Transverse carcinoma after Miles operation: a case in which preoperative evaluation was assisted by computed tomographic colonography.

BACKGROUND: There were only few case reports in which CTC was performed in patients with colostomy. CASE PRESENTATION: A 68-year-old man was admitted with right abdominal pain and bloody stool that had been present for 2 weeks prior to admission. His medical history included abdominoperineal rectal resection with permanent sigmoid stoma (Miles operation). Colonoscopy showed a sub-occlusive tumor in the transverse colon but provided no information about the proximal colon. Thus, computed tomographic colonography (CTC) was planned to assist our examination of the proximal colon under sigmoid colostomy. CTC revealed the apple core sign in the hepatic flexure, without any evident tumor in the proximal colon. Therefore, we performed transverse colectomy and lymph node dissection, preserving a part of the ascending colon and Bauhin valve. CONCLUSION: CTC examination can be an effective means of preoperatively evaluating the proximal colon in patients with occlusive tumor. Further, CTC examination was technically feasible through a sigmoid stoma.

Intraoperative air leak test was useful for the detection of a small biliary fistula: A rare case of non-parasitic hepatic cysts with biliary communication.

INTRODUCTION: Symptomatic non-parasitic hepatic cysts with biliary communication are rare and no standard treatment has been established yet. Careful attention should be paid to avoidance of postoperative bile leakage during surgical treatment. PRESENTATION OF CASE: We report the case of a 74-year-old man who visited our department complaining of right upper abdominal pain and elevated serum levels of the liver enzymes. Computed tomography revealed hepatic cysts including a large one measuring 16cm in diameter in Segments IV and VIII. Percutaneous drainage of the cyst revealed bile-staining of the cyst fluid. Endoscopic retrograde cholangiography demonstrated the presence of a cyst-biliary communication. We performed open deroofing of the cyst. During the operation, the biliary fistula was invisible, however, air injection into the bile duct through the stump of the cystic duct caused release of air bubbles from the cyst cavity, which allowed us to detect the small biliary orifice and repair it successfully by suture. DISCUSSION: We utilized the intraoperative air leak test, which has previously been reported to be effective for preventing postoperative bile leakage in patients undergoing hepatectomy to detect of a small cyst-biliary communication in a case undergoing non-parasitic hepatic cyst surgery. CONCLUSION: An intraoperative air leak test may be a useful test during surgical treatment of non-parasitic hepatic cysts with biliary communication.

Clinical and computed tomography findings of appendiceal diverticulitis vs acute appendicitis.

AIM: To study the clinical features and computed tomography (CT) findings of appendiceal diverticulitis vs acute appendicitis. METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy in our institution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis. RESULTS: Among 451 patients, 44 (9.7%) were diagnosed to have appendiceal diverticulitis and 398 (86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older (59 vs 37 years, P < 0.001) and had a longer duration of the illness (4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher (68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients (52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix (84% vs 12%, P < 0.001), absence of appendicolith (92% vs 52%, P = 0.005), and formation of abscess (68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients (24%). CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.

Clinicopathological subclassification of biliary cystic tumors: Report of 4 cases with a review of the literature.

Biliary cystic tumors are rare hepatic neoplasms, and knowledge regarding the origin and pathology of these tumors remains vague. They should be analyzed in more detail. In our institution, 4 biliary cystic tumor surgeries were performed between December 1999 and March 2010. Pathological evaluation of resected specimens was performed to evaluate the characteristics of the intracystic epithelium and to determine the presence or absence of interstitial infiltrate, ovarian mesenchymal stroma (OMS), luminal communication between the cystic tumor and the bile duct, and mucin (MUC) protein expression. We evaluated the following 4 cases: case 1, a 21-year-old woman with a biliary cystadenoma who underwent extended right hepatectomy; case 2, a 39-year-old woman with a biliary cystadenoma who underwent left hepatectomy; case 3, an 80-year-old man with a biliary cystadenoma who underwent left hepatectomy; and case 4, a 61-year-old man with a biliary cystadenocarcinoma revealing papillary proliferation of atypical epithelium and interstitial infiltrates who underwent left hepatectomy. Case 3 had papillary proliferation of the intracystic atypical epithelium but showed interstitial infiltrates. Luminal communication with the bile duct, centrally or peripherally, was found in all 4 cases. Only case 2 showed OMS. Immunohistochemical staining revealed the following findings: cases 1 and 2, MUC1-/MUC2-; case 3, MUC1+/MUC2-; and case 4, MUC1+/MUC2+. It is important to gather information on more cases of biliary cystic tumors because atypical cases were observed, where both OMS and luminal communication with the bile duct were present or absent.

Definition of T3/4 and regional lymph nodes in gallbladder cancer: which is more valid, the UICC or the Japanese staging system?

