Usefulness of prophylactic transcatheter arterial infusion of anticancer agents with lipiodol to prevent recurrence of hepatocellular carcinoma after hepatic resection

To improve the prognosis after hepatectomy for HCC, repeated postoperative transcatheter arterial infusions of anticancer drugs and lipiodol (TAI) were given. TAI may be effective as an adjuvant therapy for prevention of residual liver recurrence after hepatectomy, probably by suppression of the development of intrahepatic micrometastases rather than of multicentric carcinogenesis.

The role of median sternotomy in resections for large hepatocellular carcinomas

BACKGROUND

The aim of this study was to identify the role of median sternotomy in the hepatic resection of large hepatocellular carcinomas (HCCs).

METHODS

From 1992 to 2002, 26 patients who underwent hepatectomy for large HCCs greater than 10 cm in diameter were divided into 2 groups according to the type of incision performed: with median sternotomy (10 patients) or without median sternotomy (16 patients).

RESULTS

Median sternotomy was performed for 3 patients with tumor thrombus extending into the right atrium and for 7 patients with inadequate exposure of the hepatic veins and suprahepatic vena cava. In these 7 cases, the tumors were located mainly at the upper part of the right lobe in 4 patients and the upper part of the left lobe in 3 patients. Median sternotomy was performed in 6 of 7 patients whose tumor was located in segments 2, 4, 7, and 8, and was greater than 16 cm. No significant differences were found in the intraoperative parameters of blood transfusion, ischemic time, area of the cut surface, and operation time.

CONCLUSIONS

Median sternotomy may be suitable for use as an approach for large HCCs greater than 16 cm, which are located at the upper part of the liver.

Middle hepatic vein tributary reconstruction could not act as a complete substitute for an entirely preserved middle hepatic vein

BACKGROUND/AIMS

The necessity of the middle hepatic vein for living donor liver transplantation using right lobe graft is still controversial.

METHODOLOGY

We reviewed 7 long-term surviving right-lobe recipients in whom middle hepatic vein tributaries were not reconstructed (group A, n=4) or were reconstructed (group B, n=3). Volume regeneration of the right paramedian (segments V+VIII) and right lateral (segments VI+VII) sectors was assessed by computed tomography at 3, 6, 9, and 12 postoperative months. The right paramedian sector was further subdivided into the ventral portion in relation to the anterior branch of the right portal vein and dorsal portion.

RESULTS

The volume regeneration ratio was significantly lower in group A than in group B persistently after 6 postoperative months in regard to the right paramedian sector, the dorsal portion, and especially the ventral portion (0.64 +/- 0.19 vs. 1.22 +/- 0.17, p=0.034, 12 postoperative months). However, volume regeneration was impaired in the ventral portion as compared to other areas in group B.

CONCLUSIONS

In conclusion, middle hepatic vein tributary reconstruction improves the volume regeneration of the right paramedian sector in right lobe living donor liver transplantation However, it could not act as a complete substitute for an entirely preserved middle hepatic vein.

Antibody-Mediated Rejection after Adult ABO-Incompatible Liver Transplantation Remedied by Gamma-Globulin Bolus Infusion Combined with Plasmapheresis

Adult ABO-incompatible liver transplantation has been known to be associated with markedly desperate outcomes. Antibody-mediated rejection (AMR) has been recognized as one of the primary causes of these desperate outcomes, but its clinical features and significance have not been well understood. Recently, some clinicians have succeeded in improving the outcome of adult ABO-incompatible liver transplantation. However, in some transplant patients undergoing these treatments, AMR has still led to graft losses. We recently encountered two patients suffering from AMR after adult ABO-incompatible liver transplantation and remedied their conditions with various therapeutic modalities including direct hepatic infusion therapy and gamma-globulin bolus infusion therapy combined with plasmapheresis. In this article, we describe the clinical features of these patients and the therapeutic strategies we applied. Furthermore, we show the histologic course of the recovery from AMR in the second patient, from whom we were able to extract serial liver biopsies.

