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A pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery is often considered to be unresectable because the simultaneous division of both arteries may result in an acute severe ischemia of the liver and the stomach. We report here a case of total pancreatectomy with en bloc celiac axis resection for a 61-year-old female with a pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery. The patient had a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery, which was directly arising from the aorta. Preserving these collateral arteries, neither hepatic artery reconstruction nor total gastrectomy was needed after resection. The reported incidence of similar arterial anatomy was only 0.2% but the precise evaluation of arterial anatomy is important to offer a chance of curative resection for patients with usually unresectable locally advanced pancreatic cancer.

For resection of advanced hepatocellular carcinoma (HCC) in which tumor thrombus (TT) extends into inferior vena cava (IVC) or right atrium (RA) surgery is challenging and requires skillful techniques. Here, we report a case of recurrent HCC with TT extending to the RA, who underwent successful resection with tumor thrombectomy without concomitant cardiopulmonary bypass. A 71-year-old man, who had been followed- up for hepatitis C by a local hospital, was diagnosed as having HCC in segment 6 for which he had undergone segmentectomy of segment 6 in May 2009. During follow-up, he developed severe leg edema and ascites with investigations revealing recurrent HCC in segment 7 with TT extending to the right atrium via IVC. After transarterial embolization the patient underwent extended resection of the segment 7 with tumor thrombectomy of the IVC and the right atrium and partial resection of the IVC wall using total hepatic vascular exclusion, without concomitant cardiopulmonary bypass. Total ischemic time was 23 minutes, operation time was 6 hours and blood loss was 2,474mL. The postoperative course was uneventful. Histopathology was recurrent hepatocellular carcinoma with hepatic venous invasion. We report the case of resected recurrent HCC with TT extending to right atrium without concomitant cardiopulmonary bypass.

Background/aims: Although microRNAs are known to be post-transcriptional regulators in physiological and pathological events in the liver, their role in the obstructive jaundice liver remains unclear., Methodology: We sequenced the small RNA libraries of the bile duct ligation (BDL) mouse liver to detect the in vivo microRNA expression profiles of obstructive jaundice. We also validated the differential expression of microRNAs in the BDL liver using real-time PCR. Laser microdissection was performed to identify the origin of BDL-related microRNAs. An IL6-treated normal intrahepatic biliary epithelial cell line was used as an in vitro model of obstructive jaundice., Results: We found microRNAs that were upregulated in the BDL liver (let-7a, let-7d, let-7f, let-7g, miR-21, miR-125a-5p, miR-125b-5p, miR-194, miR-199a-3p, miR-199a-5p, miR-214, miR-221, and miR-486). Furthermore, laser-microdissection analysis showed that miR-199a-5p was significantly upregulated in the intrahepatic bile duct of the BDL liver. The in vitro expression of miR-199a-5p was appreciably elevated in accordance with increased proliferation of IL6-treated cells., Conclusions: We revealed dynamic changes in microRNA expression during obstructive jaundice using the BDL model. MiR-199a-5p was likely associated with the proliferation of intrahepatic bile ducts. Our data will facilitate further study of the pathophysiological role(s) of microRNAs in the obstructive jaundice liver.

Background/aims: Major hepatectomy for perihilar cholangiocarcinoma has considerable risk of hepatic insufficiency even with preoperative portal vein embolization (PVE). Postoperative bilirubinemia is a great concern for hepatic surgeons., Methodology: Between 1998 and 2004, 120 patients with hilar bile duct cancer (n = 72) and intrahepatic cholangiocarcinoma (n = 48) underwent major hepatectomies with extrahepatic biliary resection. Of these, 63 patients underwent preoperative PVE to increase the future remnant liver (FRL) volume. Risk factors for early bilirubinemia after hepatectomy (> or = 2.5 mg on day 1) were evaluated using univariate and multivariate analyses., Results: The median FRL volumes before surgery in patients with and without PVE were 46% and 70%, respectively. The serum total bilirubin (TB) value on day 1 after hepatectomy was higher in patients with PVE than in patients without PVE (2.9 mg/dL vs 1.9 mg/dL, p < 0.0001). However, the significant risk factors for higher bilirubinemia on day 1 were preoperative TB value > or = 1.0 mg/ dL (p = 0.01), blood loss > or = 1.8L (p = 0.01), and blood transfusion (p = 0.03). Two patients developed postoperative hepatic failure and one patient died of surgery from septic complication., Conclusion: Major hepatectomies for perihilar cholangiocarcinoma were performed with acceptable safety using preoperative PVE. Postoperative early bilirubinemia was not associated with the FRL volume in this setting.

Background/aims: The objective of this study is to clarify the pathological condition and treatment strategy of lethal obstructive colitis (LOC), which is defined as obstructive colitis with severe shock or septic shock., Methodology: We examined 5 patients with LOC (colorectal cancer or suspected in 2, fecal impaction in 2, and volvulus in 1) and evaluated their pathophysiology and management strategy from their medical records., Results: Emergency operations were performed within 150 minutes from arrival in all cases. Three were saved by repeat operations and 2 died. The systolic pressure of both survived and deceased patients were under 62 or palpable only on the common carotid artery, and there was no difference between survived and deceased patients. The mean pulse rate of the deceased patients was 76.5 while survived 117.7. Two deceased patients presented unconsciousness or conscious disorder while survived patients showed clear consciousness. The 2 deceased patients fell into VT just after arrival or during the operation., Conclusions: In managing colonic obstruction, we should be aware of this potentially lethal disease and surgical treatment should be performed as soon as possible before the patients fall into LOC. Early diagnosis and early aggressive surgery is essential for managing LOC.

