Extensive Hepatic Resection Research Articles

4558 Preliminary results of eus guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma.

Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks. Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks.

Lovastatin decreases mortality and improves liver functions in fulminant hepatic failure from 90% partial hepatectomy in rats

Background/Aims: Liver insufficiency occurs when the liver cannot perform critical functions such as ammonia metabolism, gluconeogenesis, or production of coagulation factors. The hypothesis of this study was that decreased function of existing hepatocytes may contribute to hepatic failure, and that the function of these cells might be increased pharmacologically. Lovastatin is a 3-hydroxy-3-methylglutaryl CoA reductase inhibitor that inhibits cholesterol biosynthesis and affects the activity of some signal transduction pathways and liver transcription factors. Changes in hepatic transcription factors during liver regeneration might result in decreased liver functions, and lovastatin might prevent these changes. Methods: Rats received 90% partial hepatectomy (90% PH), and either lovastatin or vehicle alone daily. Survival and liver functions were assessed. Results: Lovastatin increased survival to 58% ( vs. 6% in controls that received 90% PH without drug), decreased the peak ammonia level to 427 μM ( vs. 846 μM in controls), increased the nadir of glucose to 88 mg/dl ( vs. 57 mg/dl in controls), decreased the peak prothrombin time to 23 s ( vs 29 s in controls), and decreased the peak activated partial thromboplastin time to 29 s ( vs. 39 s in controls). The full survival and metabolic benefits were observed when lovastatin was started at 30 min after 90% PH, but lovastatin was less efficacious when started at later times. Conclusions: Lovastatin increases the function of existing hepatocytes and might be used to improve liver function after extensive hepatic resection.

Effect of hepatic invasion on the choice of hepatic resection for advanced carcinoma of the gallbladder: histologic analysis of 32 surgical cases.

The purpose of this study was to assess the patterns of hepatic invasion in advanced carcinoma of the gallbladder by histologically examining surgical specimens obtained in 32 cases of hepatectomy for that carcinoma. Two modes of microscopic tumor extension were observed. The expansive pattern was restricted to liver-bed carcinomas, in which the tumor extends into the liver, primarily from the liver bed. Most of the infiltrating patterns were found with hepatic-hilar carcinomas, in which the tumor invades the hepatic hilum along Glisson's sheath, especially tumors exhibiting a discontinuous front of tumor invasion. The average width for wedge resection of the liver bed was 15.6 +/- 2.9 mm, in contrast to 25.6 +/- 8.1 mm for resection of segments IVa and V and 44.1 +/- 10.3 mm for extensive hepatic resection (both p < 0.01). When the hepatic invasion distance is more than 20 mm, the tumor should be selectively managed by extensive hepatic resection, such as extended right hepatic lobectomy or central bisegmentectomy. The results suggest that wedge resection of the liver bed and resection of segments IVa and V are advisable for carcinoma localized to the gallbladder alone and for liver-bed carcinoma with slight hepatic invasion and an expansive tumor growth pattern. Extensive hepatic resection, however, is recommended for carcinoma of the invasive liver-bed type and carcinoma of the hepatic-hilar type.

Functional assessment of liver for extended hepatic resection in patients with obstructive jaundice

We studied whether the maximal excretion rate of indocyanine green (ICG Bmax) and the 2-h ICG excretion rate in the bile could be used to estimate the separate functions of the left and right liver in 20 patients with biliary obstruction at the hepatic hilus. ICG Bmax was measured after biliary decompression. An operative procedure that preserved the side of the liver with a positive ICG Bmax value was selected. Eighteen patients tolerated extensive hepatic resection, such as right trisegmentectomy, extended right lobectomy, extended left lobectomy, or left lobectomy. However, prolonged jaundice was observed postoperatively in five of the six patients with 2-h excretion rates of less than 25% and who had undergone extended right lobectomy. One patient on whom extended right lobectomy had been performed died because of postoperative hepatic failure. His ICG Bmax value was +0.6 and his 2-h excretion rate was very low (3%). ICG Bmax and the 2-h excretion rate in the bile reflected well the degree of separate hepatic dysfunction in patients with biliary obstruction at the hepatic confluence. If ICG Bmax value is more than +1.0, resection of more than two segments, such as trisegmentectomy or extended hepatic lobectomy, may be tolerated, and if the ICG Bmax value is positive, hepatic lobectomy may be tolerated. ICG Bmax and 2-h excretion rate in bile are useful indicators of hepatic functional reserve of the separate lobes of the liver in patients with biliary obstruction at the hepatic hilus.

