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Background/aims: The aim of this study was determine the effectiveness of adjuvant S-1 chemotherapy for patients with resected pancreatic cancer., Methodology: Patients with pancreatic carcinoma who underwent pancreatic resection without adjuvant S-1 chemotherapy (n = 11) or with adjuvant S-1 chemotherapy (n = 10) were included. S-1 was administered orally at a dose of 40 mg/m2 twice daily for 28 consecutive days followed by a 14-day pause. The cycle was repeated 4 times. Overall and disease-free survival curves were generated using the Kaplan-Meier method, and statistical differences between groups were analyzed using the log-rank test., Results: The disease-free survival and overall survival were longer among recipients of adjuvant S-1 chemotherapy than among those who received surgery alone (P < 0.05; 5-year disease-free survival rate, 30% versus 0%; 5-year overall survival rate, 65% vs 0%). Although dose reduction was needed in 2 patients because of grade 2 anorexia, only 1 patient with grade 2 hypoalbuminemia discontinued adjuvant chemotherapy because of long-term hospitalization., Conclusions: S-1 administered as a single agent showed promise as an adjuvant chemotherapy for resected pancreatic cancer.

Background/aims: We investigated the clinicopathological findings and outcome after surgery for hepatocellular carcinoma in patients without hepatitis B or C virus infection., Methodology: Among 562 patients who underwent curative resection for hepatocellular carcinoma, the sera from 97 patients (B group) were positive for hepatitis B surface antigen alone, sera from 355 patients (C group) were positive for anti-hepatitis C virus antibody alone and sera from 104 patients (NBNC group) were negative for both hepatitis B surface antigen and anti-hepatitis C virus antibody. We compared the clinicopathological findings and postoperative outcomes in the 3 groups., Results: The prevalence of diabetes mellitus, hypertension, hyperlipidemia and alcohol abuse were higher in the NBNC group than in the other groups. The prevalence of obesity was higher in the NBNC group than in the B group. Non-alcoholic steatohepatitis was detected in 16 NBNC patients. The tumor- free survival rate was higher in the NBNC group than in the C group., Conclusions: Obesity, diabetes mellitus, hypertension, hyperlipidemia, alcohol abuse and non-alcoholic steatohepatitis were the possible risk factors for hepatocellular carcinoma in the NBNC group. The patients in the NBNC group are expected to show a better outcome as compared to patients in the C group.

Background/aims: We aimed to clarify the surgical indication and describe the long-term surgical outcome for ampullary carcinoma., Methodology: The long-term outcomes of 23 patients who underwent pancreaticoduodenectomy were retrospectively reviewed. The prognostic factors for cancer-specific survival and overall survival after surgery were investigated., Results: The cancer-specific 5-, 10- and 20-year survival rates after resection of the ampullary carcinoma were 52%, 43% and 43%, respectively, while the corresponding overall survival rates were 52%, 32% and 24%, respectively. Ten of the 11 patients with recurrent ampullary carcinoma died within 5 years after surgery. Four patients died because of pancreatic cancer, colon cancer, old age after curative resection of gastric cancer, and pneumonia at later than 5 years after the surgery. The risk factors for the short cancer-specific survival period were pancreatic invasion and lymph node metastasis, while those for the short overall survival period were pancreatic invasion and the tumor grade., Conclusions: Our study indicates that recurrence of ampullary carcinoma within 5 years after its resection, especially in patients with pancreatic invasion or lymph node metastasis and development of other diseases after more than 5 years after the surgery should be carefully investigated.

In living donor liver transplantation for Budd-Chiari syndrome, it is necessary to eliminate interference with outflow from the liver without the replacement of the involved retrohepatic segment of the inferior vena cava. A 34-year-old female patient underwent living donor liver transplantation for Budd-Chiari syndrome. During surgery, the fibrous tissue surrounding the recipient inferior vena cava was dissected after removal of the recipient liver. The diaphragm was dissected and mobilized from the inferior vena cava on the cranial side to expose the intact inferior vena cava in the posterior mediastinum. The left and middle hepatic veins in the graft liver were anastomosed to a horizontal anastomotic orifice prepared in the anterior wall of the intact inferior vena cava in the posterior mediastinum. Anticoagulant therapy was begun after liver transplantation. Dynamic computed tomography after living donor liver transplantation demonstrated patent hepatic veins. The patient has been doing well, without any episode of thrombosis or occlusion of the graft hepatic veins at 1 year and 6 months after liver transplantation.