Background/aims: The prognosis for esophageal disruption is still poor. The aim of this study is to clarify the usefulness and safety of the transabdominal-mediastinal approach for spontaneous esophageal disruption., Methodology: The surgical procedure is as follows: upper median laparotomy with resection of the xyphoid process, folding up of the lateral segment of the left liver, median phrenotomy from the root of the xyphoid process to the esophageal hiatus, trans-mediastinal left thoracotomy by blunt dissection, blind lavage of the thoracic cavity, and simple interrupted suture and fundic patch of this suture line, if necessary., Results: We managed 3 cases using this technique. Two cases had severe prior chronic diseases (poorly controlled diabetes and liver cirrhosis, and hemodialysis). In all cases, the lesions were completely exposed in the abdomen by and the ruptured sites were safely and completely sutured under a good field of view. The left thoracic cavity was adequately washed. All cases were saved without lethal complication. One case showed minor leakage, which was easily managed by continuous high pressure aspiration using double luminal drainage system (CHPA-DLD)., Conclusions: We concluded that our technique is useful for esophageal disruption long after the onset, with severe prior chronic diseases, or with pleuritis.

Hepatic vein resection and reconstruction after major hepatectomy is a technically feasible but controversial procedure. Reported autologous vein grafts include the great saphenous, external iliac vein, superficial femoral, gonadal, left renal and inferior mesenteric veins. The procedures required to obtain these grafts, however, are associated with a risk of postoperative morbidity such as edema of the lower leg. We performed the reconstruction of two middle hepatic vein (MHV) branches by using an autologous left portal vein graft that was harvested with its tributaries from the left hepatectomy specimen in a 57-year-old man who had undergone a sigmoidectomy for colon cancer and a partial resection of the right lateral sector of the liver for a metastasis. In conclusion, this is the first report on the reconstruction of MHV tributaries using a single autologous Y-shaped portal vein graft during a hepatectomy. This method produces no complications related to the harvesting of the graft.

Background/aims: Today, in light of widespread adoption of H2-RA and PPI, the standard surgical procedure for perforated duodenal ulcer (PDU) is simple closure and/or omental patch (SC). However, the healing process after these techniques has not been fully examined. We have not yet confirmed the propriety of simple suture of the bottom of the ulcer. This technique has been performed based only on experience, and there is insufficient evidence to conclude that this procedure can be definitively considered a safe therapeutic technique for the majority of patients with PDU. The aim of this study is to clarify the macroscopic findings of the healing process after SC for PDU., Methodology: Thirteen patients with PDU who were treated with SC underwent postoperative gastroduodenal fiberscopy (GF) at the 7th-16th postoperative day and the healing process was monitored under sufficient informed consent. Patients with severe preoperative disease were excluded from the study. Healing condition of the ulcer and stitches, deformity, and stenosis were evaluated by postoperative endoscopy. Possible adverse effects that were evaluated included: perforation, rise in fever, worsening of inflammation on laboratory data, gastrointestinal symptoms such as abdominal pain, sense of fullness, and vomiting. The indications for SC were as follows: PDU with 1) no stenosis and 2) no prominent ulcer ridge. The surgical technique was as follows: 1) interrupted simple closure with no trimming and debridement of wound (4-5 stitches) with absorbable monofilament suture, and/or 2) omental patch, 3) administration of H2-RA (or PPI) just after operation, and 4) oral feeding 4-5 days after operation independent of postoperative GF., Results: GF findings in 2 patients showed active and healing stage, in whom surgical technique was thought to be insufficient; the ulcer had been large and included a descending portion, or a small perforation had occurred in the large ulcer bottom (the distance between the stitches and the edge of the ulcer was insufficient). In the other 11 patients, GF findings showed scar phase. There was no morbidity related to endoscopic procedure., Conclusions: Sutured PDU with SC will be in the scar phase in 1 or 2 weeks. Postoperative GF 1 week after SC for PDU is thought to be a safe examination. This study is a primitive study of a small group, and more cases that can adequately show the frequency of complications and indicate the overall safety of the procedure are needed.

Background/aims: Blunt abdominal-pelvic trauma patients with shock often require transcatheter arterial embolization (TAE), and may also require surgery if intraperitoneal bleeding (IPB) becomes massive. Deciding whether the patient should undergo surgery is highly critical. We sometimes perform TAE without attention to IPB because it has been difficult to evaluate the volume of IPB exactly during TAE. Currently we use small portable ultrasonography (PUS) as a monitor of volume of IPB during TAE. The aim of this study is to clarify the usefulness of PUS for monitoring changes in IPB during TAE., Methodology: We examined the volume of IPB by PUS during TAE without disturbing the operators of TAE. In our protocol, if the volume of IPB showed rapid increase we tried to perform a surgical procedure. The design of this study was a prospective case series study., Results: We examined 26 patients. Increase of IPB was detected in 3 cases; two were undergoing angiography for ileac and renal arteries when PUS indicated increase of IPB, which drew attention to their hepatic arteries. The other was examined initially for internal ileac artery and underwent surgery because of an increase of IPB. In the other 22 cases, we confirmed no increment of IPB by PUS and continued the procedure., Conclusions: PUS is useful for deciding the order of therapeutic procedure, and is a useful monitoring instrument for increase of IPB.

