The Effect of Adjuvant Radiotherapy in Patients Undergoing Complete Resection for Gallbladder Cancer with Lymph Node Metastasis

PURPOSE: We evaluated the effect of adjuvant radiotherapy on survival in patients who underwent curative resection for gallbladder cancer with lymph node metastasis. METHODS: Among the patients underwent curative resection even though there was lymph node metastasis; fifteen patients underwent adjuvant radiotherapy with over 40 Gy (RTx group) and 10 patients did not (no RTx group). We compared these two groups retrospectively. RESULTS: The median disease free survival (DFS) of the RTx group (21.6 months) was longer than for the no RTx group (6.6 months, p=0.451). The median overall survival (OS) of the RTx group (30.5 months) was also longer than the no RTx group (14.2 months). One-, 2-, and 5-yr OS rates were 60.0%, 40.0% and 40.0% in the no RTx group, and 86.7%, 70.9% and 26.6% in the RTx group, respectively (p=0.507). Five patients developed recurrence within 1 year (50.0%) in the no RTx group; there were 3 (20.0%) in the RTx group. CONCLUSION: Our study was limited by its retrospective nature and small numbers of patients. However, it suggests that adjuvant radiotherapy might improve DFS and OS for patients with completely resected but lymph node metastasized gallbladder cancer. Also this therapy seems to delay time to postoperative recurrence.

Temporary Placement of a Newly Designed, Fully Covered, Self-Expandable Metal Stent for Refractory Bile Leaks

Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.

Clinicopathologic Analysis of Remnant Gastric Cancer after Distal Partial Gastrectomy: Experience of Single Center during 15 Years

PURPOSE: Remnant gastric cancer (RGC) are generally detected at advanced stages or infiltration of adjacent organs. We retrospectively reviewed the surgical outcomes and clinicopathologic results of remnant gastric cancers that have operated during fourteen years in one institution of Korea. MATERIALS AND METHODS: 34 patients who were diagnosed with RGC at Ajou University Hospital from April 1995 to October 2009 were enrolled. We analyzed the features of previous operation, and according to these results, surgical outcomes and clinicopathologic results for RGC were analyzed. RESULTS: Of 34 patients, 20 patients had previously undergone distal gastrectomy for malignant disease, and 14 patients for benign disease. The period between previous operation and surgery for RGC in the patients underwent operation for malignant disease was shorter than that in benign patients (P<0.001). In surgical field, 31 patients (91.0%) were resected and curative resection was possible in 23 patients (67.6%). When 31 patients who underwent resection for RGC were divided into previous malignant and benign disease, there was no significantly different in terms of surgical outcomes and pathologic findings between two groups. Meanwhile, the patients who recently (after 2005) underwent surgery for RGC showed less advanced stage compared with the patients who underwent surgery before 2004. CONCLUSIONS: Resection was possible in the higher proportion (91.0%) of patients diagnosed with RGC compared with previous reports. The cause of previous operation did not effect on the surgical outcomes for surgery of RGC. Recent trend of RGC is to increase the proportion of early stage gastric cancer. Therefore, surgeons should consider curatively surgical resection for RGC the regardless of pattern of previous operation.

Serial Monitoring of Portal Venous Pressure/Flow during Living Donor Liver Transplantation

PURPOSE: Although living donor liver transplantations (LDLTs) are widely performed, a shortage of living donors exists continuously, which makes it difficult to find the optimal graft. A high portal venous pressure (PVP) is mainly related to small for size syndrome (SFSS), and low portal venous flow (PVF), to ischemic liver damage, leading to potential liver failure after surgery. We reviewed the literature in search of optimal PVP and PVF values during LDLTs, and tried to determine the clinical meaning of measurements of PVP and PVF for liver transplantation. METHODS: Between June, 2008 and June, 2009, we did 38 LDLTs. PVP and PVF were measured in 13 patients after laparotomy, after implantation of graft and after splenectomy. In addition, compliance (PVF/PVP) and compliance (mL/min/mmHg/g) per unit graft weight were calculated. Splenectomy was done when continuously maintained portal hypertension (>20 mmHg) occurred even after implantation. Splenectomy was also done for patients who presented preoperatively with splenomegaly and pancytopenia. RESULTS: After graft implantation, portal venous pressure decreased (16.8+/-4.1 mmHg vs. 14.7+/-3.1 mmHg)(p=.003), whereas portal venous flow increased (1236.4+/-725.3 mL/min vs. 1916.9+/-603 mL/min)(p=.019). Also, after splenectomy, portal venous pressure/flow decreased (16.4+/-3.7 mmHg vs. 13.8+/-3.3 mmHg)(p=.009)/(2136.4 mL/min vs. 1619.1+/-336.3 mL/min) (p=.001). Finally, after implantation, compliance increased (60+/-40 mL/min/mmHg vs. 126+/-18 mL/min/mmHg)(p=.007). CONCLUSION: After splenectomy, compliance remained constant (126+/-18 mL/min/mmHg vs. 122+/-34 mL/min/mmHg)(p=.364). After implantation of the graft, portal pressure decreased and portal venous flow increased. The compliance of the graft was not influenced by splenectomy. This shows that splenectomy is a good method to control high portal pressure without influencing the compliance of the graft.

