Comparison of Outcome of Hepatectomy with Thoraco-abdominal or Abdominal Approach

Background/Aims: Thoraco-abdominal approach is a suitable choice for hepatectomy to secure good view for mobilization. The aim of this study was to assess efficacy of thoraco-abdominal approach (TAA) for hepatectomy. Methodology: There were compared clinicopathological data, surgical results and postoperative complications of 425 consecutive patients who underwent hepatectomy via abdominal (AA) (n=147) or TAA (n=278). Results: Blood loss and operating time were significantly higher in TAA than AA group (970 vs. 830ml and 408 vs. 372 min.)(p<0.05). Prevalence of pleural effusion was significantly higher in TAA than AA group (24 vs. 9%) (p<0.01). However, proportions of patients who developed hepatic complications such as biloma (14 vs. 23%), and wound infection (8 vs.25%) were significantly less in TAA than AA group (p<0.05). Hospital stay after hepatectomy and mortality were similar between both groups. Presence of chronic viral hepatitis, lower platelet count, higher level of serum hyaluronic acid, larger blood loss and TAA correlated significantly with thoracic complications (p<0.05). Multivariate analysis showed that increased blood loss (p=0.011), but not TAA, was a significant determinant of thoracic complications (p=0.08). Conclusions: TAA can be considered a relatively safe approach for hepatectomy with minimal abdominal complications nevertheless of frequent pleural effusion

Characteristics of bile duct carcinoma with superficial extension in the epithelium.

BACKGROUND: Longitudinal tumor extension from the main tumor involves intramural or superficial spread along the bile duct, which influences surgical curability. Identifying the range of superficial extension is difficult by preoperative imaging. To clarify specific characteristics of bile duct carcinoma (BDC) with superficial extension of epithelium in the bile duct, we examined clinicopathologic features and patient outcomes in BDC patients with or without superficial extension who underwent surgical resection. METHODS: Between 1994 and 2008, we retrospectively examined clinicopathologic findings and outcomes for 42 BDC patients who underwent surgical resection and divided them into two groups: (1) superficial extension (SE) group (n = 10); and (2) non-SE group (n = 32). RESULTS: In terms of macroscopic growth of the main tumor, the papillary type was more common in the SE group than in the non-SE group, whereas the nodular type was dominant in the non-SE group. The prevalence of cancer-positive findings at the cut end of the bile duct was higher in the SE group. Portal vein invasion was not observed in the SE group, and the prevalence of regional lymph node metastasis was significantly greater in the non-SE group than in the SE group. No patients died of cancer in the SE group, who tended to show better survival than the non-SE group. CONCLUSIONS: The present results suggest that a good prognosis may be achieved in BDC patients with SE when complete resection is accomplished.The original publication is available at www.springerlink.co

Usefulness of measuring hepatic functional volume using technetium-99m galactosyl serum albumin scintigraphy in hilar bile duct carcinoma

This case involved a 75-year-old woman with obstructive jaundice who was diagnosed with hilar bile duct carcinoma. After endoscopic retrograde biliary drainage, the total bilirubin level was normalized. The indocyanine green test retention rate at 15 min (ICGR15) was 26%. The liver uptake ratio (LHL15) by technetium-99m galactosyl human serum albumin (99mTc-GSA) liver scintigraphy was 0.87. Left hepatectomy was scheduled by CT volumetry. However, biliary drainage was insufficient, and the functional liver volume showed functional deterioration of the left liver. After percutaneous transhepatic biliary drainage, future remnant liver volume by 99mTc-GSA liver scintigraphy changed to 52% from 42%, and ICGR15 and LHL15 were improved to 16% and 0.914, respectively. Scheduled left hepatectomy was performed following the results of functional liver volume. The measurement of functional volume by 99mTc-GSA liver scintigraphy provides useful information with respect to segmental liver function for deciding operative indications

An experience of hepatopancreatoduodenectomy in patients with hepatobiliary malignancies

BACKGROUND/AIMS: In the advanced stage of hepatobiliary malignancies, concurrent hepatopancreatoduodenectomy (HPD) is necessary to accomplish curative resection, even though high rates of morbidity and mortality still remain. METHODOLOGY: We examined the surgical records and outcome in 11 patients undergoing HPD. RESULTS: In 11 patients, diseases included bile duct carcinomas in 7 patients, gallbladder carcinomas in 3, and ampullar carcinoma in one. Hemi-hepatectomy with resection of the caudate lobe was performed in 8 patients and resection of segment 4 and 5 of the liver in two. Pancreatoduodenectomy (PD) was performed in 3 patients and pylorus-preserving PD in 8. Curative resection was accomplished in 8 patients. Two patients underwent adjuvant photodynamic therapy because of a cancer-positive margin. Morbidity rate was 36% but no hospital deaths were reported. The tumor recurrence rate was 73% and 8 patients died of cancer. Patient prognosis of gallbladder cancers (12 +/- 1 months) tended to be shorter than in patients with bile duct cancers (19 +/- 11 months) (p=0.15). Three patients with bile duct cancers survived without tumor relapse over 12 months. CONCLUSIONS: Complete surgical resection (R0) by HPD could be safely performed for diseases of the hepatobiliary malignancies, which achieved longer survival in some patients

