Significance of HBV cccDNA and clinical factors in evaluating prognosis of hepatocelluar carcinoma following surgical resection

AIM: To investigate the correlation of HBV cccDNA and clinical factors with the survival of patients with hepatocellular carcinoma (HCC) after hepatectomy.

METHODS: A retrospective analysis was carried out in 60 HCC patients who underwent radical operation from 2003 to 2006 at our hospital. Serum HBV DNA and covalently closed circular DNA (cccDNA) levels were detected by real-time PCR. In 55 patients with complete follow-up data, serum HBV DNA, cccDNA in liver tissue and clinical characteristics were retrospectively analyzed. The overall survival and recurrence-free survival (RFS) were calculated using the Kaplan-Meier method. All the data were analyzed using Log-rank test and Cox regression model.

RESULTS: HBV cccDNA was positive in only one serum sample (1/35) and in 20% (11/55) of tumor tissues. There was a significant correlation between intrahepatic cccDNA in tumor tissue and total HBV DNA in serum (r = 0.364, P = 0.006). The 1-, 3-, 5-year overall survival and RFS rates for 55 patients after HCC resection were 73%, 51% and 38%, and 63%, 29% and 19%, respectively. The independent prognostic factor influencing RFS was the level of intrahepatic cccDNA in tumor tissue. The independent prognostic factors influencing overall survival were tumor numbers and vessel invasion.

CONCLUSION: HCC patients with solitary tumor and without vessel invasion showed a higher overall survival. HCC patients with an intrahepatic HBV cccDNA level of less than 1 000 copies/μg had a higher RFS.

Application of hepatic blood blocker to control bleeding during hepatectomy

AIM: To compare a new tool named hepatic blood blocker versus the Pringle maneuver and hemihepatic vascular exclusion in controlling bleeding during hepatectomy for liver cancer.

METHODS: The clinical data for 117 patients who underwent hepatectomy for liver cancer from 2004 to 2009 were analyzed retrospectively. Of these patients, 42 underwent local hepatic blood occlusion with hepatic blood blocker (group A), 35 underwent hemihepatic vascular exclusion (group B), and 40 underwent the Pringle maneuver (group C). The blood loss, operative time, postoperative hepatic function and complications were compared among each group.

RESULTS: The average blood loss and operative time were significantly less in group A than in groups B (P < 0.05, 0.001) and C (both P < 0.001). Significant differences were seen between group A and group C in serum total bilirubin (TB) and alanine transaminase (ALT) on postoperative days 3 and day 7, and group A showed better hepatic function (TB: P = 0.014, 0.009; ALT: both P < 0.001). The Pringle maneuver significantly increased the rate of postoperative abdominal dropsy when compared to group A (P < 0.001). In group C, two patients suffered from liver failure, one suffered from alimentary tract hemorrhage and one died.

CONCLUSION: Using hepatic blood blocker during hepatectomy could effectively control bleeding, reduce operative time and preserve hepatic function, representing a safe and feasible technique.

Splenectomy affects the balance between hepatic growth factor and transforming growth factor-β and its effect on liver regeneration is dependent on the amount of liver resection in rats

Purpose

Small-for-size syndrome (SFSS) is a major problem in liver surgery, and splenectomy has been used to prevent SFSS. However, it is unknown whether splenectomy has the same effect on liver regeneration in both standard and marginal hepatectomy. The aim of this study is to see a difference in effect of splenectomy on liver regeneration according to the amount of liver resection.

Methods

Thirty male Sprague-Dawley rats (220 to 260 g) were divided into the following five groups: control (n = 6), 70% hepatectomy (n = 6), 70% hepatectomy with splenectomy (n = 6), 90% hepatectomy (n = 6), and 90% hepatectomy with splenectomy (n = 6). The animals were euthanized 24 hours after surgery and liver specimens were obtained. To assess liver regeneration, we performed immunohistochemistry of liver tissue using 5-bromo-2-deoxyuridine (BrdU) labeling and Western blot analysis of hepatic growth factor (HGF) and transforming growth factor-β (TGF-β) in the liver tissue.

Results

The splenectomized subgroup had a higher BrdU-positive cell count in the 90% hepatectomy group, but not in the 70% hepatectomy group (P < 0.001). Splenectomy significantly decreased TGF-β expression (P = 0.005) and increased the HGF to TGF-β ratio (P = 0.002) in the 90% hepatectomy group, but not in the 70% hepatectomy group.

Conclusion

The positive effect of splenectomy on liver regeneration was greater in the group with the larger liver resection. This phenomenon may be related to the relative balance between HGF and TGF-β in the liver.

Low-dose steroid pretreatment ameliorates the transient impairment of liver regeneration

AIM: To determine if liver regeneration (LR) could be disturbed following radiofrequency (RF) ablation and whether modification of LR by steroid administration occurs.

METHODS: Sham operation, partial hepatectomy (PH), and partial hepatectomy with radiofrequency ablation (PHA) were performed on adult Fisher 344 rats. We investigated the recovery of liver volume, DNA synthetic activities, serum cytokine/chemokine levels and signal transducers and activators of transcription 3 DNA-binding activities in the nucleus after the operations. Additionally, the effects of steroid (dexamethasone) pretreatment in the PH group (S-PH) and the PHA group (S-PHA) were compared.

RESULTS: The LR after PHA was impaired, with high serum cytokine/chemokine induction compared to PH, although the ratio of the residual liver weight to body weight was not significantly different. Steroid pretreatment disturbed LR in the S-PH group. On the other hand, low-dose steroid pretreatment improved LR and suppressed tumor necrosis factor (TNF)-α elevation in the S-PHA group, with recovery of STAT3 DNA-binding activity. On the other hand, low-dose steroid pretreatment improved LR and suppressed TNF-α elevation in the S-PHA group, with recovery of STAT3 DNA-binding activity.

CONCLUSION: LR is disturbed after RF ablation, with high serum cytokine/chemokine induction. Low-dose steroid administration can improve LR after RF ablation with TNF-α suppression.

More than 7-year survival of a patient following repeat hepatectomy for total 20 colon cancer liver metastases

A 54-year-old man was transferred with sigmoid colon cancer combined with multiple bilobar liver metastases. Nine metastases were in the left lobe and 5 metastases were in the right lobe. After low anterior resection, all 9 lesions in the left lobe were completely removed by wedge resections. Because the remnant liver volume after multiple wedge resection of the left lobe was not sufficient to perform a right hepatectomy simultaneously, we planned a two-stage hepatectomy. Right portal vein embolization was performed one week after the first liver operation. A right hepatectomy was safely performed 22 days after the first hepatectomy. A recurrent mass developed in the segment III 18 months after the right hepatectomy. Radiofrequency ablation (RFA) was performed to remove that lesion. Five other metastases developed 18 months after RFA whereby multiple wedge resections were performed. The patient has survived for more than 7 years after the first liver operation.

Single center experience of laparoscopic hepatectomy: the comparison of perioperative outcomes between early and late period

BACKGROUNDS/AIMS

The aim of this study is to clarify the safety and feasibility of laparoscopic hepatectomy, through comparing the early and late periods of perioperative outcomes.

METHODS

We retrospectively analyzed 138 patients who underwent laparoscopic hepatectomy from January 2003 to June 2011, at Yeungnam University Hospital. We divided the total patients to early period (from January 2003 to February 2007, n=49) and late period (from March 2007 to June 2011, n=89) groups and compared the perioperative outcomes including the mean operation time, intra-operative blood loss, postoperative hospital stay, intensive care unit (ICU) stay, and duration of liver function test (LFT) normalization.

