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Background Patients with recurrent hepatocellular carcinoma or metastatic liver cancer from colorectal cancer after surgical resection have traditionally been treated with conventional open surgery. However, recent technical advances have facilitated laparoscopic repeat hepatectomy (LapRH), which has advantages over open laparotomy. We describe the results of LapRH at our institution and retrospectively compare short-term outcomes after LapRH and initial laparoscopic partial liver resection (LapPLR). Methods From April 2010 through December 2017, 24 patients (16 men, 8 women; median age, 69 years) underwent LRH for cancer recurrence or metastasis after initial partial hepatectomy at our institution. LapRH involved partial hepatectomy in 21 patients and lateral segmentectomy in 3 patients. Short-term outcomes (operative time, intraoperative blood loss, and postoperative hospital stay) for these 24 patients were compared with those for 117 patients who underwent initial LapPLR during the same period. Results There were no significant differences between the LapPLR and LapRH groups in baseline characteristics, including patient age and underlying disease. No LapRH procedure required conversion to open surgery. There were no statistically significant differences between the groups in median operation time (268 min for LapPLR, 294 min for LapRH; p = 0.55), blood loss (224.0 mL for LapPLR, 77.5 mL for LapRH; p = 0.76), or length of hospital stay (11.0 days for LapPLR, 10.2 days for LapRH; p = 0.83). Conclusions LapRH for recurrent liver cancer yielded satisfactory outcomes when compared with those of initial hepatectomy. Further studies are needed, however, to confirm the present results.

Cecal volvulus is characterized by torsion of the cecum around its own mesentery. However, cecal volvulus rarely develops soon after elective laparoscopic cholecystectomy. We report on a case of cecal volvulus that developed in a 54-year-old women 1 day after elective laparoscopic cholecystectomy and was successfully treated via colonoscopic decompression. The symptoms gradually improved in conjunction with recovery from postoperative ileus. Whether the incidence of volvulus has increased with the use of laparoscopic procedures, including laparoscopic cholecystectomy, has yet to be determined. Considering the current trend toward minimally invasive surgery, cecal volvulus should be considered in patients who have postoperative abdominal pain and distention.

Portal vein thrombosis (PVT) is a rare complication of liver transplantation which can lead to graft failure and patient death. Treatment can be difficult, especially in cases of PVT from the intrahepatic portal vein to the proximal jejunal veins. A 55-year-old woman had undergone living-donor liver transplantation with splenectomy for end-stage liver cirrhosis due to hepatitis C with hepatocellular carcinoma. Ten months after transplantation, massive ascites and slight abdominal pain developed, and computed tomography revealed a PVT between the intrahepatic portal vein and the superior mesenteric vein. Repeated interventional radiology procedures were used in combination with thrombolysis, thrombectomy, and metallic stent replacement to obtain favorable portal flow to the graft. Five years after being treated, the patient is well, with favorable portal flow having been confirmed. In conclusion, repeated and assiduous interventional radiological treatment combined with thrombolytic therapy, thrombectomy, and metallic stent replacement could be important for severe PVT.

Laparoscopic hepatectomy has become a widespread procedure in Japan, now that the national medical insurance system covers partial resection and lateral segmentectomy. An important procedure during laparoscopic hepatectomy is the division of the vascular pedicles. In this paper we report a practical and useful method for vascular division with an Endo Mini-Retract(TM) retractor and a shortened Nelaton catheter (2.5-mm-diameter) developed in our department.

