Anatomical laparoscopic hepatectomy for hepatocellular carcinoma using indocyanine green fluorescence imaging.

PURPOSE: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC), and consequently laparoscopic hepatic resection is widely performed. However, most anatomical resections, except left lateral sectionectomy, remain difficult technically, and laparoscopy-assisted procedures have been introduced as an alternative approach because of the safety and curative success of the operation. We reported previously pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites. Herein, we describe pure anatomical laparoscopic segmentectomy using the puncture method with indocyanine green (ICG) injection under laparoscopic US. PATIENTS AND METHODS: Pure laparoscopic segmentectomy was planned for 2 patients with HCC of the liver. Identification of the segment was performed by ICG injection for optical imaging using near-infrared fluorescence under laparoscopic US guidance. RESULTS: The procedures were completed successfully, and the postoperative courses were uneventful. CONCLUSIONS: Pure laparoscopic segmentectomy for HCC with a conventional puncture technique by ICG injection under laparoscopic US is considered to be a useful procedure featuring both low invasiveness and curative success.

Pure laparoscopic subsegmentectomy of the liver using a puncture method for the target portal branch under percutaneous ultrasound with artificial ascites.

PURPOSE: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC) and, consequently, laparoscopic hepatic resection is widely performed. However, most anatomic resections, except left lateral sectionectomy, are still difficult technically and, as an alternative approach, laparoscopy-assisted procedures also have been introduced because of the safety and curative success of the operation. Herein, we describe pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites. METHODS: Pure laparoscopic subsegmentectomy of segment 6 (S6) was planned for a patient with HCC of S6 of the liver. The identification of the segment was performed by dye injection under percutaneous US guidance with artificial ascites. RESULTS: The procedure was completed successfully in a minimally invasive manner with an operative time of 260 minutes and with intraoperative blood loss of 10 mL. The difference between the size of the resected specimen and that estimated by 3-dimensional computed tomography was very small. The postoperative course was uneventful and the patient was discharged 10 days after surgery. CONCLUSIONS: Pure laparoscopic subsegmentectomy for HCC with a conventional puncture technique under percutaneous US with artificial ascites is considered to be a useful procedure featuring both low invasiveness and curative success.

Endoscopic versus open radiofrequency ablation for treatment of small hepatocellular carcinoma.

BACKGROUND: Surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is associated with superior oncological outcome in comparison with percutaneous RFA. The present study aimed to retrospectively evaluate the relative perioperative safety and postoperative outcome of the laparoscopic or thoracoscopic approach versus the open approach to RFA for small HCC. METHODS: A retrospective analysis was performed in 55 consecutive patients who underwent open (n = 32) or laparoscopic/thoracoscopic (LTS) RFA (n = 23) for primary unresectable HCC between January 2005 and December 2010. Baseline characteristics, survival/recurrence rates, and complications after treatment were compared between the two groups. RESULTS: There was a trend showing that LTS RFA was performed for tumors located in the anterior segment (e.g., segments III, V, VIII). The LTS RFA group had a significantly lower intraoperative blood loss, shorter operative time, and shorter postoperative hospital stay, compared with the open RFA group. No major postoperative complications occurred in patients who underwent LTS RFA. No significant differences in overall survival, recurrence-free survival and local recurrence rates were observed between the two groups. CONCLUSIONS: In consideration of operative invasiveness and postoperative recovery, LTS RFA is superior to the open approach in patients with small HCC. Moreover, the surgical outcome did not differ between the two approaches. Laparoscopic/thorascopic RFA can be considered to be a useful procedure for ablation therapy.

Is delayed liver resection appropriate for patients with metachronous colorectal metastases?

