5th Japanese Association of Hepato-Biliary-Pancreatic Surgery

42

Symposium $1 Postoperative Complications after Hepatopanereatoduodeneetomy

Kohji Miyazaki, Nobuo Tsutsumi, Kenji Kitahara, Michito Mori, Eizaburo Sasatomi, Yoshimi Hirohashi, Hideaki Mashima and Takeharu Hisatsugu Department of Surgery, Saga Medical School

Hepatopancreatoduodenectomy(HPD) has improved the resectability of advanced biliary tract cancers, however, the curability and the safety are still under discussion. We have performed HPD for 12 patients with advanced biliary tract cancers including one hepatoligamentopancreato- duodenectomy(HLPD) from April 1989 to March 1993 in our Department. The extents of the hepatectomy were as follows; right trisegmentectomy for 2 patients, right extended hepatic lobectomy with caudate lobectomy for one, right extended hepatic lobectomy for one, right hepatic lobectomy for one, central hepatectomy for one, medial segmentectomy(S4) with anterior inferior(SS) and posterior inferior(S6) subsegment- ectomies for one, medial inferior(S4a)+S5+ $6 for 2 and $4a+$5 for 3 patients. Combined resections were as follows; portal vein for 3, hepatic artery for one, IVC for one, colon for 3 patients. Operative death occurred in one patient undergone HLPD on the 12th postoperative day. Three patients died durlng admission; one died of hepatic failure on the 34th p.o. day, one died of the progression of dermatomysitis associsted

with her gallbladder cancer, and the other one died of MRSA pneumonia on the 52th p.o. day. Durations of the operations were 8 to 15 hours(mean: 9.5 hours). Blood loss during the operations were i000 to 2800 ml(mean: 1800 ml). All the patients experienced elevation of total bilirubin ranged from I.I to 41.6 mg/dl after operation. The patients whose peak value of the total bilirubin were less than 5 mg/dl survived the operation. The elevations of total bilirubin in the early postoperative phase correlated with the extent of the hepatectomy and the volume of CRC transfusion. The elevations of the total bilirubin in the late postoperative phase correlated with the presence of the focus of infection. HPD with the extent of hepatectomy more than two segments showed high mortality and morbidity. Therefore, in these cases, blood loss during operation should be lessened and CRC blood transfusion should be minimized. Furthermore, much efforts should be paid to avoid postoperative infections.

$2

Prevention of Complications after HPD

Yoshiaki Sugiura, Takashi Kamiya, Shungo Hlroyasu, Izuru Takatsu, Yutai~ Yoshizumi, Shingo Shima and Susumu Tanaka Dept. of Surg. II, National Defense Medical College

Hepatopancreatoduodenectomy(HPD)~ simultane-- ous resection of the hepatic lobe and pancreatic head, is atria] surgery for advanced gallbladder cancer which involves both the liver through the gallbladder bed and lymph nodes around the pancreatic head. Between 1978 and 1992, 22 patients underwent HPD. Of 22, 19 had right hepatic lobectomy and pancreatoduodenectomy as cancer invasion was mainly seen in the right lobe while 3 had left hepatic lobectomy and pancreatoduodenectomy as invasion was in the median segment of the left lobe. Combined resection of the portal vein was performed in 9 of 22. HLPD, in which the portal vein and hepatic artery were resected, was performed in 4 of 22.

The operative deaths were seen in 6/22(28%) before 1984, of which causes were anastomosis insufficiency of pancreatojejunostomy in 3 and hepatic failure in 3. As other than operative deaths, 2 died of massive gastrointestinal bleeding, one died of hepatic failure and one died of a leak of pancreatojejunostomy. The survival rates excluding 6 operative deaths were 23% at 2 years and 8%

at 5 years. One has lived 6 years after HPD and one lived 2 years after HLPD.

In order to improve results, we have to pay efforts at first to reduce an anastomotic leak in pancreatojejunostomy and then to make more strict indication for hepatic lobectomy in HPD than in hepatic lobectomy only for other lesions. To connect the soft pancreatic tail to the jejunum, we adopted the intussusception method since 1985 instead of mucosal anastomosis. That successfully decreased the leak. To prevent hepatic failure, patients' indication is decided based on Mizumoto's criteria, among which on our experience ICG RIS, OGTT and total bilirubin are important. In addition the age of a patient should be less than 70. Concernig massive gastrointestinal bleeding after HPD, one was due to an anastomotic ulcer of gastrojejunostomy but the other was impossible to be analysed in spite of autopsy~

43

$3

Complications and managements after pancreatoduodenectomy combined with liver resection for hepat ic and bil iary cancer .

Seiki Tashiro, Tatsuya Tsuji, Tsutomu Oda, Keiichiro Kanemitsu, Yukio Kamimoto, Takehisa Hiraoka, Yoshimasa Miyauch~ The 1st Dept. of Surgery, Kumamoto Univ.School of Medicine, Kumamo, Japan.

Pancreatoduodenectomy combined with liver resection underwent

on 22 patients for hepatic and biliary cancer between October

1,1980 and April 30,1993.A breakdown of individual cases

showed 1 cancer of the liver (cholangioma), 1 cancer of the bile

duct and 20 cancers of the gallbladder. Hepatic resection of more

than 2 segments (Group 1) underwent for 7 patients and hepatic

resection of less than 2 segments (Group 2) underwent for 15

patients with pancreatoduodenectomy.

hepatic resection of more than 2 segments) can be detrimental to

the diseased liver. Therefore, postoperative morbidity and

mortality should be reduced as much as possible by accurate

preoperative assessment and precise postoperative management.

Postoperative complications such as leakage of

hepaticojejunostomy or pancrcaticojejunostomy, abdominal

abscess, lung edema or/and liver failure were observed in 4 of 7

patients (57%) in Group I and 6 o,f 15 patients(40%) in Group 2.

The operative mortality rates were 14.3% in Group 1 and 6.7% in

Group 2, respectively. The morbidity and mortality rates were

increased undoubtedly in Group 1.

Hepatopancreatoduodenectomy (especially associated with

S4

Postoperative complications of hepato-,(ligament-), pancreatoduodenectomy

JUNJI TANAKA, SHIGEKI ARII, KEN-ICHI FUJITA AND MASAYUKI IMAMURA First Department of Surgery, Kyoto University School of Medicine

it is well known that biliary tract carcinomas locoregionally invade into adjacent vessels and frequently involve lymph node metastases, resulting in local recurrence after operation. This clinicopathological features strongly recommend extended surgery such as hepato-,ligament- , pancreatoduodenectomy H(L)PD operation. However, life-thretening complications are not rare in H(L)PD operation. In this report, major complications following H(L)PD operation will be clarified. Patients; In our department, 25 H(L)PD operations were performed in 14 gallbladder, 8 bile duct carcinomas and 3 other diseases for these i0 years, con- sisting of 5 HLPD. Age distribution was between 46 and 73 (mean 65), mainly in 60'th. Results: Extent of hepatic resection was as followed; < one segmentectomy (including central resection), 7 patients: 1-2 segments, 2: bisegmentectmy, 5: extended lobectomy, ii. Reconstruction of alimentary tract was 5 cases in Billroth I (Bil-I) and 20 in Bil-II mode. Vascular reconstruction, artery in 8 patients and portal in 5 patients, was

performed. Operative death was seen in 3 HLPD ( 2 extended right lobectomy and 1 extended left lobectomy) and 1 HPD (left lobectomy) patients and one hospital death was seen in HPD patient. In the 4 death cases, possible main causes were considered to be incomplete arterial reconstruction in 2 HLPD and leakage of pancreaticojejunostomy in 1 HLPD and 1 HPD. Leakage of hepaticojejunostomy was observed in 3 patients, among whom one patient resulted in hospital death 2 months later but another 2 patients could discharge. Intraperitoneal abscess and liver abscess, possibly caused by incomplete arterial reconstruction were also fatal, as indicated by operative death of both patients. Causative bacteria of severe postoperataive infection were pseudomonus, enterobacter, enterococcus and klebsiella, possibly due to prolonged operataion time and leakage of anastmoses~ In conclusion, HPD operation itself is not necessarily dangerous operation. However, successful HLPD can be achieved at least by complete arterial reconstruction.

44

S5

Postoperative Complications after Hepatopancreatoduodenectomy for Biliary Tract Carcinoma

Michio Kanai, Yuji Nimura, Naokazu Hayakawa, Junichi Kamiya, Satoshi Kondoh, Masato Nagino and Masahiko Miyachi The First Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan

Recently, hepatopancreatoduodenectomy (HPD) has been performed for advanced carcinoma of the biliary tract with various degree of success. We analyzed the postoperative complications after HPD retrospectively.

Patients and Methods. Since 1979 major hepatic resection, which was defined as larger than two segments resection of the liver, was performed in 127 patients with advanced carcinoma of the gallbladder or the bile duct. HPD was performed in 24 cases (HPD group) and hepatic resection without pancreatoduodenectomy in 103 cases (H group). Preoperative conditions and intraoperative risk factors which might affect the operative mortality were analyzed. Percutaneous transhepatic portal vein embolization (PTPE) was performed preoperatively in 4 patients of HPD group. Results. The morbidity and mortality rates for patients of

HPD group were 62.5% (15/24) and 41.6% (10/24). These rates were significantly higher than that of H group. HPD group had significantly larger resected liver volume, longer operation time and more amount of intraoperative bleeding than H group. The morbidity rates of hepatic failure, respiratory failure, renal failure, cardiac failure, sepsis and DIC were 42%, 29%, 21%, 13%, 33% and 21%, respectively. Hepatic

failure, occurring in 13 patients, was the most common complication and it progressed to be fatal in 9 patients. In HPD group, the patients with diabetes mellitus led significantly higher morbidity and mortality rates ; 86% (6/7) and 71.4% (5/7). The mortality rate was "also significantly related to elder age. The morbidity and mortality rates for patients with preoperative chotangitis were 100% (4/4) and 75% (3/4), where as they were 33% (1/3) and 0% (0/3) in patients with preoperative PTPE.

Conclusion. It was indicated that most risky factor in patient undergoing HPD was disturbance in glucose metabolism. It was suggested that resected liver volume should be minimized to avoid the hepatic failure, curative hepatic resection should be performed according to the preoperative precise diagnosis of cancer extension, and the cholangitis must be adequately managed before HPD, PTPE might play an important role to reduce the postoperative complications.

S6

POSTOPERATIVE COMPLICATIONS AND MANAGEMENT OF HEPATOPANCREATODUODENECTOMY(HPD)FOR BILE DUCT CANCER YOSHIKAWA TATSUYA, FUJIO HANYU, MITSUJI NAKAMURA, TATSUO ARAIDA, TSUKASA AZUMA, HIROAKI MUTOU, TORU MORIYAMA, MICHIO KOGURE TOKYO WOMEN' S MEDICAL COLLEGE, THE INSTITUTE of GASTROENTEROLOGY,DEPARTMENT OF SURGERY

PATIENTS AND METHODS Postoperative complications and management of HPD in seventy two patients with bile duct carcinoma were evaluated retrospectively.

RESULTS The extent of hepatectomy were as follows;PD with segmentectomy less than bisegment were performed in forty four patients, PD with segmentectomy exceeding bisegment underwent in twenty eight patients. Postoperative complications were occurred in forty four patients (61%), hospital deaths (including operative deaths) were seen in sixteen patients (22%). Postoperative complication and death were reviewed especially on the volume of hepatic resection. The morbidity and mortality rates for patients with less than bisegmentectomy was 50%, 4.5 % respectively, whereas

those of patients wi~h more than bisegmentctomy was extremely high,79%, 50% respectively~ Liver failure was listed as the major cause of deaths in our series.

CONCLUSION It was suggested that minimization of resected liver volume, operating time, bleeding, liver ischemia and secure hemostasis should be essential management during operation to avoid liver failure. Percutaneous transhepatic portal vein embolization (PTPE) might play an important role as preoperative treatment especially for patients exceeding bisegmentectomy. Prevention and elimination intraabdominal abscess was also magnitude as post operative management to avoid liver failure.

45

$7

EXPERIENCES OF COMBINED RESECTION OF LIVER AND PANCREAS FOR BILE DUCT MALIGNANCY AND SOME TRIALS AGAINST ITS COMPLICATION

Takehide Asano, Kazuo Enomoto, Hlroshi Yamamoto, Susumu Kobayashi, Tohru Nagashima, Takeshi Uematsu, Hodaka Amano, Toshio Nakagouri, Osamu Kainuma, Yoshiharu Tokoro, Yoshifumi Matsui, Kazuhiko Jinguh, Hideaki Miyauchi, Michihiro Maruyama, Chikara Iwashita and Kaiehi Isono Department of Surgery (II), Chiba Univ. Chiba, Japan

panereatico-duodenectomy with or without dissection of hepoatoduodenal ligament (HPD or HLPD) seems to bring high curability ratio. Also in our experiences of 21 cases resection (9:bileduct cancer, 10:gall bladder cancer, 2:CCC), 9 out of 9 bile duct cancer, 8 out of i0 gall bladder cancer were radically resected. This procedure seemed to be theoretically an ideal operation for bile duct malignancy which easily extend to both side, liver and pancreas through lymphatic and perineural spaces. The mortality rate of these cases was, however, extremely high (7 out of 21, 33%). These mortal cases was failed due to i) hepatic failure in 4 cases and 2) 2 from arterial bleeding due to leakage of pancreaticoduodenectomy. In this article, our recent efforts against these two major complications are reported. First, for hepatic failure it is necessary to predict precisely the functional liver mass in determining the extent of hepateetomy preoperatively. For this purpose we have used MEGX test

for assessing present functional mass and measuring hepatic protein synthesis rate of needle biopsied specimen for assessing functional liver mass in unit liver. Our clinical study of magnetic resonance spectroscopy showed enzyme activity recovery of hepatic cell in jaundice cases delayed even after free from jaundice. Therefore, MEGX test recovery was especially important to proceed safe combined resection. In the cases of combined dissection of hepatoduodenal ligament, preserving hepatic arterial flow came to be difficult. For these cases we tried to use portal arterialization to avoid hepatic cell dysfunction in early post operative periods. Second, for the problems from leakage of pancreatieo-jejunostomy, in certain cases, we abandoned anastomosis and made pancreato fistula using sprint tube into the pancreas duct covered pancreas with condom, then made fistero-jejunostomy after certain period. We will discuss our result of some trials in this presentation.

$8

Problems and management for performing "Hepato-ligamento-pancreatectomy" 1. Double portal vein bypass for ligamentectomy 2. Metabolic disorders derived from hepato-pancreatectomy

Hisashi Mimura, Keisuke Hamazaki, Hiromu Tsuge, Noriyuki Kawada, 1st Dept. of Surgery, Okayama Univ. Med. Sch., Japan

Advanced bile duct carcinoma implies carcinoma of the hepatoduodenal ligament often involving the liver, pancreas or the both. Therefore, removal of the whole hepatoduodenal ligament; ligamentectomy (L), hepato-ligamentectomy (HL), ligamento-pancreatectomy (LP) or hepato-ligamemo- pancreatectomy (HLP), would be the most potential methods for radical removal. We experienced 17 cases of ligamentectomy (HL8, LP6, HLP3) for carcinomas of the bile duct and the pancreas. On the other hand, hepato-pancreatectomy (HP) was performed in 3 cases with ligamentectomy (HLP) and in 11 cases without ligamentectomy. In ligamentectomy, double catheter bypass, a combination of the pump-controlled bypass from the femoral artery to the portal vein for maintaining hepatic circulation and the passive porto-systemic bypass for avoiding portal congestion, has been devised and effectively used under general heparinization. O2-saturated arterial bypass flow for the liver was maintained between 300-600ml/min. and the bypass pressure was monitored. Regarding the most effective flow rate, the study was performed in the similar models in dogs. From the view point of energy charge, Pto2, pathologic change of the liver and systemic circulatory dynamics, it was found in safe 20-75% of normal hepatic flow.

In clinical HP, operative mortality was extremely hige, 6/9 (66.7%) in major hepatectomy, which suggested HP with major hepatectomy should not be applied for the patients unless any innovated management arround sugery being introduced. We observed early hepatic metabolic changes after HP compared with sole hepatectomy or pancreatectomy in rat models. After HP, caloric supplement by high dose of glucose and insulin caused early high mortality accompanied by severe elevation of blood insulin level with hepatic glucokinase activity and microscopically massive vacuolation appeared in the liver. However, in sole hepatectomy or pancreatectomy, these changes were slight and early mortality was few.

46

Panel discussion

P2

Intrahepatie cholangiocarcinoma: a proposal of macroscopic classification

Junji Yamamoto, Susumu Yamasaki, Tomoo Kosuge, Kazuaki Shimada, Tadatoshi Takayama, Hideo Ozaki Department of Surgery, National Cancer Center Hospital, Tokyo, Japan

Background and Methods. To find the rational therapeutic strategy for the intrahepatic cholangiocarcinoma(ICC), clinicopathological features of ICC were studied in 26 patients who underwent hepatic resection in the National Cancer Center Hospital from 1980 to March 1993. According to the morphologic pattern, we classified the ICCs into three subcategories, mass-forming type (19cases), infiltrating type (5 cases) and papillary type (2 cases). Results. Mass-forming ICC, which made an apparent mass lesion in the liver, showed a spread based on the intrahepatic metastasis with a frequent remnant hepatic recurrence and distant metastases. Infiltrating ICC caused a stricture or an obstruction of intrahepatic bile duct with a spread along the glissonian sheath without forming a mass in the liver and yielded no remnant liver recurrence except for a local recurrence in the patient with positive surgical

margin. Papillary ICC, which was a special type of ICC with less invasive features than other types, developed a papillary growth into the bile duct lumen. Of 19 patients who underwent hepatectomy for mass-forming ICC, three survived more than 5 years without recurrence. The 1-,3-, and 5-year survival rates were 60.6%, 53.9%, and 40.4%, respectively. The 1- and 3-year survival rates of 5 patients with infiltrating ICC were 100% and 75%, respecticvely. Two patients with papillary ICCs showed no signs of recurrence and one of them survived more than 5 years. Conclusions. The different biologic behaviour should be considered when formulating an operative procedure for each type of ICC.

P3

Intrahepatic bile duct carcinoma -- It's growth and invasive patterns --

Tsutomu Tomioka, Yoshito Ikematsu, Shunichi Matsukawa, Yoshitsugu Tajima, Makoto Sasaki, Tohru Segawa, Tsukasa Tsunoda, Takashi Kanematsu The Second Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan

Intrahepatic bile duct carcinoma is one of the malignant carcinomas of the digestive system. However, it's pathogenesis is still unclear. To clarify the early growth and invasive patterns of the bile duct carcinoma, we investigate early stage of intrahepatic bile duct carcinoma of the hamster models, comparing with the tumor in the human.

< Materials and methods > Forty-four cases of human intrahepatic bile duct carcinomas were analized clinically. Resected liver specimens of 19 cases were examined pathologically. A total of 142 female Syrian golden hamsters were first subjected to cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct. Then, those were treated with weekly subcutaneous injections of N-nitrosobis (2-oxopropyl) -amine (BOP) at a dose of 10mg/kg body weight to produce bile duct carcinomas. Finally, 273 intrahepatic bile duct carcinomas were pathologically analized.

< Results > In human, 7 cases showed peripheral type and 32 cases were hilar type. In 5 of 19 cases (26.3%), one case of peripheral type and 4 cases of hilar type, papillary growth pattern was evident. The remaining 14 (73.7%) showed tubular pattern surrounding tissue pathologically. In animal, 273 tumors were classified as follows; 245 tubular adenocarcinomas, 8 papillary adenocarcinomas, 7 mucinous adenocarcinomas, 6 cystadenocarcinomas and one clear cell carcinoma. All cases of papillary adenocarcinoma showed intra ductal papillary growth pattern like human cases of hilar type. Tubular adenocarcinoma showed massive growth pattern with central necrosis like peripheral type of human cases. < Conclusions > i. Peripheral type of intrahepatic bile

duct carcinoma mainly showed tubular and massive growth pattern.

2. On the contrary, hilar type showed papillary and tubular pattern.

3. If the tumor showed papillary growth pattern, the original site of the tumor might be large bile ducts.

47

P4

Clinicopathological Features of Cholangiocellular Carcinomas in 32 Surgically Treated Patients

Naoki Yamanaka, Eizo Okamoto, Tsuyoshi Oriyama, Tatsuya Andoh, Kazutaka Furukawa The let Dept. of Surgery, Hyogo College of Medicine, Nishinomiya, Japan 663

Cho!angiocellular carcinoma(CCC) occurs much l e s s f r e q u e n t l y than h e p a t o c e l l u l a r carcinoma (HCC) in Japan as well as in most parts of the world. Early detected cases are rare and prognosis is generally poor compared with HCCs. There have been few reports concerning details on patients undergoing hepatic resection for CCC. This study reports clinicopathological features for CCC, which are quite different from those of HCC, using the surgically treated cases. Materials and Methods: During the period from 1976 through 1992, 32 CCC patients who had hepatic resections entered the present study. This population excludes cases which were hardly discriminated from hilar duct cancers and cystoadenocarcinomas. 18 (56%) of all were men and mean age was 59 years. Eight (30%) had intrahepatic stones or preivious history of biliary tract operation. Most of them showed space-occupying liver lesions excepting one patient in whom CCC was associated with intrahepatic stone. Eleven of 32 had juandice, and the remainings were juandice-free, 80% of whom had high alkaline phosphatase values. CEA was positive in 3Z% and CA19-9 in 67~.