RESULTS

The mean operation time was 308 minutes (range: 140-510) in the early group and 193 minutes (range: 40-350) in the late period group (p<0.001). The mean intraoperative blood loss was 171 ml (range: 50-1,200) in the early and 44 ml (range: 0-400) in the late group (p=0.005). The postoperative hospital stay was 9.7 days (range: 4-31) in the early and 6.8 days (range: 2-9) in the late period (p<0.001). The ICU stay hour was 21.6 hours (range: 0-120) in the early and 2.8 hour (range: 0-24) in the late period (p<0.001). The duration of LFT normalization was 5.7 days (range: 0-39) in the early and 2.1 days (range: 0-20) in the late period (p=0.003). The perioperative outcomes in the late period were better than the early period, which showed a statistically significant difference.

CONCLUSIONS

Laparoscopic hepatectomy is feasible and can be safely performed in selected patients but requires a long experience in open liver resection and mastery of laparoscopic surgical skills.

Usefulness of the Pinch-Burn-Cut (PBC) technique for recipient hepatectomy in liver transplantation

BACKGROUNDS/AIMS

Surgical bleeding during recipient hepatectomy is a major concern in liver transplantation (LT). Effective intraoperative control of bleeding is necessary. In the Pinch-Burn-Cut (PBC) technique, a small amount of tissue around the dissection plane is pinched with forceps, electocauterized and gently cut. The present study sought to estimate the usefulness of the PBC technique in LT.

METHODS

Between June 2007 and December 2010, 123 adult cases underwent LT in our center. Of these, 72 involved a recipient hepatectomy using the PBC technique (PBC group). and 51 involved the conventional technique (non-PBC group). Clinical parameters were compared between two groups.

RESULTS

The amount of blood loss and related transfusions were significantly reduced, and the operating time was shorter in the PBC group than in the non-PBC group (p=0.006, p<0.05 and p=0.002, respectively). There was also shorter duration of mechanical ventilation after LT in the PBC group (p=0.017). The incidence of postoperative hemorrhage was lower in the PBC group than in the non-PBC group, but had no statistical significance between two group (19.6% vs. 8.3%, p=0.101).

CONCLUSIONS

Our data suggest that the PBC technique is effective for bleeding control during recipient hepatectomy in LT.

Value of transcatheter arterial chemoembolization with gemcitabine plus oxaliplatin in preventing postoperative recurrence of hepatocellular carcinoma in high-risk patients

AIM: To investigate the value of transcatheter arterial chemoembolization (TACE) with gemcitabine plus oxaliplatin (GEMOX) in preventing postoperative recurrence of hepatocellular carcinoma (HCC) in high-risk patients.

METHODS: The clinical data for 120 HCC patients with high risk factors for postoperative recurrence were analyzed retrospectively. Eighty-eight patients (TACE group) received TACE 3-6 weeks postoperatively, of them 43 (GEMOX group) received new chemotherapeutics including gemcitabine and oxaliplatin and 45 (control group) received conventional chemotherapeutics. Thirty-two patients (operation group) did not receive TACE. The recurrence rate of HCC was compared between these groups within 6 months and 1 year of follow-up.

RESULTS: The recurrence rate of HCC was significantly lower in the TACE group than in the operative group within either 6 months (20.5% vs 37.5%) or 1 year (43.8% vs 59.4%) after operative. The recurrence rate of HCC was significantly lower in the GEMOX group than in the control group within 6 months after operation, but showed no significant difference within 1 year of follow-up. The incidence rates of hyperleukocytosis, nausea and emesis in the GEMOX group were significantly lower than those in the control group.

CONCLUSION: Prophylactic TACE contributes to reducing or postponing the short-term recurrence of HCC in patients with high risk factors for postoperative recurrence, and the chemotherapy regimen including gemcitabine and oxaliplatin shows better effects than conventional ones.

What we learned from difficult hepatectomies in patients with advanced hepatic malignancy

Backgrounds/Aims

By reviewing difficult resections for advanced hepatic malignancies, we discuss the effectiveness and extended indications for hepatectomy in such patients.

Methods

We reviewed 7 patients who underwent extensive surgery between July 2008 and March 2011 for advanced hepatic malignancies. They had stage IV disease, except for in one case that was a stage IIIC (T4N0M0) hepatocellular carcinoma (HCC).

Results

Patient 1 with intrahepatic cholangiocarcinoma (IHCC) underwent right hemihepatectomy and resection of the bile duct and left portal vein. At 39 months after surgery, she had no recurrence or metastasis. Patient 2 with HCC underwent palliative right trisectionectomy. At 38 months after surgery, he is alive despite residual pulmonary metastases. Patient 3 with HCC invading the hepatic vein and diaphragm underwent right trisectionectomy and caval venoplasty. At 12 months after surgery, he had no recurrence or metastasis. Patient 4, who had 2 large HCCs and pulmonary thromboembolism, underwent a right trisectionectomy. At 7 months after surgery, he had no evidence of recurred HCC. Patient 5, who had IHCC invading her inferior vena cava and main portal vein, underwent preoperative radiotherapy, left hemihepatectomy, and caval resection. At 20 months after surgery, she is well despite a caval thrombus. Patient 6 and 7 underwent repeated surgery due to a recurred IHCC and metastatic colon cancer, respectively. In addition, they are alive during each 20 and 17 months after surgery.

Conclusions

Despite macroscopic extrahepatic metastases or major vessel involvement, extensive surgery for advanced hepatic malignancy may result in relatively favorable outcomes and be important modality for improving of survival in such patients.

Primary hepatic leiomyosarcoma: Case report and literature review

Primary hepatic leiomyosarcoma are rare tumors with less than 30 cases reported in the English literature. Non specific presentations and often diagnosis delayed until they reach a large size, is the norm with therapy leading to an often dismal prognosis. A 67-year-old man presented complaining of abdominal pain and a palpable abdominal mass since Jan 2010. Abdominal ultrasonography and abdominal computed tomography revealed a large tumor in the left lobe of the liver. Surgical exploration was undertaken and an extended left hepatectomy with extension onto the dorsal part of segment 8 preserving the MHV with partial resection of segment 6 was undertaken. The weight of the resected specimen was 1300 g of the left lobectomy specimen and 8 g of the segment 6 partial resection specimen. The pathology report confirmed the diagnosis of leiomyosarcoma. On immunohistochemistry, the tumor cells were positive for smooth muscle actin stain. The patient is on regular follow up and is currently 9 mo post resection with no evidence of recurrence. We report the case of a resected primary hepatic leiomyosarcoma and emphasize the need for a global database for these rare tumors to promote a better and broader understanding of this less understood subject.

Regular hepatic segmentectomy for giant hemangioma of the liver: An analysis of 26 cases

AIM: To evaluate the safety of regular hepatic segmentectomy for giant hemangioma of the liver.

METHODS: The clinical data for patients with giant hemangioma of the liver who underwent surgical resection between January 2008 and December 2010 in Nanjing Drum Tower Hospital were analyzed retrospectively.

