Early Experiences of Robotic-assisted Laparoscopic Liver Resection

PURPOSE: The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported. PATIENTS and METHODS: Between March and May 2007, we performed 3 robot-assisted left lateral sectionectomies of the liver. Case 1 had a hepatocellular carcinoma (HCC), case 2 had colon cancer with liver metastasis, and case 3 had intrahepatic duct stones. RESULTS: All patients had successful operation and recovered without complications. Shorter length of hospital stays, earlier start of oral feeding and less amount of ascites were found. However, case 1 had recurrent HCC at 3 months after operation. CONCLUSION: Robotic-assisted liver surgery is still a new field in its developing stage. In patients with small malignant tumors and benign liver diseases, robotic-assisted laparoscopic resection is feasible and safe. Through experience, the use of robotics is expected to increase in the treatment of benign diseases and malignant neoplsms. However, careful patient selection is important and long-term outcomes need to be evaluated.

Hepatic Splenosis Preoperatively Diagnosed as Hepatocellular Carcinoma in a Patient with Chronic Hepatitis B: A Case Report

We report on a case of hepatic splenosis. A 32-yr-old man underwent a splenectomy due to trauma at the age of 6. He had been diagnosed as being a chronic hepatitis B-virus carrier 16 yr prior to the surgery. The dynamic computer tomography (CT) performed due to elevated serum alpha-fetoprotein (128 ng/mL) demonstrated two hepatic nodules, which were located near the liver capsule. A nodule in Segment IVa had a slight enhancement during both the arterial and portal phases, and another nodule in Segment VI showed a slight enhancement only in the portal phases. Dynamic magnetic resonance imaging (MRI) of the mass in Segment VI showed enhanced development in the arterial phases and slight hyperintensivity to the liver parenchyma in the portal phases. These imaging findings suggested a hypervascular tumor in the liver, which could be either focal nodular hyperplasia, adenoma, or hepatocellular carcinoma (HCC). Even though these lesions were diagnosed as HCC, some of the findings were not compatible with typical HCC. On dynamic CT and MRI, all lesions showed a slight arterial enhancement and did not show early venous washout. All lesions were located near the liver capsule. These findings, along with a history of splenectomy, suggested a diagnosis of hepatic splenosis.

Laparoscopic Enucleation of a Nonfunctioning Neuroendocrine Tumor of the Pancreas

Laparoscopic approaches are increasingly used in pancreatic surgery. In the treatment of neuroendocrine tumors (NETs) of the pancreas, enucleation is one of the recommended surgery. Although many clinical experiences have reported the safety and efficacy of laparoscopic enucleation of functioning NETs, such as insulinomas, few reports have explored such treatment for non-functioning NETs. Here, we present a case of 70-year old female patient who underwent successful laparoscopic enucleation of a nonfunctioning NET located in the body of the pancreas.

Acute Chylous Peritonitis Mimicking Ovarian Torsion in a Patient with Advanced Gastric Carcinoma

The extravasation of chyle into the peritoneal space usually does not accompany an abrupt onset of abdominal pain with symptoms and signs of peritonitis. The rarity of this condition fails to reach preoperative diagnosis prior to laparotomy. Here, we introduce a case of chylous ascites that presented with acute abdominal pain mimicking peritonitis caused by ovarian torsion in a 41-yr-old female patient with advanced gastric carcinoma. An emergency exploratory laparotomy was performed but revealed no evidence of ovarian torsion. Only chylous ascites was discovered in the operative field. She underwent a complete abdominal hysterectomy and salphingo-oophorectomy. Only saline irrigation and suction-up were performed for the chylous ascites. The postoperative course was uneventful. Her bowel movement was restored within 1 week. She was allowed only a fat-free diet, and no evidence of re-occurrence of ascites was noted on clinical observation. She now remains under consideration for additional chemotherapy.