Incidence of coexisting chronic liver disease was 15%. Type of surgery; Segmentectomy or wedge resection in 8, left lobeetomy in 15, central lobectomy in 4, right lobectomy in 4, right trisegmentectomy in one. Reconstruction of VCI was performed in one and hepaticojejunostomy in 9. Nodal metastasis was positive in 19 (59 %). Results: Surgical motality was found in four with liver failure or severe eholangitis leading to sepsis. Complete resections were employed on 13 of 82 (41%). Recurrent sites included intrahepatic lesions alone in one, extrahepatic lesions alone in 2 (lymphnodes), and both in 8. Therapies for recurrences consisted of systemic chemotherapy, radiation, arterial embolization and resection, which were much less effective as compared with those for recurrences following hepateotomy for HCC. Cumulative survival rates were 0% at one year for incomplete resections and 15% at 5 year for complete resections. Conclusion: Recognition of high risk group for CCC and early detection will be mandatory to improve long-term results.

P5

Clinicopathologica! Study on Eight Resected Carcinoma of the Intrahepatic Bile Duct

Takeshi Todorokir Toru Kawamoto, Kazuo Orii, Katashi Fukao, Yukihisa Saida* Department of Surgery and *Radiology, Institute of Clinical Medicine, University of Tsukuba

The detection of patient with intrahepatic bile duct cancer (IHBDC) have been increasing in number by recent advances in image diagnostic technology. However, the diagnostic improvements have not reflected to the surgical results of the disease, which has a dismal prognosis.

Since 1976, thirteen patients with IHBDC were treated in our department. Out of them, eight patients underwent surgical resection and the remaining five had too advanced tumor to be resected. Seven of the resected patients had hilar type tumor, which originated from bile duct between the second and the third bifurcation of the intrahepatic bile duct in either hepatic lobe, or from the twig of the intrahepatic bile duct in the hepatic hiluxn. The remaining one had peripheral type tuanor grown out of the bile duct more peripheral than the third bifurcation. Out of seven patients with hilar type tumor, four patients performed hepatic lobectomy with hilar bile duct resection (HBDR) ~ two patients have done hepatic segmentectomy (segment I, IV and V) in

addition HBDR and the remaining one had HBDR alone. For one patient with peripheral type tumor in segment VI underwent segmentectomy. Following tumor resection, four patients have been alive for 62 months, two months, one month and two weeks at the present. In this paper, clinicopathological characteristics of the eight resected IHBDC would be analyzed and a possible improvement in prognosis of this disease.

48

;)6

Peripheral cholangiocarcinoma- Clinical aspect in correlation wi th the gross appearance and spreading pattern

Masakazu Yamamoto, Ken Takasaki, Takehito Ootsubo,Hideo Katsuragawa, Chifumi Maruyama, Tatsuya Yoshikawa,Mitsuji Nakamura, Fujio Hanyu Institute of gastroenterology, Tokyo Women's Medical College

The clinical and pathological features of thirty-five patients with peripheral cholangiocarcinoma are reported. All patients underwent hepatic resection, According the gross appearance, per iphera l cholangiocarcinoma was sub classified into th ree groups, nodular type(n=31 ), multiple conf luent nodular type(n=3 ), p ro t ruded Wpe(n= I). These three types tumor differed in thei r clinicopathological findings, spreading pattern of the tumor in the liver and consequently prognostic course, At the same time denomination for each spreading pa t t e r n was proposed, Simple type(S- type)showed well-defined tumor predominantly with direct intrahepatic invasion via sinusoidal spaces(n= i0). Intrahepatic metastatic type(IM type) - revea led satellite nodules around the main t umor (n= l I ). Main portal tract invasive type(Pl type) - displayed nodular tumor which cont inued into the portal tract and spreaded towards the hilum of the l iver(n=l 4), Concerning the spreading pattern of the tumor in correlation wi th gross appearance following results were obtained. Nodular type revea led S-type (n=l 0 ) , IM- type (n=8) and Pl - type (n= 13), Multiple conf luent nodular type presented only IM type(n=3) and Pro t ruded type only P l - type (n= 1 ).

S type showed female predominance while o ther types had male predominance. Average age of IM type was 56 years but for S and Pl types was older(over 60 years) , Mean tumor size of IM type was largest(8.5cm) followed by S type(5.8cm) and PI type(4,5cm). Pat ients w i th S and IM type tumor were asymptomat ic and found incidenta l ly at rout ine fol low-up for chronic hepati t is , On the o ther hand PI type was accompanied by icterus in 57%. Major hepat ic surgery was pe r fo rmed in all the cases, In addi t ion PI type was supp lemen ted wi th bile duct reconstruction(86%). Lymph node metas tas is were most f r e q u e n t in PI type(71%), Portal ve in thrombosis was f r e q u e n t in IM type (64%) whi le other types revealed in few cases. Pl type was f r e q u e n t l y complicated with local recurrence, abdominal dissemination and lymph node metastasis . In t r ahepa t i c and remote organ metastas is t ended to occur more frequently in IM type tumors . In conclusion S type had good clinical course following operat ion bu t PI and IM types had poor prognosis, I t appears, t ha t previously proposed classification based on the gross appearance and spreading pattern of the per iphera l cholangiocarcinoma is considerably appropr ia te concerning clinicopathologic f indings which differed in each type,

P7

Clinical Features and Diagnosis of Cholangiocarcinoma with Emphasis on Diagnostic Imagings.

Hiromitsu Saisho, Masatoshi Sumita, Shuichi Okada, Toshio Tsuyuguchi, Yukihiro Tsuchiya, and Masao Ohto. The ist Dept. of InternAl Med., Chiba Univ., Chiba, Japan

Cholangiocarcinomas (CCC) are intrahepatic malignant tumors composed of cells resembl- ing those of biliary epithelium. These may be massive, nodular, diffuse and rarely cystic in the gross configuration. Some- times, papillary form grows in larger ducts. While Clonorchis sinensis, intrahepatic calculi, and hemochromatosis may be responsible for the etiology, CCC often arises in the liver without such risk factors. In general, the clinical stage of the tumor has been advanced when the patients visit doctors.

We studied the clinical, laboratory and radiological data of 46 patients with CCC diagnosed so far in our department and affiliat- ed hospitals to clarify the clinical features and the radiological findings with special reference to ultrasound (US) and computerized tomography (CT).

At the time of admission, these patients mostly complained one or more of classical symptomes such as pain, icterus and weight loss. Recently, some non-symptomatic patients were picked up by abnormality in the laboratory data at blood donation or mass medical

examination. Laboratory tests usually indicated bile stasis, while CEA and AFP values were scarcely remarkable.

Diagnostic imagings revealed three different pathologic configurations as follows: i) parenchymal type presented with a hepatic solid mass (38 patients), 2) bile duct type with outstanding intrabiliary abnormality(6)~ 3) cystic type with multilocular cysts (2). Nonetheless, in the case of CCC combined with intrahepatic calculi, the diagnosis was a challenging problem.

Differential diagnoses of this tumor from hepatocellular carcinoma, metastatic liver cancer, bile duct carcinoma of the bifurcation, gallbladder carcinoma, and hepatic hemangioma could be made correctly on the basis of comprehensive knowledge of the clinical, laboratory, and radiological features.

The early detection and diagnosis of the tumor must be the problem to be solved. The applications of peroral chlangioscopy and intraluminal ultrasound may be expected for the early diagnosis.

49

P8

Tumor Growth and Surgical Treatment of Cholangioeareinoma

Kazuhiro Hirohashi, Hiroaki Kinoshita, Shoji Kubo, Hiromu Tanaka, Tadashi Tsukamoto, Hiroyuki Hamba, Taichi Shuto, Shigekazu Takemura, Kazuo Ikeda, and Toyokazu Okuda 2rid Dept. of Surg., Osaka City Univ., Osaka, Japan

From 1981 to 1992, we performed 24 hepateetomies for choiangiocareinoma, defined as carcinoma of the bile duet developing in the periphery of the first bifurcation of the hepatic duct. We classified cholangiocarcinoma into two types macroscopically. The solid type was found in 14 patients (a localized mass in 7 patients, an infiltrating mass in 5 patients, infiltration without formation of a mass in 1 patient, a papillary growth in the hepatic duet in 1 patient) and another type was found in 10 patients (with hepatolithiasis in 7 patients, with cancerous changes in the dilated intrahepatie bile ducts in 3 patients). Cholangiocareinoma of the solid type was next classified into two kinds according to its location: the peripheral type, arising peripheral to the third branches of the hepatic duct (9 patients), and the hilar type, arising from the second branches (5 patients).

Twelve (86%) of the 14 patients with cholangiocareinoma of the solid type had upper abdominal pain, general fatigue, or weight loss, and 2 (40%) of the 5 patients with the hilar type had developed jaundice. Serum levels of carcinoembryonic antigen (CEA) were high in 7 (50%) of the 14 patients with cholangiocarcinoma of the solid type. Of the 9 patients with the peripheral type of cholangiocarcioma, 7 patients had a localized mass and 2 patients had an infiltrating mass. Of the 5 patients

with the hilar type, 3 patients had an infiltrating mass, 1 patient had infiltration without a mass, and 1 patient had a papillary growth in the hepatic duct. Cholangiocarcinoma of the peripheral type grew into adjacent organs in 3 patients and gave rise to intrahepatic metastases in 3 patients, In 4 of the 5 patients with the hilar type, there was growth into the hepatic hilum. For the solid type, the hepatectomy involved trisegmenteetomy in 3 patients, extended bisegmentectomy in 4 patients, bisegmentectomy in 4 patients and segmentectomy in 3 patients.

All 7 patients with hepatolithiasis presented with cholangitis, and 4 had high serum levels of CEA. Six of these 7 patients were first diagnosed histologically from surgical specimens. The cholangiocarcinoma was in the left lobe ia all 7. The hepatectomy involved bisegmentectomy in 6 patients and segmentectomy in 1 patient.

The 3 patients with cancerous changes of the dilated intrahepatic duct presented with upper abdominal discomfort. All patients underwent left bisegmentectomy with the caudate lobe.

The 1-, 3-, and 5-year survival rates of the 24 patients after hepatectomy were 51%, 36%, and 36%, respectively The longest survival to date was 7 years 8 months, and this patient, who had cholangiocareinoma of the peripheral type, is still alive and well without recurrence.

Video symposium vs1 Newly devised anastomosis of proximal and distal portal vein reconstruction

Satoshi Nakamura, Raisuke Nishiyama, Hiroyuki Konno, Shozo Baba The Second Dept. of Hamamatsu University School of Medicine, Hamamatsu, Japan

Portal vein reconstruction improved the resectability in many patients with ,hepatic; bilim'y and pancreatic cancer. However, vein reconstruction has many factors of anastomotic difficulties in the anastomosis. Material and methods) We performed proximal portal reconstruction (PPR) for cancer invasion to the hilum in 19 patients, consisted of 2 with hepatocelluar carcinoma, 1 with hepatic metastasis, 6 with gallbladder carcinoma, 5 with cholangio-cellular carcinoma and 5 with hilar bile duct carcinoma. Distal portal reconstruction (DPR) for 18 patients with pancreatic cancer was performed. In PPR, since there is a great difference in diameter, we performed an insert anastomosis between two veins, in which the liver-sided thin vein had a 1-cm slit and another great vein had a process to insert into the slit of the liver-sided vein. In DPR for 2 of the 18 patients, two thin branches of superior mesenteric veins were formed like a trousers and a 8-cm segment of an iliac vein was interposed between the portal trunk and the formed superior mesenteric vein. In the remaining 16 patients undergoing DPR, an end-to-end anastomosis was performed with normal method. Three patients with PPR had an autologous vein graft of iliac vein. Four of the 5 patients with DPR had an autologous vein graft, and the remaining one had a reversed Y-typed Gore-Tex graft. In vein anastomosis, 5-0 ticron or 6-0 monofilament strings were used with an interrupted suture. Eight patients undergoing PPR had

portography in early period and 5 had in late period after surgery. Eight patients undergoing DPR had portography one month after surgery. Results) One patient with PPR and one with DPR died of hemorhagic shock 3 days and 12 days postoperatively, respectively. However, there were no operative deaths due to portal reconstruction. All 8 patients had patent anastornosis in early periods after PPR, but one had stenosis at the anastomotic portion. Occlusion due to cancer recurrence in one of 5 patients with PPR

was observed in late periods after surgery. Six of the 8 patients undergoing portography after sugery showed stenosis due to tension in one, artificial graft in one, inflammation in one and unknown causes in three patients, including two patients undergoing forming of two branches of superior mesenteric veins. Discussion) Patency rate in PPR was excellent, hut not in DPR. DPR showed stenosis due to various causes. Gore-Tex graft was considered not to be suitable because of different compliance between the graft and vein. In one patient with forming two branches of superior mesenteric vein, although a great anastomotic orifice was intraoperatively confirmed, stenosis was observed at anastomotic site. A suitable tension may be necessary for reconstructed veins. Conclusion) Insert anastomosis is a usefui technique in PPR. DPR should be performed carefully to prevent stenosis.

50

VS2

Hepatic Artery Reconstruction in Surgery of Carcinoma of Biliary Tracts

Yoshifumi Ogura, Masami Tahata, Koji Takahashi, Masayoshi Ido, Shuji Isaji, Hajime Yokoi, Takashi Noguchi, Yoshifumi Kawarada and Ryuji Mizumoto The ist Dept. of Surgery, Mie Univ., Tsu, Japan

In recent years, hepatic artery reconstruction has become one of the important steps in the procedures of radical resection for carcinoma of biliary tracts. We present our technique of the hepatic artery reconstruction in this videotape.

Case I: A 62 year-old female was diagnosed as Stage IV carcinoma of the gallbladder with invasion to the hepatoduodenal ligament. Thus, she underwent extended right hepatic lobectomy and pancreaticoduodenectomy with combined resection of the hepatoduodenal ligament including the hepatic artery and portal vein. Vascular reconstructions were performed for the left hepatic artery and left branch of the portal vein. The left hepatic artery was successfully anastomosed with the left gastric artery in end-to-end fashion under magnifying scope.

Case 2: A 88 year-old female was diagnosed as Stage IV carcinoma of the hepatic duct confluence with invasion to the right hepatic artery. Thus, she underwent hilar hepatic resection and combined resections of the caudate lobe and the right hepatic artery. The resected right hepatic artery was about 2 cm in length, which included the site of cancer invasion. The arterial reconstruction was performed in end-to-end anastomosis using microsurgery technique.

VS3 Portal Vein and Hepatic Artery Resection using Catheter-Bypass of the Portal Vein Akimasa Nakao, Hiroshi Takagi Dept. of Surgery 11, Nagoya University School of Medicine, Nagoya, Japan

The combined resection of the portal vein or hepatic artery is sometimes necessary during radial surgery for hepatobiliary and pancreatic cancer. We developed an antithrombogenic bypass-catheter for the portal vein using heparinized hydrophilie polymer (Anthron | Toray) which, when used between mesenteric and femoral or intrahepatic portal veins, can prevent portal congestion or hepatic ischemia during portal vein occlusion or simultaneous occlusion of the hepatic artery.

In this video, we show three operations. The first is isolated pancreatoduodenectomy accompanied by portal vein resection for pancreatic head cancer using catheter-bypass between mesenteric and femoral veins. The second is distal panereatectomy accompanied by portal vein and common hepatic artery using catheter-bypass between mesenteric and hepatic hilar portal vein. The third is hepatic extended right lobectomy combined with pancreatoduodenectomy accompanied by portal vein resection using catheter- bypass between mesenteric and umbilical vein. Portal vein is reconstructed by end-end anastomosis or autograft of the external iliae vein. Hepatic artery is reconstructed by end-end anastomosis or autograft of the greater saphenous vein.

One hundred fifteen portal vein resections were performed in hepatobiliary and pancreatic surgery be-

tween July, 1981 and March, 1 9 9 3 , using the catheter-bypass method. The length of the resected portal vein segment ranged from 8 to 80 mm (mean, 35 mm). Occlusion time of the portal vein ranged from 20 to 302 min (mean, 83 rain), and no adverse effects attributable to the bypass-catheter were observed.

Portal vein resection and reconstruction during hepatobiliary and pancreatic surgery couid be performed with safety and ease using catheter-bypass of the portal vein.

51

VS4

Combined Resection of the Portal Vein for Pancreatic Cancer

Takukazu Nagakawa, Keiichi Ueno, Tetsuo Ohta, Masato Kayahara, Yutaka u Yuhkei Suzaki, Yuhji Tukioka and Itsuo Miyazaki The IInd Dept. of Surgery, School of Medicine, Kanazawa Univ. Kanazawa, Japan

Extended pancreatoduodenectomy followed by a translateral retroperitoneal approach have been gradually performed for pancreatic cancer since 1973. Main policy of surgical resection of pancreatic carcinoma is a complete lymphatic excision surrounding the celiac artery and the superior mesenteric artery including dissection of the nerve plexus and a vide retroperitoneal dissection surrounding the pancreas, upwards to the level of the adrenal glands and downwards to the level of the i l iac biufurcation. The portal vein is resected with this lymphatic excision. Among the 69 cases, curative resection was performed in 53 cases. Histologically curative resection was done in 34 cases. Eight cases died within one month. Eleven patients have survived for 3 years or more (35.8%). Nine patients have survived for 5 years or more. The 5 years survival rate was 32.2% in curatively resected cases and this becomes 27.4% if including operative deaths. Accord- in% to cancer stage, the 5 years survival rate showed 75.0 % in stage I, 56.0% in stage iI, 21.2% in stage III and 0 % in stage IV. Histological evalutions were done according to the General Rules of Pancreatic Cancer in Japan. According to tumor size, the 5 years survival rate showed

66.7% in t l (under 2 cm), 18.0% in t2 (2-3 cm), and 46.7% in t3 (4-6 cm). There was no difference between the groups of tumor size. According to the invasion of the retroperitoneal tissues behind the pancreas, the 5 year survival rate showed 80.0% in rpO and 16.5% in rpe. All patients with cancer invasion to the portal vein died within 2 years. According to the invasion of the external wall, the 5 year survival rate showed 68.8% in ewO and 20.5% in ewl (positive invasion within 3 mm from cancer edge, and 0% in ew2 (definitely positive invasion). Among the 45 macroscopiealty curative cases, 16 cases were microscopic- al ly noncurative. As for lymph node metastases, the 5 year survival rate showed 71.5% in nO, 17.5% in nl and 0% in n2 or n3. These findings suggest that pancreatic cancer should be resected microscopically curatively for long survival. So we speculate that combined resection of the portal vein may be important for curative resection of panereaic cancer. In this video, an operative technique of retroperitoneal lymph nodes dissection and combined resection of the portal vein will be designed.

VS5

Extended radical Whipple operation with portal resection for carcinoma of the head of the pancreas.

T. Imaizumi, F. Hanyu, M. Suzuki, T. Nakasako, N. Harada, 2". Arai, T. Hirose, A. Fukuda, S. Munakata and F. Ozawa. Department of Surgery, The Institute of Gastroenterology, Tokyo Women's Medical College. Tokyo, JAPAN

From Jan. 1968 to Dec. 1992, 266 patients with ductal adenocarcinoma of the head of the pancreas underwent radical resection with resectability of 42% in our department. 198 patients had an extended radical Whipple operation, including regional lymphadenectomy and dissection of the retroperitoneal nervous plexus in 162 (82%), resection of the portal vein in 120 (61%). Of the 120 portal resections 105 patients were reconstructed by end-to-end anastomosis, 5 had Gore-tex graft, and 10 received additional resection of the hepatic or the superior mesenteric artery.

Mean clamping time of the portal vein in the operation were 28 minutes (10 to 65 minutes) and mean length of the resected portal vein were 3.1 cm (2 to 7 cm) . Neither portal by-pass nor clamping the superior mesenteric artery were necessary. Operative death were 5 patients, 2 were liver insufficiency, 2 were liver or abdominal abscess, and 1 was intraabdominal hemorrhage. Postoperative histopathological study revealed the tumor invasion to the portal vein in the 65% of the 120 patients who had the portal vein resection.

One and 3 year survival rates were 60% and24% in the patients who had curative resection by extended radical Whipple operation. 10 patients survived more than 5 years postoperatively, 4 had had the resection of the portal vein. Extended radical Whipple operation with portal vein resection can provide long term survival for the patients with ductal adenocarcinoma of the head of the pancreas. Operative methods and techniques are shown in this video.