RESULTS: A total of 26 patients were included in the study. All patients underwent regular hepatic segmentectomy. There were no deaths, but 4 patients developed complications. The intraoperative bleeding ranged from 100 to 2 600 mL (average, 775 mL ± 132 mL), and intraoperative blood transfusion ranged between 0 and 2 200 mL (average, 384 mL ± 123 mL).

CONCLUSION: Regular hepatic segmentectomy is safe in the management of giant hemangioma occupying the liver lobe or segment.

Hemihepatic versus total hepatic inflow occlusion during hepatectomy: A systematic review and meta-analysis

AIM: To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion (HHO) compared with total hepatic inflow occlusion (THO).

METHODS: Randomized controlled trials (RCTs) comparing hemihepatic vascular occlusion and total hepatic inflow occlusion were included by a systematic literature search. Two authors independently assessed the trials for inclusion and extracted the data. A meta-analysis was conducted to estimate blood loss, transfusion requirement, and liver injury based on the levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Either the fixed effects model or random effects model was used.

RESULTS: Four RCTs including 338 patients met the predefined inclusion criteria. A total of 167 patients were treated with THO and 171 with HHO. Meta-analysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean difference (WMD) 342.27; 95% confidence intervals (CI) 217.28-467.26; P = 0.00 001; I² = 16%. Meta-analysis showed no significant difference between THO group and HHO group on blood loss, transfusion requirement, mortality, morbidity, operating time, ischemic duration, hospital stay, ALT levels on postoperative day 1, 3 and 7 and AST levels on postoperative day 3 and 7.

CONCLUSION: Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection. However, they have less liver injury after liver resections.

Comparative analysis of radiofrequency ablation and surgical resection for colorectal liver metastases

Purpose

To evaluate the comparative therapeutic efficacy of radiofrequency ablation (RFA) and hepatic resection for the treatment of colorectal liver metastasis (CRLM).

Methods

Between 1996 and 2008, 177 patients underwent RFA, 278 underwent hepatic resection and 27 underwent combination therapy for CRLM. Comparative analysis of clinical outcomes was performed including number of liver metastases, tumor size, and time of CRLM.

Results

Based on multivariate analysis, overall survival (OS) correlated with the number of liver metastases and the use of combined chemotherapy (P < 0.001, respectively). Disease-free survival (DFS) also correlated with the number of liver metastases (P < 0.001). In the 226 patients with solitary CRLM < 3 cm, OS and DFS rates did not differ between the RFA group and the resection group (P = 0.962 and P = 0.980). In the 70 patients with solitary CRLM ≥ 3 cm, DFS was significantly lower in the RFA group as compared with the resection group (P = 0.015).

Conclusion

The results indicate that RFA may be a safe alternative treatment for solitary CRLM less than 3 cm, with outcomes equivalent to those achieved with hepatic resection. A randomized controlled study comparing RFA and resection for patients with single small metastasis would help to determine the most efficient treatment modalities for CRLM.

Outcome of Hepatectomy for Huge Hepatocellular Carcinoma

PURPOSE

In spite of the recent improved results of hepatectomy for huge hepatocellular carcinomas (HCC), the prognosis of patients with huge HCCs is still poor compared to that of patients with small HCCs. This study was performed to compare the results of hepatectomy between patients with huge HCCs and those with small HCCs, to identify the prognostic factors in patients with huge HCCs, and to determine the preoperative selection criteria.

METHODS

We retrospectively analyzed 51 patients who underwent hepatectomy, between July 1994 and February 2009 at Dankook University Hospital. Patients with HCC≥10 cm were classified in large (L) group and others were classified in small (S) group. The clinicopathological features, operative procedures, and postoperative outcome were compared between both groups and various prognostic factors were investigated in group L.

RESULTS

Eleven patients were classified in group L. Tumor size, vascular invasion, and tumor stage were higher in group L. Postoperative morbidity was higher in group L, but mortality was not different between the groups. Disease-free survivals were significantly lower in group L than in group S (36.4%, and 24.2% vs. 72.0%, and 44.0% for 1- and 3-year), but overall survival rates were similar in both groups (45.5%, and 15.2% in group L vs. 60.3%, and 41.3% in group S for 3- and 5-year). Presence of satellite nodules was the only prognostic factor in multivariate analysis after surgery for huge HCC.

CONCLUSION

Regardless of tumor size, huge HCCs deserve consideration for surgery in patients with preserved liver function. Furthermore, the effect of surgery could be maximized with appropriate selection criteria, such as huge HCC without satellite nodules.

Anatomical Variation of the Glissonean Pedicle of the Right Liver

PURPOSE

Many studies have been conducted to date regarding whether the right hepatic vein is the accurate border that divides the anterior and posterior section of the right liver. It has been reported that the Glisson pedicle of the right liver may be an anatomical variation that does not have a consistent morphology. We analyzed the relationship between the true borders of the anterior and posterior sections, and the right hepatic vein, based on cadaver dissection and MD-CT image analysis of the anatomical variation of the Glisson pedicle of the right liver.

METHODS

Sixteen cadaver livers were available for dissection from the Department of Anatomy, and pre-operative MD-CTs of 20 donor livers who underwent living donor liver transplantation prior to December 2009, were obtained. We analyzed the 3D-relationship between the branches of the Glisson pedicles and the right hepatic vein of the right liver. They were divided into 3 groups according to the sliding pattern of the branches of the Glisson pedicle origin. When all segmental branches of the anterior pedicle arise from the main trunk of the anterior pedicle and all branches of posterior pedicle arise from the main trunk of posterior pedicle, it was designated as Group A (Normal Group). When a portion of the segmental branches of the anterior pedicle arises from the main trunk of the posterior pedicle, it was designated as Group B (Posterior dominant group). When a portion of the branches of the posterior pedicle arises from the main trunk of the anterior pedicle, it was designated as Group C (Anterior dominant group).

RESULTS

Among the 16 cadaver liver dissections, 6 cases were in Group A, 5 in Group B, and 3 in Group C. Two cases were excluded from the study because the inferior right hepatic vein was the main draining vein of the right liver. The analysis of preoperative MD-CT of the 20 donor livers showed that there were 13, 4, and 3 patients in Groups A, B, and C, respectively.

CONCLUSION

According to Couinaud's theory of anatomy, the right hepatic vein serves as the border between the anterior and posterior sections of the right liver. But, due to the frequent anatomical variations, an adequate understanding of the anatomical variations of the right Glisson pedicle should be necessary for liver surgery.

Prospective randomized controlled trial investigating the type of sutures used during hepatectomy

AIM: To determine whether absorbable sutures or non-absorbable sutures are better in preventing surgical site infection (SSI), in this paper we discuss the results of a randomized clinical trial which examined the type of sutures used during hepatectomy.

METHODS: All hepatic resections performed from January 2007 to November 2008 at the Department of Surgery at Iizuka Hospital in Japan were included in this study. There were 125 patients randomly assigned to an absorbable sutures (Vicryl) group or non-absorbable sutures (Silk) group.

RESULTS: SSI was observed in 13.6% (17/125) patients participating in this study, 11.3% in the Vicryl group and 15.8% in the Silk group. Incisional SSI including superficial and deep SSI, was observed in 8% of the Vicryl group and 9.5% of the Silk group. Organ/space SSI was observed in 3.2% of the Vicryl group and 6.0% of the Silk group. There were no significant differences, but among the patients with SSI, the period for recovery was significantly shorter for the Vicryl group compared to the Silk group.

