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ABSTRACT: A 42-year-old man suffering from haemophilia A and coinfection of human immunodeficiency virus (HIV) and hepatitis C virus was referred to our institution because of multiple liver tumours. He had been receiving highly active antiretroviral therapy for HIV infection. Ultrasonography showed multiple hypoechoic space-occupying lesions in the liver. Contrast-enhanced dynamic computed tomography (CT) and magnetic resonance imaging revealed multiple ring-enhanced hypervascular lesions in the liver. An ultrasonography-guided biopsy was performed and histological evaluation indicated one of the lesions to be combined hepatocellular and cholangiocarcinoma and others to be non-neoplastic. The patient underwent partial hepatic resection and is currently alive without recurrence for 15 months. Multiple ring-enhanced lesions have been undetectable in postoperative follow-up CT examinations.
Journal of clinical virology: the official publication of the Pan American Society for Clinical Virology 02/2013; · 3.12 Impact Factor
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ABSTRACT: INTRODUCTION: A high recurrence rate of hepatocellular carcinoma (HCC) remains a significant concern. The risk factors for recurrence were analysed and the optimal surgical approaches were investigated. METHODS: The subjects comprised 280 consecutive patients with primary solitary HCC measuring ≤5 cm in diameter, who underwent curative resections. Multivariate analysis was conducted to identify the risk factors for post-operative recurrence, and the clinical significance of an anatomic resection was evaluated. RESULTS: Multivariate analysis identified HCV infection, a des-gamma-carboxyprothrombin level >100 mAU/ml, underlying cirrhosis, the presence of microvascular invasion, the presence of micrometastases and non-anatomic resection as being significant risk factors for post-operative recurrence. The 5-year recurrence rate was 56.7% in the anatomic resection (AR) group and 74.7% in the non-AR group. The 5-year survival rate was 82.2% in the AR group and 71.9% in the non-AR group. Local recurrence within the same segment was observed in 25% of the patients of the non-AR group. The prognostic superiority of AR was confirmed only in patients with histopathological evidence of microvascular invasion and/or micrometastases, and in patients having a solitary HCC measuring 2 to 5 cm in diameter. CONCLUSIONS: Anatomic resection may decrease local recurrence and improve the surgical outcomes in solitary HCC measuring 2 to 5 cm in diameter.
HPB 01/2013; 15(1):31-39. · 1.60 Impact Factor
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ABSTRACT: PURPOSEHepatitis C virus (HCV) infection has been recognized as a potent risk factor for the postoperative recurrence of hepatocellular carcinoma (HCC). However, little is known about the impact of HCV viral load on surgical outcomes. The study objective was to investigate clinical significance of HCV viral load on long-term outcomes of HCC. PATIENTS AND METHODS
Three hundred seventy patients who were classified as Child-Pugh class A and underwent curative liver resections for HCV-related HCC were divided into low and high viral load groups (≤ or > 5.3 log(10)IU/mL) based on the results of a minimum P value approach to predict moderate to severe activity of hepatitis; the clinical outcomes were then compared.ResultsThe 5-year recurrence-free survival rate was 36.1% in the low viral load group and 12.4% in the high viral load group (P < .001). The 5-year overall survival rate was 76.6% in the low viral load group and 57.7% in the high viral load group (P < .001). Multivariate analysis confirmed significant correlation between high viral load and tumor recurrence with a hazard ratio of 1.87 (95% CI, 1.41 to 2.48; P < .001). Subanalysis revealed that the favorable results in the low viral load group were not attributed to whether or not serologic eradication of HCV was obtained both in primary and recurrent lesions. CONCLUSION
Low HCV viral load predicts better long-term surgical outcomes in patients with HCC regardless of the serologic eradication of HCV.
Journal of Clinical Oncology 11/2012; · 18.37 Impact Factor
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ABSTRACT: Background/Aims: The liver hanging maneuver (LHM) is a widely used novel suspending technique for facilitating liver transection. However, little evidence is available to reveal its safety and true advantages in donor operations for living donor liver transplantation (LDLT). Methodology: The medical records of 422 consecutive living donors at a single institute were reviewed. The feasibility and outcomes of the use of LHM in donor operation for LDLT were investigated. Results: Two types of hanging maneuvers, namely, Belghiti's conventional method and a modified approach where the sling is placed after full mobilization of the liver, have been routinely adopted selectively since 2000, and to date, 304 LHM have been carried out. Marked reduction in the liver transection time needed for harvesting a hemiliver graft has been obtained after the introduction of LHM (p<0.0001). No major complications associated with the LHM have been recorded. Comparison of the conventional and modified LHM revealed similar outcomes for the two, except that the modified approach required a longer liver dissection time (81 vs. 98 min; p=0.0004). Conclusions: Considering its high feasibility and several advantages in facilitating liver transection, LHM might be worth attempting in donor operations where a major hepatectomy is required.