Background/aims: Occlusion of the pancreatic duct system has been used to prevent pancreatic leakage by abolishing pancreatic exocrine secretion in pancreatic surgery. However, ductal occlusion has not proved satisfactory for preventing pancreatic fistulas in pancreaticoduodenectomy (PD)., Methodology: Pancreatic duct occlusion with a watertight drainage system around the pancreatic stump was performed following extended PD in 17 patients with (n=12) or without (n=5) a dilated pancreatic duct., Results: Transient pancreatitis during the early postoperative period occurred in all patients with a nondilated pancreatic duct. No patient developed pancreatic fistula or any other serious complication in both groups., Conclusions: Pancreatic duct occlusion may minimize the risk of pancreatic leakage in patients with a nondilated pancreatic duct and a normal pancreas as well as in those with a dilated, obstructed pancreatic duct without compromising the postoperative quality of life. This is a safe and reliable technique for managing the pancreatic remnant in patients undergoing extended PD for advanced pancreaticobiliary malignancy.

The presence of hepatic metastasis in pancreatic cancer has generally been considered to be a contraindication for surgery. However, the present case survived seven years after concomitant resection of pancreatic cancer and hepatic metastasis. This shows that hepatic metastasis may be a strong predictor of poor survival, but not a determinant of noncurability. Surgical resection may be an option for highly selected patients with pancreatic cancer complicated with hepatic metastasis.

Post-traumatic hepatic pseudoaneurysms are rare. We report a very unusual case of bile duct injury complicated with an asymptomatic post-traumatic hepatic pseudoaneurysm. A previously healthy 17-year-old man sustained multiple traumas after a motorcycle accident. Post-traumatic hepatic pseudoaneurysms were detected after blunt liver injury. The rapid growth of the pseudoaneurysms in the hepatic hilus compressed the common hepatic bile duct and caused extrahepatic bile leakage at the lateral lobe. At first, the hepatic arterial pseudoaneurysms were embolized and bile leakage at the left lobe was treated conservatively. Finally, however, segment 2 and 3 partial liver resection should have been performed to stop the bile leakage. Post-traumatic pseudoaneurysm should be ruled out, in addition to the presence of biliary tract injury, if the intraperitoneal bile leakage appears after liver injury.

Background/aims: To clarify changes in the hepatic oxygen metabolism and tissue damage resulting from oxygen-derived free radical generation from polymorphonuclear cells during a hepatic arterial clamp., Methodology: Subjects were 32 male Wistar rats. Hepatic tissue blood flow, and hepatic venous chemiluminescence, indicating oxygen-derived free radicals from polymorphonuclear cells, and liver lipid peroxide were measured, and hepatic and portal venous blood gas analysis were performed before and after 130 minutes of hepatic arterial clamping., Results: Hepatic tissue blood flow decreased by hepatic arterial clamp. The values of hepatic arterial oxygen pressure (HTBF), hepatic venous oxygen saturation (ShvO2), and O2 contents after hepatic arterial clamp were lower than those before hepatic arterial clamp (P = 0.035, 0.024, and 0.028, respectively). Hepatic venous chemiluminescence decreased and the lipid peroxide level of the liver increased by hepatic arterial clamp (P = 0.001)., Conclusions: ShvO2 is useful for the evaluation of hepatic oxygen metabolism and hepatic tissue blood flow during acute hepatic arterial clamp. This condition should prepare the following tissue damage due to oxygen-derived free radicals from polymorphonuclear cells.

The management of the cut stump after a subtotal left-side pancreatectomy is sometimes difficult compared with that after distal pancreatic resection, which is performed at or to the left of the superior mesenteric vein. This report describes a simple and effective drainage method of leaking pancreatic juice from the cut stump after subtotal left-side pancreatectomy for pancreatic adenocarcinoma located in the body and tail. Since July 20, 1994, we have applied this method to 12 patients with carcinoma of the body and tail of the pancreas other than the present case and as yet have never experienced serious postoperative complications.

Background/aims: To evaluate the usefulness of three-dimensional cholangiography and rotating cine cholangiography in depicting the anatomy of the hilar bile duct and tumor extension, and in planning surgical procedures for hilar cholangiocarcinomas., Methodology: Five patients with hilar cholangiocarcinoma and obstructive jaundice who underwent percutaneous transhepatic biliary drainage followed by resection were serially examined by cine cholangiography and three-dimensional cholangiography which were reconstructed from a helical computed tomography scan. Tumor extension to the bile ducts was prospectively diagnosed and the resection margin was planned using both cine and three-dimensional cholangiograms. The histological evaluation of the resected specimens were compared with preoperative findings of cholangiograms., Results: The three-dimensional cholangiograms from vertical projection demonstrated the bile duct anatomy with excellent image quality. To assess tumor invasion to the intrahepatic bile ducts, cine cholangiograms from lateral and oblique projections were necessary. Selection of the surgical procedure was influenced by preoperative evaluations of the lesion on both three-dimensional and cine cholangiograms. Histologically, the resected margin was free from tumor in all cases., Conclusions: Three-dimensional and cine cholangiography allowed accurate assessment of the biliary system in patients with hilar cholangiocarcinoma, which was helpful for planning the surgical procedure.

Background/aims: The purpose of the present study was to clarify the indications for a thoracoabdominal right oblique approach and an inverted L incision in posterior segmentectomy of the liver for hepatocellular carcinoma., Methodology: Forty-six patients with hepatocellular carcinoma who underwent posterior segmentectomy with thoracotomy were divided into 2 groups according to the incision: thoracoabdominal right oblique incision (group A, n = 17) and inverted L incision (group B, n = 29). The perioperative factors of the patients in the 2 groups were compared retrospectively., Results: No significant differences were found in the preoperative factors between the groups. However, a longer operation time (P = 0.01) and more blood loss (P = 0.02) were noted in group B. Although there was no significant difference between the groups in the overall morbidity rate (P = 0.36), a higher rate of pleural effusion was recognized in group A (P = 0.01)., Conclusions: Thoracoabdominal right oblique incision may be suitable for use as an approach for posterior segmentectomy when manipulation of the left lobe is not required.

