Water-filled laparoendoscopic surgery (WAFLES): feasibility study in porcine model.

PURPOSE: Recent surgical techniques have been advancing under endoscopic view and insufflation of carbon dioxide gas to expand the abdominal cavity. Isotonic fluid could be one candidate for expanding cavities to facilitate surgical maneuvering. We tested the feasibility and drawbacks of replacement of irrigating materials using a porcine model (water-filled laparoendoscopic surgery [WAFLES]). MATERIALS AND METHODS: Laparoscopic cholecystectomy was performed in two porcine models using instillation of sorbitol solution as irrigant. Solution irrigation was performed through one of four ports, with drainage via another port. Conventional forceps equipped with a monopolar electrode for electrocautery, laparoscope, video processor, ultrasound, and transducer for measuring intraabdominal pressure were used. RESULTS: Laparoscopic cholecystectomy was successfully undertaken with the following benefits: (1) clear observation of the dissecting plane throughout maneuvering; (2) control of oozing and spilled bile by irrigation and suction; and (3) ultrasonographic and laparoscopic images can be obtained simultaneously without any restriction to probe location. However, two disadvantages should be noted: (1) difficulties in managing floating organs and (2) interruption of vision by blood. CONCLUSIONS: WAFLES provides some benefits for endoscopic surgery with proper devices, including apparatuses for irrigation and suction. Efficient irrigation and selection of proper irrigant and apparatuses are required to establish an acceptable procedure.

Evaluation of the hepatic blood flow increase in the cases with liver metastasis and prediction of patent cases of liver metastasis using dynamic CT.

BACKGROUND/AIMS: This study aimed to measure hepatic blood flow increase in cases with liver metastasis and to diagnose minimal metastasis which cannot be visualized by imaging modalities. METHODOLOGY: The evaluation of hepatic arterial flow increase was performed quantitatively by newly devised index ELR (early-late-ratio) using dynamic computed tomographic (CT) scanning with contrast media. RESULTS: The ratio of the cases with liver metastasis was significantly higher than that of normal liver control. It was revealed that the ratio was correlated with microvessel proliferation in the liver around the metastasis by examination of surgical specimen. Moreover, the patent group which proved to have metastasis within 6 months also had a significant higher ELR value. CONCLUSIONS: ELR not only was useful to evaluate hepatic blood flow increase in the cases with liver metastasis but also could be applied to predict the patent group with micrometastasis.

Relationship between right portal and biliary systems based on reclassification of the liver.

BACKGROUND: Although the anatomy of the right portal and biliary systems and their interrelationships must be understood to safely and satisfactorily perform left-sided resection of hilar cholangiocarcinoma or right-lobe living donor liver transplantation, the anatomies of the right portal and biliary systems are extremely difficult to understand. METHODS: A total of 60 patients with normal liver underwent computed tomography during both portography and cholangiography to evaluate relationships between the right biliary and portal systems based on reclassification of the liver to divide the right liver into 3 segments. RESULTS: All ventral and posterior ducts constantly join medially to the anterior portal trunk. In contrast, some dorsal ducts join the ventral duct medially and others join the posterior duct lateral to the anterior trunk. CONCLUSIONS: Reclassification of the liver to divide the right liver into 3 segments facilitates an understanding of relationships between the right portal and biliary systems.

Ventral pancreatectomy associated with segmental duodenectomy including the major papilla.

During embryonic development, the head of the pancreas comprises ventral and dorsal primordia. The embryological fusion plane between the ventral and dorsal primordia reportedly separates the adult pancreas into the ventral and dorsal pancreas. The duct of Wirsung drains the ventral pancreas and terminates in the major papilla, while the duct of Santorini drains the dorsal pancreas and terminates in the minor papilla. However, complete resection of the ventral pancreas is difficult and impractical because the lower bile duct is buried in ventral pancreatic parenchyma and resection may lead to postoperative ischemic necrosis of the duodenum, particularly around the major papilla. We have therefore performed ventral pancreatectomy associated with segmental duodenectomy including the major papilla in 3 cases with intraductal papillary mucinous neoplasm that involved only the duct of Wirsung.