Bleeding from gastric varices (GVs) is generally considered more severe than that from esophageal varices (EVs) but occurs less frequently. We review the risk factors for bleeding EVs and GVs. GVs were divided into 2 groups: cardiac varices (CVs, Lg-c) and fundal varices (FVs), i.e., varices involving the fundus alone (Lg-f) or varices involving both the cardia and fundus (Lg-cf). Elevated pressure in the portal vein is a risk factor for bleeding EVs. The portal pressure in patients with GVs and a gastrorenal shunt is lower than that in patients with EVs. The large size of varices is a risk factor for bleeding EVs. Red color signs are elevated red areas that are important for predicting the risk of variceal bleeding, and red wale markings, dilated venules oriented longitudinally on the mucosal surface, have been considered to be the sign with the highest risk. Red color signs are rare in FVs, possibly because of the pronounced thickness of the mucosal layer. Bleeding EVs are not associated with use of antiulcer drugs or nonsteroidal anti-inflammatory drugs (NSAIDs). Although, in patients with bleeding GVs, "occasional" use of an oral NSAID is an important step leading to variceal hemorrhage, especially from FVs, even if the mucosa is protected by antiulcer drugs. Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EVs.

A liver tumor metastatic from a sigmoid colon carcinoma was diagnosed in a 70-year-old man. Because hepatectomy was not indicated, the patient was treated with a combination of oxaliplatin, levofolinate, and fluorouracil (5-FU) (modified FOLFOX 6 regimen). After 15 cycles of chemotherapy, this regimen was considered to have been ineffective; therefore, treatment was started with the topoisomerase inhibitor irinotecan and an intravenous infusion of 5-FU and levofolinate (FOLFIRI). After receiving irinotecan and levofolinate, the patient had chills, a severe cough, and dyspnea. We diagnosed pulmonary edema as a side effect due to oxaliplatin, and the chemotherapeutic regimen was changed from FOLFIRI to FOLFOX plus bevacizumab. After the third cycle of oxaliplatin and levofolinate, pulmonary edema recurred, and a preshock state developed again. We suspected that either oxaliplatin or irinotecan had caused the pulmonary edema and, therefore, administered levofolinate, 200 mg/m(2); 5-FU, 400 mg/m(2); and bevacizumab, 330 mg/m(2); intravenously on day 1, followed by 5-FU, 2,400 mg/m(2), as a continuous intravenous infusion at 46 hours without either of oxaliplatin, levofolanate, and bevacizumab. After being treated with levofolinate again, the patient suddenly complained of severe dyspnea; this symptom confirmed that levofolinate had caused the pulmonary edema. To our knowledge, severe pulmonary edema caused by levofolinate has not been reported previously. This adverse effect was clinically significant because it led to the patient's death.

Bleeding from esophageal varices (EVs) or gastric varices (GVs) is a catastrophic complication of chronic liver disease. In this paper, we review the management of bleeding EVs and GVs. DIAGNOSIS OF EVS AND GVS: The grading system for esophagogastric varices proposed by the Japan Society for Portal Hypertension classifies GVs into those involving the cardia (Lg-c), the fundus (Lg-f), and both the cardia and the fundus (Lg-cf). In this review, we divide GVs into 2 categories: Lg-c (cardiac varices: CVs) and Lg-cf or Lg-f (fundal varices: FVs). TREATMENT MODALITIES FOR EVS AND GVS: Treatment modalities for EVs and GVs include placement of a Sengstaken-Blakemore tube, pharmacologic therapy, surgery, interventional radiology, and endoscopic treatment. MANAGEMENT OF BLEEDING EVS AND GVS: In Japan, endoscopic treatment has recently become the therapy of choice for bleeding EVs or GVs. In other countries, especially the United States, vasoactive drugs and endoscopic treatment are routinely used to manage variceal hemorrhage. BLEEDING EVS: Endoscopic variceal ligation is useful for controlling bleeding from EVs. However, confirmation of ligation precisely at the site of bleeding is usually difficult in patients with massive variceal bleeding. The site of acute bleeding can generally be identified by means of water instillation and suction. Ligation is then performed at the bleeding point. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Transportal obliteration is useful for blocking variceal blood flow. BLEEDING GVS: Endoscopic injection sclerotherapy with a tissue adhesive, such as N-butyl-cyanoacrylate or isobutyl-2-cyanoacrylate, is effective for acute bleeding from GVs. However, bleeding from the GV injection site and rebleeding from the rupture point have been reported in patients receiving endoscopic injection sclerotherapy. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Balloon-occluded retrograde transvenous obliteration and transportal obliteration are useful for the treatment of uncontrolled bleeding from GVs. PREVENTION OF RECURRENT VARICEAL HEMORRHAGE: Given the high recurrence rate, survivors of an acute variceal hemorrhage should receive treatment to prevent recurrence. Complete eradication of EVs or GVs and maintenance of low portal venous pressure are essential for preventing recurrence of variceal hemorrhage.

