Title Usefulness of Omental Wrapping to Prevent Biliary Leakage and Delayed Gastric Emptying in Left Hepatectomy Author(s) Nanashima, Atsushi; Tobinaga, Syuuichi; Abo, Takafumi; Nonaka, Takashi; Kunizaki, Masaki; Takeshita, Hiroaki; Hidaka, Shigekazu; Sawai, Terumitsu; Yasutake, Toru; Nagayasu, Takeshi Citation Hepato-gastroenterology, 59(115), pp.847-850; 2012 Issue Date 2012-05 URL http://hdl.handle.net/10069/28627 Right © H.G.E. Update Medical Publishing S.A. NAOSITE: Nagasaki University's Academic Output SITE

BACKGROUND/AIMSPylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD.METHODOLOGYPPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009.RESULTSPancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01).CONCLUSIONSSSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

ObjectivesThe aim of the study was to accurately examine the functional volume (RI-vol) of the hepatic segments on single photon emission computed tomography/computed tomography (CT) fusion imaging by technetium-99m galactosyl human serum albumin scintigraphy and compare it with the RI-vol and morphological volume obtained on computed tomography (CT-vol). MethodsIn 60 patients with various liver background statuses who had undergone hepatectomy, the RI-vol and CT-vol were examined in each sector using imaging analysis. The values from a control group (n=91) were used as reference data. ResultsThe mean RI-vol and CT-vol of the right liver were 64±10 and 63±6%, respectively, whereas the values for the left liver were 36±10 and 37±6%, respectively. Compared with the control group, the ratios in each hemiliver were similar. The mean RI-vol and CT-vol for each sector were also similar, and significant positive correlations were identified between the two volumes (P<0.01). In four patients with hepatic tumors involving the main hepatic vessels or the bile duct and in 10 patients who had undergone portal vein embolization, the actual RI-vol in the injured sector was significantly decreased compared with CT-vol (P<0.05). There were marked changes in functional volume in segment 6+7 and segment 2+3 after portal vein embolization (P<0.05). ConclusionVolumetric measurement using single photon emission computed tomography/CT imaging with technetium-99m galactosyl human serum albumin scintigraphy is useful for evaluating the functional volume in separated livers and offers a good reflection of the background liver status.

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

Laparoscopic surgery is a less invasive treatment option for tumors in the intraabdominal organs; however, the safety and indication of laparoscopic or laparoscopy assisted pancreaticoduodenectomy (LPD) is still controversial. We attempted LPD in four cases for intraductal papillary mucinous neoplasm (IPMN) located in the pancreatic head and we report the surgical re- cords and short-term outcome. LPD was carried out in four patients including three patients with the combined type IPMN and one with the branch type, based on the International Consensus Guidelines. None of the patients had invasive carcinoma based on preoperative imaging diagnosis. Laparoscopic procedures were performed until isolation of the pancreas head and duodenum, and final resection of PD and intestinal reconstruction were performed using small incision laparotomy (7-8cm). The mean total operating time was 882 minutes (820-932 minutes), mean blood loss was 925ml (610-1550ml) and red cell transfusion was not required in any patients. One patient underwent reoperation for bleeding at the pancreaticojejunostomy site at day 1. Mean duration until patients were able to walk was 3.5 days (2-6 days) and duration of use of analgesia was lim- ited to within 7 days. Grade B pancreatic fistula was observed in one patient and jejunal ileus was observed in one patient. There were no deaths. LPD was safely performed and blood loss was limited, although the operating time was long. Postoperative recovery in patients without complications might be better than the conventional PD under laparotomy. Future study is necessary. ACTA MEDICA NAGASAKIENSIA 56: 93-97, 2011

BACKGROUND/AIMS:Surgical resection is a radical treatment option for gallbladder carcinoma (GBC); however, it is still difficult to cure and patient prognosis is poor. An assessment of the surgical results and chemotherapy options may elucidate effective treatments.METHODOLOGY:We retrospectively examined the demographics, surgical records and outcome in 33 patients with GBC undergoing surgical resection.RESULTS:Postoperative cancer recurrence was observed in 36% of patients. Mean cancer-free survival time was 84 months and 3-year cancer-free survival rate was 70% Mean overall survival time was 96 months and 5-year overall survival rate was 52%. The 3-year cancer-free survival and the 5-year overall survival were significantly different between the final tumor stages (p<0.001). Higher CEA and CA19- 9 level were significantly related to poor overall survival (p<0.05). Macroscopically, papillary type tumor showed significantly better overall survival compared to nodular or flat types (p<0.05). Degree of invasion, node metastasis, moderate or poor differentiation, vascular or perineural invasion and invasion of the liver or hepatoduodenal ligament were significantly associated with poor overall survival (p<0.05). A cancerfree margin at the hepatic cut end and dissected periductal structures showed a significantly poor prognosis (p<0.05). The overall survival in final curability A was significantly associated with better curability than B or C (p<0.05).CONCLUSIONS:Radically extended surgical resection for GBC is necessary to obtain improved patient survival and new adjuvant chemotherapy would be expected to improve results after surgery.

