Advantages of thoracoabdominal approach by oblique incision for right-side hepatectomy.

BACKGROUND/AIMS: Thoracoabdominal approach might be safe and facilitate hepatic resection for tumors located in the right lobe. To evaluate the clinical usefulness of the thoracoabdominal approach using oblique incision for the right-side hepatectomy, we compared the perioperative data with those of the abdominal approach. METHODOLOGY: The oblique incision for the thoracoabdominal approach was placed along the intercostal space (Oblique group, n=13). The J-shape incision for abdominal approach consisted of an upper median incision and transverse incision (J-shape group, n=13). RESULTS: Patient demographics were similar in the two groups. Operation time was significantly shorter in the oblique group (292 +/- 122 min) than in the J-shape group (450 +/- 137 min, p < 0.01). The difference was noted regardless of the extent of hepatic resection. Clamping time and blood loss were similar in the two groups. The postoperative period of use of analgesia tended to be shorter in the oblique group (9 +/- 3 days) than in the J-shape group (15 +/- 11 days) but not significant (p = 0.08). Postoperative liver function tests, complications and clinical outcome were not significantly different between the two groups. CONCLUSIONS: Thoracoabdominal approach using oblique incision was useful for resection of liver tumors located in the hepatic dome and posterior segment.

Comparative analysis of postoperative morbidity according to type and extent of hepatectomy.

BACKGROUND/AIMS: The aim of our retrospective study was to compare the factors contributing to postoperative complications according to the extent of hepatectomy. METHODOLOGY: We examined 166 patients with hepatobiliary carcinoma who underwent hepatectomy. Patients were divided into three groups according to the type and extent of hepatectomy: 1) left lobectomy (n=27), 2) right lobectomy or posterior segmentectomy (n=55) and 3) other hepatectomies (n=84). Patient demographics, major complications (infection, ascites, pleural effusion, atelectasis, static symptoms of the stomach, biliary leakage and hepatic failure) after hepatectomy were analyzed. RESULTS: In patients with obstructive jaundice, lobectomy was the most commonly performed operation due to the extent of tumor along the main hepatic duct. Prolonged ascites or massive pleural effusion was frequently observed after right lobectomy (p=0.001) and posterior segmentectomy (p=0.002). However, the incidences of these complications were similar in patients with chronic viral hepatitis. Symptoms related to gastric stasis and biliary leakage were significantly more common after left lobectomy than other surgeries. The incidence of hepatic failure was higher (p<0.05) after major hepatectomy, particularly right lobectomy, than other surgeries. CONCLUSIONS: Our results emphasize the need to understand characteristics of specific complications occurring after different types of hepatic resection surgery to prevent post-hepatectomy complications.

Beneficial effects of plasmapheresis before thymectomy on the outcome in myasthenia gravis.

OBJECTIVE: Since 1980, we have performed plasmapheresis before thymectomy for patients with generalized symptoms in order to protect against myasthenic crisis and to improve patient outcomes after thymectomy. The aim of this study was to evaluate an immediate and a long-term results of plasmapheresis before thymectomy for myasthenia gravis, retrospectively. METHODS: Between January 1980 and December 1997, 51 patients with Osserman class IIA or IIB symptoms were treated with transsternal thymectomy. Nineteen patients (group 1) were treated with plasmapheresis before thymectomy and 32 patients (group 2) were treated with thymectomy alone. RESULTS: In group 1, the time of plasmapheresis prior to thymectomy was 3.2 +/- 1.5. Nine (28.1%) patients in group 2 had crisis within 1 year after thymectomy as compared with only one (5.3%) patient in group 1 had crisis (p = 0.049). There was no evidence of crisis within 30 days after thymectomy in group 1 and 5 (15.6%) patients in group 2 (p = 0.0724). There was no postoperative death among patients in group 1. Responses to thymectomy in group 1 improved significantly, the improvement and pharmacologic remission rate had increased up to 100% and 79% at 5-7 years after operation, while the improvement and pharmacologic remission rate of group 2 had increased to 81.3% (p = 0.0466 vs. group 1) and 50.0% at that time (p = 0.0427 vs. group 1). CONCLUSIONS: The present study demonstrated that preoperative plasmapheresis may facilitate improved outcomes of patients with myasthenia gravis after thymectomy.

