Hepatic hypertrophy and hemodynamics of portal venous flow after percutaneous transhepatic portal embolization

Background

Percutaneous transhepatic portal embolization (PTPE) is useful for safe major hepatectomy. This study investigated the correlation between hepatic hypertrophy and hemodynamics of portal venous flow by ultrasound sonography after PTPE.

Methods

We analyzed 58 patients with PTPE, excluding those who underwent recanalization (n = 10). Using CT volumetry results 2 weeks after PTPE, the patients were stratified into a considerable hypertrophy group (CH; n = 15) with an increase rate of remnant liver volume (IR-RLV) ≥ 40% and a minimal hypertrophy group (MH; n = 33) with an IR-RLV < 40%. We investigated the hemodynamics of portal venous flow after PTPE and the favorable factors for hepatic hypertrophy.

Results

Univariate and multivariate analysis identified the indocyanine green retention rate at 15 min (ICGR15) and increase rate of portal venous flow volume (IR-pFV) at the non-embolized lobe on day 3 after PTPE as independent favorable factors of IR-RLV. Patients with IR-pFV on day 3 after PTPE ≥100% and ICGR15 ≤ 15% (n = 13) exhibited significantly increased IR-RLV compared with others (n = 35).

Conclusions

Cases with high IR-pFV on day 3 after PTPE exhibited better hepatic hypertrophy. Preserved liver function and increased portal venous flow on day 3 were important.

Clinicopathological Characteristics of Hepatocellular Carcinoma with Microscopic Portal Venous Invasion and the Role of Anatomical Liver Resection in These Cases

BACKGROUND

The aims of this study were to investigate predictive factors for microscopic portal venous invasion (mPVI) in hepatocellular carcinoma (HCC) and whether anatomical liver resection (ALR) was useful in such cases.

METHODS

We analyzed 852 patients with HCC without macroscopic portal venous invasion who were treated at our hospital between January 1990 and May 2014. These patients were stratified into a microscopic portal venous invasion group (mPVI group; n = 153) and non-microscopic portal venous invasion group (NmPVI group; n = 699).

RESULTS

PIVKA-II ≥100 mAU/ml, a tumor size ≥5 cm, a confluent lesion, and poor differentiation were found to be independent risk factors for mPVI. Among the mPVI group who had single HCC under 5 cm, serum albumin level <4.0 g/dl, PIVKA-II ≥100 mAU/ml, a positive surgical margin, and non-ALR (NALR) were independent unfavorable prognostic factors for overall survival (OS). PIVKA-II ≥100 mAU/ml, a positive surgical margin and NALR were independent unfavorable prognostic factors for relapse-free survival (RFS). ALR was significantly favorable factor for both OS and RFS of the mPVI group who had single HCC under 5 cm.

CONCLUSIONS

Even if no portal venous invasion is detectable in HCC patients preoperatively, a PIVKA-II ≥100 mAU/ml, tumor size ≥5 cm, and a confluent lesion indicate a high risk of mPVI. ALR should be considered for the patients with these characteristics because it is a favorable prognostic factor in these cases with mPVI.

Hepatectomy for hepatocellular carcinoma with portal vein tumor thrombus

Despite surgical removal of tumors with portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) patients, early recurrence tends to occur, and overall survival (OS) periods remain extremely short. The role that hepatectomy may play in long-term survival for HCC with PVTT has not been established. The operative mortality of hepatectomy for HCC with PVTT has also not been reviewed. Hence, we reviewed recent literature to assess these parameters. The OS of patients who received hepatectomy in conjunction with multidisciplinary treatment tended to be superior to that of patients who did not. Multidisciplinary treatments included the following: preoperative radiotherapy on PVTT; preoperative transarterial chemoembolization (TACE); subcutaneous administration of interferon-alpha (IFN-α) and intra-arterial infusion of 5-fluorouracil (5-FU) with infusion chemotherapy in the affected hepatic artery; cisplatin, doxorubicin and 5-FU locally administered in the portal vein; and subcutaneous injection of IFN-α, adjuvant chemotherapy (5-FU + Adriamycin) administration via the portal vein with postoperative TACE, percutaneous isolated hepatic perfusion and hepatic artery infusion and/or portal vein chemotherapy. The highest reported rate of operative mortality was 9.3%. In conclusion, hepatectomy for patients affected by HCC with PVTT is safe, has low mortality and might prolong survival in conjunction with multidisciplinary treatment.