Usefulness of the prognostic score for donor safety in living donor liver transplantation

This study sought to determine whether a prognostic score is a useful indicator of donor safety using 13 consecutive donors enrolled for liver transplantation. The donor operations were right hepatic lobectomies (n = 10) and left hepatic lobectomies (n = 3). The postoperative maximal level of serum total bilirubin was used to assess the magnitude of surgical stress. Variables such as donor age, percentage of liver resection (PLR), indocyanine green 15-minute retention rate (ICGR15), operative blood loss, operation time, prognostic score and graft weight were evaluated as predictors of the magnitude of surgical stress. The PLR and prognostic score (PS) were calculated according to the following formulae: PLR (%) = 100*Graft weight (g)/standard liver volume of the donor (mL); PS = -84.6 + 0.933*PLR (%) +1.11*ICGR15 (%) +0.999*age (years); Standard liver volume (mL) = 706.2*body surface area (m2) + 2.39. No serious complications occurred after the donor operations. Maximal bilirubin ranged from 1.9 to 10.9 mg/dL. There were no mortalities, although there were two morbidities, bile leakage and prolonged liver dysfunction. Postoperative hyperbilirubinemia was observed in two donors and in one Gilbert's syndrome donor. Linear regression analysis of each variable indicated poor correlations between those variables and maximal bilirubin. However, close correlations were seen between maximal bilirubin and both donor age and PS except for the three patients who showed postoperative hyperbilirubinemia. In these uneventful donors, statistical formulae were obtained as follows: maximal bilirubin (PMB) = 0.271 + 0.056*donor age (correlation coefficient 0.612, P < .008), PMB = 1.541 + 0.059*PS (correlation coefficient 0.597, P < .009). In conclusion, PS is useful to predict maximal bilirubin and to ensure donor safety.

Surveillance of perioperative infections after adult living donor liver transplantation

AIM

This study was conducted to clarify the management of perioperative infectious complications after adult living donor liver transplantation (LDLT).

PATIENTS AND METHODS

Fourteen adult LDLT patients were enrolled in this study. We examined the occurrence of infectious complications in these cases and the relationships of infectious complications to UNOS status and MELD score. Surveillance culture and immunoserologic analyses were performed. From the results of these analyses, we made a diagram of infection surveillance using a matrix of time and sampling site. Using the diagram, we chose sensitive antibiotics as soon as possible.

RESULTS

The infection site and its pathogen were able to be detected in four (28.5%) patients, all of whom had MRSA infections, together with lung aspergillosis in one case, pseudomonas pneumonia in another, and both in another. Two patients died of lung aspergillosis. Bacteria detected in the airway tended to spread to other sites during the postoperative period. In all four patients in whom infectious diseases were detected, and in a fifth patient in whom the site of infection was not known, the UNOS status was 1. The MELD score was calculated in eight patients, six of whom had high MELD scores (>20).

CONCLUSION

Most cases were manageable by choosing and changing antibiotics and antifungal drugs according to the results of surveillance cultures twice a week. However, aspergillosis had an extremely poor prognosis. Patients with a high MELD score or low UNOS status, or both, showed poor prognosis; and in them, multiple drug resistance bacteria caused severe perioperative infectious complications.

Indications for hepatic vein reconstruction in living donor liver transplantation of right liver grafts

BACKGROUND

To overcome problems arising from a graft of insufficient size, right liver grafts have been used extensively for adult-to-adult living donor liver transplantation (LDLT). However, there are reports of severe congestion in the anterior segment of the graft after transplantation.

CASE REPORTS

Right liver transplantation without the middle hepatic vein was performed in six cases. In the second and third cases, the inferior right hepatic vein was reconstructed because it was thick (whereas the middle hepatic vein was not). Abdominal CT revealed congestive infarction of the anterior segment in the second case and of the posterior segment in the third. It was suspected that the former resulted from the lack of an middle hepatic vein, and the latter from obstruction of the reconstructed inferior right hepatic vein. Both patients died without improvement in liver function. Accordingly, in the fifth case, the middle hepatic vein was reconstructed. The postoperative course of this case was uneventful. Doppler ultrasonography showed profuse blood flow in the interposition graft. In the sixth case, the middle hepatic vein was not reconstructed because of technical difficulties. Although abdominal CT showed a congestive area in the anterior segment, the patient recovered uneventfully, probably because the volume of functional graft was sufficient even without the congestive area.