BACKGROUND: In terms of timing of resection for synchronous liver metastases from colon cancer, some reports recommend leaving an interval (e.g., 3 months) after primary colorectal resection, because of reports of occasional and rapid remnant recurrence of residual liver metastases after simultaneous colorectal and liver resection (LR). For patients with metachronous liver metastasis (MLM), we prospectively examined the appropriateness of a 3-month interval to LR (i.e., delayed resection) following initial detection of hepatic lesions from the viewpoints of (1) detection of new metastases during this interval and (2) postoperative outcome. METHODS: Seventy-nine consecutive patients with modified Japanese criteria H1 class MLM (i.e., ≤4 nodules, 6 cm or less in diameter) and without obvious extrahepatic lesions, presenting between 1990 and 2008, were included in this study. Between 1990 and 2001, 52 patients were treated by LR without an interval (i.e., nondelayed group); from 2002, 27 patients were prospectively scheduled for LR at an interval of 3 months after initial detection of metastases (i.e., delayed group). During the 3-month interval, no adjuvant chemotherapy was given. Just prior to LR, patients were re-evaluated using computed tomography (CT) and deoxy-2-[(18)F]fluoro-D: -glucose positron emission tomography (FDG-PET) to exclude cases unsuitable for surgery. RESULTS: Out of 27 patients in the delayed group, 2 (7.4%) did not undergo LR after the 3-month interval and were excluded from the analysis: one because of multiple nodules in the bilateral lobe of the liver with pulmonary metastases and another because of para-aortic lymph node metastasis. Of the 25 patients for whom LR was indicated, 24 underwent LR as initially planned. In the remaining patient, after the 3-month interval, invasion of the tumor had occurred into the inferior vena cava (IVC) and other surgery in addition to the planned operation was required. When comparing the postoperative outcome data of the delayed group (n = 25) with the nondelayed group (n = 52), overall early recurrence within 1 year after LR was noticed in 30.9% (16/52) of the nondelayed group and 28.0% (7/25) of the delayed group; the incidence of only early extrahepatic recurrence decreased 5.1% in the delayed group (21.1% versus 16.0%, respectively). When comparing disease-free survival after liver resection, however, there was no significant difference between the groups. CONCLUSIONS: Delayed LR for MLM patients after initial detection of hepatic lesions is of no clinical benefit. Only in cases when extrahepatic lesions with MLM are suspected could an interval make such lesions clearer and assist in deciding on a suitable management plan.

Safety and efficacy of early postoperative hyperbaric oxygen therapy with restriction of transfusions in patients with HCC who have undergone partial hepatectomy.

BACKGROUND: Recent studies have shown that intraoperative blood loss and blood transfusions promote postoperative recurrence of hepatocellular carcinoma (HCC). Hyperbaric oxygen therapy (HBOT) is a specific method of oxygen administration, which is independent of fluid therapy or blood transfusion. The aim of the present study was to assess the usefulness of acute HBOT after liver resection for patients with HCC in order to minimize the requirement for perioperative blood transfusions. PATIENTS AND METHODS: Forty-one consecutive patients who showed Hb level < 9.0 mg/dl at the end of hepatic resection were randomly assigned to a control group (n = 21) or an HBOT group (n = 20). HBOT at 2.0 atm. with inhalation of 100% oxygen for a duration of 60 min was performed at 3, 24, and/or 48 h after the end of the hepatectomy. Regarding postoperative hepatic hemodynamics, liver function tests, and outcome data, prospective comparisons were completed in both groups. The two groups of patients were similar with respect to results from preoperative assessments. RESULTS: In six patients from the HBOT group, who experienced intraoperative major bleeding or showed fatal hepatic hypoxia (ShvO(2) < 50%), the levels of ShvO(2) and serum lactate were significantly improved after HBOT. When compared to the control group, the HBOT group showed better changes of ShvO(2), serum lactate, and bilirubin levels for the first 3 postoperative days following surgery. Additionally, the HBOT group did not experience any fatal complications and had a lower incidence of postoperative hyperbilirubinemia than the control group. We also observed that postoperative NK cell activity and cancer-free survival in the HBOT group tended to be better than in the control group, although the differences did not reach significance. CONCLUSION: These results suggest that acute HBOT after hepatectomy, aimed at reducing perioperative erythrocyte transfusions, may be employed for overcoming deficiencies in systemic and hepatic oxygen supply and thus diminishing postoperative complications. As an added benefit, such therapy may affect postoperative immunological responses and long-term survival after liver resection in HCC patients. Further analyses of the use of HBOT is warranted to confirm surgical outcome data and to assess the economic impact on healthcare costs.