Primary carcinoid tumor of the liver is very rare. Only 30 cases have been reported in the English literature. However, most of those cases were diagnosed only on the basis of diagnostic imaging and surgical exploration, their follow-up periods being up to 5 years. Considering the slow progression of the tumor, long-term follow-up is required to exclude occult extrahepatic primaries which may manifest afterwards, and to determine the clinical course of this disease. We experienced 3 patients with primary hepatic carcinoid tumors who underwent total resections. They all survived more than 7 years and were clinically confirmed as hepatic primary by failing to detect other primaries during their courses. One patient is disease-free for more than 7 years after resection. The other 2 were found to have recurrence in the remnant liver; 1 underwent transcatheter arterial embolization several times and is alive more than 4 years after recurrence, and the other underwent 2 more operations and survived 8 years after the 1st recurrence. Surgery might offer a possible chance of cure for primary hepatic carcinoid tumor, and transcatheter arterial embolization might be a good treatment option when an unresectable disease is confined to the liver.

There has been no English report of a long survivor after hepatectomy for metastasis from periampullary malignancies, who had previously undergone pancreatoduodenectomy (PD) for primary disease. Herein, we report 7 patients of liver metastases who underwent 8 hepatectomies after PD for peri-ampullary malignancies. One patient whose liver metastasis was neuroendocrine tumor, survived 2 years and 6 months without recurrence after hepatectomy. Another patient who had 2 hepatectomies for metastasis from duodenal leiomyosarcoma survived for 3 years and 20 days after the first hepatectomy. Procedure of hepatectomy comprised 4 limited resections (including 1 second hepatectomy) and 4 lobectomies at the first resection. Hepatic inflow clamp was used in 6 out of 8 hepatectomies and 4 out of 8 hepatectomies did not require allogeneic blood transfusion. Bacterial contamination of the drained discharge from the cut surface of the liver, mostly representative of enteric organisms, was identified in all but 2 patients who were not examined. Subphrenic abscesses developed in 2 patients after removal of the drains. Thus, prophylactic use of abdominal drain is indispensable after hepatectomy for the patients with bilioenteric anastomosis.

Background/aims: It is unclear whether resection of the extrahepatic bile duct in radical surgery for gallbladder cancer should be performed when direct infiltration into the hepatoduodenal ligament is absent., Methodology: The results of radical surgery with or without bile duct resection were compared in 55 patients with gallbladder cancer without direct extension to the hepatoduodenal ligament. Lymph node dissection and combined resection of involved organs were carried out according to the extent of the tumor., Results: Nodal involvement was present in 43% of patients with tumors more advanced than pT1. Survival rates were similar between patients with or without bile duct resection in stages I-III, while significantly better survival was observed with bile duct resection in stage IV., Conclusions: Considering the adverse effect of bilioenteric anastomosis, preservation of the extrahepatic bile duct is recommended in radical surgery for gallbladder cancer when the tumor is less advanced than stage IV and does not extend to the hepatoduodenal ligament.

Background/aims: The significance of a surgical margin for hepatic resection of hepatocellular carcinoma (HCC) in patients with impaired liver function was evaluated., Methodology: Sixty-eight patients, each with a solitary HCC, who had not received any prior treatments were divided into 2 groups, according to surgical margin: Group A included 25 patients who underwent resection with no margin (although the tumor was not exposed) and Group B included 43 patients with a sufficient surgical margin (mean distance: 9 mm). There were no significant differences in clinicopathologic variables between the 2 groups. The rate of stump recurrence, survival and recurrence-free survival were analyzed., Results: Among the 38 patients who had cancer recurrence after a median follow-up of 58 months, 9 (Group A, n=4; Group B, n=5) (24%) had recurrent lesions at the stump. The surgical margin was not a significant factor related to survival or recurrence, irrespective of cirrhosis, capsule formation, cancer spread, or tumor size., Conclusions: Our results indicated that the HCC-free surgical margin is unlikely to be related to the survival of patients with impaired liver function unless the tumor is exposed on the raw liver surface.

Background/aims: The authors aimed to study the importance of pre-operative jaundice reduction in the surgical treatment of icteric-type hepatoma (IHCC)., Methodology: A series of 10 patients with IHCC was reviewed. Eight out of the 10 patients underwent biliary drainage. Obstructive jaundice in the other 2 patients resolved spontaneously. Nine patients subsequently underwent transcatheter arterial embolization (TAE), which appeared to have an additional effect in reducing jaundice., Results: Consequently, 9 of the 10 patients achieved sufficient reduction of the jaundice preoperatively. After the evaluation of liver function, 8 patients underwent hepatectomy without any appreciable morbidity or mortality. The median survival time of the resected cases was 18 months., Conclusions: A combination of biliary drainage and subsequent TAE is a recommended pre-operative strategy for the successful surgical treatment of IHCC.