BACKGROUND: The Union for International Cancer Control (UICC) and Japanese Society of Biliary Surgery (JSBS) staging systems differ in their staging of gallbladder cancer: they define hepatic invasion with or without invasion of another organ as T3 and either T3 or T4, respectively, and posterosuperior pancreatic lymph node (PSPLN) metastases as M1 and N2, respectively. METHODS: We retrospectively evaluated the survival of 224 patients who had undergone macroscopically curative resection for gallbladder cancer and assessed the influence of the differences between the two staging systems on survival. RESULTS: JSBS staging stratified the survival curves better for stages III or IV. Fifty-seven patients were classified as UICC-T3 but JSBS-T4. These patients had better survival than did 43 patients with UICC-T4/JSBS-T4 and comparable survival to 17 patients with UICC-T3/JSBS-T3. UICC stage IIIB is composed of two subgroups: U-T2N1 (18 patients) and U-T3N1 (21 patients). Their 5-year survivals were 85 and 41%, respectively (P = 0.01). The latter was comparable to that of 28 T3N0 patients (35%, P = 0.93). The survival of the UICC-M1 patients with disease restricted to PSPLNs was significantly better than that of those with involvement beyond PSPLNs (5-year survival 35 vs. 17%; P = 0.04). CONCLUSIONS: Although UICC staging more accurately defines the T category, JSBS staging better stratifies the prognosis of patients with gallbladder cancer, mainly because UICC stage IIIB includes T1/2N1M0, which is associated with significantly better survival than T3N0M0. It would be appropriate to classify PSPLNs as regional lymph nodes.

Liver resection for multiple colorectal liver metastases with surgery up-front approach: bi-institutional analysis of 736 consecutive cases.

BACKGROUND: Preoperative chemotherapy has become more common in the management of multiple resectable colorectal liver metastases; however, the benefit is unclear. This study examined clinical outcomes following liver resection for multiple colorectal liver metastases with the surgery up-front approach. METHODS: Data collected prospectively over a 16-year period for 736 patients who underwent hepatic resection at two different centers were reviewed. Patients were divided into three groups depending on the number of tumors as follows: group A, between one and three tumors (n = 493); group B, between four and seven tumors (n = 141); and group C, eight or more tumors (n = 102). RESULTS: The 5-year overall and recurrence-free survival rates were 51 and 21 %, respectively, for the entire patient cohort, 56 and 29 % in group A, 41 and 12 % in group B, and 33 and 1.7 % in group C. Multivariate analysis showed that decreased survival was associated with positive lymph node metastasis of the primary tumor, the presence of extrahepatic tumors, a maximum liver tumor size >5 cm, and tumor exposure during liver resection. CONCLUSIONS: In patients with multiple liver metastases, the number of liver metastases has less impact on the prognosis than other prognostic factors. Complete resection with repeat metastasectomy offers a chance of cure even in patients with numerous colorectal liver metastases (i.e., those with eight or more nodules). A further prospective study is necessary to clarify the optimal setting of preoperative chemotherapy.

Prognostic impact of postoperative serum CA 19-9 levels in patients with resectable pancreatic cancer.

BACKGROUND: Perioperative serum carbohydrate antigen 19-9 (CA 19-9) level has been reported to be a useful prognostic marker in pancreatic cancer. The object of this study was to investigate the predictive factors for survival, including preoperative and postoperative serum CA 19-9 levels in patients with pancreatic cancer. METHODS: Between 2003 and 2009, a total of 269 patients with pancreatic invasive ductal carcinoma underwent macroscopically curative resection, and pre- and postoperative (within 3 months after surgery) serum CA 19-9 levels were evaluated in all of them. The prognostic significance of clinicopathologic factors was evaluated by univariate and multivariate analyses. RESULTS: Preoperative serum CA 19-9 levels were higher than normal (>37 U/ml, 38-4600 U/ml) in 218 of 269 patients. Of these, after surgery, serum CA 19-9 level returned to within a normal range in 136 patients (62%), whereas 82 patients (38%) remained in the higher-than-normal range. In univariate and multivariate analyses, node metastasis (P < 0.001) and postoperative CA 19-9 level (>37 U/ml) (P < 0.0001) were independent predictors for poor survival. Postoperative CA 19-9 level was higher in patients with microscopically positive surgical margin (P = 0.02). Hepatic recurrence and peritoneal dissemination were associated with postoperative higher CA 19-9 level. CONCLUSIONS: Postoperative CA 19-9 level was associated with positive surgical margin and hepatic or peritoneal recurrence and may be a useful predictor for survival in patients with pancreatic cancer.

Total pancreatectomy with en bloc celiac axis resection for a pancreatic adenocarcinoma involving both the gastroduodenal artery and the celiac artery.

A pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery is often considered to be unresectable because the simultaneous division of both arteries may result in an acute severe ischemia of the liver and the stomach. We report here a case of total pancreatectomy with en bloc celiac axis resection for a 61-year-old female with a pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery. The patient had a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery, which was directly arising from the aorta. Preserving these collateral arteries, neither hepatic artery reconstruction nor total gastrectomy was needed after resection. The reported incidence of similar arterial anatomy was only 0.2% but the precise evaluation of arterial anatomy is important to offer a chance of curative resection for patients with usually unresectable locally advanced pancreatic cancer.

Value of visual inspection, bimanual palpation, and intraoperative ultrasonography during hepatic resection for liver metastases of colorectal carcinoma.

BACKGROUND: Intraoperative detection of new nodules is common in patients undergoing hepatectomy for colorectal liver metastases, although the value of intraoperative diagnosis is not well assessed. METHODS: A prospectively collected and recorded database was retrospectively analyzed. Helical computed tomography (CT) results were correlated with those of the intraoperative diagnosis in 183 consecutive patients undergoing 254 consecutive hepatectomies, including repeated resection for colorectal liver metastases. RESULTS: In total, 270 nodules were newly detected during 65 hepatectomies. The sensitivity of CT to detect metastatic nodules was 72.8% (722/992), but it decreased to 34.6% (125/361) for small (≤ 1 cm diameter) tumors. Intraoperative visual inspection and/or palpation detected 207 of 270 nodules. Intraoperative ultrasonography (IOUS) played an important role in identifying deep (≥ 1 cm from the surface) and comparatively small (≤ 1 cm diameter) nodules (4/9 vs. 16/18, respectively, for those >1 cm vs. ≤ 1 cm diameter). The likelihood of intraoperative detection of new nodules increased from 10 in 112 to 6 in 9 when the preoperative tumor number increased from solitary to ≥ 10, resulting in an overall likelihood of 65 in 254 (25.6%). Of 65 patients with new nodules, 21 had at least one nodule that was detected only by IOUS. Preoperatively scheduled hepatectomy was altered in 47 (72%) patients, although additional limited resection(s) were sufficient to remove these nodules in 43 (91%) of them. CONCLUSIONS: Visual inspection, palpation, and IOUS had equally indispensable roles in detecting new nodules during hepatectomy. Detection was common and usually necessitated alteration, albeit moderately, of the surgical plan.

Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most troublesome complications after pancreaticoduodenectomy (PD). METHODS: Between 2004 and 2009, 387 patients underwent PD and of these, 302 patients (78%) underwent pylorus-preserving PD. The stapled reconstruction of duodeno- or gastrojejunostomy was introduced in 2006, and 70 patients (18%) underwent stapled Roux-en-Y reconstruction. Postoperative DGE was defined based on the International Study Group on Pancreatic Surgery classification, and grade B or C DGE was considered to be clinically relevant. Risk factors for DGE were evaluated using univariate and multivariate analyses. RESULTS: Four patients died in the hospital (1.0%). Postoperative DGE was found in 70 patients (18%). DGE was less frequently seen in stapled reconstruction than in hand-sewn reconstruction (7.2% vs. 21%, P < 0.001), and in single-layer anastomosis than in double-layer anastomosis (12% vs. 24%, P = 0.02). The multivariate logistic regression analysis revealed that the independent risk factors for DGE were postoperative pancreatic fistula (risk ratio [RR] 2.4, P = 0.002), hand-sewn reconstruction (RR 2.9, P = 0.03) and male (RR 2.2, P = 0.02). CONCLUSION: The method of alimentary reconstruction affected the occurrence of DGE. The incidence of DGE was less in stapled reconstruction than in hand-sewn reconstruction.

Prognosis of patients undergoing hepatectomy for solitary hepatocellular carcinoma originating in the caudate lobe.

BACKGROUND: Operative and nonoperative treatment for hepatocellular carcinoma (HCC) originating in the caudate lobe is regarded as challenging because of its deep location in the liver and possibly worse prognosis than HCC in other sites in the liver. The objective of this study is to investigate the clinicopathologic factors and survival of patients who underwent hepatectomy for solitary HCC originating in the caudate lobe. METHODS: A retrospective review of 783 patients who underwent curative hepatectomy for solitary HCC between 1988 was performed. Clinicopathologic factors and survival rate of 46 (5.9%) patients with HCC originating in the caudate lobe were compared with those of 737 (94%) patients with HCC arising in other sites. RESULTS: The clinical backgrounds of patients with HCC in the caudate lobe and in other sites were comparable. Hepatectomy for HCC in the caudate lobe was associated with greater operative time and blood loss than for HCC in other sites of the liver. Pathologically, HCC in the caudate lobe was associated with less frequent intrahepatic metastasis, lesser operative margins, and more frequent tumor exposure than HCC in other sites. Overall and disease-free 5-year survival rates of the 46 patients with solitary HCC in the caudate lobe were 76% and 45%, respectively; no significant difference was observed in the overall or disease-free survival rates between the 2 groups (P = .07 and P = .77, respectively). Resection of HCC in the paracaval portion of the caudate lobe (n = 27) was associated with more frequent anatomic resection, greater operative time and blood loss, and a lesser operative margin than HCC in the Spiegel lobe or caudate process (n = 19). CONCLUSION: Resection for HCC in the caudate lobe, especially in the paracaval portion, remains technically demanding. The prognosis of patients with solitary HCC in the caudate lobe, however, was as good as that of patients with solitary HCC in other sites in the liver.