Background/aims: The liver hanging maneuver is widely used in right lobectomy to resect huge tumors and harvest living donors. The convenience of tape assistance in other types of hepatectomy is not well known., Methodology: Tape-guiding technique (TGT) was applied in 30 hepatectomies of different type between April 2003 and April 2006. The indications were liver carcinoma in 22 and living-donor in 8. Hepatectomies included right lobectomy, 14; left lobectomy with caudate lobectomy, 8; left lobectomy without caudate lobectomy, 2; lateral segmentectomy, 3; central bisegmentectomy, posterior segmentectomy, and superior dorsal partial resection, 1 each. A tape was placed in front of the inferior vena cava for right hepatectomy and left hepatectomy with caudate lobectomy. In other hepatectomies, the tape was positioned to be the target of parenchymal dissection., Results: TGT was successfully performed in all 30 cases. Tape facilitated dissection by helping the surgeon maintain orientation, and traction on the tape flattened the parenchyma, making it easier to identify and manage vessels and ducts. With an assistant holding the tape, the surgeon's left hand was free, and ligation and suturing was easier and more secure., Conclusions: The TGT is a convenient technique that is applicable to different types of liver resection.

Background/aims: Liver resection for hepatocellular carcinoma in patients with cirrhosis carries risk of major hemorrhage and sometimes requires blood transfusion. We investigated risk factors for massive blood loss during liver resection and indications for storing blood for autologous intraoperative transfusion., Methodology: We analyzed clinical records of 100 patients with cirrhosis who underwent liver resection for hepatocellular carcinoma. Autologous blood was stored preoperatively for 19 patients., Results: Intraoperative blood loss ranged from 5 to 3000 mL (mean, 640). Liver resection was performed without transfusion in 67 patients and with autologous blood storage in 17 patients not receiving homologous blood. In the other 16 patients, homologous blood was transfused. Univariate analysis identified youth, large tumors (> 4cm), major hepatectomy, portal tumor involvement, hepatic vein involvement, and prolonged operation time as risk factors for massive blood loss; multivariate analysis identified portal involvement and hepatic vein involvement as independent risk factors. Blood loss exceeded 1000 mL in the 4 transfused group B patients and 3 of the 4 patients had hepatic vein involvement., Conclusions: Portal involvement and hepatic vein involvement were risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis. Autologous blood storage is indicated in patients with such risk factors.

Background/aims: Bowel injury associated liver surgery is rare but can be fatal if not adequately treated. The contribution of underlying liver disease and previous hepatectomy to bowel injury in hepatectomy for hepatocellular carcinoma is unknown., Methodology: Clinical records of 531 patients who underwent hepatic resection without combined resection of the biliary tract or intestine for hepatocellular carcinoma during 13 years were reviewed. Differences in incidence of bowel injury according to presence or absence of liver cirrhosis, technique of hepatectomy, and history of hepatectomy were investigated. Outcome after treatment also was reviewed., Results: Bowel injury occurred in 5 patients (0.9%). Previous hepatectomy history was associated with an increased incidence of bowel injury [repeat hepatectomy, 3/91 (3.3%), and first hepatectomy, 2/440 (0.5%), p = 0.038]. Injury was recognized intraoperatively in two patients and postoperatively in three. In the former two patients, the injured bowel was repaired immediately but a fistula still developed in one patient. One patient with a fistula eventually required temporary fecal diversion and eventually limited colectomy. The other three patients were treated by continuous external drainage, but two of them required debridement or colic sleeve resection., Conclusions: Previous hepatectomy increases the risk for bowel injury during hepatectomy. Care must be taken to prevent adhesion to the hepatic cut surface. Careful use of electrocautery to prevent burn injury also should be taken.

