E-PASS score as a useful predictor of postoperative complications and mortality after colorectal surgery in elderly patients.

PURPOSE: The aim of this study was to clarify whether a surgical-specific risk scoring system estimating the physiologic ability and surgical stress (E-PASS) score was useful for prediction of postoperative morbidity and mortality. METHODS: The E-PASS score consists of the preoperative risk score (PRS), surgical stress score (SSS), and the comprehensive risk score (CRS). Conventional scoring systems [colorectal physiologic and operative severity score for the enumeration of mortality (CR-POSSUM) and the prognostic nutritional index (PNI)] were also examined. We retrospectively compared these scores in patients with or without postoperative complications. We assessed the relationship between these scores, clinicopathological features and postoperative mortality. RESULTS: Postoperative complications developed in 78 patients (33%). American Society of Anesthesiologists score, performance status, PNI score, PRS, SSS, and CRS were significantly higher in patients with postoperative complications than in those without postoperative complications (p < 0.05). The area under the receiver operating characteristic curve (AUC) was highest for E-PASS [E-PASS (PRS, 0.74; SSS, 0.62; CRS, 0.78), PNI (0.62), CR-POSSUM (PS, 0.57; OSS, 0.52)]. Multivariate logistic analysis identified CRS ≥ 0.2 as a significant determinant of postoperative complications (p < 0.01; hazard ratio, 4.84). Overall survival was significantly better in the CRS < 0.2 group than in the CRS > 0.2 group (p < 0.01). CONCLUSIONS: The E-PASS score system was a useful predictor of postoperative complications and mortality, especially in patients with advanced age.

Keratinocyte Growth Factor Gene Electroporation into Skeletal Muscle as a Novel Gene Therapeutic Approach for Elastase-Induced Pulmonary Emphysema in Mice.

Pulmonary emphysema is a progressive disease with airspace destruction and an effective therapy is needed. Keratinocyte growth factor (KGF) promotes pulmonary epithelial proliferation and has the potential to induce lung regeneration. The aim of this study was to determine the possibility of using KGF gene therapy for treatment of a mouse emphysema model induced by porcine pancreatic elastase (PPE). Eight-week-old BALB/c male mice treated with intra-tracheal PPE administration were transfected with 80 µg of a recombinant human KGF (rhKGF)-expressing FLAG-CMV14 plasmid (pKGF-FLAG gene), or with the pFLAG gene expressing plasmid as a control, into the quadriceps muscle by electroporation. In the lung, the expression of proliferating cell nuclear antigen (PCNA) was augmented, and surfactant protein A (SP-A) and KGF receptor (KGFR) were co-expressed in PCNA-positive cells. Moreover, endogenous KGF and KGFR gene expression increased significantly by pKGF-FLAG gene transfection. Arterial blood gas analysis revealed that the PaO2 level was not significantly reduced on day 14 after PPE instillation with pKGF-FLAG gene transfection compared to that of normal mice. These results indicated that KGF gene therapy with electroporation stimulated lung epithelial proliferation and protected depression of pulmonary function in a mouse emphysema model, suggesting a possible method of treating pulmonary emphysema.

A variant of multicystic biliary hamartoma presenting as an intrahepatic cystic neoplasm.

A rare case of an intrahepatic multicystic tumor is described. A 26-year-old man visited our hospital because of abdominal discomfort. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography revealed a 10 × 7 cm multicystic tumor of the bile duct in the right side of the liver. The gross appearance of the tumor resembled an intraductal papillary neoplasm of the bile duct, and right hepatectomy with regional lymphadenectomy was performed. Histologically, these cystic lesions were composed of variably and irregularly dilated duct structures lined by columnar epithelium resembling bile duct lining. There were no atypical cells and no papillary growth of the epithelial cells. Interestingly, the dilated ducts contained inspissated bile, and the inter-cystic parenchyma contained variable but irregularly distributed and hamartomatous hepatic parenchyma with an abnormal lobular pattern. Though it had atypical features of a hamartoma in some aspects (age, smooth muscle), this case could finally be regarded as a variant of multicystic biliary hamartoma.

Clinicopathological characteristics of multiple primary cancers in hepatobiliary and pancreas malignancies.