CONCLUSION

When the color becomes dark in more than half of the surface of the anterior segment following clamping of middle hepatic vein tributaries and the hepatic artery, the middle hepatic vein should be reconstructed. When the diameter of the inferior right hepatic vein is more than 5 mm, its reconstruction is also recommended.

Remaining caudate lobe in the right lobe graft in living donor liver transplantation: a blind spot?

The right margin of the caudate lobe is obscure. Therefore, a part of the caudate lobe (a part of the right side of the paracaval portion) seems almost always to remain with the right lobe graft during the standard harvesting procedure. We reviewed the intraoperative findings and the postoperative courses of donors and recipients of 11 consecutive living donor liver transplantations using right lobe grafts. Further, we used computed tomography during the postoperative course to investigate whether the remaining caudate lobe was present in the right lobe graft and whether it produced serious complications. Four recipients displayed an intraoperative bile leak from a remaining part of the caudate lobe after the completion of biliary reconstruction. With the exception of one case who developed repeated bile leakage from the same origin which eventually healed during a long-term postoperative course, Most recipients showed no postoperative biliary complications. Although a remaining caudate lobe was detected on postoperative computed tomography in all recipients, it produced no serious complications. In conclusion, a part of the right side of the paracaval portion of the caudate lobe almost always remains with a right lobe graft during the standard harvesting procedure. However, the implications of this phenomenon seem to be benign.

Microscopic liver metastasis: prognostic factor for patients with pT2 gallbladder carcinoma

Hepatic metastasis is the most frequent mode of recurrence of advanced gallbladder cancer after radical resection. The aims of this study were to clarify the clinical significance of microscopic liver metastasis from pT2 gallbladder cancer and to clarify whether partial hepatectomy can prevent hepatic recurrence in patients with microscopic liver metastasis. The subjects included 20 patients with pT2 tumors who underwent radical surgery and partial hepatectomy with lymph node dissection. Microscopic liver metastasis was defined as a distant metastatic nodule including cancer cell nests in the lumen of the portal vein and discrete nodular lesions in the liver, all less than 5 mm in diameter. Cox's proportional hazard regression was used to analyze factors that contributed to outcomes. Microscopic metastases were detected in the resected livers from 5 of 20 patients. There were more metastatic lesions within 1 cm of the gallbladder bed than were located 1 to 2 cm away from it. Microscopic liver metastases showed a strong correlation with the extent of blood vessel invasion around the primary tumor and were frequently detected in patients with a primary tumor localized on the hepatic side and with more than 3 cm of subserosal invasion. In four of five patients with microscopic liver metastases, recurrence was found in the remnant liver, which led to death within 15 months after the initial operation. Microscopic liver metastasis, operative curability, and lymph node metastasis were assessed as independent prognostic factors. A large proportion of patients with microscopic liver metastasis suffered from hepatic recurrence. Our results suggest that partial hepatectomy alone cannot prevent hepatic recurrence in patients with microscopic liver metastasis.

A Basic Helix-Loop-Helix Transcription Factor Essential for Cytochrome P450 Induction in Response to Alkanes in Yeast Yarrowia lipolytica

When the alkane-assimilating yeast Yarrowia lipolytica is cultivated on n-alkanes, it changes cellular metabolism for adaptation by inducing cytochrome p450 and other genes. From a comparative analysis of promoters of alkane-inducible genes, we identified a cis-acting element, ARE1 (alkane responsive element 1), which provides transcription induction in response to n-alkanes. In a genetic selection for mutants that were defective in ARE1-mediated transcription induction in the presence of n-alkanes, we found that the YAS1 (yeast alkane signaling) gene is essential for alkane response. The YAS1 gene encodes a basic helix-loop-helix (bHLH) family protein. Loss of Yas1p causes defects in n-alkane-dependent transcription induction of the p450 gene and growth on n-alkanes. Yas1p localizes to nuclei and binds to promoters containing ARE1. Yas1p also binds to its own promoter, and the expression of YAS1 is induced by n-alkanes. These features suggest that Yas1p is a novel transcription factor mediating alkane signaling and that it provides an autoregulatory loop.