Hepato-gastroenterology 09/2012; 59(118):1939-43. · 0.66 Impact Factor
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ABSTRACT: BACKGROUND/PURPOSE: The clinical features and perioperative management of liver transplant recipients who are already sensitized against human leukocyte antigen (HLA) prior to transplantation are not yet clear. MATERIALS AND METHODS: Medical records of living donor liver transplant recipients were reviewed and clinical features of the patients possessing anti-HLA antibodies were studied. RESULTS: Among the 470 consecutive living donor liver transplant recipients, 6 patients (1.3%) had preformed anti-HLA antibodies. A review of the postoperative courses of these patients revealed that the problems included platelet transfusion refractoriness (PTR) due to immune-mediated destruction of platelet and thrombotic microangiopathy (TMA). PTR was observed in patients with anti-HLA class I antibodies and only HLA-matched platelet concentrate (HLA-matched PC) relieved thrombocytopenia. Intravenous gammaglobulin had an additive effect to HLA-matched PC in some cases, and platelet transfusion from close relatives might be a substitute for HLA-matched PC in life-threatening situations. Although the etiology of TMA is unremarkable, the incidence was high (67%, 4/6) compared with that in patients who were not sensitized against HLA (5.6%, 26/464; p < 0.01). Of the four patients, three were complicated with late-onset TMA. CONCLUSIONS: Considering these clinical features, careful preparation and postoperative management are needed for liver transplant candidates with anti-HLA antibodies.
Journal of hepato-biliary-pancreatic sciences. 03/2012;
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Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 03/2012; 10(3):e23-4. · 5.64 Impact Factor
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ABSTRACT: Right-sided ligamentum teres (RSLT) is a congenital anomaly that is sometimes encountered during hepatobiliary surgeries. However, a valid protocol for describing the segmental anatomy of livers with RSLT has not been established, and confusions or anatomic misunderstandings have been a major problem.
The vascular architecture and morphological characteristics were investigated in 35 livers with RSLT using three-dimensional (3D) simulations.
Couinaud's four sectors and three hepatic veins were clearly distinguished in the liver with RSLT using 3D simulations. The ligamentum teres was connected with the right paramedian portal pedicle, and the long axis of the cystic fossa was always observed on the left of the ligamentum teres in all 35 livers. However, when the main portal scissura was visualized using 3D simulation, the gallbladder was always located on the border of either side of the hemilivers, and the malposition of the gallbladder was not confirmed.
Although the right-sided components of the livers are well developed as a result of the right-dominant distribution of the feeding vessels in livers with RSLT, the basic segmental structure defined by the four sectors and the three hepatic veins are as well preserved as those in the typical liver anatomy.
HPB 01/2012; 14(1):32-41. · 1.60 Impact Factor
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ABSTRACT: To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC).
Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs).
Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period.
Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm).
With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.
Annals of surgery 06/2011; 254(6):992-9. · 7.90 Impact Factor
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ABSTRACT: Liver hanging maneuver is a widely used novel suspending technique to facilitate liver resection using the "anterior approach" where hepatic mobilization is preceded by parenchymal transection. However, its true indication and surgical advantages in the conventional "liver mobilization approach" are still controversial.
The medical records of 1,451 consecutive patients who underwent hepatectomy at a single institute, where conventional liver mobilization technique is routinely adopted, were retrospectively reviewed. Surgical situations in which the hanging maneuvers could actually be expected to be advantageous and the clinical outcomes of the tape-assist techniques were investigated.
Of the 1,451 hepatectomies, 1,446 (99.6%) were successfully performed using the conventional approach. Of the 1,446 patients, 42 (2.9%) required tape-assist techniques to secure safe surgical manipulation of bulky lesions (61.9%), tumor infiltration (16.7%), massive tumor thrombi (9.5%), vascular protection (7.1%), and other technical reasons (4.8%). The perioperative morbidity/mortality rates were 19.0/0% in these 42 tape-assisted cases, and 21.9/0.14% in the remaining 1,404 cases (p = 0.82 and 0.06, respectively), with no significant difference in either the overall or the recurrence-free survival between the two groups.
