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Background: We compared two types of stents in patients who underwent surgery for hepatic hilar malignancies., Methods: Twenty-one patients with hepatic hilar malignancies who underwent hepatectomy were randomly assigned to one of two groups. A 5-Fr silicon drain with an internal lumen and side holes was used for the hepaticojejunostomy in one group (intraluminal stent group), and a 10-Fr silicon drain with channels along the sides was used in the other (channel stent group)., Results: Leakage developed in four patients (36.4%) in the intraluminal stent group versus two (20.0%) in the channel stent group. Cholangitis developed in three patients with leakage (27.3%) in the intraluminal stent group versus no patient in the channel stent group. After operation, the times required for the serum alkaline phosphatase and total bilirubin levels to return to the normal range were significantly shorter in the channel stent group (5.3 +/- 2.9, 3.8 +/- 2.2 days) than in the intraluminal stent group (17.0 +/- 5.8, 9.4 +/- 5.7 days) (P < 0.0001, P = 0.0093)., Conclusion: A 10-Fr silicon drain with channels is superior to a 5-Fr silicon drain with an internal lumen for internal biliary stenting of hepaticojejunostomy in patients with hepatic hilar malignancies.

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

Background/aims: Hepatic resection is established as the best available treatment for colorectal cancer metastases to the liver, but the optimal procedure for the resection is now controversial. In this study we retrospectively evaluated the influence of the selection of surgical procedures for hepatic resection in determining the prognostic factors., Methodology: A population of 111 patients with liver metastases from colorectal cancer underwent initial and radical hepatic resection. Survival rates as a function of clinical, primary tumor pathologic TNM classification and surgical determinates were examined retrospectively with univariate and multivariate analyses., Results: The overall, 1-, 3-, 5- and 10-year survival rates were 85.5%, 51.4%, 41.6% and 30.9%, respectively. Patient survival was uncorrelated with any of the following factors: sex, age, temporal relationship, primary tumor site, tumor stage, pathological depth, pathological vascular invasion, pathological lymphatic invasion and pathological lymph node metastases of the primary tumor, maximum diameter of liver lesions, intrahepatic distribution patterns, type of hepatectomy, and number of hepatectomies. However, the number of liver tumors and the tumor-free margins were significantly associated with good prognosis., Conclusions: Safe hepatectomy with adequate tumor-free margins leads to a better prognosis.

Background: The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors., Patients and Method: A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia) at our hospital. Five patients who had received laparoscopic hepatectomy (Lap-Hx group) were compared with 5 patients who had undergone open hepatectomy (O-Hx group) in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision, a microwave coagulation device and an ultrasonically activated scalpel were used., Results: Mean patient age was 55.6 +/- 13.9 years in the Lap-Hx group and 51.8 +/- 14.1 years in the O-Hx group. Four patients in the Lap-Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O-Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 +/- 1.5 cm in the Lap-Hx group and 3.0 +/- 1.8 cm in the O-Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap-Hx than in the O-Hx groups(213 +/- 82 vs 247 +/- 97 min; 154 +/- 128 vs 648 +/- 468 ml, p=0.05: and 10.4 +/- 2.3 vs 18.0 +/- 5.1 days, p=0.017), but operating time did not differ significantly., Conclusions: Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors, in particular, hepatocellular carcinoma in the cirrhotic liver.

Background/aims: The effectiveness of intraoperative adjuvant therapy for satellite lesions of nonresectable hepatocellular carcinoma (HCC) was investigated., Methodology: We randomly assigned 30 eligible patients with advanced-stage HCC with multiple intrahepatic lesions who underwent reduction hepatectomy in conjunction with either intraoperative adjuvant therapy (hepatectomy plus microwave coagulonecrotic therapy or radiofrequency ablation) or postoperative adjuvant therapy (transcatheter arterial embolization). The cumulative survival rates were obtained for both groups using the Kaplan-Meier method and compared using the log-rank test. To evaluate whether the intraoperative adjuvant therapy significantly influenced the prognosis, we reviewed changes in clinical factors by multiple regression analysis using the Cox's proportional hazard model. Ap value of less than 0.05 was considered statistically significant., Results: The 3- and 5-year cumulative survival rates in patients who underwent intraoperative adjuvant therapy were 35.7% and 7.7%, while those in patients who underwent postoperative adjuvant therapy were 35.0% and 0%, respectively. The difference was not statistically significant. The level of a-fetoprotein, maximum tumor size, number of tumors, and clinical stage were found to be independent factors affecting survival after diagnosis. Intraoperative adjuvant therapy was not an independent prognostic factor., Conclusions: The survival rates did not differ between the patients who underwent intraoperative adjuvant therapy and postoperative adjuvant therapy for satellite lesions of non-resectable HCC.