Anatomy of the middle hepatic vein: applications to living donor liver transplantation.

BACKGROUND/AIMS: In living donor liver transplantation, right lobe graft without a middle hepatic vein (MHV) results in potential venous congestion in the anterior segment, while transplantation with MHV represents an important ethical issue from the perspective of donor safety. The present study assessed ramification patterns of the MHV and relationships between hepatic venous drainage of the anterior and medial segments, to plan optimal harvesting of the right lobe as a graft. METHODOLOGY: The authors reviewed 102 patients with normal livers who underwent contrast-enhanced multi-detector row CT. RESULTS: The hepatic vein that drained S4sup (V4sup) joined only the left hepatic vein (LHV) in 60 patients (58%), only the MHV in 25 (25%), and both LHV and MHV in 17 (17%). Both V4sup and the hepatic vein that drained S8 (V8) joined the MHV in 42 patients (42%), and V8 joined proximal to V4sup in 18 of these 42 patients. CONCLUSIONS: In donation of a right lobe graft including MHV, preservation of V4sup in the remnant donor liver seems possible in most donors.

The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries.

BACKGROUND: There is an increasing demand for living donor liver transplants. However, the biliary complication rates are still high. METHODS: The anatomy of the communicating arcade (CA) between the right and left livers and its relevance to the blood supply of the hilar bile duct was evaluated using adult cadaveric livers and cast specimens. RESULTS: In all specimens that were of sufficient quality for evaluation, the CA was found to be located extrahepatically in the hilar plate with thin tributaries branching to the hilar bile duct. On the left side, 55% of the CA originated from a segment IV artery. On the right side, 73% of the CA originated from the right anterior hepatic artery. CONCLUSIONS: To maintain an adequate blood supply for the hilar bile duct of the donor graft during living donor liver transplantation, the branching point of the CA should be preserved.

Evaluation of CT during arterial portography for preoperative diagnosis of intrahepatic cholangiocarcinoma.

BACKGROUND/AIMS: To evaluate computed tomography during arterial portography for preoperative evaluation in patients with intrahepatic cholangiocarcinoma. METHODOLOGY: Computed tomography during arterial portography was performed in 11 intrahepatic cholangiocarcinoma patients undergoing hepatectomy. Segmental perfusion defect, sensitivity of the main tumor, and sensitivity of intrahepatic metastasis on computed tomography during arterial portography were retrospectively evaluated. RESULTS: In 9 of 11 patients (81.8%), a segmental perfusion defect was seen. The sensitivities for detecting the main tumor and intrahepatic metastasis were 81.8% and 20%, respectively. In 2 patients, the main tumors existed in segmental perfusion defects and thus were not depicted. In 4 false-negative cases, intrahepatic metastatic lesions existed in the segments that were the counterparts of segmental perfusion defects on computed tomography during arterial portography. CONCLUSIONS: The sensitivity of computed tomography during arterial portography for diagnosing intrahepatic cholangiocarcinoma and its intrahepatic metastasis was low due to segmental perfusion defect. It is necessary for intrahepatic cholangiocarcinoma to be subjected to systematic segmentectomy including all areas corresponding to the segmental perfusion defect.

Two-staged hepato-pancreatoduodenectomy and interventional pancreaticojejunostomy.