Long-term Follow-up of Laparoscopic Splenectomy in Patients with Immune Thrombocytopenic Purpura

Laparoscopic splenectomy (LS) has been reserved for intractable and relapsing immune thrombocytopenic purpura (ITP) despite medical treatment. With further experiences of LS in ITP, we investigated long term outcomes of LS, especially newly developed morbidities, and tried to find predictive factors for favorable outcomes. From August 1994 to December 2004, fifty-nine patients whose follow-up period was more than 12 months after LS were investigated. After a long-term follow-up (median 54 months, range 12.5-129 months), a complete response (CR) was found in 28 patients (47.5%), partial response in 24 (40.7%), and no response in 7 (11.9%). The relapse rate during follow-up periods was 15.2%. The rapid response group (p=0.017), in which the platelet count increased more than twice of the preoperative platelet count within 7 days after LS, relapsing after medical treatment (p=0.02), and the satisfactory group as the initial result of LS (p=0.001) were significant for predicting CR in univariate analysis, but only the initial satisfactory group was an independent predictive factor for CR in multivariate analysis (p=0.036, relative risk=6419; 95% CI, 1.171-35.190). Infections were the most frequent morbidities during the follow-up period, which were treated well without mortality. LS is a safe and effective treatment modality for ITP. Active referral to surgery might be required, considering complications and treatment results related to long-term use of steroid-based medications.

Pancreaticoduodenectomy of Pancreatic Ductal Adenocarcinoma in the Elderly

PURPOSE: Pancreatic ductal adenocarcinoma has the highest incidence between the ages of 60 and 70 years. As the elderly population has been increasing in the last several decades, the proportion of patients older than 70 years of age with resectable pancreatic cancer is expected to increase in our society. This retrospective observation was performed to evaluate surgical value of pancreaticoduodenectomy for the elderly patients with pancreatic ductal adenocarcinoma. MATERIALS AND METHODS: From January 1990 to June 2005, among the patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, the elder patients older than 70 years of age were retrospectively reviewed. Perioperative surgical outcomes, including general clinicopathologic features, morbidity, mortality, and survival outcomes, were investigated based on available medical records. RESULTS: Seventy-seven patients underwent pancreaticoduodenenctomy (PD) for pancreatic ductal adenocarcinoma. Among them, 11 patients (14.3%) were 70 years older. More frequent incidences of morbidity (8 out of 11 vs. 25 out of 65, p=0.049), especially delayed gastric emptying (3 out of 8 vs. 3 out of 66, p=0.035), were observed and overall length of hospital stay was also longer in the elderly (49.2 +/- 13.9 days vs. 36.1 +/- 13.2, p=0.012). However, no significant differences in mortality rate and survival outcomes were noted when comparing with those of the younger patients (p > 0.05). CONCLUSION: We agree with the opinion that age factor can not be absolute contraindication for pancreaticoduodenectomy, however, appropriate preoperative evaluations, proper patient selection considering life expectancy, advanced surgical techniques and detailed perioperative management are mandatory to guarantee the safety of pancreaticoduodenectomy performed in the elderly with pancreatic ductal adenocarcinoma.

The First Korean Experience of Telemanipulative Robot-Assisted Laparoscopic Cholecystectomy Using the da Vinci System

With the advancement of laparoscopic instruments and computer sciences, complex surgical procedures are expected to be safely performed by robot assisted telemanipulative laparoscopic surgery. The da Vinci system (Intuitive Surgical, Mountain View, CA, USA) became available at the many surgical fields. The wrist like movements of the instrument's tip, as well as 3-dimensional vision, could be expected to facilitate more complex laparoscopic procedure. Here, we present the first Korean experience of da Vinci robotic assisted laparoscopic cholecystectomy and discuss the introduction and perspectives of this robotic system.