Regulation of signal transduction during liver regeneration

The liver has a tremendous capacity to regenerate. For example, after extensive hepatic resection, remaining hepatocytes proliferate to restore the mass of the organ within days to weeks. This proliferative response is fascinating because hepatocytes rarely replicate in the healthy adult liver. Instead, these cells perform highly specialized functions and exemplify mature, terminally differentiated cells. Therefore it is somewhat surprising that the liver can repopulate while performing its many obligate, organ-specific functions. Study of the regenerating liver remnant after partial hepatectomy has helped to delineate mechanisms that regulate proliferation and liver-specific functions in individual hepatocytes, as well as those that coordinate the behaviors of different liver cell populations to balance organ growth and tissue-specific gene expression. Hence, this review will focus on inter- and intracellular signals that regulate the hepatocyte phenotype after PH.

Prediction of the safe limits of hepatectomy by combined volumetric and functional measurements in patients with impaired hepatic function.

Because of the vast functional reserve of the liver and its capacity to regenerate, an extensive hepatic resection to remove three of the four segments can be well tolerated by most patients with normal liver function. However, more than 70% of patients with hepatocellular carcinoma (HCC) have associated cirrhosis. In these patients such extensive hepatic resection has frequently resulted in fatal hepatic failure after surgery. Computed tomography (CT) has made possible a noninvasive, in-situ measurement of the volume of various organs in the body [1]. We have previously reported on our efforts to predict the safe limits of hepatectomy [2].KeywordsBorder ZoneSafe LimitSafety ZonePrediction ScoreImpaired Hepatic FunctionThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Segmental liver resection using ultrasound-guided selective portal venous occlusion.

Anatomical segmental resection of small hepatic lesions using operative ultrasonography is improved by selective intrahepatic portal venous occlusion. The technique was successfully performed in 15 of the 18 patients in whom it was attempted. The lesions resected included 7 hepatocellular carcinomas in cirrhotic patients, 5 hepatic metastases, 2 benign tumors and 1 gallbladder carcinoma. The mean duration of local vascular exclusion was 47 minutes (range, 22 to 80 minutes) and mean blood transfusion requirement was 1.3 units (range, 0 to 7 units). Five patients sustained postoperative complications and these included chest infection (2 patients), ascites (2 patients), pleural effusion (1 patient) and hemorrhage (1 patient) from the site of hepatic resection. There were no postoperative deaths. One patient required further resection of a recurrent colonic metastasis and two patients have died of disseminated disease. This technique has allowed limited anatomical resection of lesions that would have otherwise required extensive classical hepatic resections or would have not been amenable to resection.

Pediatric Hepatic Surgery

Tumors of the liver are uncommon in children. It is imperative that surgeons caring for these patients have a knowledge of the likely diagnosis, proper radiographic evaluation, and appropriate selection and extent of surgical therapy. Of the benign lesions, infantile hemangioendothelioma often is best treated nonoperatively, whereas mesenchymal hamartoma and teratoma should be resected. All malignant lesions must be completely excised to cure the patient, but some may be converted from unresectable tumors to resectable ones by preoperative chemotherapy. Major hepatic resection is one of the most formidable procedures in the surgery of children. Careful preparation, attention to technical detail, and precise postoperative management of the critically ill child are prerequisites for success. For a recent review of the extrahepatic biliary tract problems of infants and children, the reader is referred to the article by Stolar and Altman in Surgical Clinics of North America, Volume 65, October 1985.