Effect of Microsurgery Training Program for Hepatic Artery Reconstruction in Liver Transplantation

PURPOSE: During liver transplantation (LT), complications of the hepatic artery have been decreased because of microsurgery in reconstruction of hepatic artery has been widely adopted. However, in an early step of the LT program, hepatic artery reconstruction generally tends to be done with the help of a micro-surgeon from the the plastic surgery in most of Korean medical centers. In our center, we also have done reconstruction of the hepatic artery using a microscope and the skills of a plastic surgeon. We did this between Feb, 2005 and Jun, 2008 for liver transplantations. The increased the need for micro-surgeons in liver surgery as increased the cases of liver transplantation steadily. After training general surgeons of the surgical department who had no experience with microsurgery, we invested in the micro-surgery of hepatic artery reconstruction. Here we report the result of that investment. METHODS: Liver transplant patients (n=176) were enrolled between Feb, 2005 and Jul, 2009. Between Jul, 2008 and Jul, 2009, 28 cases of reconstruction of the hepatic artery were done by a general surgeon who had micro-surgery training. Before training in hepatic artery reconstruction, the general surgeon spent 3 months being introduced to micro-surgery in the micro animal laboratory. Because the training was repeated, the surgeon became skilled in doing artery anastomosis using rat's abdominal aorta. At the same time, we trained a plastic surgeon to do hepatic artery reconstruction during liver transplantation as the first assistant. From Jul, 2008 to the present time, the general surgeon was exclusively in charge of hepatic artery reconstruction during liver transplantation. Hepatic artery reconstruction was done using a microscope. Stitching was done using 8-0 or 9-0 nylon, and an interrupted end-to-end anastomosis was done. After hepatic artery reconstruction, artery flow was confirmed by ultrasonic doppler. For group A patients, left lobe grafts were used in 33, right lobe grafts in 73, dual grafts in 6, and whole liver grafts in 36. RESULTS: For group B patients, left lobe grafts were used in 1 and right lobe grafts in 21, while whole liver grafts were used in 6. In Group A, hepatic artery complications occurred in 5 cases (3.3%), and in Group B such complications did not occur (0%). There was no statistical difference (p=0.312). CONCLUSION: For hepatic artery reconstruction, during micro-surgery under a surgical microscope, it is thought that it is best to invest in a general surgeon who has been trained in micro-surgery. We suggest that a general surgeon is suitable for hepatic artery reconstruction after only a short time of micro surgery training.

A Case Report of Helicobacter Pylori Negative Gastric MALT Lymphoma with Monoclonal Gammopathy / 대한혈액학회지

Lymphomas of mucosa-associated lymphoid tissue (MALT) comprise 7% of all newly diagnosed non-Hodgkin's lymphomas. Helicobacter pylori (H. pylori) negative gastric MALT lymphomas account for 28 to 45% of gastric MALT lymphomas. H. pylori infection has a close relationship with most gastric low-grade B cell lymphomas of the MALT type. Monoclonal gammopathy can be seen in 36% of the patients and negatively associated with responses to eradication of H. pylori in gastric MALT lymphoma. Here, we describe a case of H. pylori negative MALT lymphoma that arose from the stomach with massive plasmacytic differentiation mimicking an extramedullary plasmacytoma with monoclonal gammopathy, and that was cured by total gastrectomy, chemotherapy and radiotherapy.