Fatty acid-binding protein 5 function in hepatocellular carcinoma through induction of epithelial-mesenchymal transition

Hepatocellular carcinoma (HCC) is a highly prevalent cancer with poor prognosis. The correlation between overexpression of fatty acid-binding protein 5 (FABP5) and malignant potential of tumor growth and metastasis in several cancers has been previously reported. However, the correlation between FABP5 expression and HCC malignant behavior remains unknown. We compared FABP5 expression and patient characteristics in paired HCC and adjacent noncancerous liver tissues from 243 patients who underwent surgical resection of primary HCC. Cell proliferation, invasion, and migration assays were performed in HCC cell lines overexpressing FABP5 or downregulated for FABP5. Tumor growths were monitored in xenograft model, and liver and lung metastasis models were established. In the 243 HCC patients, FABP5-positive staining (n = 139/243, 57.2%) was associated with poor prognosis and recurrence (P < 0.0001) and showed positive correlation with distant metastasis, tumor size and vascular invasion (P < 0.05). Cell proliferation, invasion, and migration in vitro were enhanced by upregulation of FABP5 and decreased by downregulation of FABP5 in HCC cell lines. Similar results in tumor formation and metastasis were obtained through in vivo analyses. PCR array results revealed upregulation of SNAI1 in FABP5-overexpressing HepG2 cells. Western blot analysis showed significantly increased expression of E-cadherin and ZO-1 and decreased SNAI1 expression and nuclear translocation of β-catenin by knockdown of FABP5. We revealed a significant role for FABP5 in HCC progression and metastasis through the induction of epithelial-to-mesenchymal transition. FABP5 may be a potential novel prognostic biomarker and new therapeutic target for HCC.

Hepatectomy for liver metastasis from gastrointestinal stromal tumor in the era of imatinib mesylate: a case series study

The prognosis of metastatic gastrointestinal stromal tumor (GIST) has improved since the introduction of imatinib mesylate; however, acquired resistance has been reported, so alternative treatment option is needed. We evaluated the efficacy of hepatectomy for metastatic GIST. Six patients with liver metastases from GIST underwent hepatectomy. Four were treated with imatinib mesylate before hepatectomy, and all the patients were treated with imatinib mesylate after hepatectomy. Patients were followed-up for a mean duration of 113.5 months after hepatectomy. Complete resection was accomplished in four patients, with incomplete resection performed in the remaining two patients due to peritoneal dissemination. One patient with incomplete resection died 10 months after surgery. One patient with complete resection has survived without disease progression since initial hepatectomy. The remaining four patients with progressive disease during imatinib mesylate treatment developed tumor recurrence and three of them underwent a second hepatectomy. These three patients underwent complete resection during repeat surgery. In total, three patients died during the follow-up period, all of whom had tumors of small intestine origin. Primary tumor site (small intestine vs. others) was identified as a risk factor of mortality (P = 0.02). Although not statistically significant, there was a trend toward better outcomes in patients with exon 11 mutations. Surgical resection for metastatic GIST was shown to be effective and needed to achieve a better prognosis. Repeat hepatectomy demonstrated efficacy in selected patients. Hepatectomy should be considered based on tumor characteristics such as primary tumor site and c-KIT mutation status.

