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Purpose: Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively., Conclusions: In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety., (© 2024. Society of Surgical Oncology.)

Background: The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution., Methods: Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups., Results: After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien-Dindo class IIIa was similar between the two groups., Conclusions: LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC., (© 2022. The Author(s).)

Background: Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures. 1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied. 6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8., Methods: Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface, 9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion., Results: The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications., Conclusions: Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8., (© 2021. Society of Surgical Oncology.)

Background: Laparoscopic anatomic liver resection is technically demanding, given the need to safely isolate the Glissonean pedicles and expose the hepatic veins (HVs) on the liver parenchyma cut surface. Laennec's capsule is observed around the Glissonean pedicles and root of the HVs. However, its existence, particularly on the peripheral side of the HVs, remains controversial. Herein, we describe Laennec's capsule-related histopathological findings around the HVs and a safe laparoscopic left medial sectionectomy utilizing Laennec's capsule., Methods: The extrahepatic Glissonean approach was performed by connecting Gates II and III, in accordance with Sugioka's Gate theory. Liver parenchymal transection commenced along the demarcation line, which is between the medial and lateral sections, and the G4 was dissected during transection. Subsequently, via the outer-Laennec approach, the middle hepatic vein (MHV) was exposed from the root side in cranial view, while Laennec's capsule was preserved. Parenchymal transection was completed while connecting the MHV with the demarcation line. We obtained the membrane surrounding the HVs and performed histopathological examinations., Results: Six patients underwent laparoscopic left medial sectionectomy from February 2012 to November 2020. There were no cases involving complications (Clavien-Dindo classification; grade II or higher), open-surgery conversion, transfusion, or surgery-related death. The histopathological findings showed Laennec's capsule surrounding both the trunk of the major HVs and the peripheral side of the HVs., Conclusions: A cranial approach to the major HVs utilizing Laennec's capsule is a feasible and advantageous procedure for laparoscopic left medial sectionectomy. We propose that Laennec's capsule surrounds the entire length of the HVs., (© 2021. The Author(s).)

Background: The cranial approach allows easy identification of the major hepatic vein Ome et al. (2020), Honda et al. (2013), Xiao et al. (2016) and Kim (2019) [1-4] and avoids split injury of the hepatic veins (HV) by exposing the HV from the root to the periphery (Honda et al., 2013) [2]. We present the cranial approach to laparoscopic anatomic liver resections of segment 2 (S2) and segment 3 (S3) in two cases of hepatocellular carcinoma (HCC)., Methods: [Laparoscopic segmentectomy 2]After dissection of the S2 Glissonean pedicle, parenchymal transection was initiated to expose the dorsal aspect of the root of the left hepatic vein via parenchymal transection using a cranial approach. The cavitron ultrasonic surgical aspirator (CUSA) was used from the root side towards the peripheral side. The liver parenchymal dissection was completed by dissecting between the demarcation line and the left hepatic vein. [Laparoscopic segmentectomy 3]The liver transection was initiated along the falciform ligament. After the S3 Glissonean pedicle was temporally clamped, the ventral aspect of the root of the left hepatic vein was exposed peripherally. The parenchymal dissection process was completed with the S3 Glissonean pedicle dissection., Results: S2: The operation time was 191 min, the estimated blood loss was 5 ml, and the patient was discharged on postoperative day 5 with no complications. S3: The total operation time was 215 min, the estimated blood loss was 50 ml, and the patient was discharged on postoperative day 9 with no complications., Conclusion: The cranial approach is a safe method for laparoscopic anatomic liver resections of segments 2 and 3., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: We herein report 3 cases in which the right hepatic vein (RHV) involved with a liver tumor was reconstructed using an autologous jugular vein graft to raise the curability and to increase the functional volume of the liver remnant (LR). CASE 1: Cholangiocellular carcinoma (diameter 6.0 cm) in the left lobe invaded the RHV, the branch of the RHV which drains segment 7 (V7) and the middle hepatic vein (MHV). Because the ratio of the LR drained by the inferior right hepatic vein (IRHV) was 26.7%, extended left lobectomy including MHV with RHV and V7 reconstruction was carried out, resulting in a good outcome and an uneventful operative course. Surgical margins on the liver resection plane and at the IVC were 5 mm and partially zero, respectively. CASE 2: Cholangiolocellular carcinoma (diameter 9.0 cm) in the left lobe and the anterior segment invaded the RHV, V7, IVC and bile duct. In this case, the IRHV was present and not involved with the tumor. Because the ratio of the LR drained by the IRHV was 26.1%, left hepatic trisectionectomy with RHV, V7, IVC, and bile duct reconstruction was performed, leading to a good operative course. Surgical margins on the liver resection plane and at the IVC were 8 mm and partially zero, respectively. CASE 3: Hepatocellular carcinoma (diameter 2.7 cm) in segment 7 invaded the RHV. Because the hepatic functional reserve had decreased due to the presence of hepatitis C virus, extended subsegmentectomy (segment 7) with RHV reconstruction was performed, thus resulting in a sufficiently maintained LR function. Surgical margin on the liver resection plane was 7 mm., Conclusion: RHV reconstruction with an autologous jugular vein graft is considered to be useful for safely expanding the surgical indications for liver tumors.

