statistically analyzed., Results: In primary cancer tissues, a high level of SNA staining was significantly related to worse prognosis and some pathological characteristics such as lymph node metastasis, whereas a high level of MAL staining was related to worse prognosis. In metastatic lymph node tissues, positive staining was frequently found for MAL and SNA, which wasremarkable in cases categorized as N2 metastasis. Furthermore, cases with MAL-positive staining in metastatic lymph node tissues evidently indicated worse prognosis than those with MAL-negative staining., Conclusions: Aberrant expression of SNA-positive sialoglycoconjugates in primary colorectal cancer tissues is important in terms of unfavorable pathological characteristics of the cancer. In addition, aberrant expression of MAL-positive sialoglycoconjugates in metastatic lymph node tissues might be related to worse prognosis.

Background/aims: Knowledge of intrahepatic vascular variations, especially in hepatic venous anatomy, is inevitable for carrying out liver surgery safely. However, vascular anatomy of the right liver or right side tributaries of the MHV has been focused in various studies and there have been only a few reports on the left liver., Methodology: Sixty consecutive living donors for liver transplantation in a single institute were reviewed. Ramification patterns and drainage volume of each venous tributary were evaluated using 3D-CT venography., Results: Four characteristic venous tributaries; left superficial vein (LSV), umbilical fissure vein (UFV), and superior/inferior veins of Segment IV (V4sup/4inf) were detected on 3D-CT. Of these, LSV and UFV were sometimes rather thick overwhelming the LHV trunk and drained more than 20% of the left liver in 11 (18.3%) and 4 patients (6.7%), respectively. In such cases, proportions of Segment II (LSV drainage area) or Segment III+IV (UFV drainage area) were significantly large compared with those in typical venous ramification cases., Conclusions: Clinically significant findings on venous variations in the left liver were described. Preoperative volumetric assessment of the draining areas of these veins is useful in surgical decision making on venous reconstruction and/or extent of liver resection.

Background/aims: Despite the impressive results of living donor liver transplantation, hepatic venous reconstruction remains a controversial component., Methodology: A total of 211 consecutive donor hepatectomies were performed. The proximal route of the hepatic vein was exposed by dissection of the connective tissue around the hepatic vein and by dividing and ligating all of the inferior phrenic veins that open into the hepatic vein, into the confluence of the hepatic vein and inferior vena cava, or directly into the inferior vena cava., Results: In the 114 left-side hepatectomy procedures, the number of divided left inferior phrenic veins ranged from 1 to 4 and the diameters of the left and middle hepatic veins ranged from 7 to 33mm. For the 97 right-side procedures, the number of divided right inferior phrenic veins ranged from 1 to 4 and the diameters of right hepatic veins ranged from 9 to 34mm. This maneuver safely allowed for the safe exposure of all trunks and routes of the hepatic veins and the suprahepatic portion of the inferior vena cava., Conclusions: Our technique is useful for obtaining a wide ostium and a sufficient length of the hepatic vein for grafts obtained from living donors.

Background/aims: Although the Model End-Stage Liver Disease (MELD) score has been effective in the prediction of mortality in patients awaiting liver transplantation, its predictive value of survival after living donor liver transplantation (LDLT) needs further study., Methodology: We report our experience with 142 cases of LDLT, analyzing the impact of the MELD score on the graft survival after LDLT., Results: Of 142 grafts, 18 failed during the observation period. One-, 3- and 5-year survival rates were 92%, 87% and 82%, respectively. Cox proportional hazard model revealed that MELD score did not predict graft survival (p=0.43, relative risk = 1.0)., Conclusions: The present results may indicate that the preoperative MELD score was of little help for determining the indication of LDLT.