Effect of Pre-operative Biliary Drainage on Surgical Outcomes after Pancreaticoduodenectomy in Patients with Common Bile Duct Cancer

INTRODUCTION: Biliary drainage is tried before surgery because it is thought that obstructive jaundice is associated with post-operative mortality and morbidity. However, there are no confirmed criteria about the optimal operation time after drainage. We attempted to determine the appropriate pre-operative bilirubin level after drainage which should be achieved before pancreaticoduodenectomy is done for extrahepatic bile duct cancer. METHODS: We reviewed 100 patients (69 males and 31 females with a mean age of 61.3 +/- 9.4 years) who underwent pancreaticoduodenectomy after a pre-operative biliary drainage procedure for distal common bile duct cancer by one surgeon at the Asan Medical Center in Seoul Korea between 1994 and 2005. RESULTS: We compared the group with pre-operative bilirubin levels or = 5.0 mg/dl (N = 86). In the bilirubin or = 5.0 group (p = 0.032). CONCLUSION: The pre-operative bilirubin or = 5.0 groups had a clear difference in postoperative morbidity. Therefore, we suggest waiting until the pre-operative bilirubin level decreases to <5.0 mg/dl after biliary drainage.

Comparison of The Characteristics of Extraheaptic Bile Duct Cancer between Patients who are Younger than 54 Years and Older than 75 Years

PURPOSE: The objective of this study was to compare the clinicopathologic characteristics of the patients with extrahepatic bile duct cancer between the patients who are younger than 54 years and those who are older than 75 years. METHODS: Between 1994 and 2008, 63 patients underwent resectional surgery or palliative treatment for extrahepatic bile duct cancer. The medical records of these patients, including the clinicopathologic characteristics and the other relevant data, were retrospectively reviewed. RESULTS: There were some differences between the patient groups for the tumor location, distant metastasis and preoperative co-morbidity. The frequency of tumor locations were 58% proximal, 13% middle, 22% distal and 5% diffuse in the young patients and these were 33%, 18%, 48% and 0%, respectively, in the older patient group (p=0.049). The frequency of distant metastasis was 13% in the young patient group and none in the older patient group (p=0.026). The elderly patient group showed more preoperative co-morbidities (68% vs 29%, respectively) (p=0.009), but there was no statistical difference between the two groups for postoperative complications (p=0.301). There was no correlation between the preoperative co-morbidity and the operative complications for both groups. There were no differences in the other clinicopathologic characteristics and the survival rate for both groups. CONCLUSION: Young and elderly patients with extrahepatic bile duct cancer had different clinicopathologic characteristics. Especially, in the young patients, there were more proximally located-tumors and distant metastases. Although there were more preoperative co-morbidities in the elderly patient group over the age of 75, this did not affect the operative complication rate when the co-morbidities were well controlled preoperatively.

Synchronous Triple Primary Cancers - Liver, Gallbladder and Pancreas

We report here on a case of synchronous triple primary cancers that occurred in the liver, gall bladder and pancreas. A 69-year-old man who presented with symptoms of diarrhea, poor oral intake and dyspepsia was referred to our hospital. The diagnostic images showed a gall bladder mass (about 2cm in size), a pancreas head mass (2.7cm in size) and a liver mass (about 4cm in size) in segment 7. On positron emission tomography, the liver mass did not show a hypermetabolic uptake. We could not confirm a liver mass between the metastatic lesion and the hepatocellular carcinoma, and so we performed liver biopsy, which revealed hepatocellular carcinoma. Pylorus-preserving pancreaticoduodenectomy, extended cholecystectomy and liver wedge resection of segment 7 were performed. The biopsy showed gall bladder adenocarcinoma, pancreas ductal adenocarcinoma and hepatocellular carcinoma. Many multiple primary malignant neoplasms have previously been reported on, however, reports in the medical literature on synchronous multiple primary cancers occurring in the hepatobiliary and pancreas systems are very rare.