Inhibitory effect of cimetidine on liver regeneration after two-thirds hepatectomy in rats

The effects of cimetidine on the regenerating liver were studied in rats after they had two-thirds hepatectomy. In Group I, standard two-thirds hepatectomy was performed. In Group II, cimetidine in a dose of 40 mg/kg was given intramuscularly immediately and 24 and 48 hours after two-thirds hepatectomy. In Group III, the same amount of cimetidine was given after a sham operation. Mortality rate, liver weight restoration, mitotic activities of remnant livers, and serum levels of aminotransferases and albumin were examined from 24 hours to 14 days after operation. The mortality rate was 11.1 percent in Group II, whereas no rats in Groups I and III died. Although there were no differences in the residual liver weights among the hepatectomized groups, treatment with cimetidine induced substantial suppression and delay of liver cell division. The serum aminotransferase levels in Group II increased significantly after hepatectomy compared with the levels in Group I. The albumin synthesis remained suppressed in Group II. Light microscopy showed prolonged liver steatosis and marked dilatation of the sinusoidal space in that group. Our results may indicate that cimetidine has an inhibitory effect on liver regeneration and that it should be administered very carefully after extensive hepatic resection if applied as prophylaxis for the life-threatening complication, stress ulcer syndrome. Otherwise, antacid therapy or other trials should be carried out.

Release of lysosomal enzymes after partial hepatectomy: study of patients with and without cirrhosis of the liver.

Serum activities of lysosomal enzymes beta-glucuronidase and acid phosphatase were serially estimated in 14 patients with and without cirrhosis of the liver who underwent 40% to 80% hepatic resection. Substantial increases in enzyme activities were observed two to eight weeks after operation in ten of 11 patients who did not suffer from postoperative liver failure. Regeneration of the residual livers was almost satisfactory in all 11, as evidenced by clinical, roentgenologic, and histologic findings. In three patients with advanced cirrhosis who died of hepatic failure 21 to 39 days after extensive hepatic resection, there was neither the enzymatic reaction nor evidence of regeneration of the liver remnants. In the light of this study and our previous experimental studies, serial determination of the lysosomal enzyme activities in blood is probably a beneficial biochemical index for detection of progressive hepatic regeneration.

Remnant liver function during surgery for extensive hepatic resection

True functional reserve of remnant liver should be determined at the same condition that contemplated hepatectomy has been performed, and this condition can be achieved before resection by temporary clamping of the inflow vessels of hepatic lobes to be removed. Using indocyanine green (ICG), the remnant liver function (RLF) was evaluated whether or not the method can be a useful indicator for or against hepatomy. In the study of healthy dogs, the RLF proved to be a reliable indicator to prospect hepatic failure which may occur after extensive resection of the liver. Then, the method was employed in nine patients who underwent 40 to 70 per cent hepatectomy. The results indicated that the RLF with ICG during surgery, if performed under stable hemodynamics, is a beneficial tool to decide the resectability in equivocal cases.

Primary chemotherapeutic management of unresectable and metastatic hepatoblastoma in children: Report of four cases

Four children presenting with unresectable hepatoblastomas and one with metastatic disease are reported. Following initial biopsy all were treated with chemotherapy which included Adriamycin. Three of the four children showed a significant reduction in tumor size, and in two, delayed resection of the primary lesion was possible. Chemotherapy including Adriamycin represents effective initial cytoreductive therapy for childhood hepatoblastoma, thereby reducing the morbidity and mortality associated with the extensive hepatic resection usually required for an untreated lesion.

The management of extrahepatic bile duct carcinoma.