CONCLUSION: The incidence of SSI in patients receiving absorbable sutures and silk sutures is not significantly different in this randomized controlled study; however, the period for recovery in patients with SSI was significantly shorter for absorbable sutures.

Classification and management of bile duct injuries

To review the classification and general guidelines for treatment of bile duct injury patients and their long term results. In a 20-year period, 510 complex circumferential injuries have been referred to our team for repair at the Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” hospital in Mexico City and 198 elsewhere (private practice). The records at the third level Academic University Hospital were analyzed and divided into three periods of time: GI-1990-99 (33 cases), GII- 2000-2004 (139 cases) and GIII- 2004-2008 (140 cases). All patients were treated with a Roux en Y hepatojejunostomy. A decrease in using transanastomotic stents was observed (78% vs 2%, P = 0.0001). Partial segment IV and V resection was more frequently carried out (45% vs 75%, P = 0.2) (to obtain a high bilioenteric anastomosis). Operative mortality (3% vs 0.7%, P = 0.09), postoperative cholangitis (54% vs 13%, P = 0.0001), anastomosis strictures (30% vs 5%, P = 0.0001), short and long term complications and need for reoperation (surgical or radiological) (45% vs 11%, P = 0.0001) were significantly less in the last period. The authors concluded that transition to a high volume center has improved long term results for bile duct injury repair. Even interested and tertiary care centers have a learning curve.

Recurrent pyogenic cholangitis treated by left hepatectomy

Recurrent pyogenic cholangitis is managed mostly by conservative treatment or by clearance of stones and biliary enteric by-pass procedure. Hepatectomy is rarely needed. We report a case of recurrent pyogenic cholangitis in a 34-year old man, who presented with recurrent upper abdominal pain, mild jaundice, and fever since childhood. Contrast enhanced computed tomography of abdomen and magnetic resonance cholangiopancreatography confirmed the diagnosis and showed significant atrophy of the left lobe of the liver. Patient was treated successfully with left hepatectomy and was well at 9 month follow-up.

Hemi-hepatectomy in pediatric patients using two-surgeon technique and a liver hanging maneuver

AIM: To evaluate the efficacy of the two-surgeon technique with the liver hanging maneuver (LHM) for hepatectomies in pediatric patients with hepatoblastoma.

METHODS: Three pediatric patients with hepatoblastoma were enrolled in this study. Two underwent right hemi-hepatectomies and one underwent a left hemi-hepatectomy using the two-surgeon technique by means of saline-linked electric cautery (SLC) and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) and the LHM.

RESULTS: The mean operative time during the parenchymal transections was 50 min and the mean blood loss was 235 g. There was no bile leakage from the cut surface after surgery. No macroscopic or microscopic-positive margins were observed in the hepatic transections.

CONCLUSION: The two-surgeon technique using SLC and CUSA with the LHM is applicable to even pediatric patients with hepatoblastoma.

Surgical strategy for bile duct cancer: Advances and current limitations

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon’s ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud’s segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.

Hepatic veins as a site of clot formation following liver resection

Pulmonary embolism occurs more frequently after hepatectomy than previously thought but is infrequently associated with peripheral deep vein thrombosis. In this paper, we report 2 cases of postoperative hepatic vein thrombosis after liver resection. Both patients had undergone major hepatectomy of a non-cirrhotic liver largely exposing the middle hepatic vein. Clots were incidentally found in the middle hepatic vein 4 and 17 d after surgery despite routine systemic thrombo-prophylaxis with low molecular weight heparin. Coagulation of the transition plan in a context of mutation of the prothrombin gene and inflammation induced biloma were the likely predisposing conditions. Clots disappeared following curative anticoagulation. We conclude that thrombosis of hepatic veins may occur after liver resection and is a potential source of pulmonary embolism.

Simple and sure methodology for massive hepatectomy in the mouse

BACKGROUND

Reliable models for massive hepatectomy in the mouse are required for experimental liver research.

METHODS

We analyzed anatomical findings in 100 mice following massive hepatectomy induced by liver reduction >70%. The impact of various factors in the different models was also analyzed, including learning curves, operative time, survival curves and histopathological findings.

RESULTS

According to anatomical results, murine models with 75%, 80% and 90% of liver resection produced massive hepatectomy. Learning curves and operative times were most optimal with the clip technique. Each hepatectomy performed using the clip technique produced a reasonable survival curve, and there were no differences in histopathological findings between the suture and clip techniques.

CONCLUSION

Massive hepatectomy by the clip technique is simple and can provide reliable and relevant data.

Multiple cerebral infarction and paradoxical air embolism during hepatectomy using the Cavitron Ultrasonic Surgical Aspirator -A case report-

A venous air embolism and paradoxical air embolism (PAE) are serious complications in patients undergoing a hepatectomy. We report a case of PAE and cerebral infarctions in a patient undergoing a hepatic resection using a Cavitron Ultrasonic Surgical Aspirator (CUSA®). A 65-year-old woman underwent a left lobe hepatectomy. During the middle phase of the liver resection with CUSA®, there was a sudden decrease in arterial blood pressure, end-tidal carbon dioxide and SpO₂. With resuscitation, intraoperative ultrasonography revealed massive air emboli in both her left and right heart, which lasted for 40 min. The hepatectomy was completed after the disappearance of the air emboli from her heart. After surgery, her mental status was stuporous. The brain CT and MRI revealed multiple acute cerebral infarctions. Finally, she died from septic shock. This case highlights the need for anesthetists and surgeons to be aware of the potential for CUSA®-related massive PAE.

Hepatic organ protection: From basic science to clinical practice

Hepatic ischemia and reperfusion (I/R) injury during liver surgery is still the main cause of postoperative liver failure and the subsequent rise of mortality in these patients. During the last few years, a multitude of underlying mechanisms have been extensively characterized and many different protective approaches have been evaluated under experimental conditions. Some of them have already found their way into small sized clinical trials. In this Topic Highlight series of articles, we present recent insights into promising protective concepts including the regulation and optimization of hepatic blood flow, molecular mechanisms of preconditioning and pharmacological approaches with the aim of limiting hepatic I/R injury. Leading international experts present the latest experimental evidence in their fields stressing clinically relevant ideas, which are now on the edge of entering clinical practice.

Current protective strategies in liver surgery

During liver resection surgery for cancer or liver transplantation, the liver is subject to ischaemia (reduction in blood flow) followed by reperfusion (restoration of blood flow), which results in liver injury [ischemia-reperfusion (IR) or IR injury]. Modulation of IR injury can be achieved in various ways. These include hypothermia, ischaemic preconditioning (IPC) (brief cycles of ischaemia followed by reperfusion of the organ before the prolonged period of ischaemia i.e. a conditioning response), ischaemic postconditioning (conditioning after the prolonged period of ischaemia but before the reperfusion), pharmacological agents to decrease IR injury, genetic modulation of IR injury, and machine perfusion (pulsatile perfusion). Hypothermia decreases the metabolic functions and the oxygen consumption of organs. Static cold storage in University of Wisconsin solution reduces IR injury and has prolonged organ storage and improved the function of transplanted grafts. There is currently no evidence for any clinical advantage in the use of alternate solutions for static cold storage. Although experimental data from animal models suggest that IPC, ischaemic postconditioning, various pharmacological agents, gene therapy, and machine perfusion decrease IR injury, none of these interventions can be recommended in clinical practice. This is because of the lack of randomized controlled trials assessing the safety and efficacy of ischaemic postconditioning, gene therapy, and machine perfusion. Randomized controlled trials and systematic reviews of randomized controlled trials assessing the safety and efficacy of IPC and various pharmacological agents have demonstrated biochemical or histological improvements but this has not translated to clinical benefit. Further well designed randomized controlled trials are necessary to assess the various new protective strategies in liver resection.