Single Institutional Experiences of Insulinoma

PURPOSE: We present our experiences of pancreatic insulinoma among the functioning neuroendocrine neoplasm of the pancreas, to review the natural history and suggest proper management. METHODS: From June 1990 to August 2006, patients with diagnosis of pancreatic insulinoma were retrospectively reviewed. RESULTS: Thirteen patients (5 men and 8 women) with median age of 42 years (range, 12~68 years) were investigated. One patient (12%) with pancreatic insulinoma was MEN 1. Intraoperative ultrasound scan (sensitivity, 88%) was the most powerful modality for tumor localization. Sixteen neoplasms with median tumor size 1 cm (range, 0~3 cm) were found. Ten neoplasm (62%) were located in the heads/ necks of the pancreas. Six neoplasm (38%) were located in the tails. Five neoplasm (31%) were located around the neck areas near the SMV or PV. Twelve patients (92%) underwent enucleation, and two patients (15%) underwent distal pancreatectomy with splenectomy. 100% of patients with pancreatic insulinoma have survived and the overall disease free 10-year survival was found to be about 85.7%. CONCLUSION: Exact localization of tumor by intraoperative ultrasound and effective surgical removal can be significantly beneficial for good prognosis.

Surgical Experiences of Neuroendocrine Neoplasms of the Pancreas : Comparative Study of Functioning vs. Non-functioning Neoplasms

BACKGROUND: Aims A neuroendocrine neoplasm (NEN) of the pancreas is rare, and can be divided into functioning and nonfunctioning NEN. This study was carried out to determine the characteristics and surgical outcomes of NEN of the pancreas experienced in a single institution. METHODS: The medical records of patients diagnosed with NEN of the pancreas (pancreatic islet-cell neoplasm) between June 1900 and June 2005 were retrospectively reviewed. RESULTS: A total of 33 patients with NEN of the pancreas were examined. Nineteen patients (57.6%) had a nonfunctioning NEN and 14 (42.4%) had a functioning NEN. By comparison, the tumor size (p=0.001), distant metastasis (p=0.042), malignant characteristics (p=0.010) and survival (p=0.002), were significantly different. Surgical resections were almost always possible in the cases of functioning NEN. Patients with functioning NENs of the pancreas had a significantly higher survival than those patients with nonfunctioning NENs (p=0.002). A curative resection provided a better survival outcome in patients with nonfunctioning NENs (p=0.005) and offered a more than 80% disease-free survival in those with functioning NENs of the pancreas. CONCLUSION: Nonfunctioning NENs of the pancreas appeared to be more aggressive than functioning NENs. A complete resection of the NENs of the pancreas can provide a good prognosis.

The development of an efficient rat hepatic cirrhosis model

INTRODUCTION: Applying clinical conditions to on experimental animals forto verifverifyingy the mechanism of disease and drug effects is crucial. Cirrhotic livers induced by Hepatitis B virus are frequent, and eEspecially in Korea where a great deal of more liver-related diseases occurs, cirrhotic livers induced by Hepatitis B virus are frequent, and, such viral-induced cirrhosis, and this often impedes other medical treatments. Therefore, creating a proper elucidating properly deriveding cirrhosis method in animal model to simulate the actual pathophysiology of cirrhosis can benefit future researches. AIMS: We wanted toTe testing various hypotheticalsized methods of inducing cirrhosis in animal models, and we wanted the model to have a with higher rate of reproducibility. METHOD: To induce cirrhotic liver, thioacetamide (Sigma, St. Louis, USA) wasis given either freely via oral intaken or it wasand injected into the peritoneal space ofn Sprague-Dawley(SD) rats. The SD rats wereare divided into four groups: the oOral intake gGroup 1 ((N=10, 0.03%, 13 weeks), the oOral intake gGroup 2 (N=20, 0.04%, 30 weeks), the iIntraperitoneal Injected gGroup 1 (N=10, 300mg/kg, 12 weeks (3 times per week for first 2 weeks, 2 times per week for next 10 weeks) and the iIntraperitoneal Injected gGroup 2 (N=20, 300mg/kg, 2 times per week for 16 weeks). The mMortality rate of the tested subjects is recorded, and a visual test of the livers is performed at the end of the experiment, a visual test of the livers is performed. Also, the extracted liver cells that were dyed with Trichrome are compared to evaluate the extent of the liver cirrhosis. RESULT: For theIn oral intake group 1, no loss of occurred until wWeek 13, and 5 of the SD rats (50%) showed signs of liver cirrhosis by the Trichrome dye test. However, the extent of cirrhosis greatly differed betweenfrom each of the subjects. ForIn the oral intakae group 2, no loss occurred until wWeek 30. 20 of the SD rat (100%) in this group possessed a cirrhotic liver. However, the weight of the cirrhoscirrhotic liversis differed from a minimum of 231g to a maximum of 770g. For theIn Injected Group 1, 4 tested subjects (40%) died between wWeeks 3 and 4; however, the rest of them survived and they all revealed a signs of cirrhosis. ForIn the iInjected Group 2, only 3 tested subjects (15%) died, and after wWeek 16, 17 survivors (100%) showed a signs of cirrhosis. CONCLUSION: The short-term oral administration of thioacetamide only induced a minimal amount of cirrhosis;, thus, a longer period of consumption is suggested. Injection of thioacetamide into the peritoneum resulted in higher death rate when thoacetamide wasis injected frequently. Therefore, selecting a proper method to create a cirrhotic liver, with considering the reproducibility, on cirrhotic liver, the survival rate of the experimental animals, and the length of the experiment, isare strongly suggested for creating an animal model of cirrhotic liverfor further experiments.

