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ABSTRACT: The aim of the study was to clarify the incidence, risk factors and treatment of percutaneous transhepatic biliary drainage (PTBD) catheter tract recurrence in patients with resected cholangiocarcinoma.
The medical records of 445 patients with perihilar and distal cholangiocarcinoma who underwent resection following PTBD were reviewed retrospectively.
PTBD catheter tract recurrence was detected in 23 patients (5.2 per cent). The mean(s.d.) interval between surgery and onset of the recurrence was 14.4(13.8) months. On multivariable analysis, duration of PTBD (60 days or more), multiple PTBD catheters and macroscopic papillary tumour type were identified as independent risk factors. In four patients with synchronous metastasis, the PTBD sinus tract was resected simultaneously, at the time of initial surgery. Of 19 patients with metachronous metastasis, 15 underwent surgical resection of the metastasis. Survival of the 23 patients with PTBD catheter tract recurrence was poorer than that of the 422 patients without recurrence (median 22.8 versus 27.3 months; P = 0.095). Even after surgical resection of PTBD catheter tract recurrence, survival was poor.
PTBD catheter tract recurrence is not unusual. The prognosis for these patients is generally poor, even after resection. To prevent this troublesome complication, endoscopic biliary drainage is first recommended when drainage is indicated.
British Journal of Surgery 12/2010; 97(12):1860-6. · 4.61 Impact Factor
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ABSTRACT: The term perihilar cholangiocarcinoma has been used for all tumours involving or requiring resection of the hepatic confluence. However, it does not distinguish between intrahepatic and extrahepatic hilar tumours, and has no clinicopathological basis. This retrospective study examined whether the concept of perihilar cholangiocarcinoma is valid clinically.
Some 250 patients with perihilar cholangiocarcinoma were divided into extrahepatic (EHC, 167 patients) and intrahepatic (IHC, 83) groups based on tumour location. Clinicopathological data were compared between these groups.
Liver, portal vein, venous and lymphatic invasion, and nodal metastasis were more common in IHCs than EHCs, whereas histological grade and incidence of perineural invasion were similar. IHCs were more advanced at the time of surgery; stage III or IV disease was found in 37.7 per cent of EHCs and 59 per cent of IHCs. Survival was marginally better for patients with EHCs than for those with IHCs (29.3 versus 20 per cent at 5 years; P = 0.057), but survival rates were similar for each tumour stage in the American Joint Committee on Cancer classification.
Combining EHC and IHC under the term perihilar cholangiocarcinoma is valid, as these tumours have comparable biological behaviour, with similar clinical management depending on stage and invasion.
British Journal of Surgery 09/2009; 96(8):926-34. · 4.61 Impact Factor
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ABSTRACT: Farrar's criteria for cystic duct carcinoma (histopathologic diagnosis of a carcinoma strictly limited to the cystic duct) are impractical especially when making a diagnosis of primary cystic duct carcinoma in its advanced stage. Therefore, in our previous study, we proposed a new definition of cystic duct carcinoma: a gallbladder tumor, the center of which is located in the cystic duct. In this study, we further propose a new classification for cystic duct carcinomas diagnosed by our definition.
This study included 44 surgical patients with cystic duct carcinoma diagnosed by our criteria. These patients were further classified into two groups: hepatic hilum type (HH, n = 29), in which the tumor mainly invades the hepatic hilum, and cystic confluence type (CC, n = 15), in which the tumor mainly involves the confluence of the cystic duct. The clinicopathologic features of these two groups were analyzed retrospectively.
There was more papillary or well differentiated adenocarcinoma in the CC type lesions than in the HH type. The perineural and vascular invasion were more common in the HH type than in the CC type. The survival rate tends to be higher for patients with the CC type than for those with the HH type (p = 0.064). Moreover, we found a significantly different sex ratio between these two groups (female sex was predominant for the HH type, whereas male sex was predominant for the CC type).
Our new classification showed two distinct types of advanced cystic duct carcinoma, which may help in understanding the clinical characteristics of the carcinoma originated in the cystic duct.