Background/aims: To evaluate whether resection of peritoneal metastases arising from hepatocellular carcinoma (HCC) has a role to play in the management of the disease., Methodology: Resections of peritoneal metastases from HCC were performed in 6 patients. The survival of the patients was evaluated in relation to feature of primary liver tumor, number of peritoneal metastases and period between hepatectomy and resection of peritoneal metastases., Results: Two patients had peritoneal metastases at the time of hepatectomy for HCC, their resection being carried out synchronously. In the other 4 patients, peritoneal metastases became evident between 6 and 34 months (mean: 18) after hepatectomy; resection was performed at the time of presentation of the metastases. Patient survival after resection of the peritoneal metastases ranged from 3-31 months. The 4 patients who survived for more than 1 year had the following features: 1) a small number of metastatic nodules (= or < 4); 2) low alpha-fetoprotein (AFP) values (mean: 205 ng/ml); and, (3) metachronous occurrence of the peritoneal metastases., Conclusions: Resection of peritoneal metastases arising from HCC may be of value in improving patient survival.

Background/aims: Pleural effusion is a complication occasionally encountered in hepatic surgery. The production of pleural effusion was compared between thoracoabdominal and abdominal approach for hepatic surgery of hepatocellular carcinoma., Methodology: All the 98 patients undergoing liver resection for hepatocellular carcinoma at the National Cancer Center Hospital from May 1992 to March 1994 were included into the study, of those 70 were by the thoracoabdominal and 28 by the standard abdominal approach. Comparisons were made in regard to the rate of pleural effusion, the rate of postoperative thoracentesis, the number of postoperative thoracentesis procedures per patient, the total volume of pleural effusion obtained by thoracentesis per patient, and the duration of pleural effusion., Results: Forty-three percent of patients treated with the abdominal approach in contrast to 73% of patients treated with the thoracoabdominal approach developed pleural effusion (p < 0.01). Seven percent of the patients treated with the abdominal approach in contrast to 17% of the patients treated by the thoraco-abdominal approach required thoracentesis. The number of thoracentesis required for the abdominal approach was 1, for the thoracoabdominal approach was 3 (p < 0.02). The bile leakage rate was 17% for thoracoabdominal versus 33% for abdominal approach., Conclusions: Due to frequent pleural effusion, the thoracoabdominal approach should not be used for every liver operation. However, when treatment to the neck of the right hepatic vein is necessary, the thoracoabdominal approach might be recommended because of the easy access to the operating field and the reduced rate of bile leakage.

The experience with hepatectomy for metastatic renal cell carcinoma (RCC) has been very rarely reported, because multiple organ metastases ordinarily coexist when hepatic metastases are found out. Three patients who underwent hepatectomy for metastatic RCC are presented here. Radical nephrectomy was performed for the primary renal lesions in all the patients, and their hepatic metastases were resected simultaneously in one of them with a solitary tumor, and about one month later in two of them with multiple (3 and 6) tumors. These operations produced no distinct complications. The patients with 1 and 3 hepatic metastatic lesions survived without tumor recurrence for 12 and 21 months, respectively, while the patient with 6 hepatic metastatic lesions had tumor-free interval of only 2 months and died 10 months after hepatectomy due to lung metastasis. Hepatectomy may be the only promising treatment for hepatic metastases from RCC, but the indication for surgery should be evaluated according to the number of hepatic metastases.

Background/aims: Helical (spiral) computed tomography (CT) decreases scanning time and respiratory motion artifact. These characteristics are convenient for the evaluation of postoperative intra-abdominal conditions. We investigated the usefulness of helical CT in detecting complications after pancreaticoduodenectomy., Material and Methods: Helical CT scans were carried out in 21 patients with symptoms suggesting postoperative complications after pancreaticoduodenectomy. Twenty-one patients who underwent pancreaticoduodenectomy were examined postoperatively by helical CT scans. Findings were correlated with the subsequent clinical course., Results: Abnormal findings were detected by helical CT scan in 16 (76%) of 21 patients. These included 13 patients with fluid collection, 7-with localized liver infarction, 5 with intra-abdominal abscess, 3 with pleural effusion or ascites, and 2 with pseudoaneurysms or wound abscesses. Liver infarctions were found in 7 of 10 patients who underwent combined resection of the portal and/or superior mesenteric veins, but not in any of 11 patients without combined vascular resection., Conclusions: Helical CT was useful in evaluating intra-abdominal conditions and detecting complications after pancreaticoduodenectomy.

Purpose: To determine the appearance of pancreatic adenocarcinoma on delayed contrast enhanced computed tomography (CT) and verify the diagnostic significance., Patients and Methods: Twenty-two surgically resected lesions of pancreatic adenocarcinoma were studied with dynamic CT and findings were compared with those on histopathology., Results: Ten (45%) of 22 pancreatic adenocarcinoma demonstrated masses on unenhanced CT, while 21 (95%) demonstrated on early contrast-enhanced CT (early CT), and 15 (68%) demonstrated masses on delayed contrast-enhanced CT (late CT). Pancreatic mass was demonstrated as a low-density area on unenhanced and early CT, but mass density varied on late CT. Delayed enhancement of the mass was predominantly observed in small lesions; 3 (75%) of 4 lesions 2 cm or smaller were detected as high-density areas. Histologically, delayed enhanced lesions showed severe or moderate degrees of fibrosis., Conclusion: Late CT is useful for the detection of pancreatic adenocarcinoma with fibrosis as a high-density area, especially in small lesions.