52

Video session

V1

Laparoscopic Biliary Surgery: Some Tips for a Safe Operation

Hideo Nagai, Yasuo Kondo, Toshihiko Yasuda, Toshimitsu Ishibashi, Kogoro Kasahara, Kyotaro Kanazawa Department of Surgery, Jichi Medical School, Tochiqi, JaDan

Since October 1990 we have performed 176 laparoscopic cholecystectomies, 12 of which were combined with laparoscopic choledocho- lithotomies. Most of the laparoscopic operations were done with the abdominal wall- lift method developed by the authors. Four cases of 164 cholecystectomies without cho- ledocholithotomies were converted to open surgery due to bleeding, bile duct injury, and gallbladder cancer. Minilaparotomy was used for T-tube insertion in 2 cases of 12 cholecystectomies with choledocholithoto- mies. From these experiences, we consider that the following tips might be useful for a safe laparoscopic biliary surgery: 1)Hold up the gallbladder (GB) neck, not the fundus before ligating (clipping) the cystic duct. Elevation of the fundus tends to let small GB stones enter the bile duct. 2)Start dissection of Calot's triangle from the lower part of the GB neck, and expose the uppermost portion of the cystic duct. An attempt to expose the middle portion of the cystic duct from the first may result in an injury to the bile ducts or an unin- tentional ligation of an "accessory" duct joining the cystic duct.

3)Be sure to perform intraoperative cholangiography. Cannulation should be from the uppermost portion of the cystic duct in order to avoid an injury to the bile ducts. 4)Insert a small-calibered deflectable fi- berscope (BF-N20, 2mm) through the cystic duct, if you are not certain whether a shadow defect in the bile duct is a stone or an air bubble. 5)Try to remove choledochal stones through the cystic duct with a small choledocho- scope (URF-P2, 3.3mm). If that fails, open the common bile duct. T-tube insertion and suture of the bile duct wall are much easi- er in the abdominal wall-lift method than in the peritoneal insufflation method. 6)Remove incarcerated stones in the neck or in the cystic duct at first, if the preop- rative cholangiography shows a necative GB. Incarcerated stones often cause marked inflammation and obscure the anatomy. Per- form intraoperative cholanglography from the room made by removal of the stones. 7)Make use of an abdominal wall-lift method, which enables us to effectively use an aspirator on encounter with an abrupt bleeding.

V2

Laparoscopic surgery for choledocholithiasis -A case of exploratory choledochotomy,T-tube drainage and postoperative cholangioscopy-

Yasuro Ishikawa,Ichiro Konagaya,Teturo Naoe,Hitoshi Amano,Hisashi Kasugai,Shigeru Sakai Nobuyasu Kano,Tatsuo Yamakawa Department of surgery,Teikyo University Mizonokuchi Hospital

For the surgical treatment of CBD stones, laparoscopic approach is a treatment of choice when it isthought to be possible.Indi- cation of laparoscopic approach and the selection of patients age,general condition, complication and the history of upper abdominal surgery,and so on.Especially,preoperative cholangiopancreatography(ERCP) is most imprtant to decide an adequate method of treatment.Laparoscopic cholecystectomy combined with preoperative sphynctectomy(EST) and endoscopic lithotripsy is first choice for the case in which preoperative ERCP is successfully performed.Laparoscopic cholecystectomy and transcystic CBD exploration or choledochotomy for lithopripsy of CBD s- tones is indicated for the case in which p- reoperative ERCP had been feiled or whose CBD stone is too big in size or confluenced. In the former case,T-tube drainage is ness- essary for the procesude of postoperative remnant stones.On the other hand,in the la- tter case,postoperative transpapillary lithotripsy for residual stones is possible w- ithout T-tube port,but number of the patients for whom it is possible is limited because of reliability of intraoperative inte-

rvention. In some patients,T-tube must be in place to ensure ductal cleansing with postoperative cholangioscopy. 19 cases of choledocholithiasis was successfully treated by laparoscopic approach.17 c- ases of them were treated with preoperative or postoperative EST and the others with CBD exploration.One case had a big CBD atone,3cm in diameter.Therefore laparoscopic cholecystectomy,choledochotomy for lithotripsy and T-tube dramnagewere performed,and postoperative cholangioscopy through T-tube port was done to ensure ductal cleansing.The operatio n of this case is detailed at the presentation.

V3

Laparoscopic Surgery for Choledocholithiasis

Nobumi Tagaya, Mitsuo Kaneko, Kazutoshi Takagi, Makoto Itoh, Hiroaki Kogure and Yoshio Tajima The 2nd Dept. of Surg., Dokkyo Univ., Tochigi, Japan

Laparoscopic surgery for choledocholithiasis has been getting wider acceptance these days. We tried laparoscopic surgery for 8 cases ( 7 cases of cholecystocholedocholithiasis, one case of choledocholithiasis ) with good results and report this surgical procedure by VTR. We successfully performed removal of common duct stones in 7 cases; the procedures included transcystic ductal choledocholithotripsy in 3 cases, choledocho tomy in 3 cases, percutanous transhepatic cholangioscopic lithotripsy in one case. In another one case, we were unsuc cessful in the approach of transcystic duct for the separation of the cystic duct. The indication of operative procedures are transcystic duetal approach for those cases of up to 2~3 common duct stones with the maximal diameter of 5 mm and choledochotomy for other cases with T tube drainage unless the preoperative PTCD tube has been inserted.

53

V4

Laparoseopie doom resection for liver cyst

Hideo Yamamoto*, Yuji Nimura, Naokazu Hayakawa*, Jtmichi Kamiya, Satoshi Kondo, Masato Nagino, Katsura Hamaguchi, Shunichiro Komatu*, Dept. of Surg., Tokai Hospital*, The 1st Dept. of Surg., Nagoya University, School of Medicine

The successful application of taparoscopic surgery to gallbladder disease and acute appendicitis has encouraged surgeons to manage other gastrointestinal diseases. A case

performed laparoscopic doom resection for benign liver cyst is reported.

The patient is a 58-year-old female with complaint of epigastric discomfort for a few years. A liver cyst was pointed out on abdormnal computed tomography (CT) at near hospital and she was referred to our hospital for further investigations because of continous symptom. The all laboratory investigations on admission, including serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9), indicated no abnormalities. Abdominal c r and ultrasonography showed a multilocular liver cyst in the left lateral segment of the liver. Percutaneous transhepatic cyst drainage (PTCD) was carried out for a liver cyst containing serous fluid. Percutanous transhepatic cholangioscopy (PrCS) demonstrated no protruding lesions and biopsy specimens revealed no malignancy. After making diagnosis of benign liver cyst, laparoscopic doom resection was carried out. Postoperative course was uneventful

and she was discharged 10 days after surgery. In conclusion, laparoscopic doom resection is advantageous for benign liver cysts.

54

Y5

Laparoscop ic dis ta l pancrea tec tomy in the canine model

Masayuki Yoshida and Taizo Kimura

The 1st Dept. of Surg., Hamamatsu Univ. Sch. of Med., Hamamatsu, Japan

The purposes of this exper iment were to examine

the feas ibi l i ty and safety of laparoscopic distal

p a n c r e a t e c t o m y .

A dog weighing 11 kg was used under general

anesthesia. Four trocars (10 ram, 12 nun, 5 m m x

2) were inserted for laparoscope (45 degree) and

ins t rumenta t ion . The s tomach and omen tum was

l i f ted up to expose the left pancreas (the distal

pancreas in humans). The left pancreas was

d issec ted f rom the deeper layer of omentum.

The vessels f rom the splenic artery and vein

were d iv ided using endo-c l ips . These procedures

were p roceeded unti l anter ior p a n c r e a t i c o -

duodena l ar tery appeared. Then, the lef t pancreas

was separated using a single firing of a 30 m m

endo-s tapler . There was no b leeding f rom the cut

end of the pancreas. The entire procedure

Free paper

F1 Cl lncal Eva lua t ion of HepatopancreatoduodenectoBy

Koulchlro Tsugawa, Kohjl Konlshl , Osamu Takada, Takuya Nagata, Fumio Futagaml, S e l i c h i Yamamoto, Kl ich l Maeda, Kazuhisa Yabushlta, Yoshltaka guroda and Masahiko Tsuj i Department of Surgery, Toyama Centra l P r e f e c t u r a l Hosp i t a l , Toyama, Japan

From March 1983 to June 1991, hepatopancreato-

duodeneetomy (HPD) was performed in 13 cases .

Major hepa t i c r e s e c t i o n in which more than two

segments were r e sec t ed was performed in 4 cases .

Minor hepa t ic r e s e c t i o n in which l e s s than two

segments were r e sec t ed was performed in 9 cases .

Eight p a t i e n t s had g a l l b l a d d e r cancer , two

p a t i e n t s had pancrea t i c cancer, and th ree

p a t i e n t s had g a s t r i c cancer. Operat ive m o r t a l i t y

r a t e was 15.4~ in a l l HPD cases . Pos topera t ive

compl ica t ions were occurred in 8 cases (61.5~) ;

Hepatic f a i l u r e (2 cases ) , Renal f a i l u r e (2

cases ) , Leakage of pancreatojejunostomy (2

cases ) , Bi le leakage (3 cases ) , I n t r a p e r i t o n e a }

hemorrhage (1 case) , I n t r a p e r i t o n e a l abscess (1

case ) , Liver abscess (1 case) , Sepsis (1 case ) ,

lasted one hour. The dog did not lose his weight

at the t ime of sacrif ice (2 weeks after the

opera t ion) . I n t r aabdomina l f inding showed no

pancreat ic ju ice leakage f rom the stump of the

p a n c r e a s .

These resul ts sugges t that l aparoscopic

panc rea tec tomy in the canine model is feas ib le

and safe. Therefore, i t may be possible to

pe r fo rm lapa roscop ic d is ta l pancrea tec tomy in

h u m a n s .

Disorder of blood coagula t ion (2 cases ) , and

Hyperammoninemia (2 cases ) . The incidence of

pos tope ra t ive complicat ion was 55.6~ and

ope ra t ive m o r t a l i t y r a t e was 11.1~ in minor HPD

cases , however, these were 75g and 25~ in major

HPD cases . These r e s u l t s showed wide hepa t ic

r e s e c t i o n increased opera t ive r i s k . However, wide

r e s e c t i o n has brought c u r a b i l i t y , so we would

in tend to improve the r e s u l t s of HPD by

renovat ion of p reope ra t ive and ope ra t ive

management.

55

F2

A Study of the Results and Success Rate for Hepatectomy Concomitant with Pancreato- duodenectomy

Johji Takada, Yutaka Saji, Hitoshi Arisato, Nobuaki Kurauchi, Keizo Kazui, Shoji Yamaga, Masato Nakayama and Juniohi Uchino First Department of Surgery, Hokkaido University School of Medicine, Sapporo, Japan

In our department, from September, 1981 to December 1990 , in order to try to improve the cure rate for advanced carcinoma of the biliary tract, we carried out hepatectomy concomitant with pancreatoduodenectomy (hereafter referred to as HPD) for mainly stage IV gall bladder cancer or widely spreaded bile duct cancer. Our study covers 6 cases of gall bladder cancer and 8 cases of bile duct cancer. The average age of the patients was 61.9 years old. The resection areas varied depending on the region of focus, and there was a high mortality rate in operations where the amount of liver resection exceed two of eight hepatic segments or where there was a large amount of bleeding (5,000 ml). There was also a high rate (42.9%) of insufficient pancreaticoduodenostomy which frequently resulted in death. Our department was able to obtain an improvement in the curability of operations by HPD for stage III and IV gall bladder cancer and extensive bile duct cancer, but at the present stage, we are not able to obtain an improvement in the prognosis. However,

we did have one case of stage IV extensive biliary duct cancer where the patient survived for 6 years after a HPD. Such a case, we believe, shows the value of HPD.

F3

Combined Resction of the Liver and Pancreas for Bile Duct Cancer

Shin Takahasi and Toshiharu Tsuzuki Department of Surgery, School of Medicine, Keio University, Tokyo, Japan

Between January 1980 and December 1992, combined resection of the liver and pancreas was performed in 11 patients with bile duct cancer in the advanced stage. The diagnosis was gallbladder cancer in 8 patients, middle bile duct cancer in 1 and cancer of the papilla of Vater in 1. Hepato-ligamento- pancreatoduadenectomy (HLPD) was camed out in 2 patients, and hepato-pancreatoduodenectomy (HPD) was performed in 9. The liver resection procedures were partial resection of 84b,5 in 6 patients, right posterior segmentectomy in 1, extended right lobeetomy in i, and right trisegmenteetomy in 1. Ten of the 11 patients tolerated the surgery and were discharged from the hospital. The remaining patient who had undergone HPD had an apparently unventful course, until he died suddenly on postoperative day 30. Autopsy findings revealed that death was attributable to hemoperi toneum due to leakage at the pancreatojejunostomy. Severe liver dysfunction was observed in 2 patients who underwent HLPD. The total bilirubin level increased to 6 mg/dl and 12 mg/dl postoperatively, respectively. These 2 patients received intensive care on a respirator for 10 and 13 days. The liver dysfunction gradually improved and the patients subsequently had a smooth recovery.

The mean survival time of the 10 patients discharged from the hospital was 7.8 months, the longest survival being 17 months. The 2 patients who underwent HLPD died of recurrence at 5 and 7 months postoperatively. It is now clear that HPD and HLPD are feasible procedures for bile duct cancer in advanced stage. However, strict selection of candidates and meticulous postoperative care are mandatory.

56

F4

Our Experiences of Hepatopancreatoduodenectomy and Hepatopancreatoduodenectomy with hepatoduodenal ligamentectomy

Akira Nakano, Hitoshi Sekido, Itaru Endo, Yasuhisa Mochizuki, Tadao Fmkushima, Shingo Fukasawa, Kohei Yoda, Kensuke Ogura and Hiroshi Shimada Second Department of Surgery, Yokohama City University, School of Medicine, ~apan

Advanced biliary tract carcinoma is one of the most difficult malignancies to achieve a curative resection in spite of a recent progress in imaging diagnostic techniques. We herein present our experiences of seven patients who underwent hepatopancreatoduodenectomy (HPD) and HPD with hepatoduodenal ligamentectomy (HLPD) for advanced gallbladder carcinoma and hilar cholangiocarcinoma. The significance of HPD and HLPD in advanced biliary tract carcinomas were retrospectively reviewed. Palienls: The study group consisted of one male and six females with a mean age of 66 years (range 60 to 73). Operative procedure and Results: Radical resection was performed for all cases as summarized in Table 1. In patient 1-3 and 5 (gallbladder carcinoma), segmentectomy of liver ($4a,5) and pancreatoduodenectomy (PD) were performed. Extended right hepatectomy with PD and partial hepatectomy with pylorus preserving PD (PPPD) were performed for case 4 and 6, respectively. In the patient 7 (hilar cholangiocarcinoma), left hepatectomy with simultaneous caudate lobectomy, hepatoduodenal ligamentectomy and PPPD was performed. There were two post-operative complications; case 4 had liver failure with hyperbilirubinemia that was probably caused by extended hepatic resection, case 7 had multiple liver abscesses that was probably due to the occlusion of reconstructed hepatic artery. Mortality(: Overall mortality rate was 14% (1/7). One patient died of early post-operative liver failure. Five patients were

died of recurrence (liver, lymph nodes, peritoneum and local region). One patient has survived for 29 months after the operation. An

raverage survival time was 9.8 months. Curabilj~.' patients with relatively non curative operation (4 cases) had longer survival time than those had an absolutely non curative operation (3 cases). Conclusion: It can be said that the radical operation featuring an extended resection may be one possible solution for advanced biliary tract carcinoma to accomplish a longer survival time.

Table 1

Case Age Sex DiseaseOperation s hinfh bif v n Curability Recurrence Prognosis

$4a5 se 2 0 0 2 2 RNC Lymph node d.eath PD +IORT (2vmo/

68 F GB

73 F GB $4a5 ss 0 ~ 2 2 4 ANC Liver death PD (7too)

61 F GB $4a5 si 1 1 3 2 4 ANC Local death PD + IORT (6too)

60 F GB ExRt si 3 0 3 0 3 ANC Liver death PD (7too)

69 M GB $4a5 si 3 0 3 2 3 ~NC - death PD (2too)

68 F O B Pt se 0 0 0 1 4 RNC - alive PPPD (5too)

60 F HC Lt I 0 0 1 2 ~ C Peritoneum death LPPPD (8too)

IORT: Intra operative irradiation therapy

ANC: absoIutely non curative RNC: relativelj non curative

1

2

3

4

5

6

7

GB: Gall bladder carcinoma HC: Hilar cholangiocarcinoma ExRt: Extended right hepatectomy Lt: Left hepatectomy

F5

Management of patients with cancer of the bi!iary tract and ongoing major hepatectomy and concomitant pancreaticoduodenectomy

Kazuhiro Tsukada, Katsuyosi Hatakeyama, Isao Kurosaki, Katsuyuki Uchida, Yosio Shirai, Terukazu Muto The First Department of Surgery, Niigata University School of Medicine, NIIGATA, JAPAN

INTRODUCTION: Complications of major hepatectomy and pancreatoduodectomy (HPD) which is composed of two surgical intervention for patients with advanced carcinoma and jaundice are serious. In this paper we investigated management of the patients undergoing HPD.

PATIENTS AND METHODS: Between 1985 and 1992, HPD was performed in 9 patients with biliary tract cancer; 4 of gallbladder cancer ( GBC ) and 5 of bile duct cancer ( BDC ). Four patients were men and 5 were women. The average age was 85 years (55 to 79 years). Percutaneous transhepatic biliary drainage was performed in 8 of 9 patients before HPD. Intraoperative blood loss ranged from 1850 to 4985 mL. Complications after surgery was divided into two categories. One was technical problem such as anastomotic failure, intraabdominal bleeding and/or intraabdominal infection, and the other was hepatic failure caused by reduced liver.

RESULTS: All patients had intraabdominal infection which varied in degree after

operation. Anastomotic failure was developed in 4 patients. Serum bilirubin levels elevated more than 5 mg/dL in all patients. However hepatic failure (hepatic coma, hyperbilirbinemia more than 5 mg/dL prolonged over 8 days and/or lower hepaplastin levels less than 30 %) was recognized in four patients. Three patients with both hepatic failure and abdominal infection showed intraabdominal bleeding. Two of three patients died 18 days and 46 days after initial operation. Underlying disease of the two patients was BDC. Of remain 7 patients, five patients died 58, 27, i0, 8, and 6 months after operation, and the other two patients with recurrent tumor are alive 27, 12 months after operation.

CONCLUSION: Complications occur in all patients after HPD. However, HPD is one of the option for curative resection for advanced carcinoma of biliary tract~ Management and avoidance of postoperative infection and hepatic failure are mandatory because postoperative bleeding was caused by these complications and was fatal.

F6

A PROBLEM IN POSTOPERATIVE CARE OF 5 CASES OF HEPATECTOMY WITH PANCREATICODUODENECTOMY

Seigo Takano, Noriyoshi Seki, Toshihiko Ooishi9 Yoshihiro Watanabe, Tokio Higaki, Masanori Moriguchi Yutaka Itou and Takashi Tanaka The 3rd Dept. of Surgery., Nihon Univ., Tokyo Japan

The mortality of hepateotomy with

panereaticodenectomy(HPD) is very high

owing to excessive damage. We examined the

postoperative complication and treatment in

w cases of HPD.

All patients presented with gallbladder

cancer. PTCD was performed in all cases

preoperatively. Extended right lobectomy

with PD was 4 cases, mixed right

intermediate hepatectomy with PD was I case

and I case of the replacement of portal

vein with great saphenous vein was included

among them. Of w eases, 3 cases had died in

hospital, on the other hand, 2 cases were

out of hospital.

Significantly elevated total bilillbin

leve!s(over 6 mg/dl) were Found in all of

patients after postoperative 3 days. Out

of them, 2 cases which undewent plasma

exchange (PE) had died.

intra-adbominal infection were found in all

of patients, 2 cases in which were detected

Methicillin Resistant Staphy. Aureus

(MRSA) had died. Serum bilillubin levels

decreased slowly in 2 cases which performed

an oontenious lavage by puncture using a

ultrasonography.

It is suggested that postoperative liver

failure and multiple organ failure are

prevented by inhibition of intra-adbominal

infection, and the drainage and eontenious

lavage using a ultrasonography are useful

in such a situation, on the other hand, PE

is not useful.

.57

F7

COMPLICATIONS AND COUNTERMEASURES AFTER PANCREATODUODENECTOMY WITH HEPATIC RESECTION

Ryoko Sasaki, Senji Kanno, Yoshiro Hayakawa, Masahiko Murakami, Hidenobu Kawamura, Yutaka Shimada,

Takayuki Suto, Yoshiyuki Tamasawa and Kazuyoshi Saito The First Dept. of Surgery, Iwate Medical Univ., Morioka, Japan

In order to improve the result after pancreatoduodenec-

tomy with hepatectomy, the complications were investigated

and countermeasures were worked out.