Two-staged pancreatoduodenectomy, including exteriorization of the pancreatic juice and second-look pancreaticojejunostomy, has been recommended for high-risk patients to avoid pancreatic leakage, which often causes intra-abdominal hemorrhage. We present a new technique of interventional pancreaticojejunostomy under both fluoroscopy and endoscopy without second-look laparotomy. A 77-year-old woman with local recurrence and liver metastasis from colon cancer underwent hepato-pancreatoduodenectomy with the external drainage of pancreatic juice via the pancreatic duct tube without pancreaticojejunostomy. Two months later, the jejunum was punctured with the insertion of a 5-F needle-knife into the pancreatic fistula during endoscopic observation of jejunal lumen, followed by the insertion of two 0.35-inch guidewires into the jejunum and the pancreatic fistula. Finally, a 10-Fr stenting tube was placed between the jejunum and the pancreatic fistula. No complications developed.

Communicating arcade between the right and left hepatic arteries: evaluation with CT and angiography during temporary balloon occlusion of the right or left hepatic artery.

PURPOSE: To evaluate prospectively the relationship between the arterial collateral system at the hepatic hilum and the blood supply to the hilar bile duct by using computed tomography (CT) and angiography during temporary balloon occlusion of the right or left hepatic artery. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. The study included 13 patients with no lesions at the hepatic hilum (eight men and five women; age range, 41-78 years; mean, 65.8 years). After serial angiographic studies were performed for preoperative evaluation or transcatheter arterial chemoembolization, a 5.5-F catheter with an occlusion balloon was positioned in the right or left hepatic artery. Eleven patients underwent angiography of the left hepatic artery with temporary occlusion of the right hepatic artery, and two patients underwent angiography of the right hepatic artery with temporary occlusion of the left hepatic artery. In addition, 11 patients underwent single-level dynamic CT during hepatic arteriography (CTHA) with temporary occlusion of the right or left hepatic artery. The images from angiography and CTHA were interpreted by two authors who assessed the existence of the arterial communication and its branching points, location, and relationship to the hilar bile duct and caudate lobe. RESULTS: During temporary occlusion of the right or left hepatic artery, the communicating arcade (CA) between the right and left hepatic arteries was immediately evident in all patients. On the left side, the CA originated from the segment IV artery in eight patients (62%) and from the left hepatic artery in five (38%). On the right side, the CA originated from the right anterior hepatic artery in six patients (46%), the right hepatic artery in two (15%), and both arteries in five (38%). The CA was extrahepatically located close to the hilar bile duct and forked into a few branches to the caudate lobe. CONCLUSION: The CA may play an important role not only in the interlobar arterial collateral system but also in the blood supplies to the caudate lobe and hilar bile duct.

Generation of antitumor immunity against large colon tumors by repeated runs of electrochemotherapy.

BACKGROUND/AIMS: Electrochemotherapy, which uses two parallel electrodes for delivery of electric pulses, may be useful for treatment of tumor nodules. However, in clinical fields, tumors that are larger than the distance between the two electrodes are frequently observed, and it would be difficult in such cases to deliver electric pulses to the tumor. This study was done to define how host antitumor immunity is generated by repeated electrochemotherapy treatments, and whether it is associated with regression of even large tumor nodules. METHODOLOGY: Balb/c mice and Balb/c nude mice were inoculated subcutaneously with colon 26. Electrochemotherapy using bleomycin and electroporation (CUY21) was administered as a treatment for tumor nodules that were larger than the distance between the electrodes. RESULTS: In Balb/c mice, growth of large tumors at the start of treatment is not inhibited by a single electrochemotherapy treatment. However, complete tumor regression was obtained through repeated electrochemotherapy treatments. No tumor cure was observed among Balb/c nude mice under the same therapeutic conditions. Inflammatory cells were accumulated in the tumor tissue seven days after the third electrochemotherapy treatment. CONCLUSIONS: Repeated electrochemotherapy is a promising treatment, even for large tumors, such as are usually encountered in clinical practice, by generating T-cell dependent, antitumor immunity.

Relationship between glucose transporter, hexokinase and FDG-PET in esophageal cancer.

