Search

Background: Recent improvements in imaging technologies have enabled surgeons to perform precise planning using virtual hepatectomy (VH). However, the practical and clinical benefits of VH remain unclear. This study sought to assess how three-dimensional analysis using a VH contributed to preoperative planning and postoperative outcome in patients undergoing liver surgery for the treatment of colorectal liver metastases (CRLM)., Methods: From 2007 to 2017, a total of 473 CRLM patients who received curative hepatectomy were retrospectively assessed. A 1:1 matched propensity analysis was performed between patients who did not receive a VH (without 3D group: n = 188) and received a VH (3D(+) group: n = 285)., Result: The rate of VH increased over the study period (P < 0.001). After propensity score matching (n = 150 for each group), no significant differences were observed in the intraoperative and postoperative outcome, including liver transection time, blood loss, or morbidity between the groups. More patients received a small anatomical resection (plus limited resections) in the 3D(+) group (25 vs 11%, [P = 0.03]). A submillimeter margin was less frequent in the 3D(+) group. No significant differences in the 5-year overall survival and disease-free survival rates were seen between the without 3D group and the 3D(+) group (38.0 vs. 45.9% [P = 0.99], 11.1 vs. 21.7%, respectively [P = 0.109])., Conclusion: Although VH did not significantly influenced on the long-term outcome after hepatectomy, a more parenchymal-sparing operative procedure (anatomical resections, plus limited resections) was selected and the risk of a submillimeter surgical margin was reduced after introduction of VH.

Background: Whether non-colorectal non-neuroendocrine liver metastasis (NCNNLM) should be treated surgically remains unclear., Methods: Data regarding 1,639 hepatectomies performed between 2001 and 2010 for 1,539 patients with NCNNLM were collected from 124 institutions. Patient characteristics, types of primary tumor, characteristics of liver metastases, and post-hepatectomy outcomes were analyzed., Results: The five most frequent primary tumors were gastric carcinoma (540 patients [35%]), gastrointestinal stromal tumor (204 patients [13%]), biliary carcinoma (150 patients [10%]), ovarian cancer (107 patients [7%]), and pancreatic carcinoma (77 patients [5%]). R0/1 hepatectomy was achieved in 90% of patients, with 1.5% in-hospital mortality rate. Overall and disease-free survival rates of 1,465 patients included in survival analysis were 41% and 21%, respectively, at 5 years, and 28% and 15%, respectively, at 10 years. Five-year survival associated with the five frequent primary tumors were 32%, 72%, 17%, 52%, and 31%, respectively, and factors predictive of a poor outcome differed by the primary tumor type., Conclusions: Our data indicated that hepatectomy is safe for NCNNLM and that patient prognoses vary depending on the type of primary tumors. Indications for hepatectomy should be determined with reference to survival rates and risk factors specific to each of the various types of primary tumor., (© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: The concept of borderline resectability has not yet been introduced for extrahepatic cholangiocarcinoma (ECC). In this study, the surgical results of ECC patients were analyzed to clarify the implications of surgery for distal ECC with portal vein (PV) invasion as a preliminary step for the introduction of the concept of borderline resectability., Methods: The clinicopathological data of 129 patients who had undergone pancreatoduodenectomy of distal ECC were reviewed retrospectively. Combined PV resection was performed in 10 patients. The clinicopathological variables were evaluated using univariate and multivariate analyses., Results: Pathological PV invasion was observed in eight of the 129 patients. The survival rates of patients with PV invasion were significantly poorer than those of patients without PV invasion: 3 and 5 years after surgery, 17% and 0% versus 50% and 39% (P < 0.001), respectively. Presence of pancreatic or PV invasion, tumor progression, nodal status, and residual tumor were significant prognostic factors on univariate analysis. On multivariate analysis, PV invasion was the only significant independent predictive factor of a poor prognosis., Conclusions: PV invasion of distal ECC should be regarded as indicating borderline resectability., (© 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Purpose: Hepatectomy of segments 4a and 5 (S4a+5) is the recommended treatment for pT2 gallbladder cancer. However, gallbladder bed resection is also occasionally used. Using nationwide data from the Japanese Biliary Tract Cancer Registry and a questionnaire survey, we retrospectively compared these 2 methods of treatment., Method: The study involved 85 patients with pT2, pN0 gallbladder cancer (55 treated with gallbladder bed resection, and 30, with S4a+5 hepatectomy). The prognosis and mode of tumor recurrence following treatment were analyzed retrospectively, with overall survival as the endpoint., Results: The 5-year survival rate did not differ significantly between the 2 groups. Univariate analysis showed that bile duct resection and perineural tumor invasion were significant prognostic factors, but the extent of hepatectomy, location of the major intramural tumor, regional lymph node excision, and histological type were not. Multivariate analysis identified perineural tumor invasion as a significant prognostic factor. Recurrence occurred most frequently in both lobes than S4a+5 of the liver following gallbladder bed resection., Conclusion: In the present study of cases of Japanese Biliary Tract Cancer Registry, it was not possible to conclude that S4a+5 hepatectomy was superior to gallbladder bed resection.

In the treatment of hepatocellular carcinoma (HCC), control of the tumor itself, vascular invasion, and minute intrahepatic metastases is the main important factor to be considered. Based on previously reported indirect evidence, liver resection would seem to have advantages over percutaneous ablation for single HCCs measuring between 2 and 5 cm in diameter. In conclusion, liver function permitting, resection would be the therapeutic option of first choice. In cases with poor liver functional reserve, liver transplantation would be a good therapeutic option, depending on the age of the patient.