PATIENTS : Eleven patients, who underwent hepatopancreato-

duodenectomy (HPD) from October, 1986 to April, 1993,

were investigated. Eight cases were gallbladder carcinoma

and 3 cases were bile duct carcinoma.

RESULTS : The operative death were 2 cases (18.1~), but

in the cases who underwent more than bisegmentectomy,

the mortality rate was 50.0~ ( 2 of 4 cases).

The longest survivor is alive at 6 years and 6 months after

operation.

Seven of 11 cases (63.6~) had some complication, and

the contents were 4 cases (36.4~)of leakage at pancre-

atojejunostomy, 3 cases ( 2 7 . 3 ~ ) of leakage at biliojeju- nostomy, and 1 case of hepatic failure, cholangitis, abscess at hepatectomy, intraperi toneal abscess, GI-bleeding, intraperitoneal bleeding and multiple organ failure. The first case of operative death, who underwent panc re - atoduodenectomy with extended right lobectomy, died from hepatic failure because of bent portal vein. In another case, who underwent pancreatoduodenectomy

with right trisegmentectomy included caudate lobectomy,

intraperitoneal bleeding due to leakage at pancreato-

gastorostomy was occured, and patient died from multiple

organ failure.

CONCLUSIONS: i. Patient who underwent HPD is expected

of long survival after tolerated the operation. 2. In the

cases who underwent more than bisegmentectomy, it is

considered that introduction of preoperative emholization of

portal vein may be necessary to prevent the hepatic failure.

3. It is considered that emergency angiography is the first

choice against the intraperitoneal bleeding.

58

F8

Squamous Cell Carcinoma of The Gallbladder Curatively Resected by Hepatopanereatoduodenectomy

Kenji Kitahara, Kohji Miyazaki, Nobuo Tsutsumi, Eizaburoh Sasatomi and Takeharu Hisatsugu Department of Surgery, Saga Medical School, Saga, Japan

Gallbladder cancer has acquired a sinister reputation based on patterns of the late diagnosis, the unsatisfactory treatment and the poor prognosis. On the contrary, the squamous cell carcinoma of the gallbladder was reported to have a tendency to invade the adjacent organs directly without metastasis compared with the adenoearcinoma or the adenosquamous carcinoma of the gallbladder. Therefore, resection of involved organs as a part of a radical operation seems justified in cases where the lesion tends to remain localized without metastasis or peritoneal seeding. Here we describe a case of the squamous cell carcinoma of the gallbladder, resulted in macroscopical curative resection by hepatopancreatoduodenectomy. The patient was a 77-year-old man complaining of right hypochondrial discomfort without a deve'lopment of jaundice. Results of multiple imaging examinations were consistent with the carcinoma of the gallbladder with direct invasion into the liver, the duodenum and the transverse colon. A pancreatoduodenectomy, subsegment- ectomies(S4a,5,6) of the liver and partial resection of the transverse colon were per-

formed. There has been no recurrence up to 4 months after the operation. Histopathologi- cally the tumor was composed of squamous cell carcinoma of gallbladder with no evidence of lymphatic, vascular or perineural invasions. We must heed, however, that multiple sections must be examined before a diagnosis of pure squamous cell carcinoma is issued, because some adenosquamous carcinoma have a prominent squamous cell component. The squamous cell carcinoma of the gallbladder is characterized by a well-localized growth and a rarity or lack of metastasis. The limiting factor for the radical operation of the gallbladder cancer is the extent of the invasion to its adjacent area including the liver which isn't usually cirrhotic advantageously. Squamous cell carcinoma of the gallbladder is rare, but extensive redical surgeries according to the infiltrating patterns might offer a chance of cure to patients who could have been untreated in the past, even if the tumor is fairly large.

F9

Ezrly complications in 7 patients undergoing hepato-pancreatoduodenectomy

Toshitaka Okuno, Shinji Nakayama, Toshiyuki Fukuhara, Takashi Flashimoto Yoshikazu Takamine, Yutaka Konishi, Tomohiko Tani, Tatehiro Kajiwara The First Department of Surgery, Kobe City General Hospital, Kobe, Japan

Early complications in 7 patients (one with gastric cancer and 6 with carcinoma of gallbladder) who underwent hepatopancreatoduodenectomy (HPD) in our hospital from August 1981 to September 1992 were studied. Clinical stages of the lesions were all stage IV. Hepato-pancreatoduodenectomy were performed in 6 patients with gallbladder cancer and hepato- ligament-pancreatoduodenectomy (HLPD) was performed in the patient with gastric cancer. One patient with gallbladder cancer is still alive without recurrence. Another one died within two months after the operation. The remaining 5 patients died of recurrence at 7 months in average (3 to 11 months) after operation. Two serious complications were observed. One of them was liver insufficiency develping following HLPD which was performed in the patient with gastric cancer. In this case, left extended hepatectomy and resection of the portal vein and the proper hepatic artery were performed. Ischemic time of the liver was 30 minutes and the portal vein was replaced by the left iliac vein and the hepatic artery by the saphenous vein. After administration of prostaglandin, glucose-insulin treatment and plasmapheresis, his liver function recovered and he was alive for three months after the operation.

One of the gallbladder cancer cases had Needing from pseudoaneurysm which formed in succession to the leakage of pancreato-jejunal anastomotic site. Bleeding was successfully controlled by transarterial embolization, but was followed by multiple organ failure leading to the patient's death on 57 post operative day. In this case, pancreatoduodenectomy had been performed with Whipple's procedure. We believe that in HPD and HLPD operation, hepatectomy should be limited to the segment adjacent to the tumor and proper preoperative evaluation of the liver function is mandatory. Even more important is to carefully and firmly anastomose the resected end of the pancreas with the jejunum.

59

FIO

Postoperative Complications in HPD and Management

Setuo Okada, Tetuaki Hashimoto, Hisao Wakabayashi, Takashi Maeba, Satoshi Tanaka The First Dept. of Surgery, Kagawa Medical School, Kagawa, Japan

HPD has a high rate of postoperative complications, compared to the simple hepatectomy or PD, ecpecially when the major hepatectomy was performed. In our institute 9 cases of HPD were performed. Post operative complications in 4 cases of HPD, in which the extended fight lobectomy was performed, were reviewed and our management was reported. PTPE was applied to 2 patients prior to the operation. As a major complication the followings were found; liver failure in 3 cases, peritoneal abscess ( subphrenic abscess) in 3 cases, leakage (especially of the colonostomy) in 2 cases, ARDS in 3 cases. To avoid the postoperative liver failure, the following care was considered. 1) By applying PTPE hepaic reserve function should be increased prior to the operation. In 2 cases, the volume of the non-embolized lobe increased by 20% and 94% each in 2 weeks after the PTPE. 2) The patient should be covered with a small dosage of steroid perioperatively. 3) Once liver dysfunction is found postop, the plasma exchange should be applied as early as possible. To eliminate subphrenic abscess, continuous washing or suction through draining tubes

should be considered. To avoid leakages, pancreatogastrostomy should be considered as a primary reconstruction method after PD. Furthermore, when the colon was resected in the operation, stoma should be considered, because leakage of the colonostomy is likely and life-threatening. And to prevent and treat the ARDS, using a small dosage of steroid seemed to be effective.

F l l

Complications of hepatopancreatoduodenectomy for cancer of the biliary tract

Toshinori Oishi, Ken-iehi Kumazawa, Koichi Kubota, Toshihiko Hosokawa, Shuichi Yoshizawa, Yoshiaki Asami, Shun-ichiShiozawa, Yoichi Otani, Shnnsuke Haga and Tetsuro Kajiwara Department of Surgery, Tokyo Women's Medical College Daini Hospital, Tokyo, Japan

Recently, hepatopancreatoduodenectomy (HPD) is often performed as a radical operation for cancer of the biliary tract. However, this procedure involves great surgical insult and increases the risk of early postoperative complications. In this study, complications observed early after HPD were evaluated clinically and by animal experiments. HPD has been performed in 13 patients with cancer of the biliary tract at our department to date. This disease was located in the gallbladder in 10, bile duct in 2, and the papillary region in 1. In this HPD group, the mean duration of opreration was 578.8-+ 73.4 minutes, and the mean volume of hemorrhage was 3601.5---1421.9 ml (mean-+ SD). Seven patients (53.8%) developed complications early after the operation; hyperbilirubinemia was observed in 3 (23.1%), hepatic insufficiency in 1 (7.7%), ruptured suture in 3 (23.1%), postoperative hemorrhage in 3 (23.1%), and operative death in 2 (15.4%). Liver disorders and sutural insufficiency at the site of pancreatojejunostomy were evaluated as typical complications after HPD. First, liver disorders were compared between HPD group and 21 patients who underwent hepatectomy for cancer of the biliary tract 0 t group). Hyperbilirubinemia was observed in 3 patients (23.1%) in the HPD group and 5 patients (23.8%) in the H group, and hepatic insufficiency in I (7.7%) in the HPD group and 2

(9.5%) in the H group, with no difference in the incidence of these conditions. Next, the incidence of sutural insufficiency at the site of

pancreatojejunostomy was compared between the HPD group and 54 patients who underwent pancreatoduodenectomy (PD group). It was observed in 2 (15.4%) in the HPD group but in 5 (9.3%) in the PD group. Pancreatojejunostomy was performed in adult mongrel dogs, and the effects of hepatectomy on the site of pancreatojejunostomy were evaluated. The incidence of sutural insufficiency was 23.5% in the hepatectomy group but 12.5% in the non-hepatectomy group. Small abscess were observed at the anastomosis site by gross examination in 86.7% in the hepatectomy group and 28.6% in the non- hepatectomy group (p<0.05). Histologically, wound healing tended to be delayed in the hepatectomy group. Concerning the local hemodynamics at the anastomosis site, the portal pressure was 13.6--+ 0.5 cmHzO in the non-hepatectomy group but was higher at 17.1 +-- 1.7 cmHzO in the hepatectomy group (p<0.01). The tissue oxygen partial

pressure on the jejunal side of the anastomosis was reduced in the hepatectomy group at 31.9- + 1.5 mmHg as compared with 37.0----- 2.7 mmHg in the non-hepatectomy group (p<0.01). These findings suggest that hepatectomy causes congestion and a reduction in the tissue oxygen partial pressure on the jejunal side of the anastomosis, leading to a delay in wound healing at the anastomosis site. Pancreatojejuno- stomy should be performed with the greatest care in HPD.

60

F12

L i v e r E n e r g y S t a t u s a f t e r S i m u l t a n e o u s M a j o r R e s e c t i o n o f t h e L i v e r a n d t h e P a n c r e a s in R a t s

Akin Ha rada , Tsuyosh i K u r o k a w a , H i r o t a k a M a r u y a m a , Hi royuki Kobayash i , Tosh iak i Nonami , A k i m a s a Nakao and Hiroshi Takag i D e p a r t m e n t o f Su rge ry II., N a g o y a Univ . , N a g o y a , J a p a n

H e p a t o - p a n c r e a t o d u o d e n e c t o m y (HPD) ha s been indi- c a t e d r e c e n t l y for h e p a t o b i l i a r y m a l i g n a n t d e s e a s e s , e s p e c i a l l y c a n c e r o f t h e g a i l b l a d d e r or c a n c e r o f t he b i le duc t . I ts r e s u l t s , h o w e v e r , h a s b e e n not s a r i s - f a c t o r y b e c a u s e o f h igh m o r t a l i t y and m o r b i d i t y r a t e a f t e r su rge ry . A l t h o u g h t h e m o s t i m p o r t a n t c a u s e o f d e a t h soon a f t e r HPD w a s h e p a t i c f a i l u r e of m u l t i o r - gan f a i lu re , i t s p a t h o p h i s i o l o g i c a l s t a t u s h a s no t b e e n c l a r i f i e d ye t . T he pu rpose of th i s e x p e r i m e n t a l s t udy was to i n v e s t i g a t e t h e h e p a t i c e n e r g y leve l a f t e r m a j o r r e s e c t i o n o f t h e l iver and t h e p a n c r e a s . M a t e r i a l and m e t h o d s : Male W i s t e r r a t s w e i g h i n g 200g w e r e used . T h e m e d i a n and l e f t lobes o f t h e l iver (70% h e p a t e c t o m y ) and also g a s t r o - s p l e n i c po r t i on o f t he p a n c r e a s (50% p a n c r e a t e c t o m y ) w e r e r e s e c t e d (group HP). In t h e c o n t r o l g roup 70% h e p a t e c t o m y only was p e r f o r m e d (group H ) . On t he 1st, 3rd, 5 th p o s t o p e r a t i v e days , t h e f ive e x p e r i m e n t a l a n i m a l s in e a c h g roup w e r e s a c r i f i c e d , and l iver and blood s a m p l e s w e r e c o l l e c t e d . L iver a d e n i n e n u c l e o t i d e s , BrdU labe l ing index (LI), l iver r e g e n e r a t i o n r a t e (RR) and blood b i o c h e m i s t r y d a t a we re m e a s u r e d . S t a t i s t i - cal s i g n i f i c a n c e w a s d e t e r m i n e d by a n a l y s i s o f D u n n e t ' s t e s t . R e s u l t s : On t h e 1st day a d e n o s i n e t r i p h o s p h a t e (ATP) and t o t a l a d e n i n e n u c l e o t i d e (TAN) in t he l iver d e c r e a s e d m a r k e d l y in g roup HP, and did no t r e c o v e r

to p r e o p e r a t i v e l eve l s on t h e 5 th day. But in g roup H the d e c r e a s e of A T P and T A N on t h e 1st day w e r e s m a l l e r and r e c o v e r e d to p r e o p e r a t i v e l eve l s on t he 5 th day. T h e r e w e r e s i g n i f i c a n t d i f f e r e n c e s b e - t w e e n t h e two g roups on t h e 1st and 5 th day (p<0.05). LI on t h e 1st and 3rd day w e r e 18% and 13% in g roup HP, and 25% and 16% in g roup H, r e s p e c t i v e l y . T h e r e w e r e s i g n i f i c a n t d i f f e r e n c e s b e - t w e e n t h e two g roups on b o t h days (p<0.05). RR w e r e s i g n i f i c a n t l y lower in g roup HP on t he 3rd and 5 th day (p<0.05). The s e r u m b i l i rub in and g l u c o s e l eve l s o n t h e 5 th day w e r e h i g h e r in g roup HP. C o n c l u s i o n s : In t h e p r e s e n t e x p e r i m e n t a l m o d e l l iver e n e r g y level in group HP d e c r e a s e d m a r k e d l y on t h e 1st day a f t e r s u r g e r y and d e m o n s t r a t e d p ro lo n g ed r e c o v e r y in c o m p a r i s o n wi th t h a t in g roup H. Liver r e g e n e r a t i o n r a t e was also s u p p r e s s e d in t h e ea r l y p o s t o p e r a t i v e pe r iod in g roup HP. T h e s e r e s u l t s s u g - g e s t t h a t m a j o r h e p a t i c r e s e c t i o n w i th s i m u l t a n e o u s p a n c r e a t i c r e s e c t i o n m a y s u p p r e s s l iver e n e r g y level in t h e ea r l y r e g e n e r a t i n g pe r iod r e s u l t i n g in u n - f a v o r a b l e i n f l u e n c e on l iver f u n c t i o n a l s t a t u s . C a r e - ful m a n a g e m e n t wi th an a t t e n t i o n to l iver e n e r g y s t a t u s is e x t r e m e l y i m p o r t a n t a f t e r HPD.

F13

Intraportally Administration of Prostaglandin El in hepatectomized patients with liver cirrhosis

T a d a s h i K a t s u r a m a k i , M a s a m i K i mura , H a j i m e T akasaka , Mi t suh i ro Muka iya , K a z u h i r o Y a m a s h i r o , T o s h i h i k o Mikami , H i romich i K i m u r a , and Koich i H i r a t a Firs t D e p a r t m e n t o f Surgery, S a p p o r o Med ica l Univers i ty , Sapporo , Japan .

( Purpose )

Prostaglandin El ( P G E 1 ) was intraportally administered after

hepatectomized patients with liver cirrhosis, and the effect of PGE1

on postoperative improvement of liver function and prevention of

cholestasis was investigeted.

( Patients and Methods )

The study population consisted of 26 adult hepatectomized patients

with liver cirrhosis. They were assigned to receive no treatment ( 12 ) ,

intraportal ( i . p . ) PGE1 ( 8 ) and intravenous ( i .v . ) PGE1 as

systemic administration ( 6 ) , and these 3 groups were compared.

No noteworthy difference was found in background factors. In the

i.p. PGE1 group, a catheter was inserted into the gastroepiploic

vein or umbilical vein, and 250 pg or 500 /zg/day of PGE~ were

administered by continuous infusion over 24 hr. In the i.v. Group,

720/zg/day of PGE1 were administered through the central vein by

continuous infusion over 24 hr. In principle, the treatment was

continued until serum total bilirubin (T.Bil) decreased to 3 mg/ dl2

or less, for 4 to 5 days on the average. The efficacy was evaluated

based on alanine aminotransferase ( A L T ) and serum T.Bil on

Day 7 after operation.

( Results )

( 1 ) The ALT on Day 7 was 73.0---+48.5 IU/g in the untreated

group, 34.0 + 17.5 IU/1~ in the i.v. group, and 29.0 • 12.8 IU//~ in

the i.p. group, the ALT in the i.p. group was significantly lower than

the control level. On Day 7, the number of pattients with ALT

exceeding the normal level was 7 of the 12 controls ( 58% ) , 3 of

the 6 i.v. patients ( 50% ) , and the fewest, 2 of the 8 i.p. patients

( 25% ) .

( 2 ) The serum T.Bil on Day 7 was 3.0 ---+ 2.1 'mg/dg in the

untreated group, 3.6 ---+ 2.5 mg/ dl~ in the i.v. group. On Day 7, the

number of patients with serum T.Bil exceeding 3 mg/dl~ was 4 of

the 12 controls ( 33.3% ) , 3 of the 6 i.v. patients ( 50% ) , and the

fewest, l of the 8 i.p. patients ( 12.5% ) .

( Discussion ) These results show that i.p. administration of PGEi was useful in

postoperative improvement of liver function and prevention of

cholestasis in hepatectomized patients with liver cirrhosis. This

indicates that direct administration of POE1 into the liver is

effective. Furthermore, these results suggest the possibility that a new

treatment by direct intrahepatic injection of various drugs will be

developed.

61

F14

Evaluation of 99m-Tc-GSA Liver Scintigraphy for the hepatic functional reserve.

Takuji Mimura, Keiji Koguchi, Keisuke Hamazaki, Masanobu Mori, Tooru Edahiro, Noriyuki Kawada, Hiromu Tsuge, Hisashi Mimura, Kunzo Orita Ist Dept. of Surgery, Okayama Univ. Med. Sch., Okayama, Japan

99m-Tc-Galactosyl human serum albumin (99m-Te-GSA) is a new liver imaging radiopharmaeeutieal which specifically binds to the asiologlycoprotein- receptor on the liver cell membrane. We investigated the usefullness of the 99m-Tc-GSA liver scintigraphy, for the evaluation of the hepatic functional reserve, analyzing the time-activity curve of the liver and heart. The 99m-Te-GSA liver scintigraphy was performed on 14 patients, who were scheduled to operate: hepatoceller carcinoma (9), metastatic liver cancer (2), hepatolithiasis (i), haemangioma (i), pancreatic head cancer after PTCD. (i). The 99m-Tc-GSA liver scintigraphy showed more clear and sharp and stable liver images than the 99m-Tc-Phytate images. The time-activity curve of the liver and heart was analyzed from several compartment and we calculated K-GSA, which represented the hepatic uptake rate, LHLI5 (Receptor Index), which was a ratio of liver region radioactivity over liver region plus heart region radioactivities at 15min post injection, and HHI5 (Clearance Index), which was a ratio of heart ROI radioactivity at 15min over that at 3min post injection. K-GSA had a good correlation with K-ICG (n=14, r=0.754, p=O.O019), ch-E (n=lO, r=0.593, p=0.0750), and ICG-RI5 (n=lO, r=0.588, p=0.0735). However we

could not had a correlation between LHLI5 or HHI5, and any other parameter for liver function test. We concluded that K-GSA was more usefull than LHLI5 and HHI5, for the evaluation of the hepatic functional reserve.

F15

Quantitative Measurement of Blood Flow in Human Hepatic Tumors by Positron Emission Tomography (PET) Using C~O2 Steady State Method and H2150 Dynamic Study.

