Treatment of biliary tract stones after gastrectomy in the era of laparoscopic cholecystectomy.

BACKGROUND: The incidence of biliary tract stones has widely been reported to be high after gastrectomy. Treatment of biliary tract stones in post-gastrectomy patients was examined retrospectively, particularly minimally invasive therapy with laparoscopic cholecystectomy for gallbladder stones and endoscopic bile duct lithotomy for common bile duct stones. METHODS: Treatment of 122 post-gastrectomy patients with biliary tract stones was examined retrospectively from 1995 to April 2015. RESULTS: Symptomatic biliary tract stones were found in 3.7% of post-gastrectomy patients. The frequency of bile duct stones was higher in post-gastrectomy patients with gallbladder stones (44%) than in the nongastrectomy patients (11%). Laparoscopic cholecystectomy was carried out in 84% of the patients with gallbladder stones. Endoscopic bile duct lithotomy was feasible in 89% of patients with common bile duct stones. CONCLUSIONS: Laparoscopic cholecystectomy was feasible for removing gallbladder stones after gastrectomy. Endoscopic bile duct lithotomy followed by laparoscopic cholecystectomy was a good option for patients in whom endoscopic intervention could be performed. On the other hand, choledochoenterostomy could be a good option for patients in whom endoscopic bile duct lithotomy cannot be performed, particularly considering the risk of recurrent bile duct stones.

Long-term prognosis after resection of cryptogenic hepatocellular carcinoma.

BACKGROUND: We investigated the patterns and predictors of recurrence and survival in cryptogenic non-B, non-C, non-alcoholic hepatocellular carcinoma (CR-HCC). We compared the findings with those hepatitis virus B (B) and hepatitis virus C (C)-HCC. CR-HCC does not include HCC developed on NASH. METHODS: From 1990 to 2011, of 676 patients who underwent primary curative liver resection as initial therapy for HCC at our institution, 167 had B-HCC, 401 had C-HCC, and 62 had CR-HCC. Differences between three groups were analyzed using the Chi-squared test. Cumulative overall survival (OS) and disease-free survival (DFS) were determined by the Kaplan-Meier method, prognostic factors involved in OS/DFS were evaluated by univariate analysis using the log-rank test, and stepwise Cox regression analysis. RESULTS: Liver function was better in CR-HCC than in B/C-HCC, and mean tumor size was larger in CR-HCC than in B/C-HCC. In CR-HCC, OS was equivalent to that of B/C-HCC, and DFS was equivalent to that of B-HCC. Both tumor-related factors and background liver function appeared to be prognostic factors for three groups. CONCLUSION: Our findings indicate that the probability of survival of advanced CR-HCC was not longer than that of B/C-HCC. Given our findings, a postoperative follow-up protocol for CR-HCC should be established alongside that for B/C-HCC.

Liver resection for hepatocellular carcinoma using a microwave tissue coagulator: Experience of 1118 cases.

AIM: To present our extensive experience of hepatectomy for hepatocellular carcinoma using a microwave tissue coagulator to demonstrate the effectiveness of this device. METHODS: A total of 1118 cases (1990-2013) were reviewed, with an emphasis on intraoperative blood loss, postoperative bile leakage and fluid/abscess formation, and adaptability to anatomical resection and hepatectomy with hilar dissection. RESULTS: The median intraoperative blood loss was 250 mL; postoperative bile leakage and fluid/abscess formation were seen in 3.0% and 3.3% of cases, respectively. Anatomical resection was performed in 275 cases, including 103 cases of hilar dissection that required application of microwave coagulation near the hepatic hilum. There was no clinically relevant biliary tract stricture or any vascular problems due to heat injury. Regarding the influence of cirrhosis on intraoperative blood loss, no significant difference was seen between cirrhotic and non-cirrhotic patients (P = 0.38), although cirrhotic patients tended to have smaller tumors and underwent less invasive operations. CONCLUSION: This study demonstrated outcomes of an extensive experience of hepatectomy using heat coagulative necrosis by microwave tissue coagulator.

Primary Adrenal Lymphoma Possibly Associated With Epstein-Barr Virus Reactivation Due to Immunosuppression Under Methotrexate Therapy.

