Search

Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes.This study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible.The mean operative time for all patients was 281 min. The mean blood loss was 37 mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days.Laparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2.

Sorafenib was previously considered a first-line treatment for hepatocellular carcinoma (HCC) patients with macroscopic portal vein tumor thrombus (PVTT). This case-matched analysis was performed to evaluate the best first-line treatment for HCC in patients with macroscopic PVTT.The HCC patients with Vp2 (PVTT invaded into a second-order portal branch), Vp3 (first-order portal branch), and Vp4 (main trunk or contralateral portal vein) PVTT who underwent hepatectomy and those treated with sorafenib were included. Treatment results were compared between the two modalities for each PVTT category, and a propensity analysis was performed for patients with Vp3 and Vp4 (Vp3/4).The median survival times (MSTs) of patients with Vp2, Vp3, and Vp4 PVTT who underwent hepatectomy were 21.4, 13.6, and 14.9 months, respectively; the MSTs for those with Vp2, Vp3, and Vp4 PVTT who received sorafenib treatment were 6.9, 5.5, and 3.6 months, respectively, with a significant difference. In a propensity-matched cohort of patients with Vp3/4 PVTT (36 patients in each), the MST of patients who underwent hepatectomy (15.1 months) was significantly better than the patients treated with sorafenib (4.5 months).Hepatectomy can be associated with prolonged survival in HCC patients with macroscopic PVTT.

Introduction With the aging of the population in Japan, gallbladder cancer (GBC) in the elderly is increasing. However, the available clinical data are limited, and the optimal treatment is still controversial. The aim of this study was to evaluate the benefit of surgical resection in GBC patients ≥75 years of age. Methods A retrospective single center analysis of patients who had undergone surgical resection for GBC between 2000 and 2019 was carried out. Patients aged ≥75 years (elderly group, n = 24) or Results Both younger and elderly patients exhibited similar clinicopathological characteristics, but comorbidity in the latter was significantly greater, as was the frequency of less invasive surgery. Nonetheless, the incidence of postoperative complications was similar in elderly and younger patients. The proportion of patients receiving adjuvant chemotherapy was lower in the elderly. Overall survival of elderly and younger patients was not significantly different (65.0 vs 62.4% at 5 years, P = .600). In multivariate analysis, residual tumor status but not age was an independent prognostic factor. Discussion This study demonstrated that appropriate surgical treatment of elderly GBC patients was safe and effective, despite their having more comorbidities and lower rates of adjuvant chemotherapy than younger patients.

Atezolizumab plus bevacizumab and lenvatinib are the key drugs in the current systemic chemotherapeutic regimen for hepatocellular carcinoma (HCC). Studies have reported the potential effectiveness of lenvatinib introduction after an atezolizumab plus bevacizumab treatment; however, the therapeutic effectiveness of a lenvatinib rechallenge after an atezolizumab plus bevacizumab treatment remains unclear.Thirteen consecutive patients who were rechallenged with lenvatinib after clinical failure following treatments with lenvatinib and atezolizumab plus bevacizumab were included. A comparative study was conducted on the duration and treatment efficacy of the first and second lenvatinib treatments and on the pre- and post-treatment liver function.The median ratios of the 1-month post-treatment alpha-fetoprotein (AFP) levels to the pretreatment AFP levels were 0.750 and 0.667 for the first and second lenvatinib treatments, respectively, without significant difference (p=0.9327). Meanwhile, the median ratios of the 1-month post-treatment albumin-bilirubin (ALBI) scores to the pretreatment ALBI scores were 1.063 and 0.827 for the first and second lenvatinib treatments, respectively, with significant difference (p=0.015). The median duration of the second lenvatinib treatment was significantly shorter than that of the first lenvatinib treatment [2.8 months (range=0.9-4.7 months) vs. 8.7 months (range=3.1-29.7 months)].Lenvatinib re-administration after atezolizumab plus bevacizumab treatment can act as a double-edged sword, as it exerts an anti-tumor effect while being associated with potential liver function deterioration. However, this treatment sequence can be useful, and requires careful monitoring of the transitions in the liver function and the patient's performance status.

Bile leakage is a major complication after liver transplantation and remains as a significant source of morbidity and mortality. In 2011, the International Study Group of Liver Surgery (ISGLS) defined bile leakage as a drain/serum bilirubin ratio ≥3. However, to our knowledge there is no literature assessing serum and drain bilirubin concentrations after liver transplantation. The aim of this study was to describe the natural postoperative changes in serum and drain fluid bilirubin concentrations in patients after liver transplantation.We included 32 patients who underwent liver transplantation at Kobe University Hospital from January 2007 to December 2020. We enrolled 34 living donors who had no complications as the control group.The recipient serum total/direct bilirubin concentration were higher compared with the donors from postoperative day (POD) 1 to 5 with a statistical difference (P.05). The recipient drain/serum total bilirubin ratio was lower than donors on POD 3 (0.89 ± 0.07 vs 1.53 ± 0.07: P.0001), which was also confirmed by the recipient drain/serum direct bilirubin ratio (0.64 ± 0.10 vs 1.18 ± 0.09: P.0001). On POD 3, the drain fluid volume (647.38 ± 89.47 vs 113.43 ± 86.8 mL: P.001) and serum total bilirubin concentration (6.73 ± 0.61 vs 1.23 ± 0.60 mg/dL: P.001) was higher in the recipients than in donors. Categorized in 2 groups, the higher drain fluid volume and bilirubin concentration recipients showed lower drain/serum total bilirubin ratio compared with the other group (P = .03) CONCLUSION: The drain/serum bilirubin ratio in the transplanted patients could be calculated lower compared with the hepatectomy patients because of high drain fluid volume and hyperbilirubinemia. Great care should be taken when assessing the bile leakage in liver transplant recipients using the ISGLS definition.