Background/aims: In liver surgery, blood loss during hepatic transection is important. The use of an ultrasonic dissector was not always superior to conventional clamp crushing for performing hepatic parenchymal transections. The purpose of this study is to evaluate the effect of an ultrasonic dissector equipped with electrocautery in hepatic surgery., Methodology: A prospective study was conducted in 66 consecutive patients who underwent a partial hepatectomy using a new small ultrasonic dissector equipped for electrocautery. To evaluate the effectiveness of using the new instrument, the surgical outcomes were compared with those of historical control., Results: The surgical outcomes of procedures using the new ultrasonic dissector were comparable to those of patients in the conventional ultrasonic dissector group; median blood loss, transection time, transection speed, percentage of tumor exposure at surgical margin, morbidity rate. The number of technical errors and the percentage of patients with an incomplete landmark appearance were lower in the new dissector group, but the differences were not significant. The distribution of hepatectomy grades also did not differ significantly., Conclusions: The surgical outcome of hepatectomies performed using an ultrasonic dissector cannot be significantly improved by the addition of an eletrocautery function to the dissector.

Background/aims: Need for abdominal drains after liver resection is debated. However, unrecognized bile leak is relatively frequent: to prevent bile collection we adopted the use of long-term drains. The aim of this study was to validate this policy checking the bilirubin concentration in the drain discharge and serum along the postoperative course., Methodology: A prospective cohort study enrolling 58 consecutive patients with liver tumors was carried out. All patients underwent liver resection and received abdominal drains which were maintained for at least 7 days postoperatively. The bilirubin concentration in serum and drain discharge was sampled on the 3rd, 5th and 7th postoperative days., Results: No postoperative mortality and major morbidity were observed. The bilirubin level in drain discharge was higher on the 5th postoperative day than on the 3rd and 7th postoperative days: difference between the 3rd and 5th postoperative days was significant. No differences were observed among serum bilirubin levels on 3rd, 5th and 7th postoperative days., Conclusions: The bilirubin level in drain discharge increases late in the postoperative course. Therefore, bile leakage should be evaluated between the 5th and 7th postoperative days. The use of long-term drains helps protect against undiscovered collections and thus impacts postoperative course.

Hepato-pancreaticoduodenectomy was performed for common bile duct carcinoma associated with celiac axis stenosis. To secure arterial blood flow to the upper abdominal organs, we preserved the anterior arcade in the pancreas head acting as a collateral pathway between the superior mesenteric artery and the celiac artery. This is another valid alternative procedure for pancreaticoduodenectomy in a patient with celiac axis stenosis.

Background/aims: Complete outflow is impossible to maintain on both sides in donors undergoing hemi-liver graft harvesting, because the middle hepatic vein (MHV) can be preserved on only one side. The area in which outflow veins are disrupted becomes congested, and does not sufficiently regenerate., Methodology: The subjects of the study were 55 living donors who provided the left liver with caudate lobe, including the MHV. The midpoint between the tributaries of the MHV and the right hepatic vein was determined preoperatively with computed tomography. The midpoint between the tributaries of the MHV and right hepatic vein and the borderline between the right and left liver were used to predict the MHV drainage area volume. Total bilirubin levels, the prothrombin time international normalization ratio, and alanine aminotransferase were measured in donors on postoperative days 1, 3, 5 and 7., Results: The parameters that correlated with the MHV drainage area volume included total bilirubin on days 5 and 7, prothrombin time international normalization ratio on day 3, and alanine aminotransferase on day 7., Conclusions: Middle hepatic vein drainage area volume, calculated using the present method, correlated with early liver function after left liver harvesting with the MHV.

Background/aims: Hepatic artery and portal vein thromboses after liver transplantation remain significant causes of graft loss. Doppler ultrasonography is useful for detecting the thrombosis early. Doppler examination requires specialized equipment and training. However the results depend on the skill of the operator., Methodology: We developed a new Doppler probe that can be implanted in the abdominal cavity. The probe was used for 48 hours in 10 living donor liver transplantation patients., Results: In all recipients, hepatic arterial and portal flows were monitored continuously. The medical staff could easily operate the ultrasonography system at the bedside., Conclusions: The technique was useful for detecting hepatic blood flow for 48 hours after liver transplantation.

