[Show abstract][Hide abstract] ABSTRACT: . Hepatic peribiliary cysts (HPCs) usually originate due to the cystic dilatation of the intrahepatic extramural peribiliary glands. We describe our rare experience of pure laparoscopic left hemihepatectomy (PLLH) in a patient with HPCs accompanied by a component of biliary intraepithelial neoplasia (BilIN).
. A 65-year-old man was referred for further investigation of mild hepatic dysfunction. Contrast-enhanced computed tomography showed dilatation of the left-sided intrahepatic bile duct, and biliary cytology showed class III cells. The patient was highly suspected of having left side-dominated cholangiocarcinoma and underwent PLLH. Microscopic findings revealed multiple cystic dilatations of the extramural peribiliary glands; hence, this lesion was diagnosed as HPCs. The resected intrahepatic bile duct showed that the normal ductal lumen comprised low columnar epithelia; however, front formation on the BilIN was observed in some parts of the intrahepatic bile duct, indicating that the BilIN coexisted with HPCs.
We chose surgical therapy for this patient owing to the presence of some features of biliary malignancy. We employed noble PLLH as a minimally invasive procedure for this patient.
[Show abstract][Hide abstract] ABSTRACT: Background:
In a statement by the second International Consensus Conference for Laparoscopic Liver Resection (LLR), minor LLR was confirmed to be a standard surgical practice, as it has become adopted by an increasing proportion of surgeons. However, it is unclear whether this applies to the more complex group of patients suffering from cirrhosis. Therefore, the aim of this retrospective study was to compare the feasibility and safety of LLR for hepatocellular carcinoma (HCC) between non-liver cirrhosis (NLC) patients and liver cirrhosis (LC) patients at a single high-volume laparoscopy center.
From the beginning of 2000 to the end of 2013, open liver resection (OLR) was performed in 99 HCC patients, and LLR was in 118. The HCC patients who underwent LLR were divided into NLC-LLR (n=60) and LC-LLR (n=58) groups, and we compare the short-term outcomes between them.
There was no significant difference in the incidence of blood loss and transfusion requirements between the NLC-LLR group and the LC-LLR group, although wedge resection was mainly performed in the LC-LLR group. There was no significant difference in the complication rate between the two groups, and the remarkable finding was that there was a significantly lower incidence of postoperative ascites in the LC-LLR group than in the NLC-LLR group.
According to our experience, it appears that LLR for selected HCC patients with cirrhosis is a feasible and promising procedure that is associated with less blood loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted.
[Show abstract][Hide abstract] ABSTRACT: The incidence of double cancer of the esophagus and breast is rare, and axillary lymph node metastasis (ALM) in esophageal cancer is also very rare. We report a case of advanced esophageal cancer with left ALM and synchronous right breast cancer. A 64-year-old woman was admitted to our hospital with dysphagia. The clinical diagnosis was esophageal cancer (T3N0M1 stage IV) and right breast cancer (T1cN0M0 stage I). She was initially treated with triple chemotherapy with docetaxel, cisplatin, and 5-fluorouracil. The primary lesion in the esophagus achieved almost complete response as assessed by esophageal endoscopy. A computed tomography scan showed that the left ALM reduced in size and that stable disease was achieved for the right breast cancer. She underwent partial mastectomy of the right breast and bilateral axillary lymph node dissection. The histopathological diagnosis of the breast cancer was T1cN1M0 stage IIA. The lymph nodes from the left axilla contained metastatic cells from the squamous cell carcinoma of the esophagus. Complete response was achieved for the primary lesion in the esophagus following chemoradiotherapy (CRT), and the patient has been relapse free 2 years after treatment. Thus, we report the successful treatment of synchronous double cancers of the esophagus with left ALM and right breast by combination therapy with chemotherapy, CRT, and surgery.
[Show abstract][Hide abstract] ABSTRACT: Introduction:
Small-cell carcinoma of the esophagus (SCCE) is a rare disease with aggressive progression and a poor prognosis. A standard treatment strategy for SCCE is yet to be established.
Presentation of case:
A 40-year-old woman with dysphagia was admitted to our hospital. A clinical diagnosis of SCCE (T3N1N0 stage IIIA) was established. She was initially treated with chemotherapy using cisplatin (CDDP) and irinotecan (CPT-11). After two courses of treatment, the primary lesion in the esophagus was not detectable by esophageal endoscopy. Likewise, swelling of the right recurrent nerve lymph node present prior to treatment could not be detected. The chemotherapy resulted in a complete response. One month after the conclusion of chemotherapy, radical esophagectomy with three-field lymph node dissection was performed. Histopathological examination of the excised specimen revealed no residual tumor or lymph node metastasis. The patient was discharged from hospital 29 days after surgery with no complications. The patient is alive and has remained cancer-free for 48 months after the surgery.