A number of factors can lead to the life-threatening liver dysfunction in the aftermath of an extended hepatectomy. Prominent among them is the high portal pressure induced by the concentrated flow of the entire stream of portal blood toward the small remnant liver. Twelve beagle dogs were randomly divided into group A (n=6, 70% hepatectomy) and group B (n=6, 70% hepatectomy after jejunectomy). Three dogs in each group were euthanized at 1 or 4 weeks after the operation and examined to evaluate hemodynamic changes, liver functions, and liver histology. One hour after the hepatectomy, the animals in group B exhibited a significantly lower portal pressure (P=0.002) and significantly higher hepatic arterial flow (P=0.004) than the animals in group A. As more time passed, the total hepatic flow and hepatic tissue flow both rose up to levels significantly higher than those in group A (P=0.037 and P=0.025, respectively). The alkaline phosphatase, total protein, albumin, and anti-thrombin III were all significantly better in group B than in group A on the 1st post-operative day. Liver specimens biopsied at 1 h after the hepatectomy showed significantly more swelling of the hepatocytes in group A than in group B. In addition, an immunohistochemical study using the TUNEL method for liver biopsy on the seventh post-operative day revealed numerous positive cells in group A but few in group B. Our results suggest that the portal pressure control by the enterectomy can forestall dysfunction of the remnant liver after extended hepatectomy, especially during the early post-operative period.

Background/aims: We performed a randomized trial to evaluate whether fixation of the greater omentum to the peritoneum prevents delayed gastric emptying and other complications after left-sided hepatectomy., Methodology: Patients undergoing left lateral segmentectomy or left hepatectomy were randomly assigned to a fixation group (n=24) and a non-fixation group (n=25). In the fixation group, the greater omentum was sutured to the peritoneum to prevent the stomach from contacting the cut surface of the liver., Results: Delayed gastric emptying developed in 4 of the patients in the non-fixation group (16%) versus none of the patients in the fixation group. According to univariate analysis, fixation significantly lowered the risk of delayed gastric emptying (p<0.05). The overall morbidity was higher in the non-fixation group (20.0%) than in the fixation patients (8.3%) without significance., Conclusions: Fixation of the greater omentum to the peritoneum decreased the occurrence of delayed gastric emptying following left-sided hepatectomy.

Hemophagocytic syndrome (HPS) is a hypercytokinemia caused by activated T lymphocytes and macrophages in immunologically compromised patients. We report a 37-year-old female who was diagnosed with HPS after undergoing living-donor liver transplantation (LDLT) for fulminant liver failure of unknown etiology. After liver transplantation, recipients with pancytopenia should be tested for serum ferritin. When the serum ferritin is abnormal, the bone marrow should be biopsied to screen for HPS as soon as possible. If the condition is caught early and promptly treated, the outcome of this devastating condition might be improved. In addition, HPS should be ruled out in LDLT candidates with acute liver failure before their operations.

We describe successful resection of rapidly enlarging liver metastases from an alpha-fetoprotein-producing gastric cancer, as these usually carry a dismal prognosis. A 68-year-old woman underwent distal gastrectomy for an alpha-fetoprotein-producing gastric cancer without liver metastasis. The tumor was a moderately differentiated tubular adenocarcinoma with invasion of the muscularis propria. Venous and lymphatic invasion were noted, as was metastasis to lymph nodes along the greater curvature. Serum alpha-fetoprotein was 331 ng/mL before gastrectomy, decreasing to 18.6 ng/mL by postoperative day 28. At 2 months after operation, computed tomography detected no metastasis, but at 4 months alpha-fetoprotein increased to 2,190 ng/mL, and at 5 months liver tumors were detected by ultrasonography and computed tomography. Serum alpha-fetoprotein increased to 5,673 ng/mL, and serum PIVKA2 concentration was 18 mAU/ml just before operation. Extended left hepatectomy was performed. The resected specimen of segment 4 contained two well-defined tumors, measuring 5 x 4 cm and 2 x 2 cm, while that of segment 5 contained a similar-appearing tumor measuring 2 x 2 cm. The resected tumors had the same histologic appearance as the previously removed gastric cancer. The tumor cells were immunohistochemically reactive for alpha-fetoprotein. The postoperative course was uneventful, and the patient was discharged on postoperative day 15. Serum alpha-fetoprotein decreased to 20 ng/mL by postoperative day 15, and to 5 ng/mL by 2 months after operation. For 5 months since operation, no recurrence has become evident, and serum alpha-fetoprotein has remained within the normal range.