Although liver resection may be accomplished safely by the conventional approach in most cases, its safety may be enhanced by the use of valid tape-assist techniques in selected situations.
Journal of Gastrointestinal Surgery 06/2011; 15(6):988-95. · 2.83 Impact Factor
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ABSTRACT: Our aim was to accurately assess the correlation between findings of contrast-enhanced intraoperative ultrasound using Sonazoid and histologic grade of hepatocellular carcinoma (HCC).
We enrolled 239 consecutive patients who were undergoing surgery for HCC for this study. Because 33 extensively necrotic HCCs were excluded, a total of 374 histologically proven HCCs were detected in all resected specimens and were the study subjects (71 well-differentiated, 239 moderately differentiated, and 64 poorly differentiated HCCs). After a laparotomy and liver mobilization, contrast-enhanced intraoperative ultrasound in the harmonic mode was performed after a Sonazoid injection. The first minute was defined as the vascular phase, in which the vascularity of the 239 HCCs was assessed. After an approximately 15-minute delay, a thorough liver exploration was performed (Kupffer phase). Preoperative dynamic CT was routinely performed, and the findings were assessed for reference.
The proportion of hypervascular tumors during the vascular phase tended to be lower among well-differentiated than among moderately and poorly differentiated HCCs (66% vs 80%, p = 0.058). The proportion of hypoechoic tumors during the Kupffer phase was significantly lower among well-differentiated than among moderately and poorly differentiated HCCs (54% vs 92%, p < 0.0001). In dynamic CT, the proportions of hypervascular tumors during the early phase and hypodense tumors during the late phase were significantly lower among well-differentiated HCCs than among moderately and poorly differentiated HCCs, respectively (early phase, 51% vs 87%, p < 0.0001; late phase, 59% vs 85%, p < 0.0001).
Contrast-enhanced intraoperative ultrasound using Sonazoid is useful for estimating the histologic grade of HCC.
American Journal of Roentgenology 06/2011; 196(6):1314-21. · 2.78 Impact Factor
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Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 10/2010; 9(2):e14-5. · 5.64 Impact Factor
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ABSTRACT: The Spiegel lobe is located deep in the dorsal portion of the liver, and isolated resections of this region are technically demanding, especially in bulky and/or invasive lesions or in hypertrophied cirrhotic livers.
Anterior approach using the isolated hanging maneuver of the Spiegel lobe was attempted in patients in whom the conventional method of mobilizing the Spiegel lobe prior to liver transection would have been difficult. Clinical outcomes were compared with the conventional approach performed during the same period.
Of 42 consecutive isolated resections of the Spiegel lobe, the presently reported technique was required in 12 patients (28.6%). The median diameter of the tumors was 33 mm, and tumor invasion to the retrohepatic inferior vena cava was observed in four patients. Although minor vascular injury was observed in one patient during retrohepatic dissection, the isolated sling suspension of the Spiegel lobe was successfully conducted in all cases. No remarkable inferiority of the present technique compared with the conventional approach was noted either in operation data or clinical outcomes.
Anterior approach using the isolated sling-suspension technique may be a safe alternative surgical option for bulky and/or invasive lesions located in the Spiegel lobe of the liver.
Journal of hepato-biliary-pancreatic sciences. 05/2010; 17(3):359-64.
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ABSTRACT: To investigate the actual three-dimensional (3D) anatomy of the intersegmental plane of the liver to enable safe and precise anatomic resections of the portal territories.
Anatomic resection of the liver requires the precise detection of the intersegmental plane. However, we have sometimes encountered a dissociation between conventional understanding of the anatomy of the intersegmental plane and its actual 3D shape.
3D simulations of the livers of 81 healthy donors for living donor liver transplantation were reviewed. Several key angles formed between the plane of each venous trunk and the actual intersegmental plane on 3D simulation images were measured. The relation between these angles and the volume ratio of the liver segments located on both sides of the intersegmental plane were also investigated.
The dissociation between the plane of the venous trunks and the actual intersegmental plane was remarkable, especially in the subphrenic region of the right lobe. The volume ratio of segment VIII compared with segment VII was correlated with the degree of cranio-lateral protrusion of segment VIII (r=0.35, P=0.001); this finding was attributed to the intricate surface of the right portal scissura. The same tendency was observed in the left portal scissura between the angle and the volume ratio of segment III/II (r=0.23, P=0.049), whereas the main portal scissura exhibited a relatively flat surface compared with the other longitudinal scissurae.