We report a case of xanthogranulomatous cholecystitis (XGC) that was diagnosed preoperatively by means of ultrasonography (US) with the contrast-enhancement agent Sonazoid after a false-positive result had been obtained with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET). A 69-year-old woman was admitted because of right upper quadrant pain. Blood tests revealed a serum CA19-9 level of 749.8 IU/L. Computed tomography (CT), US, and magnetic resonance imaging of the abdomen showed abnormal thickening of the gallbladder wall but no stones. The border between the gallbladder and the liver was unclear. FDG-PET revealed a lesion with increased uptake of tracer in the gallbladder wall. The thickness of the lesion was similar to that on CT. We suspected gallbladder carcinoma with hepatic invasion. To confirm the tentative diagnosis, we performed US with the contrast-enhancement agent Sonazoid. The gallbladder wall was homogeneously enhanced in the early vascular phase and remained enhanced for 90 seconds. Enhancement of the gallbladder wall was smooth and regular. The border between the gallbladder and liver was clear and smooth. On the basis of these examinations, we diagnosed chronic cholecystitis (XGC suspected), not gallbladder carcinoma. At surgery, the gallbladder wall was observed to be extremely thick because of severe inflammation, and cholecystectomy was performed. XGC was diagnosed on intraoperative pathological examination. Histopathological examination showed XGC, severe proliferative fibrosis with formation of multiple yellow-brown intramural nodules, and foamy histiocytes without malignant cells. In conclusion, the present case of XGC was diagnosed preoperatively with contrast-enhanced US after a false-positive result had been obtained with FDG-PET. Contrast-enhanced US can thus play important roles in diagnosing gallbladder disease and selecting treatment.

Hepatic angiomyolipoma is a rare hepatic mesenchymal tumor. We report a case of hepatic angiomyolipoma that was successfully resected along with a giant hemangioma. A 53-year-old Japanese woman was admitted to our hospital for further evaluation of a liver tumor in segment 4. The tumor was detected on positron emission tomography during a health check-up. Abdominal ultrasonography revealed a well-defined mass of mixed echogenicity, 1.5 cm in diameter, in segment 4, and a giant hemangioma of mixed echogenicity, 7 cm in diameter, in segment 7. On enhanced computed tomography, the tumor in segment 4 showed hyperattenuation in the early phase and hypoattenuation in the delayed phase. On magnetic resonance imaging, the tumor in segment 4 showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and hyperintensity on diffusion-weighted images. On angiography, the tumor in segment 4 appeared as a circumscribed hypervascular mass in the early phase and a slightly hypovascular mass in the delayed phase. The imaging findings suggested a primary hepatocellular carcinoma. The patient consented to resection of the tumor in segment 4 along with the giant hemangioma in segment 7. These tumors were resected with tumor-free surgical margins by partial resection of segments 4 and 7 of the liver. The cut surface of the resected specimen of segment 4 showed a yellowish tumor consisting of mature adipose tissue. The histopathological diagnoses of the resected specimens were angiomyolipoma in segment 4 and cavernous hemangioma in segment 7. The tumor in segment 4 consisted of mature lipocytes with angiomatous and small lymphocytic components, but no mitotic figures. The tumor showed immunoreactivity to smooth muscle antigen and homatropine methylbromide 45 and no immunoreactivity to AE/E3. The postoperative course was uneventful, and the patient remains well 1 year after the operation.