World Journal of Surgery 05/2008; 32(4):621-6. · 2.36 Impact Factor
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ABSTRACT: BACKGROUND: Portal vein embolization (PVE) improves outcome following major hepatectomy, and basic studies have presented evidence related to the mechanisms responsible for hepatic regeneration. Hemodynamic changes following PVE are similar to, but slightly different from, those of partial hepatectomy (PH) because arterial flow to the embolized lobe is preserved. However, the process of hepatic regeneration is essentially the same after both PVE and PH. A number of mediators are involved in PVE or PH-induced hepatic regeneration. These include inflammatory cytokines, vasoregulators, growth factors, eicosanoids, and various hormones. These mediators activate a complex network of signal transduction that promotes hepatic regeneration. A variety of conditions have been shown to modulate the function of these mediators and inhibit regeneration. These include biliary obstruction, diabetes, chronic ethanol consumption, malnutrition, gender, aging, and infection. CONCLUSION: Optimizing these factors, where possible, before PVE or PH, is essential to maximize hypertrophy of the liver. A fuller understanding of hepatic physiology and pathophysiology following PVE or PH may lead to greater functional capacity of the remaining liver and extend the indications for hepatectomy in patients who require large liver volume resection.
World Journal of Surgery 03/2007; 31(2):367-74. · 2.36 Impact Factor
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ABSTRACT: Although intrahepatic cholangiojejunostomy is technically difficult, with recent improvements in surgery it should be possible to perform the anastomosis safely. The aim of this study was to evaluate the incidence of anastomotic leak after intrahepatic cholangiojejunostomy and to identify risk factors for such leakage.
Intrahepatic cholangiojejunostomy was performed in 423 patients undergoing hepatobiliary resection between January 1991 and December 2005. Anastomotic leak was proven radiographically by leakage from the anastomosis of contrast medium introduced via a biliary drainage tube placed during surgery.
Anastomotic leak occurred in 27 patients (6.4 per cent), and was not related to the number of bile ducts reconstructed. The leak rate decreased significantly from 9.5 per cent (19 of 199) in the first 10 years to 3.6 per cent (eight of 224) in the last 5 years. Anastomotic leak was often followed by infections such as wound infection, intra-abdominal abscess and bacteraemia. Multivariable analysis identified age and intraoperative blood loss as independent risk factors for anastomotic leak. All leaks were treated by maintaining a prophylactically placed drain near the cholangiojejunostomy; neither repeat laparotomy nor percutaneous transhepatic biliary drainage was required.
Although demanding, intrahepatic cholangiojejunostomy can be performed successfully with a relatively low failure rate. Routine use of prophylactic drains and anastomotic stenting allows safe management of anastomotic leak with conservative therapy.
British Journal of Surgery 02/2007; 94(1):70-7. · 4.61 Impact Factor
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ABSTRACT: Macroscopic volume changes after portal vein embolization (PVE) can be assessed accurately by computed tomography, but histological changes remain poorly understood. The aim of this study was to clarify hepatocyte morphology and kinetics after PVE.
The resected livers from 25 patients who underwent extended hepatectomy after PVE and five normal livers were examined using hepatocyte paraffin 1 staining for histomorphometric analysis of hepatocytes. Cell kinetics were determined by Ki-67 staining and terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick-end labelling assay. Kupffer cells were examined by CD68 immunostaining.
The number of hepatocytes was similar in the embolized lobe, non-embolized lobe and normal liver, but hepatocyte volume was greater in the non-embolized lobe than in the embolized lobe (P = 0.017). The Ki-67 labelling index was higher in the non-embolized lobe (P < 0.001) whereas the apoptotic index was higher in the embolized lobe (P < 0.001). There were more Kupffer cells per unit area in the embolized lobe (P < 0.001).
Hepatocyte hypertrophy and replication leads to volume enlargement of the non-embolized hepatic lobe, whereas hepatocyte atrophy and apoptosis causes a decrease in volume of the embolized lobe.
British Journal of Surgery 06/2006; 93(6):745-51. · 4.61 Impact Factor
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ABSTRACT: Hepatobiliary resection with caudate lobectomy has been conducted in the surgical treatment of bile duct carcinoma of the hepatic hilus. However, insufficient attention has been paid to the anatomy of the right portion of the caudate lobe, and techniques to visualize the portal branches of the right caudate lobe (P1r) have not been reported. Contrast medium was injected into the dorso-caudal branches of the middle hepatic vein (MHV) and images were obtained by digital subtraction venography. Retrograde portography of the P1r was achieved in 64 (84%) out of 76 cases. The mean number of visualized branches was 2.1 (137 out of 64) and the P1r coursed beyond the trunk of the MHV in 36 (56%) out of the 64 cases. Contrast medium flowed into the right portal vein from 59 P1r branches in 32 cases and into the left portal vein in 20 cases. No complications were encountered. Retrograde portograms of the P1r may provide valuable information not previously available to surgeons operating on the caudate lobe.