Analysis of Prognostic Factors after Curative Resection for Gallbladder Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: Despite the development in diagnostic tools, gallbladder carcinoma is often diagnosed at an advanced stage. Therefore, early diagnosis and radical resection are most important factors for the prognosis of gallbladder carcinoma. However, prognostic factors after radical resection of gallbladder carcinoma have not been well identified. The aim of this study was to evaluate the prognostic factors of gallbladder carcinoma after curative resection. METHODS: We reviewed the records of the 115 patients with gallbladder carcinoma who underwent curative surgery between 1989 and 2004 at Yonsei University Medical Center (YUMC). The relationship between survival and clinicopathological variables was assessed. RESULTS: In 311 patients presenting with gallbladder carcinoma, 195 patients (62.5%) were radically resected. Among 195 patients, 80 patients were excluded because of incomplete clinicopathologic data and unsatisfactory follow-up. The 5 year overall survival rate was 36.0%, and disease free 5 year survival rate was 3.9%. Univariate analysis showed that survival was closely related to gross morphology, depth of tumor invasion, lymph node metastasis and preoperative serum CA19-9 level. Three significant factors identified by multivariate analysis were depth of tumor invasion, gross morphology, and preoperative serum CA19-9 level. CONLUSIONS: Depth of tumor invasion, gross morphology, and preoperative serum CA19-9 level are independent significant prognostic factors of resectable gallbladder carcinoma.

Solitary Paraaortic Lymph Node Metastasis of Primary Hepatocellular Carcinoma which was Misdiagnosed as Primary Retroperitoneal Tumor

The prognosis of primary hepatocellular carcinoma is very poor, and a curative resection is capable only in few selected patients. Most patients die from tumor recurrence. The rate of intrahepatic recurrence of hepatocellular carcinoma is much higher than extrahepatic recurrence or metastasis. The most common site of extrahepatic metastasis is lung, and followed by lymph nodes, bone and adrenal gland. Common sites of node metastasis are celiac lymph nodes and hepatoduodenal lymph nodes, however paraaortic lymph node metastasis is very rare. Here, we report an experience of solitary paraaortic lymph node metastasis from hepatocellular carcinoma which was misdiagnosed as primary retroperitoneal tumor by preoperative imaging studies.