AIM: The present study was designed to define the clinicopathological characteristics of multiple cancers (MC) in 597 patients with hepatobiliary and pancreas (HBP) malignancies who underwent curative resection, in order to clarify risk factors and prognostic significance. PATIENTS AND METHODS: Patients' demographics, clinicopathological parameters and survival rates were compared between solitary (SC) and MC HBP malignancies for 267 patients with hepatocellular carcinoma (HCC), 77 with intrahepatic cholangiocarcinoma (ICC), 84 with extrahepatic bile duct carcinoma (BDC), 72 with gallbladder carcinoma (GBC) and 97 with pancreatic cancer (PC). RESULTS: MC was observed in 66 patients (11%) and more than three cancers were observed in 13 (2.2%). The mean age of patients of the MC group was significantly higher than that of the SC group. The proportion of Nagasaki atomic bomb survivors among the MC group was significantly higher than among the SC group. These findings were significant in HCC and ICC. The histopathological aggressiveness of malignancies was lower with HCC, BDC and PC. In HCC, the disease-free survival of MC patients with more than three tumors was significantly lower than those with SC and double cancers. In GBC, the overall survival of the MC group was significantly better than the SC group. In PC, the disease-free and overall survival were significantly better in MC than SC. CONCLUSION: Careful follow-up for second or third occurrence of primary malignancies after primary curative treatment for HBP malignancy is necessary.

Short-term outcomes of laparoscopic surgery for colorectal cancer in oldest-old patients.

BACKGROUND/AIMS: Oldest-old patients generally have several comorbidities, and laparoscopic-assisted colectomy (LAC) has not been performed on these patients. However, the surgical technique of LAC has improved, and its indications have been extended. The aim of this study was to evaluate the safety and effectiveness of LAC for patients over 85 years old. METHODS: Fifty-eight patients over 85 years old who underwent colectomy were retrospectively analyzed. The patients were divided into two groups (LAC group n = 15; open surgery group (Open group) n = 43), and clinicopathological features, surgical characteristics, and outcomes were compared. RESULTS: There were no significant differences in clinical background characteristics between the groups. The LAC group had longer operation time and greater lymph node dissection (both p < 0.01). Postoperatively, the use of analgesics (p = 0.01) was less and the start of oral liquid intake (p = 0.03) was faster in the LAC group. Postoperative complications occurred in 3 patients (20%) in the LAC group and 13 patients (30%) in the Open group (p = 0.66); delirium (n = 6) and sub-ileus (n = 4) developed only in the Open group. CONCLUSION: After LAC, elderly patients tended to have less postoperative pain and started oral liquid intake earlier. LAC can be safe and effective, preventing postoperative complications that occur specifically in oldest-old patients.

Comprehensive Predictors of Portal Pressure from Functional Liver Reserve in Patients Who Underwent Hepatectomy.

Portal hypertension is a major risk factor for hepatic failure or intestinal bleeding in patients with liver disease but cannot be measured indirectly. We attempted to comprehensively evaluate preoperative parameters of functional liver reserve that correlated with portal pressure (PP) in patients with various liver diseases. We examined 93 patients in whom portal pressure was directly measured during preoperative portal vein embolization (PVE) or operation. Background liver included chronic viral liver disease in 43 patients, obstructive jaundice in 29 patients, and normal liver in 21. Multivariate logistic analysis and linear regression analysis were applied to create a predictive formula for PP. Mean PP was 13.4 ± 4.9 cm H2O, and PP was significantly associated with severity of liver injury, hepatic fibrosis, intraoperative blood loss, and post-hepatectomy morbidity (p < 0.05 each). Mean PP after PVE (22.5 ± 7.8 cm H2O) was significantly increased compared to that before embolization (13.1 ± 4.7 cm H2O; p < 0.01). Univariate analysis identified seven significant parameters of preoperative liver function associated with PP: indocyanine green (ICG) test result, liver uptake and clearance index (HH15) on (99m)Tc-galactosyl serum albumin liver scintigraphy, total bilirubin level, prothrombin activity, and hyaluronate level. Using multiple linear regression analysis, the predictive formula using ICG and HH15 was as follows: Y (estimated PP) = 0.273 + 0.086 × ICGR15 + 0.193 × HH15. The calculated PP (11.5 ± 4.6 cm H2O (-1.9 cm H2O)) was lower than true PP, which was significantly associated with post-hepatectomy morbidity (p < 0.05). The correlation between true and calculated PP was weak, and prediction using the conventional liver functional parameters was limited at present and, however, estimating PP appears to be useful in evaluating portal hypertension and post-hepatectomy morbidity.