Perioperative liver function in hepatectomy: evaluation and influencing factors

Hepatectomy is currently still the major treatment for hepatocellular carcinoma. Although hepatectomy has become safer because of progress made in surgical techniques, it is still frequently associated with the development of postoperative liver insufficiency. Therefore, investigation of factors influencing perioperative liver function in hepatectomy and intraoperative evaluation of residual liver function can help surgeons predict post-hepatectomy outcome and select appropriate postoperative rehabilitation treatment.

Huge immature teratoma of the liver in an adult: a case report and review of the literature

Teratoma tumors are tumors of childhood and, to the best of our knowledge, only 9 cases of hepatic teratoma and 1 case of immature teratoma of the liver had been reported in adults in the English literature. We present the second case of immature liver teratoma in a 22-year-old woman who presented with a 4-month history of abdominal pain and fullness sensation. A computed tomography (CT) scan of the abdomen and pelvis showed a huge well-defined heterogeneous mass in the right lobe of the liver containing fat, calcification, and cystic and solid parts, all suggestive of a teratoma. A right hepatectomy and an omentectomy were performed. The pathology report showed a 27 cm mass composed of ectodermal, mesodermal and endodermal components with minimal atypia and foci of immature components suggestive of immature teratoma, which is the largest liver teratoma to be reported. The patient was discharged in good health. During 8 months of follow-up, a CT scan and α-fetoprotein levels were both normal, and the patient is still alive.

Staging systems for predicting survival of patients with hepatocellular carcinoma after surgery

AIM: To compare the staging systems for stratifying and predicting the prognosis of patients with hepatocellular carcinoma (HCC) after partial hepatectomy (PH).

METHODS: Clinical data about 438 HCC patients who underwent PH from January 1991 to December 2004 at our hospital were retrospectively analyzed. Tumor stage was evaluated following the Chinese tumor node metastasis (TNM) and barcelona clinic liver cancer (BCLC) staging systems, respectively. Survival curves for the HCC patients were plotted using the Kaplan-Meier method and differences were compared by the log-rank test. The accuracy of each system for predicting death of HCC patients was evaluated by calculating the area under the receiver operating characteristic curve.

RESULTS: The HCC patients were classified into stages I-III, stages I-IV and stages A-C, according to the 3 staging systems, respectively. Log-rank test showed that the cumulative survival rate was significantly different for the HCC patients at 3 Chinese system stages, TNM stages I and II, TNM stages III and IV, and 3 BCLC stages (P < 0.05). However, no significant difference was found in the HCC patients at TNM stages II and III. The accuracy of the Chinese and BCLC staging systems was higher than that of the TNM staging system for predicting the survival rate of HCC patients.

CONCLUSION: The Chinese and BCLC staging systems are better for stratifying and predicting the prognosis of HCC patients after PH than the TNM staging system.

Evaluation of the effects of somatostatin on portal hemodynamics in rabbits after hepatectomy by color Doppler ultrasound

AIM: To investigate the value of color Doppler ultrasound in evaluating the effects of somatostatin on portal hemodynamics in rabbits after hepatectomy.

METHODS: Thirty-two rabbits were randomly divided into three groups: control group (n = 6), normal saline group (n = 13), somatostatin group (n = 13). The normal saline group and somatostatin group underwent 50% hepatectomy, while the control group underwent a sham operation. Color Doppler ultrasound was then used to measure and compare various portal vein hemodynamic parameters, including flow direction, diameter, hemokinetic velocity, average flow rate, and blood flow volume, among each group.

RESULTS: There were no significant differences in portal diameter and hemokinetic velocity among all the three groups before and after the surgery (all P > 0.05). However, the average flow rate and blood flow volume were significant lower in the somatostatin group than in the control group and normal saline group (all P < 0.05).

CONCLUSION: Application of somatostatin early after hepatectomy may reduce the flow rate and blood flow volume in the portal vein, which may be the cause that somatostatin reduces elevated portal pressure. Color Doppler ultrasound is effective in evaluating the effects of somatostatin on portal hemodynamics in rabbits after hepatectomy.

Regeneration and DNA demethylation do not trigger PDX-1 expression in rat hepatocytes

AIM: To explore the possibility that PDX-1 gene is reactivated as a consequence of molecular events that occur during liver regeneration.

METHODS: Rat hepatocytes were maintained in DMEM-F12, 10% fetal bovine serum (FBS), penicillin/streptomycin and geneticin when applicable. Rat insulinoma RIN 1046-38 cells were maintained in M-199-10% FBS and penicillin/streptomycin. The final concentration of glucose was 11.1 mmol/L. During regeneration, lateral and medial liver lobes of adult male Wistar rats were surgically removed, with up 70% loss of liver mass. In methylation experiments, 5-aza-deoxycytidine (5-aza-dC) was used. Primer3 software was used for polymerase chain reaction (PCR). Quantitative real time PCR (qRT-PCR) was performed using SYBR Green technology; primers were designed by Beacon Designer 6 software. Western blotting and SDS-PAGE were performed according to standard procedures. Antibodies were purchased from commercial suppliers.

RESULTS: We explored the possibility that liver regeneration could trigger PDX-1 expression, and hence insulin production. Twenty-four hours after surgical liver removal, regeneration was active as demonstrated by the increased proliferating cell nuclear antigen; however, all the other checked genes (involved in insulin gene expression): PC-1, Ngn3, NeuroD1, Btc, PDX-1 and Ins-1, were not related to the molecular events caused by this process. The only marker detected in regenerating liver was E47: a transcription factor of the the basic helix-loop-helix family known to be expressed ubiquitously in mammalian cells. In the rat pancreas, almost all of the tested genes were expressed as shown by RT-PCR, except for Ngn3, which was silenced 2 d after birth. Therefore, the molecular events in liver regeneration are not sufficient to promote PDX-1 expression. DNA methylation is a known mechanism to achieve stable repression of gene expression in mammals: Hxk 2 gene is silenced through this mechanism in normal hepatocytes. The administration of 5-aza-dC to cultured cells is in fact able to upregulate Hxk 2 mRNA. We investigated whether PDX-1 silencing in liver cells could be exerted through methylation of CpG islands in both the promoter and the gene coding regions. The results show that the drug increased the expression level of the Hxk 2 control gene but failed to rescue the expression of PDX-1, thus DNA demethylation is not sufficient to override repression of the PDX-1 gene.

CONCLUSION: During liver regeneration, PDX-1 gene is not reactivated. Demethylation does not de-repress PDX-1 gene expression. Therefore gene silencing is not achieved through this epigenetic mechanism.

Rational therapeutic strategy for T2 gallbladder carcinoma based on tumor spread

AIM: To evaluate the adequacy of surgical treatment of T2 gallbladder carcinoma (GBCa) according to tumor spread in the subserosal layer.

METHODS: A series of 84 patients with GBCa were treated at Saga University Hospital, Japan between April 1989 and October 2008. The tumor stage was graded according to the TNM staging for GBCa from the American Joint Committee on Cancer Manual 6th edition. Tumor staging revealed 30 patients with T2 tumors. T2 GBCa was divided into three groups histologically by the extent of tumor spread in the subserosal layer, using a score of ss minimum (ss min), ss medium (ss med) or ss massive (ss mas).