Introduction: Some cystic liver tumors are huge when the diagnosis is made or surgery is needed. Although reducing tumor size by preoperative aspiration or drainage of the contents of the cystic tumor is helpful for liver resection, such procedures have a risk of tumor dissemination., Materials and Surgical Technique: After the round ligament was dissected, a 12-Fr drainage catheter was inserted into the tumor via the round ligament under ultrasonography. At that time, close attention was paid to avoid having the catheter deviate outside the round ligament. Through the inserted catheter, fluid was drained from the cystic lesion, and the stump of the round ligament was clipped to avoid fluid leakage. The left Glissonian pedicle was then taped. Laparoscopic left hemihepatectomy was performed under a good operative field because of tumor shrinkage., Discussion: Three cases underwent these procedures without any spillage of the contents of the cystic tumor. This method is useful for the reduction of tumor size and has a low risk of intra-abdominal leakage of the contents, resulting in a secure and good operative field., (© 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Introduction: The intra-operative detection of hepatocellular carcinoma (HCC) by ultrasonography is indispensable for laparoscopic partial hepatectomy. However, it is occasionally difficult to localize an HCC on an ultrasound in chronic liver disease. Two cases of partial hepatectomy using hookwire marking under CT guidance are presented., Materials and Surgical Technique: The location of the HCC was identified by CT scan, and the puncture site was determined. A hookwire system, made of a stainless steel hook, was used to localize the HCC. The hookwire was placed percutaneously close to the HCC, and then the patient was taken to the operating room as soon as possible. After identification of the hookwire marker, the cutting line was determined on the liver surface to ensure a sufficient surgical margin in laparoscopic partial hepatectomy., Discussion: Two cases underwent these procedures with easy intra-operative marking of the resection area. This technique facilitates safe laparoscopic partial hepatectomy for an HCC that is invisible on ultrasound., (© 2016 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Background: Hepatocellular carcinoma (HCC) patients with hepatic vein tumor thrombosis (HVTT) extending to the inferior vena cava (IVC) have an extremely poor prognosis. Here we report a case of HCC with HVTT and renal dysfunction after hepatic arterial infusion chemotherapy (HAIC) successfully treated by liver resection and active veno-venous bypass., Case Presentation: A 77-year-old man was diagnosed to have a large HCC with intrahepatic metastases and HVTT extending to the IVC. Due to the advanced stage, HAIC with cisplatin was performed 13 times in a period of 17 months. As a consequence of this treatment, the size of the main HCC markedly decreased, and the advanced part of the HVTT went down to the root of the right hepatic vein (RHV). However, because of renal dysfunction, HAIC with cisplatin was discontinued and right hepatectomy with patch graft venoplasty of the root of the RHV was performed. Because progression of renal dysfunction had to be avoided, veno-venous bypass was activated during IVC clamping to prevent renal venous congestion and hypotension. Histological examination showed foci of a moderately differentiated HCC with extensive fibrosis and necrosis in the main HCC. Histologically, the HVTT in the RHV showed massive necrosis and tightly adhered to the vascular wall of the RHV. The postoperative function of the remnant liver was good, and no further deterioration of renal function was detected. The patient did not show signs of recurrence 15 month after surgery., Conclusion: In the present case, HAIC using cisplatin in combination with hepatic resection and patch graft venoplasty of the IVC provided a good long-term outcome with no HCC recurrence. Renal function was preserved by using active veno-venous bypass during IVC clamping to prevent renal venous congestion and hypotension.