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

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

Background/aims: Differences in hepatic organic anion transporters were compared in rats to identify a causative factor for early stage acute hepatic failure after 70% or 90% hepatectomy (Hx)., Methodology: Male Wistar rats (8 weeks, 250-330g) were randomly assigned to one of two groups for 70% Hx or 90% Hx, and sacrificed at 0, 6, 12, 24, 48, or 72 hours after Hx. Posthepatectomy expression of the bile salt export pump (Bsep), multidrug resistance proteins 2 and 3 (Mrp2, Mrp3), sodium-dependent taurocholate co-transporting polypeptide (Ntcp), and organic anion transporting polypeptides 1 and 2 (Oatp1, Oatp2) were analyzed by Northern blotting. Serum liver function tests were also performed., Results: Postoperative survival rates at 72 hours after 70% and 90% Hx were 100% and 50%, respectively. mRNA expression of Bsep and Mrp3 was increased after 90% Hx, while decreased after 70% Hx. These values were significantly greater at 12 and 24 hours after 90% Hx than after 70% Hx (p < 0.05). In contrast, Mrp2 expression was downregulated to a half of the preoperative level after 90% Hx, while increased after 70% Hx. mRNA expression of uptake transporters (Ntcp, Oatp1, Oatp2) was decreased after 70% Hx and 90% Hx with a similar extent. Total serum bilirubin and bile acid levels were significantly increased after both hepatectomy procedures with a greater extent after 90% Hx., Conclusions: Alteration of mRNA expression of Bsep, Mrp2 and Mrp3 may be characteristic behavior in the early stage of acute liver failure.

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

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

Fibronectin (FN) is a multifunctional glycoprotein present in the extracellular matrix (ECM) and plasma. We previously reported that the glycosylation and ligand-binding of vitronectin (VN) change markedly after partial hepatectomy (PH). Here we show the changes of FN during liver regeneration. The yields of purified sham-operated (SH-) and PH-FN were higher than that of non-operated (NO)-FN, while binding activities of FNs to ECM ligands were changed only slightly by hepatectomy. The carbohydrate concentration of PH-FN decreased to 66% of that of NO- and SH-FN. By using LC/MS(n), eight kinds of complex-type N-glycan structures were found to be present in all FNs, and bi- and trisialobiantennary glycans were the major structures. Fucosylation was markedly increased, while O-acetylation of sialic acid was found to be decreased in PH-FN. The alterations in glycosylation and biological activities of FN after PH are different from those of VN, suggesting that these glycoproteins play different biological functions in tissue remodeling.

Background & Aims: The surgical indications for multiple hepatocellular carcinomas (HCCs) and for HCC with portal hypertension (PHT) remain controversial., Methods: We reviewed 434 patients who had undergone an initial resection for HCC and divided them into a multiple (n = 126) or single (n = 308) group according to the number of tumors. We also classified 386 of the patients into a PHT group (n = 136) and a no-PHT (n = 250) group according to whether they had PHT (defined by the presence of esophageal varices or a platelet count of <100,000/microL in association with splenomegaly)., Results: Among Child-Pugh class A patients, the overall survival rates in the multiple group were 58% at 5 years, and 56% in the PHT group, which were lower than those in the single group (68%, P = .035) and the no-PHT group (71%, P = .008). Among Child-Pugh class B patients with multiple HCCs, the 5-year overall survival rate was 19%. Multivariate analyses revealed that the presence of multiple tumors was an independent risk factor for postoperative recurrence (relative risk, 1.64; 95% confidence interval, 1.23-2.18; P = .001). A second resection resulted in satisfactory overall survival after the diagnosis of recurrence in the multiple (73% at 3 years) or PHT (73%) groups, as well as in the single (79%) or no PHT (81%) groups., Conclusions: Resection can provide survival benefits even for patients with multiple tumors in a background of Child-Pugh class A cirrhosis, as well as in those with PHT.

The currently used criteria, such as the Milan criteria, to select a candidate of liver transplantation for HCC consists of size and number of tumors because vascular invasion and poor differentiation, the strongest prognostic factors, are difficult to be assessed preoperatively. We hypothesized that inclusion of two tumor markers (alpha-fetoprotein and des-gamma-carboxy prothrombin) into the criteria would increase the prediction accuracy of these factors. Our hypothesis was tested in 478 HCC patients undergoing liver resection. The models with or without markers, constructed at predicting vascular invasion (n=150) or poor differentiation (n=49), were compared. The model including markers was superior at predicting the absence of vascular invasion to either the Milan criteria alone [at 81.2% sensitivity; specificity, 52.4 vs 43.3%; difference, 9.1%(95% CI, 1.3-14.2%)] or a model in which size and number varied freely [AUCs of receiver operating characteristic curves, 75.2 vs 69.1%; difference, 6.1%(2.33-10.7%)]. The model incorporating markers was also superior at predicting well to moderate differentiation to either the Milan criteria [at 74.5% sensitivity; specificity, 57.1 vs 38.8%; difference, 18.3%(2.4-32.7%)] or a model with size and number [AUCs, 71.5 vs 59.0%; difference, 12.5%(5.84-21.4%)]. In conclusion, the tumor marker levels should be considered when selecting patients with HCC for liver transplantation.