Clinicopathological parameters associated with surgical site infections in patients who underwent pancreatic resection.

BACKGROUND/AIMS: To clarify parameters associated with postoperative surgical site infection (SSI) after pancreatectomy, we examined clinicopathological and surgical records in 186 patients who underwent pancreatectomy at a single academic institute. METHODOLOGY: Patient demographics, liver functional parameters, histological findings, surgical records and post-hepatectomy outcomes during hospitalization were compared between the non-SSI and SSI group, in which SSIs included superficial and deep SSIs. RESULTS: The prevalence of SSI (29-35%) has not changed over an 18-year period. With respect to patient demographics and laboratory data, no parameters were associated with postoperative SSI. In surgical records, the operating time in the SSI group tended to be longer in comparison with that in the non- SSI group (618 vs. 553 minutes, respectively) but not significantly different (p=0.070). With respect to postoperative outcomes, time to oral intake in the SSI group was significantly longer than that in the non-SSI group (21.2 vs. 13.7 days, respectively) (p<0.01). Incidences of pancreatic fistula, postoperative bleeding, long-term ascites and re-operation were significantly more frequent in the SSI group in comparison with the non-SSI group (p<0.05). Decrease of body weight after surgery in the SSI group was significantly greater than that in the non- SSI group (-4.1 vs. -2.7kg, respectively) (p<0.05). Period of hospital stay in the SSI group was significantly longer than that in the non-SSI group (37 vs. 25 days) (p<0.05). Multivariate analysis showed that only postoperative pancreatic fistula was significantly associated with SSI (p<0.01). CONCLUSIONS: SSI is an important risk factor of longer hospital stay after pancreatectomy and prevention of pancreatic fistula through the future improvement of surgical procedures is necessary to decrease SSI rates.

Clinical significance of vessel-sealing device usage for pancreatectomy: a retrospective cohort study.

BACKGROUND/AIMS: We compared each vessel-sealing device to evaluate safety and efficacy for controlling surgical results in 200 patients undergoing pancreatectomy. METHODOLOGY: Sixty-seven patients applied the hemostatic devices (VS group) consisted of LigaSure™ (LS) or the Harmonic ultrasonic dissector (USD). Results were compared with that of a historical control group (n=134). RESULTS: In pancreaticoduodenectomy, the prevalence of lymph node dissection was high in the VS group. Blood transfusion was significantly less frequent in the VS group than in the control group (p<0.01). The prevalence of surgical site infection and systemic complications was significantly lower in the VS group than in the control group (p<0.05). The duration of hospitalization was significantly shorter in the VS group than in the control group (p<0.01). In distal pancreatectomy, the prevalence of cutting stapler usage for transection was low in the VS group. Postoperative weight loss and the prevalence of surgical site infections was higher in the VS group than in the control group but were more frequently observed in the USD group than in the LS group. CONCLUSIONS: Use of energy sealing devices improves surgical results and avoids pancreatectomy-related complications. These devices are safe and effective for use in pancreatic surgery.

How to access photodynamic therapy for bile duct carcinoma.