Background/aims: Aberrations of the pRb (Retinoblastoma gene protein)-p16INK4 pathway play a critical role in carcinogenesis. Our objective is to evaluate its role in tumorigenesis and the development of ampullary cancer., Methodology: We examined expression status of p16INK4 protein and pRb immunohistochemically and assessed their possible prognostic relevance in 36 ampullary cancers., Results: Thirty-four specimens (94.4%) exhibited alteration of p16INK4 and/or pRb expression, with 63.9% (23/36) of cancers showing p16INK4 negative expression and 94.4% (34/36) pRb abnormal expression. p16INK4 protein negative expression correlated significantly with tumor progression features such as advanced tumor stages (p=0.0291), lymph node metastasis (p=0.005), pancreas invasion (p=0.0002) and duodenum invasion (p=0.0101). Cases with both p16RNK4 protein negative expression and pRb overexpression showed poorer differentiation, more invasive growth (p=0.0425), higher level tumor stages (p=0.0079) and more frequent pancreas invasion (p=0.0024), compared with the others. p16INK4 protein expression showed no relationship with pRb expression (p=0.2199). No association was found in pRb expression status compared with any clinicopathological parameters analyzed., Conclusions: The disruption of the pRb-p16NK4 pathway plays an important role in ampullary carcinogenesis, the absence of p16INK4 protein expression might be involved in ampullary tumor progression.

Background/aims: Right lateral sector (RLS, segments VI and VII according to Couinaud's nomenclature for liver segmentation) graft was introduced as an alternative liver graft. The authors report their surgical techniques for bile duct division in RLS graft harvest., Methodology: Between January 2000 and December 2001, 11 donors provided their RLS. Intraoperative cholangiography was performed and the anatomy of the upper biliary confluence was confirmed. When the right lateral duct entered the common bile duct (caudal right lateral duct), the duct was divided at its root in situ. In other situations, the right portal branch was first dissected and taped. With the right portal branch pulled cranially, the right lateral duct was dissected from surrounding connective tissues and divided as long as possible., Results: Cholangiography revealed various right lateral duct anatomies, such as entering the right duct (n=6), the left and right bifurcation (n=2), the common bile duct (n=2) and the left duct (n=1). The postoperative course was uneventful in all donors. All of the patients survived the operation., Conclusions: Careful attention should be paid to bile duct division in donor hepatectomy. The present technique can ensure a safe harvest of RLS graft with a long right lateral duct.

Background/aims: Cytomegalovirus (CMV) infection is one of the most common infectious diseases complicating liver transplantation. Data regarding the incidence and results after CMV infection or disease after living donor liver transplantation, however, are limited., Methodology: A total of 169 patients who underwent living donor liver transplantation in. our department were enrolled in the study. All of the patients were preemptively treated with intravenous ganciclovir (10mg/kg/d) when the pp65 antigenemia assay was positive. The incidence of CMV infection and disease, and risk factors for CMV infection were evaluated., Results: The incidence of CMV infection and CMV disease was 44% and 3%, respectively. Acute rejection was significantly associated with CMV infection., Conclusions: The incidence of CMV disease was low, suggesting that our strategy might be effective for preventing the development of CMV disease.

Background/aims: Cell surface glycosylation changes during oncogenesis and is thought to correlate with the malignant potential of cancers. To investigate the role of sialylation in carcinoma of the papilla of Vater, histochemical analyses were performed using sialic acid-binding lectins, Maackia amurensis leukoagglutinin and Sambucus nigra agglutinin., Methodology: Thirty-six papillary carcinoma tissues and 8 normal papillary tissues were subjected to lectin-histochemical staining. The relationship between lectin staining characteristics and clinicopathological parameters was statistically analyzed., Results: Epithelial cells of glands in normal tissues were stained with Sambucus nigra agglutinin but not with Maackia amurensis leukoagglutinin. Of 36 papillary carcinoma tissues, 20 showed Maackia amurensis leukoagglutinin-positive staining in cancer cells, whereas all 36 were Sambucus nigra agglutinin-positive in cancer cells. According to Maackia amurensis leukoagglutinin-staining characteristics, the 36 cases were divided into two groups: positive (n=20) and negative (n=16). Statistical analysis indicated that positive staining in cancer cells was frequent in cases of lymph node metastasis (p=0.001) and in cases classified > or = T2 by TNM classification (p=0.036)., Conclusions: Aberrant expression of sialoglycoconjugates recognized by Maackia amurensis leukoagglutinin might participate in lymph node metastasis and in an advanced stage of invasion in carcinoma of the papilla of Vater.