Treatment Modalities for Adrenal Metastasis from Hepatocellular Carcinoma

PURPOSE: The adrenal gland is one of most the common sites for an extrahepatic metastasis from a hepatocellular carcinoma (HCC). However, there are no definitive guidelines for the treatment of adrenal metastasis. This study examined the effect of each therapeutic modality in an attempt to clarify the treatment strategy for adrenal metastases from a HCC. METHODS: This study reviewed the records of 11,770 consecutive HCC patients in the Yonsei University Medical Center from 1991 to 2005. Among the 11,770 patients, 648 were diagnosed with an extrahepatic metastasis. Of the extrahepatic metastases, 45 (6.9%) had an adrenal metastasis. Among these 45 patients, 15 patients with multiorgan metastases including the adrenal gland were excluded leaving 30 patients for review. The survival duration was evaluated according to the treatment modality, which included an adrenalectomy, non-surgical treatment (TACE, Chemotherapy), and conservative treatment. RESULTS: There were 24 men and 6 women, and the average age was 52.3 years (+/-9.1 years). The location of the adrenal metastasis was in the Rt, Lt, and both glands in 17 (56.7%), 9 (30.0%), and 4 (13.3%) patients, respectively. The initial HCC had been treated by a hepatectomy in 6 patients, and by non-surgical treatments such as TACE, chemotherapy and radiotherapy in 24 patients. The adrenal metastasis was treated by an adrenalectomy in 5 patients, by non-surgical treatment in 19 patients, and by conservative treatment in 6 patients. The overall median survival duration in the 30 cases was 11.1 months. The median survival time of the adrenalectomy, non-surgical treatment and conservative treatment groups was 21.4 months, 11.1 months, and 2.2 months respectively. The difference in the cumulative survival according to the treatment modality was statistically significant. CONCLUSION: The prognosis of an adrenal metastasis from HCC is quite poor. However, an adrenalectomy for an adrenal metastasis from a HCC is a safe procedure, and an acceptable way of achieving long-term survival.

Surgical Experiences of Functioning Neuroendocrine Neoplasm of the Pancreas

We present our surgical experiences with functioning neuroendocrine neoplasms of the pancreas to define its natural history, and to suggest its proper management. From June 1990 to June 2005, patients with diagnosis of functioning neuroendocrine (islet cell) neoplasms of the pancreas were retrospectively reviewed. Fourteen patients (5 men and 9 women) with a median age of 49 years (range, 12 - 68 years) were identified. Twelve patients (86%) had insulinoma, two (14%) had gastrinoma. One (7%) with pancreatic insulinoma was multiple endocrine neoplasia type 1. Intraoperative ultrasound scan (sensitivity, 83%) was the most powerful modality for tumor localization. Fifteen neoplasms with median tumor size 1 cm (range 0-3 cm) were resected. Four insulinomas (26.7%) were located in the head of the pancreas and 5 (36%), in the tail. Another 5 (36%) insulinomas and 1 (7%) gastrinoma were located around the neck area near the SMV or PV. Eleven patients (79%) underwent enucleation, and 2 patients (14%), distal pancreatectomy with splenectomy. 100% of patients with functioning neuroendocrine neoplasms of the pancreas have survived. The overall disease free 10-year survival was found to be about 81%. Exact localization of tumor by intraoperative ultrasound and surgical removal are promising for good prognosis.

Surgical Experiences of Functioning Neuroendocrine Neoplasm of the Pancreas

We present our surgical experiences with functioning neuroendocrine neoplasms of the pancreas to define its natural history, and to suggest its proper management. From June 1990 to June 2005, patients with diagnosis of functioning neuroendocrine (islet cell) neoplasms of the pancreas were retrospectively reviewed. Fourteen patients (5 men and 9 women) with a median age of 49 years (range, 12 - 68 years) were identified. Twelve patients (86%) had insulinoma, two (14%) had gastrinoma. One (7%) with pancreatic insulinoma was multiple endocrine neoplasia type 1. Intraoperative ultrasound scan (sensitivity, 83%) was the most powerful modality for tumor localization. Fifteen neoplasms with median tumor size 1 cm (range 0-3 cm) were resected. Four insulinomas (26.7%) were located in the head of the pancreas and 5 (36%), in the tail. Another 5 (36%) insulinomas and 1 (7%) gastrinoma were located around the neck area near the SMV or PV. Eleven patients (79%) underwent enucleation, and 2 patients (14%), distal pancreatectomy with splenectomy. 100% of patients with functioning neuroendocrine neoplasms of the pancreas have survived. The overall disease free 10-year survival was found to be about 81%. Exact localization of tumor by intraoperative ultrasound and surgical removal are promising for good prognosis.