Hiroshi Koyama, Hiroki Taniguchi, Atsushi Oguro, Kazumi Takeuchi, Keigo Miyata, Hiroki Tanaka, and Toshio Takahashi First Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan

Although the measurement of blood flow in human liver tumors has been attempted using many methods and instruments, the non-invasive, quantitative measurement of neoplastic blood flow has never been performed. However, it is important for the diagnosis and treatment of liver tumors to measure the blood flow accurately and quantitatively. We succeeded in quantifying human liver tumor blood flow using C~502 steady state method and H21~O dynamic study by positron emission tomography (PET). These method are non-invasive, physiologically relevant, accurate, and can be replicated. Assuming that Kety's single compartment model can be applied and that a given hepatic neoplasm is supplied only from the hepatic artery, a hepatic PET using a steady state C~50 a method and H2asO dynamic study were performed to quantify the regional blood flow in the tumor. A total of 19 patients were studied with their informed consent. Twelve patients (9 males and 3 females) with hepatocellular carcinomas were examined. There were also 6 males and 1 female presenting 13 metastatic liver tumors. Of these 13 tumors, 6 were gastric cancer, 6 were colorecta[ cancer, and 1 was a leiomyosarcoma of the jejunum. PET measurement were performed with fasted patients in a recumbent position on the bed of a whole body PET scanner. C1502 gas and H2~50 was produced by a medical cyclotron.

Three PET scans, 10 mm in width and spaced at 15 mm intervals, were performed. ROIs were set on the liver tumors of the PET images, always referring to the X-ray computed tomographic images of on the same slices. Based on the PET images, the radioactive concentrations in the liver neoplasms were calculated; the blood flows in each was then determined by triplicate scans. Two blood samples were taken from the left brachial artery just before and after the PET measurements in C~Oa steady state method. Ten blood samples were taken for 5 minutes concurrent with PET measurements, at a rate of 1 every 5 seconds for the first 30 seconds and at intervals of 30 seconds thereafter, to give a total of 12 samples in 4 minutes during H~50 Dynamic Study. Radioactivity concentrations in the blood samples were measured immediately in a precalibrated well counter.and the radioactivity was measured immediately in a precalibrated well counter. In the current study, the specific gravity of the tumor were assumed to be 1, and 0.34/rain was used as the physical decay constant for 150. The blood flow values in hepatocellular carcinomas was significantly higher than metastatic liver tumors, but there was no significant difference between the various types of metastatic liver tumors. There was a significant correlation between steady state C1502 method and H2150 dynamic study.

62

F16 Changes in Hepatic Tissue Flow During Pringle Maneuver for Hepatectomy in Men

Takah!=c Ishii, Yang Ii Kim, Masanori Aramaki, Kimihiro Nakashima, Takanori S~<hida and Michio Kobayashi Department of Surgery I, Oita Medical University, Oita, Japan

Occlusion of the hepatic portal triad (Pringle maneuver) has been used to control haemorrhage during liver resection. We sometimes encounter profuse bleeding when this method is used and the question of possible ischemia had to be addressed. The aim of our study was to evaluate changes in blood flow in the liver tissue (LBF) using a laser Doppler flowmeter during Pringle maneuver.

Liver blood flow was measured in 34 non- cirrhotic patients. There were 25 men and 9 women, who ranged in age from 29 to 77 years (mean: 59 years). Sixteen patients (47%) had a histologic diagnosis of primary liver cancer, nine (26%) had secondary liver cancer and five (15%) were with gall bladder cancer. Major hepatectomy was done in 19 patients (extended right lobectomy in three, right lobectomy in 12, and left lobectomy in four, respectively). Changes in LBF were evaluated before and at the end of occlusion using a laser Doppler flowmeter.

ranged from 38 to 75 minutes (57.0• min, mean• Although hepatic inflow occlusion led to a significant reduction in LBF (from 29.2• ml/100g tissue/min to 6.3•176 24.4• of the pre-ischemic flow was detectable. Occasionally, there was a profuse haemorrhage from hepatic veins during parenchymal dissection.

As based on our data, we suggest that the Pringle maneuver induces partial rather than a full ischemia of the liver. The clinical implications of hepatic inflow occlusion are discussed together with surgical techniques minimizing blood loss during liver resection.

All patients survived. The time of ischemia

F17

Examination of Cases in which Laparoscopic Cholecystectomy was Changed to Open Surgery

Shinsuke Ohura, Tomoe Beppu, Kaoru Ohashi, Isamu Watanabe, Kuniaki Kojima, Masaki Fukasawa and Shunji Futagawa The 2nd Department of Surgery, Juntendo University

In our department laparoscopic cholecystectomy (LC) was performed inl30 patients during the period from April 1991 to February 1993. As use of this technique improved, this procedure has been indicated to cases in which cholangiography taken prior to surgery showed negative

cholecystogram. The number of cases in which LC was changed to open surgery was 9 (6.9%): 5 cases of negative cholecystogram including 3 cases of actue cholecysfitis and 4 cases of severe chronic cholesystitis. The reasons for changing LC to open surgery were unqontrollable bleeding (2 cases), a case of injury to choldochus (1 case), a fistula between gallbladder and duodenum (1 case) and difficulties in dissection due to severe chronic inflammation (5 cases). LC could be performed in 3 out of 20cases (15%) in which cholangiography taken before surgery showed negative cholecystogram and in 3 out of 10 cases (30%) with acute cholesystitis. Although LC is principally applied to almost all cholelithiasis at present, we consider that laparoscopic surgery should be changed

to open surgery if LC requires a long time because of

severe chronic inflammation.

63

F18

Management of Bile Duct Strictures

Yutaka Itou, Ssigo Takano, Noriyoshi Sski, Toshihiko Ooishi, Yoshihiro Watanabe, Tokio Higaki, Masanori Moriguchi, Tomohide Takahashi

The 3rd Dept. of Surgery., Nihon Univ., Tokyo Japan

In an effort to evaluate pathophysiologic

face of benign strictures and interven-

tional treatment in the management of the

strictures, a retrospective analysis was

carried out on 39 consecutive patients with

bile duct strictures treated 1986 and 1992.

The patients presented with pancreas

disease (14) Postoperaive stricture (11),

cholangitis(6), Mirizzi syndrome (3),vessel

oppression (3), confluence stone (I), and

foreign body (I). Postoperative stricture

included intraoperativs injury (4) and

scarred stricture (7). The group of sympto-

matic cholangitis performed choledochodrai-

nags or reconstruction, and one of suspici-

ous of eholangioma had radical hepatectomy.

Pancreas disease was classified chronic

pancrsatitis (i2) and others (2). Chronic

pancreatitis included cyst and tumor form-

ing pancreatitis induced bile duct

stricture. Having intraoperative biopsy,

choleduchudrainage(1), pancreatioco-duoden-

ectomy (7), pancreaticojeunnostomy (I) and

biliary rscinstruction (I) offered the

dissapearance of stricure.

Vessel oppresion has not been found untill

laparotomy, and choledochodrainge offered

the remmision of stricture.

We concluded that surgical reconstruction

remains the standard therapy for patients

with bili duct strictures. Asymptomatic

strictures must need carefull observation,

and symptomatic strictures should be

indicated for biliary reconstruction.

Making pancreatic biliary sturucture diffi-

cult differentiation for malignancy, intra-

operative US and biopsy is useful.

F19

Aggressive Surgery for Intrahepatic Cholangiocarcinoma

Motohide Shimazu, Toshiharu Tsuzuki and Haruo Aoki* Departments of Surgery, School of Medicine, Keio University, and Fujita Health University School of Medicine*

Intrahepatic cholangiocarcinoma is notorious for its poor prognosis. The patients usually die of extensive metastases without surgery, and early recurrence is the rule even though resection is carried out.

Between January 1973 and December 1992, 36 patients were admitted to our institutions. Seventeen (47%) of the 36 patients underwent resection. The procedures were right and left trisegmentectomies in 3 and 2 patients each, extended right and left lobectomies in 4 each, right lobectomy in 2, and extended segmentectomy in 2. Caudate lobectomy was carried out in 10. Resection of the bile ducts with hepaticojejunostomy was performed in 8. Combined resection of the blood vessels was performed as follows: both hepatic artery and portal vein in I patient, portal vein in 2, and inferior vena cava in I.

We classified this tumor into 3 types according to location: (I) peripheral type, 6 patients; (2) hilar type, 3; and (3)

mixture of peripheral and hilar types, 8. The tumor had the appearance of an intrahepatic parenchymal growth but some tumors also showed periductal or intraductal growth, which is indistinguishable from cancer of the main hepatic duct junction.

Postoperatively, no patients died within I month but thereafter 3 succumbed to liver failure. The 3-year and 5-year actuarial survival rates were 30% and 15%, respectively. Five patients are currently alive, the longest survivor being well for 8 years and 5 months after extended right lobectomy. Patients with nonresectable tumors died of cancer progression within I year after diagnosis.

it should be emphasized that aggressive surgery is the only way to achieve long- term survival.

64

F20

Histopathological features and outcome of patients with cholangiocelluar carcinoma

Yoshio Naomoto, Noriyuki Kawata, Hisashi Mimura, Hiromu Tsuge, Keisuke Hamazaki, Masanobu Mori and Kunzo Orita First Dept. of Surg., Okayama Univ. Med. $ch., Okayama, Japan

The records of 32 patients with cholangiocellular carcinoma seen between Jan. 1980 and Jan. 1993 were reviewed to determine the histopathological features and the outcome of the operated cases. Nineteen patients (59 percent), underwent hepatectomy; including two instances with mild cirrhosis. Of these 19 patients, 12 had peripheral type and 7 had hilar type cholangiocarcinoma. Nine and six patients respectively had 2 or more hepatic segments resected but remained with positive margins. All the 12 patients with peripheral type had far advanced tumors, with 8 patients presenting lymph node involvement (N2 or more), 7 presenting multiple intrahepatic lesions, and 6 with invasion into adjascent organs. Of the 7 patients with hilar type, 4 presented positive lymph nodes (N2 or more). Histological examination revealed 67 percent of lymphovascular invasion, and 50 percent of perineural invasion. 17 of 19 cases died within I year postoperatively. The remainder 2 patients are still alive 11 months and 9 years postoperatively. This instance of long-term survival was accomplished after

further resections at 6 months and 15 months of follow-up. These results indicate that cholangiocarcinoma even in early stages may already present positive regional lymph nodes. And considering the high risk for lymphovascular and neural invasion the authors suggest that a wider free-margin excision and wider lymph node dissection is necessary to increase curability.

F21

Clinicopathological Studies of Resected Intrahepatic Cholangiocarcinoma with Special Reference to the Involvement of Lymph Node.

Tatsuya Tsuji, Seiki Tashiro, Tsutomu Oda, Keiichiro Kanemitsu, Yukio Kamimoto, Takehisa Hiraoka, Yoshimasa Miyauchi The 1st Dept. of Surgery, Kumamoto Univ.School of Medicine, Kumamo, Japan

During the 22-year period from 1971 to 1992,hepatic resections

and regional lymphadenectomies were performed on 29 patients

with intrahepatic cholangiocarcinoma including 11 cases of the

hilar type and 18 cases of the peripheral type.

Among them, 59% had lymph node metastasis (64% in the hilar

type and 56% in the peripheral type).Nodal involvement were

recognized in the hepatoduodenal ligament(76%),node around

hepatic artery(65%),para-aortic node(47%)and posterior

pancreaticoduodenal node (41%).

The pathways of lymph node metastasis were subdivided into the

following four routes ; Route 1 (to the para-aortic node along the

subphrenic artery); Route 2 (to the celiac node from cardiac node

along left gastric artery); Route 3 (to the lymph node around the

common hepatic artery via the hepatoduodenal ligamant); Route 4

(to the posterior pancreaticoduodenal node via the hepatoduodenal

ligament).

As a result, all routes were recognized in the hilar type and left

peripheral type,but route 3 and 4 in the right peripheral type.

It can be concluded that lymphadenectomy along the route 3 and

4 is necessary in the right peripheral type, and in the hilar or left

peripheral type lymphadenectomy not only along the route 3 and

4 but also the route 1 and 2 should be performed.

F22

Surgical Management of Cholangiocellular Carcinoma, Study of Its Location and Patterns of Extention

Tetuaki Hashimoto, Setuo Okada, Hisao Wakabayashi, Seiji Mori, Atushi Misawa, Takashi Maeba, Satoshi Tanaka The First Dept. of Surgery, Kagawa Medical School, Kagawa, Japan

Twenty-four cases of cholangiocellular carcinoma (12 men and 12 women) were treated in our institute. Operation was performed on 15 patients (62.5%). In this study cases were divided into 2 groups in accordance with its location in the liver, the hilar type and peripheral type. In each group the patteren of tumor extention was examined, and how the operation can be done was studied. Although the hilar type of the cholangiocellular carcinoma should be differenciated from the hilar cholangioma, this type needs to be operated in the way for cholangioma. In the peripheral type of cholangiocellural carcinoma, large extention in the Glison sheeth and distant lymphnode metastasis were found in a few cases. Therefore, it seemed to be important that lobectomy of the liver, resection of the bile duct, and radical dissection of the nerves and lymphnodes in the hepatoduodenal ligament should be involved in the surgical procedure.

65

F23

Mode and Treat=ent of Recurrences Following Curative Resection for Cholangiocellular Carcinoma

Tatsuya Andoh, Eizo Okamoto, Naoki Yamanaka, Tsuyoshi Oriyama, Kazutaka Furukawa, Eisuke Kawamura, Tsuneo Tanaka, Fumihito Tomoda, Nobutaka I chikawa, Wataru Tanaka, Chiaki Yasui and Youichi Kuroda The 1st Dept. of Surgery, Hyogo College of Medicine, N ishinomiya, Japan

Clinicopathological features of cholangio-

celliular carcinoma (CCC) are quite diffe-

re.nt from those of hepotoceilular carcino-

ma (HCC) . This study reports mode of rec-

urrence and prognosis following surgery.

32 patients were undergone hepatic resect-

ion with or without lymphatic dissections No. AGE-SEX T N

in the hila~ to hepatoduodenal area !976

through ~,992. Complete resections were 1 67M 3 0 0 2 62 M 3 0 0

employed on ]3 of them. Their clinicopat- 3 74 M 3 1 0

hological features were shown in Table I . 4 60 M 2 0 o

Site of recurrences following 1 3 complete 5 66 F 2 0 0

resections was categorised into three gro- 6 67 F 3 0 0

ups; intra hepatic recurrences (IHR} alone 7 62M 2 0 0

in I , extra hepatic recurrences (EHR) alo- 8 44 F 2 0 0 9 68 M 3 0 0

n e i n 2 , a n d b o t h I H R a n d E H R i n 8 . M a j o r 10 G5 F 1 0 0

sites of EHR included lung, pleura, hilar n 37F 4 0 0

lymphnodes and bones. There were no sig- 12 51 F 4 2 0

nificant differences in prognosis between 13 52 v 4 i 0

IHR and EHR group. Mean time of recurren- * [ HR : intra hepatic recurrence

ces was earlier in IHR group ( 6 month )

than EHR group ( I I month ) . Therapies for

recurrences included systemic chemotherapy

�9 radiation �9 embolization and resection,

which were less effective as compared with

those for recurrences in HCCs. Survival

rates at 5 year showed 6 % for overall.

Table-i C linicopathological features of 13 patients ~ith curative resection

M STAGE I H R * E H R * P~OGNOSIS

+ + 108m death

m + - 8 m death

m + + 12m death

H + + IYm death

H + + i g m death

I V - B + + 24m death

+ + 24m death

H - + l l m death

m + + 12m death

I - - 36ra a l i v e

I V - A - - 27ra alive

IV- B + + 7 m death

IV- A - + 9 m death

E H R : extra hepatic r e c u r r e n c e

66

F24

Clin ica l S t u d y of C h o l a n g i o c a r c i n o m a

Naoharu Mori, Akihiro Yamaguchi, Masatoshi lsogai, Akihiro ttori, Atsuyuki Maeda, Masami Kawai, Manabu Takano, Ryuzo Yamaguchi, Tomoyuki Kubota, Ta t suha ru Yamada, Yukihiro Yokoyama and Kazuya Matsunaga Depa r tmen t of Surgery, Ogaki Municipal Hospital, Ogaki, J apan

This s tudy retrospect ively assessed the clinico-

pathological f indings of cholangiocarc inoma. Between 1982 and 1992, 16 pa t i en t u n d e r w e n t t r e a t m e n t in

our surgical unit . There were 10 m en and 6 women,

ranging in f rom 43 to 78 years. Tumor in the left lobe was seen in 10 cases, in the r ight lobe was seen

in 6 cases. There was only one case with in t rahepa t ic

bile duc t stone. According to "General Rules for the Clinical and Pathological Study of Pr imary Liver

Cancer" in Japan, there were one pa t ien t at Stage I, 2 pa t ien ts at Stage II, 6 pa t ien ts at Stage III, 5 pa t ien ts at

Stage IV-A and 2 pa t ien ts at Stage IV-B. Radical

resect ion was pe r fo rmed in 9 cases. Palliative

p rocedure was pe r fo rmed in 6 cases, and explora tory

l aparo tomy was done in only one case. The morta l i ty

ra te was 6.25%. The 3-year survival ra te for pa t ien ts

with radical resect ion was 62.5%. However, all pa t ients receiving pall iat ive surgery died wi th in pos topera t ive

two y e a r s .

F25 Clinicopathological Study of Peripheral Cholangiocarcinoma

Yuuki Takeuchi, Toshiaki Nonami, Akio Harada, Akimasa Nakao and Hiroshi Takagi Department of Surgery II, Nagoya University School of Medicine, Nagoya, Japan

Cholangiocarcinoma (CC) is a malignant epithelial neoplasm arising from the epithelial cells of the bile duct. Intrahepatic CC is divided into peripheral and hilar types. In this study, we describe clinico-pathological features of intrahepatic peripheral CC including treatment and prognosis. We encountered thirty-nine patients with intrahepatic CC at the Nagoya University Hospital between 1981 and 1992; twenty-two patients with peripheral type and seventeen with hilar type. Among ten patients (45.5%) who had undergone hepatectomies, one was stage II, one stage III, two stage IV-A, and six stage IV-B according to the pTNM classification for primary liver cancer. Six of them had lymphonode metastasis (more than N2) and this contributed significantly to non- curative resection. None of them had cirrhotic liver. Among seven patients with detailed histological studies, one had well differentiated adenocarcinoma, while three had moderately and

three poorly differentiated ones.. Their prognosis tended to be worse with poorer tumor cell differentiation. The invasion pattern was different from that of hepatocellular carcinoma; two had lymphatic tract invasion, two portal vein invasion, one Glisson's ligament invasion, and one in which the invasion replaced the epithelial cells of the bile ducts. The curative surgical operations presented difficulties because most patients in the advanced stages, then they tended to have early recurrences and poor prognosis. So we consider that preoperative and adjuvant chemotherapies are neccesary to improve their prognosis. In twelve patients without hepatectomies, six patients with hepatic arterial chemotherapy and three with transcatheter hepatic arterial embolization had longer survivals. We propose that patients with CC require radical surgery with sufficient lymphonode resection and aggressive chemo-therapies should be undertakenn for patients with unresectable CC.

67

F26

Macroscopic Classification of Intrahepatic Cholangiocarcinoma A proposal for new classification

Tomoko Ogawa, Masami Tabata, Shuji Isaji, Hajime Yokoi, Yoshifumi Ogura, Takashi Noguchi, Yoshifumi Kawarada and Ryuji Mizumoto The 1 st Department of Surgery, Mie University, Mie, Japan

Macroscopic classification of intrahepatic cholangiocarcinoma (ICC) has not yet been clearly defined because of the small number of such cases. As a result, in Japan the classification of hepatocellular carcinoma has been adopted temporarily. In the present study, macroscopic and pathological findings of 21 patients with ICC were reviewed in an attempt to propose a more accurate classification of this disease.

Materials and Methods: Among 34 patients with ICC admitted to our hospital over a period of 16 years and 7 months, 21 (62%) underwent hepatic resection. These 21 resected cases were divided into two groups according to the location of the main tumor in the liver: central tumor (7 cases) and peripheral tumor (14 cases). Moreover, they were classified by the macroscopic findings of the lesions in the hepatic parenchyma as well as those in the intrahepatic bile duct. The lesions in the hepatic parenchyma were divided into three types: nodular, massive and diffuse types. Furthermore, the nodular type was classified into three subtypes: single nodular, nodular invasive and multinodular fused types. The lesions in the intrahepatic bite duct were divided into five types: papillary, nodular, papillary invasive, nodular invasive and invasive types. Additionally, macroscopic tumor findings of 38 resected cases with carcinoma of the hepatic duct confluence experienced during the same period were compared with those of the central tumor of ICC. Also examined were 35 cases of ICC among

8045 autopsies during the past 10 years.

