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ABSTRACT: Key Words: Hepatocellular carcinoma; Platelet count; Surgical outcome; Prognostic factors. Abbreviations: Hepatocellular carcinoma (HCC); Low Platelt Count (LPC); Indocyanine Green Retention Rate at 15 min (ICGR15); Total Bilirubin (T-Bil); Albumin (ALB); Prothrombin Time (PT); Alkaline Phosphatase (ALP); Esophagogastric Varices (EV); Tumor invasion to the main branch or trunk of portal vein (Vp3, 4); α-fetoprotein (AFP); Transcatheter Arterial Chemoembolization (TACE); Surgical Margin (SM). Background/Aims: Hepatocellular carcinoma (HCC) patients often have low platelet count (LPC). The aim of this study was to determine unique features of HCC patients with LPC. Methodology: HCC patients who underwent surgery were divided into two groups: LPC group (platelet count ?100,000/mm3, n=84) and control group (platelet count >100,000/mm3, n=240). Surgical outcomes, risk factors for postoperative complications and prognostic factors were retrospectively compared. Results: HCC patients with LPC had poorer liver function, smaller tumors, less anatomical resection and more frequent postoperative liver failure than control group patients. Postoperative survival was not different between the two groups. Tumor invasion to the main branch or trunk of portal vein (Vp3, 4) was the only risk factor for postoperative substantial complications in the LPC group. Postoperative survival was worse in patients with tumor diameter ?4cm or multiple tumors and in those who underwent preoperative transcatheter arterial chemoembolization (TACE) in the LPC group by multivariate analysis. Among them, preoperative TACE were not prognostic factors in the control group. Conclusions: In HCC patients with LPC, Vp3, 4 patients should be carefully monitored after surgery and preoperative TACE is not recommended for long-term postoperative survival.
Hepato-gastroenterology 10/2012; 59(119):2269-72. · 0.66 Impact Factor
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ABSTRACT: Solitary necrotic nodule of the liver is a rare nonmalignant lesion of unknown etiology. It is defined as a nodule with a
completely necrotic core enclosed by a hyalinized fibrotic capsule containing elastic fiber. We report a 74-year-old woman
with a solitary necrotic nodule of the liver that mimicked metastasis from a previous rectal adenocarcinoma. She was referred
to us for an asymptomatic liver nodule in segment 8 that had increased in diameter from 5 to 15mm over the past 8months.
Ultrasonography showed a well-defined, oval, hypoechoic mass, and computed tomography showed a hypodense area without contrast
enhancement except for a ring-like enhancement during hepatic arteriography. Magnetic resonance imaging revealed a mass that
was hypointense on T1-weighted imaging and slightly hyperintense on T2-weighted imaging. The patient underwent hepatectomy
of segment 8. The resected specimen contained an oval nonencapsulated nodule with firm and gritty consistency and a well-defined
margin. Histologic findings were compatible with those of solitary necrotic nodule. Clinicians should recognize the existence
of this lesion as one of the differential diagnoses of metastatic liver nodule. Solitary necrotic nodules can change size,
and when enlarged, differentiation from metastasis is extremely difficult.
KeywordsNecrotic nodule-Liver-Metastasis
Clinical Journal of Gastroenterology 04/2012; 2(5):355-360.
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ABSTRACT: BACKGROUND: The incidence of surgical site infections (SSIs) is high after pancreaticoduodenectomy (PD). METHODS: We divided 116 consecutive patients who underwent PD into an early group (n = 58) and a later group (n = 58) according to time of surgery. In both groups, endoscopic retrograde biliary drainage was mainly employed for the patients with obstructive jaundice. In the later group, prophylactic antibiotics were selected according to the susceptibility of microorganisms isolated from SSIs in the early group. The incidence of SSIs was compared between the groups. RESULTS: The background characteristics (including methods of preoperative biliary drainage and microorganisms in the bile obtained before or during operation) of the patients were not significantly different between the groups, except for the serum albumin level, which was lower in the later group than in the early group (P = 0.0026). The incidence of SSIs was significantly lower in the later group (24.1 %) than in the early group (46.6 %) (P = 0.0116). Belonging to the later group was one independent negative risk factor for SSI. CONCLUSIONS: Selection of prophylactic antibiotics on the basis of microorganisms isolated from SSIs in the early group contributed to the reduced incidence of SSIs in the later group after PD.
Journal of hepato-biliary-pancreatic sciences. 04/2012;
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ABSTRACT: This study aimed to verify diagnostic criteria and severity assessment of the Tokyo Guidelines for acute cholangitis.