Objective: To evaluate the efficacy of intraoperative (IO) ultrasonography (US) as compared with other imaging modalities on the primary and repeated hepatectomies for hepatocellular carcinoma., Design: Retrospective study., Setting: University hospital., Patients: From January 6, 1995, to December 26, 2002, 430 patients underwent 555 operations for hepatocellular carcinoma., Main Outcome Measures: New tumors detected by IOUS at the primary and second hepatectomies were analyzed. The long-term outcomes were also studied., Results: Intraoperative US sensitivity was the highest. The detection rate by each imaging modality slightly but uniformly decreased at the second hepatectomy. Intraoperative US detected 56 new tumors in 30 cases (7.0%) at the primary hepatectomy and 13 new tumors in 8 cases (7.3%) at the second hepatectomy. The mean +/- SD tumor sizes were 8.7 +/- 3.8 mm and 9.0 +/- 5.2 mm at the primary and second resections, respectively. The preoperative surgical plan was changed owing to the IOUS findings alone in 24 cases (5.6%) at the primary hepatectomy and in 7 cases (6.4%) at the second. Although recurrence was frequent in patients with new tumors at the primary hepatectomy, long-term survival after appropriate treatment for recurrence was similar to that of patients without new tumors., Conclusions: Despite the recent progress in imaging modalities, IOUS is still the most sensitive. The same degree of precaution is necessary for new tumors when performing IOUS during repeated hepatectomy. Patients with new tumors are at high risk for recurrence, so regular follow-up is important to prolong survival.

Background: Duct-to-duct reconstruction is theoretically suitable for short segmental defects of the bile duct. This technique would also be useful, without jeopardizing the curability, in selected cases with hepatic malignancies requiring concomitant liver and bile duct resection., Methods: For biliary reconstruction after hepatectomy, duct-to-duct reconstruction was performed in 4 patients at our institution between 1994 and 2004. The surgical techniques used are presented, along with the results of evaluation of the outcome, including postoperative and long-term morbidity and survival., Results: Duct-to-duct reconstruction was safely performed in the 4 patients with the defects ranging in size from 10 to 19 mm. None of the cases developed local recurrence at the anastomotic site. None of the cases developed stenosis of the anastomotic site either, but cholangitis occurred in 1 patient., Conclusions: Duct-to-duct reconstruction for short segmental defects after the removal of hepatic malignant tumors is feasible with less operative and long-term morbidity. It is essential to select patients carefully when thinking of performing duct-to-duct anastomosis without complication and cancer infiltration.

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

To resect a small liver tumor located in the paracaval portion, we adopted transhepatic enucleation, i.e. enucleation of the tumor from the transected plane along the main portal fissure. In contrast to caudate lobectomy, this procedure can save dissection around the liver and vena cava, which would increase operation time and blood loss especially in repeat surgery after removal of Couinaud's segment VII or the right lateral sector. It can also minimize the liver parenchymal volume to be resected. The transhepatic enucleation would be a safe and recommendable surgical technique for a small paracaval tumor in repeat resection and/or in patients with poor liver functional reserve., (Copyright (c) 2007 S. Karger AG, Basel)

A 27-year-old woman with no history of liver disease or oral contraceptive use presented with sudden abdominal pain. Laboratory data showed mild liver dysfunction with jaundice. Computed tomography and angiography revealed centrally located large liver cell adenomas (LCAs) and an intrahepatic portosystemic venous shunt (IHPSS) in the left lobe. The serum des-gamma-carboxy prothrombin (known as "protein induced by a lack of vitamin K or antagonist II," PIVKA-II) level was extremely high (6,647 mAU/ml), indicating malignant transformation of the tumors. Under the diagnosis of LCAs and IHPSS, the patient underwent simultaneous resection of the four liver tumors and portovenous shunt, and the hepatic vascular abnormality was resolved. The pathological diagnosis was LCAs without hepatocellular carcinoma. Immunohistochemical analysis with an anti-PIVKA-II monoclonal antibody showed positive staining of the adenoma cells. This case shows that LCA without malignant transformation can produce PIVKA-II, leading to high serum levels of PIVKA-II. Simultaneous resection of multiple tumors and closure of the portosystemic shunt are strongly recommended in a patient with LCA associated with IHPSS.

Objective: To establish a safer and technically easier retrohepatic dissection for the liver hanging maneuver with the assistance of intraoperative ultrasound (IOUS)., Summary Background Data: The liver hanging maneuver described by Belghiti et al is an innovative suspending technique of the liver and is useful in difficult major right hepatectomies or in donor operations for living donor liver transplantation. The most important complication of this procedure is injury to the short hepatic veins and subsequent massive bleeding with an incidence of 4% to 6%., Methods: After the cranial dissection of the suprahepatic inferior vena cava (IVC) between the middle and left hepatic veins, a long light curved Kelly clamp is inserted from the caudal edge behind the caudate lobe and passed cranially along the anterior midline of the IVC. On the midway of the dissection, the proper hepatic vein draining the caudate lobe (PrCV) is visualized. A safe dissection path is confirmed by IOUS, identifying the position of the clamp tip, PrCV, and the caudal end of the cranial retrohepatic dissection. When IOUS shows that the clamp tip has reached the caudal end of the cranial dissection, the operator can feel the clamp tip with his/her finger and the retrohepatic dissection is completed., Results: From September 2003 to July 2004, 50 donor operations were performed for adult living donor liver transplantation. Retrohepatic dissection was feasible in 40 cases (80%). Of these, a US-assisted retrohepatic dissection was performed in 34 donors. PrCVs were visualized by IOUS in 48 donors (96%). The location of these PrCVs varied significantly (60 degrees -175 degrees from the right edge of IVC), and there were no distinct landmarks for identifying the location of PrCVs and safe dissecting course (55 degrees -130 degrees ). IOUS found that the dissecting clamp was heading to the PrCV in 3 cases and the direction of dissection was shifted to avoid injury. No substantial bleeding or no other complication related to retrohepatic dissection was encountered in any of the cases., Conclusions: With the aid of IOUS, the whole course of the blind dissection between the anterior surface of the IVC and the liver could be clearly visualized. IOUS could also identify the PrCV, the most dangerous point in the retrohepatic dissection.