Living donor liver transplantation for Patients with beyond Milan hepatocellular carcinoma

BACKGROUND: To find the patients who have a significant chance of cure with living donor liver transplantation (LDLT) among the patients suffering with beyond-Milan hepatocellular carcinoma (HCC), we retrospectively analyzed the tumor factors that could affect a good prognosis after LDLT for patients who suffer with beyond Milan HCC. METHODS: Between March 2005 and May 2007, 18 cases of LDLT for beyond Milan HCC were performed. None of the patients had preoperative radiological evidence of vascular invasion. Excluding the 3 cases of in-hospital mortality, we analyzed the survival, the disease-free survival and the prognostic factors for recurrence in 15 beyond Milan HCC patients. The mean follow-up period was 18.8degrees +/- 8.8 months (range: 4-34 months). RESULTS: The two-year survival and disease-free survival rates after LDLT were 61.7% and 31.1%, respectively, in 15 beyond-Milan patients. Among them, 9 patients had recurrence of HCC during follow-up. The one-year survival rate after tumor recurrence was 55.5%. An alphafetoprotein (AFP) level < 400 ng/mL, Edmonson-Steiner histology grade I and II and the presence of graft rejection were analyzed as the good prognostic factors of disease-free survival after LDLT for beyond-Milan HCC (p < .05). The patients with negative preoperative positron emission tomography (PET) findings (n = 5) showed a better prognosis than the PET-positive patients (n = 10) with statistical significance (p = .05). CONCLUSION: Allowing that HCC patients exceed the Milan criteria, we can find the potentially curable candidates for LDLT with using tumor biologic markers such as a serum AFP level < 400 ng/mL, negative PET uptake or low grade histology, as assessed by preoperative needle biopsy. Further investigation is needed to evaluate the relation between graft rejection and tumor recurrence after liver transplantation.

The Outcome of Postoperative Radiation Therapy for Patients with Stage II Pancreatic Cancer (T3 or N1 Disease) / 대한방사선종양학회지

PURPOSE: To analyze retrospectively the outcome of postoperative radiation therapy with or without concurrent chemotherapy for curatively resected stage II pancreatic cancer with T3 or N1 disease. MATERIALS AND METHODS: Between January 1996 and December 2005, twenty-eight patients completed adjuvant radiation therapy at Ajou University Hospital. The patients had either pathologic T3 stage or N1 stage. The radiation target volume encompassed the initial tumor bed identified preoperatively, resection margin area and celiac nodal area. In the case of N1 patients, the radiation field extended to the lower margin of the L3 vertebra for covering both para-aortic lymph nodes bearing area. The median total radiation dose was 50 Gy. Ten patients received concurrent chemotherapy. RESULTS: Thirteen patients (46%) showed loco-regional recurrences. The celiac axis nodal area was the most frequent site (4 patients). Five patients showed both loco-regional recurrence and a distant metastasis. Patients with positive lymph nodes had a relatively high probability of a distant metastasis (57.1%). Patients that had a positive resection margin showed a relatively high local failure rate (57.1%). The median disease-free survival period of all patients was 6 months and the 1- and 2-year disease free survival rates were 27.4% and 8.2%, respectively. The median overall survival period was 9 months. The 2- and 3-year overall survival rates were 31.6% and 15.8%, respectively. CONCLUSION: The pancreatic cancer patients with stage II had a high risk of local failure and a high risk of a distant metastasis. We suggest the concurrent use of an effective radiation-sensitizing chemotherapeutic drug and adjuvant chemotherapy after postoperative radiation therapy for the treatment of patients with stage II pancreatic cancer.

Comparison of Laparoscopy-assisted Total Gastrectomy with Conventional Open Total Gastrectomy for Treating Early Proximal Gastric Cancer

PURPOSE: The purpose of this study was to compare the short-term clinical outcomes of laparoscopy-assisted total gastrectomy (LATG) with conventional open total gastrectomy (OTG) for treating proximal early gastric cancer and to determine the usefulness of the LATG procedure. METHODS: The records of 21 patients who underwent LATG for proximal early gastric cancer from January 2004 to August 2006 were retrospectively reviewed and compared with those records of 20 patients who underwent OTG during the same period. RESULTS: The patient characteristics, including gender, age, body mass index and comorbidities, were similar between the two groups. Combined resections were more frequently done in the OTG group than in the LATG group. The blood loss in the LATG group was significantly less than that in the OTG group. The operating time, time to first flatus and initial oral intake and the postoperative hospital stay were significantly shorter in the LATG group. The number of resected lymph nodes, lymph node metastasis, histologic type, TNM stage, complications, leukocyte counts and serum lactic acid levels were not significantly different between the two groups. CONCLUSION: LATG is a technically safe and feasible procedure for treating proximal early gastric cancer. Prospective multi-center trials are necessary to establish LATG as the standard treatment for proximal early gastric cancer.