BACKGROUND: Photodynamic therapy (PDT) is a promising treatment option for local control of remnant cancer after surgical resection or biliary stenosis by the unresectable tumor in patients with bile duct carcinomas (BDC). To achieve effective tumor necrosis, an appropriate approach to laser irradiation is necessary. METHODS: The efficacy of endoscopy-guided PDT using porfimer (n=12) or talaporfin sodium (n=13) was investigated by evaluating the transhepatic biliary routes and endoscopic retrograde biliary (ERB) routes in 25 patients with BDC. RESULTS: Diseases included perihilar intrahepatic cholangiocarcinoma (ICC) in four patients, extrahepatic BDCs in 19 and ampular carcinoma (AC) in two patients. Adjuvant PDT after surgical resection was performed in 18 patients, and PDT for tumor biliary stenosis was performed in seven. In patients undergoing surgical resections, the mean period between the operation and PDT was 87±42 days. In patients who underwent prior surgical resections, the transhepatic route was used in five (28%), the jejunal loop was used in 11 (61%), the T-tube route was used in one, and the endoscopic retrograde cholangiography (ERC) route via papilla Vater was used in one. In unresectable BDC, the ERC route was used in four patients (57%), and the transhepatic biliary route was used in three (43%). Endoscopic-guided PDT could not be performed in one patient because of a technical failure. Except for the complication of photosensitivity, endoscopy-related complications were not observed in any patients. Patients undergoing PDT with porfimer sodium had a significantly longer admission period compared to patients undergoing PDT with talaporfin sodium (36 vs. 5 days, respectively) (P<0.01). CONCLUSIONS: PDT was safely and definitively performed using the endoscopy-guided approach via the transhepatic or ERC route. By considering the disadvantages of both routes, PDT must be adequately achieved for local control of BDC.

Prediction of portal pressure from intraoperative ultrasonography.

BACKGROUND: Portal hypertension is a major risk factor for hepatic failure or bleeding in patients who have undergone hepatectomy, but it cannot be measured indirectly. We attempted to evaluate the intraoperative ultrasonography parameters that correlate with portal pressure (PP) in patients undergoing hepatectomy. METHODS: We examined 30 patients in whom PP was directly measured during surgery. The background liver conditions included chronic viral liver disease in seven patients, chemotherapy-associated steatohepatitis in four patients, fatty liver in one patient, hepatolithiasis in one patient, obstructive jaundice in one patient, and a normal liver in 16 patients. A multivariate logistic analysis and linear regression analysis were conducted to develop a predictive formula for PP. RESULTS: The mean PP was 10.4 ± 4.1 mm Hg. The PP tended to be increased in patients with chronic viral hepatitis. A univariate analysis identified the association of the six following parameters with PP: the platelet count and the maximum (max), minimum (min), endo-diastolic, peak-systolic, and mean velocity in the portal vein (PV) flow. Using multiple linear regression analysis, the predictive formula using the PV max and min was as follows: Y (estimated PP) = 18.235-0.120 × (PV max.[m/s])-0.364 × (PV min). The calculated PP (10.44 ± 2.61 mm Hg) was nearly the same as the actual PP (10.43 ± 4.07 mm Hg). However, there was no significant relationship between the calculated PP and the intraoperative blood loss and post hepatectomy morbidity. CONCLUSIONS: This formula, which uses ultrasonographic Doppler flow parameters, appears to be useful for predicting PP.

Successful Colectomy for Hemorrhagic Colitis with Hemolytic Uremic Syndrome and Acute Encephalopathy due to Escherichia coli O157 Infection.

An 81-year-old man was admitted to a primary care hospital due to bloody diarrhea. The findings of abdominal computed tomography indicated ischemic colitis, so conservative therapy was started. On the 4th hospital day, the patient was transferred to our hospital because of renal dysfunction. Physical examination showed clouding of consciousness and abdominal distention. Abdominal computed tomography revealed massive ascites and thickening of the whole colonic wall. With a diagnosis of acute abdomen, an emergent laparotomy was performed. Extended right hemicolectomy was performed because of severe ischemic change and necrosis of the right side of the colon. In the stool culture before the operation, Escherichia coli O157 and verotoxin were found, so this case was diagnosed as hemorrhagic colitis with hemolytic uremic syndrome and acute encephalopathy due to Escherichia coli O157 infection. Postoperatively, the hemolytic uremic syndrome and acute encephalopathy were prolonged. However, with intensive care, the patient recovered and was discharged on the 33rd postoperative day.

Associated factors with surgical site infections after hepatectomy: predictions and countermeasures by a retrospective cohort study.