Objectives: To evaluate the prognostic impact of anatomic versus nonanatomic resection on the patients' survival after resection of a single hepatocellular carcinoma (HCC)., Summary of Background Data: Anatomic resection is a reasonable treatment option for HCC; however, its clinical significance remains to be confirmed., Methods: Curative hepatic resection was performed for a single HCC in 210 patients; the patients were classified into the anatomic resection (n = 156) and nonanatomic resection (n = 54) groups. In 84 patients assigned to the anatomic resection group, segmentectomy or subsegmentectomy was performed. We evaluated the outcome of anatomic resection, including segmentectomy and subsegmentectomy, in comparison with that of nonanatomic resection, by the multivariate analysis taking into consideration 14 other clinical factors., Results: Both the 5-year overall survival and disease-free survival rates in the anatomic resection group were significantly better than those in the nonanatomic resection group (66% versus 35%, P = 0.01, and 34% versus 16%, P = 0.006, respectively). In the segmentectomy and subsegmentectomy group, the 5-year overall and disease-free survival rates were 67% and 28%, respectively, both of which were also higher than the corresponding rates in the nonanatomic resection group (P = 0.007 and P = 0.001, respectively). The results of multivariate analysis revealed that anatomic resection was a significantly favorable factor for overall and disease-free survivals: the hazard ratios were 0.57 (95% confidence interval, 0.32-0.99, P= 0.04), and 0.65 (0.43-0.96, P = 0.03)., Conclusion: Anatomic resection for a single HCC yields more favorable results rather than nonanatomic resection.

Donor hepatectomies for adult living donor liver transplantations were performed in 200 consecutive donors to harvest a left liver (LL) graft (n = 5), a LL plus caudate lobe (LL + CL) graft (n = 63), a right liver (RL) graft (n = 86), a RL and middle hepatic vein (RL + MHV) graft (n = 28) or a right lateral sector (RLS) graft (n = 18). The graft type was selected so that at least 40% of the recipient's standard liver volume was harvested. No donor deaths occurred, and no significant differences in the morbidity rates among either donors or recipients were observed when the outcomes were stratified according to the graft type. Donors who donated RL exhibited higher values of serum total bilirubin and prothrombin time than those who donated non-RL (LL, LL + CL, RLS) grafts. The time taken for hilar dissection and parenchymal transection increased in the following order: RLS graft, LL graft and RL graft harvesting. In conclusion, non-RL grafting was more time consuming, but the hepatic functional loss in the donors was smaller. Our graft selection criteria were useful for reducing the use of RL grafts with acceptable morbidity in both donors and recipients.

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.

Preoperative assessment of liver function and prediction of postoperative remaining functional liver parenchymal mass and reserve is of paramount importance to minimize surgical risk, especially in patients with hepatocellular carcinoma (HCC), the majority of whom have liver cirrhosis as a complication. We have established a decision tree for deciding the safe limit of hepatectomy based on three variables: whether ascites is present, the serum total bilirubin level, and the indocyanine green retention rate at 15 minutes (ICGR-15), an indicator of sinusoidal capillarization. In patients who show a sign of decompensated cirrhosis as reflected by an elevated bilirubin value or uncontrollable ascites, hepatectomy is not indicated. In patients without ascites and with normal bilirubin level, the ICGR-15 value becomes the main determinant for the resectability and hepatectomy procedure. Incorporation of ICGR-15 into the decision tree enables patients conventionally classified into Child-Turcotte-Pugh class A or score 5-6 to be subdivided into several groups in which various hepatectomy procedures are feasible: enucleation, limited resection, segmentectomy, mono- to bisectoriectomy, and trisectriectomy. During strict application of this decision tree to 1429 consecutive hepatectomies, of which 685 were performed on HCC patients, during the last 10 years, we encountered only a single mortality.

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.

While inflow occlusion techniques such as Pringle's maneuver are accepted methods of reducing bleeding without inducing liver injury during liver surgery, donor hepatectomy for living donor liver transplantation is currently performed without inflow occlusion for fear that injury to the graft may result. We have performed donor hepatectomy for 12 years using selective intermittent inflow occlusion, a technique in which the portion used to form the graft is perfused during hepatectomy. Starting in November 2000, we applied intermittent Pringle's maneuver to donor hepatectomy in 81 cases of living donor liver transplantation. We reviewed our experience with Pringle's maneuver and selective inflow occlusion techniques in donor hepatectomy in living donor liver transplantation. The quality of the grafts was assessed and compared by determining maximum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values. Neither primary nonfunction nor dysfunction occurred. Maximum AST values in the recipients were the same whether the liver segments that formed the grafts were totally ischemic during dissection (total ischemia), partially ischemic (partial ischemia), perfused only with arterial blood flow (portal ischemia), or not ischemic at all (no ischemia). Maximum ALT values in the recipients of the total ischemia group was lower, albeit not significantly, than in other groups. Total inflow occlusion can be applied to living donor hepatectomy without causing graft injury. In conclusion, because the transection surface is blood-free, there is decreased risk to the donor during living donor liver transplantation surgery, and surgeons should not hesitate to apply this technique because it contributes to donor safety.