Primary adrenal lymphoproliferative disorder (LPD) is an extremely rare disease that is widely known to be associated with methotrexate (MTX) use in patients with rheumatoid arthritis (RA).A 70-year-old man was incidentally found to have a tumor at the dorsal part of the liver in a medical check-up. He had a history of RA treated with MTX. Abdominal ultrasonography demonstrated a low echoic mass (30 mm in diameter) at the dorsal part of the liver, located close to the inferior vena cava. Preoperative differential diagnoses included intrahepatic cholangiocarcinoma, adrenal tumor, and hepatic malignant lymphoma, but no definitive diagnosis was reached. On exploratory laparotomy, the tumor seemed to be derived from the right adrenal gland and adhered tightly to segment 7 of the liver. Therefore, right adrenectomy with partial resection of segment 7 of the liver was performed. Pathological findings revealed diffuse inflammatory cell infiltration with a population of small atypical lymphoid cells, with positive immunohistochemical evidence for Epstein-Barr virus (EBV). Final diagnosis was primary adrenal iatrogenic EBV-positive LPD, classified as "other iatrogenic immunodeficiency-associated LPDs: Hodgkin-like lesions."In this report, we described the possibility of the spontaneous healing of MTX-associated LPD (MTX-LPD) before treatment and the importance of doubting MTX-LPD and doing immunostaining to necrotic tissue. To our knowledge, this is the first reported case of MTX-related EBV-positive LPD, Hodgkin-like lesion, of the unilateral adrenal gland in patient with RA.

Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy--A novel pancreatic-gastric anastomosis technique.

BACKGROUND: Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform. RESULTS: One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013. CONCLUSIONS: Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD. TRIAL REGISTRATION: ISRCTN16761283 . Registered 16 January 2015.

Pancreatic cancer accompanied by a moderate-sized pseudocyst with extrapancreatic growth.

BACKGROUND: Pancreatic cancer accompanied by a moderate-sized pseudocyst with extrapancreatic growth is extremely rare. Diagnosis of pancreatic cancer on preoperative imaging is difficult when the pancreatic parenchyma is compressed by a pseudocyst and becomes unclear. Despite advances in imaging techniques, accurate preoperative diagnosis of cystic lesions of the pancreas remains difficult. In this case, it was challenging to diagnose pancreatic cancer preoperatively as we could not accurately assess the pancreatic parenchyma, which had been compressed by a moderate-sized cystic lesion with extrapancreatic growth. CASE PRESENTATION: A 63-year-old woman underwent investigations for epigastric abdominal pain. She had no history of pancreatitis. Although we suspected pancreatic ductal carcinoma with a pancreatic cyst, there was no mass lesion or low-density area suggestive of pancreatic cancer. We did not immediately suspect pancreatic cancer, as development of a moderate-sized cyst with extrapancreatic growth is extremely rare and known tumor markers were not elevated. Therefore, we initially suspected that a massive benign cyst (mucinous cyst neoplasm, serous cyst neoplasm, or intraductal papillary mucinous neoplasm) resulted in stenosis of the main pancreatic duct. We were unable to reach a definitive diagnosis prior to the operation. We had planned a pancreaticoduodenectomy to reach a definitive diagnosis. However, we could not remove the tumor because of significant invasion of the surrounding tissue (portal vein, superior mesenteric vein, etc.). The fluid content of the cyst was serous, and aspiration cytology from the pancreatic cyst was Class III (no malignancy), but the surrounding white connective tissue samples were positive for pancreatic adenocarcinoma on pathological examination during surgery. We repeated imaging (CT, MRI, endoscopic ultrasound, etc.) postoperatively, but there were neither mass lesions nor a low-density area suggestive of pancreatic cancer. In retrospect, we think that the slight pancreatic duct dilation was the only finding suggestive of pancreatic cancer. CONCLUSIONS: It is difficult to diagnose pancreatic cancer with pseudocyst preoperatively. If a pancreatic cyst is found in patients who had normal tumor marker levels or no history of pancreatitis, we should always consider the possibility of pancreatic cancer. In such cases, slight pancreatic duct dilation may be a diagnostic clue.

Implication of an extremely high preoperative alpha-fetoprotein value (>4,000 ng/mL) for the long-term outcomes of hepatectomy for resectable hepatocellular carcinoma.