Background/aims: The characteristics of patients with multicentric hepatocellular carcinoma (HCC) differ from those of patients with intrahepatic metastatic HCC. However, there are few reports regarding the long-term results in patients with HCC of multicentric occurrence. The purpose of this study was to clarify the prognosis of a group of patients with multicentric HCCs., Materials and Methods: We evaluated the outcome in 28 patients with multiple hepatocellular carcinoma (HCC) suggestive of multicentric occurrence, all of whom underwent hepatic resection. The disease-free survival, recurrence pattern and survival were analyzed in the two subgroups of 12 patients with single advanced HCC (AdHCC) nodule and an early HCC (eHCC) or early advanced HCC (eAdHCC) nodule [Group A] and 16 patients with two AdHCC lesions [Group B]. These data were also compared with those of 58 patients with solitary AdHCC [Group C]., Results: Both the disease-free survival and survival periods for Groups A and C were significantly longer than those for Group B, while no significant difference was seen between Group A and C. No significant differences among the three groups were recognized in the incidence of various types of recurrence pattern., Conclusions: The long-term results in patients with multicentric HCC apparently vary depending on the pathological condition at the time of operation. Among patients with multicentric HCC, those with AdHCC combined with an eHCC or eAdHCC are likely to show improved prognosis as a result of hepatic resection.

Background/aims: This study was conducted to clarify the effect of percutaneous ethanol injection (PEI) in combination with transcatheter arterial embolization (TAE) on prolonging the survival time of patients with postoperative recurrence of hepatocellular carcinoma (HCC)., Materials and Methods: The subjects were 97 consecutive patients (pts) treated for postoperative recurrent HCC between February 1987 and March 1993. Of these, 25 pts received both TAE and PEI and 72 pts received TAE alone. In the TAE & PEI group, treatment was selected according to the indications: 15 pts received TAE for multiple recurrences following PEI, and the other 10 pts received PEI for a new or residual lesion following TAE. Fourteen demographic, pathological, and clinical variables were evaluated to estimate the relative risk of pts treated with TAE & PEI or with TAE alone., Results: The 1-, 3- and 5- year survival rates in the TAE & PEI group were 100%, 73.2% and 27.2%, respectively, and those in the TAE alone group were 88.9%, 30.2% and 5.5%, respectively. Based on multi-variate Cox regression analysis, the relative risk of cancer death in the TAE & PEI group was 0.32 (95% confidence interval, 0.15 to 0.67)., Conclusion: The combination of TAE and PEI had a positive palliative effect and increased survival time of patients with postoperative recurrent HCC, compared to results obtained by TAE alone.

A case of intrahepatic cholangiocarcinoma with intrabile duct tumor growth is presented. A 70-year-old female with prolonged obstructive jaundice and cholangitis was diagnosed with a mass lesion in the left lobe of the liver accompanied by an intrabile duct component which caused hilar bile duct obstruction. Percutaneous transhepatic biliary drainage (PTBD) was performed via three routes with intensive care of the drainage catheters over a 2-month period to alleviate jaundice and cholangitis. Extended left hepatic lobectomy with combined resection of extrahepatic bile duct and regional lymph nodes were carried out curatively. Macroscopically, a tumor formed a 8 x 6 cm mass with a scalloped margin in the left lobe and had an intraductal component with a round smooth surface protruding from the lumen of the left hepatic duct into the common bile duct. The histologic type of the tumor was well differentiated tubular adenocarcinoma. The intraluminal tumor grew expansively without invasion to the bile duct wall. The postoperative course was uneventful and the patient has remained in good health without recurrence for 1 year and 3 months since surgery. This case report discusses a rare extension pattern in ICC and the management of malignant hilar obstruction during radical surgery.

A very rare form of adenosquamous carcinoma arising from the intrahepatic bile duct which had diverse morphologic and histologic components is presented. A 77-year-old female complained of relapsing febrile attack accompanied by upper abdominal pain. From the imaging studies, which revealed an atrophic left lobe with dilated intrahepatic bile duct, cholangiocarcinoma constricting the orifice of B3 was considered the most likely diagnosis. Surgery, which included resection of the left hepatic and caudate lobes with lymph node dissection, revealed an atrophic lateral segment indicating recurrent inflammation. Pathologic examination revealed a combined tumor composed of papillary squamous cell carcinoma arising at the orifice of the lateral inferior segmental bile duct and intramucosal adenocarcinoma spreading distal to the polypoid tumor. Two different components were connected with a thin stalk, but there was no apparent transitional zone. Contrary to ordinary mass-forming adenosquamous carcinoma in the liver, which is reported to pursue a very rapid, fatal course, our patient made an uneventful recovery and has remained in good health without recurrence for 2 years and 3 months since surgery.

Background/aims: The ability of CT to differentiate small polypoid lesions of the gallbladder was evaluated., Material and Methods: CT followed by cholecystectomy was performed in 20 patients with small polypoid lesions (< or = 20mm) of the gallbladder measured by preoperative ultrasonography. Detectability of the lesions on both unenhanced and enhanced CT, and the configuration and density of the polypoid lesions on enhanced CT were evaluated in comparison with histopathology., Results: Unenhanced CT detected 8 of 20 polypoid lesions (40%), whereas enhanced CT detected all lesions. All the cholesterol polyp (n = 9) and hyperplastic polyp (n = 2) were not detected on unenhanced CT. Configurations of the polypoid lesions were classified into three types; pedunculated, sessile, and mass forming type. All of cholesterol polyp and hyperplastic polyp were demonstrated as pedunculated type, and adenomyomatosis (n = 2) as mass forming type in all lesions, respectively. Two of adenoma were seen as pedunculated type in one and as mass forming type in the other. Adenocarcinoma (n = 5) was depicted as sessile type in four lesions and as pedunculated type in one. The density of the lesions compared with the liver parenchyma on enhanced CT was not specific., Conclusions: The configuration of polypoid lesions depicted on enhanced CT and visualization of them on unenhanced CT are helpful in differentiating neoplastic lesions which should be resected from other benign lesions.