We report a case of recurrent pancreatic VIPoma with liver and peritoneal metastases who has been surviving over 7 years by a successful treatment with a combination of surgical resection and loco-regional therapies. A 59-year-old female underwent distal pancreatectomy for pancreatic endocrine tumor. Five years after pancreatectomy, she had a recurrence of liver and peritoneal metastases with the symptoms by hypersecretion of VIP, and she underwent hepatectomy and peritoneal tumor resection. Seven months later, multiple liver metastases appeared and were treated with transcatheter arterial chemoembolization (TACE). Additionally radiofrequency ablation( RFA) for remnant viable lesion was performed. Seven years and eight months after primary panceatectomy and two years and six months after resection of the liver and peritoneal recurrences, she is now disease-free with good quality of life. The progression of well-differentiated pancreatic neuroendocrine carcinoma is usually slow. It is potentially useful in controlling of liver metastases to combine the loco-regional therapy like TACE and RFA with surgical resection.

A 54-year-old male visited our hospital with the chief complaint of anorexia. Based on various tests, a diagnosis of scirrhous gastric carcinoma accompanied by bone metastasis and liver metastasis was made. As DIC developed following hospital admission, 5-FU and PTX therapy (5-FU at 600 mg/m(2), 24-hour continuous infusion, day 1-5 and PTX at 80 mg/m(2), iv, day 8, 15, 22) were administered. Although primary foci, bone metastasis, and liver metastasis were observed by image diagnostic procedures, recovery from DIC was achieved. 5-FU+PTX therapy is considered to be effective for DIC due to bone metastasis of gastric carcinoma.

Eighteen subjects with cases of HCC who underwent endoscopic local coagulation therapy at Hiroshima City Hospital between 1998 and 2004 were studied and compared with 6 cases of HCC patients who underwent laparoscopic partial hepatectomy during the same period. The subjects composed of 10 cases of laparoscopic microwave coagulation therapy (L-MCT), 5 cases of laparoscopic radio frequency ablation therapy (L-RFA), and 3 cases of thoracoscopic microwave coagulation therapy (T-MCT). The operation time was 114 minutes for L-MCT and 92 minutes for L-RFA, both of which were significantly shorter than 208 minutes for resection cases. No complications were developed in any of the cases and the postoperative hospitalization period of the cases was 13.1 days, 8.2 days, and 13.0 days, respectively. Although each case of local recurrence was observed both in L-MCT and L-RFA groups, one case displayed observation difficulty from the liver surface and the other required a daughter nodule. The three-year survival rate was 71.4%, while the five-year survival rate was 53.6%. Endoscopic local coagulation therapy is not too invasive and useful for hepatocellular carcinoma in which percutaneous RFA is difficult. However, it is well indicated when the scope is evident with observation being feasible from the liver surface.

We evaluated the significance of multimodality therapy for cases of liver metastases of gastric cancer. Accumulated survival rate and median survival time were analyzed for twenty cases of such gastric cancer. Survival rates of H1+H2 group and hepatic resection (HR) group were higher than that of H3 group and non-HR group. MST of HR group and hepatic arterial infusion (HAI) group were longer than that of non-HR group and non-HAI group. Survival rate of HAI group was higher than that of non-HAI group among eleven cases of HR group. On the other hand, survival rate of HR group was higher than that of non-HR group among eleven cases of HAI group. These results suggested that HAI chemotherapy after hepatic resection for gastric cancer patients with synchronous liver metastasis would improve prognosis.