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

BACKGROUND/AIMSRecent developments in radiological technology allowed acquisition of images with high spatial resolution that facilitate effective 3-dimensional (3D) reconstruction of fusion images. Present study utilized 3D cholangiography and angiography with multi-detector-row computed tomography (MDCT) to acquire information regarding operative simulations.METHODOLOGY3D-fusion images were evaluated in 39 patients with hepatobiliary malignancies who underwent surgical resections.RESULTSAn aberrant branch of segment 3 over the umbilical portal vein, a large hepatoma compressed the hilar vessels, an aberrant branch of the caudate lobe vasculature in case of metastatic liver tumor with a right-sided umbilical portal vein and transected biliary leakage were clearly observed by 3D imaging system. Four patients with intrahepatic cholangiocarcinoma underwent multiple biliary stent placements and adequate placement of biliary stents was possible. In 22 patients with extrahepatic biliary carcinomas, visualization of the extent of tumor invasion by 3D-fusion images was equivalent to conventional cholangiography. In 2 patients, adequate placement of multiple stents could be visualized with this system. In 2 patients who underwent hepatectomy, more extended cancer invasion was observed than was visualized by 3D-fusion images.CONCLUSIONS3D fusion images were very useful for preoperative simulations in order to understand relationships between tumors and adjacent vasculatures.

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

To achieve complete extended right hepatectomy or trisectionectomy for a bismuth type IV hilar bile duct carcinoma, we propose the application of Belghiti's liver hanging maneuver (LHM) using a small nasogastric tube. This small nasogastric tube was placed in the cut plane: the top of the tube was placed between the hepatic veins. The tube was placed along the border between the left lateral sector and Spiegel's caudate lobe and the bottom of the tube was placed at the left side of the umbilical Glissonian pedicle. Hepatic parenchyma was transected using a vascular sealing device. Hepatic transection was always targeted to the tube and, eventually, a cut line of left hepatic ducts remained. We report the case of a 76-year-old female and an 83-year-old female with widely extended hilar bile duct carcinomas showing Bismuth type IV. Applying the modified LHM for extended right hepatectomy, the cut planes were easily and adequately obtained in patients with hilar bile duct carcinoma.

BACKGROUND/AIMS Efficacy of fibrin glue to prevent biliary or pancreas fistula at the resected edge of the liver or pancreas is controversial. We examined surgical results of fibrin glue use in patients who underwent hepatectomy or pancreatectomy to assess the efficacy of its use. METHODOLOGY Subjects were divided into two groups; the fibrin glue group in hepatectomy (n=228) and in pancreatectomy (n=113), and the non-fibrin glue group in hepatectomy (n=94) and in pancreatectomy (n=24). In case of hepatectomy, the fibrin glue was sprayed on the cut-surface or anastomotic site of hepatico-jejunostomy. In case of pancreatectomy, the fibrin glue was sprayed on the anastomotic site of pancreato-jejunostomy or closed pancreatic stump. RESULTS In the hepatectomy group, uncontrolled ascites were more frequent in the fibrin glue group (p<0.05). The use of fibrin glue for both groups has been less frequent in recent years. Prevalence of biliary fistula was not significantly different between groups. Hospital stay in the fibrin glue group was significantly longer than that in the non-fibrin glue group, and was not significantly different between hepatectomy or pancreatectomy groups. There was no significant difference of any complications including pancreatic fistula between groups. Prevalence of pancreatic fistula was not significantly different between the fibrin glue group and the non-fibrin glue group. CONCLUSIONS Use of fibrin glue did not prevent biliary or pancreatic fistula in patients who underwent hepatectomy and pancreatectomy with or without enteric anastomosis.

Background. Indocyanine green retention rate at 15 min (ICGR15) is a useful marker of liver function in deciding on the extent of hepatectomy. To determine ICGR15 regardless of liver condition, we sought to establish a formula for converted ICGR15 based on conventional blood tests and technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy.Materials and Methods. We measured liver function parameters, including ICGR15, in 307 patients, including 265 liver cancer patients without biliary obstruction (no obstruction group) and 42 with biliary obstruction (obstruction group).Results. In the no obstruction group, multiple regression analysis identified blood pool clearance ratio (HH15), liver uptake ratio (LHL15) calculated by heart and liver activity between 3 and 15 min after injection of (99m)Tc-GSA, and serum hyaluronic acid as significant correlates (P < 0.05). The calculated converted ICGR15 was then equal to 0.02* HA D 0.276*(HH15*100)-0.501*(LHL15*100) + 41.41. The mean difference between actual and converted ICGR15 was significantly lower in the obstruction than in the no obstruction group (P = 0.031). A significantly larger proportion of patients of the obstruction group had lower converted ICGR15 than those of the no obstruction group (P = 0.045).Conclusion. The converted ICGR15 is useful for evaluating hepatic function in patients with biliary obstruction who plan to undergo major hepatectomy. (C) 2011 Elsevier Inc. All rights reserved.