Models predicting the risks of six life-threatening morbidities and bile leakage in 14,970 hepatectomy patients registered in the National Clinical Database of Japan

To construct a robust morbidity risk-prediction model based on a Japanese nationwide web-based database of patients who underwent liver surgery.Although liver resection has become safer, patient mortality and morbidity still occur. This study investigated postoperative morbidity risks in patients who underwent hepatectomy in Japan at institutions registered in the National Clinical Database.This analysis involved 14,970 patients who underwent hepatectomy of more than 1 section, except for left lateral sectionectomy, during 2011 and 2012 at 1192 hospitals in Japan. Patients were randomized into 2 subsets, with 80% of patients analyzed for model development and the remaining 20% for model validation.Rates of 90-day inhospital mortality and overall morbidity were 3.7% and 25.7%, respectively. Rates of surgical site infection and bile leakage were 9.0% and 8.0%, respectively, but these morbidities showed little association with mortality. Rates of nonsurgical complications, including postoperative transfusion over 5 units, unexpected intubation, renal failure, cardiac events, septic shock, and postoperative pneumonia, ranged from 0.2% to 2.6%. These complications were highly associated with mortality, suggesting they were life-threatening. Risk models for morbidity yielded high C-indices for transfusion of over 5 units (0.758), unplanned intubation (0.755), renal failure (0.80), cardiac events (0.779), septic shock (0.783), pneumonia (0.768), and bile leakage (0.676).Preoperative parameters/comorbidities can accurately predict life-threatening complications after hepatectomy. These models allow early identification of patients at risk of mortality and may be useful in deciding on surgical interventions and in improving surgical quality.

[Analysis of Oxaliplatin Combination Therapy for Unresectable or Recurrent Gastric Cancer]

We analyzed 26 cases of unresectable or recurrent gastric cancer treated with oxaliplatin(OX)combination therapy between September 2014 and January 2016. The number of unresectable gastric cancer cases was 14 and there were 12 recurrent cases. The number of patients receiving S-1 plus OX(SOX), SOX plus trastuzumab(Tmab), capecitabine(Cape)plus OX(CapeOX), and CapeOX plus Tmab was 17, 1, 6, and 2, respectively. The starting dose of OX was 130mg/m2 in 12 patients and 100mg/m2 in 14. The median follow-up duration from the first treatment was 6 months(1-14). The median number of treatment cycles was 5(1-19). Dose reductions occurred in 14 cases, and treatment delay occurred in 13 cases. Grade 3 adverse events occurred in 2 cases(8%); thrombocytopenia and stomatitis occurred in 1 case. The response rate was 23%, the disease control rate was 69%, and the median relapse-free survival time was 4 months(1-14). OX combination therapy for unresectable or recurrent gastric cancer was feasible in terms of safety and might be effective for disease control.

Intratumoral artery on contrast-enhanced computed tomography imaging: differentiating intrahepatic cholangiocarcinoma from poorly differentiated hepatocellular carcinoma

AIM

Differentiating intrahepatic cholangiocarcinoma (ICC) from poorly differentiated hepatocellular carcinoma (p-HCC) is often difficult, but it is important for providing appropriate treatments. The purpose of this study was to examine the features differentiating ICC from p-HCC on contrast-enhanced dynamic-computed tomography (CT).

METHODS

This study examined 42 patients with pathologically confirmed ICC (n = 19) or p-HCC (n = 23) for which contrast-enhanced dynamic CT data were available. CT images were analyzed for enhancement patterns during the arterial phase, washout pattern, delayed enhancement, satellite nodules, capsular retraction, lesion shape, and presence of an intratumoral hepatic artery, intratumoral hepatic vein, intratumoral portal vein, and bile duct dilation around the tumor, portal vein tumor thrombus, lobar atrophy, or lymphadenopathy.

RESULTS

Univariate analysis revealed the presence of rim enhancement (p = 0.037), lobulated shape (p = 0.004), intratumoral artery (p < 0.001), and bile duct dilation (p = 0.006) as parameters significantly favoring ICC, while a washout pattern significantly favored p-HCC (p < 0.001). Multivariate analysis revealed intratumoral artery as a significant, independent variable predictive of ICC (p = 0.037), and 15 ICCs (78.9%) showed this feature. Washout pattern was a significant, independent variable favoring p-HCC (p = 0.049), with 15 p-HCCs (65.2%) showing this feature.