Background: Indications for hepatectomy in patients with 4 or more hepatic colorectal metastases remain controversial., Methods: A retrospective cohort study was performed with data from 131 patients who underwent a total of 198 hepatectomies. Patients were grouped according to the number of metastases at the initial hepatectomy (analysis 1) or by the total number of metastases removed by multiple hepatectomies (analysis 2)., Results: In analysis 1, the risk ratios for death of patients with 4 to 9 and 10 nodules to those with 1 to 3 nodules were 2.12 (95% CI, 0.99-4.23) and 7.32 (95% CI, 2.82-16.9), respectively. In analysis 2, the risk ratios for death were 1.32 (95% CI, 0.66-2.59) and 3.07 (95% CI, 1.41-6.36), respectively. These values in 106 patients with negative surgical margins were 1.52 (95% CI, 0.51-3.73) and 5.40 (95% CI, 1.25-16.5), and 1.06 (95% CI, 0.45-2.32) and 1.70 (95% CI, 0.49-4.61), respectively. In analysis 2, the 5-year survival rates of patients with 1 to 3, 4 to 9, and 10 or more nodules were 51%, 46%, and 25%, respectively., Conclusion: Hepatic resection for patients with 4 to 9 nodules clearly is warranted. On the other hand, for patients with 10 or more tumor nodules, surgery cannot be ensured absolutely to be contraindicated in high volume centers at which the surgical mortality rate is nearly zero.

Due to the prevalence of hepatitis virus infection, the incidence of hepatocellular carcinoma (HCC) is very high in Japan. Many techniques have been devised by Japanese surgeons to reduce the mortality rate after hepatectomy for HCC: preoperative precise evaluation of hepatic functional reserve, portal venous embolization as preoperative preparation, anatomical and nonanatomical limited resections using intraoperative ultrasonography, and intermittent inflow occlusion during liver transection. Several challenging surgical procedures are also being tried for advanced HCC: HCC with portal and hepatic venous tumor thrombus, multiple and/or recurrent HCC, and HCC in the caudate lobe. As a result, the latest national survey of HCC revealed that operative mortality was 0.9% and the 5-year survival rate after surgery was 52%. Living-donor liver transplantation for adult patients with HCC is another surgical treatment developed in Japan. After the success of adult-to-adult living donor liver transplant using a left liver graft in 1993, a right liver graft, a left liver graft with caudate lobe, and a right lateral sector graft were developed. Indications for reconstructing the middle hepatic vein tributaries in right liver grafts were also proposed. Consequently, in our series of 36 patients with HCC who underwent living-donor liver transplantation, operative mortality was 3%, and the 2-year survival rate was 84%.

Background: Despite improvements in diagnostic and surgical techniques, operative mortality associated with liver resection is still greater than 2% in most of the recent studies., Hypothesis: By refining preoperative and postoperative care and surgical skills, liver resection mortality can be decreased to zero., Design: Retrospective cohort study to analyze postoperative morbidity and mortality in 1056 consecutive hepatectomies performed at a single medical center during 8 years., Setting: Tertiary referral center., Patients: A total of 915 patients who underwent 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign diseases., Main Outcome Measures: Operative mortality and morbidity rates., Results: No operative mortality occurred. Major complications, as defined by postoperative radiologic or surgical intervention, occurred in 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary malignancy, and 5% of living donor liver transplantation donors. Using multiple logistic regression, independent risk factors associated with major complications were operative blood loss of 1000 mL or greater for hepatocellular carcinoma and total bilirubin level of 1.0 mg/dL or greater (>or=17 micro mol/L) and operative time greater than 6 hours for other liver malignancy. No independent factors associated with major complications were identified for biliary malignancy or for living donor liver transplantation donors among the variables investigated in this study., Conclusions: Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.

Background: A right liver graft without the middle hepatic vein (MHV) trunk is now commonly used in living-donor liver transplantation for adult patients. The significance of MHV reconstruction on regeneration or functional recovery of right liver grafts after living-donor liver transplantation, however, remains unclear., Methods: From 2000 to 2002 at the University of Tokyo Hospital in Tokyo, Japan, 56 adult patients received a right liver graft. The patients were divided into three groups by graft type: right liver graft without MHV trunk or MHV reconstruction (n=17); right liver graft without MHV trunk, but with MHV reconstruction (n=27); and extended right liver graft (n=12). Regeneration rate and postoperative liver function were compared among groups. Predictive factors associated with the graft regeneration were identified among clinical variables, including the graft type., Results: The regeneration rate of the right paramedian sector and the whole graft was lowest in the right liver grafts without the MHV trunk or MHV reconstruction. The regeneration rate of the lateral sector was highest in this type of graft, but the difference was not statistically significant. The factors that significantly correlated with the regeneration rate were preoperative graft volume and graft type. There was no significant difference among groups in any of the liver function parameters., Conclusions: In the present series, satisfactory outcome was independent of the type of graft used, which indicates that MHV reconstruction should not be omitted routinely but should be performed in selected patients.

