Journal of hepato-biliary-pancreatic surgery最新文献

Background/purpose: In patients with complete bile duct obstruction, the only pathway for the elimination of cholephilic compounds is through the urine. Although changes in various transporters in the liver and kidney in cholestasis have been elucidated, little is known about how effectively the elimination of these compounds is compensated for by urinary excretion.

Methods: In the present study, the urinary excretion of pravastatin and temocapril was studied in bile-duct-ligated rats (BDLR) for 3 days and in Eisai hyperbilirubinemic rats (EHBR). After urinary bladder cannulation, radiolabeled pravastatin and temocapril were injected intravenously. Urine samples were collected every 1 h for 4 h, and the radioactivity was counted.

Results: Urinary excretion of pravastatin was markedly increased in BDLR (85.9% of the dose after 4 h) and moderately increased in EHBR (35.9% of the dose after 4 h) compared with that in control rats (5.5% of the dose after 4 h). Similar but less prominent differences were observed with temocapril after it was administered (50.7%, 38.2%, and 22.0% of the dose after 4 h in BDLR, EHBR, and the controls, respectively).

Conclusions: The absence of biliary excretion of anionic drugs was compensated for by urinary excretion in BDLR and EHBR, and the compensation was more efficient with pravastatin than with temocapril. In patients with complete bile duct obstruction, the only pathway for the elimination of cholephilic compounds is through the urine. Although changes in various transporters in the liver and kidney in cholestasis have been elucidated, little is known about how effectively the elimination of these compounds is compensated for by urinary excretion.

Background: Although many studies have reported the beneficial effects of hepatic resection for colorectal liver metastases on survival rates, it is still difficult to preoperatively select good candidates for hepatectomy.

Methods: Fifteen clinicopathological features, which were recognized only before or during surgery, were selected retrospectively in 81 consecutive patients in one hospital (Group I). These features were entered into a multivariate analysis to determine independent and significant variables affecting long-term prognosis after hepatectomy. Using selected variables, we created a scoring formula to classify patients with colorectal liver metastases to select good candidates for hepatic resection. The usefulness of the new scoring system was examined in a series of 70 patients from another hospital (Group II).

Results: Multivariate analysis, i.e., Cox regression analysis, showed that serosa invasion of primary cancers (P = 0.0720, risk ratio = 2.238); local lymph node metastases of primary cancers, i.e., Dukes' C (P = 0.0976, risk ratio = 2.311); multiple nodules of hepatic metastases (P = 0.0461, risk ratio = 2.365); nodules of hepatic metastases greater than 5 cm in diameter (P =0.0030, risk ratio = 4.277); and resectable extrahepatic distant metastases (P = 0.0080, risk ratio = 4.038) were significant and independent prognostic factors for poor survival after hepatectomy. Using these five variables, we created a new scoring formula to classify patients with colorectal liver metastases. Finally, our new scoring system classified patients in Group II and Group I well, according to long-term outcomes after hepatic resection.

Conclusions: Our new scoring system to classify patients with colorectal liver metastases is simple and useful in the preoperative selection of good candidates for hepatic resection. Although many studies have reported the beneficial effects of hepatic resection for colorectal liver metastases on survival rates, it is still difficult to preoperatively select good candidates for hepatectomy.

Background/purpose: We evaluated the role of operative cholangiography and of conversion to decrease major bile duct injuries.

Methods: We report 1074 patients who underwent laparoscopic cholecystectomy, out of a total of 1195 patients who underwent laparoscopy, over an 8-year period. The planned laparoscopic operative procedure in all the patients was the standard four-port technique with the operator on the left side of the patient. Operative cholangiography was performed with Olsen's pliers.

Results: We performed 993 (83%) operative cholangiographies; 121 (10.1%) patients were converted from laparoscopic to open cholecystectomy. Despite a prolonged time of dissection, 54 (4.5%) patients were converted because of unclear anatomy of Calot's triangle. One hundred and ninety patients suffered acute cholecystitis and, of those, 52 (27.3% of 190 patients) were converted. Fifteen patients showed intraoperative biliary duct stones and they were converted. Seven (0.58%) bile duct injuries (one stricture and six fistulas) are reported.

Conclusions: The low number of major bile duct injuries reported in our study showed the value of operative cholangiography during laparoscopic cholecystectomy. Moreover, another important factor found to reduce major bile duct injuries was conversion when, despite accurate dissection, the anatomy of Calot's triangle remained unclear.