The Effect of Preoperative Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

OBJECTIVE: To evaluate the impact of preoperative transarterial chemoembolization (TACE) for the treatment of patients undergoing curative liver resection for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Preoperative TACE was performed in 164 of 339 HCC patients that had a curative resection and follow-up. Retrospective clinico-pathological analysis was performed with regard to the safety and response to treatment, early and late incidence and the pattern of recurrence as well as survival. RESULTS: For 159 patients in the TACE group (96.9%), TACE was performed preoperatively only once. The mean waiting time from TACE to resection was 19.5 days. There was no difference in the operative time, postoperative mortality and duration of hospital stay after resection between the two groups (patients that underwent TACE and patients that did not undertake the procedure). Ed-highlight-you did not define the two groups-is the above description in parentheses accurate? Microvascular invasion was significantly decreased in the TACE group (p < 0.01) and complete necrosis of the tumor was induced in 21 patients (12.8%) of the TACE group. Early and late recurrence patterns were not different between patients in the two groups. Overall survival and disease-free survival rate was not different between patients in both groups. However, the 3 year disease-free survival rate was significantly improved in the TACE group (p = 0.04) and the 3 year disease-free survival rate was also improved (p = 0.06), especially for patients with AJCC stage I or II. Multivariate analysis showed microvascular invasion, large tumor size, the presence of daughter nodules, gross portal invasion, Child classification and histological stage of cirrhosis to be risk factors for HCC recurrence and poor survival. CONCLUSION: Preoperative TACE is a safe procedure and can improve early postoperative recurrence and survival, especially in stage I or II HCC patients.

Outflow Reconstruction using Cryopreserved Aortic Patch in Right Lobe Living Donor Liver Transplantation

METHODS: Living donor liver transplantation (LDLT) using a right lobe graft has been widely used to compensate for the cadaveric organ shortage. Successful reconstruction of the middle hepatic vein (MHV) is required to provide an adequate functional volume in LDLT with using the right lobe. We describe herein a new technique using a cryo-preserved aortic patch for outflow reconstruction of the right lobe graft with or without MHV. METHODS: From November 2005 through March 2006, 20 adult patients who received a right lobe graft (n=10) or an extended right lobe graft (n=10) for LDLT were included. During the bench procedure of the right lobe graft, we reconstructed the new MHV with using cryopreserved veins just like the MHV of the extended right lobe graft, and we then made a venous pouch to form a common trunk between the MHV (or new MHV) and the RHV of the right lobe graft with using a cryopreserved aortic patch. During graft implantation, anastomosis of an outflow tract was made between the venous pouch of the graft and the common trunk of recipient's RHV-MHV-LHV. One week following the transplantation, measurement of the pressure gradient between the MHV and IVC was done, as well as performing regular follow-up 3D-CT scans and liver function tests. RESULTS: The mean pressure gradient between the reconstructed MHV and the recipient's IVC was 2.3+/-1.2mmHg, and in all cases, the serial liver function tests showed gradual improvement as the days progressed post-operatively. There was no evidence of hepatic venous congestion of the graft and/or obstruction of the reconstructed MHVs according to the serial postoperative follow-up images of the Doppler US and MD-CT. CONCLUSION: We suggest that reconstructing the outflow tract with a cryopreserved aortic patch is a good alternative technique for preventing anterior segment congestion in LDLT with using a right lobe graft with or without MHV.

Use of a Postoperative Hepatic Arterial Embolization in Patients with Postoperative Bleeding due to Severe Hepatic Injuries

