Measuring intraoperative anesthetic parameters during hepatectomy with inferior vena cava clamping.

PURPOSE: Uncontrollable bleeding remained problematic in anatomical hepatectomy exposing hepatic veins. Based on the inferior vena cava (IVC) anatomy, we attempted to analyze the hemodynamic and surgical effects of the combined IVC-partial clamp (PC) accompanied with the Trendelenburg position (TP). METHODS: We prospectively assessed 26 consecutive patients who underwent anatomical hepatectomies exposing HV trunks between 2020 and 2023. Patients were divided into three groups: use of IVC-PC (group 1), no use of IVC-PC (group 2), and use of IVC-PC accompanied with TP (group 3). In 10 of 26 patients (38%), hepatic venous pressure was examined using transhepatic catheter insertion. RESULTS: IVC-PC was performed in 15 patients (58%). Operating time and procedures did not significantly differ between groups. A direct hemostatic effect on hepatic veins was evaluated in 60% and 70% of patients in groups 1 and 3, respectively. Group 1 showed significantly more unstable vital status and vasopressor use (p < 0.01). Blood or fluid transfusion and urinary output were similar between groups. Group 2 had a significantly lower baseline central venous pressure (CVP), while group 3 showed a significant increase in CVP in TP. CVP under IVC-PC seemed lower than under TP; however, not significantly. Hepatic venous pressure did not significantly differ between groups. Systolic arterial blood pressure significantly decreased via IVC-PC in group 1 and to a similar extent in group 3. Heart rate significantly increased during IVC-PC (p < 0.05). CONCLUSION: IVC-PC combined with the TP may be an alternative procedure to control intrahepatic venous bleeding during anatomical hepatectomy exposing hepatic venous trunks.

Retroperitoneal-first dissection approach at the dorsal space for a huge serous cystic neoplasm of the pancreatic tail: a case report.

BACKGROUND: Large tumors of serous cystic adenomas in the pancreatic body-to-tail severely compress the surrounding organs and retroperitoneal space. CASE PRESENTATION: We present a unique surgical challenge for distal pancreatectomy (DP). We present the case of a patient who had a massive mass lesion measuring more than 20 cm in size that had been misdiagnosed as a retroperitoneal tumor by the previous hospital. However, an expert radiologist at our institute diagnosed serous cystadenoma of the pancreas based on imaging characteristics. We decided to perform retroperitoneal space first dissection using a small incision because we were concerned about tumor infiltration or compressive adhesions in important retroperitoneal vessels. We safely attempted distal pancreatectomy by limiting the laparotomy incision step-by-step while securing the main vascular injury of the retroperitoneum. In addition to the ordinary cooperation with urological surgeons, this technique is referred to by the concept of retroperitoneal procedures for minimally invasive surgery in urology. CONCLUSIONS: This approach is useful for lifting resected specimens by prior and wide retroperitoneal dissection, which may lead to safety and the prevention of unexpected vascular injury.

Novel Mathematical Diagnostic Analysis of Malignant Biliary Stenosis Using Magnetic Resonance Cholangiography in Patients Undergoing Pancreaticoduodenectomy.

BACKGROUND/AIM: A novel mathematical diagnostic analysis using Fourier transform (FT) algorithm of the extrahepatic bile duct (BD) using magnetic resonance-cholangiography (MRC) was performed to evaluate irregularities of the bile duct lumen indicating BD cancer (BDC) extension compared to pancreatic head malignancies controls. PATIENTS AND METHODS: BD lumen was automatically traced, and a 2D-diagram cross-section was measured and a FT-based integrated-power-spectral-density-function value (FTV) of both diameter and area (mm 2  and mm 4 /Hz) was calculated for cancerous and non-cancerous parts utilizing a computer workstation. RESULTS: FT analysis that was achieved in 59 patients consisted of BDC in 31, pancreatic cancer with biliary stenosis (PC) in 10 and pancreatic neoplasm without stenosis (PN) in 18. FTV-diameter and -area of non-tumorous proximal BD were larger compared to tumor involving BD (p<0.01), and those of the entire BD in BDCs were significantly larger than those in PN (p<0.01). FTV-diameter and -area in proximal BDC-positive were smaller than those in BDC-negative (p<0.05). BDC part was significantly discriminated by the cutoff value (286 mm 2 Hz -1  in diameter and 10,311 mm 4 Hz -1 in area) compared to PC and diagnostic accuracy was over 70% (p<0.01). CONCLUSION: Novel mathematical MRC FT-analysis is promising for differentiating between BDC and PC with biliary stenosis and can be utilized as an objective diagnostic tool in the future.

A rare case of long-term survival of a patient who underwent radical operations for sextuple malignancies.

Multiple cancer patients who achieve long-term survival are sometimes encountered. Multiple carcinogenesis may occur due to genetic or environmental characteristics. We report the case of a 74-year-old woman who was diagnosed with synchronous double carcinoma of the duodenal papilla and gall bladder without clinical symptoms, who underwent postoperative follow-up for familiar adenomatous polyposis coli with multiple colonic adenocarcinomas, ileal adenocarcinoma, left urinary tract neoplasm, and left upper lobe lung adenocarcinoma. Computed tomography also showed an intraductal papillary mucinous neoplasm of the pancreas and a lesion that was suspected to be uterine body carcinoma; however, they did not show any clear malignant behavior. No metastatic lesions of either of these biliary cancers were observed. Based on preoperative diagnostic imaging, subtotal stomach preserving pancreaticoduodenectomy with gall bladder bed liver resection with D2 lymphadenectomy was planned and R0 resection was achieved. The postoperative histological diagnosis showed early carcinoma of the duodenal papilla and gall bladder pyloric gland adenoma without node metastasis. The postoperative course was uneventful and the patient had a good prognosis without tumor recurrence or new malignant lesions for two years after the last operation, without adjuvant therapy. Six metachronous carcinomas of eight different organ neoplasms were diagnosed, which is rare. This represents the first reported case of ampullary carcinoma in a patient with sextuple cancer.

Successful Right Hepatectomy for Recurrent Liver Tumor Originating from an Inferior Vena Cava Leiomyosarcoma: A Follow-Up Case Report.

BACKGROUND Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignancy, and complete resection may provide better patient survival. Hepatectomy for intrahepatic tumor recurrence has not been previously reported. CASE REPORT A 58-year-old woman underwent resection of an IVC-LMS with en bloc nephrectomy, adrenalectomy, and retroperitoneal soft tissue resection without IVC reconstruction 3 years 8 months ago. Twenty-nine months after the primary operation, a solitary intrahepatic liver tumor was found adjacent to the right and middle hepatic veins during imaging follow-up. The patient was diagnosed with LMS recurrence. As her liver functional parameters permitted major hepatectomy, right hepatectomy combined with resection of the vena cava wall leaving a tumor-free margin and securing the confluence of the middle hepatic vein were successfully accomplished via an anterior approach, without adverse events. Intrahepatic metastasis of LMS invading the vena cava wall has been diagnosed historically. Her postoperative course was uneventful, and at 1-year follow-up after the second surgery, she was observed to have no tumor relapse without any adjuvant treatment. Previous reports have shown that IVC-LMS is often observed, and operative risk or prognosis is based on the extension of the LMS toward the hepatic veins or cardiac atrium. CONCLUSIONS Radical hepatectomy for recurrent IVC-LMS has not been previously reported, and our case experience revealed that a challenging surgical intervention resulting in complete tumor removal can provide good survival outcomes.