Background/purpose: The effects of preoperative biliary drainage for obstructive jaundiced patients are controversial. Although experimental studies have proven the benefit of internal biliary drainage (ID) over external biliary drainage (ED), ID has several clinical problems, such as clogging or tube replacement. The aim of this study was to determine whether there were any differences in T-cell function, liver function, and histology, between rats in ID and ED groups in short-term experiments.

Methods: Following bile duct ligation (BDL) for 14 days, rats in the ED and ID groups had 7 days of ED and 7 days of ID, respectively. Normal rats were used as negative controls (control group). For positive controls, we used a group with BDL and no drainage (BDL group). Serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were measured, splenic T-cell proliferation was assayed to check cellular immunity, and liver histology was examined.

Results: Recovery of bilirubin and ALT was similar in the ED and ID groups. Recovery of AST was worse in the ID group than in the ED group, but the difference was not statistically significant. Levels of ALP in the BDL and ID groups were significantly higher than those in the control and ED groups. Rats in the BDL group showed a significant decrease in T-cell function compared to the control group. The ED group showed better recovery of T-cell function than the ID group in the 7 days after relief of obstructive jaundice. The livers in the ID group demonstrated histologically moderate interface hepatitis with periportal inflammation and lymphocyte infiltration, which strongly suggested incomplete tube obstruction, but those in the ED group showed minimal change.

Conclusions: ED is superior to ID concerning the recovery of cellular immunity and liver inflammation in the short-term after relief from biliary obstruction in this model. As the patency of the tube is well maintained in ED compared to ID, patency of the tube is essential to obtain good recovery of cellular immunity, irrespective of the drainage method.

Hepatic resection remains the "gold standard" for patients with resectable disease. Nevertheless, for a variety of reasons this is not feasible for the majority of patients. A wide range of locally ablative techniques has been developed for use in these patients with the aim of improving survival. Unfortunately, as with many recent techniques in surgery, much of the development of these methods, and particularly their introduction clinically, has not been based on sound scientific data. The relative merits and limitations of the more commonly used techniques are discussed, although this lack of prospective, randomized data precludes firm conclusions to be drawn from many of the studies reported. By far the most popular methods now employed, thermal techniques have certain limitations, particularly when treating tumors adjacent to major vascular or biliary structures. The authors believe that this situation represents the "niche" for which ablative techniques may ultimately find their logical application, where a single awkwardly placed metastasis deems a patient unresectable. If such a metastasis can be completely and safely ablated, a potentially curative resection may then become a realistic option. The relatively new, nonthermal technique of hepatic electrolysis has been extensively studied and shown to be safe and effective in close proximity to major intrahepatic veins due to a subtle electrochemical action rather than a rapid "burn". This technique is discussed in the context of other, more traditional thermal methods of ablation.

Background/purpose: We aimed to determine the rationality of pericardial devascularization (PCDV) plus proximal splenorenal shunt (PSRS) for cirrhotic patients with portal hypertension with variceal bleeding, using a duplex sonography study of the effects of the different surgical procedures (PCDV, PSRS, and PCDV + PSRS) on the hemodynamics of the portal system.

Methods: Ninety-nine patients with cirrhotic portal hypertension and a history of bleeding esophageal varices were studied. These patients were divided into three groups (PSRS group, PCDV group, and PCDV + PSRS group). The hemodynamic parameters of the portal systems of all patients were measured by Doppler color-flow imaging perioperatively.

Results: In the PSRS group, the postoperative portal venous flow (PVF) and free portal pressure (FPP) decreased by 57 +/- 9% and 52 +/- 5%, respectively (P < 0.01). In the PCDV group, the postoperative PVF lessened by 8 +/- 5% (P > 0.05), and the postoperative FPP was reduced by 19 +/- 7% (P < 0.05). In the PCDV + PSRS group, the postoperative PVF and FPP were lowered by 36 +/- 8% and 34 +/- 10%, respectively (P < 0.05). The postoperative decreases of PVF and FPP in the PCDV + PSRS group were between those of the PSRS and PCDV groups. The differences among these groups were statistically significant (P < 0.05).

Conclusions: Combined devascularization and splenorenal shunt (PCDV + PSRS) significantly decreases portal venous flow and portal pressure, as well as maintaining hepatopedal flow, thus entailing fewer complications compared to either PCDV or PSRS. We aimed to determine the rationality of pericardial devascularization (PCDV) plus proximal splenorenal shunt (PSRS) for cirrhotic patients with portal hypertension with variceal bleeding, using a duplex sonography study of the effects of the different surgical procedures (PCDV, PSRS, and PCDV + PSRS) on the hemodynamics of the portal system.