Recently, it has been suggested that hepatitis C virus infection plays a role in the pathogenesis of some intrahepatic cholangiocarcinomas (ICC). We describe two patients with small ICC detected after interferon therapy for chronic hepatitis C. Case 1 was diagnosed with ICC by preoperative biopsy and underwent anterior segmentectomy of the liver, while Case 2 was diagnosed with hepatocellular carcinoma preoperatively and the tumor was diagnosed as ICC after biopsy and microwave coagulonecrotic therapy. Both patients are in good health six months and five months, respectively, after operation. It is important to monitor carefully for ICC as well as hepatocellular carcinoma in patients with chronic hepatitis C, even when interferon therapy has been carried out, since the outcome of treatment for small ICC is favorable.

Clinicopathologic variables favoring recurrence after hepatic resection for intrahepatic cholangiocarcinoma showing intraductal growth remain unclear. We investigated various clinicopathologic features in three patients who underwent resection for this type of intrahepatic cholangiocarcinoma. All underwent extended left hepatectomy plus resection of the caudate lobe and lymph node dissection. Lymph nodes showed no pathologic involvement. Although no cancer cells were seen in the mucosal layer by intraoperative pathologic examination at the bile duct stump in any patient, pathologic examination of resected specimens showed cancer cells invading beyond the mucosal layer in connective tissues surrounding the bile duct stump (interstitial invasion) of the Glisson's sheath in 2 patients. One of them died of cancer recurrence near the bile duct stump, while the third patient, without interstitial invasion, has survived for 10.6 years. In the intraductal growth type of intrahepatic cholangiocarcinoma, absence of cancer cells should be confirmed by intraoperative pathologic examination of not only the mucosal layer of the bile duct but also the connective tissue surrounding the bile duct, since interstitial invasion may be a risk factor for cancer recurrence.

A 71-year-old woman was admitted to our hospital with obstructive jaundice. Magnetic resonance cholangiography revealed a 9-cm spindle-shaped tumor in the common bile duct. Laboratory examination noted a high concentration of total serum bilirubin. Although the serum concentration of carcinoembryonic antigen was within normal limits, the serum concentration of carbohydrate antigen 19-9 was elevated. We diagnosed the lesion as an extrahepatic bile duct cancer and performed a laparotomy. The anterior wall of the common bile duct was incised, and the tumor was found to have a small base in only the posterior wall of the duct, and spread within the duct was from the common hepatic duct to the intrapancreatic bile duct. Bile duct resection, cholecystectomy with lymphadenectomy and hepaticojejunostomy were performed. Frozen sections of the proximal and distal surgical margins of the bile duct were free of cancer. Macroscopically, the lesion was an expansive polypoid tumor measuring 9x3cm in diameter arising from a 5-mm base. Histologic examination revealed that the tumor was a well-differentiated tubular adenocarcinoma that had infiltrated the fibromuscular layer at its base. Longitudinal spread was more extensive hepatopetally than hepatofugally. The patient is alive and well without any complaints 8 months after surgery.

Background/aims: We investigated the correlation between vascular endothelial growth factor (VEGF) and CD44 expression in hepatocellular carcinoma (HCC) and the frequency of extrahepatic metastasis, in order to evaluate the influence of vascular growth and adhesion molecules in facilitation of distant metastasis., Methodology: We obtained materials from primary lesions of HCC with no extrahepatic metastasis (control group) and primary lesions and metastatic lesions with extrahepatic metastasis (metastasis group). Immunohistochemical staining was performed using anti-human CD44v3 monoclonal antibodies and anti-human VEGF ab-3 monoclonal antibodies. Although pathological parameters such as tumor size, differentiation, capsule formation, and vascular invasion were analyzed, there was no marked difference among the groups., Results: Percentages of nodules with VEGF-positive tumor and sinusoidal cells were low in primary lesions of the control and metastasis groups, while high in metastatic lesions in the metastasis group. On the other hand, percentages of nodules with CD44-positive tumor and sinusoidal cells were low in primary lesions of the control group, while high in primary lesions and metastatic lesions of the metastasis group., Conclusions: The present study demonstrated that CD44 expression in primary lesions is related to a higher frequency of extrahepatic metastasis, suggesting that this is a clinicopathologically useful parameter in predicting the occurrence of distant metastasis.