RESULTS: For ss min GBCa, there was no positive pathological factor and patient survival was satisfactory with simple cholecystectomy, with or without extra-hepatic bile duct resection. For ss med GBCa, some pathological factors, h-inf (hepatic infiltration), ly (lymphatic invasion) and n (lymph node metastasis), were positive. For ss mas GBCa, there was a high incidence of positive pathological factors. The patient group with extra-hepatic bile duct resection with D2 lymph node dissection (BDR with D2) and those with S4a5 hepatectomy had significantly better survival rates.

CONCLUSION: We suggest that radical surgery is not necessary for ss min GBCa, and partial hepatectomy and BDR are necessary for both ss med and ss mas GBCa.

Radiofrequency ablation in the treatment of small hepatocellular carcinoma: A meta analysis

AIM: To evaluate survival and recurrence after radiofrequency ablation (RFA) for the treatment of small hepatocellular carcinoma (HCC) using a meta-analysis.

METHODS: Literature on RFA vs surgical resection for the treatment of small HCC published between January 1990 and December 2008 was retrieved. A meta-analysis was conducted to estimate pooled survival and recurrence ratios. A fixed or random effect model was established to collect the data.

RESULTS: The differences in overall survival at 1-year, 3-years and at end of follow-up were not statistically significant between the RFA and surgery groups (P > 0.05). There were no differences in 1-year and 3-year recurrences between the RFA and surgery groups (P > 0.05). However, recurrence in the RFA group was lower than that in the surgery group up to the end of follow-up (P = 0.03). Survival was not significantly different. There was a significant difference in recurrences at the end of follow-up after RFA compared with surgical resection.

CONCLUSION: RFA did not decrease the number of overall recurrences, and had no effect on survival when compared with surgical resection in a selected group of patients.

Total laparoscopic anatomical hepatectomy for primary liver cancer: a report of 16 cases

AIM: To evaluate the efficacy and safety of total laparoscopic anatomical hepatectomy in the management of primary liver cancer.

METHODS: The clinical data for 16 primary liver cancer patients who underwent total laparoscopic anatomical hepatectomy were analyzed retrospectively.

RESULTS: The operation was successful in all the 16 patients, including 5 undergoing total laparoscopic anatomical left hemihepatectomy and 11 undergoing total laparoscopic anatomical left lateral sectionectomy. The operation time ranged from 90-125 min and the intraoperative blood loss from 50-400 mL. The mean postoperative hospitalization was 7.7 d. No complications occurred in all cases.

CONCLUSION: Total laparoscopic anatomical hepatectomy is a safe and effective treatment for primary liver cancer.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM: To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS: From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS: LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 ± 43 min vs 132 ± 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 ± 2.8 d vs 10.2 ± 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 ± 56 mL vs 184 ± 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION: LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

A case of intrahepatic clear cell cholangiocarcinoma

Intrahepatic clear cell cholangiocarcinoma is very rare - only 8 cases have been reported. A 56-year-old Japanese man with chronic hepatitis B infection was diagnosed with a 2.2 cm hepatocellular carcinoma on imaging, and hepatic segmentectomy was performed. Histopathologically, the tumor cells had copious clear cytoplasm and formed glandular structures or solid nests. These pathological findings suggested the tumor was a clear cell variant of intrahepatic cholangiocarcinoma. Particular stains and radiological images suggested that the cause of the clear cell change had been glycogen, not mucin nor lipid. On immunohistochemical staining, cytokeratin (CK) 7 and CK19 were positive, whereas CK20 was negative. Vimentin was detected on the cell membranes, and CD56 was focally positive. The patient was given adjuvant chemotherapy and is currently free from the tumor 7 mo postoperatively. Careful follow-up with adequate postoperative supplementary chemotherapy is necessary because the characteristics of this type of tumor are unknown.

Role of radiofrequency ablation in the treatment of small hepatocellular carcinoma

Radiofrequency ablation (RFA), one of the most advanced loco-regional ablative therapeutic methods, is widely utilized in the treatment of hepatocellular carcinoma (HCC). Because of its minimal invasiveness and high efficacy, RFA has been regarded as a curative therapy as alternative to surgical resection and liver transplantation. It brings new hope and a new treatment pattern for small HCC. In this article, we summarize the important role of RFA in the treatment of small HCC according to our clinical experience over six years. The prognosis of small HCC after RFA is comparable to that of surgical resection but with higher safety, less complications, wider applicability, and good long-term survival. RFA will play a more and more important role in the clinical treatment of small HCC.

Concurrent and subsequent radiofrequency ablation combined with hepatectomy for hepatocellular carcinomas

Partial hepatectomy has long been the standard treatment modality for patients with hepatocellular carcinoma (HCC), although the majority of patients with HCCs are not candidates for curative resection. Radiofrequency ablation (RFA) has been widely used as the preferred locoregional therapy. RFA and hepatectomy can be complementary to each other for the treatment of multifocal HCCs. Combining hepatectomy with RFA permits the removal of larger tumors while simultaneously ablating any smaller residual tumors. By using this combination treatment, more patients might become candidates for curative resection. For treating recurrent tumors involving the liver after hepatectomy, RFA has been performed recently instead of transcatheter arterial chemoembolization or ethanol ablation. Many retrospective studies on the combination of RFA and hepatectomy demonstrate favorable results of effectiveness and safety. However, further investigation of prospective design will be needed to confirm these encouraging results.

Granulocyte colony-stimulating factor promotes liver regeneration in mice

AIM: To investigate the effect of granulocyte colony-stimulating factor (G-CSF) on liver regeneration after major hepatectomy in mice.

METHODS: Mice were subjected to 70% hepatectomy and randomly divided into three groups: control group (intraperitoneally injected with normal saline 24 h after hepatectomy, once a day for 5 d), G-CSF pretreatment group [intraperitoneally injected with recombinant human G-CSF (rhG-CSF) at 150 μg/kg body weight daily for 5 d and underwent hepatectomy 24 h later], and G-CSF treatment group (intraperitoneally injected with rhG-CSF 24 h after hepatectomy, at 150 μg/kg body weight daily for 5 d). Serum and hepatic tissue samples were harvested seven days after hepatectomy. Liver function parameters were measured using an automated biochemical analyzer. Immunohistochemistry was used to detect the expression of proliferating cell nuclear antigen (PCNA) and bromodeoxyuridine (BrdU)-positive cells.

RESULTS: The percentages of PCNA- and BrdU-positive cells in the G- CSF pretreatment and treatment groups were significantly higher than those in the control group (PCNA: 74.08% ± 8.86% and 68.91% ± 9.64% vs 57.36% ± 13.37%, respectively; both P < 0.05). Inflammatory response was noted in 27% (3/11) of mice in the G-CSF pretreatment group. Serum ALT and AST levels were significantly higher in the G-CSF pretreatment group than in the other two groups (both P < 0.05).

CONCLUSION: G-CSF promotes liver regeneration after major hepatectomy in mice, but G-CSF pretreatment induces infammatory response.