Right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk of the portal vein. An 80-year-old woman underwent curative sigmoidectomy for sigmoid cancer 3 years prior to presentation. After 1 year, small solitary liver metastasis was noted in segment 4. Because the patient experienced recurrence of the same lesion after chemotherapy and radiofrequency ablation, she was referred to our hospital. CT revealed an anomaly of the liver with RSLT, classified as an independent posterior branch type. The tumor in the left paramedian section was located in the right umbilical portion (RUP), and BDTT was advanced to the common bile duct. Because the estimated future remnant liver volume was 35.2%, transileocecal portal vein embolization (PVE) for the portal branches from the RUP increased it to 43.5% in 3 weeks. Left trisectionectomy with extrahepatic bile duct resection and hepaticojejunostomy were performed. The patient was discharged on postoperative day 75. We successfully performed a left trisectionectomy after PVE in a patient with RSLT. Understanding the vascular and biliary anomalies of patients with RSLT is essential. When the future remnant liver is small, PVE can be considered for safe hepatectomy.

Purpose: Posthepatectomy liver failure (PHLF) is a major complication of hepatectomy. Although the extent of liver resection and fibrosis stages were previously identified as predictors of the development of PHLF, fibrosis stages were diagnosed using samples from resected livers. We evaluated the association between preoperative/intraoperative liver biopsies and final fibrosis stages.Methods: We included 272 patients who underwent an initial hepatectomy at our facility between January 2014 and December 2018.Results: PHLF occurred in 70 patients (25.7%) and decreased their overall survival (p = 0.0001). Preoperative/intraoperative liver biopsies showed a significant correlation with final fibrosis stages (p < 0.0001). The underestimation rates of preoperative and intraoperative F0/F1/F2 were 16.9% and 28.2%, respectively. Among the preoperative factors, 99mTc-GSA scintigraphy LHL < 0.91 was significantly associated with the resected liver fibrosis stages (hazard ratio [HR], 2.38; 95% confidence interval [CI]: 1.37–4.21; p = 0.0022). The underestimation rates of preoperative F0/F1/F2 with 99mTc-GSA scintigraphy LHL > 0.91 and Conclusions: The fibrosis stages of the resected livers were associated with preoperative and intraoperative liver biopsies. Successful hepatectomies could be performed in accordance with findings from preoperative liver biopsies, 99mTc-GSA scintigraphy, and intraoperative liver biopsies without the incidence of PHLF.

Purpose The aim of this study was to investigate the risk factors for delayed gastric emptying (DGE) and the impact of DGE on postoperative nutritional status after subtotal stomach-preserving pancreatoduodenectomy (SSPPD). The pathophysiology of DGE after SSPPD is still unknown, and the precise impact of DGE on various nutritional markers has been scarcely reported. Methods The risk factors for DGE were analyzed using a database created for a previously reported randomized controlled trial (UMIN000005827). To investigate the impact of DGE, data on patient nutrition were analyzed. Results Data from 196 patients were analyzed. DGE occurred in 30 patients (15.3%). Hand-sewn gastrojejunostomy was found to be significantly associated with DGE (P = 0.005). Serum levels of albumin (3.16 g/dL in patients with DGE versus 3.4 g/dL in patients without DGE) and total cholesterol (125.1 mg/dL in patients with DGE versus 147.2 mg/dL in patients without DGE) in DGE patients were lower at postoperative month (POM) one. There was no statistically significant difference in any of the nutritional parameters at POM three or later. On multivariate analysis, preoperative serum albumin P = 0.002) and DGE (Odds ratio, 2.68; P = 0.043) were significantly associated with decreased serum albumin level (

Resecting liver tumors located in Couinaud's segment VII is challenging; the efficacy and safety of laparoscopic liver resection for segment VII lesions compared to open liver resection remain unclear.Medical records of 84 patients who underwent liver resection of segment VII at Kobe University Hospital and Hyogo Cancer Center between 2010 and 2021 were retrospectively analyzed. Surgical outcomes were compared between laparoscopic liver resection and open liver resection groups using propensity matching analysis.Thirty-one and 53 patients underwent laparoscopic liver resection and open liver resection, respectively. After propensity matching, 29 patients were included in each group. The laparoscopic liver resection group had a significantly longer operation time (407 vs. 305 min, P = 0.002), lower blood loss (100 vs. 230 mL, P = 0.004), and higher postoperative alanine aminotransferase levels (436 vs. 252 IU/L, P = 0.008) than the open liver resection group. In patients with liver cirrhosis, the proportion of patients with postoperative liver-specific complications was higher in the laparoscopic liver resection group than in the open liver resection group (57% vs 11%, P = 0.049), although there was no significant difference in postoperative liver-specific complication rates between the groups in patients without liver cirrhosis.For liver resection of segment VII, laparoscopic liver resection led to higher postoperative liver damage than open liver resection. Open liver resection may be better for patients with liver cirrhosis to avoid postoperative liver-specific complications. Laparoscopic liver resection could be an acceptable procedure for patients without liver cirrhosis, with some merits such as less blood loss.