Background/aims: Although percutaneous trans-hepatic portal vein embolization (PTPE) expands the candidate pool for hepatectomy in patients with hepatobiliary malignancies, the role of PTPE in patients with active hepatitis or cirrhosis has yet to be determined., Methodology: Records of patients who underwent PTPE of the right portal vein between 1984 and April 2001 were reviewed retrospectively. To determine the indication for PTPE and subsequent hepatectomy, clinical variables, including serum concentrations of hyaluronic acid (HA), procollagen type III peptide (P-III-P), and the 7S domain of type IV collagen (7S-IV), were compared between patients who underwent right hepatectomy (group A; n=44) and the other patients (group B; n=17)., Results: The scores for prediction of postoperative liver failure (prediction score) and serum HA and P-III-P concentrations were different in the two groups. Thirteen of 30 patients (43%) whose prediction score was more than 50, the limit of the hepatectomy without PTPE, successfully underwent right hepatectomy following PTPE. The resectability ratios increased to 75% and 100%, when the HA concentration was < or = 100mg/L and the P-III-P concentration < or = 0.7/mL., Conclusions: Serum HA and P-III-P concentrations are useful guidelines for identifying candidates for right hepatectomy following PTPE.

We report two cases of benign biliary strictures managed by metallic stent placement because the patients refused surgical repair. One patient is a 67-year-old man who had a stricture of the right hepatic duct and a bile leak following a cholecystectomy. The second patient is a 50-year-old man who had a stricture of the left hepatic duct following a right hepatic lobectomy for hepatolithiasis. For treatment of these bile duct strictures, a Gianturco-Rosch Z stent was placed in the former case and a Wallstent in the latter. Luminal patency of the stent was maintained for 7 years in the former case but in the latter, luminal stenosis of the stent was induced soon after placement. However, in the former, bile stasis in the left hepatic duct system, which emptied into the side of the stent, gradually developed without signs or symptoms of cholangitis or biliary obstruction. Therefore, the use of metallic stents for benign biliary stricture remains controversial. However, if metallic stent placement is the only therapeutic option, it is necessary to maintain bile flow not only through the stent but also in the bile ducts which flow into the side of the stent.

Background/aims: Serum concentrations of the 7S fragment of type IV collagen (7S collagen), amino-terminal propeptide of type III procollagen (PIIIP), and hyaluronic acid (HA) have been reported to serve as serologic markers of liver fibrosis in hepatitis and cirrhosis. We investigated whether these fibrosis markers reliably reflect histologic changes in the livers of patients with hepatocellular carcinoma., Methodology: Subjects included 165 patients undergoing liver resection for hepatocellular carcinoma. Most were seropositive for chronic hepatitis B or C. Histopathologic changes in liver tissue resected with the tumor were scored according to Knodell's histologic activity index. Serum was sampled for assays shortly before surgery., Results: Significant correlations were found between hepatitis activity score and 7S collagen, PIIIP, and HA. Concentrations of 7S collagen differed significantly between activity grades, but differences were not significant for PIIIP or HA. Significant correlations were found between fibrosis staging score and all these three markers. When patients were divided according to activity grade, 7S collagen showed stronger correlation with fibrosis staging score than did PIIIP or HA., Conclusions: The 7S collagen fragment correlated more strongly than PIIIP or HA with stage and activity grade in patients with hepatocellular carcinoma. However, overlapping of results between histologically defined groups appeared to limit clinical diagnostic usefulness of all markers in individual patients.

Liver transplantation in patients with end-stage hepatolithiasis is complicated by the high incidence of the suppurative cholangitis and systemic infection. A 43-year-old Korean-Japanese woman with hepatolithiasis, biliary cirrhosis, suppurative cholangitis, and biliary-bronchial fistula underwent living-related liver transplantation (LRLT) using a right lobe graft of her sister. The risk of infection was minimized by preoperative percutaneous transhepatic biliary drainage initiated 2 months before transplantation. The native liver was resected en bloc with the extrahepatic bile ducts and the infected section of the right hemidiaphragm. Opportunistic infection was prevented by limiting antimicrobial therapy to the interval from preoperative day 3 to postoperative day 4. Immunosuppressive agents were given below standard dose. The postoperative course following LRLT was uncomplicated, and hepatic function was good. Careful management of infection and adequate graft size are essential for successful LRLT in patients with end-stage hepatolithiasis.