Surgical and Radiologic Anatomy 03/2004; 26(1):24-7. · 1.06 Impact Factor
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ABSTRACT: The aim of this study was to determine the most appropriate line of resection for extrahepatic bile duct carcinoma.
A retrospective review was carried out of 253 resected specimens of extrahepatic bile duct carcinoma. Carcinomas were classified histologically as invasive or non-invasive in addition to assessment of the resection margin.
Tumour was present microscopically at the resection margin in 80 (31.6 per cent) of 253 cases, with 46 showing marginal involvement by non-invasive carcinoma, 20 showing invasive carcinoma at a margin, and 14 showing both. Involvement of the resection margin by invasive carcinoma was encountered only when the margin was shorter than 10 mm, whereas non-invasive carcinoma was encountered even when the margin length reached 40 mm. The observed length of microscopic extension of invasive carcinoma beyond the macroscopically evident tumour mass was limited to 10.0 mm. Median microscopic extension of non-invasive carcinoma beyond the mass was 10 mm (75th percentile 19.5 and 14.5 mm in proximal and distal directions respectively; maximum 52 mm). Margins of 20 mm could be assured to be negative proximally in 89.0 per cent of cases and distally in 93.8 per cent.
For eradication of invasive extrahepatic bile duct carcinoma, a 10-mm margin is required. However, additional removal of any non-invasive component requires a 20-mm margin. These guidelines should be followed in any operation performed with curative intent.
British Journal of Surgery 11/2002; 89(10):1260-7. · 4.61 Impact Factor
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Endoscopy 10/2002; 34(9):751. · 5.21 Impact Factor
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ABSTRACT: The clinical significance of perineural invasion of gallbladder carcinoma remains unclear. The aim of this study was to elucidate the incidence and mode of perineural invasion of gallbladder carcinoma and clarify its prognostic significance.
A clinicopathological study was conducted on 68 patients who underwent attempted curative resection for gallbladder carcinoma. According to the pathological tumour node metastasis (pTNM) classification of the Union Internacional Contra la Cancrum, there were five (7 per cent), nine (13 per cent), 20 (29 per cent) and 34 (50 per cent) patients with pT1, pT2, pT3 and pT4 disease respectively. Twenty patients (29 per cent) had pM1 disease, including involved para-aortic nodes, liver metastases and localized dissemination.
The overall incidence of perineural invasion was 71 per cent (48 of 68 patients). Forty-four (96 per cent) of 46 patients with extrahepatic bile duct invasion had perineural invasion. Although several histological factors were associated with perineural invasion, multivariate analysis demonstrated that extrahepatic bile duct invasion was the only significant factor correlated with perineural invasion (odds ratio 99.0, P < 0.001). The perineural invasion index, defined as the ratio of the number of involved nerves to the total number of nerves examined, was significantly higher at the centre than in the proximal and distal parts of the tumour in the 46 patients with extrahepatic bile duct invasion (P < 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower than that for patients with no invasion (7 versus 72 per cent; P < 0.001). Cox proportional hazard analysis identified perineural invasion (relative risk (RR) 5.3, P < 0.001) and lymph node metastasis (RR 2.5, P = 0.008) as significant independent prognostic factors.
Perineural invasion is common in advanced gallbladder carcinoma and has a significant negative impact on patient survival.
British Journal of Surgery 09/2002; 89(9):1130-6. · 4.61 Impact Factor
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ABSTRACT: The relationship between atherosclerosis and abdominal aortic aneurysm is now controversial. To better define the contribution of atherosclerosis to the development of aneurysm of the infrarenal aorta, we determined the incidence of aortic dilatation in patients undergoing arterial reconstruction for an atherosclerotic aortoiliac occlusive disease (AIOD). The role of aortic wall calcification and intraluminal thrombus was also determined.
Setting: patients treated in a university hospital. Subjects: 40 patients who underwent bifurcated graft bypass operation for AIOD without an abdominal aortic aneurysm =or>4 cm in size.
Diameter, luminal calcification and intraluminal thrombus of the infrarenal aorta were evaluated using preoperative contrast enhancement computed tomography.
Sixteen patients (40%) had an infrarenal aorta larger than the aorta at the level of the left renal vein. Of these, 5 patients (12.5%) had a 50% enlargement or more. Infrarenal aortic diameter correlated negatively with the extent of calcification of the infrarenal aorta and positively with the amount of intraluminal thrombus.
Infrarenal aortic dilatation less than 4 cm in size is not unusual in patients with AIOD, suggesting a possible relationship between aortic atherosclerosis and dilatation. An aorta with atherosclerotic plaque containing abundant thrombus and few calcifications may develop enlargement.