Risk factors of posthepatectomy liver failure after portal vein embolization

BACKGROUND/PURPOSE

Major hepatectomy has been successfully performed after portal vein embolization (PE). However, post-hepatectomy liver failure following hyperbilirubinemia (HB) sometimes occurs even after PE. Our objective was to determine what factors affected post-hepatectomy HB and liver failure.

METHODS

Forty-two patients underwent PE before major hepatectomy or repeat hepatic resection after partial hepatectomy. Having a prognostic score over 40, they all belonged to a high-risk group. They were classified into two groups according to post-hepatectomy levels of total bilirubin: normal group and HB group. The HB group was further divided into two subgroups: recovered subgroup and fatal subgroup. We investigated the differences between the two groups and the two subgroups.

RESULTS

Ten of 14 cases (71%) in the HB group were biliary tract disease with jaundice before PE. The indocyanine green retention rate (ICGR15) before PE, skeletonization of the hepatoduodenal ligament (HDL), and portal venous pressure after PE were significantly different between the two groups as shown by multivariate analysis. Postoperative complication was the only factor significantly different between the two subgroups by univariate analysis.

CONCLUSIONS

When the patients underwent major hepatectomy combined with skeletonization of the HDL for biliary tract disease with jaundice, they were subject to post-hepatectomy HB even after PE. If they had postoperative complications, fatal hepatic failure must have occurred.

Surgical strategy for the management of biliary injury in laparoscopic cholecystectomy

BACKGROUND/AIMS

The incidence of biliary injury during laparoscopic cholecystectomy remains high and several complications resulting from injuries have recently been reported. The aim of this study is to elucidate the surgical strategy for the management of biliary injury during laparoscopic cholecystectomy.

METHODOLOGY

Ten patients with biliary injury during laparoscopic cholecystectomy are retrospectively reviewed.

RESULTS

Second operations as initial repair were performed in five patients in our institute. Duct-to-duct anastomosis for one and duct-enterostomies for two were performed in three common bile duct transections. Simple closures were performed for the other two biliary injuries. Another five cases underwent both laparoscopic cholecystectomies and second operations for initial repair when they were referred to our service. Four were treated by a third operation in our institution including hilar bile duct resections and duct-enterostomies in two, and right hepatic lobectomies in the other two cases. The last patient could not be treated because of his poor condition and he died of hepatic failure soon after the consultation.

CONCLUSIONS

Complications resulting from biliary injury have recently been reported, necessitating liver transplantation. Laparoscopic surgeons should avoid biliary injury and must not perform inadequate biliary reconstruction, which leads to secondary biliary cirrhosis, cholangitis, liver failure, and finally patient death.

Caudate lobectomy combined with resection of the inferior vena cava and its reconstruction by a pericardial autograft patch

A 53-year-old woman with remnant liver metastasis originating from colon cancer was referred to our department. She underwent successful caudate lobectomy combined with resection of the inferior vena cava (IVC), including reconstruction with a pericardial autograft patch. IVC clamping was performed between the IVC below the confluence of the left hepatic vein and the infrahepatic IVC in order to preserve the hepatic circulation. After 18 months, the graft was patent and there was no sign of recurrence. A part of the pericardium used as an autograft for patch repair of the defect of the IVC was very useful because it was easily available, required only division of the diaphragm, and was of sufficient length and width.

Effects of portal vein embolization before major hepatectomy

BACKGROUND/AIMS

Major hepatectomy can now be successfully performed after portal vein embolization, but the effects of portal vein embolization have not been clearly delineated. Our objective is to examine whether portal vein embolization really contributes to the success of major hepatectomy.

METHODOLOGY

Thirty-eight patients underwent portal vein embolization and hepatectomy of two subsegments or more. They all belonged to a high-risk group according to a prognostic score. We selected 9 of 38 patients with liver metastases (PE-meta group) and 32 patients who had undergone hepatectomy without portal vein embolization (non-PE-meta group) during the study period to compare the serum levels of total bilirubin after hepatectomy. Fifteen of 38 patients had the levels of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex examined after hepatectomy (PE group) and so did 20 patients without portal vein embolization (non-PE group).