Adjuvant photodynamic therapy for bile duct carcinoma after surgery: a preliminary study.

BACKGROUND: Photodynamic therapy (PDT) is a new palliative option in patients with non-resectable bile duct carcinoma (BDC). Here, we assessed the efficacy of adjuvant photodynamic therapy in eight patients with BDC who underwent surgical resection. METHODS: Five patients had extrahepatic BDC, two had intrahepatic cholangiocarcinoma, and one had ampullary carcinoma. Cancer cells were microscopically detected in the stump of the hepatic duct in six patients, and biliary stenosis caused by remnant tumor was observed in one patient. One patient had tumor recurrence with occlusion of the bile duct. At 48 h prior to PDT, porfimer sodium was injected intravenously. A pulse laser by an eximer dye laser (50-100 J/cm2) with a wavelength of 630 microm was applied through an endoscope to the hepatic stump or tumor lesion. RESULTS: Marked destruction of the tumor and ductal epithelium was observed on day 1 after PDT. After PDT, four patients developed mild dermatitis, but no severe morbidity or mortality was noted. In patients who underwent PDT for the stump, one patient showed distant metastasis at 31 months, and four patients did not show tumor recurrence at 17, 12, 12, and 6 months, respectively. However, one of the eight patients died at 2 months, of an unrelated cause. In two patients with occlusion caused by tumor growth, resolution of bile duct stenosis was noted on day 7. These patients showed re-occlusion by tumor at 20 and 8 months. CONCLUSIONS: Adjuvant PDT is a safe and useful option for a better survival benefit in patients with BDC undergoing surgical resection.

Relationship between indocyanine green test and technetium-99m galactosyl serum albumin scintigraphy in patients scheduled for hepatectomy: Clinical evaluation and patient outcome.

The clinical significance of and discrepancy between the indocyanine green retention rate at 15min (ICGR15) and liver activity at 15min (LHL15) by technetium-99m galactosyl human serum albumin ( [Formula: see text] -GSA) scintigraphy and clinical outcome were examined in 140 patients who underwent hepatectomy. Both ICGR15 and LHL15 were significantly associated with portal pressure and liver function tests, fibrotic degree and regeneration of the remnant liver ( [Formula: see text] ). The significance of the correlation between LHL15 and liver functions and HAI score appeared to be better than that with ICGR15. A significant correlation was observed between ICGR15 and LHL15 ( [Formula: see text] 0.591, [Formula: see text] ) for all but 12 patients (8.6%). Of three patients with LHL15 better than ICGR15, two had obstructive jaundice and one had an intrahepatic shunt. Patient outcome was relatively good. In nine patients with LHL15 worse than ICGR15, the HAI score was higher (=7) and six of the nine had hepatic failure or uncontrolled ascites. Complications were frequently observed in patients with LHL15 below 0.875 (80% versus 30%, [Formula: see text] ). Our results indicate that [Formula: see text] -GSA scintigraphy is a reliable auxiliary test of hepatic functional reserve combined with ICGR15 for selecting the extent of hepatectomy and predicting patient outcome.

Efficacy and safety of inhaled tacrolimus in rat lung transplantation.