Result: Our findings revealed that the most frequent type of lesion in the hepatic parenchyma was the nodular invasive in both peripheral and central tumors (43% and 57%). Whereas, by adopting classification of hepatocellutar carcinoma, the predominant type was the massive type. In the present study, however, by taking the intrahepatic bile duct lesion into consideration, some cases with this type were found to be the nodular invasive. The predominant type of the lesions in the intrahepatic bile duct was the invasive type in both peripheral and central tumors (50% and 71%). In cases with peripheral tumor, two cases of secondary dilatation of the intrahepatic bile duct, one due to papillary and the other due to nodular tumors, were observed. All cases with central tumor showed massive invasion of the bile duct wall. In carcinoma of the hepatic duct confluence, the major type was the invasive type (50%), but papillary and nodular tumors without invasion of the bile duct wall were observed in 4 cases each.

C o n c l u s i o n : Since some cases with central rumor are especially difficult to distinguish from carcinoma of the hepatic duct confluence, in categorizing ICC, it is very important to classify the tumors according to the different findings of each in the hepatic parenchyma and those in the intrahepatic bile duct. This procedure will afford a more accurate classification of ICC.

F27

Two Types of Intrahepatic Bile Duct Carcinoma : Solid and Cystic

Junichi Kamiya, Yuji Nimura, Naokazu Hayakawa, Satoshi Kondo, Masato Nagino and Michio Kanai

The 1st Dept. of Surg., Nagoya University School of Medicine, Nagoya, Japan

Intrahepatic bile duct carcinoma can be classified as solid or cystic by imaging techniques or macroscopic f indings of resected specimen. We performed c l in ico- pathological studies on 32 patients with the carcinoma who u n d e r w e n t h e p a t e c t o m y at our d e p a r t m e n t .

[Patients] From September 1979 through March 1993, 103 patients with bile duct carcinoma underwent hepatectomy at our department. 24 cases (23%) were solid type carcinoma, and 8 cases (8%) were cystic. The age of the patients with the solid type ranged from 34 to 73 years (mean, 61 years), and that of patients with cystic type from 36 to 73 (mean, 67). 15 patients (62%) with the solid type were women, and 5 pat ients (63%) of the cyst ic type were women.

[Solid type] The main tumor located in the anterior segment was observed in 9 cases (38%), and 8 cases (33%) in the medial segment. Obstructive jaundice were observed in 14 cases (58%) and percutaneous transhepatic biliary drainage was performed in all of them. 19 cases (79%) received hepatic lobectomy or extended lobectomy. Resection and reconstruction of the portal vein was performed in 7 cases (29%). Perineural invasion was observed in 20 cases (83%), and lymph node

nodes. The 3-year and 5-year survival rates for alI 24 cases were 41% and 12%, respectively.

[Cystic type] The main lesion was observed in the caudate lobe in 4 cases (50%). We performed percutaneous transhepatic cholangioscopy (PTCS) in all of 8 cases to make a precise diagnosis. 4 cases received extended left lobeetomy with total caudate lobectomy. In 2 cases carcinoma spread superficially along the bile duct mucosa, which was able to be diagnosed by PTCS. Perineural invasion was observed in 3 cases (38%), whereas lymph node metastasis was observed in only one case. 5-year survival rate for all 8 cases was 75%.

[ C o n c l u s i o n ] Two types of in t rahepat ic bi le duct carcinoma demonstrate different clinicopathologicai features. Preoperative diagnosis and surgical treatment for them should be planned according to their characteristics.

68

F28

I n t r a h e p a t i c C h o l a n g i o c e l l u l a r e C a r c i n o m a

Ikuo N agas hima, Tosh iyuk i S umita, Mo toh ide S odey ama ,

H ideak i S aito, N o b u h i r o K a w a n o and Te tsu ich i ro Muto

The F i r s t Depa r tmen t of Surgery , U n i v e r s i t y of Tokyo, Tokyo, Japan

We r e v i e w e d twe lve cases with in t rahepa t ic

cho l ang ioce l l u l a r e ca r c inoma u n d e r g o i n g su rge ry

be tw een 1970 and 1992 at our depa r tmen t . And we

r e c o g n i z e d some f o l l o w i n g po in t s .

1 ,pe r iphe ra l type (n=7) ; 1)No pa t ien t was not

j aund iced but 30% had cho le l i th i a s i s . 2)Due to high

rate of bi l iary in f i l t ra t ion (100%) and lymph node

metas tas i s (70%), cura t ive r e sec t i on was rare.

3 )CA19-9 was p o s i t i v e in 100%,each of AFP and

CEA was pos i t i ve in 50%. 4 )Diagnos t i c imag ing was

s imilar to that o f metas ta t ic l iver tumor f rom

adenoca rc inom a .

2 , p r o x i m a l type (n=5); 1)No pa t ien t had

cholel ithiasis but 40% was j a u n d i c e d at d i a g n o s i s .

2 )Desp i t e of bi le i n f i l t r a t i on , cu ra t i ve r e s e c t i o n was

p o s s i b l e if su rg ica l marg in was f ree f rom ca rc inoma.

3 )Tumor marker was rare ly p o s i t i v e (0 -20%) ,

4 ) H y p e r e c h o i c mass in the bile duct and d i la ta t ion of

its d is ta l bile duct were spec i f i c f i n d i n g s by

u l t r a s o n o g r a p h y .

3 ,Ear ly d i a g n o s i s by u l t r a s o n o g r a p h i c s c r e e n i n g

s h o u l d be impor t an t in future .

F29 The Mode of Spread of Cholangiocellular Carcinoma and the Strategy for Surgical Treatment

Muneki Yoshida, Tsuyoshi Takahashi, Kazunori Fnruta, Hisanao tzumika, Harumi Omiya, Yoshiki Hiki and Akira Kakita

Dept. of Surg., Kitasato Univ., Kanagawa, Japan

Twenty-two consecutive patients with Cholangiocellular

Carcinoma (CCC) were surgically treated at our institute between

1971 and 1992. The tumor originated from the hilar portion of the

liver in 8 patients (Hilar type) and from the periphery of the liver in

14 patients (Periphery type). Of the 22 patients, 10 patients (45.5~)

underwent resection of the tumor with curative intent (the resected

group) and 12 patients (54.5~) underwent laparotomy and/ or pal-

liative procedures aimed at relieving the biliary obstruction (the

non-resected group). [resected group] All patients underwent major liver resections to

macroscopically encompass the tumor. Four patients underwent a com-

plete tumor resection, while other 6 patients had palliative resection

because of positive surgical margin. In- hospital mortalities were en-

counterd in 3 patients. Exept for a patient who is alive for 27 months after the operation, all

of the patients surviving the operation died of recurrence of the dis.

ease after 5-25 months of the operation with the median survival of

12.8 months. The recurrence was seen in the liver, lung, bone and skin in this group. And the local recurrence of the surgical margin was also seen in all patients of the Hilar type. Histological investigation at

the time of the operation showed the tumor widely spreading into Glis-

son' s capsule as the characteristics of the disease. It is suggested that invasion to the vessels of Glisson' s capsule caused the tumor recurr-

ence after the operation. [non- recected group] Inspite of the effort of intensive adjuvant

therapeutic modalities such as radiation, chemotherapy and hyper-

thermia, the prognosis of the non- resected patients was very poor. 11

out of 12 patients died of the disease within l l months after the op-

eration with median survival of 4.1 months. Oly one patiet treated by

eholangioenteric bypass with partial resection of the tumor is alive for

11 months after surgery. [conclusion] CCC tends to widely spread within the liver throuth

Glisson' s capsule. The tumors were rapidly fatal when they were left

utreated, and no survival advantage was seen when macroscopic

tumor was left behind at the operation. However, patients with microscopically positive margins of resection fared equaly well as patients recieving complete resection. Therefore,

resection of the tumor should be considered as much as possible, even

if the operation will turn out to be non- curative due to positive sur

gical margins.

69

F30

C t i n i c a l C h a r a c t e r i s t i c s and Treatment of the P a t i e n t s with I n t r a h e p a t i c C h o l a n g i o c e l l u l a r Carcinoma

Tsunetake Hata, Yoshie Une, Yasuaki Nakajima, Naoki Sate , Michiaki g a t s u s h i t a , Toshiya Kamiyama, Tsuyoshi Shimamura, Takahiro Nakagawa, Kazuhito Uisawa and Jun ich i Uchino The 1st Dept. of Surgery, Hokkaido Un iv . ,Sappo ro , J apan

Over the pas t 20 years , in our department, we have t r e a t e d 26 cases with i n t r a h e p a t i c cholan- g i o c e l l u l a r carcinoma. In these 26 cases , hepa t i c r e s e c t i o n s (HR) were performed in t0 cases and hapa t i c a r t e r i a l c a n n u l a t i o n s under laparotomy(H Ac) were performed in 8cases. In t h i s s tudy , c ! i n i c a l c h a r a c t e r i s t i c s and t rea tment were examined on 18 cases (HR-IO, HAC-8) t r e a t e d by ope ra t ions .

Two cases were c l a s s i f i e d as s t a g e ~ , four as s tageIlI , n ine as IV A, three as IV B according to the c l a s s i f i c a t i o n p r e s c r i b e d in the general ru l e s for the c l i n i c a l and pa tho log ica l s tudy of primary l i v e r cancer in Japan. The reasons for u n r e s e c t a b i t i t y were tumor i n f i l t r a t i o n to the e n t i r e l i v e r (4cases) , i nvas ion to i n f e r i o r vena cava (2 cases) and p e r i t o n e a l d i s s e m i n a t i o n (2 cases) . In r e sec ted cases, r e s e c t i o n s beyond lobectomy were performed in a l l cases except for one, and a caudal lobe r e s e c t i o n was also per - formed in one case. Seven of the cases were non-

(2cases ) .For RNG , t h e r e were 3 cases of p o s i t i v e TW and 1 case of d i s t a n t m e t a s t a s i s r e s e c t i o n . The mean su rv iva l per iod was 15.6 months in re - sected cases (except ANC) and 9.9 months for unresec ted cases. In the c u r a t i v e ' c a s e s , the mean s u r v i v a l per iod was able to be extended to 19.9 months compared with 11.4 months in nNCcases.

Despite the f ac t tha t the i n t r a h e p a t i c cholan- g i o e e l l u l a r carcinoma of the p a t i e n t s in t h i s study was d iscovered in a very advanced s t a t e and the prognos is was poor, i t was p o s s i b l e to prolong the su rv iva l ra te through c u r a t i v e re- s e c t i ons . This s tudy shows the importance of de- t e c t i n g p a t i e n t s with r e s e c t a b l e i n t r a h e p a t i c c h o l a n g i o c e l l u l a r carcinoma, and performing cu ra - t i v e ope ra t ions .

F31 A Clinical Study on Choledocholithiasis Following Gastrectomy

Takayoshi hkiyama, Keitarou Seto, Hitoshi Saitou. Masato Kiriyama, Fujio Tomita, Taken Kosaka, tchirou Kits and Shigeki Takashima The Dept. of General and GastroenterologicaI Surg., Kanazawa Me&Univ., Ishikawa, Japan

It is genera l ly said that gastrectomy increases the

incidence of the gallstones. We previously reported a study

on the etiology of cholecystolithiasis following gastrectomy

from the view point of gallbladder %nction. In order to

c la r i fy the etiology of choledocholi thiasis following

gastrectomy, we investigated the pat ients with chole-

l i thiasis following gastrectomy experienced at our hospital

in this study. We have experienced 61 cases of chole-

l i thiasis folowing gastrectomy in 9 years. The locations of

stones in these 61 cases were as fol lows:cholecysto-

li thiasis;31 cases(50.8%), choledocholithiasis;4 cases(6.6

%), choledochocystol i thias is ;24 cases(39.3%), hepato-

!ithiasis;2 cases(3.3~. In patients of choledocholithiasis

following gastrectomy, the ages were older, intervals from

gastrectomy to development of stones were shorter, and

diameters of the common bi le ducts were larger than in

pat ients of chelecystol i th ias is following gastrectomy.

~oreover, choledocholithiasis were developed more frequently

following gastrectomy with lymph-node dissection for gastric

cancer or total gastrectomy than following gastrectomy

without lymph-node dissection for benign gastic disease or

partial gastrectomy. Pigment stones and bi l iary infection

were more frequent in choledocholithiasis than in cholecysto

- l i th ias i s following gastrectoy. The fact that choledocho-

l i t h i a s i s were developed more f requent ly fol lowing

gastrectomy with lymph-node dissection for gastric cancer

than following gastrectomy for benign gastr ic disease

suggested that denervation due to lymph-node dissection on

gastrectomy for gastric cancer faci l i ta ted development of

choledocholithiasis.

7O

F32

Comparison of Complications and Nutritional State after Pancreatoduodenectomy and Pylorus--preserving Pancreatoduodenectomy

Koichiro Misuta, Akira Nakano, Hitoshi Sekido, Ataru Endo, Yasuhisa Mochizuki, Tadao Fukushima and Hiroshi Shimada

The 2nd Dept. of Surgery, Yokohama City Univ., Yokohama, Japan

Even in our insti tution pylorus -- preserving

pancreatoduodenectomy (PPPD) has become prevalent instead

of s tandard pancreatoduodenectomy ( P D ) . We evaluate

morbidity and nutri t ional state in 25 patients underwent PD

or 14 patients underwent PPPD, for pancreatic and

periampullary cancer and chronic pancreatitis, from 1983 to

1993. There were no difference in age, sex, pr imary disease

and tumor stage between patients undergoing PD or PPPD.

Median follow--up was 12 months. In the early complications,

the incidence of leakages at the pancreatojejunostomy was

higher after PD (8 cases, 32%) than that after PPPD (none).

The delay in gastric emptying lasting for more than 2 weeks

was observed in 8 patientg who underwent PPPD, bu t this

usually resolved within 4 weeks. In the late complications,

malnutri t ion occurred after PD in three patients without

cancer recurrence, and ulceration at the duodenNejunal

anastomosis occurred after PPPD in only one patient. There

is no difference of total protein and serum albumin after a

month post--operat ive period between two groups. However

the loss of body weight after PPPD was less than that after

PD, even in the respect of difference of diseases and

radicality of lymph nodes dissection. In conclusion, incidence

of complications was low after PPPD, and the short and long

term beneficial effects of PPPD on pat ient well being and

nutri t ional state were confirmed. It is possible to t reat with

chemotherapy, irradiation and hyperthermia in the early stage

after PPPD for pat ients with malignant disease.

F33 Vascular Reconstruction Using Technique of Microsurgery for Surgical Treatment of Pancreatic Cancer

Eiji Shimozawa, Hiroyuki Kato, Takehiko 0oura*, Kunihiko Nohira *~, Yoshinao Shintomi** The 2nd Dept. of Surgery, Dept. of Plastic Surgery ~, Hokkaido Univ.,Soshundo clinic**, Sapporo, Japan

Many of the patients with pancreatic cancer can not be resected because of perineural invasion and vascular invasion. However, surgical excision with vascular resection improves the prognosis of pancreatic cancer. In recent 9 months, 4 patients with pancreatic cancer were treated by surgical resection with vascular reconstruction using technique of microsurgery. The method and some ideas were presented.

(Patients) There were 2 men and 2 women, with a mean age of 58 years (range, 48-63). In one patient, pancreaticoduodenectomy was performed; in 3 patients total pancreatectomy was done.

(Techniques and ideas) i) After resection of invased hepatic artery, right hepatic artery was reconstructed by anastomosis with ist jejunal artery, which was existing in the pedicle of choledochojejunostomy. 2) Left hepatic artery was reconstructed by saphenous vein graft with common hepatic artery. 3) In a case of total pancreatectomy, superior mesenteric artery (SMA) was reconstructed by the splenic artery graft,

which was obtained from the resected pancreas. 4) Portal vein was reconstructed by the splenic vein graft, which had several ramifications, between portal vein trunk and several ramifications of superior mesenteric vein. 5) After resection of invased SMA, SM~o was anastomosed with splenic artery, obtained from total pancreatectomy.

(Discussion) i) Vascular reconstruction using technique of microsurgery is highly successful method. 2) Even in the abdominal surgery, microsurgery is successful in cooperation with anesthesiologist to overcome the respiratory movement. 3) Splenic vein and artery graft with several ramifications is useful to reconstruct several arteries and veins. 4) Adequate diameter in the anastomosis should be obtained. In the inadequate cases, we experienced liwer dysfunction and intestinal congestion.

71

1=34

Operative Management for Massive Intraabdominal Hemorrhage after Pancreaticoduodenectomy

Toshihiko Yasuda, Kogoro Kasahara, Hideo Nagai, Yasuo Kondo, Kyotaro Kanazawa

Department of Gastrointestinal & General Surgery, Jichi Medical School

In spite of recent advances in perioperative

management, pancreaticoduodenectomy might

occasionally bring about fatal complications

postoperatively. A leaking pancreatic anastomosis,

most life-threatening, may cause massive

intraabdominal hemorrhage or intracable peritonitis

with sepsis. However, there has never been a

widely-acceptable definitive way to treat with this.

We applied a operative management to 5 patients

developing massive bleeding following

pancreaticoduodenectomy, who were encountered in

1988 to 1992. Firstly, emergent abdominal

angiography was performed to confirm bleeding

vessels (GDA, CHA or PV) and if possible, to

occlude it by coils or gelforms. On laparotomy,

pancreaticojejunostomy was taken down, followed by

cyanoacrylate injection into the duct and closure of

the pancreas stump. Four of 5 patient recovered well,

but the other one died of uncontrollable bleeding

from the IVC after several laparotomies.

We report our operative management in detail for

massive bleeding postpancreaticoduodenecotmy, and

discuss long-term effects of the procedure on

exocrine and endocrine pancreatic function.

F35

Reconstruction of Portal Vein for Advanced Pancreatic and Biliary Tract Carcinoma

Kenji Yuzawa, Takeshi Todoroki, Masaaki Otsuka, Mutsumi Nozue, Toru Eawamoto, Shuji Kato, Katashi Fukao, Kenmei Kuramoto* Dept. of Surg. and *Radiol., Inst. of Clin. Med., Univ. of Tsukuba, Tsukuba, Japan

Portal vein resect ions and reconstruct ions external i l i ac vein graft and umbilical were performed in 17 pat ients in extended vein patch graft , tn an end-to-end radical operations and/or in t raopera t ive anastomosis, one suture was placed at each radia t ion therapies for advanced pancreat ic corner of the vessel to be sutured. The and b i l i a ry t r ac t carcinoma (pancreas for 3, pos ter ior wall sutures of the vessels were bile duct for 8, gal lbladder for 6) from performed from within the lumen with the January 1991 to March 1993 at Tsukuba continuous ve r t i ca l -ma t t r e s s sutures for Universi ty Hospital. Resected portal veins the eversion of the pos ter ior anastomosis. were main trunks in 14 pat ients and right The over-and-over running sutures were made or l e f t main branches in 3 pat ients . We on the anter ior wall. Completing the used portal vein bypass in 2 pat ients with anastomosis, to prevent the stenosis, we resect ion of main trunks, using heparin- used a ~growth factor , ~ that is, the suture bonded tube from superior mesenteric vein used for anastomosis is t ied some distance to umbilical vein. Portal veins were away from the wall of the vessel (one half anastomosed in an end-to-end fashion if to one diameter). Using this technique for reconst ruct ion could be performed without portal venous reconstruct ion, we did not any s t re tch on the anastomosis. If have the major adverce resul t from the impossible, we implanted the auto-venous reconstruct ion. In this presentation, we graf t for reconstruct ion. Reconstructions will analyze our experiences with the were performed by end-to-end anastomosis in portal vein reconst ruct ion and will report 14 and by graf t ing of auto-venous in 3. As our technique for the reconstruct ion. the graft for portal vein reconstruct ion, we used greater saphenous vein graft ,

72

F36 Portal vein Resection and Arterialization in Patients with Biliary Tract and Pancreas Cancer

Yasuo Kasano, Hiroshi Tanimura , Katsutoshi T a n i g u c h i Motonori Hayashido, Katsunari Takifuj i ,

Department of Gastroenterological S u r g e r y , Wakayama, Japan

Takashi Ozaki

For 7 years between 1986 and 1993, 59 patients with pancreas head and body cancer admitted our hosp i t a l .

Twenty five patients were performed pancreatoduodene-

ctomy (PD) and in 6 patients portal vein was r e sec ted .

During the same period in 32 of 71 pat ients wi th

biliary tract cancer PD was performed. Two patients

were r e sec t ed their portal vein and in 8 patients

hepatectomy were done at the same time. In the 8th

case of HPD portal ar ter ia t izat ion was added.

By the" portal vein resec t ion , we could reach n~c ro -

scopic curative operation and there was s ignif icant

d i f fe rence in the mortality rate between pall iat ive

operation and portal vein r e sec t ion groups, but non-

portal vein resect ion group. Re-cons idera t ion of

operative indication, isolated pancreatectomy and

postoperat ive adjuvant chemotherapy should be need

for be t te r mortal i ty r a te .