PURPOSE: Acute liver failure after massive partial hepatectomy is critical condition with high mortality. To prevent postoperative liver failure from being induced by a massive partial hepatectomy, many doctors do a minimal resection on the single lobe of the liver that might cause postoperative bleeding from the remaining ruptured parenchyma. The objective of this study was to assess clinical experience with postoperative hepatic arterial embolization to control bleeding from the remaining ruptured liver during the postoperative period. METHODS: This retrospective 4-year study was conducted from May 2002 to April 2006 and included consecutive patients who had sustained massive hepatic injuries and who had undergone a laparotomy, followed by postoperative hepatic arterial angiographic embolization to control bleeding. Data on the injury characteristics, the operative treatment and embolization, and the amount of transfused packed red cells (PRBC) were gathered and analyzed. In addition, data on the overall complications and survival rate were collected and analyzed. RESULTS: Every case showed severe liver injury, higher liver injury scaling grade IV. Only ten cases involved a ruptured bilateral liver lobe. A lobectomy was done in 6 cases, a left lobectomy was done in 3 cases, and a primary suture closure of the liver was done in 2 cases. Suture closure was also done on the remaining ruptured liver parenchyma in cases of lobectomies. The postoperative hepatic arterial embolizations were done by using the super-selection technique. There were some cases of arterio-venous malformations and anomalous vessel branches. The average amount of transfused PRBC during 24 hours after embolization was 2.36+/-1.75, which statistically significantly lower than that before embolization. Among the 11 cases, 9 patients survived, and 2 died. There was no specific complications induced by the embolization. CONCLUSION: In cases of postoperative bleeding in severe hepatic injury, if there is still a large amount of bleeding, postoperative hepatic arterial embolization might be a good therapeutic option.

Clinical Analysis of Gastric Carcinoma with Single Node Metastasis

PURPOSE: In order to examine the significance of a sentinel lymph node for gastric cancer, we investigated single node metastases that were hypothesized to represent the sentinel lymph node. METHODS: Of 2, 265 primary gastric cancers patients we experienced from 1994 to 2003, 140 patients having gastric carcinoma with a single node metastasis were enrolled in this study. The factors we studied including age, gender, tumor size, location, cellular differentiation, stage, and the patients' survival rate. RESULTS: Single node metastases were found in 30.7% of T1, 35.0% of T2, 29.3% of T3 and 5.0% of T4 staged tumor. Metastatic lymph nodes were mainly located near the tumor in 122 of 140 patients (87.1%). Skip metastases, which were defined as metastases that were found at more distant locations, were found in 18 patients (12.7%), and they were mainly located around the left gastric artery, the common hepatic artery, the proper hepatic artery and the splenic artery. The frequency of skip metastases significantly increased when the tumor was located upper part of the stomach, the tumor size was more than 5 cm in diameter and depth of tumor invasion was deeper (P<0.05). We found more frequent skip metastases in lymph nodes for the diffuse type of tumor infiltration than the macronodular type (P<0.05). The patients' overall 5 year survival was 76.9%, and skip metastasis did not affect on the survival rate. CONCLUSION: Our study supports the understanding of the biology of sentinel nodes. During gastrectomy in gastric cancer patients, great attention should be paid to remove the sentinel nodes and D2 dissection should be done when skip metastasis is suspected.

Safety of 'Isolated IVb (Inferior) Resection of the Liver' by Cadaver Dissection

PURPOSE: Healey divided segment IV of the live as the 'superior portion (IVa) ' and the 'inferior portion (IVb) '. On the contrary, Couinaud suggested that there was no useful purpose in dividing segment IV because of several reasons. Our goal is to evaluate the safety of the 'isolated IVb (inferior) resection of the liver' via performing the dissection of cadavers. METHODS: There were ten total cadavers. Cadaver dissection proceeded with respect to the Glissonian pedicle, the portal vein and the bile duct, respectively. The total number of Glissonian pedicles at segment IV was measured. The distance between the origins of the IVa and IVb branches was measured. Additional pedicles that were known to exist at segment IVa were also evaluated. RESULTS: The mean number of Glissonian pedicles in segment IV, IVa, and IVb was 5 (+/-1.3), 1.6 (+/-7), and 3.4 (+/-0.9), respectively. The mean distance between the origins of the IVa and IVb branches was 5.6 mm (+/-3.9 mm). Two of 10 cases had a very short distance between the origins that were considered as having common origin. Additional pedicles were identified at the Lt. main Glissonian pedicle in all the cases (8 cases: 1 each, 2 cases: 2 each). CONCLUSION: Considering the possible existence of a common origin of segment IVa and IVb Glissonian pedicles, there is the risk that the segment IVa will be injured during 'iso lated IVb resection'. Inevitable ligation of the additional pedicle of segment IVa from the Lt. main Glissonian pedicle can be made during the 'isolated IVb resection'. Therefore, we think that 'isolated IVb resection of the liver' can be safe only when the surgeon divides the branches of segment IVb with meticulous preservation of the IVa branches.