Systemic chemotherapy for SCCE in combination with surgery was treated after surgery in most reports. Neoadjuvant chemotherapy is advantageous from three viewpoints, namely achievement of downstaging, increasing complete resection rates, and a better completion of treatment compared with postoperative chemotherapy. Neoadjuvant chemotherapy following esophagectomy could be a useful treatment option for patients with limited disease (LD) of SCCE.
We report a case of SCCE achieving a pathologically complete response with neoadjuvant chemotherapy using CDDP and CPT-11, and long-term survival followed by surgery.
Preview · Article · Nov 2015 · International Journal of Surgery Case Reports
[Show abstract][Hide abstract] ABSTRACT: Background
A strategy for accelerating liver regeneration after hepatectomy would offer great benefits in preventing postoperative liver failure and improving surgical outcomes. Transforming growth factor (TGF) β is a potent inhibitor of hepatocyte proliferation. Recently, thrombospondin (TSP) 1 has been identified as a negative regulator of liver regeneration by activation of local TGF-β signals. This study aimed to clarify whether the LSKL (leucine–serine–lysine–leucine) peptide, which inhibits TSP-1-mediated TGF-β activation, promotes liver regeneration after hepatectomy in mice.
Mice were operated on with a 70 per cent hepatectomy or sham procedure. Operated mice received either LSKL peptide or normal saline intraperitoneally at abdominal closure and 6 h after hepatectomy. Perioperative plasma TSP-1 levels were measured by enzyme-linked immunosorbent assay in patients undergoing hepatectomy.
Administration of LSKL peptide attenuated Smad2 phosphorylation at 6 h. S-phase entry of hepatocytes was accelerated at 24 and 48 h by LSKL peptide, which resulted in faster recovery of the residual liver and bodyweight. Haematoxylin and eosin tissue staining and blood biochemical examinations revealed no significant adverse effects following the two LSKL peptide administrations. In the clinical setting, plasma TSP-1 levels were lowest on the first day after hepatectomy. However, plasma TSP-1 levels at this stage were significantly higher in patients with subsequent liver dysfunction compared with levels in those without liver dysfunction following hepatectomy.
Only two doses of LSKL peptide during the early period after hepatectomy can promote liver regeneration. The transient inhibition of TSP-1/TGF-β signal activation using LSKL peptide soon after hepatectomy may be a promising strategy to promote subsequent liver regeneration.
Full-text · Article · Apr 2015 · British Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Benign esophageal tumors are rare, with a prevalence of 0.005–5.1 %, based on autopsy results, and account for <1–10 % of all esophageal neoplasms. Leiomyomas constitute 70–80 % of these benign esophageal neoplasms. Other benign esophageal tumors, such as granular cell tumors or schwannomas, are extremely rare. Esophageal leiomyomas are usually detected in patients between 20 and 50 years of age, with a twofold male predominance, and most commonly occur in the lower third of the esophagus. At least 50 % of patients with esophageal leiomyomas are asymptomatic; in symptomatic individuals, dysphagia is the most commonly reported symptom, followed by chest tightness and pain. These tumors are usually discovered, incidentally, during esophagography or endoscopic examination of the upper gastrointestinal tract for unrelated reasons. The treatment strategy for esophageal benign tumors, such as leiomyomas, involves continued monitoring of smaller tumors and surgical resection of larger or symptomatic tumors. Conventional, open thoracotomy for enucleation of this tumor type has been gradually replaced by less invasive thoracoscopic or laparoscopic approaches. In the present report, we describe our experience with patients undergoing surgical enucleation of esophageal leiomyomas via thoracoscopic or laparoscopic approaches.
[Show abstract][Hide abstract] ABSTRACT: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly common cause of chronic liver disease worldwide. The diagnosis of NASH is challenging as most affected patients are symptom-free and the role of routine screening is not clearly established. Most patients with severe obesity who undergo bariatric surgery have NAFLD, which is associated insulin resistance, type 2 diabetes mellitus (T2DM), hypertension, and obesity-related dyslipidemia. The effective treatment for NAFLD is weight reduction through lifestyle modifications, antiobesity medication, or bariatric surgery. Among these treatments, bariatric surgery is the most reliable method for achieving substantial, sustained weight loss. This procedure is safe when performed by a skilled surgeon, and the benefits include reduced weight, improved quality of life, decreased obesity-related comorbidities, and increased life expectancy. Further research is urgently needed to determine the best use of bariatric surgery with NAFLD patients at high risk of developing liver cirrhosis and its role in modulating complications of NAFLD, such as T2DM and cardiovascular disease. The current evidence suggests that bariatric surgery for patients with severe obesity decreases the grade of steatosis, hepatic inflammation, and fibrosis. However, further long-term studies are required to confirm the true effects before recommending bariatric surgery as a potential treatment for NASH.