Skeletal muscle-derived stem cells differentiate into hepatocyte-like cells and aid in liver regeneration

The liver is unique for its ability to regenerate after injury, however, critical injuries or disease cause it to lose this quality. Stem cells have been explored as a possibility to restore the function of seriously damaged livers, based on their self-renewability and multiple differentiation capacity. These experiments examine the ability of muscle derived stem cells (MDSCs) to differentiate into hepatocyte-like cells in vitro and acquire functional liver attributes for repairing damaged livers. In vitro experiments were performed using MDSCs from postnatal mice and mouse hepatocyte cell lines. Our data revealed that MDSCs differentiated into hepatocyte-like cells and expressed liver cell markers, albumin, hepatocyte nuclear factor 4 α, and alpha feto-protein, both at the RNA and protein level. Additionally, in vivo studies showed successful engraftment of MDSCs into hepatectomized mouse livers of mice. These results provide evidence suggesting that MDSCs have the capacity to differentiate into liver cell-like cells and may serve as potential candidates to aid in liver regeneration.

Prognostic factors in the surgical treatment of caudate lobe hepatocellular carcinoma

AIM: To evaluate the short- and long-term outcomes of liver resection for caudate lobe hepatocellular carcinoma (HCC).

METHODS: We retrospectively analyzed 114 consecutive patients with HCC, originating from the caudate lobe, who underwent resection between January 2001 and January 2007. Univariate and multivariate analyses were performed on several clinicopathologic variables to determine the factors affecting long-term outcome and intrahepatic recurrence.

RESULTS: Overall mortality and morbidity were 0% and 18%, respectively. After a median follow-up of 31 mo (interquartile range, 11-66 mo), tumor recurrence had occurred in 76 patients (66.7%). The 1-, 3-, and 5-year disease-free survival rates were 65.7%, 38.1%, and 18.4%, respectively. The 1-, 3-, and 5-year overall survival rates were 76.1%, 54.7%, and 31.8%, respectively. Univariate analysis showed that subsegmental location of the tumor (45.7% vs 16.2%, P = 0.01), liver cirrhosis (12.3% vs 47.9%, P = 0.03), surgical margin (18.5% vs 54.6%, P = 0.04), vascular invasion (37.9% vs 23.2%, P = 0.04) and extended caudate resection (42.1% vs 15.4%, P = 0.04) were related to poorer long-term survival. Multivariate analysis showed that only subsegmental location of the tumor, liver cirrhosis and surgical margin were significant independent prognostic factors.

CONCLUSION: Hepatectomy was an effective treatment for HCC in the caudate lobe. The subsegmental location of the tumor, liver cirrhosis and surgical margin affected long-term survival.

Therapy and prognostic features of primary clear cell carcinoma of the liver

AIM: To clarify the therapeutic strategies and prognosis factors of primary clear cell carcinoma of the liver (PCCCL).

METHODS: The clinical pathological data of 64 patients with PCCCL treated with hepatectomy in our hospital from January 2000 to January 2006 were analyzed retrospectively. The patients were divided into two groups to make treatment analysis: curative resection only (n = 40); and curative resection and postoperative chemotherapy with calcium folinate and tegafur (n = 24). Meanwhile, the PCCCL patients were subdivided into two subgroups on the basis of the proportion of clear cells in the tumor for pathological analysis. There were 36 cases in subgroup A for which the proportion of clear cells was more than 70%, and 28 cases in subgroup B for which the proportion was less or equal to 70%, comparing analysis of median survival time of the counterpart groups. Univariate and multivariate analyses were performed to examine factors that affected clinical prognosis, recurrence and metastasis.

RESULTS: Median survival period of the curative surgery group was 38 mo, while the counterpart was 41 mo. Median survival period for group A was 41 mo, while group B was 19 mo. The Kaplan-Meier method showed that capsule formation, preoperative liver function, hepatitis C virus infection, large vascular invasion and multiple tumor occurrences were related to disease-free survival. Cox regression analysis showed that the clear cell ratio, capsule formation, preoperative liver function and large vascular invasion were independent risk factors for overall survival.

CONCLUSION: Postoperative chemotherapy has no obvious effect on survival of patients with PCCCL. Clear cell ratio, capsule formation, preoperative liver function, and vascular invasion were independent risk factors for prognosis.

Type IVa choledochal cyst: Results following haemihepatectomy and mucosectomy of intrahepatic cyst

Choledochal cyst is a rare condition characterised by congenital dilatation of the biliary tree. Commonly seen in the oriental countries, patients usually present with a varying combination of abdominal pain, jaundice, lump or cholangitis. Untreated patients or incomplete removal of the cysts usually leads to portal hypertension and cholangiocarcinoma. Almost one-third of the cases have intrahepatic cyst, making complete cyst excision often impossible. We are reporting a 9-year-old girl with type IVa choledochal cyst presented to us with recurrent pain abdomen and intermittent jaundice for 1 year. Excision of extrahepatic cyst, left hepatectomy, mucosectomy of the residual cyst wall of right lobe of the liver and a wide bilioenteric anastomosis was done. Patients followed up with an magnetic resonance cholangiopancreatography (MRCP) 2 months later showed shrinkage of the residual cyst and good bile drainage. Mucosectomy of intrahepatic cyst may prevent recurrent cholangitis, calculus formation and cholangiocarcinoma in the long run.

Outcomes for patients following hepatic resection of metastatic tumors from gastric cancer

PURPOSE

Although several studies have reported the efficacy of hepatic resection for the long-term survival of patients with gastric cancer metastases, the optimal treatment remains to be determined.

METHODS

Seventeen patients underwent a hepatic resection for gastric cancer metastases at the National Defense Medical College Hospital. We retrospectively analyzed the clinical outcomes of surgical resection and identified factors associated with prognosis for patients who underwent hepatectomy for gastric cancer metastases.

RESULTS

In 17 patients, the accumulated 5-year survival rate after hepatic resection was 31.5% and the median survival time was 34 months. Univariate and multivariate analyses showed that gastric tumors less than 6.0 cm and D2 lymphadenectomy were the most important predictors of survival. The five patients who survived more than 5 years after hepatic resection had a D2 lymphadenectomy, modest lymphatic invasion, primary gastric tumors less than 6.0 cm, and a solitary liver metastasis.

CONCLUSION

Although recent progress in adjuvant therapy should be the key to a good prognosis, we believe that surgical resection may bring some hope of long-term survival for judiciously selected patients with hepatic metastases from gastric cancer.

A case of laparoscopic hepatectomy for recurrent hepatocellular carcinoma

Conventional hepatectomy is an effective way to treat hepatocellular carcinoma. However, it is invasive and stressful. The use of laparoscopy in hepatectomy, while technically demanding, reduces surgical invasiveness and stressfulness but still achieves complete resection with adequate margins. Compared with conventional hepatectomy, laparoscopic hepatectomy provides a better chance and situation for further surgery in the case of recurrence of hepatocellular carcinoma. Even aged patients can successfully endure repeated hepatectomy using laparoscopy, as shown in the present report. This report presents a case of repeated laparoscopic hepatectomy treating hepatocellular carcinoma and its recurrence in an aged patient having cirrhosis, a disease causing extra difficulty for performing laparoscopic hepatectomy. The report also describes techniques of the operation and displays characteristic results of laparoscopic hepatectomy such as smaller wounds, less blood loss, less pain, less scars and adhesion, shorter postoperative hospital stay, and faster recovery.

Total laparoscopic liver resection in 78 patients

AIM: To summarize the clinical experience of laparoscopic hepatectomy at a single center.