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.

A resection of the caudate lobe often needs to be combined with a hemi-hepatectomy for hilar cholangiocarcinoma or a liver tumor in segment 1. To achieve complete resection of the whole caudate lobe, the cut line between the right edge of the paracaval portion and the right lateral sector should be precisely controlled. The liver-hanging maneuver (LHM) is a useful anterior approach that does not require mobilization of the remnant liver. However, the precise set-up of the cut line of the right edge has not been optimized in previous reports. We herein introduce a new modification of LHM that we named the "dorsally fixed liver-hanging maneuver" (DF-LHM) based on the results in five patients who underwent left hepatectomy combined with a total resection of segment 1. This technique provided adequate cut planes along the right edge of the caudate lobe, shortening the transection time and reducing intraoperative blood loss. The DF-LHM may represent a new key technique for this type of hepatectomy, and further applications for other anatomical resections can be modeled on the strategy.

BACKGROUND/AIMSExpert technique and special anatomical or physiological knowledge are needed in the field of pancreatic surgery. The establishment of basic policies and operative techniques for pancreaticoduodenectomy (PD) and stepwise training for young pancreatic surgeons are necessary.METHODSWe scheduled PD for ampullar, biliary and pancreas carcinoma, and evaluated types of pancreatic anastomosis or results by each operator such as a chief, fellowship and resident doctors (> 5 years after graduation).RESULTSBased on a questionnaire distributed to young residents (n = 30), only half of them have experienced PD or PPPD, which was related to operating volume at the hospital. Post-operative complications at the teaching hospital were observed in 50 of 88 patients (56%). Post-operative complications were not significantly correlated with the type of anastomosis; however, duct-to-mucosa anastomosis of the pancreas might decrease pancreatic fistula (0% vs. 26% in pancreaticogastrostomy and 13% in pancreaticojejunostomy without duct-to-mucosa anastomosis). Based on the stepwise education protocol of technique, patient demographics, the surgical records and the post-operative complications were not significantly different between experienced teaching surgeons, fellowship surgeons and senior residents, although the time of operation and anastomosis tended to be longer in resident surgeons (p = 0.22).CONCLUSIONCompetent operative techniques for inexperienced surgeons and the achievement of safe resection at each stage are our educational goals for PD.

Title Evaluation of Surgical Resection for Ampullar Carcinoma at Japanese Single Cancer Institute Author(s) Nanashima, Atsushi; Tobinaga, Syuuichi; Abo, Takafumi; Ohnita, Ken; Norimura, Daisuke; Yajima, Hiroyuki; Takeshita, Hiroaki; Onaka, Takashi; Hidaka, Shigekazu; Takeshima, Fuminao; Yamaguchi, Naoyuki; Isomoto, Hajime; Sawai, Terumitsu; Nakao, Kazuhiko; Nagayasu, Takeshi Citation Acta Medica Nagasakiensia, 55(1), pp.23-28; 2010 Issue Date 2010-08 URL http://hdl.handle.net/10069/24158 Right NAOSITE: Nagasaki University's Academic Output SITE

Vascular infiltration (VI) is an important prognostic factor for hepatocellular carcinoma (HCC) and predictive parameters are necessary to preoperatively decide treatment strategies in patients with HCC.

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

Background: First-line treatment for <= 3 hepatocellular carcinomas (HCCs) <= 3 cm in size remains controversial. The superiority of survival benefit needs to be clarified between these modalities for such lesions.Methods: We examined post-treatment survival of 144 consecutive HCC patients who underwent hepatectomy and of 56 consecutive HCC patients who underwent thermal ablation therapy limited to the HCC (<= 3 cm, <= 3 lesions).Results: Pretreatment liver function was significantly worse and prevalence of Child-Pugh classification B/C was significantly higher in the ablation group compared to the hepatectomy group. Prevalence of tumor recurrence after treatment did not differ significantly between groups, irrespective of solitary or multiple HCC. In solitary HCC, overall survival rates in both groups did not differ significantly. Even in Child-Pugh B patients, survival was not significantly different between hepatectomy and ablation. In HCC with 2-3 lesions <= 3 cm, overall survival was significantly longer with hepatectomy than with ablation and mean survival periods in the hepatectomy and ablation groups were 4.5 and 1.2 years, respectively.Conclusion: In cases of multiple small HCCs, hepatic resection is recommended over local ablation therapy as the first-line treatment in cases where liver function has been preserved. J. Surg. Oncol. 2010;101:481-485. (C) 2010 Wiley-Liss, Inc.