Full-text · Article · Oct 2014 · Frontiers in Endocrinology
[Show abstract][Hide abstract] ABSTRACT: Early on, laparoscopic liver resection (LLR) was limited to partial resection, but major LLR is no longer rare. A difficulty scoring system is required to guide surgeons in advancing from simple to highly technical laparoscopic resections. Subjects were 90 patients who had undergone pure LLR at three medical institutions (30 patients/institution) from January 2011 to April 2014. Surgical difficulty was assessed by the operator using an index of 1-10 with the following divisions: 1-3 low difficulty, 4-6 intermediate difficulty, and 7-10 high difficulty. Weighted kappa statistic was used to calculate the concordance between the operators' and reviewers' (expert surgeon) difficulty index. Inter-rater agreement (weighted kappa statistic) between the operators' and reviewers' assessments was 0.89 with the three-level difficulty index and 0.80 with the 10-level difficulty index. A 10-level difficulty index by linear modeling based on clinical information revealed a weighted kappa statistic of 0.72 and that scored by the extent of liver resection, tumor location, tumor size, liver function, and tumor proximity to major vessels revealed a weighted kappa statistic of 0.68. We proposed a new scoring system to predict difficulty of various LLRs preoperatively. The calculated score well reflected difficulty.
Full-text · Article · Oct 2014 · Journal of Hepato-Biliary-Pancreatic Sciences
[Show abstract][Hide abstract] ABSTRACT: Background
The important point in safely performing laparoscopic hepatectomy (LH) is to control bleeding. The aims of this study were: (i) to assess the bleeding reduction effect by occlusion of the hepatic artery in LH; and (ii) to evaluate the risk of carbon dioxide (CO2) gas embolism (GE) in the case of high pneumoperitoneum (PP).Methods
Nine piglets underwent laparoscopic left medial lobe and left lateral lobe resection, receiving either occlusion of the hepatic artery (hepatic artery clamping group: HACG, n = 9) or no occlusion (hepatic artery declamping group: HADCG, n = 9) using a PP of 15 mmHg. In addition, we observed changes in hemodynamics induced by PP. The state of GE was observed using transesophageal echocardiography (TEE) during LH (n = 8). GE was graded as grade 0 (none), grade 1 (minor), and grade 2 (major).ResultsThe HACG had significantly less bleeding compared to the HADCG (P < 0.01). During LH, four animals showed grade 1 (37.5%) and one animal showed grade 2 (12.5%) GE at 15 mmHg. At 20 mmHg, all animals showed grade 2 (100%) GE.Conclusion
The occlusion of the hepatic artery in LH reduces blood loss. The control of bleeding from the hepatic vein is feasible with a high PP, but there is a possibility of GE.
Full-text · Article · Aug 2014 · Journal of Hepato-Biliary-Pancreatic Sciences
[Show abstract][Hide abstract] ABSTRACT: Biliary complications, such as stricture or obstruction after living donor liver transplantation (LDLT), are still major problems. Magnetic compression anastomosis (MCA) is a minimally invasive and nonsurgical procedure in patients with biliary structure or obstruction. A 49-year-old woman who had had ABO-incompatible LDLT 16 months previously presented with obstructive jaundice. After sufficient improvement of obstructive jaundice by percutaneous transhepatic cholangiodrainage (PTCD), the rendezvous technique between PTCD and endoscopic retrograde cholangiopancreatography was attempted in order to break through the stricture, but this was not successful. Therefore, MCA was performed. A parent magnet was endoscopically placed at the common bile duct side of the stricture, and the daughter magnet, attached to a guidewire, was also inserted to the intrahepatic bile duct. Both magnets were advanced to positions immediately prior to the biliary obstruction, and it was confirmed that the two magnets attracted each other magnetically, sandwiching the stricture. Twenty-four days after MCA, as recanalization could be achieved without any adverse events, the magnets were removed via the PTCD fistula. MCA enabled us to create a fistula without complications. In conclusion, when a conventional endoscopic or percutaneous approach, including the rendezvous technique, has failed, MCA is a novel method for patients with the stricture of the choledochocholedochostomy after LDLT.
Full-text · Article · Aug 2014 · Clinical Journal of Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Postoperative hyperglycemia is associated with infectious complications after various types of surgery. Our objective was to determine whether postoperative blood glucose levels up to 1 week after highly invasive esophageal cancer surgery are associated with the incidence of postoperative infections (POIs).
We conducted a retrospective chart review of 109 consecutive thoracic esophageal squamous cell cancer patients who underwent invasive esophagectomy with thoracotomy and laparotomy. The incidence of postoperative POIs and risk factors for POIs, including postoperative blood glucose levels, were evaluated.
Of the 109 patients, 37 (34.0 %) developed POIs. Clinically, 73.0 % of the POIs became evident on or after postoperative day 4 (median, 5.25 days; interquartile range, 3.00-9.25 days). On and after postoperative day 3, chronological changes in blood glucose levels were significantly different between two groups of patients with or without POIs, as indicated by repeated measures ANOVA (P = 0.006). Multivariate logistic regression analysis results showed that an increased blood glucose concentration on postoperative day 3 was a significant risk factor for POIs.
Our findings suggested that postoperative hyperglycemia on postoperative day 3 was a predictive factor of POIs after highly invasive esophageal cancer surgery.
Full-text · Article · Jul 2014 · Journal of Gastrointestinal Surgery