Usefulness of Omental Wrapping to Prevent Biliary Leakage and Delayed Gastric Emptying in Left Hepatectomy

Background/Aims: To identify the clinical significance of the omental wrapping (OW) technique after left hepatectomy to reduce bile leakage and delayed gastric emptying. We examined clinical and surgical parameters after left hepatectomy with or without biliary reconstruction in 79 patients. Methodology: This was a retrospective study of data from 14 patients undergoing OW compared to 65 patients in the control group. Results: Bile leakage and delayed emptying after hepatectomy were observed in 15 and 11 patients, respectively. Gender, background liver function, liver diseases and preoperative liver function tests were not significantly different between both groups. Prevalence of extent of hepatectomy, existence of segment 1 resection, biliary-enteric anastomosis, operating time and blood loss were also not significantly different between groups. Prevalence of bile leakage was similar between the OW and the control group (14 vs. 20%) (p=0.91). Prevalence of delayed gastric emptying was not significantly different between groups, but this complication was not observed in the OW group in comparison with the control group (0% vs. 20%) (p=0.31). Prevalence of other complications and hospital stay after hepatectomy were similar between groups.Conclusions: Significant differences for preventing left hepatectomy related complications were not found; however, it is possible that OW could reduce delayed gastric emptying

Usefulness of intraoperative diagnosis of hepatic tumors located at the liver surface and hepatic segmental visualization using indocyanine green-photodynamic eye imaging

Background To improve the diagnostic accuracy for hepatic tumors on the liver surface, we investigated the usefulness of an indocyanine green-photodynamic eye (ICG-PDE) system by comparison with Sonazoid intraoperative ultrasonography (IOUS) in 117 patients. Hepatic segmentation by ICG-PDE was also evaluated. Methods ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. ICG was injected into portal veins to determine hepatic segmentation. Results Accurate diagnosis of liver tumors was achieved with ICG-PDE in 75% of patients, lower than with IOUS (94%). False-positive and false-negative diagnosis rates for ICG-PDE were 24% and 9%, respectively. New small HCCs were detected in 3 patients. The ICG fluorescent pattern in tumors was strong staining in 41%, weak staining in 13%, rim staining in 20% and no staining in 26%. Hepatocellular carcinoma predominantly showed strong staining (61%), while rim staining predominated in cholangiocellular carcinoma (60%) and liver metastasis (55%). Hepatic segmental staining was performed in 28 patients, proving successful in 89%. Conclusion ICG-PDE is a useful tool for detecting the precise tumor location at the liver surface, identifying new small tumors, and determining liver segmentation for liver resection

Preoperative Diagnosis of Lymph Node Metastasis in Biliary and Pancreatic Carcinomas: Evaluation of the Combination of Multi-detector CT and Serum CA19-9 Level.

BACKGROUND: It is difficult to diagnose lymph node metastasis in biliary and pancreas carcinomas before surgery. AIM: The aim of this study was to assess the utility of the combination of multi-detector computed tomographic (MDCT) findings and serum carbohydrate antigen (CA)19-9 level in the diagnosis of lymph node metastasis in biliary and pancreas carcinomas. METHODS: The subjects were 139 patients with biliary and pancreas carcinomas who underwent surgical resection. We calculated the positive predictive values (PPV), sensitivities, specificities, positive likelihood ratios (PLR) and accuracies of diagnosis by MDCT alone, serum CA19-9 level alone, and their combination. RESULTS: The PPV and sensitivity were higher for node metastasis in hepatoduodenal ligament than in common hepatic artery (CHA) or para-aortic region (PAR). Specificity, accuracy and PLR were highest for CHA in biliary carcinoma. With pancreatic carcinoma, PLR was slightly higher in PAR compared to other regions. The sensitivity of CA19-9 for node metastasis was higher than that of MDCT, while the PPV, specificity, accuracy and PLR were low for both biliary and pancreas carcinoma. The combination of positive CT findings and high CA19-9 level had the highest positive rate for node metastasis for both types of carcinomas. Nodes around the supra-mesenteric vein could not be fully observed on CT. CONCLUSION: The combination of high-resolution MDCT and CA19-9 is useful for the diagnosis of lymph node metastasis in biliary and pancreas carcinomas.The original publication is available at www.springerlink.co