The intersegmental plane of the liver has an uneven and curved surface, especially in the right and left portal scissurae. The identification and exposure of the landmark vein on the cut surface is an important technique for avoiding disorientation during anatomic liver resection.
Annals of surgery 05/2010; 251(5):917-22. · 7.90 Impact Factor
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ABSTRACT: Acute appendicitis has been reported to be managed with non-operative therapy at relatively high successful rate. However, risk factors for negative outcome have not been established.
Three hundred eighty consecutive patients who underwent initial therapy for suspected appendicitis were reviewed. They were divided into three groups: operation group, the group successfully managed with non-operative therapy (success group), and the group required surgical conversion (failure group). Preoperative clinical data were compared among the groups and risk factors for negative outcomes were investigated.
Thirteen patients were excluded due to contraindication for non-operative therapy. Of the remaining 367 patients, 143 patients (39.0%) were primarily treated with surgery, and 224 patients (61.0%) were initially managed with antibiotics. Among the 224 patients, 91 patients (40.6%) were refractory to antibiotics and converted to surgery after more than 24 h usage of antibiotics. Multivariate analysis revealed that elevated C-reactive protein (CRP) level (>4 mg/dL) and presence of appendicolith were significant risk factors for conversion. Morbidity rate showed no significant difference between the operative and failure groups.
Elevated CRP concentration and appendicolith may predict the negative outcome in non-operative management. However, immediate appendectomy can possibly be avoided at least 24 h without increasing morbidity under the usage of antibiotics.
Journal of Gastrointestinal Surgery 11/2009; 14(2):309-14. · 2.83 Impact Factor
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ABSTRACT: In extended left hepatectomy including venous resection of proximal portion of the MHV, a simple new venous reconstruction technique was attempted to bypass the long gap between the stump of peripheral portion of MHV and IVC.
One of the hepatic venous branches in resecting side of the liver was dissected during liver transection. The dissected vein was left attached to the IVC at its proximal portion and the distal end was directly anastomosed with the stump of MHV as an alternative venous drainage rout.
Of 282 hepatectomies performed for metastatic liver tumor in Tokyo University Hospital from 1995 to 2004, two patients were treated with the present technique. With the in situ hepatic vein graft method, postoperative venous congestion was successfully avoided in both of two cases and drainage areas of the reconstructed vein showed sufficient parenchymal regeneration.
In situ hepatic vein graft might be useful and possibly superior to conventional free venous graft in reconstructing long venous gap in selected patients from the viewpoint of its safety, curative potential, and the long-term patency.
Hepato-gastroenterology 10/2007; 54(78):1748-51. · 0.66 Impact Factor
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Kazushige Kawai,
Takeyuki Hiramatsu,
Ryo Kobayashi,
Naoki Takabayashi,
Yukio Ishihara,
Ko Ohata,
Hirotaka Niwa,
Junji Yasuike,
Hiroki Tanaka,
Mitsutoshi Kimura, Junichi Shindoh
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ABSTRACT: Although sepsis after surgery for colorectal perforation frequently results in severe coagulation disorders and consequent death of the patient, the correlation between coagulation abnormalities and postoperative mortality of colorectal perforation has not been clarified.
The medical records of 101 consecutive patients receiving surgery for colorectal perforations between January 1994 and July 2006 were retrospectively reviewed. The abnormalities of preoperative laboratory data reflecting coagulation disorders and other possible risk factors were analyzed by univariate and multivariate analysis.
Prolonged prothrombin time and activated partial thromboplastin time significantly correlated with a poor prognosis (both P < 0.001). Among the several risk factors analyzed, only the presence of coagulation disorders was an independent predictive factor of postoperative mortality.
Prolonged prothrombin time and activated partial thromboplastin time are useful prognostic factors for predicting the surgical outcome for patients with colorectal perforation.
Journal of Gastroenterology 06/2007; 42(6):450-5. · 4.16 Impact Factor
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ABSTRACT: We developed a new method of xenogeneic direct hemoperfusion of a bioartificial liver support system consisting of a leukocyte-adsorbent column, an immunoglobulin-adsorbent column, and the substitute unit for hepatic function. By this method, we performed xenogeneic direct hemoperfusion experiment using resected whole swine liver for treatment of a canine liver failure model, and compared the contribution of each adsorbent column both by blood analysis and from the histological point of view.
Canine liver failure model was produced by portocaval shunting and ligating the entire hepatoduodenal ligament. The xenogeneic direct hemoperfusion system was constructed using a roller pump, a leukocyte-adsorbent column, an immunoglobulin-adsorbent column, a combined device of oxygenator and warmer, the resected whole swine liver accommodated in a chamber, and a dissolved oxygen meter through which canine whole blood leaving the external jugular vein circulated in this order.