The cases of HPD which were combined hepatic

t r isegmentectomy have fallen into hepatic failure

because of insufficiency of hepatic blood flow at the

postoperat ive early s tage and the postoperative

survival has been best on 185 days . Thus, to avoid

this problem we performed portal ar ter ia l izat ion and

could avoid hepatic failure in a pa t ient , who is doing

well 450 days postoperat ively.

Poster session

FP1

Neurotensin Secretion After Pancreatoduodenectomy

Tomosaburo Sakamoto, Masahiko Miyata, Masaaki Izukura, Yasuhiro Tanaka, Shin Mizutani, Harumi Tominaga, Katsuhide Yosidome, and Hikaru Matsuda The First Dept of Surg., Osaka Univ. Medical School., Osaka Japan.

Neurotensin (NT) is one of gut hormones which secretes from lower small intestine. NT is known to have both trophic effect on normal pancreatic tissue and growth effect on pancreatic cancer cells. We have reported that the obstructive jaundice produced the hypersecretion of NT in patients with pancreatic head cancer. However, NT secretion after pancreatectomy is not yet elucidated. In the present study we investigated the NT secretion before and after pancreatoduodenectomy (PD) in patients without obstructive jaundice. Materials and Methods: In eight patients with pancreatic head cancer who had not obstructive jaundice, secretion of NT was investigated before and after PD (mean 6 weeks). Fifty ml of fat (Lipomul| was given orally, and plasma levels of NT were serially measured by radioimmunoassay for 180min. Ten healthy volunteers were served as normal controls. Integrated incremental values from 0 to 180min (z,~NT) and maximum respondal value (peak value minus basal value, MAXANT) were calculated in individual cases.

Results:

N.C. Before PD After PD (n=10) (n=8) (n=8)

~.ANT 2.02+_0.23 2.77+_0.77* 13.63+_5.08" (ng mintml) ** **

MAXA NT 22.7+_3.0 40.5+_11.3* 293.8+_127.2* (pq/ml) ** **

N.C. : Normal Controls * P<0.05 vs Normal Controls ** P<0.05 vs After Operation

Summary: Both z3NT and MAX~NT after PD were significantly higher than those before operation and in normal controls. Conclusion: Pancreatoduodenectomy increased NT secretion induced by fat ingestion.

73

FP2

Serum Inflammatory Cytokine Levels and Hepatic Function in Severe Sepsis 1) Yasuyuki Shimahara, 2) Masato Ichimiya, 2) Maeng-Bong Jin, 2) Koichi Kinoshita, 2) Keiichiro Moil, 2) YoshioYamaoka, 1) Nobuaki Kobayashi, 3) Kazue Ozawa : 1) The First Department of Surgery, Ehime University, 2) The Second Department of Surgery, KyotoUniversity, 3) Shiga Medical College

Inflammatory cytokines have been recognized as very important mediators to initiate a number of biological responses involved in severe infection. On the other hand, liver has a potent capacity to respond to an increased metabolic load caused by severe infection. In this study, a relationship between serum cytekine levels and hepatic mitochondrial redox potential was investigated by measuring serum TNF, IL-1, IL- 6 and arterial blood ketone body ratio (AKBR) which reflects hepatic mitochondrial redox potential in the postoperative or end stage of carcinoma patients with severe infection and sepsis.

The subjects are patients with sepsis who received major operation including hepatic resection or were treated for end stage of carcinoma. In these patients, a total of 83 times of arterial blood sampling was performed in various states of clinical courses to the death. Serum levels of TNF, IL-1, IL-6, and AKBR were measured. The blood samples were classified into 4 groups: Group N with AKBR of larger than 1.0 (n=23), Group A with AKBR between 1.0 and 0.7 (n=14), Group B with AKBR between 0.7 and 0.4 (n=22), and Group C with AKBR of below 0.4 (n=24). The serum levels of TNF, IL-1 and IL-6 were analyzed in relation to the level of AKBR.

In the three cytekines, IL-6 responded most sensitively and drastically along with the progress of sepsis.The levels of IL-6 are 204___ 80, 402 + 185, 1301 ___ 340 and 34216 -+- 12975pg/ml in groups N,A,B and C, respectively (Groups B and C, P<0.001 as compared to that of Group N). In Group C, 58 % of the cases exhibited more than 5000 pg/ml of serum levels of IL-6 with the maximum of 199000 pg/ml. The analysis limit of serum IL-1 is 10 pg/ml. The percentage of the samples which could be determined was 26, 29, 23, 25 % in groups N, A, B and C with the serum levels of 17__.3.7, 21.3--+3.8, 13.2___

2.8, 90.7-+73 pg/ml. In the same way, the analysis limit of serum TNF level is 5 pg/ml and the percentage of the cases which could be determined was 8.6, 21.4, 36.4 and 62.5 % in groups N, A, B and C with the serum levels of 5.5-+ 0.7,

11.3-+4.2, 14.1-+2.6 and 33.6___ 14.0 pg/ml. It was clarified that serum levels of inflammatory cytekines

tended to be higher along with decrease in AKBR. Especially, there is a close relationship between the serum level of IL-6 and AKBR. These results suggest that production of inflammatory cytokines is closely related to deterioration of hepatic function.

FP3

C a n c e r o f the M i n o r P a p i l l a o f V a t e r ; R e p o r t o f a C a s e

Norih iko Kawabe, Sumio Matsumoto, Kiyoshi Matsumoto, Yoshihiko Yoshida, Makoto Sano, Kenj i Meri, Norio Tsukada, Hiroaki Ki tagawa, Yuhou Mizuno, Tadahiro Kimura, Hiroichi rou Suzuki, Tetsuya Banno Dept. of Surg., Fu j i ta Health Univ. School of Medcine , Second Teaching Hospi ta l , Nagoya, Japan

The case is a 78-yea r -o ld man was admi t ted to our hospi ta l with a compla in t of pol lakiur ia . Cystoscope showed chronic cys t i t i s . Under t r ea tment , he com- p la ined of ep igas t ra l d i scomfor t . F ibe r scop ic examina t ion of upper gas t ro i n t e s t i n a l t rac t r e v e a l e d a pro tuberant Iesion with u lcera t ion in the descending pa r t o f d u o d e n u m , and the b i o p s i e d s p e c i e m e n s f r o m s u r f a c e of the l e s i o n c o n f i r m e d an a d e n o c a r c i n o m a . H y p o t o n i c d u o d e n o g r a p h y showed we l l - de f ined 1 5 • s ized tumor above pap i l l a Vater . E n d o s c o p i c r e t r o g r a d e c h o l a n g i o p a n c r e a t o g r a p h y r e v e a l e d and open ing of minor p a n c r e a t i c duct in the cen t r a l par t o f the tumor . Serum CA19-9 and CEA leve l s were wi thin normal l imi ts . Any metas - tatic lesion was not de tec ted in pro-opera t ive examinat ion. P y r o l u s - p r e s e r v i n g p a n c r e a t o d u o d e n e c t o m y was c a r r i e d out. The l e s ion was 15*12mm in size. H i s to log ica l examinat ion : Tubu la radenocarc inoma, W e l l - d i f f e r e n t i a t e d type , M e d u l l a r y type , pane(2) ,

d(3), I N F ( / 3 ) , ly (1) , v(0) , pn(0) , g i n f ( 0 ) , h in f (0 ) ,

ow(-), aw(-) , ew(-), n ( 1 ) ~ stageIII ( c l a s s i f i ed by G e n e r a l Ru le s f o r S u r g i c a l and P a t h o l o g i c a l

Studies on Cancer of B i l i a ry Tract --- Japanese So- c ie ty of B i l i a ry Surge ry ) . In r ev i ewing the only 2 cases of cancer of minor pap i l l a of Vater prev ious- ly repor ted in Japanese and English l i terature.

74

FP4

The Similar Lesions of Hepatocellular Carcinoma in the Youth

Tsuyoshi Takahashi, Hiroshi Hiraoka, Nobuyoshi Morita, Shinji Noshima, Hidetaka Shinagawa, Kensuke Esato

1st Dept. of Surgery, Yamaguchi Univ. School of Medicine, Ube, Japan

We experienced two cases of the similar 1 esions of

hepatocellular carcinoma (HCC) in the youth.

[Case 1] A 21-year-old woman complained of an

epigastric painless tumor. The patient had never taken any

hormonal drugs such as contraceptives. Preoperative

examination revealed a hypervascularized liver tumor in the

medial segment, and left lobectomy was performed. A

cirrhotic apperance was not seen in the non-tumorous part of

the liver. Although the lateral segment was atrophic, the

right lobe was almost normal and no daughter nodules were

detected macroscopically and ultrasonographically. Histologic

examination of surgical specimen showed cord-like growth

of tumor cells, which resembled hepatocytes and were

devoid of any atypism and capsular invasion.

[Case 2] A 20-year-old man complained of a general fatigue.

Further examination revealed a hypervascularized liver tumor

in the posterior segment. Angiography showed spoke-wheel

appearance which suggested focal nodular hyperplasia (FNH).

Laparoscopicliver biopsy was performed. Pathological

diagnosis was FNH. He is followed in the outpatient.

Dignosis and treatment were discussed about these two

young patients.

FP5

l'he Spectrum of' Pancreas Cyst

Tosio ~iki , Yutaka !to, Seigo Takano, Tokio Higaki, Masanori Moriguti, and Tomohide Takahasi The 3rd Dept. of Med., Niilen Univ., Tokyo, Japan

Within a 15-year period we treated 33 patients with pancreas cyst, including 21 pancreas pseudocysts, 6 true cysts, 2 cystadenomas, 1 cystadenocarcinoma, and 1 cystadenocarcinoma accompanied with cystaenoma. Pseudocyst ~ad single cyst which did not, show septum formation and homoginous echo free space. CT and Ultrasonograpky(US) was useful for detection, and for showing rim calcfication. Budoscopic retrograde pancreatograhic(ERP) finding of pseudocyst was characterized by epperession and deviation of pancreas duct which was not co~nnnicated with this lesion. Non-neoplastic true cyst showed simple cyst and smmoth

mural nodule. Cystadenoma had various sized septum formation and mural

nodule. Giant sized one shwed ireegular mural nodule and obliterance of pancreas duct. Cystadenecarcinoma showed irregular mural nodule which

had ferny and beak-like projection. ERP finding cystadenocarcinoma was characterized obliterance of pancreatic branch duct and stenosis, encasement of main

pancreatic duct. These results suggest that the evidence of septum and

mural nodules in the pancreatic cysts by US and CT is useful in differentiat ing neoplastic cysts from non-neopla s t i c cyst. The evidence of encasement or obstruction of pancreatic duct is contributed to malignant parameter.

FP6

INTRAOPERATIVE ULTRASONOGAPHY FOR DETECTION OF THE EXTENT OF BILE DUCT CARCINOMA

Toshiomi Kusano, Kaneatsu Honma, Fumio Tokumine, Satoshi Tamaki, Norihiko Okushima, Yoshihiro Mut0, Masato Furukawa* The ist Dept. of Surg., Univ.of the Ryukyus., Okinawa, Japan. Dept.of Surg., Nagasaki Chuo National Hospital., Nagasaki. Japan*

The purpose of this study was to test the clinical feasibility of intraoperative ultrasonography (IOUS) to detect the exact extent of bile duct carcinoma invasion, especially its longitudinal invasion in wall, comparing the characteristics of US images of bile duct cancers to its histological findings of resected specimen.

The records of 14 bile duct carcinomas resected for the last 5 years were analyzed. [0US was done in all patients. The 18 resected specimens were fixed in formaldehyde solution for 24 hours and then processed for a comparison of the US images of the resected bile duct to its histological findings.

The echo levels of primary tumor by IOUS completely coincided with those of resected bile duct specimens fixed in formaldehyde solution. Hyperechoic area (HEA) adjacent to the primary tumor was often revealed in i n v a s i v e t y p e o f t h e p r i m a r y t u m o r ( F i g . l ) . H y p e r e c h o i c a r e a was h i s t o l o g i c a l l y c o i n c i d e d w i t h a l a y e r o f f i b r o t i c h y p e r t r o p h y a r o u n d the primary tumor. Although it was impossible to delineate canser0us invasion itself by IUOS, intramural invasion was not to beyond a high echo area in all patients except 2.

_•u•Hd. Of Echo levels of Presence of Primary tumor adjacent HEA

Tumor type~ high, iso, low.

Nodular (n=4) 1 2 I(25.0%) Nodular Invasive (n=9) 2 3 4 8(66.7%) Invasive (n=5) 2 3 5(100.0%)

Total (n=18) 4 8 6 12(56.7%)

Find.0f U & H : Findings of ultrasonography and histopathology

(Fig.l).

It was concluded that IOUS was feasible in intra0perative detection of the intramural invasion of bile duct carcinoma, helping in the selection of operative procedure especially in bile duct carcinoma at the hepatic hilar region.

75

FP7 Gastroduodenal Artery- and Pylorus-Preserving Pancreatoduodenectomy (GPPPD)

Hideo Nagai, Yasuo Kondo, Toshihiko Yasuda, Kogoro Kasahara ~,

Kyotaro Kanazawa Department of Surgery, Jichi Medical School, Tochigi, Japan

PURPOSE & METHOD Pylorus-preserving pancreatoduodenectomy (PPPD) has several me- rits over conventional pancreatoduodenectomy (PD) from the viewpoints of postoperative quality of life. PPPD is usually associated with transection of the gastroduodenal artery (GDA) at its origin from the common hepatic artery. The division of GDA poses a couple of problems. First, it deteriorates the arterial supply to the duodenal stump, making the duodenojejunal anastomosis unstable. Second, the division renders the risk of postoperative lethal hemorrhage very high once the pancreatic anastomosis disrupts.

Preservation of GDA eliminates these disadvantages. However, there is a concern that the GDA preservation might leave metastatic foci around GDA or that it might be a very tedious procedure. We studied the specimens of cancer of the lower bile duct and the papilla of Vater resected by PD or PPPD to find whether cancerous metastasis or invasion could be found around GDA on histologic sections. Then we performed GDA- preserving PPPD (GPPPD) upon two patients,

one with bile duct cancer and the other with cancer of the papilla of Vater, both of whom had a normal appearance of the pancreas ( "risky" pancreas ). RESULTS 1)Histologic study of PD/PPPD specimens: Metastatic or invasive loci were not found around GDA in any of the cases of lower bile duct cancer ( 7 cases ) or cancer of the papilla of Vater ( 3 cases ) which had been resected by PD or PPPD from 1988 to 1992. 2)GPPPD experience: Dissection of GDA from the anterior surface of the head and neck of the pancreas was easy. The origins of the superior pancreaticoduodenal arteries ( anterior and posterior ) were identified and divided without difficulty. Other minute branches, 3-5 in number, arose from GDA, but they were easily tied and divided. The blood flow of the 3 cm -long stump of the duodenum was sufficient. The postoperative course was uneventful in both cases. CONCLUSION GPPPD would be recommended for cases of lower bile duct cancer or cancer of the papilla of Vater with a "risky" pancreas.

76

FP8

Intrahepatic Blood Flow Assessment After Portal Vein Reconstruction Using Color Doppler Ultrasound

Yukoh Kin, Yuji Nimura, Naokazu Hayakawa, Junichi Kamiya, Satoshi Kondo, Masato Nagino, Masahiko Miyachi and Michio Kanai The 1st Dept. of Surg., Nagoya Univ., Nagoya, Japan

Portal vein blood flow after various major hepatectomy was analyzed in ten patients who underwent combined portal vein and liver resection and compared with 8 hepatectomized patients without portal vein resection (control group ). Segmental excision of the portal vein was performed in 8 of the 10 and wedge resection in 2. Early postoperative portal blood flow images and velocities until the third postoperative day were obtained by color Doppler ultrasound (CDUS) at the umbilical portion for the right hepatectomy patients (8 of reconstruction group ; 6 of control), at the right posterior branch for the left hepatectomy ones (1 of reconstruction group ; 2 of control) and at the both site for one patient who underwent hepatic central bisegmentectomy. These velocities except one patient are shown in the figure. Based on color

flow imaging, complete obstruction of the reconstructed portal vein was recognized in one patient and abnormal swirling flow in another, both of them died postoperatively due to liver

failure. In conclusion, CDUS is useful to evaluate the reconstructed portal vein blood flow and on the early postoperative days portal blood flow velocity distal to anastomosis above 20 cm/s may indicate acceptable blood velocity for satisfactory outcome

after portal vein reconstruction.

RIGHT HEPATECTOMY LEFT HEPATECTOMY

._, 30

20 "3 O "6

O

=T ,'T . . ; ; ~3o

i; U

I I I _ 0

PV + PV + Control LF + LF -

O :I

PV + Control L F -

Right hepatectomy ; extended right hepatic lobectomy or right trisegmentectomy

Left hepatectomy ; left trisegmentectomy PV+ LF+ ; portal vein reconstruction with postoperative liver failure PV+ LF- ; portal vein reconstruction without liver failure Control ; without portal vein resection

FP9

Right Hepatic Trisegmentectomy with Total Caudate Lobectomy and Combined Portal Vein Resection Following Preoperative Portal Vein Embolization of the Right Trisegments of the Liver: Report of a Case of Hilar Bile Duct Carcinoma

Katsuhiko Uesaka, Yuji Nimura, Masato Nagino, Naokazu Hayakawa, Junichi Kamiya, Masahiko Miyachi and Michio Kanai The First Department of Surgery, Nagoya Univ. School of Med., Nagoya, Japan

A 44-year-old female was admitted to our department with a chief complaint of jaundice. Due to malignant obstruction of the hepatic confluence, intrahepatie bile ducts were separated into several units. Five percutaneous transhepatic biliary drainage catheters were placed

to drain all of the separated ducts. According to imaging diagnosis,

right hepatic trisegmentectomy with total caudate lobectomy and combine portal vein resection was scheduled, and preoperative portal

vein embolizatio (PTPE) of the right trisegments was performed.

Volumetric measurement using computed tomography revealed relative size of the left lateral segment as 33.8% before PTPE and 41.0% 3 weeks after PTPE. Relative functional capacity of the left lateral segment estimated by mesuring biliary indocyanine green excretion was 42.5% before PTPE and 61.7% 2 weeks after PTPE.

The scheduled operation was carried out on Jan. 19, 1993. Proximal

bile duct was devided at 1,5cm left side of the umbilical portion of the left portal vein, and free surgical margin of left lateral anterior (B3) and posterior (B2) ducts was obtained. Postoperative course was uneventful, and the maximum total bilirubin level was 3.2mg/dl. This is the first report of preoperative PTPE of the right trisegments.

77

FPIO LAPAROSCOPIC MICROWAVE CHOLECYSTECTOMY -USING A NEW MICROWAVE KNIFE (BLADE TYPE ELECTRODE) - Yoshihiro Sugimoto, Katsuyoshi Tabuse, Nakahiro Shimotsuma, Seiki Yamamoto, Masahiro Sakaguchi, Kazunari Mori, Masami Oka, Satoshi Asano, Hiroyuki Kinoshita, Miho Nagahama, Kazuo Arii and Koji Minami Dept.of Surgery, Osaka-Minami National Hospital, Osaka, Japan

Recently as a new variety of microwave electrodes we devised a blade type which is designed for dissecting tissues with the excellent ability of coagulation so as to permit cutting with hemostasis. From Feburary 1991 through March 1993 we applied it to 72 cases of laparoscopic cholecystectomy (LC) without using electrocautery and laser and obtained good results. MICROTAZE, which consists of a microwave generator and its electrodes introduced in 1980, can now apply to LC through a coaxial cable with two forms of blade-type electrode; sickle shaped and common knife shaped. We induce pneumoperitoneum with laughing gas by means of Hasson's technique and use a laparoscope flexible near the ob- ject lens. Mild coagulation on the peritoneal reflection over the cystic duct and artery to facilitate further dissection of those two vessels. Burn injuries to the common bile duct and other important structures never happened as microwave coagulation takes place gradually to be easily controlled. After placing clips on and severing the cystic duct and the artery in the usual manner the gallbladder is

removed from the liver bed using the microwave blade type electrode, which shows excellent dissecting and hemostatic ability.

Of 72 cases we convert 7 cases to a open cholecystectomy from LC; 3 common bile duct injuries which were not associated with microwave,2 uncontrollable bleeding from the cystic artery, I severe adhesion, I stone incarceration in the cystic duct. We performed 3 cases of laparotomies because of postoperative complications ; 2 bile leakages, I bleeding from the liver bed. There were no fatalities. This paper reports our first 72 laparoscopic microwave cholecystectomies emphasizing the usefullness of microwave newly devised electrodes.