Usefulness of contrast-enhanced intraoperative ultrasound using Sonazoid in patients with hepatocellular carcinoma.

OBJECTIVE: To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC). BACKGROUND: Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs). METHODS: Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period. RESULTS: Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm). CONCLUSIONS: With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.

Correlation between contrast-enhanced intraoperative ultrasound using Sonazoid and histologic grade of resected hepatocellular carcinoma.

OBJECTIVE: Our aim was to accurately assess the correlation between findings of contrast-enhanced intraoperative ultrasound using Sonazoid and histologic grade of hepatocellular carcinoma (HCC). SUBJECTS AND METHODS: We enrolled 239 consecutive patients who were undergoing surgery for HCC for this study. Because 33 extensively necrotic HCCs were excluded, a total of 374 histologically proven HCCs were detected in all resected specimens and were the study subjects (71 well-differentiated, 239 moderately differentiated, and 64 poorly differentiated HCCs). After a laparotomy and liver mobilization, contrast-enhanced intraoperative ultrasound in the harmonic mode was performed after a Sonazoid injection. The first minute was defined as the vascular phase, in which the vascularity of the 239 HCCs was assessed. After an approximately 15-minute delay, a thorough liver exploration was performed (Kupffer phase). Preoperative dynamic CT was routinely performed, and the findings were assessed for reference. RESULTS: The proportion of hypervascular tumors during the vascular phase tended to be lower among well-differentiated than among moderately and poorly differentiated HCCs (66% vs 80%, p = 0.058). The proportion of hypoechoic tumors during the Kupffer phase was significantly lower among well-differentiated than among moderately and poorly differentiated HCCs (54% vs 92%, p < 0.0001). In dynamic CT, the proportions of hypervascular tumors during the early phase and hypodense tumors during the late phase were significantly lower among well-differentiated HCCs than among moderately and poorly differentiated HCCs, respectively (early phase, 51% vs 87%, p < 0.0001; late phase, 59% vs 85%, p < 0.0001). CONCLUSION: Contrast-enhanced intraoperative ultrasound using Sonazoid is useful for estimating the histologic grade of HCC.

Volume regeneration after right liver donation.

After right hepatectomy with the middle hepatic vein trunk for a graft, the venous outflow in segment IV is disturbed. There are limited data, however, regarding the effect of middle hepatic vein deprivation on liver regeneration or functional recovery. Living donors who underwent right hepatectomy with preservation of the middle hepatic vein (Group A, n = 58) and those deprived of the middle hepatic vein (Group B, n = 13) were reviewed. When the donor was under 50 years old and the remnant left liver was estimated to be more than 35% of the whole liver, right liver graft harvesting with the middle hepatic vein trunk was considered. Volume regeneration of segments I-III, segment IV, and overall liver volume was assessed at the third postoperative month using computed tomography. The regeneration rate of segment IV was significantly impaired in Group B donors compared with that in Group A donors (125% vs. 45%, P = 0.008). In contrast, the regeneration rate of segments I -III was significantly higher than that in Group A (208% vs. 263%, P = 0.004). There was no significant difference in the regeneration rate of the whole left liver or functional recovery between groups. Multivariate analysis revealed that the resection type (group) was a significant predictive factor for the regeneration rate of segments I-III and segment IV. When deprived of the middle hepatic vein, liver regeneration of segment IV was impaired but was compensated for by the regeneration of segments I-III. In conclusion, extended right hepatectomy can be safely performed with careful preoperative consideration using these criteria.

Positive T lymphocytotoxic cross-match in living donor liver transplantation.

The influence of lymphocytotoxic cross-match on survival or acute rejection in living donor liver transplantation (LDLT) has not been well examined. We analyzed 133 consecutive adult LDLT cases and assessed patient survival and acute rejection rates. Patients with a positive T lymphocytotoxic cross-match (n = 12) had a significantly higher chance of rejection within 6 weeks of LDLT (67% versus 28%, P <.001). All of the rejection episodes were successfully treated with bolus methylprednisolone therapy or anti-T cell monoclonal antibody. T lymphocytotoxic cross-match-positive grafts had no influence on patient survival (79% versus 90% at 3 years, P =.91). The results show that a positive cross-match graft should not be considered a contraindication for LDLT.