Right liver graft without middle hepatic vein reconstruction from a living donor

A case of adult-to-adult, living-donor liver transplantation using a right liver graft is described. In the donor operation, when the middle hepatic vein (MHV) was clamped after hepatic transection, reversed flow was detected in MHV tributaries by intraoperative color Doppler ultrasonography. Regurgitated flow in the clamped inferior right hepatic vein was also demonstrated. Portal flow remained hepatopetal during the procedure. Based on these ultrasonographic findings, neither the MHV tributaries nor the inferior right hepatic vein was reconstructed.     

New titanium spacer for cervical laminoplasty: initial clinical experience. Technical note

Many commercially available hydroxyapatite (HA) spacers for cervical laminoplasty have been introduced but have disadvantages such as lack of plasticity, easy cracking, and occasional difficulty in fixation by sutures. Here we present the short-term results of a newly designed titanium spacer (Laminoplasty Basket) in open-door cervical laminoplasty, and evaluated clinically and radiologically. The titanium box-shaped spacer with two arms for fixation was easily inserted and fixed into the laminoplasty space with 4-mm or 5-mm length screws after the posterior cervical arch was repositioned for the canal expansion. Twenty-one patients with cervical myelopathy due to spondylosis or ossification of the longitudinal ligament or developmental narrow canal observed for more than 6 months postoperatively were enrolled in this study. The neurological condition of these patients improved from 9.4 points on the Japanese Orthopaedic Association scale preoperatively to 13.5 points at 6 months after surgery. Postoperative radiological evaluation showed no laminar closure or implant failure and cervical spine curvature was maintained. These results seemed to have no significant difference compared with those using HA spacers. This titanium spacer is a potential substitute for conventional HA or other similar devices in cervical laminoplasty.     

A simple technique ligating the corresponding inflow and outflow vessels during anatomical left hepatectomy

Background Massive bleeding remains one of main factors of morbidity and death in liver resections. For this reason, the Pringle maneuver or total vascular exclusion is commonly used during liver resection. However, ischemic damage is still a major problem. Some surgeons used the “glissonean” approach for bleeding control, but the technique is tedious and also time consuming, with high incidence of bile leaks in the postoperative period. The aim of this paper is to describe a new bleeding control technique, rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection during anatomical left liver resection and to analyze the feasibility, blood loss, transfusion requirements, and postoperative complications. Materials and methods During the past 18 years, we used the new hemorrhage control technique in left liver resection in 630 patients with malignant or benign tumors. Results The median blood loss in all 630 patients was 110 ± 250 ml (range 50–750), and no patient required blood transfusion. The median total operative time was 77 ± 35 min (range 25–155). No bile leaks and liver failure of the patients occurred postoperatively. There was no death within 30 postoperative days. Conclusion The rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection is a feasible, safe, and bloodless technique during the left liver resection. A commentary on this paper is available at     

Biliary complications in right lateral sector graft live donor liver transplantation.

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.     

Role of the Fas system in liver regeneration after a partial hepatectomy in rats.

Apoptosis is involved in the homeostatic control of organs. The aim of this study was to define the in vivo role of apoptosis-related proteins including the Fas system and Bcl-2 in liver regeneration following a partial hepatectomy (PH). We used 70% hepatectomized rats which were serially sacrificed from 12 h to 28 days. The expressions of Fas, Fas ligand, and Bcl-2 were examined by semiquantitative RT-PCR and immunohistochemistry. Liver regeneration, as examined by PCNA staining, peaked from 24 h to day 3, and declined from day 5. On the other hand, hepatocyte apoptosis, as examined by TUNEL staining, was seldom observed until 24 h, but increased from 1 week after PH. In the RT-PCR study, Fas showed an early decline by 24 h, followed by a later peak from days 3 to 5, and then a constant expression thereafter. Meanwhile, the Fas ligand was also low until day 3, but showed a remarkable increase from days 5 to 7, followed by a gradual decrease. On the other hand, Bcl-2 showed an early peak until 24 h, followed by a decline from day 5. In an immunohistochemical study, the time courses of these protein expressions were almost synchronous with their mRNAs in the RT-PCR study. We thus conclude that the coordinated interplay between these apoptosis-related proteins and hepatocyte apoptosis suggests the possible involvement of these proteins in the course of liver regeneration.     

Prognostic evaluation for squamous cell carcinomas of the lower thoracic esophagus treated with three-field lymph node dissection