OBJECTIVE: Because acute rejection is the most important cause of chronic rejection in lung transplantation, the use of conventional systemic immunosuppression to improve long-term survival needs to be reassessed. The aim of this study was to investigate the efficacy and safety of inhaled tacrolimus for preventing acute rejection of rat lung allografts. METHODS: Orthotopic left lung transplantation was performed in rats that were divided into 6 groups: control group received no treatment; groups 1.0-IM, 0.5-IM, and 0.3-IM received tacrolimus by intramuscular injection at 1.0, 0.5, and 0.3 mg/(kg.d), respectively; and groups 12-IT and 6-IT received 12 and 6 puffs of inhaled tacrolimus 3 times per day, respectively. Allografts were studied histologically. Whole blood and allograft tacrolimus concentrations were determined. RESULTS: In groups 1.0-IM and 12-IT, histologic grade of the graft showed significantly less rejection than in the other groups. The blood tacrolimus concentration in group 12-IT (4.87 ng/mL) was significantly lower than that in group 1.0-IM (13.05 ng/mL, P = .0017) on postoperative day 7. Higher allograft tacrolimus concentrations were achieved in group 1.0-IM (478.0 ng/g) than in group 12-IT (270.4 ng/g, P = .009). Weight loss and diarrhea in group 12-IT were less severe than in the groups that received systemic tacrolimus. The proliferating cell nuclear antigen index in bronchus-associated lymphoid tissue cells was significantly lower in group 12-IT than in group 1.0-IM (P = .0209). CONCLUSION: Local immunotherapy with inhaled tacrolimus has great potential for controlling pulmonary allograft rejection in clinical lung transplantation because it has fewer side effects than systemic immunosuppressive agents.

Relationship between CT volumetry and functional liver volume using technetium-99m galactosyl serum albumin scintigraphy in patients undergoing preoperative portal vein embolization before major hepatectomy: a preliminary study.

To clarify the relationship between morphological measurements of hepatic volume by computed tomography (CT-vol) and functional volume (RI-vol) by technetium-99m galactosyl human serum albumin (99mTc-GSA) scintigraphy, and its clinical significance, we examined 16 patients with a background liver status of either normal liver function (n=4), chronic hepatitis or cirrhosis (n=7), or obstructive jaundice (n=5). In five patients who underwent preoperative portal vein embolization (PVE), volumetric measurement was performed 2 weeks after PVE. The mean values of CT-vol and RI-vol of the right lobe were 692+/-147 cm3 (66.1+/-10.7%) and 668+/-159 cm3 (67.8+/-13.2%), respectively, and those of the left lobe were 329+/-138 cm3 (33.9+/-10.6%) and 328+/- 170 cm3 (32.2+/-13.2%), respectively. There were no significant differences in the volume measurements between the two volumetric techniques. Correlations between CT-vol and RI-vol in the right and left lobes were positive and significant (r=0.912 and 0.903, respectively; both P's<0.001). The mean values of post-PVE CT-vol and RI-vol of the right lobe in five patients were significantly different (628+/-149 and 456+/-211 cm3, respectively; P=0.033). However, the mean values of post-PVE CT-vol and RI-vol of the left lobe were not different (496+/-124 and 483+/-129 cm3, respectively). We propose that volumetric measurement by 99mTc-GSA scintigraphy is useful for detecting changes in functional volume of individual lobes of the liver and is a more dynamic method compared with detection of morphological changes by CT scan.

Preoperative serum hyaluronic acid level as a good predictor of posthepatectomy complications.

PURPOSE: We evaluated the efficiency of measuring hyaluronic acid (HA) levels preoperatively in patients with injured liver disease as a predictor of complications after hepatectomy. METHODS: We examined patients who underwent hepatectomy for liver tumors secondary to chronic viral liver diseases or obstructive jaundice. RESULTS: The preoperative HA level correlated significantly with the indocyanine green retention rate at 15 min, liver activity at 15 min by technetium-99m galactosyl human serum albumin scientigraphy, and the histopathological activity index. It was also significantly elevated in patients with severe fibrosis caused by cirrhosis. After hepatectomy, the HA level was increased on postoperative day (PODS) 7, but had normalized by POD 28. The preoperative HA level tended to correlate with the regeneration rate on POD 28, and was significantly higher in patients with prolonged ascites or hepatic failure postoperatively. Multivariate analysis identified a serum HA level above 200 or 150 ng/ml as the only significant predictor of postoperative hepatic failure or long-term ascites, respectively (P < 0.05). CONCLUSION: Our findings indicate that the preoperative serum HA level is a good predictor of postoperative complications in patients who undergo hepatectomy for injured liver disease.