We re-examined whether acute cholangitis was concomitant with gallstones according to the Tokyo Guidelines in 248 patients with choledocholithiasis. Our conventional diagnoses based on physician decision were compared with diagnoses from the Tokyo Guidelines. Problems with severity grade criteria were also evaluated.
In total, 53 cases of acute cholangitis were determined by using the Tokyo Guidelines, including three false-negative and seven false-positive cases (acute cholecystitis or pancreatitis was concomitant with choledocholithiasis). Sensitivity, specificity, and accuracy were 94%, 96%, and 96%, respectively. Forty of the 53 patients underwent biliary drainage (mean interval between admission and drainage, 1.4 days). Severity grades were mild in 10, moderate in 30, and severe in 13 patients. Of these 13 patients with severe disease, 2 had chronic renal failure, 1 had liver cirrhosis, and 1 had severe acute pancreatitis and liver cirrhosis. No patients died, irrespective of severity grade.
Acute cholangitis should be carefully diagnosed when other inflammatory disease is concomitant with choledocholithiasis. A few patients have absolute acute cholangitis even when they do not meet Tokyo Guidelines diagnostic criteria. Classification into mild or moderate grade using the Tokyo Guidelines is difficult when early biliary drainage is routinely performed. When determining severity grade, clinicians must distinguish between organ dysfunction associated with cholangitis itself and that associated with the underlying/concomitant disease. Apart from a few problems like these, the Tokyo Guidelines are mostly acceptable for the diagnosis and management of acute cholangitis.
Journal of hepato-biliary-pancreatic sciences. 10/2011; 19(4):487-91.
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ABSTRACT: Surgical strategy for patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT) remains to be established.
From 1990 to 2008, 48 hepatocellular carcinoma patients with PVTT detected by preoperative imaging underwent hepatic resection, and their clinical data were retrospectively analyzed. Possible prognostic factors for survival were analyzed with postoperative survival curves, and significant factors were determined by univariate and multivariate analysis. The frequency of postoperative severe complications was investigated for each prognostic factor.
Significant prognostic factors included patient age <60 years, serum total bilirubin (T-Bil) >0.8 mg/dl, serum aspartate aminotransferase >30 IU/L, serum alkaline phosphatase (ALP) >300 IU/L, tumor size >4 cm, PVTT in the main trunk (Vp4), and a surgical margin <1 mm by univariate analysis, and independent prognostic factors were serum T-Bil, ALP, and Vp4. No patient with Vp4 survived for more than 400 days after surgery, and frequency of postoperative severe complications in these Vp4 patients was significantly higher than in other Vp1-3 patients.
Hepatic resection as a first-choice treatment should be carefully selected in patients with Vp4 unless emergent removal of the PVTT is required.
Journal of Gastrointestinal Surgery 03/2009; 13(6):1078-83. · 2.83 Impact Factor
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ABSTRACT: To examine whether vertical retrocolic duodenojejunostomy is superior to antecolic duodenojejunostomy with respect to gastric emptying in a prospective, randomized, controlled study of patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD).
Thirty-five patients undergoing PpPD between March 2005 and July 2007 were enrolled in the study. All provided informed consent. During PpPD, the patients were randomly assigned to either the antecolic (antecolic group, n = 17) or vertical retrocolic route (vertical retrocolic group, n = 18) just before the reconstruction. Each patient ingested (13)C-acetate in a liquid meal before surgery and on postoperative day (POD) 30. Gastric emptying variables (Tmax, T1/2) were determined and compared between groups.
Clinical delayed gastric emptying, defined as an inability of patients to take in an appropriate amount of solid food orally by POD 14, was found in 1 of 17 patients (6%) in the antecolic group and in 4 of 18 patients (22%) in the vertical retrocolic group, but the difference was not significant (P = 0.34). Tmax and T1/2 on POD 30 were prolonged in both groups in comparison to preoperative levels, but no significant difference was found between the two groups. Follow-up examinations revealed that gastric emptying had recovered to the preoperative level by POD 30 in approximately 80% of the patients, regardless of the reconstruction route.
Vertical retrocolic duodenojejunostomy does not seem to offer an advantage with respect to gastric emptying.
Journal of Hepato-Biliary-Pancreatic Surgery 01/2009; 16(1):49-55. · 1.60 Impact Factor
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ABSTRACT: Background/PurposeTo examine whether vertical retrocolic duodenojejunostomy is superior to antecolic duodenojejunostomy with respect to gastric
emptying in a prospective, randomized, controlled study of patients undergoing pylorus-preserving pancreaticoduodenectomy
(PpPD).