A case of repeated obstructive jaundice and acute pancreatitis caused by mucus plug produced by metastatic liver tumor is reported. A 74-year-old woman, who had a past history of curative resection of mucinous rectal cancer, showed repeated obstructive jaundice and acute pancreatitis during the follow-up period. Neither computed tomographic scan nor abdominal ultrasound could detect the recurrent lesion, however, cholangioscopy detected mucin and tumor projection into the left hepatic duct. Since the biopsy specimen of the tumor revealed adenocarcinoma, left hepatectomy was performed. The tumor was mucinous adenocarcinoma having the same histology as the primary rectal cancer, with partly mucosal replacement and formation of intraluminal mucus plaque. This case indicates that repeated obstructive jaundice and acute pancreatitis should be considered one of the manifestations of liver metastasis of mucinous cancer.

Background/aims: To understand the three-dimensional relationship between the liver vasculature and tumor by intraoperative sonography, some training is inevitable. Three-dimensional ultrasound has been evaluated in various fields, but not yet in intraoperative sonography., Methodology: Extracorporeal 3-D ultrasonography was performed in 32 patients. Of these, 20 underwent intraoperative 3-D ultrasonography. Using these images, we evaluated whether or not the portal vein, hepatic vein and its branches were discernible., Results: Satisfactory images were obtained in all 32 patients by extracorporeal methods and in 15 by intraoperative 3-D ultrasonography. The number of visualized veins, including the right portal vein, its anterior branch, posterior branch, anterior superior branch, anterior inferior branch and right hepatic vein, was 32, 32, 23, 28, 22, and 30 by extracorporeal 3-D ultrasonography, and 15, 14, 10, 8, 5, and 12 by intraoperative 3-D ultrasonography. The relationships between the intrahepatic artery, portal vein, and hepatic vein were more clearly visualized by intraoperative 3-D sonography., Conclusions: Intraoperative 3-D ultrasonography clearly showed small branches of the liver vasculature and their 3-D relation, which may be helpful for liver surgery. However, this method requires further improvement.

We present a surgical procedure for liver metastases with hepatic hilar invasion, which was originally developed for hilar bile duct cancer. A 64-year-old man with 8 metastatic nodules from colon cancer and hepatic hilar invasion received this technique, and lived for more than 5 years without any restriction in his life. The authors recommend this procedure for those patients in order to preserve their quality of life.

Background/aims: One of the main causes of postoperative morbidity and mortality following major hepatic resection is hepatic ischemia deliberately designed to reduce intraoperative hemorrhage. This study assessed the effects of intermittent or continuous hepatic ischemia and reperfusion with or without methylprednisolone pretreatment in the rat., Methodology: One hundred and eighty rats were divided into 3 groups undergoing hepatic ischemia of 60, 90, and 120 minutes total duration. Each group of rats were subdivided to receive either a continuous Pringle maneuver, or 30 min or 15 min of intermittent liver pedicle clamping. Ten minutes before ischemia induction, 10 rats from each group were pretreated with intravenous 3 mg/100 g bw methylprednisolone., Results: With continuous hepatic pedicle clamping the rat survival rates inversely correlated with the duration of ischemia (survival: 70%, 40%, and 20% with ischemia of 60, 90, and 120 min). Survival rates at 15-min and 30-min intermittent ischemia groups were significantly higher than in the continuous clamping group (p<0.05). Methylprednisolone pretreatment did not significantly increase survival but resulted as a significant reduction in liver enzyme release (AST, ALT), at 90 min (p<0.05) and at 120 min (p<0.05) in the continuously clamped groups. When ischemia lasted 120 min, methylprednisolone pretreatment was associated with higher preservation of ATP liver content (p<0.05)., Conclusions: This study confirms that intermittent hepatic pedicle clamping significantly improves survival in rats undergoing hepatic vascular inflow occlusion with a decrease in transaminase release and greater maintenance of intrahepatic ATP after prolonged total ischemia when animals were pretreated with methylprednisolone.