BACKGROUND/AIMS: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been established as a powerful diagnosing modality in clinical oncology. FDG accumulation has been demonstrated to correlate with hexokinase activity. However, recent reports suggest that glucose transporters participate in FDG accumulation. The aim of this study is to evaluate glucose transporter and hexokinase expression and clarify the relationship between them and FDG accumulation. METHODOLOGY: FDG-PET was performed in 72 preoperative patients with esophageal cancer. The ratios of tumor radioactivity to plasma radioactivity (Ci/Cp values) were obtained 60 minutes after administration. We studied the expressions of glucose transporter 1 (Glut1) and type-II hexokinase (HK-II) by immunohistochemical analysis of the resected specimen. The percentages of cells expressing Glut1 and HK-II were scored on a 5-point scale (1=0-20%, 2=20-40%, 3=40-60%, 4=60-80%, 5=80-100%). Then the 3 scores obtained from 3 counting trials were averaged to give the Glut-index and HK-index. RESULTS: All esophageal cancers showed marked FDG accumulation. All 72 cancers expressed Glut1 and 71 of 72 cancers expressed HK-II. The Glut-index had a weak correlation with the Ci/Cp value (not significant). The HK-index had a close positive correlation with the Ci/Cp value (p<0.005). CONCLUSIONS: FDG accumulation correlates more with type-II hexokinase expression than with glucose transporter 1 expression.

Proposal for a reclassification of liver based anatomy on portal ramifications.

BACKGROUND: Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery. METHODS: A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed. RESULTS: In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally. CONCLUSIONS: We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

Anterior fissure of the right liver--the third door of the liver.

BACKGROUND/PURPOSE: Although the anterior segment of the liver has been divided into segments 8 and 5, we have, during surgical or interventional procedures, occasionally encountered patients in whom the right anterior portal vein does not bifurcate into the superior and inferior branches. Thus, the in vivo anatomy of the right liver was reevaluated to clarify the segmental anatomy. METHODS: We evaluated the hepatic venous and portal ramification patterns, using three-dimensional images reconstructed from computed tomography. In addition, liver volumetry was performed. RESULTS: All branches arising from the anterior trunk were divided into two groups: the right ventral portal branches (RVP) and the right dorsal portal branches (RDP), and the anterior fissure vein crossed between the RVP and RDP. The ventral and dorsal regions of the anterior segment were approximately equal from a volumetric point of view. CONCLUSIONS: The anterior segment seems to be divided into the ventral and dorsal segments by the anterior fissure, and we propose a reclassification of the right liver that divides the right liver into three segments. Dissection of the parenchyma along the anterior fissure makes the third door of the liver open, resulting in the exposing of all Glissonian pedicles of the right liver. The introduction of our segmental anatomy and surgical procedure will allow more systematic and limited liver resections.

[A case of the 5-year survivor of ascending colon cancer associated with synchronous multiple liver metastasis and peritoneal dissemination successfully treated with combination therapy of systemic and hepatic arterial infusion chemotherapy].

A 67-year-old woman was diagnosed by a series of examinations as having ascending colon cancer with synchronous multiple liver metastasis. She underwent an operation after the PTPE (percutaneous transhepatic portal vein embolization) to the right lobe of the liver, as we considered that the metastatic liver tumors were all resectable. In the surgery, we identified seven peritoneal tumors and a lymph node swelling. We then pathologically diagnosed them as being peritoneal dissemination (p3) and lymph node metastasis (n2(+)). Therefore, hepatectomy was not performed, but the right hemicolectomy (D2) and insertion of an arterial infusion catheter into the hepatic artery were performed. In addition, all seven peritoneal tumors were resected. After being discharged from hospital, she was treated as an outpatient with the combination chemotherapy of systemic intravenous administration (5-fluorouracil or 5-FU, 2,500 mg/month) and hepatic arterial infusion (5-FU, 1,500 mg/week) for 16 months. Then, she continued to take tegafur uracil (300 mg/day) by mouth for 39 months. The metastatic liver tumors were gradually reduced and resulted in complete response (CR) for 20 months after the operation. She has been in remission for the past 5 years without recurrence. During the treatment, we noticed a complete atrophy that was sustained in the right lobe of the liver to which PTPE was performed. As far as hepatic arterial infusion chemotherapy is concerned, our case study was interesting and effective.