Xenogeneic direct hemoperfusion was successfully performed for 3 h without hyperacute rejection occurring. Adequate ammonia detoxification and bile juice secretion were exhibited, and no findings of hepatocyte destruction by immunological cells and proteins were detected. Blood data showed that the immunoglobulin adsorbent were more effective than the leukocyte adsorbent in avoiding hyperacute rejection. This result indicates that hyperacute rejection has a closer relation to humoral immune responses, especially regarding removal of complements than to cellular immune responses.
We successfully performed xenogeneic direct hemoperfusion of the whole swine liver without hyperacute rejection using our method.
Journal of Surgical Research 06/2003; 111(2):229-35. · 2.25 Impact Factor
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ABSTRACT: We have developed a new extracorporeal whole-liver accommodation device in which a whole swine liver is placed in a physiological state by modeling the intraabdominal arrangement in the pig body, with the liver supported by a special inferior vena cava tube. Furthermore, we employed a diaphragm-type artificial heart in our system to produce pulsatile blood flow through the hepatic artery, which is considered to be indispensable to dilate peripheral vessels and supply oxygenated whole blood to the peripheral liver tissue. Beneficial effects were demonstrated in visual findings and bile juice secretion. The color of the liver surface in our system remained bright red, indicating that the liver vessels were well drained and free from congestion, and bile juice secretion was maintained at more than 10 ml/h throughout the perfusion period. Our system exhibited excellent ammonia removal and urea nitrogen synthesis, and serum aspartate aminotransferase levels showed no increase, indicating the absence of hepatocyte destruction. Histological findings showed that the liver could expand appropriately and was free from compression caused by its own weight. In conclusion, our original liver accommodation device enabled appropriate expansion of the whole liver and supplied adequate oxygenated blood to peripheral areas by means of a pulsatile pump.
Journal of Artificial Organs 02/2003; 6(3):211-7. · 1.59 Impact Factor
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ABSTRACT: Knowledge of intrahepatic vascular variations, especially in hepatic venous anatomy, is inevitable for carrying out liver surgery safely. However, vascular anatomy of the right liver or right side tributaries of the MHV has been focused in various studies and there have been only a few reports on the left liver.
Sixty consecutive living donors for liver transplantation in a single institute were reviewed. Ramification patterns and drainage volume of each venous tributary were evaluated using 3D-CT venography.
Four characteristic venous tributaries; left superficial vein (LSV), umbilical fissure vein (UFV), and superior/inferior veins of Segment IV (V4sup/4inf) were detected on 3D-CT. Of these, LSV and UFV were sometimes rather thick overwhelming the LHV trunk and drained more than 20% of the left liver in 11 (18.3%) and 4 patients (6.7%), respectively. In such cases, proportions of Segment II (LSV drainage area) or Segment III+IV (UFV drainage area) were significantly large compared with those in typical venous ramification cases.
Clinically significant findings on venous variations in the left liver were described. Preoperative volumetric assessment of the draining areas of these veins is useful in surgical decision making on venous reconstruction and/or extent of liver resection.
Hepato-gastroenterology 53(72):831-5. · 0.66 Impact Factor
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ABSTRACT: Background/Aims: To establish an objective and precise vascular naming method to explore the segmental anatomy of the liver with major anomalies using threedimensional (3D) simulations. Methodology: Two algorithms, "Alternative vascular visualization method" (Algorithm A) and "Cholecystic axis based definition" (Algorithm B), were devised. Twenty livers with typical anatomy and four anomalous cases were screened by six masked physicians using a blinded protocol. Results: After confirming the feasibility in subjects with a typical anatomy, the accuracies of the algorithms were tested in anomalous cases. Using conventional 3D screening, the accuracies of the portal and hepatic venous definitions were 40.6% and 61.1%, respectively. However, after the introduction of the presently reported algorithms, these results improved to 83.4% and 83.4%, respectively, for Algorithm A, and 88.5% and 83.3%, respectively, for Algorithm B. In particular, the accuracy was further improved to nearly 100% when the naming process was started from the larger side of the liver in Algorithm A. Conclusions: The present study confirmed that Algorithm A enables the precise vascular definitions when the process is started from the larger side of the liver. This method may be a useful tool for anatomic exploration of liver with major anomalies.
Hepato-gastroenterology 59(114):511-4. · 0.66 Impact Factor