CONCLUSION

The presence of an intratumoral artery in the arterial phase on contrast-enhanced dynamic CT was a predictable finding for ICC, and the presence of a washout pattern was a predictable finding for p-HCC, differentiating between ICC and p-HCC.

Significance of functional hepatic resection rate calculated using 3D CT/99mTc-galactosyl human serum albumin single-photon emission computed tomography fusion imaging

AIM: To evaluate the usefulness of the functional hepatic resection rate (FHRR) calculated using 3D computed tomography (CT)/^99mTc-galactosyl-human serum albumin (GSA) single-photon emission computed tomography (SPECT) fusion imaging for surgical decision making.

METHODS: We enrolled 57 patients who underwent bi- or trisectionectomy at our institution between October 2013 and March 2015. Of these, 26 patients presented with hepatocellular carcinoma, 12 with hilar cholangiocarcinoma, six with intrahepatic cholangiocarcinoma, four with liver metastasis, and nine with other diseases. All patients preoperatively underwent three-phase dynamic multidetector CT and ^99mTc-GSA scintigraphy. We compared the parenchymal hepatic resection rate (PHRR) with the FHRR, which was defined as the resection volume counts per total liver volume counts on 3D CT/^99mTc-GSA SPECT fusion images.

RESULTS: In total, 50 patients underwent bisectionectomy and seven underwent trisectionectomy. Biliary reconstruction was performed in 15 patients, including hepatopancreatoduodenectomy in two. FHRR and PHRR were 38.6 ± 19.9 and 44.5 ± 16.0, respectively; FHRR was strongly correlated with PHRR. The regression coefficient for FHRR on PHRR was 1.16 (P < 0.0001). The ratio of FHRR to PHRR for patients with preoperative therapies (transcatheter arterial chemoembolization, radiation, radiofrequency ablation, etc.), large tumors with a volume of > 1000 mL, and/or macroscopic vascular invasion was significantly smaller than that for patients without these factors (0.73 ± 0.19 vs 0.82 ± 0.18, P < 0.05). Postoperative hyperbilirubinemia was observed in six patients. Major morbidities (Clavien-Dindo grade ≥ 3) occurred in 17 patients (29.8%). There was no case of surgery-related death.

CONCLUSION: Our results suggest that FHRR is an important deciding factor for major hepatectomy, because FHRR and PHRR may be discrepant owing to insufficient hepatic inflow and congestion in patients with preoperative therapies, macroscopic vascular invasion, and/or a tumor volume of > 1000 mL.

[Effect of Preoperative Bowel Preparation on Surgical Site Infection in Liver Surgery]

BACKGROUND

In our institute, the protocol for preoperative bowel preparation before liver surgery has been changed from polyethylene glycol lavage (NiflecR: N group) to magnesium citrate (MagcorolR: M group).

METHODS

Ninety patients who underwent hepatectomy without reconstruction of the bile duct, gastorectomy, or colorectal resection from 2012 to 2013 were enrolled in this study. The impacts of preoperative bowel preparation were compared between the 2 groups.

RESULTS

There were no significant differences between the 2 groups in terms of surgical procedure, operative time, bleeding amount, and duration of postoperative hospital stay. Surgical-site infection did not occur in both groups. There were no significant differences in the white blood cell count and platelet count of the patients in both groups. The C-reactive protein level in the M group was significantly lower than that in the N group on days 1, 3, and 5 after the operation, whereas the ammonia level in the M group was significantly lower than that in the N group on day 5 after the operation.

CONCLUSION

It is possible to simplify preoperative bowel preparation associated with liver surgery while ensuring appropriate safety.