METHODS: Between November 2003 and March 2009, 78 patients with hepatocellular carcinoma (n = 39), metastatic liver carcinoma (n = 10), and benign liver neoplasms (n = 29) underwent laparoscopic hepatectomy in our unit. A retrospective analysis was done on the clinical outcomes of the 78 patients.

RESULTS: The lesions were located in segments I (n = 3), II (n = 16), III (n = 24), IV (n = 11), V (n = 11), VI (n = 9), and VIII (n = 4). The lesion sizes ranged from 0.8 to 15 cm. The number of lesions was three (n = 4), two (n = 8) and one (n = 66) in the study cohort. The surgical procedures included left hemi-hepatectomy (n = 7), left lateral lobectomy (n = 14), segmentectomy (n = 11), local resection (n = 39), and resection of metastatic liver lesions during laparoscopic surgery for rectal cancer (n = 7). Laparoscopic liver resection was successful in all patients, with no conversion to open procedures. Only four patients received blood transfusion (400-800 mL). There were no perioperative complications, such as bleeding and biliary leakage. The liver function of all patients recovered within 1 wk, and no liver failure occurred.

CONCLUSION: Laparoscopic hepatectomy is a safe and feasible operation with minimal surgical trauma. It should be performed by a surgeon with sufficient experience in open hepatic resection and who is proficient in laparoscopy.

Liver transplantation for polycystic liver with massive hepatomegaly: A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease. Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008. The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack). Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and finally, right hepatectomy was performed. OLT was performed successfully. The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed first during OLT if the liver is over enlarged.

Bilateral liver resection for bilateral intrahepatic stones

AIM: To evaluate the short- and long-term outcomes of bilateral liver resection for bilateral intrahepatic stones.

METHODS: We reviewed retrospectively 101 consecutive patients with bilateral intrahepatic stones who underwent bilateral liver resection in the past 10 years. The short- and long-term outcomes of the patients were analyzed. The Cox proportional hazards model was used to identify the risk factors related to stone recurrence.

RESULTS: There was no surgical mortality in this group of patients. The surgical morbidity was 28.7%. Stone clearance rate after hepatectomy was 84.2% and final clearance rate was 95.0% following postoperative choledochoscopic lithotripsy. The stone recurrence rate was 7.9% and the occurrence of postoperative cholangitis was 6.5% in a median follow-up period of 54 mo. The Cox proportional hazards model indicated that liver resection range, less than the range of stone distribution (P = 0.015, OR = 2.152) was an independent risk factor linked to stone recurrence.

CONCLUSION: Bilateral liver resection is safe and its short- and long-term outcomes are satisfactory for bilateral intrahepatic stones.

Effects of somatostatin on portal vein hemodynamics in the early stage after hepatectomy

AIM: To investigate the effects of somatostatin on portal vein hemodynamics in the early stage after hepatectomy and explore the mechanism under such effects.

METHODS: Thirty-two rabbits were randomly divided into three groups: group A (n = 6, control group), group B (n = 13, normal saline treatment group) and group C (n = 13, somatostatin treatment group). Rabbits in all three groups underwent portal vein catheterization, while only those in Groups B and C underwent 50% partial hepatectomy. An intraoperative and postoperative intravenous infusion of normal saline and somatostatin was given. Before and after the treatment (0.5, 1, 2 h), the pressure, flow direction, diameter, hemokinetic velocity, average flow rate and blood flow of the portal vein were detected and compared.

RESULTS: After hepatectomy, the portal pressure increased. The increase in the portal pressure in group B was significantly higher than that in group C (0.5 h: 436.001 ± 169.654 Pa vs 258.012 ± 167.497 Pa, P < 0.05; 1 h: 394.324 ± 163.182 Pa vs 224.767 ± 164.653 Pa, P < 0.05; 2 h: 193.092 ± 154.356 Pa vs 351.861 ± 183.579 Pa, P < 0.05). There were no significant differences in portal diameter and hemokinetic velocity among all the three groups before and after treatment (P > 0.05). However, the average flow rate and blood flow of the portal vein in group C were significant lower than those in groups A and B (both P < 0.05). Two hours after hepatectomy, no significant differences in the expression of ALT and AST were noted between groups A and B.

CONCLUSION: Application of somatostatin in the early stage of hepatectomy may reduce elevated portal pressure, which may be associated with somatostatin-induced decrease in flow rate and blood flow of the portal vein.

Prognosis of hepatocellular carcinoma accompanied by microscopic portal vein invasion

AIM: To investigate the prognostic factors in patients with hepatocellular carcinoma (HCC) accompanied by microscopic portal vein invasion (PVI).

METHODS: Of the 267 patients with HCC undergoing hepatic resection at Aso Iizuka Hospital, 71 had PVI. After excluding 16 patients with HCC that invaded the main trunk and the first and second branches of the portal vein, 55 patients with microscopic PVI were enrolled.

RESULTS: The patients with HCC accompanied by microscopic invasion were divided into two groups: solitary PVI (PVI-S: n = 44), and multiple PVIs (PVI-M: n = 11). The number of portal vein branches invaded by tumor thrombi was 5.4 ± 3.8 (2-16) in patients with PVI-M. In cumulative survival, PVI-M was found to be a significantly poor prognostic factor (P = 0.0019); while PVI-M and non-anatomical resection were significantly poor prognostic factors in disease-free survival (P = 0.0213, and 0.0115, respectively). In patients with PVI-M, multiple intrahepatic recurrence was more common than in the patients with PVI-S (P = 0.0049). In patients with PVI-S, non-anatomical resection was a significantly poor prognostic factor in disease-free survival (P = 0.0370). Operative procedure was not a significant prognostic factor in patients with PVI-M.

CONCLUSION: The presence of PVI-M was a poor prognostic factor in patients with HCC, accompanied by microscopic PVI. Anatomical resection is recommended in these patients with HCC. Patients with HCC and PVI-M may also be good candidates for adjuvant chemotherapy.

Estimating glomerular filtration rate preoperatively for patients undergoing hepatectomy

AIM: To compare creatinine clearance (Ccr) with estimated glomerular filtration rate (eGFR) in preoperative renal function tests in patients undergoing hepatectomy.

METHODS: The records of 197 patients undergoing hepatectomy between August 2006 and August 2008 were studied, and preoperative Ccr, a three-variable equation for eGFR (eGFR3) and a five-variable equation for eGFR (eGFR5) were calculated. Abnormal values were defined as Ccr < 50 mL/min, eGFR3 and eGFR5 < 60 mL/min per 1.73 m². The maximum increases in the postoperative serum creatinine (post Cr) level and postoperative rate of increase in the serum Cr level (post Cr rate) were compared.

RESULTS: There were 37 patients (18.8%) with abnormal Ccr, 31 (15.7%) with abnormal eGFR3, and 40 (20.3%) with abnormal eGFR5. Although there were no significant differences in the post Cr rate between patients with normal and abnormal Ccr, eGFR3 and eGFR5 values, the post Cr level was significantly higher in patients with eGFR3 and eGFR5 abnormality than in normal patients (P < 0.0001). Post Cr level tended to be higher in patients with Ccr abnormality (P = 0.0936 and P = 0.0875, respectively).

CONCLUSION: eGFR5 and the simpler eGFR3, rather than Ccr, are recommended as a preoperative renal function test in patients undergoing hepatectomy.