Vascular isolation of the liver is a useful technique in major hepatic surgery that involves hepatic veins and the inferior vena cava. In some patients, exposure of the suprahepatic inferior vena cava is suboptimal from the abdominal cavity, and extension into the chest is required. This report details technical considerations of the control of the inferior vena cava within the pericardium from the abdominal cavity, through a vertical incision in the diaphragm, and without the need for a thoracic incision. We review the clinical situations when a transdiaphragmatic, intrapericardial access of the inferior vena cava should be considered.

Background/purpose: A case of polycystic liver disease with right predominance treated with laparoscopic right hemihepatectomy is described.

Patient: A 43-year-old woman complaining of right upper abdominal pain came in for consultation. Abdominal ultrasonography and computed tomography studies showed multiple liver cysts occupying mainly the right lobe, renal cysts, and splenomegaly.

Methods: Four trocars were used. A 12-mm trocar placed under the umbilicus was used for abdominal exploration. The other three trocars, two 12-mm trocars and one 5-mm trocar, were used as working ports. The liver was transected with ultrasound scissors and LigaSure. Major vessels such as the right portal vein, the right bile duct, and the hepatic vein were divided with a vascular endostapler. Operation time was 320 min, intraoperative blood loss was 120 ml, and postoperative oral intake occurred on day 3.

Results: No complication was observed during the perioperative period.

Conclusions: Laparoscopic right hemihepatectomy is generally considered to cause excessive intraoperative bleeding and a long operation time. For our patient with multiple liver cysts, the procedure was a safe and minimally invasive option because little hepatic parenchymal resection was necessary for the multiple cysts.A case of polycystic liver disease with right predominance treated with laparoscopic right hemihepatectomy is described.

Background/purpose: Celiac axis (CA) stenosis is a fairly common condition in candidates for upper abdominal surgery. In this report, we have documented 5 patients with CA stenosis or occlusion who underwent pancreaticoduodenectomy, and we have discussed the surgical strategy for this condition.

Methods: We reviewed the records of 126 patients who had undergone resection of the pancreatic head during the past 10 years, and a search was made for obstructive lesions of the CA.

Results: Among these 126 patients, there were 5 cases (4%) of CA stenosis or occlusion. Three of them were interpreted as typical CA compression syndrome, based on arteriographic or operative findings, and an excision of the median arcuate ligament dramatically improved the blood flow of the celiac branches after division of the main collaterals. The remaining 2 patients, with organized occlusion of the CA, successfully underwent pancreaticoduodenectomy through preservation of the collateral pathway between the superior mesenteric artery and the celiac branch. In one of these 2 patients, the main collateral pathway, which ran across immediately behind the pancreatic head, was skeletonized and preserved. All 5 patients had uneventful postoperative courses.

Conclusions: We conclude that, in pancreaticoduodenectomy for patients with organized CA occlusion, precise assessment of the vascular anatomy and preservation of the main collateral pathway are essential for carrying out a successful operation. Celiac axis (CA) stenosis is a fairly common condition in candidates for upper abdominal surgery. In this report, we have documented 5 patients with CA stenosis or occlusion who underwent pancreaticoduodenectomy, and we have discussed the surgical strategy for this condition.

Tumors of the papilla and ampulla of Vater are rare neoplasms which are usually detected at an early stage due to their symptoms. The accurate preoperative histological diagnosis and staging of ampullary tumors is often difficult and inconclusive, leading to controversy over the adequate treatment of these lesions. Three procedures are currently being used to treat such tumors. Pancreatoduodenectomy (PD) is a procedure with low morbidity and mortality at experienced centers, and is considered the treatment of choice for invasive carcinoma and large benign ampullary lesions with suspicion of malignancy. Transduodenal local excision (TDE) of ampullary tumors is a relatively simple procedure with operative morbidity and mortality rates comparable to PD. TDE is challenged at endoscopic centers by endoscopic snare excision (ESE). Due to technical advances, the safety and outcomes of ESE for ampullary tumors have improved in recent years. ESE and TDE represent adequate methods for treatment of benign tumors and also for small malignant tumors detected at an early stage if the diagnosis and stage have been accurately established preoperatively. Due to the safety of PD and the technical advances of ESE, TDE is reserved for selected patients. Randomized controlled studies are needed to establish the correct indications for PD, TDE, and ESE.