Background/aims: Biliodigestive anastomoses to small bile ducts after extensive liver resection or central bile duct remain difficult. The inherent problems associated with this particular procedure have not been widely discussed. In order to demonstrate that reconstruction of segmental or subsegmental bile ducts with mucosa-to-mucosa alignment using transanastomotic stents can reduce morbidity associated with the procedure, we have reviewed our experience with small biliodigestive anastomosis after liver resection., Methodology: Thirteen patients were operated on from 1995 to 1997. Twelve had malignant diagnoses. A comprehensive standardized technique included the use of short or trans-intestinal trans-anastomotic stents and single layer interrupted absorbable sutures with mucosa-to-mucosa alignment. In the patients, in-hospital morbidity and mortality with focus on bile leaks and long-term signs of cholangitis and stricture formation were investigated with a median observation period of 42 months., Results: Eleven underwent extensive liver resections and two had complicated central resections including the bile duct confluence. The procedures included 40 transected bile ducts and 32 anastomoses to the jejunum. One patient died as a result of rupture of a splenic arterial aneurysm caused by a pancreatic pseudocyst. Other complications which occurred in seven patients were intra-abdominal fluid collection (n=5), wound infection (n=1), minor bile leakage from the liver cut surface (n=1), and pleural effusion (n=4). Postoperatively four patients, who had local recurrence with jaundice, showed cholangitis, whereas the remaining nine patients showed no signs of cholangitis., Conclusions: Our technique for reconstructing small bile ducts with mucosa-to-mucosa alignment is considered adequate from the viewpoint of short- and long-term results.

Middle hepatic vein reconstructions for modified right liver grafts in living donor liver transplantation provide satisfactory results. We report a patient who had undergone transjugular intrahepatic portosystemic shunt before living donor liver transplantation, in which the middle hepatic vein was reconstructed using a preserved great saphenous vein. A 41-year-old Japanese man with a 5-year history of alcoholic liver cirrhosis and esophageal varices was admitted to our hospital for living donor liver transplantation. He had undergone endoscopic variceal ligations and transjugular intrahepatic portosystemic shunt for esophageal variceal bleeding, and ascites. He had living donor liver transplantation, which was performed using his sister's right lobe without the middle hepatic vein. The recipient's estimated standard liver volume calculated by abdominal computer-assisted tomography was 1166 mL. The exact weight of the donor's right lobe was 507 g, which was equivalent to 44% of the recipient's standard liver volume. At bench surgery, the middle hepatic vein was reconstructed using a preserved great saphenous vein, which was cut in 2 strips to make a thicker tube graft by suturing, and subsequently, the newly made tube graft end was anastomosed to V5 and V8 branches of the graft. The metallic stent for transjugular intrahepatic portosystemic shunt buried in the recipient's right hepatic vein was removed with the right hepatic vein. The other end of the saphenous tube graft was anastomosed to the right anterior aspect of the vena cava. Stumps of the middle and left hepatic veins were oversewn. Postoperative blood flow in the graft and the reconstructed hepatic veins has been satisfactory with normal liver functions.