BACKGROUND: The implication of extremely high preoperative alpha-fetoprotein (AFP) values for the long-term outcomes of hepatectomy for resectable hepatocellular carcinoma (HCC) remains uncertain. METHODS: A total of 762 hepatectomized HCC patients were divided into 3 groups according to preoperative AFP serum concentrations: 578 patients with AFP <100 ng/mL (low [LAP]), 147 patients with AFP 100-4,000 ng/mL (high [HAP]), and 37 patients with AFP ≥4,000 ng/mL (extremely high [EAP]). The clinicopathologic features and prognosis of the EAP group were compared with those of the other 2 groups to investigate their characteristics and whether the choice of hepatectomy was valid. RESULTS: The EAP group had a greater proportion of younger patients and those with hepatitis B compared with the other 2 groups. Large tumor size, poor histologic differentiation, and microscopic vascular invasion were also more common in the EAP group. The recurrence-free and overall survival rates of the EAP group were worse than those of the LAP group (both P < .01) but were not greatly different from those of the HAP group (P = .65 and P = .80, respectively). When the analysis was limited to solitary HCC cases, both recurrence-free and overall survival rates of EAP were not significantly different from those of LAP (P = .79 and P = .99, respectively). CONCLUSION: An extremely high AFP level does not provide additional postoperative prognostic implications beyond those provided by a high AFP level. Hepatectomy should be performed without reservation for cases of HCC associated with an extremely high AFP value.

The influence of histological differentiation grade on the outcome of liver resection for hepatocellular carcinomas 2 cm or smaller in size.

BACKGROUND: Small hepatocellular carcinomas (HCC) with poorly differentiated components (PDC) are reportedly at risk of dissemination and needle tract seeding after percutaneous radiofrequency ablation, although it is the preferred treatment for HCC ≤ 2 cm because of the low rate of vascular invasion. On the other hand, the clinical outcomes after hepatectomy for these tumors are still unclear because of their rarity. METHODS: A total of 233 cases of solitary HCC ≤ 2 cm were retrospectively reviewed and divided into two groups according to the presence of PDC: 199 without PDC (NP-HCCs) and 34 with PDC (P-HCCs). The clinicopathological characteristics and prognosis were compared. RESULTS: A comparison of clinicopathological characteristics showed that the elevation of the tumor markers alpha-fetoprotein (AFP) (>20 ng/mL) and des-gamma-carboxyprothrombin (DCP) (>40 AU/L) was significantly frequent in P-HCCs. The 3- and 5-year recurrence-free survival rates for P-HCCS were 39 and 29 %, respectively, which were significantly worse than those for NP-HCCs (64 and 50 %, respectively) (p < 0.01). Initial recurrence of P-HCCs was significantly more frequent, as well as extrahepatic recurrence and advanced recurrence in the early period after the operation. Recurrences with tumor dissemination were observed in 15 % of P-HCCs and 4 % of NP-HCCs (p = 0.03). CONCLUSION: PDC is present in 15 % of HCC < 2 cm and should be suspected when the both tumor markers are elevated. Moreover, significantly worse post-hepatectomy outcomes such as early advanced recurrence or recurrence with dissemination should be taken into account if PDC is present even in HCCs ≤ 2 cm.

Long-term survival after two surgical resections of peritoneal metastases from hepatocellular carcinoma with an interval of 4 years.

KEY CLINICAL MESSAGE: We propose that surgical resections of peritoneal metastases arising from hepatocellular carcinoma are an option for selected patients with controlled HCC in the liver, and without metastases in other organs, when the complete removal of such metastases can be achieved, especially in the case of patients with normal liver function.

Right hepatectomy for giant cavernous hemangioma with diffuse hemangiomatosis around Glisson's capsule.

Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson's capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn't diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavernous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.

Hepatectomy for liver abscess caused by stones spilled during laparoscopic cholecystectomy.

An abdominal abscess caused by spilled stones is a serious complication of laparoscopic cholecystectomy that requires drainage or reoperation to remove the scattered stones. Herein, we report the case of a 50-year-old woman, who was on dialysis for renal failure. She underwent major hepatectomy for a liver abscess caused by stones spilled during laparoscopic cholecystectomy.

Factors associated with early cancer-related death after curative hepatectomy for solitary small hepatocellular carcinoma without macroscopic vascular invasion.

BACKGROUND: Unexpected early cancer-related death (ECRD) within 2 years due to recurrence after curative hepatectomy for solitary small (<5 cm) hepatocellular carcinoma without macroscopic vascular invasion (SSHCC) is occasionally observed. METHOD: A total of 415 patients were enrolled (19 patients with ECRD and 396 patients with non-ECRD) to elucidate the risk factors of ECRD after curative hepatectomy for SSHCC. They were initially compared by limiting variables to preoperative factors to reveal predictors that could enable the modification of primary treatment. Subsequently, the same analysis was performed with all variables, including perioperative and histological factors. RESULTS: In the preoperative factors, tumor size > 3 cm and elevation of tumor marker level were independent predictors of ECRD. In the analysis with all variables, excessive intraoperative blood loss, poor differentiation, and microscopic vascular invasion were predictors of ECRD. In the recurrence patterns, 79% of ECRD presented as advanced (four or more lesions) or extra-hepatic recurrence, whereas these accounted for 18% in the non-ECRD. CONCLUSION: Excessive blood loss during the operation and histopathological findings of microscopic vascular invasion and poor differentiation are predictive factors of cancer-related death within 2 years of a hepatectomy for SSHCC.