Hepatoblastoma usually occurs in children, but a few cases have also been reported in adults. We report the unusual case of hepatoblastoma in an 18-year-old adult with chronic hepatitis B. He visited a local hospital with right upper abdominal pain. Abdominal ultrasound showed a large mass in the right lobe of his liver. He was referred to our hospital and admitted for further examination. At admission, liver function tests gave slightly elevated results (aspartate aminotransferase (AST) 103 IU/l, alanine aminotransferase (ALT) 63 IU/l). A test for hepatitis virus revealed that he was a hepatitis B surface antigen (HBsAg) carrier and had experienced seroconversion. His alpha-fetoprotein (AFP) was elevated to 1 548 000 IU/ml. Abdominal ultrasound showed a 109 x 96 x 80-mm mass with mosaic pattern in the right lobe of the liver and right portal vein thrombus. Abdominal computed tomography (CT) demonstrated a large low-density mass occupying the right lobe, with some high-density parts that showed calcification. From these results, we diagnosed hepatoblastoma in a young adult. A right lobectomy was performed. Pathological examination showed a highly differentiated hepatoblastoma. Adjuvant chemotherapy was performed with cisplatin and pirarubicin. The patient has been well and free of recurrence for 12 months, and his AFP level remains almost normal.

A rare case of ruptured hepatocellular carcinoma (HCC) of the caudate lobe is reported. A 67-year-old man came to the hospital with complaints of abdominal pain and distension. Computed tomography (CT) showed haemoperitoneum and a mass in the caudate lobe. Angiography demonstrated a tumor stain. However, extravasation of the contrast medium was not clear. Although transcatheter arterial embolization (TAE) was performed, bleeding from the tumor could not be controlled. The caudate lobe, including the tumor, was resected. The patient died of multiple organ failure despite intensive care. This case suggests that TAE is not always effective and may not be safely or easily performed when treating ruptured HCC in the caudate lobe. This is attributed to the multiple feeding arteries of the tumor, derived from the proximal portion of the right and left hepatic arteries. If bleeding from the ruptured HCC in the caudate lobe is not controlled, immediate resection of the tumor is recommended.

We report a rare case of hepatic adenomas (HA), in a 20-year-old Japanese girl treated for 6 years with anabolic androgens for aplastic anemia. In a review of the world literature using computer MEDLINE search, we found only 17 cases of androgen-induced HA published between 1975 and 1998 in the English-language literature. The patient was referred to us because of liver lesions detected during a follow-up examination for familial adenomatous polyposis. After being diagnosed with aplastic anemia at 14 years of age, she had been treated with oxymetholone (30 mg/day) for 6 years. Laboratory evaluation revealed normal liver function. Ultrasonography (US) and computed tomography (CT) demonstrated multiple liver lesions. Histopathological examinations of biopsied specimens from the liver tumor showed HA. After the patient was diagnosed with HA, oxymetholone was tapered off. Patients taking androgenic-anabolic steroids should be carefully monitored with US and CT and tumor markers should be measured. This report may be helpful in identifying the population who is at risk of developing hepatic sex hormone-related tumors.

The prognosis of patients with hepatic metastasis from breast cancer is usually extremely poor. We present the case of a 39-year-old Japanese woman diagnosed with multiple liver metastasis from breast cancer. A novel approach consisting of hormone-cytokine-chemotherapy with an arterial infusion therapy was carried out. Computed tomography and ultrasonography revealed that the multiple liver metastases were reduced with remaining calcification. Tumor markers decreased rapidly. Complete regression was achieved after these treatments. To date, there has been no relapse during the 8-year follow-up period. These results suggest that the hormone-cytokine-chemotherapy might be a rational modality of treatment against multiple metastatic breast cancer.

Histopathological studies were conducted on the resected lesions in eight cases of small liver cancer, and therapeutic methods are discussed. Examinations revealed tumor cell infiltration into the fibrous capsule in 5/7 (71%), into extracapsular tissues in 3/7 (43%), and vascular invasion by tumor cells in 2/8 (25%) cases. Seven patients were complicated with liver cirrhosis and one patient with hepatic fibrosis. On the basis of preoperative TAE performed in three cases and studies on the resected indicating that tumor cells remained that have infiltrated into extracapsular areas, resection was considered to be necessary to attain radical cure. At 100%, the one-year survival rate was encouraging. However, two cases of recurrence would suggest that further studies are necessary on areas to be resected.