Preoperative segmentation of the liver, based on 3D CT images, facilitates laparoscopic anatomic hepatic resection for small nodular hepatocellular carcinoma in patients with cirrhosis.

BACKGROUND/AIMS: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC) complicated with cirrhosis. Laparoscopic hepatectomy is feasible for such patients. However, most procedures undertaken at the present time are non-anatomic partial resection or limited resection, except for left hepatectomy and bisegmentectomy 2 and 3. Because anatomic hepatic resection for small HCC yielded more favorable results than non-anatomic resection, we conducted laparoscopic anatomic hepatic resection as image-navigated surgery by referring to portal 3D images. METHODOLOGY: Detailed descriptions of laparoscopic anatomic resection, such as segmentectomy and subsegmentectomy are presented. Preoperative 3D images clarified the anatomical relationships between HCC and its portal territory and enabled determination of the transection line. Laparoscopic anatomic resection was completed with mini-laparotomy or -thoracotomy with equal success to the conventional procedure under an open approach. RESULTS: Five patients with primary HCC with cirrhosis underwent the above procedure between January 2008 and February 2009. There were 2 male and 3 female patients, with a median age of 74.4 (70-80) years. All procedures were successful, with no conversions to open surgery required. The median operation time was 251 min (range: 222-280 min), and the median estimated blood loss was 183 ml (range 50-320 ml). There was no surgical mortality and major morbidity. CONCLUSIONS: These procedures contributed reduced invasiveness, even for elderly patients with cirrhosis: low blood loss and no postoperative complication. Laparoscopic anatomic hepatic resection based on navigation of the portal 3D images might be useful not only to facilitate minimally invasive surgery but also to improve the therapeutic efficacy.

[Chemoradiotherapy for locally recurrence after primary resection of biliary-pancreatic cancer].

Chemoradiotherapy for the unresectable pancreatic cancer and biliary cancer has been used for improving survival. In this study, we examined its safety and efficacy in cases with the local recurrence of pancreatic or biliary cancer after primary resection. Seven consecutive patients with recurrence of carcinoma of pancreas (n=3) and biliary system (n =4) were treated chemoradiotherapy. Local recurrence occurred around the portal vein in 6 patients and remnant pancreas in one patient respectively. Disease free survival after primary surgery was 22 months (range: 5-84). All patients received 50 Gy of conformal three-dimensional radiotherapy with concurrent 5-FU, Gemcitabine or S-1. Grade 3 of anorexia and elevation of transaminase level occurred in one patient respectively. Local tumor response was observed in two patients of pancreatic and biliary cancer respectively. Median survival calculated from the start of the chemoradiotherapy was 14.5 months (range: 6.4-23.9) in pancreatic cancer and 13.5 months (range: 10.8-19.8)in biliary cancer. Our data suggest that chemoradiotherapy is feasible and effective treatment option in patients who present local recurrence after primary surgery in pancreatic or biliary cancer.

[A case of effective treatment with chemosensitivity test-guided chemotherapy for advanced pancreatic and gastric cancer with peritoneal metastasis].

A 63-year-old man with abdominal pain was diagnosed as locally advanced pancreatic tail cancer and gastric cancer with peritoneal metastasis based on computed tomography (CT) and gastrointestinal series. Preoperative serum CA19- 9 was 1,357 U/mL. During laparotomy, peritoneal dissemination was observed and confirmed pathologically. An ileoileostomy was performed and peritoneal tissue was submitted to a chemosensitivity test. Based on the chemosensitivity test, CPT-11 (50 mg/body), 5-FU (750 mg/body), and Leucovorin (375 mg/body) were administered intravenously once a week for 3 weeks with a 1-week rest as 1 course. The patient received 9 courses of chemotherapy until progressive disease. Stable disease in tumor size was observed and serum CA19-9 level dropped to 81 U/mL. He remained well without any symptoms and pursued normal activity for 15 months. He died of peritoneal dissemination 26 months after diagnosis. Chemosensitivity test-guided chemotherapy seems to be an effective regimen as individualized chemotherapy for advanced pancreatic and gastric cancer.

[A resected case of effective treatment with gemcitabine for advanced pancreatic cancer with peritoneal metastasis].