The Actual Five-year Survival Rate of Hepatocellular Carcinoma Patients after Curative Resection

The five-year survival rate of patients after curative resection of hepatocellular carcinoma (HCC) has been reported to be 30 to 50 %, however the actual survival rate may be different. We analyzed the actual 5-year survival rate and prognostic factors after curative resection of HCC. Retrospective analysis was performed on 63 HCC patients who underwent curative resection from 1998 to 1999. A total of 63 cases were reviewed, consisting of 53 men and 10 women, with a median age of 49 years. These cases included all four pathologic T stages (pT stage) and had the following representation: stage 1 (1 case), stage 2 (17 cases), stage 3 (38 cases), and stage 4 (7 cases). In our study, the actual 5-year survival rate was 57.0% and the median survival time was 60 months. In addition, the patients in our study had an actual 5-year disease-free survival rate of 50.2% and a median disease-free survival time of 46 months. Thirty-one patients had recurrences, with a majority occurring within one year (65%). These patients with early recurrences had a poor actual 5-year survival rate of 5%. A univariate analysis showed that the prognostic factors influencing survival rate were the presence of satellite nodules, increased pT stage, HCC recurrence, and the time to recurrence (within one year). Interestingly, microvascular invasion made a difference in survival rate but was not statistically significant (p = 0.08). Furthermore, factors influencing the disease free survival rate include the presence of satellite nodules, microvascular invasion, and pT stage. Multivariate analysis identified pT stage as the only statistically related factor in determining the disease-free survival rate. The most important prognostic factor of HCC is recurrence. Moreover, the major risk factor for recurrence is an advanced pT stage. Therefore, performing prospective studies of postoperative adjuvant therapy is necessary to prevent recurrences after hepatic resection. Furthermore, active preventative treatment and early diagnosis of recurrences should be of the highest priority in the care of high-risk patient groups that have an advanced pT stage.

Central Bisectionectomy for Centrally Located Hepatocellular Carcinoma

PURPOSE: We wanted to analyzed the safety and the results of central bisectionectomy for treating patients with hepatocellular carcinoma. METHODS: Fourteen HCC patients who underwent central bisectionectomy were retrospectively reviewed. RESULTS: Eleven men and 3 women were included, and their mean age was 53 years old. Ten patients had HBV hepatitis. The indocyanine green retention rate at 15 minutes (ICG-R15) was 8.5 %. The mean operation time was 386 minutes, and the mean amount of intraoperative bleeding was 2150 ml. The mean weight of the resected liver was 304 gm. The mean size of tumor was 4.7 cm, and 11 patients had single tumor. The tumor stage was II in 7 patients, III in 5, and IV in 2, respectively. Seven patients(50%) suffered postoperative complications, there were 5 biliary complications (35.7%), such as biloma and bile leakage, two cases of pleural effusion(14.3%), two cases of ascites (14.3%), and one cases of liver failure due to necrosis of the remained right liver. Postoperative mortality occurred for 1 patient at the 70th postoperative day due to necrosis of the residual liver and liver failure. Recurrence was noted have occurred in 4 patients. The median follow period was 23 months (range:12~89 months). CONCLUSIONS: Central bisectionectomy can be is safely performed in selected patients for treating centrally located HCC. However, it is necessary to understand the biliary and vascular anatomy and to preserve the vascular supply to the residual liver.

Clinical Characteristics of Sarcomatoid HCC in Single Hospital Experience

PURPOSE: Sarcomatoid hepatocellular carcinoma (HCC) is a rare neoplasm and it has been found in only 1.8% of the surgically resected HCC patients, and in only 3.4~9.4% of the autopsied HCC cases. The pathogenesis of this tumor has't yet been thoroughly clarified, and such a tumor has been variously referred to as spindle cell carcinoma, sarcomatoid carcinoma, pseudosarcoma, or carcinosarcoma. There is only a little difference between the clinical characteristics of the sarcomatoid HCC and those of ordinary HCC. The diagnosis of the sarcomatoid HCC is made by pathological and immunohistochemical techniques after surgical resection, biopsy, or autopsy. METHODS: We reviewed the 10 cases of pathologically confirmed sarcomatoid HCC that were registered at the Yonsei University Medical Center from 1992 to 2004. RESULTS: Surgical operation was performed in seven cases, and curative resection was done only in five. Three patients were treated with chemotherapy or transarterial chemoem-bolization (TACE) with or without concurrent radiotherapy after the diagnosis of sarcomatoid HCC by liver biopsy. Six patients expired within 4 months after the diagnosis. The 6 month and 12 month survival rates for sarcomatoid HCC were 40% and 20%, respectively. The 6 month survival rates for radical resection and non-radical resection were 60% and 0%, respectively. The difference in cumulative survival according to the treatment of sarcomatoid HCC was statistically significant. CONCLUSION: The prognosis of sarcomatoid HCC is very poor; therefore, curative resection, adjuvant chemoradiotherapy, and close follow-up are necessary for patients suffering with sarcomatoid HCC.