BACKGROUND: To clarify the factors associated with post-hepatectomy surgical site infections (SSIs), the clinicopathological data of 526 patients who underwent hepatectomy was retrospectively examined as a retrospectively cohort study. METHODS: Patient demographics, liver functions, histological findings, surgical records and post-hepatectomy morbidity were compared between non-SSI and SSI groups; the SSI group included superficial and deep SSIs. RESULTS: The prevalence of SSIs (5-8%) has not changed over an 18-year period. Deep SSIs were significantly more increased in male patients with lower performance statuses and American Society of Anesthesiologists (ASA) scores (p < 0.05). SSIs tended to be less prevalent, although not significant (p = 0.10), in patients who underwent laparoscopic hepatectomies compared to those who underwent laparotomies. For patients in whom hemostatic devices were used, the prevalence of superficial SSIs was significantly lower than those in whom the devices were not used (p < 0.05). Blood loss and transfusion were significantly more frequent in the deep SSI group compared to other groups (p < 0.01). Hospital stay in the deep SSI group was significantly longer compared to other groups. The incidence of morbidity was more frequent in the SSI groups compared with the non-SSI group (p < 0.001). A multivariate analysis showed that not using a vessel sealing device was significantly associated with superficial SSIs; male gender, hepatic failure and bile leakage were significantly associated with deep SSIs (p < 0.05). CONCLUSIONS: SSIs were important indicators of patient outcomes after hepatectomies, and preventing SSI development after surgical procedures is an important step in improving the overall prevalence of SSIs.

Usefulness of evaluating hepatic elasticity using artificial acoustic radiation force ultrasonography before hepatectomy.

AIM: To evaluate hepatic fibrosis and tumor diagnosis preoperatively, we investigated the elasticity calculated by the new parameter of ultrasonography, acoustic radiation force impulse (ARFI). METHODS: We examined ARFI of the non-tumorous right and left lateral liver and in the tumor by push pulse of probe in 95 patients with hepatic malignancies undergoing hepatectomy. Measurement of ARFI as hepatic stiffness was indicated as the Vs (m/s). RESULTS: Measuring the Vs in the non-tumor region was achieved in the right liver in 99% and at the left lateral liver in 94%. The Vs in the right liver was significantly lower than in the left lateral liver, and the Vs of the liver tumor was significantly higher than in the non-tumorous liver. The Vs in the right and left lateral liver was correlated with the platelet count, aspartate aminotransferase, fibrotic indices and indocyanine green test. The Vs in the right liver was significantly correlated with the fibrotic marker or index. The Vs of liver cirrhosis and histological stage 4 in the right and left liver was significantly the highest compared to the others. The Vs in the right liver showed a high area under the receiver-operator curve value predicting histological fibrosis. The Vs in the right was significantly correlated with blood loss and postoperative complications, particularly uncontrolled ascites. CONCLUSION: Non-invasive ARFI imaging elastography is useful in evaluating impaired liver function or in the differential diagnosis of liver malignancies, highly hepatic fibrosis and in predicting posthepatectomy morbidity.

Improvement of Surgical Records and Outcomes after Hepatectomy at a Single Academic Institute in Japan.

BACKGROUND/AIMS: To clarify improvement of hepatic resection in the recent years, we examined surgical records of 544 patients who underwent hepatectomy in 3 periods between 1994 and 2011 at a single academic institute. METHODOLOGY: Subjects were divided into 3 groups: group 1 (1994-1999, n = 156), group 2 (2000-2006, n = 228) and group 3 (2007-2011, n = 160). Clinical factors, surgical records and post-hepatectomy outcomes during hospitalization were compared between groups. RESULTS: In group 3, patient age was significantly higher and the incidences of alcoholic or fatty liver and obstructive jaundice were significantly higher than in group 1 (p < 0.05). Preoperative liver function was not different between groups, and only prothrombin activity was significantly better in group 1 in comparison with the other groups (p < 0.05). In comparison with group 1, the incidence of resident surgeons as the main operator were significantly higher than in group 3 (p < 0.01). Incidences of laparoscopic hepatectomy and thoraco-abdominal approach were increased in group 3 (p < 0.01). Incidences of combined organ and major vessels resections were significantly higher in group 3 in comparison with group 1 (p < 0.01). Use of omental wrapping and hemostatic devices were significantly more frequent in group 3 than in group 1 (p < 0.01). Surgical records were not different between groups but the red cell transfusion rate in group 3 was significantly lower than in group 1 (p < 0.05). Hospital stay in group 3 was significantly shorter than in group 1. Incidence of hepatectomy-related complication, particularly bile leakage, was significantly lower in group 3 than in group 1 (p < 0.05). CONCLUSIONS: According to this evaluation of different time periods, surgical outcomes have been improved with new surgical procedures and perioperative management.