Background: To control bleeding in the deeper parenchymal plane in right hepatectomy, Belghiti et al. (J Am Coll Surg 2001;193:109) proposed a liver-hanging maneuver using a sling passed between the anterior surface of the inferior vena cava (IVC) and the liver parenchyma. We applied this technique in donor operations in which a hepatic parenchymal transection should be performed before dividing the feeding or draining vessels for the graft., Methods: After passing a tape between the liver and the IVC, the lower tip of the tape is pulled up behind the hepatic hilum to enable effective traction of the dorsal part of the liver. To preserve significant middle hepatic vein (MHV) tributaries in right-liver graft, the tape is gradually repositioned behind the veins, and parenchymal transection is completed before dividing the venous tributaries. Congestion of the graft is minimal until harvest. In right hepatectomy with the MHV, the tape is switched behind the MHV to preserve the MHV., Results: Since March 2000, this technique has been used in 71 consecutive donor operations, including 37 right hepatectomies without the MHV, 8 right hepatectomies with the MHV, 20 left hepatectomies with the caudate lobe, and 6 right lateral sectorectomies. Taping behind the liver was successful in all but one donor (98.6%). There were no major complications related to this procedure., Conclusions: This new approach to the sling suspension of the liver with a gradual tape manipulation facilitated the suspending action and was useful in four types of donor operation. These techniques are feasible in most living donors and are recommended as basic procedures to enhance the safety of the donor and the quality of the graft.

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

Although liver resection is accepted as the only available treatment that regularly produces long-term survival with possible cure in patients with colorectal carcinoma metastatic to the liver, controversy appears to exist regarding the surgical indication for patients with more than four nodules. Similarly, it may be arguable to perform a repeated hepatic resection for a patient who developed multiple recurrent liver metastases with a short disease-free period after the initial liver resection. During the last 7 years, we have adopted constantly the aggressive surgical approach to patients with colorectal carcinoma metastatic to the liver if the number of tumor nodules identified preoperatively were less than ten and irrespective of the length of disease-free period after the previous resection. Here we report on a patient who underwent hepatic resection twice at an interval of 3 months and in whom a total of 22 metastatic nodules (6 in the initial hepatic resection and 22 in the repeated resection) were removed. The patient is now alive and remains disease-free, 5 years after the first liver resection.

Background: Bile duct-to duct reconstruction is now used in living-related liver transplantation for adult patients. However, the feasibility remains controversial., Methods: Bile duct-to-duct reconstruction was performed in 25 adult patients. In the total hepatectomy of the patients, the hilar plate was dissected at the second-order branch of the bile ducts. The anastomosis was performed using an interrupted suture with an external stent tube. A C tube was inserted from the stump of the cystic duct and introduced into the duodenum., Results: All of the patients survived the operation. During the observation period ranging from 34 to 345 days, biliary complications were observed in 8% cases. Dilation of the bile ducts and an absence of bile output were recognized in one patient each, and necessitated surgical revision., Conclusions: Our preliminary experience in biliary reconstruction seems to warrant its long-term observation in the postoperative period.

Hypothesis: Blood loss in hepatic resection is an important determinant of operative outcome., Objective: To clarify whether reducing the tidal volume would be effective in decreasing blood loss during liver transection., Design: Randomized controlled trial., Setting: University hospital., Patients: Eighty patients scheduled to undergo hepatic resection were randomly assigned to receive liver transection under normoventilation (n = 40) or hypoventilation (n = 40)., Interventions: During liver transection, in the normoventilation group, the tidal volume was 10 mL/kg and the respiratory rate was 10/min; in the hypoventilation group, the tidal volume was reduced to 4 mL/kg and respiratory rate was increased to 15/min. Liver transection was performed under total or selective inflow occlusion., Main Outcome Measure: Blood loss., Results: Between the normoventilation and hypoventilation groups, no significant difference was found in total blood loss (median [range]: 630 mL [72-3600 mL] vs 630 mL [120-3520 mL]; P =.44) or blood loss per transection area (median [range]: 7.3 mL/cm(2) [1.2-55.4 mL/cm(2)] vs 9.8 mL/cm(2) [0.9-79.9 mL/cm(2)]; P =.55). During liver transection, the central venous pressure was significantly reduced in the hypoventilation group than in the normoventilation group (median [range]: -0.7 cm H(2)O [-3.0 to 1.8 cm H(2)O] vs -0.2 cm H(2)O [-4.0 to 2.0 cm H(2)O]; P =.007). The maximum end-tidal carbon dioxide level in the hypoventilation group was significantly higher than that in the normoventilation group (maximum [range]: 50 mm Hg [28-66 mm Hg] vs 37 mm Hg [27-60 mm Hg]; P<.001). Transection time, postoperative liver function, hospitalization length, morbidity, and mortality were similar in the 2 groups., Conclusion: This randomized trial suggested no beneficial effect of reduction of tidal volume on bleeding during hepatic resection.