International angiology: a journal of the International Union of Angiology 09/2002; 21(3):222-7. · 1.65 Impact Factor
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ABSTRACT: The purpose of this study was to clarify the efficacy of, and define the indications for, extensive surgery for gallbladder carcinoma.
Between 1979 and 1994, 116 patients with gallbladder carcinoma underwent operation. Radical resection was performed in 80 patients.
In 68 patients with stage III or IV disease, extensive resection including extended right hepatectomy (n = 40), pancreaticoduodenectomy (n = 23) and/or portal vein resection (n = 23) was employed to achieve complete tumour excision. The hospital mortality rate was 18 per cent. The postoperative 3- and 5-year survival rates were 44 and 33 per cent respectively in the patients with stage III disease (n = 9), and 24 and 17 per cent respectively in patients with stage IV (M0) disease (n = 29). In contrast, the postoperative survival rate for the 30 patients with stage IV (M1) disease (7 per cent at 3 years and 3 per cent at 5 years) was worse than that for patients with stage III and stage IV (M0) disease (P = 0.009 and P = 0.062 respectively).
Radical resection should be undertaken for stage III and stage IV (M0) gallbladder cancer. Although portal vein resection and/or pancreaticoduodenectomy did not contribute to long-term survival, better survival was obtained than that for the unresected patients.
British Journal of Surgery 03/2002; 89(2):179-84. · 4.61 Impact Factor
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ABSTRACT: Portal vein resection has become common in hepatobiliary resection for biliary cancer with curative intent. When cancer invasion of the portal vein is very limited, wedge resection followed by transverse closure is indicated. Longitudinal closure is contraindicated, as this procedure causes stenosis of the portal vein. In the case of right hepatectomy, segmental resection is feasible before liver transection. Reconstruction is completed with end-to-end anastomosis, in which an intraluminal technique is used for posterior anastomosis and an over-and-over suture for anterior anastomosis. More than 5-cm resection of the portal vein often requires reconstruction with an autovein graft. In the case of left hepatectomy, portal vein resection after liver transection is preferable. The resection and reconstruction method should be determined based on both the extent of cancer invasion of the right portal vein and the length of the right portal trunk. So far, we have aggressively carried out combined portal vein and liver resection in 106 patients with advanced biliary cancer (62 cholangiocarcinoma and 44 gallbladder carcinoma). Twenty-nine patients underwent wedge resections and 77 segmental resections (66 end-to-end anastomosis and 11 autovein grafting using an external iliac vein). In patients with hilar cholangiocarcinoma (n = 58), 3- and 5-year survival rates were 23% and 8%, respectively. Three patients survived for more than 5 years after resection. In contrast, the prognosis of patients with gallbladder cancer (n = 44) was dismal. All of the patients died within 3 years after surgery, although they survived statistically longer than unresected patients. These data suggest that portal vein resection has survival benefit for patients with cholangiocarcinoma. However, the indications for this procedure in gallbladder cancer should be reevaluated.
Nippon Geka Gakkai zasshi 12/2001; 102(11):815-9.
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ABSTRACT: We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30-day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).
World Journal of Surgery 10/2001; 25(10):1277-83. · 2.36 Impact Factor
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ABSTRACT: p73, a homologue of p53 gene, is expressed in several normal tissues including central nervous system, but data regarding tumors are scant. In this study, we have analyzed the status and expression of the p73 gene in primary breast tumors, as well as 4 normal salivary glands, 2 carcinomas with metaplasia and mixed tumors. We found that periductal myoepithelial cells of all of the mammary gland examined were clearly stained with the specific anti-p73 antibody. Furthermore, we found the expression of p73 in the neoplastic myoepithelial cells in carcinomas with metaplasia and in mixed tumors. The findings in the present study provide valuable information on the characteristics of myoepithelial cells.