We report a resected case of advanced pancreatic cancer after successful chemotherapy. A 69-year-old man with abdominal pain was diagnosed as locally advanced pancreatic tail cancer with peritoneal metastasis based on computed tomography (CT). Preoperative serum CA 19-9 was 5,046 U/mL. In the outpatient setting, gemcitabine (GEM) at a dose of 1,000 mg/m(2)was administered once a week for 3 weeks with a 1-week rest as 1 cycle. Abdominal CT scan after 5 cycles of chemotherapy revealed that ascites disappeared and the tumor dramatically shrank. Serum CA 19-9 also dropped to 12 U/mL. Thus, we considered the patient had a partial response, and performed distal pancreatectomy and splenectomy with D 3 lymph node dissection. Peritoneal seeding was not found and peritoneal washing cytology was negative. Histological examination of the primary lesion revealed a small amount of residual cancer cells. However, he died of peritoneal metastasis only 3 months after the operation. Surgical resection following chemotherapy should be performed carefully after close evaluation of the antitumor efficacy including residual isolated tumor cell for patients with previously distant metastases.

Role of positron emission tomography in decisions on treatment strategies for pancreatic cancer.

BACKGROUND/PURPOSE: The purpose of this study was to estimate the usefulness of positron emission tomography (PET) in deciding on strategies for the treatment of pancreatic cancer. The following two parameters were evaluated: the ability of PET to provide an estimation of the progression of pancreatic cancer, and the ability of PET to predict survival and the effect of chemoradiotherapy. METHODS: Forty-two patients underwent PET as part of the procedure for making a diagnosis of pancreatic tumors. The maximum standardized uptake value (SUVmax) levels were compared with clinicopathological factors and analyzed. RESULTS: PET provided a sensitivity of 87%, a specificity of 67%, and an overall accuracy of 85% for the diagnosis of pancreatic malignancy. Tumors with distant metastases showed significantly higher SUV levels than tumors without metastasis. In the patients who received chemoradiotherapy, the overall survival of the group in which SUVmax was less than 7.0 was better than that of the group in which SUVmax was more than 7.0. CONCLUSIONS: We conclude that PET is a useful tool for determining pathological status and distant metastasis in pancreatic cancer, and for predicting the prognosis of patients receiving chemoradiotherapy.

Value of magnetic resonance cholangiopancreatography with secretin stimulation in the evaluation of pancreatic exocrine function after pancreaticogastrostomy.

BACKGROUND/PURPOSE: The aim of this study was to assess the value of magnetic resonance cholangiopancreatography with secretin stimulation (secretin-MRCP) in evaluating the remnant pancreatic exocrine reserve after pancreaticogastrostomy with pancreaticoduodenectomy. METHODS: Forty-three patients who had undergone pancreaticoduodenectomies and who were given pancreaticogastrostomies for reconstruction were studied. Dynamic MRCPs, using a half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence were obtained before and up to 10 min after secretin administration. The morphologic features and diameter of the main pancreatic duct were monitored and graded before and after secretin stimulation. The results were compared with those of endoscopic findings, secretin stimulation testing with a collection of pancreatic fluid, N-benzoyl- L-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion testing, and fecal chymotrypsin concentration. RESULTS: The results of secretin-MRCP were classified into three distinct groups: a good-secretion group (group 1; n=22; 51%), a moderate-secretion group (group 2; n=10; 23%), and a poor-secretion group (group 3; n=11; 26%). This MRCP classification correlated significantly with the concentrations of the pancreatic enzymes p-type amylase, lipase, and trypsin in the gastric juice. The BT-PABA test value was 59.8% in group 1, 46.1% in group 2, and 46.5% in group 3, and was significantly higher in group 1 than in groups 2 or 3. The fecal chymotrypsin concentration was 20.5 U/g in group 1, 14.5 U/g in group 2, and 0.7 U/g in group 3, and there was a significant correlation between the MRCP classification and fecal chymotrypsin concentration. CONCLUSIONS: MRCP with secretin stimulation favorably reflected the presence of remnant pancreatic exocrine function. Therefore, secretin-MRCP is a feasible and effective follow-up examination method to evaluate remnant pancreatic exocrine function after pancreaticogastrostomy.