Limited resection of the right hemiliver based on reclassification of the right anterior segment of the liver.

We proposed that the anterior segment was divided into ventral and dorsal segments, and reclassified the right hemiliver into three segments; ventral, dorsal, and posterior segments. According to our classification we successfully performed limited resection of the right hemiliver.

Limited resection based on reclassification of segment 8 of the liver.

Liver vein patterns which differ from those previously described are occasionally encountered during surgery. Therefore, we reclassified the anterosuperior segment (S8) into S8v (ventral area) and S8d (dorsal area), and the right paramedian sector into the ventral segment (S8v+S5) and the dorsal segment (S8d) based on portal and hepatic vein patterns. Using this new classification, we performed three types of limited resection of S8 in six patients with neither major nor minor procedural complications including biliary leaks, and no blood transfusion. This new classification allows development of surgical procedures where resection is limited to the portal unit and tumor.

Relation between hepatic and portal veins in the right paramedian sector: proposal for anatomical reclassification of the liver.

Although a right liver graft without a middle hepatic vein resulted in potential venous congestion in the right paramedian sector, the details of the hepatic venous distribution in the right paramedian sector have not been established. In this study, the ramification patterns of the hepatic veins draining the right anterosuperior segment (S8) and the relation between the hepatic and portal veins were assessed using multislice computed tomography in 44 patients without lesions in the liver. All 52 drainage veins of the ventral area of S8 joined the middle hepatic vein, and all 48 drainage veins of the dorsal area joined the right hepatic vein. The hepatic vein crossing between the ventral and dorsal areas was observed in each patient examined. Therefore, we propose a reclassification wherein the right paramedian sector is divided into ventral and dorsal segments. This new classification may contribute to the development of new and safer surgical procedures, including more limited resection and right lobe adult living donor liver transplantation to avoid graft congestion.

The diagnostic value of endoscopic ultrasonography and magnetic resonance imaging for anorectal malignant melanoma: report of a case.

A 74-year-old Japanese woman presented with a 3-month history of anal bleeding. Proctoscopy revealed an unusual polypoid lesion with focal pigmentation at the dentate line, which was histologically diagnosed as a malignant melanoma. Whole-body clinical and radiographic evaluations revealed no alternative primary source. Endoscopic ultrasonography (EUS) showed well-delineated hypoechoic tumors invading the muscularis propria, and magnetic resonance imaging (MRI) revealed regional lymphadenopathy. Following this evaluation, an abdominoperineal resection with regional lymphadenectomy was performed. The excised tumor was histologically confirmed to be malignant melanoma, and its depth and metastatic lymph nodes proved to have been accurately and precisely evaluated by the preoperative examinations. Thus, EUS and MRI are useful preoperative diagnostic tools for the tumor staging of primary anorectal malignant melanomas, as for other rectal tumors.

[Treatment of colorectal cancer--hepatic metastases].

The aim of this study was to evaluate the effect of the local therapy for colorectal liver metastases on overall survival. Seventy-two patients who had resected liver metastases from colorectal cancer during the period from 1982 to 2001 were evaluated for survival. There was no significant difference in overall survival by either surgical method for colorectal liver metastases or postoperative arterial infusion chemotherapy. However, the 5-year survival rate of resected metachronous liver metastases with postoperative arterial infusion chemotherapy was 44.9%, and that for patients with no extra hepatic metastases was 57.4%. Patients who have metachronous liver metastases from colorectal cancer should therefore be considered for postoperative arterial infusion chemotherapy. It is necessary to improve the outcome for cases that have extra hepatic metastases.