Thoracoscopic Splanchnicectomy for Intractable Abdominal Pain

PURPOSE: In patient with intractable abdominal pain due to cancer, with respect to the quality of life, it is often insufficient to relieve pain with the use of analgesics. The development of laparoscopic surgery has made a thoracoscopic splanchnicectomy possible, but the results by using several different methods have varied between different authors. Herein, we introduce a modified method of thoracoscopic splanchnicectomy on the basis of anatomical background from cadaver dissection. METHODS: Sixteen thoracoscopic splanchnicectomies were performed, with the Numerical rating scale (NRS) used for the assessment of pain. The procedure was performed, under general anesthesia, using a double lumen catheter to deflate the lung on the operation side with the patient in the lateral decubitus position. Openings were made in the 7th intercostal space at the postaxillary line for a 12 mm trocar and in the 4th and 5th intercostals spaces for 5 and 2 mm trocars, respectively. The terminal branch of the greater splanchnic nerve ends In 5th intercostal space. Six or seven branches of the splanchnic nerve were cut, dissected downward to just above the diaphragm and then cut. The sympathetic trunk was also cut in this level if the patient suffered from constipation. RESULTS: A splanchicectomy appeared to result in significant reduction of abdominal pain in all cases. The average reduction in the pain score was 78%. There were no postoperative complications. CONCLUSION: A thoracoscopic splanchnicectomy is the treatment of choice for intractable intraabdominal cancer pain, helping with drug cessation or the reduction and recovery of daily activity in most patients.

Changes of Liver Volume and Functions after Hepatic Resection according to the Fibrosis (Stage of Chronic Hepatitis) of Liver Parenchyma

PURPOSE: The aim of this study was to assess the regeneration rate and functional recovery of the liver due to the stage of parenchymal fibrosis following a hepatectomy. METHODS: We reviewed 41 patients that had undergone a hepatectomy for living liver donation and 35 for an HCC. The HCC patients were classified into three groups according to their histopathological status. The liver volume was serially estimated using CT scans before the operation, and on postoperative days (POD) 7 and 30. The liver function tests for AST, ALT and bilirubin were serially checked before the operation, immediately postoperative, and on POD 1, 3, 5, 7 and 30. RESULTS: There were 61 and 15 males and females, respectively, with a mean age of 40 years. Patients were divided into four subgroups: parenchymal fibrosis, none (normal), periportal, septal and cirrhotic fibrosis. Within all the patients 55, 13 and 8 right lobectomy (RL), left lobectomy (LL) and left lateral segmentectomy (LLS), respectively, were performed. In the RL cases, the regeneration rate (RR) was significantly higher than those in the cases of LL and LLS. The RR of the fibrotic livers was significantly lower than that of normal livers, and became lower as the degree fibrosis increased. The RR at POD #7 was lowest in cirrhotic livers. The levels of Serum AST and ALT rapidly increased on the immediate postoperative day, and increased maximally on POD #1, but thereafter decreased gradually, and recovered to normal on POD #30. The serum bilirubin level reached a maximal value on POD #2, and returned to normal on POD #7. CONCLUSION: The regenerative activity in chronic hepatitis patients is poor, especially in cases of severe fibrosis - cirrhosis. Therefore, in cases of major resection in HCC patients with chronic hepatitis, it is advisable to decide the extent of resection after confirmation of the stage of fibrosis.