Clinical significance of hepatectomy for primary biliary cirrhosis patients with hepatocellular carcinoma: Report of a single center case series and review of the published work.

AIM: Hepatectomy for hepatocellular carcinoma (HCC) in patients with primary biliary cirrhosis (PBC) has seldom been reported, and the clinical significance of this procedure remains unclear, although HCC has often been observed in end-stage PBC patients. METHODS: To understand the characteristics of hepatectomy on HCC in PBC patients, we examined seven cases at our institute, as well as 22 reported hepatectomy cases in the English-language and Japanese published work. Furthermore, to assess the treatment efficacy of hepatectomy for HCC in PBC patients, we compared these patients with viral hepatitis patients who underwent hepatectomies at our institute during the same period. RESULTS: In the review of 29 cases, more than 70% of the patients were aged over 65 years, and the mean Mayo risk score was low at 5.17. The resected tumors were mainly solitary (79%), and the median maximum tumor size was 37 mm. Approximately two-thirds of the patients met the Milan criteria. In the comparison between the PBC and viral hepatitis cases, there were no differences in the postoperative prognoses, although the tumor size was greater in the PBC cases. CONCLUSION: Hepatectomy for HCC in selected PBC cases is a feasible and potentially curative treatment option, similar to hepatectomy for HCC in viral hepatitis patients. This procedure is particularly useful for patients with preserved liver function who are not ideal candidates for liver transplantation.

In hepatocellular carcinomas, any proportion of poorly differentiated components is associated with poor prognosis after hepatectomy.

BACKGROUND: Hepatocellular carcinoma (HCC) often consists of various differentiation components in a single tumor. However, the categorization of histologic grade in hepatectomy for those tumors has not been standardized. Some studies have determined the differentiation grade of the tumor according to its worst component, whereas others have determined it according to its predominant component. The present study aimed to resolve the controversy about whether the worst component or the dominant component determines the nature of the tumor, especially focusing on the presence of a poorly differentiated component (PDC). METHODS: In total, 427 hepatectomized patients with solitary HCC were divided into three groups, tumors without a PDC (NP), tumors with a PDC but dominantly consisting of non-PDC as poorly contained (PC), and tumors predominantly consisted of a PDC as poorly dominant (PD). PC was compared with PD and NP. RESULTS: Statistical analysis revealed that large tumors and high alpha-fetoprotein level were significantly more frequent in PC than in NP (P < 0.01 and P = 0.04, respectively), although no remarkable difference was observed between PC and PD. Both recurrence-free and overall survival rates were significantly worse in the PC and PD groups than in the NP group (PC vs. NP: P = 0.01 and P < 0.01, PD vs. NP: P < 0.01 and P < 0.01, respectively), but there was no significant difference in these parameters between PC and PD. CONCLUSIONS: All HCC, including PDC, should be categorized as poorly differentiated HCC regardless of the predominant differentiation component.

Anatomical versus nonanatomical resection in patients with hepatocellular carcinoma located in the left lateral segment.

To date, no reported studies comparing anatomical resection (AR) and nonanatomical resection (NAR) for hepatocellular carcinoma (HCC) have restricted cases by tumor location. Thus, right hepatectomy and left lateral sectionectomy are both analyzed together as AR, whereas limited resection of both peripherally and centrally located liver tumors is categorized as NAR. This categorization may result in inaccurate conclusions in the analyses comparing AR and NAR. We conducted a retrospective comparison between AR (n = 30) and NAR (n = 57) for solitary and small (5 cm or less) HCC limited to the left lateral segment (LLS) to clarify whether AR is superior to NAR for HCC in LLS. The 1-, 3-, and 5-year recurrence-free survival rates were 83.3, 71.3, and 52.9 per cent for the AR group and 82.5, 51.0, and 40.7 per cent for the NAR group, respectively (P = 0.10). The 3-, 5-, and 7-year overall survival rates were 96.0, 82.8, and 77.9 per cent for the AR group and 84.1, 77.0, and 54.2 per cent for the NAR group, respectively (P = 0.07). The postoperative complication, recurrence patterns, and secondary treatment types after recurrence were not significantly different between the two groups. The multivariate analysis including the confounders related to background liver function indicated AR to be a significant protective factor against recurrence, although AR did not influence overall survival. AR was superior to NAR in preventing recurrence without increasing postoperative risks among patients with small solitary HCC limited to the LLS, although AR could not improve overall survival.