Background/aims: The factors influencing the effect of portal vein embolization performed prior to hepatectomies are not clearly understood., Methodology: In 18 patients who underwent portal vein embolization, serum transforming growth factor-alpha levels and the nonembolized liver volume were studied after portal vein embolization. The increase in the nonembolized liver volume was compared with the change in serum transforming growth factor-alpha levels and several other clinical variables., Results: The volume of the nonembolized liver significantly increased from 430+/-114 cm3 to 521+/-113 cm3. The serum transforming growth factor-alpha levels significantly increased on the 7th day after portal vein embolization and peaked on the 18th day. The percentage increase in the nonembolized liver volume 14 days after portal vein embolization was significantly correlated with the nonembolized liver volume and the increase in the portal flow velocity, and it was independently and significantly correlated with the increase in the transforming growth factor-alpha level 14 days after portal vein embolization (r2=0.674, P=0.0014 and r=0.761, P<0.0005)., Conclusions: The increase in the transforming growth factor-alpha level 14 days after portal vein embolization was the only independent factor related to the hypertrophy of the nonembolized liver. Measurement of its serum level may be a useful indicator in the scheduling of subsequent extensive hepatectomies.

Milan criteria are standards for considering the indications of liver transplantation for hepatocellular carcinoma. A 57-year-old man underwent living donor liver transplantation for hepatitis B-related liver cirrhosis and hepatocellular carcinoma. Hepatocellular carcinoma had been treated with percutaneous microwave coagulation therapy and transarterial chemoembolization. Resected specimens revealed a solitary necrotic tumor 5 cm in diameter, which satisfied the Milan criteria. Although the patient survived the operation, he suffered from tumor recurrence in the graft and lung 2 months afterward. Adjuvant chemotherapy had no effect and the patient expired 7 months after transplantation. The present results indicate that a tumor satisfying the Milan criteria does not necessarily guarantee long-term survival after transplantation.

Background/aims: The present study examined the impact of portoenterostomy on the morbidity and mortality of patients who later underwent living donor liver transplantation for biliary atresia., Methodology: Sixty-one consecutive patients from January 1996 to May 2001 were analyzed. They were divided into two groups according to the number of previous portoenterostomies: once (group A, n=26) and twice or more (group B, n=35). Preoperative status, mortality, morbidity, hospital duration and survival were examined and compared between the groups., Results: Preoperative parameters regarding liver function and urgency status were comparable between the groups. The operation duration tended to be longer in group B than in group A (p=0.07). The blood loss and transfusion volumes in group B were greater than those in group A (p=0.03 for both comparisons). Vascular complications tended to be more frequent in group B patients. However, this difference was not significant (12% vs. 29%, p=0.06). The duration of hospitalization was longer in group B (p=0.04). Survival rates were comparable between the groups., Conclusions: Our surgical results suggest that multiple previous portoenterostomies might have negative short-term effects in patients who undergo living donor liver transplantation for biliary atresia.

Background/aims: The purpose of the present study was to examine the changes of spleen volume and platelet numbers after living donor liver transplantation in adults., Methodology: The spleen volume was measured by computed tomography preoperatively and 1, 6, and 12 months in 19 patients after liver transplantation. The platelet numbers were followed on the same time schedule., Results: The preoperative average spleen volume was 451+/-276 mL, which decreased gradually after liver transplantation. The preoperative averaged platelet number was 15.4+/-9.0x10(4)/mL, which did not change significantly during the observation period., Conclusions: The changes in spleen volume in the present study were consistent with the previous data, suggesting that living donor liver transplantation effectively reduced hypersplenism for adult patients.

Recurrence of hepatitis C virus after liver transplantation is common and cholestatic hepatitis occurs in approximately 10% of the patients and leads to accelerated graft failure and death. A 47-year-old man underwent living donor liver transplantation for hepatitis C-related liver cirrhosis. Preemptive antiviral therapy was started using interferon-alpha2b (6 MU x 3 per week) and ribavirin (600 mg per day) two months after living donor liver transplantation. The response to the combined therapy was not satisfactory. He developed liver failure and expired 11 months after the transplantation. The present results indicate that a rapid development of graft failure can occur in spite of preemptive antiviral therapy after living donor liver transplantation.