Background/aim: We studied the influence of alcohol abuse (ethanol intake > 80 gm/day for > 5 yr.) on recurrence in 81 patients with hepatocellular carcinoma who had undergone curative hepatic resection. Twenty-nine patients were positive for alcohol abuse [AA(+)] and 52 were not [AA(-)]., Results: Recurrence of carcinoma within 2 and 27 postoperative months was observed in 45 (55.6%) of the 81 patients. The median disease-recurrence time was 12.0 mo in the AA(+) group and 24.1 mo in the AA(-) group (p<0.01). The patterns of recurrence were classified into the following 4 types: single-nodular type (intrahepatic single nodule); multi-nodular type (intrahepatic multiple nodules); whole liver type (diffuse recurrence over the whole remnant liver); and extrahepatic type (extrahepatic recurrence alone). Five (29.4%) of the 17 patients with recurrence in the AA(+) group demonstrated the whole liver type, compared with only 2(7.1%) of the 28 patients in the AA(-) group (p<0.05)., Conclusion: Patients with alcohol abuse should be followed up particularly closely, even if they have received curative surgery, since alcohol abuse is strongly related to postoperative recurrence.

Background/aims: A cirrhotic case of hepatocellular carcinoma (HCC) complicating portal vein tumor thrombi which underwent posterior segmentectomy with anterior portal venoplasty is reported., Materials and Methods: The HCC originated in the right posterior segment and grew intraluminally up to the right portal vein, and the laboratory data indicated a presence of severe cirrhosis. The operative procedure undertaken consisted of internal shunting of the portal blood stream by mesentero-umbilical bypass, resection of the posterior segment and the anterior portal venous root, and reconstruction of the anterior portal branch by patch grafting., Results: This operation produced no distinct complications, and it was defined pathologically as being curative., Conclusion: The case here introduces rationale of this modified hepatic segmentectomy in view of functional preservation of the residual cirrhotic liver.

We present a case of liver abscess after percutaneous ethanol injection (PEI) therapy for the treatment of recurrent hepatocellular carcinoma (HCC). The 56-year-old woman had a past history of cholecystoduodenostomy for cogenital dilatation of the bile duct, and pneumobilia was observed in the intrahepatic bile ducts prior to PEI. The abscess was successfully treated by percutaneous abscess drainage and antibiotic therapy. Klebsiella pneumonia, one of the most common causative organisms of biliary tract infection, was isolated from the abscess. Thus, biliary tract infection related to the previous biliary-enteric anastomosis operation may have been one of the causative factors in the liver abscess in this patient. The rare experience reported here suggests that a careful search for coexistent abscess at the time of PEI is important in HCC patients with biliary-enteric anastomosis, especially in those with pneumobilia.

The tumor volume doubling time of 27 recurrent hepatocellular carcinoma nodules measuring < or = 2.0 cm in diameter discovered after hepatectomy in 19 patients was analyzed by ultrasonography for 31 to 331 days. The tumor volume doubling time ranged from 39 to 420 days before specific treatment, with a mean of 112 days and a median of 80 days. It correlated with age and intrahepatic site of recurrence, which was sometimes the same lobe as that of the prior hepatocellular carcinoma, sometimes not. The tumor volume doubling time also tended to correlate with hepatitis C antibody status and initial tumor diameter. The tumor volume doubling time was, however, independent of sex, hepatitis B surface antigen status, number of recurrent tumors, initial serum alpha-fetoprotein level, interval between hepatectomy and recurrence detection, and associated liver disease. On the basis of the shortest tumor volume doubling time of the recurrent hepatocellular carcinoma nodules, we recommend that US and/or CT be performed at least every four months to screen for small recurrent carcinomas in postoperative patients.

The long-term outcome in 480 patients with primary hepatocellular carcinoma (HCC) who underwent hepatic resection between 1980 and 1990 was investigated. Overall 5- and 10-year survival rates were 44.1% and 17.8%, respectively, with a hospital mortality rate of 3.1%. The survival of patients who underwent curative resection was better than that of patients treated with noncurative resection. Tumor invasiveness, defined by the presence of vascular invasion and/or intrahepatic metastases, was a major prognostic factor for early recurrence in the patients treated with curative resection. The effect of tumor size and number on prognosis was attributable to a strong correlation with tumor invasiveness. One-third of patients with multiple lesions were considered to have multicentric disease, and their prognosis was better than that of patients with invasive lesions. The width of the resection margin did not affect the prognosis. An unfavorable effect of associated liver disease, especially cirrhosis, was prominent in the later period. A beneficial effect of anatomically systematic resection was apparent in non-cirrhotic patients with non-invasive HCC.

During the last 12 years, hepatic resection was carried out on 268 patients with a diagnosis of hepatocellular carcinoma. Of these, 78% developed tumor recurrence in the remaining liver within 5 years. The indications for repeat hepatectomy were evaluated in the same way as for the first operation. Eighteen second hepatic resections and six third hepatic resections were performed 4 to 63 months after the first hepatectomy, with no operative deaths. The cumulative survival rate of these 24 patients was 87.1% at 3 years, 87.1% at 5 years and 72.6% at 7 years after the first hepatic resection, respectively. The present results show that repeat hepatectomy can be safely indicated for recurrent tumors in patients whose liver functional status has been relatively stable since the first hepatic resection.