Background/aims: Ornithine decarboxylase activity, a rate-limiting enzyme in polyamine biosynthesis, is correlated with the degree of malignancy of hepatocellular carcinoma. We investigated the relationship between polyamine metabolism in hepatocellular carcinoma tissues and the recurrence after resection of hepatocellular carcinoma., Methodology: The subjects were 49 patients who underwent liver resection for hepatocellular carcinoma. The relationship between ornithine decarboxylase activity and polyamine concentration in hepatocellular carcinoma tissues and the pathologic findings or recurrence after the operation was studied., Results: The prevalences of moderately or poorly differentiated hepatocellular carcinoma, portal invasion, and intrahepatic metastasis were higher in patients with a high ornithine decarboxylase activity (> or = 100 pmol putrescine/h/mg protein) than in patients with a low ornithine decarboxylase activity (< 100 pmol putrescine/h/mg protein). The tumor-free survival rate was significantly lower in patients with a high ornithine decarboxylase activity than in patients with a low ornithine decarboxylase activity (p=0.0394). The tumor-free survival rate was significantly lower in patients with a high spermidine concentration (> or = 80 nmol/mg protein) than in patients with a low spermidine concentration (< 80 nmol/mg protein, p = 0.0454)., Conclusions: A high ornithine decarboxylase activity and a high spermidine concentration of hepatocellular carcinoma were risk factors for recurrence after resection of hepatocellular carcinoma.

Background/aims: Some patients who undergo thoracoabdominal hepatectomy suffer from pain and discomfort after because rib and/or costal cartilage was cut during the operation. The usefulness of absorbable rib connecting pins in thoracoabdominal hepatectomy was evaluated., Methodology: Of 18 patients who underwent thoracoabdominal hepatectomy, the stumps of ribs were not fixed in 9 patients (group 1) and the stumps of ribs were fixed with the rib connecting pins in 9 other patients (group 2). We evaluated the usefulness of these pins in thoracoabdominal hepatectomy., Results: In 8 patients in group 1 and 2 patients in group 2, pain continued for 1 month after the operation (p = 0.015). At 2 months after the operation, pain continued in 6 patients in group 1 and no patients in group 2 (p = 0.009). At 6 months after the operation, 2 patients in group 1 still had pain. Rib instability continued in 8 patients in group 1 at 6 months after the operation, although rib instability disappeared by 2 months after the operation in all group 2 patients (p = 0.0004)., Conclusions: Biodegradable absorbable pins for rib fixation are useful for preventing pain and discomfort around the cut stumps of ribs in thoracoabdominal hepatectomy.

A 42-year-old man with acute myocarditis developed a right lung abscess and tricuspid regurgitation with valvular vegetations. A chest tube was inserted from the 8th intercostal space on the anterior axillary line to drain acute thoracic empyema caused by rupture of the lung abscess. Six hours after the insertion, the patient went into shock. Since abdominal ultrasonography showed intraabdominal bleeding, an urgent laparotomy was performed. A large amount of blood was present in the peritoneal cavity. Pulsatile bleeding from the hepatic laceration and penetration of diaphragm were observed. Mattress sutures were used to close the hepatic laceration and the rent in the right hemi-diaphragm. Because the patient was hemodynamically stable postoperatively tricuspid valvular replacement was performed 5 days after the laparotomy. Four months after valve replacement, the patient is in good condition without any complaints.