A 74-year-old woman with advanced carcinoma of the gall bladder underwent anterior and medial segmentectomies, extrahepatic bile duct resection, lymph node dissection, and hepaticojejunostomy with retrograde transhepatic biliary drainage. On the sixteenth postoperative day, bleeding was noted through the biliary drain, but it stopped spontaneously. Two days later, the biliary drain showed bleeding again. Ultrasonography revealed mild dilatation of the intrahepatic bile duct. Cholangiography via the drain disclosed a defect in the jejunal limb. Emergency angiography revealed an aneurysm, 2 cm in diameter, in the posterior branch of the right hepatic artery. Contrast medium demonstrated extravasation into the jejunal limb. The pseudoaneurysm was embolized with coils. No further hemorrhage was noted, and the patient was discharged 30 days after operation.

Background/aims: We introduced an ultrasonic surgical aspirator with electrosurgical coagulation to increase safety of the liver resections performed for hepatocellular carcinoma., Methodology: This system was evaluated by analyzing the intraoperative blood loss, the duration of hepatectomy, the ischemia time, and the postoperative clinical course and comparing these same parameters with the traditional forceps' fracture method., Results: There was no significant difference in the duration of surgery and the mean liver resection time between the two methods. The mean blood loss by using this system was 2458 +/- 4742 mL and by forceps' fracture method 956 +/- 252 mL. The mean ischemia time was 44.4 +/- 35.9 min by using this system and 23.9 +/- 29.1 min in forceps' fracture method. There was a significant decrease in intraoperative blood loss and ischemia time using the new system. This may decrease postoperative complications., Conclusions: This system may enable all surgeons to perform liver resection easily and safely.

Background/aims: We encountered a case of posthepatectomy splenic enlargement and hypersplenism followed by disseminated intravascular coagulopathy with airway hemorrhage causing death., Methodology: We, therefore, retrospectively investigated postoperative splenic enlargement, hypersplenism and disseminated intravascular coagulopathy by computed tomography and laboratory data in 57 hepatectomized patients with a malignant or benign disease in the postoperative period., Results: Of 32 patients with hepatocellular carcinoma or biliary tract carcinoma (group A), 12 with metastatic hepatic lesions (group B), and 13 with benign liver disease (group C); remarkable (20%) splenic enlargement was noted in 8 patients in group A, 2 in group B, and 2 in group C. Seven of the 12 patients were associated with liver cirrhosis, 5 with preoperative splenomegaly, and 8 had undergone major hepatectomy. Postoperative hypersplenism developed in 5 patients in group A, and one patient in group C. All of them were associated with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and five had undergone hepatic lobectomy or more extensive resections. All except for the disseminated intravascular coagulopathy case recovered. Statistically, splenic enlargement was significantly related to the extent of hepatectomy; lobectomy versus segmentectomy = 28.3 +/- 28.5% (n = 14) versus 12.4 +/- 13.8% (n = 20), (unpaired Student's t test, P = 0.037). Platelet counts of the patients with liver cirrhosis or chronic hepatitis is lower than those without the diseases, both pre- and postoperatively (14.0 +/- 6.0 x 10(4)/mm3 vs. 21.5 +/- 6.2 x 10(4)/mm3, P = 0.0001)., Conclusions: Postoperative hypersplenism was noted only in the patients with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and developed more frequently after larger hepatectomies than after smaller hepatectomies; 5 (45%) of 11 versus 1 (7%) of 14, chi 2 test, P = 0.026).

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