New Surgical Technique for Hepatolithiasis: Ventral Hilar Exposure Method

PURPOSE: Various treatments have recently been applied for hepatolithiasis and their results also have been reported. We introduce herein a new surgical technique, the Ventral Hilar Exposure Method, for hepatolithiasis. This method has been performed for the last ten years at our hospital, and we now report the results of this procedure. METHODS: We evaluated the outcomes of 128 patients among 153 patients who had received hepatectomy with the method of ventral hilar exposure for hepatolithiasis at our hospital from June 1994 to June 2004. We analyzed the rates of residual and recurrent stone, the risk of the treatment and the rate of concomitant cholangiocarcinoma. With these results, we evaluated the utility of the ventral hilar exposure method for hepatolithiasis. RESULTS: There was no post-operative mortality and severe complications in the 128 patients who had received hepatectomy by the ventral hilar exposure method. Among those patients, the rate of residual stone and recurrent stone were 5.4% and 4.2%, respectively. The rate of concomitant cholangiocarcinoma was 11%. CONCLUSION: The ventral hilar exposure method hepatectomy is safe and it shows a more improved treatment result for hepatolithiasis. We think that the direct exploration of intra-hepatic hilar bile duct structure during hepatectomy resulted in the improved outcomes. Therefore, we recommend this procedure of hepatectomy as a standardized surgical treatment method for hepatolithiasis.

Surgical Anatomy of Left Lobe of the Liver (Couinaud's and Healey's Anatomy) through Korean Cadaver Liver Dissection

PURPOSE: Couinaud described segment IV as being equivalent to segments II and III, as the umbilical portion of the portal vein (PV), and its equal branch of segment II, originated from the transverse portion of the PV. On the contrary, Healey suggested the presence of left lateral and medial segments, on the basis of umbilical fissure. Recently, some author have claimed the branch of segment II originated from the distal portion of the ligamentum venosum (LV), and that this branch was not equal to, only a branch of, the umbilical portion. Our goal was to evaluate the surgical anatomy of the left lobe of the liver through dissecting Korean cadavers. METHODS: The number of cadavers dissected totaled 10. PV, its branches, and the LV were dissected and the length of the transverse portion measured. The distance between the origin of the transverse portion and that of the segment II branch were also measured. RESULTS: The branch of segment II originated from the distal portion of the LV in all 10 cases. The length of the transverse portion was 18.8+/-5.8 mm, and the distance between the origins of the LV and segment II branch was 7.0+/-3.1 mm. CONCLUSION: Considering the embryology of the liver, as well as the above result, the umbilical portion and segment II branch were not equal anatomic structures. The umbilical portion and LV are equal anatomic structures. The branch of segment II is only one of the branches of the umbilical portion. We think Healey's classification is more accurate for the left lobe of the liver.

Influence of Preoperative Portal Vein Branch Ligation in Regeneration of Remaining Rat Liver with or without Jaundice

Purpose: The goal of this study is to define whether or not preoperative portal vein embolization has any additional role in the total amounts of liver regeneration and functional improvement after major hepatectomy in rat model. In addition, this study is to define obstructive jaundice has any positive or negative effect on it. METHODS: There were a total of 650 rats, divided into three experimental groups. Experiment A was done under the normal liver status, experiment B was done under the obstructive jaundice status, experiment C was done under the external biliary drainaged status. Each experimental group was divided into three groups that had been made by different surgery. One was 70% partial hepatectomy, another was 70% portal vein branch ligation, and the other was 70% portal vein ligation followed by 70% hepatectomy. Each operational group required over 60 rats for serial data collection which was taken at the operation and 6, 12, 24, 48, 72 hours after operation. RESULTS: We finally observed that there was no additional regeneration of remaining liver by doing preoperative portal vein embolization. It was same in obstructive jaundice group and external biliary drainaged group. And also, there was no significant fucntional improvement or deterioration by existence of obstructive jaundice. Conclusion: We conclude it is no worth doing preoperative portal vein embolization for getting additional liver regeneration and obstructive jaundice does not has significant positive or negative effect on liver regeneration and hepatic function in itself.