We describe a patient with intracystic hemorrhage from one of multiple hepatic cysts. A 66-year-old woman was admitted to Nippon Medical School Hospital because of pain in the right upper quadrant of the abdomen. The medical history included multiple hepatic cysts and angina pectoris, which had been treated with aspirin. Three weeks before presentation, pain occurred in the right upper quadrant of the abdomen but resolved spontaneously. Ultrasonography revealed multiple hepatic cysts. One of the cysts in segment 8 had a hypoechoic structure and contained fluid. Computed tomography showed an area of homogenous density (diameter, 6 cm) which was slightly greater than that of the other hepatic cysts in segment 8. There was calcification of the cyst wall. On magnetic resonance imaging, this cyst showed heterogeneous hyperintensity on T1- and T2- weighted sequences which was greater than that of the other hepatic cysts. Intracystic hemorrhage of one of the multiple hepatic cysts was diagnosed. The pain gradually resolved without drainage, embolization, or operation, and the patient was discharged. After discharge, the upper abdominal pain did not recur. On magnetic resonance imaging 14 months later, the cyst showed heterogeneous hyperintensity on T1- and T2- weighted sequences which was less than that on the previous scan.

We describe a 35-year-old man with hepatocellular carcinoma (HCC) that recurred in the diaphragm after right hepatic lobectomy. The patient had undergone right hepatic lobectomy for HCC with chronic hepatitis B virus infection 1 year previously. On pathological examination, the tumor measured 15 × 14.4 × 11 cm and was moderately well differentiated. The surgical margins were negative. After 1 year, computed tomography of the abdomen revealed a mass extending from the right side of the diaphragm to the retroperitoneal space. The mass was enhanced in the early phase and washed out in the late phase. Extrahepatic recurrence of HCC in the diaphragm was diagnosed. We performed tumor resection with partial resection of the right side of the diaphragm and wedge resection of the right lower lobe of the lung. The diaphragm was reconstructed with a sheet of artificial pericardium. The histopathological diagnosis was recurrence of HCC in the diaphragm with invasion of the right lung. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. He underwent chemotherapy with cisplatin and 5-fluorouracil. After 9 months, the patient died of unresectable recurrence of HCC in the brain. No recurrence was detected in the right subphrenic area.

We describe a patient with a ruptured and rapidly enlarging secondary tumor of the liver metastasized from an alpha-fetoprotein (AFP)-producing gastric cancer. The ruptured liver metastasis was successfully treated by transarterial embolization (TAE) followed by hepatic resection. A 65-year-old woman was admitted to our hospital with residual gastric cancer. No liver metastasis was detected by preoperative computed tomography (CT), or ultrasonography, and total gastrectomy was performed. Microscopically, the tumor was a poorly differentiated adenocarcinoma invading no deeper than the subserosa, with positive staining for AFP and positive staining for Ki67 in approximately 80% of the tumor cells. Severe venous and lymphatic involvements were evident. The serum AFP level was 100 ng/ml at 3 weeks after the total gastrectomy, but decreased to 16 ng/ml by the end of postoperative month 3. At 6 months, the patient was referred and readmitted to our hospital with sudden severe pain in the upper abdomen. She was admitted in a state of shock with laboratory findings of anemia. A liver tumor surrounded by effusion was detected in segment 8 and diagnosed as a ruptured liver metastasis. Emergency arteriography revealed a large hypervascular tumor, and a TAE performed promptly thereafter was successful in improving the blood pressure. A second TAE was performed 2 months after first TAE due to a dramatic elevation of serum AFP to 180,000 ng/ml. The second TAE decreased the patient's serum AFP to 2,200 ng/ml, but the level remained in the abnormal range. A right hepatectomy was performed after confirming the absence of other detectable metastatic tumors. The resected specimen contained a well-defined tumor, measuring 6 x 6 cm that appeared almost necrotic under microscope. Over the 6 years since the hepatectomy, no recurrence has appeared and serum AFP has remained within the normal range.