[Efficacy of Sorafenib for Extrahepatic Recurrence of Hepatocellular Carcinoma after Liver Resection]

Sorafenib is the first molecularly targeted drug recommended as a treatment for advanced hepatocellular carcinoma (HCC). Herein, we report the efficacy of sorafenib for extrahepatic recurrence of HCC. From September 2004 to March 2015, 47 patients who were diagnosed with recurrent HCC after liver resection were treated with sorafenib. The overall response rate was 17.5% (complete response: CR 1, partial response: PR 6, stable disease: SD 17, progressive disease: PD 13, SD beyond PD 3), and the disease control rate was 67.5%. The median time to disease progression, including extrahepatic recurrence, was significantly better than in the group with only intrahepatic metastasis (p=0.034). Therefore, sorafenib might be an effective treatment for extrahepatic recurrence of HCC.

Our technique of preceding diaphragm resection and partial mobilization of the hepatic right lobe using a vessel sealing device (LigaSure™) for huge hepatic tumors with diaphragm invasion

We describe and assess our technique of preceding diaphragm resection and partial mobilization of the hepatic right lobe to treat a huge hepatic tumor with diaphragm invasion. The right hepatic artery and portal vein were divided at the hepatic hilum, and the mesenteries were then dissected with a vessel sealing device (LigaSure Impact™). The invaded diaphragm was dissected roundly using a vessel sealing device and the right lobe was partially mobilized. A soft catheter was then passed along the anterior aspect of the retrohepatic inferior vena cava and the liver parenchyma was dissected via a liver hanging maneuver. We performed eight hepatectomies using this technique. The median blood loss was 532.5 ml and the mean excised liver weight was 1859 g. Our results demonstrate the safety and efficiency of the preceding diaphragm resection and partial mobilization technique using a vessel sealing device for right hepatectomy to resect a very large tumor with diaphragm invasion.

ZEB1 expression is associated with prognosis of intrahepatic cholangiocarcinoma

Background/Aim

Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive malignant tumours, so the identification of molecular targets for ICC is an important issue. Zinc finger E-box binding homeobox 1 (ZEB1) is a key inducer of epithelial–mesenchymal transition (EMT). The aim of the present study was to clarify the clinical significance of ZEB1 in ICC and the associations between ZEB1 expression and EMT-related proteins.

Methods

We immunohistochemically examined the expression of EMT-related proteins, namely ZEB1, vimentin and E-cadherin, in ICC specimens from 102 patients. The clinicopathological and prognostic values of these markers were evaluated.

Results

ZEB1 and vimentin were expressed in 46.1% and 43.1% of tumours, respectively, and E-cadherin expression was lost in 44.1% of tumours. ZEB1 expression showed a significant inverse correlation with E-cadherin expression (p=0.004) and a positive correlation with vimentin expression (p=0.022). Altered expression of ZEB1 was associated with aggressive tumour characteristics, including advanced tumour stage (p=0.037), undifferentiated-type histology (p=0.017), lymph node metastasis (p=0.024) and portal vein invasion (p=0.037). Moreover, overall survival rates were significantly lower for patients with high ZEB1 expression than for patients with low ZEB1 expression (p=0.027). Kaplan–Meier analysis also identified E-cadherin expression (p=0.041) and vimentin expression (p=0.049) as prognostic indicators for overall survival.

Conclusions

ZEB1 expression is associated with tumour progression and poor prognosis in patients with ICC through positive correlations with vimentin and negative correlations with E-cadherin. ZEB1 expression is associated with a poor prognosis and might be an attractive target for the treatment of ICC.

Multiplication of alpha-fetoprotein and protein induced by vitamin K absence-II is a powerful predictor of prognosis and recurrence in hepatocellular carcinoma patients after a hepatectomy

AIM

To evaluate the oncological implications of multiplication of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonists-II (PIVKA-II) in patients with hepatocellular carcinoma (HCC).

METHODS

Data were prospectively collected from 516 consecutive patients who underwent a curative primary hepatectomy for HCC between 1998 and 2010. The AP-factor (AFP × PIVKA-II) was evaluated in relation to 2-year survival outcomes by receiver-operator curve analysis to determine the cut-off values. Patient survival, recurrence-free survival and risk factors were analyzed in accordance with the preoperative AP-factor.