Background/aims: We investigated the relationship between the serum concentration of type IV collagen 7s domain (7s collagen) and viral status and the effects of these factors on recurrence after resection of hepatitis B virus-related hepatocellular carcinoma., Methodology: Serum concentration of 7s collagen was measured in 39 patients who underwent liver resection for hepatitis B virus-related hepatocellular carcinoma. The clinicopathologic findings and tumor-free survival rate were compared between patients with a low serum concentration of 7s collagen (< 7.0 ng/mL, group 1) and those with a high serum concentration of 7s collagen (> or = 7.0 ng/mL, group 2)., Results: Aspartate aminotransferase activity and the proportion of patients with a high viral load and cirrhosis were significantly higher in group 2 than in group 1. The tumor-free survival rate was significantly lower in group 2 than in group 1 (P = 0.0050). The survival rate was significantly lower in patients with a high viral load than in patients with a low viral load (P = 0.0006)., Conclusions: A high serum concentration of 7s collagen was closely related with a high viral load of hepatitis B virus. A high serum concentration of 7s collagen and a high viral load of hepatitis B virus are risk factors for recurrence after resection of hepatitis B virus-related hepatocellular carcinoma.

Background/aims: We investigated the safety and efficacy of percutaneous transhepatic angioplasty with self-expanding metallic stent implantation to treat malignant portal vein stenosis., Methodology: Since 1995, we have performed metallic stent implantation in 7 cases of malignant portal vein stenosis (cholangioma, 3 cases; and cancer of the hepatic hilum, pancreatic cancer, metastatic liver tumor, and hepatocellular carcinoma, 1 case each) and in 1 case of obstruction by local recurrence of a hilar tumor. In the 7 cases of portal vein stenosis, a Wallstent was implanted percutaneously transhepatically. In the case of portal vein obstruction, a Gianturco-Rosch Z stent was implanted via the ileocolic vein during laparotomy., Results: There were no complications related to stent placement, and the portal vein pressure decreased after stent implantation in all cases. The patency of the stent was documented by ultrasonography in all 7 cases of portal vein stenosis and was confirmed at autopsy in two cases. No patient treated for portal vein stenosis developed symptoms of portal hypertension., Conclusions: Percutaneous transhepatic angioplasty with stent insertion is a safe and useful treatment for malignant portal vein stenosis and preserves quality of life by preventing symptoms of portal hypertension.

Background/aims: The prognosis after curative resection for patients with carcinoma of the papilla of Vater is relatively better than that for other peripancreatic cancer. However, prognostic factors after resection of the carcinoma have not been identified., Methodology: From 1983 to 1999, 16 patients with carcinoma of the papilla of Vater underwent standard pancreatoduodenectomy and dissection of regional lymph nodes. We followed the patients for 63 days to 17 years (median, 27 months) and analyzed clinicopathologic variables in relation to prognosis., Results: The survival rate at 5 years was 50.5%. The morphologic factors predicting poor outcome were macroscopic ulcer formation and microscopic pancreatic, venous, or perineural invasion. Tumors with ulcer formation tended to infiltrate into the duodenum and pancreas, but not into veins or the perineural space. Eight of 16 patients died due to recurrence of the cancer; liver metastasis (n = 6) or peritoneal dissemination (n = 2)., Conclusions: Patients with carcinoma of the papilla of Vater demonstrating ulcer formation or invasion into the pancreas, vein, or perineural space may benefit from adjuvant therapy to reduce the risk of liver metastasis. Careful observation is essential for liver metastasis or peritoneal dissemination after surgery; especially in patients with ulcer formation or venous invasion.

Intraoperative biliary tract injuries are relatively uncommon, but are a cause of significant morbidity and mortality. We have repaired open biliary tract injuries found postoperatively in three patients without reoperation by percutaneous intervention. In two cases, biliary stents were placed percutaneously across the injured portion of the bile duct. For this procedure, a unique coaxial guidewire technique was used. The bile leaks resolved soon after insertion of the biliary stents. In one patient, an expandable metallic biliary endoprosthesis was inserted, and the temporary stent was removed. This patient had no signs or symptoms of cholangitis or biliary obstruction at the 6-year follow-up. The other patient died of heart failure soon after reconstruction. In the last patient, a biliary drain was inserted through the injured duct via the biliocutaneous fistula. In this case, biliary drainage alone resulted in resolution of the bile leak, because the injury was partial without a stricture. This patient was well at the 3-year follow-up. Percutaneous management of bile duct injuries is an alternative in selected patients.