Evaluation of Surgical Resection for Pancreatic Carcinoma at a Japanese Single Cancer Institute

Background/Aims: Surgical resection is a radical treatment option for pancreatic carcinoma (PC); however, it is still difficult to cure and patient prognosis is poor at this stage. Methodology: We examined the demographics, surgical records and outcome in 64 patients with hilar PC undergoing surgical resection. Results: Pancreatoduodenectomy (PD) was carried out in 48 patients, distal pancreatectomy (DP) in 14 and total pancreatectomy in two. Postoperative complications were observed in 18 patients (28%) but no hospital deaths. All stage I patients showed carcinoma in situ of intraductal papillary mucinous carcinoma (IPMC). Postoperative adjuvant chemotherapy was performed in 15 patients (23%) using gemcitabine or S-1. Cancer recurrence was observed in 36 patients (56%) and 31 died of carcinoma. The 5-year cancer-free and overall survival rate was 12% and 14%, respectively. CA19-9 level, morphological type, T category, lymph node metastasis, extrapancreatic nerve plexus invasion, retropancreatic tissue invasion, distal bile duct invasion, duodenal invasion and arterial system invasion were significant poor prognostic factors; however, portal vein system invasion was not significantly associated with prognosis. Cancer infiltration at bile duct cut-end and dissected peripancreatic tissue margin and presence of residual tumor showed a poor prognosis. Surgical prognosis in only non-invasive IPMC was satisfactory.Conclusions: Radically extended surgical resection is necessary and newly effective adjuvant chemotherapy is a promising modality to improve patient survival in PC patients

Experience of Surgical Resection for Hilar Cholangiocarcinomas at a Japanese Single Cancer Institute

Background/Aims: Surgical resection is a radical treatment option for hilar bile duct carcinoma (HBDC); however, it is still difficult to cure and postoperative morbidity is high at this stage. Methodology: We examined the demographics, surgical records and outcome in 38 patients with hilar cholangiocarcinoma undergoing operation. Results: Five patients (13%) underwent probe laparotomy because of peritoneal dissemination or liver metastasis. Of 33 patients, extended hemi-hepatectomy was performed in 32 patients.Postoperative complications were observed in 46% including hepatic failure in 3 and hospital death was observed in 4 patients. Advanced tumor stage more than stage III was observed in 23 patients. Curability of operation was A in 5 patients, B in 17 and C in 11 and postoperative adjuvant chemotherapy was administered in 24% including photodynamic therapy in 3. Tumor recurrence was observed in 41% of HBDC patients. The 3- and 5-year tumor-free survival was 38% and 10%, respectively and 3- and 5-year overall survival was 48% and 32%, respectively. By comparison with tumor stage or final curability, survival rates were not significantly different between groups.Conclusions: Surgical resection is still the only curative treatment option to improve patient survival even in advanced stage HBDC

Laparoscopy-Assisted Pancreaticoduodenectomy for Pancreatic Head Tumor at a Japanese Cancer Institute

Laparoscopic surgery is a less invasive treatment option for tumors in the intraabdominal organs; however, the safety and indication of laparoscopic or laparoscopy assisted pancreaticoduodenectomy (LPD) is still controversial. We attempted LPD in four cases for intraductal papillary mucinous neoplasm (IPMN) located in the pancreatic head and we report the surgical records and short-term outcome. LPD was carried out in four patients including three patients with the combined type IPMN and one with the branch type, based on the International Consensus Guidelines. None of the patients had invasive carcinoma based on preoperative imaging diagnosis. Laparoscopic procedures were performed until isolation of the pancreas head and duodenum, and final resection of PD and intestinal reconstruction were performed using small incision laparotomy (7-8cm). The mean total operating time was 882 minutes (820-932 minutes), mean blood loss was 925ml (610-1550ml) and red cell transfusion was not required in any patients. One patient underwent reoperation for bleeding at the pancreaticojejunostomy site at day 1. Mean duration until patients were able to walk was 3.5 days (2-6 days) and duration of use of analgesia was limited to within 7 days. Grade B pancreatic fistula was observed in one patient and jejunal ileus was observed in one patient. There were no deaths. LPD was safely performed and blood loss was limited, although the operating time was long. Postoperative recovery in patients without complications might be better than the conventional PD under laparotomy. Future study is necessary