There are few reports of central pontine myelinolysis after living donor liver transplantation. A 59-year-old male received a right liver graft from his daughter for hepatitis B-related liver cirrhosis. Methylprednisolone and tracrolimus were used for immunosuppression. Dysarthria and dysphasia were noted on the second postoperative day. Brain magnetic resonance image taken on the 9th postoperative day revealed a hyperintense area at the center of his pons in T2-weighted images. The symptoms improved spontaneously 1 month after the operation. Central pontine myelinolysis should be included in the differential diagnosis when neurologic manifestations are observed after living donor liver transplantation.

Hepatic allograft rejection after liver transplantation remains an important problem. We report a case of corticosteroid and anti-T cell monoclonal antibody-resistant acute cellular rejection in living related liver transplantation. A 57-year-old female received a right liver graft from her daughter for hepatitis C-related liver cirrhosis. Methylprednisolone and tracrolimus were used for immunosuppression. The patient experienced acute rejection 10 days after the operation. Rescue therapy was attempted using high doses of methylprednisolone and then monoclonal antibodies. Deterioration of graft function, however, was not prevented, resulting in graft and patient loss. Graft lost due to refractory acute rejection could also occur in living related liver transplantation, although it should be rare.

The case of a 55-year-old woman with a pedunculate adenoma of the papilla of Vater is presented. Diagnostic imaging modalities including ultrasonography, CT scan, magnetic resonance of cholangiopancreatography, simultaneous duodenography and cholangiography, and angiography showed a giant tumor protruding intraluminally and moving forward in the duodenum by peristalsis. It had a duodenal intussusception-like appearance, with remarkable left-lower deviation of the common bile duct and major pancreatic duct in the papilla of Vater as far as the left side of the aorta. Episodes of jaundice or ileus were absent, probably because the tumor was mobile in the duodenum. As biopsy specimens showed no malignancy and intraductal ultrasonography in the common bile duct revealed no intraductal invasion of the tumor in the papilla of Vater, the patient underwent transduodenal papillectomy with papilloplasty with pancreatic ductoplasty. Pathological diagnosis of consecutive specimens was a papillary adenoma with moderate atypia and occasional tubular structure. There seems to be an exceptional subtype of the tumor in the papilla of Vater, like this case, demonstrating the duodenal intussusception-like appearance without prominent clinical symptoms.

Background/aims: The phenylalanine breath test may serve as a liver function test, although its clinical usefulness has never been clarified. This study aimed to evaluate the role of preoperative phenylalanine breath test in patients undergoing hepatectomy., Methodology: Twenty-seven patients undergoing hepatectomy were studied. The PBT30 (phenylalanine excretion ratio at 30 min) was measured after oral administration of 100 mg of L-[1-(13)C]-phenylalanine. Postoperative mortality and morbidity were compared with the value of PBT30, ICGR15 (plasma retention rate of indocyanine green at 15 min), Child-Pugh score, and other blood chemical tests together with operative factors. Independent factors contributing to postoperative mortality and morbidity were evaluated by multiple logistic regression analysis., Results: Postoperative mortality and morbidity rates were 0 and 25.9%, respectively. PBT30 and ICGR15 values were significantly different between the groups with and without postoperative complication, and these two parameters independently contributed to prediction of postoperative complication., Conclusions: PBT30 is a clinically useful predictor for postoperative complication in patients undergoing hepatectomy.

The case of a 57-year-old woman with a benign biliary stricture is described. Radiological examinations showed granularly elevated lesions in the common hepatic duct and severe stenosis at the hepatic hilum. Under a tentative diagnosis of hepatic hilar bile duct cancer, the patient underwent extended right hepatectomy with bile duct resection. However, pathological and immunohistochemical studies revealed a benign stricture with remarkable formation of lymph follicles with germinal centers, which could be termed "follicular cholangitis". This is the first case report of this uncommon presentation of inflammatory changes of the bile duct. Its etiology was unknown, and more investigation is encouraged to clarify its relationship to systemic disorders and malignancies. As difficulty remains in discriminating between benign and malignant strictures by nonsurgical modalities at present, surgical resection without complications provides a feasible approach to such a benign lesion.