Objective: The efficacy of esophagectomy with three-field lymph node dissection in surgical treatment for patients with squamous cell carcinomas of the lower thoracic esophagus remains controversial. This report documents the outcomes of this surgical procedure for a large series. Methods: From February 1986 to November 1998, 437 patients with squamous cell carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with three-field lymph node dissection. One hundred and sixteen of these had cancer of the lower thoracic esophagus. To avoid the influence of adjuvant therapy on survival, 20 who also received radiation and/or chemotherapy were excluded, leaving 96 patients who were retrospectively analyzed. Results: The operative morbidity, and 30-day and in-hospital mortality rates were 62, 0, and 3%, respectively. The overall 1-, 3-, and 5-year survival rates were 89, 65, and 59%, with a median survival of 76 months. In those with lymph node metastases (66% of cases), the values were 87, 56, and 48%, as compared with 94, 84, and 79%, respectively (P=0.005) for patients without lymph node metastasis. Factors significantly influencing the overall survival rates were patient age (≥65 vs. <65), clinical N status (cN1 vs. cN0), clinical M status (cM1 vs. cM0), longitudinal tumor length of resected specimen (≥5 vs. <5 cm), pathologic T status (pT3 vs. pT1, 2), pathologic N status (pN1 vs. pN0), lymphatic invasion (positive vs. negative), vascular invasion (positive vs. negative) and intramural metastasis (present vs. absent). Independent prognostic factors for survival determined by multivariate analysis were pathologic T status (P=0.02), pathologic N status (P=0.03), and presence of intramural metastasis (P=0.04). Additional pathologic M1 status, cervical or celiac lymph node metastasis, was without significant influence. Conclusions: Patients with pathologic T3 tumors with both pathologic N1 status and the presence of intramural metastasis in the lower thoracic esophagus had a poor prognosis. Cervical or celiac lymph node metastasis in patients with carcinomas of the lower thoracic esophagus should be distinguished from pathologic M1 status in the UICC-TNM staging system.     

Liver resection without total vascular exclusion: hazardous or beneficial? An analysis of our experience

OBJECTIVE: To evaluate retrospectively the safety and radicality of liver resection performed without total vascular exclusion (TVE). SUMMARY BACKGROUND DATA: TVE is recommended for safe liver surgery, at least in the case of resection of the paracaval portion of the liver. However, it has some drawbacks because of its invasiveness. METHODS: The authors retrospectively evaluated 329 of 471 consecutive patients who underwent liver resection from October 1994 to October 1999. All of these patients had tumors involving segments 1, 7, or 8 or the cranial portion of segment 4, or underwent major hepatectomies that required exposure of the inferior vena cava (IVC), the main trunks of the hepatic veins, or both. Sixty-four patients underwent resection that included segment 1, with or without the reconstruction of the IVC, the hepatic vein, or both. RESULTS: Three hundred twenty-four of 329 procedures were done under intermittent warm ischemia; no clamping methods were used in 6. TVE was never needed. There were no postoperative 30-day deaths. The complication rate was 25.5%, and only 2.1% had major complications. Only 13 (3.9%) patients required whole blood transfusion. Part of the wall of the IVC was resected in six patients, and the hepatic veins were reconstructed in four. Surgical clearance was achieved in all patients undergoing surgery for a tumor. CONCLUSIONS: These results show that liver surgery performed without TVE is safe and effective even in aggressive procedures for liver tumors involving the cavohepatic junction. Therefore, TVE should be further restricted to exceptional patients.     

Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus

OBJECTIVE: To examine the usefulness of the authors' method involving preoperative transcatheter arterial chemoembolization followed by hepatectomy. SUMMARY BACKGROUND DATA: The presence of portal vein tumor thrombus in a patient with hepatocellular carcinoma is one of the most significant factors for a poor prognosis. No standard therapy has been established. METHODS: Forty-five of 455 patients with hepatocellular carcinoma (10%) from 1989 to 1998 were included in this study. These patients had gross portal vein tumor thrombus but no distant metastases. The 23 patients (50%) who had indications for surgery received preoperative transcatheter arterial chemoembolization: 18 underwent hepatic resection and 5 underwent ligation of the hepatic artery or portal vein on laparotomy. Among the remaining 22 patients who did not have indications for hepatectomy, 10 received regional chemotherapy and 12 underwent transcatheter arterial chemoembolization. RESULTS: The mean duration of survival was 3.4 +/- 2.7 years in the 18 patients who received transcatheter arterial chemoembolization and hepatectomy and 0.36 +/- 0.26 years in the 27 patients who did not receive hepatectomy. The survival rate of the 18 patients who received hepatic resection with preoperative transcatheter arterial chemoembolization was 82% at 1 year, 42% at 3 years, and 42% at 5 years. Portal trunk occlusion by tumor thrombus, three or more primary nodules, an indocyanine green retention rate at 15 minutes of 20% or worse, and therapeutic choice other than hepatectomy were significant predictors of a poor prognosis on univariate analysis. Hepatectomy was the only factor that was significant on multivariate analysis. CONCLUSIONS: Patients may enjoy long-term survival if they receive hepatectomy with preoperative transcatheter arterial chemoembolization, when the number of primary nodules is no more than two, the portal trunk is not occluded by tumor thrombus, and the indocyanine green retention rate at 15 minutes is better than 20%.     

Idiopathic calcinosis cutis in fingertip treated with occlusive dressing using aluminum foil: a case report.

Calcium deposition in the skin, known as calcinosis cutis, is an uncommon disorder caused by an abnormal deposit of calcium phosphate in the skin. We report a case of idiopathic calcinosis cutis in fingertip treated with surgical excision followed by the occlusive dressing using aluminum foil, and obtained significant pain relief and round-shaped fingertip which looked normal.