Four patients, one woman and three men, with biliary cystadenocarcinoma were surgically treated during a 7-year period. The mean age was 58 years. Symptoms prior to admission were mild, and blood tests including liver function tests, CEA and AFP were for the most part within the normal range. Surgery followed diagnostic work-up including US, ERCP, CT, angiography and MRI. Radical surgery was accomplished in three patients by extended left lobectomy in two and extended right lobectomy in one patient, respectively, in this latter patient preceded by therapeutic embolization of the right portal branch prior to resection, while the fourth patient had a palliative resection. Histological examination revealed papillary adenocarcinoma with mucin production within the cyst. The size of the cyst (maximum diameter) varied between 4.5 and 24 (mean 12) cm. The postoperative course was uneventful in all patients. Two patients are alive with no sign of recurrence 5 and 53 months after surgery, while two patients died after 26 and 75 months, respectively. Thus, radical resection of this rare kind of malignant hepatic tumor seems to offer a chance of long-time survival.

An impaired liver function secondary to liver disease is considered a contra-indication for extensive liver resection because of the risk of liver failure. Selective embolization of the portal branch corresponding to the part of the liver that is considered for resection, carried out three to four weeks before surgery, reportedly induced atrophy of the embolized part of the liver with hypertrophy of the nonembolized part. This policy showed satisfactory early results in 46 patients who had extended liver resection. One patient with severe cholangitis died in the first 30 days. Seven patients had minor complications, which responded well to conservative management (subphrenic abscesses 3, wound infections 3, pulmonary infection 1). Selective portal embolization was well tolerated and was associated with temporary mild side effects. Liver functions before and after embolization returned to pre-embolization values. The present results support the policy of selective portal embolization in patients with impaired liver function in whom extensive liver resection is necessary. Embolization is a promising ancillary preoperative alternative.

Primary lymphoma of the common bile duct is an extremely rare disease. Only two detailed case reports have been published in the literature. In the present paper, a 68-year-old female with obstructive jaundice and a primary lymphoma of the common bile duct, which was resected, is described in detail because of the rarity of the lesion in the literature. The cholangiogram demonstrated stricture of the common bile duct. The findings at angiography and computed tomography were non-specific, but a hypo-echoic mass filling the lumen of the bile duct was demonstrated by ultrasonography. Subtotal resection of the common bile duct and cholecystectomy was performed as the method of choice, although the frozen section examination was not definitive. The final histological diagnosis was malignant lymphoma of the diffuse, small cleaved cell type. There was no metastasis to dissected regional lymph nodes. External irradiation was effective when recurrent tumors were found six months later. However, the patient developed generalized disease one year after resection. Although combination chemotherapy was effective this time for her lymphadenopathy, she died of pneumonia one year and four months after surgery. It can be postulated that ultrasound would be useful in diagnosing this rare entity, and that adjunctive radiotherapy after resection would be preferable to prevent progression of the disease.

We examined serial changes of tumor images in a patient with hepatocellular carcinoma. The hepatocellular carcinoma was initially detected as a homogeneous low-echo area with unclear margins, which was not enhanced by contrast media on computed tomograms, and did not reveal any vascular abnormalities on hepatic angiography. About 11 months later, the tumor growth accelerated, with a parallel increase in serum alpha-fetoprotein levels, and the ultrasonographic features of the tumor changed from a homogeneous low-echo area to a mixed low- and high-echo area with a peripheral low-echo zone. Hepatic angiography revealed a hypervascular tumor at this time. The present case indicates that tumor growth and imaging patterns of hepatocellular carcinoma are closely related to vascularization of the tumor.

Extrahepatic division of the right hepatic vein, after division of the inferior vena cava ligament and, if necessary, of the adrenal gland, was performed during 87 liver resections, and the results compared with those of intraparenchymal division of the right hepatic vein in 32 similar hepatectomies. The selection of the method reflected the surgeon's preference, and was unrelated to the weight of the resected specimen. The incidences of injury to the adrenal gland, inferior vena cava and short hepatic veins were comparable with the two methods, 28 versus 26%, but massive bleeding occurred in 13 vs. 6%, and the mean operative bleeding was 3.8 vs. 1.8 liters (p less than 0.01) during intrahepatic and extrahepatic dissection, respectively. Tumors close to the junction of the right hepatic vein with the inferior vena cava cannot be removed radically with intraparenchymal division of the right hepatic vein. For these reasons, we prefer extrahepatic right hepatic vein division, which was technically possible in 75 of the 84 cases in whom it was attempted.

Ultrasonography plays an important role in the early detection of hepatocellular carcinoma. Ultrasonography detected 53% of 287 patients with small (less than or equal to 5 cm) hepatocellular carcinomas. Among 486 patients with hepatocellular carcinomas, sensitivities of intra-operative ultrasonography in detecting 451 small primary hepatocellular carcinoma nodules, intrahepatic metastasis in 330 patients with small hepatocellular carcinoma and 63 tumor thrombi were 98, 48 and 67%, respectively. The sensitivity of intra-operative ultrasonography in detecting small primary tumors was 10% better than ultrasonography, computed tomography, and angiography. The sensitivity of intra-operative ultrasonography in intrahepatic metastasis and tumor thrombus was two to three times better than pre-operative examination. Intra-operative ultrasonography was useful in detecting nonpalpable tumors and in guiding the transection of the liver, biopsy, and cryosurgery. Moreover, intra-operative ultrasonography made possible new hepatectomy procedures: systematic subsegmentectomy and hepatectomies which preserve the inferior right hepatic vein. Systematic subsegmentectomy guided by intra-operative ultrasonography resulted in better survival rates than the limited resection in patients with small hepatocellular carcinoma two years after hepatectomy; by the sixth year, this difference was significant (p less than 0.05). Ultrasonography and intra-operative ultrasonography are indispensable in the early detection, accurate diagnosis, operative guidance and postoperative care of hepatocellular carcinoma.