International Journal of Oncology 09/2001; 19(2):271-6. · 2.40 Impact Factor
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ABSTRACT: Superoxide production in response to cyclic stretch (1 Hz, 20% in length) was investigated in human umbilical vein endothelial cells (HUVECs). The basal production of superoxide without stretch increased gradually, while the production of superoxide with stretch increased significantly as compared to that without stretch and it became significant 80 min after the onset of cyclic stretch (P<0.05, n=8-14). The superoxide production increased in a stretch-dependent manner and became significant when stretch was more than 10% (p<0.05, n=11-16). To investigate the involvement of SA channel, we added Gd3+ or EGTA in the reaction solution and examined the stretch-induced superoxide production. In cells stretched in the presence of 20 microM Gd3+, the stretch-induced superoxide production was significantly inhibited (at 120 min, p<0.05, n=8-18). The cyclic stretch-induced superoxide production was also significantly inhibited by the removal of extracellular Ca2+ with 5 mM EGTA (at 120 min, p<0.05, n=8-18). Neither the application of Gd3+ nor the removal of extracellular Ca2+ significantly changed the basal production of superoxide. These data suggest that the stretch-induced superoxide production increases in time- and stretch-dependent manner and that the stretch-induced superoxide production in HUVECs is regulated by Ca2+ influx through SA channels.
Life Sciences 09/2001; 69(15):1717-24. · 2.53 Impact Factor
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ABSTRACT: The aim of this study was to evaluate serial changes in liver volume after major hepatectomy for biliary cancer and to elucidate clinical factors influencing liver regeneration.
Serial changes in liver volume were determined, using computed tomography, in 81 patients with biliary cancer who underwent right hepatic lobectomy or more extensive liver resection with or without portal vein resection and/or pancreatoduodenectomy. Possible factors influencing liver regeneration were evaluated by univariate and multivariate analyses.
The remnant mean(s.d.) liver volume was 41(8) per cent straight after hepatectomy. This increased rapidly to 59(9) per cent within 2 weeks, then increased more slowly, finally reaching a plateau at 74(12) per cent about 1 year after hepatectomy. The regeneration rate within the first 2 weeks was 16(8) cm3/day and was not related to the extent of posthepatectomy liver dysfunction. On multivariate analysis, the extent of liver resection (P < 0.001), body surface area (P = 0.02), combined portal vein resection (P = 0.024) and preoperative portal vein embolization (P = 0.047) were significantly associated with the liver regeneration rate within the first 2 weeks. In addition, body surface area (P < 0.001) and liver function expressed as plasma clearance rate of indocyanine green (P = 0.01) were significant determinants of final liver volume 1 year after hepatectomy.
The liver regenerates rapidly in the first 2 weeks after major hepatectomy for biliary cancer. This early regeneration is influenced by four clinical factors. Thereafter, liver regeneration progresses slowly and stops when the liver is three-quarters of its original volume, approximately 6 months to 1 year after hepatectomy.
British Journal of Surgery 08/2001; 88(8):1084-91. · 4.61 Impact Factor
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Endoscopy 08/2001; 33(7):643. · 5.21 Impact Factor
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ABSTRACT: The aim of this study was to clarify clinicopathologic characteristics of, and to evaluate an aggressive treatment strategy for, hepatocellular carcinoma with biliary tumor thrombi.
From 1980 to 1999, a total of 132 patients underwent hepatectomy for hepatocellular carcinoma. Of these, 17 patients had macroscopic biliary tumor thrombi and were retrospectively analyzed.
The operative procedures included right hepatic trisegmentectomy (n = 1), right or left hepatic lobectomy (n = 11), and segmentectomy or subsegmentectomy (n = 5). In 13 patients, tumor thrombi extended beyond the hepatic confluence and was treated by thrombectomy through a choledochotomy in 8 patients and extrahepatic bile duct resection and reconstruction in 5 patients. The 3- and 5-year survival rates were 47% and 28%, respectively, with a median survival time of 2.3 years. These survival rates were similar to those achieved in 115 patients without biliary tumor thrombi. In a multivariate analysis, expansive growth type and solitary tumors were independent prognostic variables for favorable outcome after operation, whereas biliary tumor thrombi was not a significant prognostic factor.
Surgery after appropriate preoperative management of hepatocellular carcinoma with biliary tumor thrombi yields results similar to those of patients without biliary involvement. Hepatectomy with thrombectomy through a choledochotomy appears to be as effective as a resection procedure.
Surgery 07/2001; 129(6):692-8. · 3.10 Impact Factor
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ABSTRACT: Inflammatory pseudotumors involving the hepatic hilum are rare. Only 14 cases have been reported (Table). Liver transplantation has been required when the pseudotumor has invaded extensively into the right and left lobes. (1,2) However, transplantation is associated with the lifelong use of immunosuppressants. This is particularly problematic in children. we report a case of a 6-year-old boy with an inflammatory pseudotumor extensively invading the hepatic hilum who was treated with aggressive surgical excision using the techniques devised for the treatment of hilar cholangiocarcinoma. (3)
Surgery 07/2001; 129(6):757-60. · 3.10 Impact Factor