Hypothesis: Hepatic parenchymal transection is a technical priority in liver surgery. The use of an ultrasonic dissector for hepatectomy may result in less blood loss than conventional clamp crushing., Design: Randomized controlled trial., Setting: University teaching hospital., Patients: The 132 patients scheduled to undergo partial hepatectomies were randomly assigned to receive hepatic transection by ultrasonic dissector or by clamp crushing (66 patients by each method)., Interventions: All resections were performed with inflow occlusion and were guided ultrasonographically. Hepatectomies were graded according to a predefined system based on 6 criteria (blood loss, transection time, technical error, surgical margin, landmark appearance, and postoperative morbidity), each with 3 scores (lower scores indicating higher quality)., Main Outcome Measures: Blood loss and hepatectomy grade., Results: No difference was found between the ultrasonic and clamp groups in median blood loss (515 mL [range, 15-2527 mL] vs 452 mL [range, 17-1912 mL]; P =.63), transection time (61 minutes [range, 16-177 minutes] vs 54 minutes [range, 7-205 minutes]; P =.58), or transection speed (1.1 cm(2)/min [range, 0.4-4.0 cm(2)/min] vs 1.0 cm(2)/min [range, 0.4-3.0 cm(2)/min]; P =.90). Ultrasonic dissection caused more frequent histologically proven tumor exposure at the surgical margin (9 vs 3 patients; P =.09), incomplete appearance of landmark hepatic veins on the cut surface after anatomical resection (12 vs 4 patients; P =.03), and postoperative morbidity (20 vs 14 patients; P =.32) than did clamp crushing. The hepatectomies with clamp crushing had significantly higher grades than those with ultrasonic dissection (P =.05), as indicated by the lower median sum score (4.0 [range, 0-12] vs 5.0 [range, 0-19]; 95% confidence interval for difference, -2.0 to 0; P =.03). The transection method independently influenced hepatectomy grade (adjusted odds ratio = 3.06; 95% confidence interval, 1.35-6.92; P =.01)., Conclusions: Ultrasonic dissection offers no reduction in blood loss compared with clamp crushing for transection of the liver. Clamp crushing results in a higher quality of hepatectomy and is therefore the option of choice.

Objective: To evaluate retrospectively the safety and radicality of liver resection performed without total vascular exclusion (TVE)., Summary Background Data: TVE is recommended for safe liver surgery, at least in the case of resection of the paracaval portion of the liver. However, it has some drawbacks because of its invasiveness., Methods: The authors retrospectively evaluated 329 of 471 consecutive patients who underwent liver resection from October 1994 to October 1999. All of these patients had tumors involving segments 1, 7, or 8 or the cranial portion of segment 4, or underwent major hepatectomies that required exposure of the inferior vena cava (IVC), the main trunks of the hepatic veins, or both. Sixty-four patients underwent resection that included segment 1, with or without the reconstruction of the IVC, the hepatic vein, or both., Results: Three hundred twenty-four of 329 procedures were done under intermittent warm ischemia; no clamping methods were used in 6. TVE was never needed. There were no postoperative 30-day deaths. The complication rate was 25.5%, and only 2.1% had major complications. Only 13 (3.9%) patients required whole blood transfusion. Part of the wall of the IVC was resected in six patients, and the hepatic veins were reconstructed in four. Surgical clearance was achieved in all patients undergoing surgery for a tumor., Conclusions: These results show that liver surgery performed without TVE is safe and effective even in aggressive procedures for liver tumors involving the cavohepatic junction. Therefore, TVE should be further restricted to exceptional patients.

Background/aim: A new gross classification of hepatocellular carcinoma in which Eggel's nodular type is subclassified into type 1 (single nodular type), type 2 (single nodular type with extranodular growth), and type 3 (contiguous multinodular type) has been widely used in Japan. The aim of the study was to determine whether this classification is correlated with patient outcome., Methods: Sixty-five resected hepatocellular carcinoma nodules (< or = 5 cm) were classified using this new classification., Results: The 65 tumors were classified into 30 type 1 (46%), 20 type 2 (31%), and 15 type 3 (23%) hepatocellular carcinomas. The rate of microscopic vascular invasion significantly increased from type 1 to type 2, and to type 3 tumors (p=0.03). Kaplan-Meier estimates showed that type 1 was significantly associated with lower recurrence rate (type 1 vs. type 2, p=0.01; type 1 vs. type 3, p=0.004; log-rank test), and higher disease-specific survival (type 1 vs. type 2, p=0.02; type 1 vs. type 3, p=0.002). Cox's proportional-hazards model demonstrated that type 1 was an independent factor for low risk of recurrence (p=0.002) and low risk of disease-specific death (p=0.02)., Conclusion: The gross classification of hepatocellular carcinoma is of clinical value in predicting patient outcome.

Hypothesis: An intraoperative bile leakage test will assist in decreasing postoperative bile leakage in patients undergoing hepatic resection., Design: Randomized controlled trial., Setting: University hospital., Patients: One hundred three consecutive patients who were scheduled for hepatic resection without biliary reconstruction. Associated cirrhosis was present in 49 patients (48%), and only 24 (23%) had normal livers. Patients were randomized to undergo (n = 51) or to not undergo (n = 52) a bile leakage test, according to age, liver function, and hepatectomy method. The 2 groups were similar in baseline demographics., Intervention: A bile leakage test was carried out by injecting isotonic sodium chloride solution through the cystic duct, and interrupted suturing was taken for a bile leak on the transected liver surface., Main Outcome Measures: The incidence of postoperative bile leakage and the length of the postoperative hospital stay. Bile leakage was defined as continuous drainage, with a bilirubin level of 86 micromol/L or more (> or =5 mg/dL), beyond 1 week., Results: Twenty-one patients (41%) in the test group showed a bile leak, and a median of 1 site (range, 1-6 sites) was closed during the test. Postoperative bile leakage was observed in 3 patients (6%) in the test group and in 2 (4%) in the control group (P = .99). The odds ratio of the event was 1.53 (95% confidence interval, 0.25-9.44). The median postoperative hospital stay lasted 17 (range, 13-47) and 18 (range, 12-41) days for the test and control groups, respectively (P =.98)., Conclusion: This randomized trial suggested no advantage in using a bile leakage test during hepatic resection.