A series of 63 patients with primary bile duct carcinomas seen at the UCLA Hospital since 1955 have been analyzed and divided into four groups, depending upon the site of the tumor in the extrahepatic ductal system. More than half of the tumors occurred in the upper one-third, while the other half was about equally divided between those occurring in the middle and lower thirds of the extrahepatic duct system. Three wide-spread intraluminal papillary tumors have been placed in a special category. The difficulties of establishing a correct diagnosis at the time of operation are again demonstrated in this series. The most commonly used palliative procedure has been the insertion of a tube into the duct that passes above and below the tumor through the site of obstruction. The tumors are generally small, well-localized, and frequently slow-growing. Tumors in the lower one-third of the duct may be treated by radical en bloc resection (pancreaticoduodenectomy) and offer the best prognosis, both for long-term palliation and cure. More than half of the tumors in this series were located at or near the confluence of the hepatic ducts, and resection of the tumor was attempted in only six of 34 cases. It is possible that, were procedures available that would permit a more extensive en bloc resection of tumors in the middle and upper thirds of the duct system, the period of palliation might be extended and more “cures” obtained. Detailed anatomical studies of the hepatic ducts, arteries, and portal veins at the hilus support the concept of combining extended hepatic resection with tumor excision and including segments of the hepatic blood supply in selected patients with tumors in the upper one-third of the duct. Operative procedures for resection of the right and left lobes have been proposed. One such operation has been performed; in a second patient, hepatic lobectomy and tumor excision were performed without interruption of the blood supply to the remaining lobe.

Exchange transfusion for fulminant hepatic failure following hepatic resection.

A patient with extensive trauma to liver and shock was treated by hepatic lobectomy rather than suture and packing. Hepatic coma was noted on the fifth postoperative day and exchange blood transfusions were performed on the seventh and eighth days. The patient became conscious with each exchange. The patient subsequently recovered. Repeated exchange blood transfusions may be useful in sustaining the patient following extensive hepatic resection until regeneration can occur.

Liver regeneration following hepatectomy, evaluated by scintillation scanning.

In 1952, Lortat-Jacob and Robert reported in the French literature on a method of controlled right hepatic lobectomy (7), and at about the same time Quattlebaum in this country described a similar technic (15). At the present time lobectomies are commonly performed for liver fracture, primary or secondary tumors, and cysts (2, 5, 11). Extensive hepatic resection is possible because of the liver's remarkable regenerative ability. The purpose of this paper is to report 3 cases from the Los Angeles County General Hospital, Los Angeles, Calif., in which hepatic resections and follow-up studies, including liver scans, were performed. Case Reports Case I: H. W., a 20-year-old Negro female, was admitted to the hospital on April 10, 1964, with blunt abdominal trauma following an automobile accident. The abdomen was distended, tender, and silent, and the patient was in shock. At laparotomy she was under anesthesia for seven hours and twenty minutes. Lacerations of the spleen and the right lobe of the liver were disclosed, and an 80 per cent right hepatic lobectomy and splenectomy were carried out. Two episodes of cardiac arrest on the table were managed by open heart massage. Twenty-two units of whole blood and 8 liters of miscellaneous fluids were required during surgery. The postoperative course was stormy, with pneumothorax, hypotension, low-grade fever, electrolyte imbalance, traumatic pancreatitis, wound infection, and bleeding tendency. The patient was treated with antibiotics, vitamin K, fibrinogen, blood, plasma, and intravenous fluids. Liver function tests were abnormal in the immediate postoperative period, but returned to normal or near normal in four to six weeks. Liver scans were obtained two and a half months, nine months, and eighteen months after hepatectomy (Figs. 1–3), using 150–170 microcuries of gold 198 and a 3-inch-crystal photoscanner. At the time of her last scan, the patient was clinically well, and the findings on her laboratory tests were normal. Case II: M. C, a 35-year-old Caucasian female, was admitted to the hospital Nov. 12, 1965, after suffering blunt abdominal trauma in an automobile accident. She was in mild shock, and the abdomen was silent and tender. At laparotomy a fracture of the hepatic right lobe was found, and 80 per cent of it was resected. The patient was under anesthesia for three hours and fifteen minutes. Postoperatively, she went into shock and required re-exploration and splenectomy for bleeding. Liver function tests returned to normal by three weeks, and recovery was fairly smooth. The liver scans in Figures 4 and 5 were obtained two months after hepatectomy. When the patient, was last seen in March 1966, liver function tests including Bromsulphalein retention were normal, and she felt well. Case III: Y. K., a 72-year-old Japanese male, underwent a 75 per cent gastrectomy for carcinoma in 1958.