Retroperitoneal cavernous hemangioma resected by a pylorus preserving pancreaticoduodenectomy.

A retroperitoneal hemangioma is a rare disease. We report on the diagnosis and treatment of a retroperitoneal hemangioma which had uncommonly invaded into both the pancreas and duodenum, thus requiring a pylorus preserving pancreaticoduodenectomy (PpPD). A 36-year-old man presented to our hospital with abdominal pain. An enhanced computed tomography scan without contrast enhancement revealed a 12 cm × 9 cm mass between the pancreas head and right kidney. Given the high rate of malignancy associated with retroperitoneal tumors, surgical resection was performed. Intraoperatively, the tumor was inseparable from both the duodenum and pancreas and PpPD was performed due to the invasive behavior. Although malignancy was suspected, pathological diagnosis identified the tumor as a retroperitoneal cavernous hemangioma for which surgical resection was the proper diagnostic and therapeutic procedure. Reteoperitoneal cavernous hemangioma is unique in that it is typically separated from the surrounding organs. However, clinicians need to be aware of the possibility of a case, such as this, which has invaded into the surrounding organs despite its benign etiology. From this case, we recommend that combined resection of inseparable organs should be performed if the mass has invaded into other tissues due to the hazardous nature of local recurrence. In summary, this report is the first to describe a case of retroperitoneal hemangioma that had uniquely invaded into surrounding organs and was treated with PpPD.

Total pancreatectomy for recurrent intraductal papillary mucinous carcinoma in remnant pancreas of pancreaticoduodenectomy for intraductal papillary mucinous adenocarcinoma.

A 62-year-old man underwent pancreaticoduodenectomy (PD) for intraductal papillary mucinous carcinoma (IPMC) in 2006. No signs of adenocarcinoma at the resection margin were found by intraoperative pathological examination of frozen sections. The postoperative pathological diagnosis was invasive carcinoma derived from IPMC and moderately differentiated tubular adenocarcinoma. A blood analysis in 2011 showed serum (CA19-9) to be increased since the initial resection. Imaging test showed a recurrent tumour at the site of the pancreaticogastrostomy (PG) in the remnant pancreas. We conducted total remnant pancreatectomy for recurrent IPMC and partial gastrectomy. Because both lesions had a histopathological resemblance, the pathological diagnosis was recurrent invasive IPMC. Based on this experience, it is important to facilitate early detection by annual check-up. And also, we recommend PG as a reconstructive intervention in patients at high risk of IPMC recurrence in the remnant pancreas following PD as it is grossly visible on upper gastrointestinal endoscopy.

Minimum resection margin should be based on tumor size in hepatectomy for hepatocellular carcinoma in hepatoviral infection patients.

AIM: In patients with hepatoviral infection, although a wide resection margin can eradicate the microsatellite lesions around hepatocellular carcinoma (HCC), a large-volume hepatectomy may diminish remaining liver function and become an obstacle for treating recurrent HCC. The optimal width of the resection margin for these patients is still controversial. This study was conducted to investigate the optimal resection margin in hepatectomy for hepatoviral infection patients. METHODS: We retrospectively investigated the influences of the resection margin status on recurrence patterns and long-term prognosis in a group of 311 HCC patients with hepatoviral infection who had a solitary HCC without perioperative anti-HCC treatment. RESULTS: The resection margin status did not statistically influence the postoperative recurrence-free and overall survival rates (3-year recurrence-free survival of 61.0% vs 55.1%, P = 0.33; 5-year overall survival of 74.9% vs 81.5%, P = 0.77 in without a margin vs with a margin, respectively), although resection without a margin increased the local recurrence with marginal significance (P = 0.055). Regarding the width of the resection margin, in 30-mm or smaller HCC, resection margin did not significantly improve the prognosis among hepatoviral infection patients. However, for tumors larger than 30 mm, a resection margin wider than 3 mm showed significant impacts on the prevention of recurrence in spite of the influence of multicentric carcinogenesis. CONCLUSION: The resection margin used for eradication of microsatellite lesions showed differences that were dependent on tumor size in hepatoviral infection patients. Resection margin should be based on not only background liver function but also tumor characteristics.