Long-term survival after the resection for liver metastasis from breast cancer is rare. We report on a 49-year-old woman who has been alive and well for 12 years following hepatic resection for metastatic breast cancer. Fourteen years before, the patient underwent a radical mastectomy for cancer of the right breast. One year after the operation the patient presented with right upper quadrant pain and a large isolated right lobe liver metastasis was found. Initially, it was too large to be treated by hepatectomy. Thus, intra-arterial one-shot injection of 20 mg of mitomycin C mixed with 4 mL of lipiodol was given three times at 1-month intervals and was followed by 5-fluorouracil (250 mg) and mitomycin C (2 mg) administered 9 times at 2-week intervals through the implanted port. Additionally, 150 mg of 5-fluorouracil and 1200 mg of medroxiprogesterone acetate were orally administered for 5 months. These therapies led to a remarkable reduction in tumor size and the metastasis was safely resected by an extended right hepatic lobectomy. The specimen was completely necrotic and histologically no viable tumor cell was observed. In the present case, the aggressive preoperative chemo- and hormonal therapies might be significant in making a contribution to longer survival.

A 70-year-old man with double carcinomas of the hilar bile duct and stomach underwent extended right hepatectomy and total gastrectomy with double Roux-en-Y reconstruction in a one-stage procedure 15 days after right portal embolization. The postoperative course was uneventful, and he was discharged 33 days after surgery. This report describes details of the surgical techniques employed in this patient.

Nowadays, tumor clearance for colorectal liver metastases can be achieved in most patients undergoing liver resection with survival benefits. Most merits of conservative and radical resections should probably be addressed to the extensive use of intraoperative ultrasound. Mostly for this reason, surgery can be still considered the treatment of choice. For this purpose, intraoperative ultrasound-guidance technique should be a familiar instrument for the hepatic surgeon. The technical tricks needed to perform a real intraoperative ultrasound-guided hepatectomy in the management of liver metastases from colorectal cancer are described.

We describe a case of cystic duct carcinoma, the computed tomography findings of which had been incidentally obtained several times over the preceding three years before obstructive jaundice appeared. Under the diagnosis of extrahepatic bile duct carcinoma, a 75-year-old man underwent surgery. Two years before obstructive jaundice appeared, the arterio-portal phase of enhanced computed tomography demonstrated an ovoid mass with peripheral rim enhancement, measuring 1.5 cm in diameter, beside the extrahepatic bile duct. One year later, a repeat enhanced computed tomography consistently showed the ovoid mass with peripheral rim enhancement, and the lower slice of the contiguous computed tomography scan revealed a uniformly enhanced mass compressing the neck of the gallbladder. Four months before obstructive jaundice, the uniformly enhanced mass beside the extrahepatic bile duct markedly infiltrated the surrounding tissues with spicula-formation. At laparotomy, a solid and hard tumor was localized on the right side of the extrahepatic bile duct, in the cholecystic duct and the neck of the gallbladder. Of 29 reported cases fulfilling Farrar's criteria in the English literature other than autopsy cases, computed tomography imaging was only performed in two cases, and the computed tomography findings of cystic duct carcinoma in its early stages, have never been fully described.

Background/aims: The purpose of the present study was to examine variations in spleen size in adults., Methodology: The spleen volume was measured by computed tomography in 150 healthy donors for liver transplantation. The correlations between spleen volume and age, gender, body weight and body surface area were analyzed., Results: The mean volume of the spleen was 112 cm3, ranging from 32 to 209 cm3. The spleen volume significantly correlated with age (R = 0.36, p = 0.0002), but not with body weight or surface area. Gender did not influence the variation in spleen size., Conclusions: A crude normal range stratified by age should provide useful information in the diagnosis of splenomegaly.