RESULTS

The AP-factor was categorized into three groups depending on the serum concentrations of AFP and PIVKA-II as follows: AP1 (n = 206; AFP < 200 ng/mL and PIVKA-II < 100 mAU/mL), AP2 (n = 152; AFP × PIVKA-II < 10(5) ) and AP3 (n = 158; AFP × PIVKA-II ≥ 10(5) ). The AP-factor was found to be significantly related to pathological factors such as differentiation, portal vein invasion, hepatic vein invasion and intrahepatic metastasis. Multivariate analysis was performed to identify the risk factors for survival and recurrence. Albumin, AP-factor and pathological factors including portal vein invasion, hepatic vein invasion and intrahepatic metastasis are independent risk factors for survival. Tumor number, AP-factor, and a non-cancerous liver were determinants of recurrence.

CONCLUSION

The AP-factor is closely related to differentiation and microscopic vascular invasion, and was selected by multivariate analysis as an independent factor for survival and recurrence, in HCC. Patients hopeful of obtaining good outcomes after a hepatectomy could be selected by the AP-factor evaluation.

Resection of liver metastasis derived from alpha-fetoprotein-producing gastric cancer-report of 4 cases

As is the case for metastatic liver tumors derived from standard gastric cancers, there is no consensus about the optimal treatment for metastatic liver tumors derived from alpha-fetoprotein (AFP)-producing gastric cancer, including regarding the surgical indications for such lesions. We report the cases of 4 patients in whom metastatic liver tumors derived from AFP-producing gastric cancer that were curatively resected. One of the patients had a thrombus in his inferior vena cava at the time of the liver resection, and both the liver tumor and thrombus were completely removed. The patient has survived 93 months after receiving multidisciplinary therapy including partial pneumonectomy, chemotherapy, and radiotherapy and currently has no evaluable disease. Another patient has survived for 3 years without suffering any recurrence. Since long-term survival is possible, liver resection should be considered as a treatment for liver metastases from AFP-producing gastric cancers.

Effect of high expression of fatty acid binding protein 5 on prognosis and epithelial-mesenchymal transition in hepatocellular carcinoma

310

Background: Hepatocellular carcinoma (HCC) is one of the cancer types with poor prognosis. The high expression of Fatty Acid Binding Protein 5 (FABP5) has been reported its malignant potential in several cancers. However, the function of FABP5 in HCC remains unknown. We analyzed the correlation between the expression of FABP5 and malignant behavior of HCC using HCC tissues and human HCC cell lines. Methods: A total of 231 HCC samples were obtained through our institute and subjected to immunohistochemical analysis. In vitro, protein expression of FABP5 in HCC cell lines was assessed by Western blot analysis. To the higher FABP5 expression cell lines, we performed proliferation assay, migration assay and invasion assay with or without genetic down-regulation of FABP5 by short hairpin RNA (shRNA). Results: The intensity of immunostaining in HCC tissues was determined comparing to immunoreactivity of Kupffer cells, and the patients were divided into a strong staining group (n=127) and a weak staining group (n=104) according to the intensity of immunostaining. In the strong staining group, 5-year overall survival rate was 58.3%, compared with 90.5% in the weak staining group (p<0.0001). In addition, 5-year relapse free survival rate in the strong staining group was 23.1%, compared with 46.9% in the weak staining group (p<0.0001). Moreover, the strong staining of FABP5 positively correlated with early recurrence, extrahepatic metastasis, AFP, AFP-L3%, PIVKA II, tumor size, poor differentiation, and micro/macro vascular invasion (P<0.05). In vitro, the knockdown of FABP5 significantly inhibited cell proliferation, migration and invasiveness. Additionally, the knockdown of FABP5 was associated with inhibition of epithelial-mesenchymal transition (EMT), including down-regulation of N-cadherin, and Snail converse to the activation of E-cadherin and ZO-1. Conclusions: FABP5 was closely related with the gain of malignant potential through the activation of EMT, and also behaved as a significant prognostic and recurrence factor. Therefore, FABP5 may serve as a new biomarker of HCC and a potential molecular target for the development of HCC therapies.