Three-dimensional printing model of liver for operative simulation in perihilar cholangiocarcinoma.

3-dimensional printed liver was constructed using 3D vascular imaging in a patient with intrahepatic cholangiocarcinoma who underwent major hepatectomy. The reproducibility of 3D modeling by the latest imaging has been clarified and future preoperative simulation should be adramatically changed.

Usefulness of vessel-sealing devices combined with crush clamping method for hepatectomy: a retrospective cohort study.

BACKGROUND: Blood loss during resection of the hepatic parenchyma in hepatectomy can be minimized using vessel-sealing (VS) devices. Some sealing devices were retrospectively compared to evaluate the efficacy of each device for controlling blood loss, transection time and postoperative complications in hepatectomy as a cohort study. METHODS: Between 2005 and September 2012, hepatectomy was underwent in 150 patients using one of three types of LigaSure™ (Dolphin Tip Laparoscopic Instrument, Precise or Small Jaw) or the Harmonic Focus or Ace ultrasonic dissecting sealer. Results were compared to crush-clamping alone as the control method by the historical study (n = 81). RESULTS: Irrespective of the vessel-sealing device used for underlying chronic hepatitis, blood loss, blood transfusion rate, operating time and transection time were significantly reduced in the VS group compared with controls (p < 0.05). Rates of postoperative bile leakage and intra-abdominal abscess formation were significantly lower in the VS group than in controls (p < 0.05). Comparing devices, LigaSure Small Jaw and Harmonic Focus showed lower blood loss, shorter transection time and reduced rates of post-hepatectomy complications, in turn resulting in shorter hospital stays (p < 0.05). Tendencies toward uncontrolled ascites and bile leakage were only concern with the use of Harmonic Focus. Satisfactory surgical results were achieved using the sealing device for laparoscopic hepatectomy. CONCLUSIONS: The use of energy sealing devices improves surgical results and avoids hepatectomy-related complications. Adequate use of vessel sealers is necessary for safe and rapid completion of hepatic resection.

Recent advances and significance of intra-arterial infusion chemotherapy in non-resectable colorectal liver metastasis.

In era of systemic chemotherapy for colorectal liver metastasis (CLM), role of hepatic intraarterial infusion chemotherapy (HAIC) remains important. We examined treatment effects of HAIC in 36 patients with non-resectable CLM using 5-FU or CPT-11. Tumor response was complete response (CR) in 4, partial response (PR) in 19, stable disease (SD) in 6, and progressive disease (PD) in 7. Tumor control rate was 81% and response rate was 64%. Six patients showed catheter-related complications. Median survival period was 62 months in CR, and 25 with PR. HAIC has a major impact in high chemotherapy response and prolonging survival.

NX-PVKA levels before and after hepatectomy of hepatocellular carcinoma as predictors of patient survival: a preliminary evaluation of an improved assay for PIVKA-II.