Donor safety is the first consideration in living related liver transplantation. Left hemihepatectomy including the middle hepatic vein is a reasonable donor procedure for obtaining a large graft for living related liver transplantation. This procedure, however, needs to be modified in donors with hepatic venous variation. While carrying out donor hepatectomy, we encountered two cases showing a variant form of hepatic venous drainage comprising a thick middle hepatic vein draining segment 6 of the liver. This variation made it necessary to preserve the middle hepatic vein in the donor liver remnant. Failure to recognize such a variant would result in congestion in the remaining right liver of the donor. To guarantee donor safety, evaluation of the drainage area of the corresponding hepatic vein is a matter of great importance in donor hepatectomy.

Background/aims: Although percutaneous transhepatic biliary drainage is widely performed for jaundice reduction, the clinical significance and mechanism responsible for delayed decrease of the bilirubin level remains unclarified., Methodology: The rate of bilirubin decrease was estimated in 104 consecutive patients who underwent drainage. Morbidity and mortality after major and minor operations for hepato-biliary-pancreatic diseases in groups showing slow and rapid bilirubin decrease were estimated. The risk factors for slow bilirubin decrease were also examined by uni- and multivariate analyses., Results: A statistically significant difference between the slow and rapid bilirubin decrease groups was found only in the morbidity rates of major surgery (73% vs 28%, p < 0.05). Univariate analysis showed that the longer interval from onset of jaundice to drainage, the use of multiple catheters for jaundice reduction, and advanced age were significant risk factors for slow bilirubin decrease. These factors were found to be independent by multivariate analysis (p < 0.05), Conclusions: A slow rate of jaundice reduction is a predictor of high risk in major surgery. It can be attributed to 3 factors; longer term of undrained jaundice, multiple biliary drainage, and age. Careful post-operative management is required when major surgery is scheduled for patients with these risk-predictive factors.

Background: Hepatocyte transplantation has been studied as an alternative to organ transplantation. Hepatocyte transplant models should provide sufficient cell mass for replacement function and hepatotrophic stimulation of the transplanted cells in heterotopic locations., Method: The authors used three-dimensional porous polyvinyl-alcohol matrices as cell carriers, which were implanted between mesenteric leaves of the intestine. In this study, different methods were evaluated for hepatotrophic stimulation. Fifty million transplanted hepatocytes (approximately 10% liver mass) were implanted in Lewis rats. We compared 70% partial hepatectomy, portacaval shunt, cotransplantation of enterocytes, cotransplantation of islets of Langerhans, and methylprednisolone injection to a control group with only hepatocyte transplantation. Portacaval shunt and islet cotransplantation also were used in combination. Specimens were harvested 2 weeks after transplantation, and area per histological cross section compromised by hepatocytes was measured., Results: Seventy percent partial hepatectomy, enterocyte cotransplantation, and methylprednisolone injection resulted in hepatocyte maintenance similar to control group (3,100 +/- 7,592 microm2). Portacaval shunt (96,866 +/- 55,039 microm2) and islet cotransplantation (173,020 +/- 75,977 microm2) yielded a highly significant increase in hepatocyte area. The combination of portacaval shunt and islet cotransplantation resulted in a significant increase compared with using these methods individually (288,930 +/- 86,726 microm2). Additional immunohistochemical stains for active DNA synthesis, insulin, and glucagon demonstrated the proliferative abilities of the hepatocytes and the synthesis of insulin and glucagon in the cotransplanted islets., Conclusion: Hepatocyte transplantation can be performed using polymer carriers and that hepatocyte survival and maintenance can be improved with portacaval shunt and islet cotransplantation.

Liver surgery requires a reduction in the operative blood loss to avoid postoperative liver failure. We carried out elective hepatic resection in 229 patients with Pringle's maneuver, which involves complete, intermittent clamping of the hepatic flow, and in 56 patients with selective vascular occlusion. Twenty-seven donors for living-related liver transplantation were also included in the latter series. The clinical outcomes were evaluated based on clamping method used. The cumulative clamping time and amount of blood loss were 64 +/- 46 min (mean +/- SD) and 828 +/- 665 ml in the Pringle's maneuver group and 88 +/- 44 min and 907 +/- 555 ml in the selective vascular occlusion group. Laboratory data showed good tolerance of vascular clamping in both groups, and serum aspartate aminotransferase levels returned to the baseline within one week. Operative morbidity rates were 23% and 27%, respectively, and no operative deaths occurred in this series. In living-related liver transplantation, modified selective vascular occlusion can preserve graft viability, as verified by the fact that all the recipients in this series had a good postoperative course, except for one death and one graft loss. In conclusion, intermittent total or selective vascular clamping is indispensable procedure during hepatic resection.

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.