Hand-assisted laparoscopic splenectomy for sclerosing angiomatoid nodular transformation of the spleen complicated by chronic disseminated intravascular coagulation: a case report

A 36-year-old man who presented with a nosebleed and anemia was referred to our hospital. Laboratory test results showed platelet depletion, decreased levels of fibrinogen, and increased fibrinogen degeneration products. CT showed a 13-cm splenic tumor. T2 -weighted MRI revealed a high-intensity mass. We preoperatively diagnosed splenic hemangioma with chronic disseminated intravascular coagulation and scheduled an operation to relieve the disseminated intravascular coagulation. We also performed hand-assisted laparoscopic splenectomy to ensure easy handling of the splenomegaly. The resected specimen microscopically consisted of hemorrhages and hemangiomatous lesions, and multiple angiomatoid nodules were scattered and separated by fibrocollagenous stroma with inflammatory cells. Three types of vessels (capillaries, sinusoids and small veins) were contained in the angiomatoid nodules, and the pathological diagnosis was sclerosing angiomatoid nodular transformation. The results of this case suggest that we should consider sclerosing angiomatoid nodular transformation in the differential diagnosis of patients with splenic tumors, as sclerosing angiomatoid nodular transformation with hemangiomatous features may cause coagulation disorders for which splenectomy should be performed.

Usefulness of artificial vascular graft for venous reconstruction in liver surgery

Background

The purpose of this study was to evaluate the results of hepatectomy with inferior vena cava or hepatic vein resection, followed by vessel reconstruction with an artificial vascular graft.

Methods

From 2000 to 2011, 1,434 patients underwent several types of hepatectomy at our institution. Of these, we reviewed the cases of eight patients (0.56%) who underwent hepatectomy with inferior vena cava or hepatic vein resection and subsequent reconstruction using an expanded polytetrafluoroethylene (PTFE) graft.

Results

We resected the inferior vena cava in six patients and the hepatic vein in two patients. All eight patients underwent subsequent reconstruction using an expanded PTFE graft. The median operative time was 443 minutes and the median blood loss was 2,017 mL. The median postoperative hospital stay period was 18.5 days and the in-hospital mortality rate was 0%. Complications occurred in four patients: two patients experienced bile leakage, one experienced a wound infection, and one experienced pleural effusion. The two patients who experienced bile leakage had undergone reoperation on postoperative day 1. No complication with the artificial vascular graft occurred in these eight cases. Histological invasion to the replaced inferior vena cava or hepatic vein was confirmed in four cases. All artificial vascular grafts remained patent during the observation period.

Conclusions

Hepatectomy combined with inferior vena cava or hepatic vein resection, followed by reconstruction with an expanded PTFE graft can be performed safely in selected patients.

Long-term outcome of laparoscopic hepatectomy in patients with hepatocellular carcinoma

BACKGROUND/AIMS

The long-term prognosis for patients with hepatocellular carcinoma (HCC) who undergo laparoscopic hepatectomy has not been well compared with that for patients after open hepatectomy.

METHODOLOGY

We analyzed patient survival (PS) and disease-free survival (DFS) of 310 consecutive patients who underwent primary hepatectomy between January 2001 and March 2010. The patients were divided into Group LAP (laparoscopic approach) (n = 24) and Group OPN (with open laparotomy) (n = 286). The median follow-up time was 60.9 months (range, 12.0-123.9 months).

RESULTS

The 5-, and 7-year PS rates of Group LAP were 87.9%, and 87.9%, and those of Group OPN were 82.2% and 69.3%, respectively (P = 0.5638). The 5-, and 7-year DFS rates of Group LAP were 47.1%, and 31.4%, and those of Group OPN were 29.4%, and 24.3%, respectively (P = 0.4594). Laparoscopic hepatectomy in patients of Group LAP resulted in a better outcome of blood loss (P = 0.0314), operative time (P < 0.0001), and hospital stay (P = 0.0008).