Although the protein-induced vitamin K absence or antagonist-II (PIVKA-II) is used as a prognostic marker in hepatocellular carcinoma (HCC), a newly-improved assay, NX-PVKA (PIVKA-II measured using P-11 and P-16 antibodies) and NX-PVKA-R (ratio of PIVKA-II and NX-PVKA), are more accurate markers of PIVKA-II. We conducted a prospectively preliminary analysis of the relationship between NX-PVKA-R and clinicopathological parameters and prognosis in 22 patients with HCC who underwent hepatectomy and measured changes of this marker's levels after treatment. Median value of PIVKA-II (80 mAU/ml), NX-PVKA (60 mAU/ml), NX-PVKA-R (1.5) and NX-PVKA-D (difference of markers, 15 mAU/ml) were determined. Tumor relapse was observed in six patients, and the one year relapse-free survival rate was 88%. Correlation between PIVKA-II or alpha-fetoprotein levels and NX-PVKA, NX-PVKA-R or -D levels was significant (p<0.001). NX-PVKA-R was significantly correlated with tumor size (p<0.05). In patients who underwent pre-treatment before hepatectomy, PIVKA-II, NX-PVKA and NX-PVKA-R tended to be higher than in patients without pre-treatment, but this difference was not significant (p>0.10). For macroscopic findings, NX-PVKA-R for the confluent-nodular type was significantly higher than that for the simple-nodular type (p<0.05). The tumor-free survival rate in the group with a high NX-PVKA-R was significantly lower than that in the group with a low NX-PVKA-R group (p<0.05). In patients with tumor recurrence, postoperative NX-PVKA-R increased again. We conclude that a high value of NX-PVKA-R after hepatectomy for HCC reflects malignant potential and predicts early recurrence in patients with HCC.

Does the placement of a cystic duct tube after a hepatic resection help reduce the incidence of post-operative bile leak?

BACKGROUND: In this retrospective study, the effects of cystic duct (C) tube use on the incidence of post-hepatectomy bile leak were assessed. METHODS: The subjects were 550 patients who underwent a hepatectomy during 1990-2011, with (n = 83) and without (n = 467) C tube drainage. The use of a C tube was based on the surgeon's choice. RESULTS: Bile leakage was observed in 44 (8%) patients, and its incidence post-operatively correlated with intrahepatic cholangiocarcinoma, parenchymal transection with forceps fracture and tie, a major hepatectomy, prolonged surgery and excessive blood loss (P < 0.050) but not with the use of a C tube. The incidence of an intra-abdominal infection was higher and the hospital stay was longer in the leak (49 days) than non-leak group (21 days, P < 0.001). ISGLS grade B and C bile leak post-hemi-hepatectomy and extended-hepatectomy were more frequent in the non-C than C tube group (P = 0.016). The duration of hospitalization was not different between the two groups; however, 7 patients in the non-C tube group had prolonged hospitalization (> 60 days) compared with none in the C tube group (P = 0.454). CONCLUSION: The usefulness of the C tube in preventing post-hepatectomy bile leak could not be confirmed; however, both bile leak requiring clinical management and long hospitalization after a major hepatectomy could be reduced with C tube use.

Functional liver reserve parameters predictive for posthepatectomy complications.

BACKGROUND: Posthepatectomy complications have markedly decreased with advances in techniques and management; however, surgical risk to patients with injured livers is still not negligible. We evaluated several preoperative parameters of functional liver reserve tests in patients with various liver diseases as predictors of posthepatectomy complications. A comprehensive evaluation of preoperative liver functions is necessary for the prediction of the risk of posthepatectomy complications. METHODS: Over a 10-y period, we examined 442 patients who underwent hepatectomy for liver and biliary diseases. The patients' background liver diseases included chronic viral liver diseases in 211 patients, obstructive jaundice in 29 patients, and normal liver in 202 patients. Hepatectomy-related postoperative complications (i.e., long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 115 (26%) patients. A multivariate logistic analysis was performed to detect the predictive parameters, and a multivariate linear regression analysis was performed to derive a predictive formula for complications. RESULTS: A univariate analysis identified 15 significant parameters associated with hepatectomy-related complications, and eight parameters (i.e., presence of chronic hepatic injury, clearance index by technetium-99 m galactosyl human serum albumin liver scintigraphy of ≥ 0.60, total bilirubin level of >1 mg/dL, serum hyaluronic acid level of ≥ 75 ng/mL, major hepatectomy, blood loss of ≥ 950 mL, operating time of ≥ 500 min, and combined resection of another organ or major vessel) were independent predictive factors identified in the multivariate analysis. Clearance index by technetium-99 m galactosyl human serum albumin liver, bilirubin level, hyaluronic acid level, and major hepatectomy were the parameters included in the predictive formula. CONCLUSIONS: In the present study, we present a comprehensive formula based on the predictive parameters for hepatic complications for prospective assessment to avoid posthepatectomy morbidity.