MethodsThirty-five patients undergoing PpPD between March 2005 and July 2007 were enrolled in the study. All provided informed consent.
During PpPD, the patients were randomly assigned to either the antecolic (antecolic group, n=17) or vertical retrocolic route (vertical retrocolic group, n=18) just before the reconstruction. Each patient ingested 13C-acetate in a liquid meal before surgery and on postoperative day (POD) 30. Gastric emptying variables (Tmax, T1/2) were
determined and compared between groups.
ResultsClinical delayed gastric emptying, defined as an inability of patients to take in an appropriate amount of solid food orally
by POD 14, was found in 1 of 17 patients (6%) in the antecolic group and in 4 of 18 patients (22%) in the vertical retrocolic
group, but the difference was not significant (P=0.34). Tmax and T1/2 on POD 30 were prolonged in both groups in comparison to preoperative levels, but no significant difference
was found between the two groups. Follow-up examinations revealed that gastric emptying had recovered to the preoperative
level by POD 30 in approximately 80% of the patients, regardless of the reconstruction route.
ConclusionsVertical retrocolic duodenojejunostomy does not seem to offer an advantage with respect to gastric emptying.
Journal of Hepato-Biliary-Pancreatic Surgery 12/2008; 16(1):49-55. · 1.60 Impact Factor
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ABSTRACT: To clarify the characteristics of hepatocellular carcinoma (HCC) with bile duct invasion, we retrospectively analyzed clinical features and surgical outcome of HCC with bile duct invasion (b(+) group, n = 15) compared to those without bile duct invasion (b(-) group, n = 256). In the b(+) group, four patients (27%) showed obstructive jaundice, and a diagnosis of bile duct invasion was obtained preoperatively in seven patients (47%). The levels of serum bilirubin and carbohydrate antigen 19-9 were significantly higher in the b(+) group. Macroscopically, confluent multinodular type and infiltrative type were predominant in the b(+) group (P = 0.002). Microscopically, capsule infiltration (P = 0.040) and intrahepatic metastasis (P = 0.013) were predominant in the b(+) group. Portal vein invasion was associated significantly with the b(+) group (P = 0.004); however, the frequency of hepatic vein invasion was similar (P = 0.096). The median survival after resection was significantly shorter in the b(+) group than in the b(-) group (11.4 vs. 56.1 months, P = 0.002), and eight of 11 intrahepatic recurrences in the b(+) group occurred within 3 months after surgery. HCC with bile duct invasion has an infiltrative nature and a high risk of intrahepatic recurrence, resulting in poor prognosis.
Journal of Gastrointestinal Surgery 12/2008; 13(3):492-7. · 2.83 Impact Factor
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ABSTRACT: Hepatic resection is one of the main treatment modalities for patients with hepatocellular carcinoma (HCC); however, surgery is generally stressful and often is avoided for elderly patients. This retrospective study was designed to determine whether the indications for hepatic resection in younger patients with HCC are applicable to elderly patients.
Subjects were 294 patients in whom 319 hepatic resections were performed for HCC (male/female ratio, 238/81; age range, 18-83 years). The patients were divided into two groups according to age at the time of surgery: 70 years or older (n = 109) and 69 years or younger (n = 210). Surgical strategy and postoperative follow-up methods did not differ between groups. The incidence and severity of postoperative complications classified by the Clavien system were compared between the two groups. Postoperative survival was compared between the two groups and between subgroups based on Japan Integrated Staging (JIS) scores. HCC-related death rates also were compared.
No significant between-group difference was found in background liver function or type of hepatic resection. Differences were found in performance status and type of hepatitis virus infection. No difference was observed in the incidence or severity of postoperative complications. Postoperative survival was similar between the two age-based study groups and between the JIS-based subgroups. HCC-related death rates did not differ between groups.
The absence of differences in postoperative outcomes between groups suggests that hepatic resection is justified for HCC in selected patients aged 70 years or older.