CONCLUSIONS

The long-term outcome of laparoscopic hepatectomy for patients with HCC was identified to be comparable to open hepatectomy with regard to PS and DFS. Laparoscopic hepatectomy is a promising therapeutic option for patients with HCC.

[Long-term survival of a patient with metachronous lymph node metastasis and bile duct tumor thrombus due to hepatocellular carcinoma successfully treated with repeated surgery]

A 64-year-old man with hepatocellular carcinoma located in the left lateral lobe and segment 5 was referred to our hospital for surgical treatment. We performed left lateral sectionectomy and segmentectomy 5. The pathological diagnosis was moderately to poorly differentiated hepatocellular carcinoma, and the pathological stage was stage III. Eight months later, intrahepatic recurrence in segment 1 and lymph node metastasis in the hepatoduodenal ligament occurred. Partial resection of segment 1 was performed, and the metastatic lymph node was surgically removed. Twenty four months after the first operation, lymph node metastases along the lesser curvature and retropancreatic space were extirpated. Lymph node metastases along the common hepatic artery were removed 76 months after the first operation. The patient developed jaundice 88 months after the initial surgery, and the bile duct tumor thrombus derived from intrahepatic recurrence in segment 1 caused obstructive jaundice. After percutaneous transhepatic biliary drainage, we performed median sectionectomy and bile duct tumor thrombus removal without bile duct resection. At his 8-year follow-up visit after the primary operation, the patient was healthy and did not show any signs of recurrence. Lymph node metastasis and bile duct tumor thrombus are rare patterns of hepatocellular carcinoma recurrence, and aggressive surgery can result in long-term survival when complete resection is anticipated.

Surgical management of hepatocellular carcinoma with tumor thrombi in the inferior vena cava or right atrium

Background

The prognosis for advanced hepatocellular carcinoma (HCC) with tumor thrombi in the inferior vena cava (IVC) or right atrium (RA) is poor, and there is no established effective treatment for this condition. Thus study aimed to evaluate the efficacy of surgical resection and prognosis after surgery for such cases.

Methods

Between January 1990 and December 2012, 891 patients underwent hepatectomy for HCC at our institution. Of these, 13 patients (1.5%) diagnosed with advanced HCC with tumor thrombi in the IVC or RA underwent hepatectomy and thrombectomy. Data detailing the surgical outcome were evaluated and recurrence-free and overall survival rates were calculated using the Kaplan-Meier method.

Results

Seven patients had an IVC thrombus and six had an RA thrombus. Extra-hepatic metastasis was diagnosed in 8 of 13 patients. Surgical procedures included three extended right lobectomies, three extended left lobectomies, five right lobectomies, and two sectionectomies. Right adrenal gland metastases were excised simultaneously in two patients. All IVC thrombi were removed under hepatic vascular exclusion and all RA thrombi were removed under cardiopulmonary bypass (CPB). Four patients (30.8%) experienced controllable postoperative complications, and there was no surgical mortality. The mean postoperative hospital stay for patients with IVC and RA thrombi was 23.6 ± 12.5 days and 21.2 ± 4.6 days, respectively. Curative resection was performed in 5 of 13 cases. The 1- and 3-year overall survival rates were 50.4%, and 21.0%, respectively, and the median survival duration was 15.3 months. The 1- and 3-year overall survival rates for patients who underwent curative surgical resection were 80.0% and 30.0%, respectively, with a median survival duration of 30.8 months. All patients who underwent curative resection developed postoperative recurrences, with a median recurrence-free survival duration of 3.8 months. The 1-year survival rate for patients who underwent noncurative surgery and had residual tumors was 29.2%, with a median survival duration of 10.5 months.

Conclusions

Aggressive surgical resection for HCC with tumor thrombi in the IVC or RA can be performed safely and may improve the prognoses of these patients. However, early recurrence and treatment for recurrent or metastatic tumors remain unresolved issues.