RESULTS

The maximum levels of total bilirubin in non-PE-meta group correlated with the percentage of hepatic parenchyma to be resected. In the patients receiving portal vein embolization, the pre-PE and post-PE levels were both below the regression. Similar shifts were seen in the graphs of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex.

CONCLUSIONS

The effects of preoperative portal vein embolization on safety in major hepatectomy were proved by its suppression of rise in total bilirubin, polymorphonuclear leukocyte elastase and thrombin-antithrombin complex after hepatectomy.

Prostaglandin E1 improved the function of transplanted fatty liver in a rat reduced-size-liver transplantation model under conditions of permissible cold preservation

The aim of this study was to determine whether the minimum necessary volume of a moderate fatty liver graft was similar to the normal liver volume and to elucidate means for improving the function of the transplanted fatty liver if it were inferior in volume to a normal liver under conditions of permissible cold preservation. Nine-week-old male Wistar rats were used. Normal rat chow was fed to the normal liver group, and fat-enriched rat chow was fed to the fatty liver group for 4 weeks to induce a moderately fatty liver. Liver transplantation with various volumes of reduced-size grafts, including whole liver graft (100%LT), 70% volume graft (70%LT), and 30% volume graft (30%LT), was performed with both groups of rats as donors. All procedures were performed under the conditions of 2-hour cold preservation. All rats with an implanted normal liver were surviving at 7 days after the operation regardless of the graft volume (100%LT, 5 of 5; 70%LT, 5 of 5; 30%LT, 5/5). In contrast, the survival rates decreased according to the graft volume in rats implanted with fatty livers (100%LT, 8 of 8; 70%LT, 5 of 8; 30%LT, 2/8). To improve the survival of 30%LT with fatty liver, we employed two potent inhibitors of ischemia-reperfusion injury: FK506 and prostaglandin E1. Though FK506 had no advantageous effect, prostaglandin E1 significantly improved the survival rate and diminished serum levels of alanine aminotransferase and hyaluronic acid. In conclusion, the volume of graft necessary for successful transplantation is larger in fatty livers than in normal livers in permissible cold preservation. Also, prostaglandin E1 protects grafts against ischemia-reperfusion injury and improves the functioning of a transplanted fatty liver.

Reconstruction of the hepatic vein using a patch graft from the autologous pericardium

We describe a patch graft technique using the autologous pericardium for reconstruction of the right hepatic vein after hepatectomy. A male patient underwent hepatectomy for removal of metastatic tumors from colon cancer. A 2.5-cm-diameter tumor, which was located in the antero-superior segment (S8) of the right lobe, invaded the right hepatic vein. A patch graft was obtained from the autologous pericardium. After clamping of the proximal and distal parts of the right hepatic vein invaded by the cancer, part of the anterior wall, measuring 2.0 x 1.5 cm, was resected. The patch fitted the defect in the right hepatic vein well and was sutured in place using running sutures of 6-0 Proline. Its patency was maintained 14 months after surgery. This technique can be applied for reconstruction after partial resection of a vein in this and other sites.

Severe fatty change of the graft liver caused by a portosystemic shunt of mesenteric varices

Portosystemic shunt is a common complication in patients with portal hypertension. Mesenteric varix is one of the collaterals that can cause post-transplant liver dysfunction. In this case report, a 45-year-old woman underwent living relative donor liver transplantation for alcoholic cirrhosis. Although the early postoperative course was uneventful, she was readmitted for treatment of liver hypofunction. Fatty change in the graft liver was confirmed by histopathology of the biopsy specimen. The venous phase of a superior mesenteric angiogram revealed large-caliber mesenteric varices comprising portosystemic venous shunts. Surgery was performed to ligate the shunts. The intraoperative color Doppler ultrasonography showed hepatofugal portal blood flow, which was corrected to hepatopetal blood flow by clamping the shunt vessels. The portal pressure was moderately elevated from 13.6 cm to 21.8 cm H(2)O. Two shunt vessels were ligated and divided. Her liver function returned to nearly normal thereafter. We recommend that descending collaterals be divided during liver transplantation.