World Journal of Surgery 10/2008; 32(10):2223-9. · 2.36 Impact Factor
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ABSTRACT: To evaluate surgical results and the effect of adjuvant chemotherapy in cases of hilar cholangiocarcinoma, we retrospectively analyzed 27 consecutive patients who underwent surgical resection (eight bile duct resections, 18 bile duct resections plus hepatectomy, one hepatopancreaticoduodenectomy). There was no operative mortality, and the morbidity was 37%. Curative resection (R0 resection) was achieved in 20 (74%) patients. Overall survival at 3 and 5 years was 44% and 27%, significantly higher than that of 47 patients who did not undergo resection (3.5% and 0% at 3 and 5 years, p < 0.0001). Survival of patients with positive margins (R1/2 resection) was poor; there were no 5-year survivors. However, survival was better than that of patients who did not undergo resection (median survival: 22 vs 9 months, p = 0.0007). Univariate analysis identified lymph node metastasis as a negative prognostic factor (p = 0.043). Median survival of patients who underwent adjuvant chemotherapy was significantly longer than that of patients who did not (42 vs. 22 months, p = 0.0428). Resection should be considered as the first option for hilar cholangiocarcinoma. There appears to be a survival advantage even in patients with cancer-positive margins. Adjuvant chemotherapy may increase long-term survival.
Journal of Gastrointestinal Surgery 06/2008; 12(6):1033-40. · 2.83 Impact Factor
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ABSTRACT: Long-term postoperative survival and prognostic factors were examined retrospectively in patients with hepatocellular carcinoma (HCC) with serum hepatitis B surface antigen (HBsAg) or hepatitis C antibody (HCVAb) and in those without virus infection. Subjects were 265 consecutive HCC patients treated surgically at one institution during the period 1990 to 2006. Postoperative survival was analyzed and compared between HBsAg-positive (B-HCC), HCVAb-positive (C-HCC), and hepatitis B- and C-negative (NBNC-HCC) patients. Prognostic factors for overall and recurrence-free survival were also analyzed. Overall and recurrence-free survival rates were significantly higher in the NBNC-HCC group than in the C-HCC group. Significant prognostic factors for overall survival identified by univariate and multivariate analyses were age, serum alkaline phosphatase (ALP) level, tumor multiplicity, portal vein invasion (Vp), hepatic vein invasion (Vv), and operative blood loss in the B-HCC group; serum albumin level, ALP level, tumor size, and Vv in the C-HCC group; and tumor multiplicity in the NBNC-HCC group. Significant factors for recurrence-free survival were age, ALP level, tumor multiplicity, Vp, and operation time in the B-HCC group; ALP level, prothrombin time, tumor size, Vv, and width of the surgical margin in the C-HCC group; and age, tumor size, tumor multiplicity, and Vp in the NBNC-HCC group. Thus, postoperative survival and prognostic factors in cases of HCC differ according to the presence of serologic viral markers.
Journal of Gastrointestinal Surgery 04/2008; 12(3):468-76. · 2.83 Impact Factor
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ABSTRACT: A 77-year-old woman with a complaint of itching was shown to have an elevated serum bilirubin level. She had no history of liver disease. Computed tomography and magnetic resonance cholangiopancreatography revealed a 17-mm-diameter cystic lesion obstructing the main hepatic duct at the hepatic hilum. Drip infusion cholangiographic computed tomography and endoscopic retrograde cholangiography showed that the cyst did not communicate with the biliary tree; thus, a peribiliary cyst was diagnosed. Cystectomy was performed, and the jaundice resolved. Peribiliary cysts are generally asymptomatic and rarely cause obstructive jaundice. They are usually multiple and caused by an underlying liver disorder with a poor prognosis. Our case suggests that peribiliary cysts can arise in healthy liver and cause symptoms. Cystectomy is the treatment of choice if the cyst is solitary.
Journal of Gastrointestinal Surgery 01/2008; 13(1):174-6. · 2.83 Impact Factor
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ABSTRACT: The aim of this study was to clarify the role of bile duct resection without hepatectomy (hilar resection) in hilar cholangiocarcinoma.
We retrospectively compared surgical results for hilar cholangiocarcinoma between 8 patients treated with hilar resection and 21 patients treated with hepatectomy.
All hilar resections were performed for Bismuth type I or II tumors with T2 or less lesions, whereas hepatectomy was done for type III or IV tumors excluding one type II tumor. R0 resection was equally achieved in both groups (62.5% in hilar resection group and 76.2% in hepatectomy group, p=0.469) and overall 5-year survival rates were comparable (21.9% vs. 23.6%, p=0.874). With respect to gross tumor appearance, R0 resection was achieved in all patients with papillary tumor in both groups with the excellent 5-year survivals (100% vs. 100%). In patients with nodular and flat tumors, R0 resection was achieved less frequently in the hilar resection vs. hepatectomy group (50% vs. 77.8%) mainly due to failure to clear the proximal ductal margin, resulting in poorer 5-year survival (0% vs. 18.7%).
Hilar resection may be indicated for papillary T1 or 2 tumors in Bismuth type I or II cholangiocarcinoma.
Hepato-gastroenterology 59(115):696-700. · 0.66 Impact Factor
