Resected Intrahepatic Cholangiocarcinoma with Anaphylactic Shock from a Preoperative Liver Function Test before Hepatectomy

The indocyanine green test is a reliable liver function examination before major hepatectomy, and anaphylaxis is rarely a concern. A 65-year-old male patient without epigastralgia was diagnosed with a 2.2-cm intrahepatic cholangiocarcinoma. He had no history of allergic reactions. Some liver dysfunction was indicated by the laboratory data; however, there was no marked obstructive jaundice and the liver functional reserve was maintained by technetium-99m galactosyl serum albumin. The indocyanine green test was routinely performed, but the patient immediately demonstrated severe anaphylaxis due to indocyanine green administration. He had cardiorespiratory arrest, but recovered after immediate resuscitation. Although acute renal and respiratory failure was significant, the patient recovered at day 10 after the event, and his liver function and other organ functions were improved. Then, the scheduled left hepatectomy with caudate and extrahepatic duct resection was successfully performed without issues. The patient exhibited no allergic response against the administration of antibiotics or other drugs and the postoperative course was uneventful. The patient was discharged on day 17. The tumor was diagnosed as stage III intrahepatic cholangiocarcinoma and R0 resection was accomplished. Preoperative management, including the liver functional loading test, should be carefully carried out before major hepatectomy

Sonazoid-enhanced intraoperative ultrasonography in patients with gall bladder diseases: A preliminary study

Background:Ultrasonography using Sonazoid, a novel contrast agent containing microbubbles, is a useful diagnostic modality for intrahepatic mass lesions with specific characteristics in two phases: contrast enhancement of early vascular perfusion and perfusion defect of the lesion in the late phase. To improve the diagnostic accuracy of intraoperative ultrasonography (IOUS) in biliary neoplasms, particularly gall bladder, we investigated the usefulness of the Sonazoid contrast agent in a preliminary study.Subjects and Methods:We examined IOUS images of 23 patients with gall bladder disease. Sonazoid was administered intravenously, and early arterial and venous phase images of the tumor were obtained during laparotomy.Results:Tumors included the localized type of adenomyomatosis in the fundus of the gallbladder (GAM) in seven patients as benign controls, adenomatous diseases in three, and gallbladder carcinoma (GC) in 13. Sonazoid IOUS scanning was performed in all patients, with no adverse effects. Although GC showed high enhancement in 77% of the tumors, GAM and adenoma also showed mild enhancement in more than half of them. Pseudo-positivity was observed in one case of hyperplastic polyps, and pseudo-negativity was observed in two patients. Cholesterol polyps and a suspicious lesion of liver metastasis by the computed tomography were not enhanced with Sonazoid treatment.Conclusion:Although there remains a problem of pseud-positivity in the intracystic lesions, Sonazoid IOUS may be a useful tool to detect vascularity and its location or extension of gallbladder diseases; however, neither significance of differential diagnosis with benign diseases nor other clinical significance was found

Risk factors for hepatic insufficiency after major hepatectomy in non-cirrhotic patients

Summary: Background: Although recent advances in surgical techniques and perioperative management have reduced the morbidity and mortality after hepatectomy, hepatic insufficiency after major hepatectomy remains an important concern. This study aimed to clarify the risk factors for post-hepatectomy liver insufficiency. Methods: We enrolled 103 consecutive patients who underwent major hepatectomy which was defined as resection of four or more segments. Hepatic insufficiency is defined as an increase in serum total bilirubin after hepatectomy of 7 mg/dL or more, or death from multiple organ failure. We compared the patient disposition, demographics, perioperative factors such as surgical method, combined procedure, morbidity and so on between the patients with or without hepatic insufficiency. Results: Hepatic insufficiency occurred in 14 patients (14%) and six of them died during the hospital stay (6%). Risk factors by univariate analysis were the percentage of hepatic parenchyma to be resected (P = .025), combined procedure (P = .008) and postoperative morbidity excluding hepatic insufficiency (P < .001). A combined procedure (P = .036) and postoperative morbidity excluding hepatic insufficiency (P = .002) were a significant risk factor by multivariate analysis. Conclusion: Unless remaining liver after hepatectomy has enough volume, combined procedure may account for hepatic insufficiency, which can follow the development of postoperative morbidity. Keywords: Risk factor, Hepatic insufficiency, Major hepatectom

Recent Advances in Photodynamic Imaging and Therapy in Hepatobiliary Malignancies: Clinical and Experimental Aspects

The therapeutic and diagnostic modalities of light are well known, and derivative photodynamic reactions with photosensitizers (PSs), specific wavelengths of light exposure and the existence of tissue oxygen have been developed since the 20th century. Photodynamic therapy (PDT) is an effective local treatment for cancer-specific laser ablation in malignancies of some organs, including the bile duct. Although curability for extrahepatic cholangiocarcinoma is expected with surgery alone, patients with unresectable or remnant biliary cancer need other effective palliative therapies, including PDT. The effectiveness of PDT for cholangiocarcinoma has been reported experimentally or clinically, but it is not the standard option now due to problems with accompanied photosensitivity, limited access routes of irradiation, tumor hypoxia, etc. Novel derivative treatments such as photoimmunotherapy have not been applied in the field hepatobiliary system. Photodynamic diagnosis (PDD) has been more widely applied in the clinical diagnoses of liver malignancies or liver vascularization. At present, 5-aminolevulinic acid (ALA) and indocyanine green (ICG) dyes are mainly used as PSs in PDD, and ICG has been applied for detecting liver malignancies or vascularization. However, no ideal tools for combining both PDD and PDT for solid tumors, including hepatobiliary malignancies, have been clinically developed. To proceed with experimental and clinical trials, it is necessary to clarify the effective photosensitive drugs that are feasible for photochemical diagnosis and local treatment