FPl l Experience of 122 hepatectomies of hepatocellular carcinoma using microwave tissue coagulator

Kazunari Mori, Katsuyoshi Tabuse, Seiki Yamamoto, Yoshihiro Sugimoto,Masami Oka, Satoshi Asano and Hiroyuki Kinoshita Dept.of Surgery, Osaka-Minami National Hospital, Osaka, Japan

During the period from 1981 to 1990, total of 122 patients of hepatocellular carcinoma were subject to liver resection using the microwave tissue coagulator(MTC). In 100 patients, the remnant liver parencyma was liver cirrhosis and 13 out of 22 patients without cirrhosis had chronic hepatitis. Nearly 3/4 of the cases, atypi- cal resection, which consist of the resection of portion of parencyma not limited by anatomical segment, were performed. The ratio of non-transfused cases was 64%(9 out of 14 cases)in partial resection, 45%(27 out of 60) in subsegmentectomy, 31%(9 out of 29) in segmentectomy and 37%(7 out of 19) in lobectomy. Median volume of intraoperative bleeding was 403mi in partial resection, 800ml in subsegmentectomy, 1300mi in segmentectomy and 1,180mi in lobectomy. The mortality were 3 cases of operative death and another 9 cases of hospital death. But postoperative complications which might relate to this operation methods were only 4 cases of stump abscess and 2 cases of bile leakage. The cumulative 1-year,3-year and 5-year survival rates among the patients with

cirrhosis were 80%, 58% and 28%, respectively, and the cumulative 5-year survival rate for the patient with tumor less than 3 cm was 80%. We would like to emphasize the excellent hemostatic ability, small number of complication and standard survival rate provided by the hepatectomy using the MTC.

78

FP12 A Study on Histological Effect of Pre-operative Irradiation for Superior Bile Duct Cancer

Kaoru Mizusaki, Tsuneo Takahasi, Satoru Yanagisawa, Masaru Naruse, Haruyuki Akita,

Youichi Touyama, Takemasa cho, Jun Tanaka, Teruaki Aoki Department of Surgery(~),The Jikei University School of Medicin

[Purpose] The prognosis of superior bile duct cancer is not satisfactory, at present, even if

it can be resected. As part of interdisciplinary treatments, we performed

pre-operative irradiation and its histological effect was investigated in the resected preparations.

[Subjects] Ten cases of superior bile duct cancer

were operated on frora January 1982 to December 1992. Six cases underwent pre-operative irradiation, and, furthermore, 4 cases underwent resection. Three cases were able to be histologically

examined. [Results] The dose of pre-operative irradiation averaged 46. 5 Gy. As for the histrogicaf �9 type, 2 cases were well differentiated

tubular adenocarcinoma and i case was moderately differentiated tubular adenocarcil~oma. As for the effect on the

bile duct wall, many non viable cells were observed in the vicinity of the mucosa and viable cells tended to remain in the serosal side.

In a case in which infiltration was observed up to the intrahepatic bile ducts, many viable cells remained in the

intrahepatic bile ducts and ma~y non viable cells were observed in the extrahepatic bile duct. The lesion was in

hinfl at the site of direct intrahepatic infiltration but many viable cells remained. Perinerve infiltration was observed in 2 cases and viable cells remained. The effect was Grade ~B in all 3 cases according to the histopathological criteria presented by Ohbosi and Siraosato.

[Conclusion] i The effect of irradiation for stlperior

bile duct cancer was Grade [B in all 3

cases. 2 The effect of irradiation was

diminished for the intrahepatic bile duct infiltration, intrahepatic direct infiltration, and perinerve

infiltration. 3 The pre-operative irradiation was

considered to be useful as supplementary treatment for superior bile duct cancer.

FP13

Open drainage for acute necrotizing pancreatitis with infection and/or sepsis.

Junichiro Yamauchi, Kazunori Takeda, Kazuhiko Shibuya, Makoto Sunamum, Kousuke Arai, Shinya Kawaguchi, Masao Kobari, Seiki Matsuno. The 1st Dept. of Surg. Tohoku University School of Medicine, Sendai, Japan

Secondary infection of pancreatic necrosis is recognized as the

most lethal complication of acute pancreatitis. Pancreatic

necrosis alone is not indication of surgery, however, once

secondary infection has been established, surgical intervention

is absolutely required.

From 1986 to October 1992, 40 patients with acute necrotizing

pancreatitis were admitted to the First Department of Surgery of

Tohoku University. In 40 patients, 22 patients with infected

pancreatic necrosis were treated by necrosectomy and 11 of

those were managed by open drainage after operation. The

etiology of 11 patients were alcohol in 5, biliary tract disease in

3, ERCP in 1, and idiopathic in 2. Average APACHE II score

on admission was 14.2 + 2.2. After intensive medical care,

surgical treatment was performed during 6-23 days (average;

14.1 + 1.2) after the onset. The average amount of

intraopemtive bleeding was approximately 2500 ml (renge; 186-

7330 ml). 4 of 11 patients died and the overall motality

rate was 36.4 per cent. Two died from liver failure, one

from respiratory failure, myocardial infarction but none

died of sepsis. Major complications were, massive

bleeding in 4, perforation of intestine in 3, and intractable

fistula in 3.

The usefulness of open drainage is first to remove necrotic

infected material, second, to drainage toxic intraabdominal

substances, third, to deal effectively with re-accumulating

slough and infections.

Major comlications in open drainage were post-operative

bleeding, intestinal perforation, intractable fistula, and

prolonged paralytic ileus. We have adopted prophylactic

diverting ileostomy for preventing from these complications.

FP14

The difficulty of preoperative differential diagnosis between chronic cholecystitis and gallbledder carcinoma

Masayuki Shiobara, Masaru Miyazaki, Hiroshi Itoh, Takashi Kaiho, Katsuhiko Andoh, Satoshi Anbiru, Shinichi Hayashi, Eiji Gohchi, Motoki Nagai, Kijurou Takanishi, Akira Togawa, Masayuki Ohtsuka, Kazuhiro Sasada, Yoshiaki Shimizu, Shigeru Yoshioka, Hiroyuki Yoshidome, Atsushi Katoh, Syunta Nakamura, Nobuyuki Nakajima First Department of Surgery, Chiba University, Chiba Japan

79

Despite of the advent of various modern imaging technology, the different ial diagnosis between chronic cholecysti t is and gal lbladder caranoma is sometimes difficult preoperatively and even in operation. This s tudy is aimed to assess the difficulty in eighty seven pat ients with a preoperat ive diagnosis of ei ther gal lbladder carcinoma on chronic choleeytitis. Gallbladder carcinoma was histologically revealed is seventy nine of 83 patients (95 % ) wi th preoperat ive diagnosis of gal lbladder carcinoma and chronic cholecytitis in four of those patients (5%). In four pat ients preoprat ively diagnosed as chronic cholecystitis ;no malignant cells were fouud histologically. The operative procedures for four false positive pat ients in diagnosis of gallbladder carcinoma included extended cholecystectmy in one patient, extended r ight hepatectmy with bile duct resection in two patients and hepato lower central hepatectmy with pancreat icoduodenectomy in one patient. These four false posi t ive pat ients could not be evaluated as benign diseases before and even dur ing operat ion. Pa t ien ts with diff icul ty of a different ia l diagnosis between gal lbladder carcinoma and chronic cholecystitis is usually experiensed. In operation for these pat ients , a histological defini te diagnosis using f resh

frozen section should be required especially in the case of selection of extended operat ive procedures.

FP15 Heterogeneity in the nuclear DNA content of cells in hepatocellular carcinnomas

Takayuki Sutohl) , Kohsuke Sasaki2), Ryoukou Sasakil), Senji Kannol) and Kazuyoshi Saitol) 1)First Department of Surgery, 2)First Department of Pathology, Iwate Medical University School of

Medicine., Iwate, Japan

Using flow cytometry, we measured the nuclear

DNA content of cells in fresh surgical specimens

from 16 patients with hepatocellular carcinoma

(HCC). We took multiple samples from the same

tumor to investigate the frequency of aneuploidy

and of heterogeneity in DNA ploidy within one

tumor. The frequency of aneuploid samples was

81,3% in HCO. The incidence of heterogeneity in

DNA ploidy within a tumor was 56.3% in HCC,

Both diploid cells and aneuploid cells existed

together in the same tumor in 37,5% of HCC. So

if a sample was taken from a single lesion in

these cases, the tumor could be mistaken

diploid. Therefore, it is necessary to take multiple

fresh samples from the same tumor to accurately

measure the variations in nuclear DNA

content. The frequency of tetraploidy in HCC

was more than the other cancer of the

digestive tract. No significant correlation was

observed between DNA ploidy pattern or

DNA index and histological classification or

staging. It was indicated that the diagnosis of

malignancy only by the existence o f

aneuploid cells needs great care.

80

FP16

An Evaluation of Surgical Treatment for The Colorectal Cancer with Liver Metastasis, with Special Reference to The Necessity to Dissect The Hepatic Hilus Lymph Node.

Wataru Takayama, Kazuo Watanabe, Hiroshi Yamamoto Chiba Cancer Hospital.,Chiba, Japan

During the past ten years, thirty eight patients with liver metastasis from the colorectal cancer received hepatic resection in Chiba Cancer Hospital. In this paper we evaluated its clinical result and the necessity of dissection of the hepatic hilus lymph node on improving prognosis. The survival rate of all was 76% (1year), 28%(3years), 17%(5years). In 19 cases which metastasis to one lobe (H1) the survival rate was 65%(1year), 42%(3years), 25%(5years). In 14cases few scattered metastasis foci in both lobes(H2)was 100%(1year), 18%(2years), O%(3years). In 5 cases multiple metastasis in both lobes (H3) was 60%(1year), O%(2years). In the recurrence site of H1 metastasis, seven were residual liver recurrence and five were local recurrence. Of H2 metastasis, eight were residual liver recurrence and two were local recurrence. Of H3 metastasis, all cases were residual liver recurrence. 8 cases of all who had obstructive jaundice due to the metastasis of the hepatic hilus , the initial site of the recurrence after hepatic resection were residual liver in 6cases, local lesion in 1case and hepatic hilus of surgical margin in 1case. No patient had the initial recurrence in the hepatic hilus lymph node.

The clinical factors influence survival after hepatic resection was not the hepatic hilus lymph node

metastasis but the residual liver recurrence. These result indicated it is not necessary to dissect the hepatic hilus lymph node.

FP17

Four Cases of Caudate Lobectomy for Hepatocellular Carcinoma

Toshimasa Asahara,Kiyohiko Dohi,Hideki Nakahara,Yusou Okamoto,Makoto Ochi,Kouji Katayama, Toshiyuki Itamoto,Shinnya Nomura,Seiji Marubayashi,Eiji Ono,Hiroshi Yahata,Yasuhiko Fukuda, The 2nd Dep. of Surgery,Hiroshima University,Hiroshima,Japan, Hisashi 0oshiro, The Ist Dep. of Surgery,Hiroshima Pref. Hospital,Hiroshima,Japan

Only a small number of reports about successful caudate lobectomy for HCC,because the frequency of the tumor originating in caudate lobe is quite low. Generally,control of bleeding during hepatic resection is not so easy in a case with liver cirrhosis.Therefore high quality of surgical technique is needed for resection of caudate lobe.This is the another reason why the reported cases of resected HCC in caudate lobe are still very feN. In these 3 years,we experienced four cases of caudate lobectomy for HCC. In the one case the tumor was located in right side of caudate lobe. In the other three cases tumor originated in the left side of caodate lobe grew into the right side. The most important point for safe procedure of caudate lobectomy is sure manner of cut and ligation of short hepatic vein,hepatic artery branch and portal vein branch. As the tumor in caudate lobe is in contact ~ith right, middle and left hepatic vein, it is difficult to keep the enough TW(tumor margin) in case of large tumor Control of bleeding from the hepatic vein is also the important point of the operation. Gastro-intestinal bleeding after operation ~as seen in one case, but this was improved by con- servative therapy. Every four cases discharged

the hospital within 60 days after operation.

81

FP18

Rupture of the Hepatic Artery after the Hepatectomy with Lymph Node Dissection for the Bile Duct Carcinoma

c .i) Makoto ~asakl , Tsutomu Tomioka I), Tsukasa Tsunoda I), Takashi Kanematsu I), and Naofumi Matsunaga 2) 2nd Dept. of Surg. I), Dept. of Diagnostic Radiology 2), Nagasaki Univ. School of Med., Nagasaki, Japan

Transcatheter arterial embolization (TAt) was carried out for two cases with rupture of the hepatic artery after the hepatectomy with lymph node dissection for the bile duct carcinoma. In the first case, intraabdominal bleeding was first recognized on the 26th day after surgery (resection of left lobe and caudate lobe of the liver plus pancreatoduodenectomy accompanied with Lymph node dissection). On the 32th day, hypovolemic shock due to massive hemorrhage occurred. Two site of extravasation at the right hepatic artery were evident in the selective arteriography. TAt by stainless steel coil and microcoils was immediately performed. Subsequently, complete hemostasis was obtained but hepatic failure developed. In the second case, intraabdominal bleeding was recognized on the 20th day after left lobectomy of the liver, TAE of the right hepatic artery was carried out on the 41th because blood supply into the liver from the right phrenic artery were present. The bile leakage of the hepaticojejunostomy continued from early period after surgery was common to the two cases. The bile was consider to be risk factor

that injured bared arterial wall after the lymph node dissection. The initial diagnostic arteriography should be performed in early time of several episodes of intraabdominal bleeding. But virtually, indication of TAE of the residual hepatic artery were restricted within under some conditions, such as, without hypovolemic shock, proximal rupture site and enough arterial blood supply through the collateral.

FP19 T h e Role o f M u l t i d i s c i p l i n a r y T h e r a p y f o r E a r l y R e c u r r e n c e o f H e p a t o c e l l u l a r C a r c i n o m a a f t e r H e p a t e c t o m y

Atsuhiko Maki, Arimichi Takabayashi Depar tment of Surgery, Kitano Hospital, Tazuke-Kofukai Medical Institute, Osaka, Japan

Early recurrence af ter h e p a t e c t o m y is one of the difficulties for surgical t r e a t m e n t against hepa to- cel lular ca rc inoma (HCC). According to the report f rom the liver cancer s tudy group of Japan (1992), 48.9% of the recurrence af ter hepa tec tomy for HCC takes place wi th in 6 m o n t h s a f t e r operat ion. Therefore, it is crucial for the improvemen t of the prognosis to control early recurrent tumor.

In this report , we are t rying to clarify the role of mul t id i sc ip l inary the rapy , including t ranscatheter a r te r ia l embol iza t ion (TAt), i n t e rmi t t en t chemo- infusion and ad juvan t c h e m o t h e r a p y to get longer survival of recurrent HCC.

We analyzed eight of 105 (7.6%) patients referred for su rg ica l t r e a t m e n t of HCC, who had su f f e r ed recur rence within 6 m on t hs af ter ope ra t i on and survived longer than 1 year. Average age was 57 years old (6 male and 2 female). Macroscopic stage was I in one case, 2 in three cases and 3 in four cases. Curative operat ion was pe r fo rmed in four cases a n d

non-cu ra t ive was in four, respect ive ly . Average disease free interval was 117 days. Average survival after the disclosure of recurrent tumor was 736 days. Seven cases received adjuvant 5-FU derivatives as a less toxic subst ra te for combinat ion chemotherapy . Five cases underwent TAt, which was repea ted 4.2 t imes in a v e r a g e us ing a n y c o m b i n a t i o n of Mitomycin C, adr iamycin and CDDP. Along with TAt, two cases were given same group of ant i-cancerous agen t r e p e a t e d l y into hepa t i c a r t e r y t h r o u g h i n d w e l l i n g t u b e ( I n f u s - A - P o r t TM) i n s e r t e d intraoperat ively. One case was managed only with repeating hepatic arterial infusion. Repeating arterial infusion using Infus-A-Port TM could be pe r fo rmed safely on out-pat ient basis.

Consecutively, in our opinion, the mul t id isc ipl inary therapy is able to improve the patients survival and qua l i t y of life even a f te r ear ly p o s t o p e r a t i v e recurrence of HCC.

82

FP20

Two cases of extrahepatically growing hepatocellular carcinoma

Yoshimasa Kurumi, Akihiro Kishida, Kazuo Haeuchi, Takumi Yamamoto~ Hidejiro Watanabe~ Takanobu Hase, Masashi Kodama First Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-cho, 0tsu Shiga 520-21, Japan

Hepatocellular carcinoma (HCC) usually grows and resides within the liver and rarely grows outward extrahepatieally, invading adjacent structures. This rare type of hepatocellular carcinoma designated here as extrahepatically growing type has been enigmatic in that nothing has been found regarding the factor which determines the direction of tumor growth. Extrahepatically growing HCC differs in evaluation and treatment from HCC of usual type. Two cases of HCC of this type will be presented that we experienced in our insti- tution. Case #I 31-y/o-female without associated liver cirrhosis. The pedunculated tumor was removed by postero-inferior subsegmen- tal resection 6 years and 8 months ago. She has been doing well without any evidence of recurrence since then. Case #2 62-y/o-male without liver cirrhosis. In this case, the protruding tumor was found to invade the pancreas. He underwent left hepatic lobectomy with distal pancreatectomy. The postoperative course was relatively uneventful, but he

succumbed to pneumonia 7L days after surgery. The pedunculated type HCC like case #I is likely to be resectable even a huge one with minimal resection of non-tumor bearing hepatic tissue while the protruding type like case #2 tends to invade the adjacent structures, requiring extended resection. Therefore in case of the extrahepatically growing HCC, precise preoperative evaluation is mandatory to determine resectability and the most appropriate surgical procedure.

FP21 C l i n i c a l a n d S u r g i c a l F e a t u r e s o f C h o l e l i t h i a s i s in t h e E l d e r l y

Yoshihisa Marugami, Toshiki Matubara, Hisatomo Futawatari, Kohji Nakamura, Hiroki Imazu, Kazufumi Arai, Kikuo Mori, Masashi Snganima, Hirosi Morishita, Yoshinori Sasayama, Singo Tsuda,Yuuji Maruta, Masaaki Muraoka, Masahiro OchJai, Takahiko Funabiki Department of Surgery,School of Medicine,Fujita Health University

B e t w e e n January 1984 and D e c e m b e r 1992, 379

(age range 2 0 - 9 0 years ) p a t i e n t s d i a g n o s e d as

c h o l e l i t h i a s i s ( c h o l e c y s t o l i t h i a s i s 315 , c h o l e d o -

e h o l i t h i a s i s 56, h e p a t o l i t h i a s i s 8) , were referred to

our d e p a r t m e n t . To c l a r i f y the c l i n i c a l and s u r g i c a l

t h e r a p e u t i c f e a t u r e s t h e s e p a t i e n t s were d i v i d e d into

three groups . (A) y o u n g e r p a t i e n t s under 64 years

old as 6 6 % ( 2 5 1 c a s e s ) . (B) p r e s e n i l e p a t i e n t s

b e t w e e n 65 and 74 years old as 2 1 % ( 8 0 c a s e s ) . (C)

e lder p a t i e n t s over 75 years old as 13%(48 c a s e s ) .

C l i n i c a l f ea tures in e lder p a t i e n t s were the

f o l l o w i n g :

(1) The i n c i d e n c e of e h o l e d o c h o l i t h i a s i s i n c r e a s e d

wi th age.

(2) In e lder p a t i e n t s , acute c h o l e c y s t i t i s and o b -

s t r u c t i v e j a u n d i c e occurred more f r e q u e n t l y than in

y o u n g e r p a t i e n t s .

(3) P r e o p e r a t i v e c o m p l i c a t i o n s were more f r e q u e n t l

in e l d e r l y than y o u n g e r patien~.s.

(4) C a n c e r s of the g a l l b l a d d e r and other organs

were found more f r e q u e n t l y in pre s e n i l e and e lde r

p a t i e n t s .

(5) P o s t o p e r a t i v e c o m p l i c a t i o n s in e l d e r g r o u p were

more f requent than in the y o u n g e r group.

(6) The 30 day m o r t a l i t y r a t e a f t e r s u r g e r y was

0 . 6 % ( t w o d e a t h s ) , a l t h o u g h t he y were not pre s e n i l e

nor e lder p a t i e n t s .

The present resu l t s s u g g e s t that surgery s hou ld be

per formed in aged p a t i e n t s w i t h s u f f i c i e n t pre and

p o s t o p e r a t i v e m a n a g e m e n t , m h i c h w o u l d be s a f e for

even e lder p a t i e n t s .

83

FP22

A role of polymorphonuclear neutrophils for hepatic failure after hepatectomy in obstructive jaundiced patients by a clinicopathological study. Masayuki Ohtsuka, Masaru Miyazaki, Hiroshi Itoh, Takashi Kaiho, Katsuhiko Andoh, Satoshi Anbiru, Shinichi Hayashi, Eiji Gohchi, Motoki Nagai, Kijurou Takanishi, Akira Togawa, Kazuhiro Sasada, Masayuki Siobara, Yoshiaki Shimizu, Shigeru Yoshioka, Hiroyuki Yoshitome, Atsushi Katoh, Syunta Nakamura, Nobuyuki Nakajima I), Yoichiro Kondoh 2) First Department of Surgery 1), Second Department of Pathology 2), Chiba University, Chiba Japan

To explore the role of polymorphonuclear neutrophils (PMNs) for hepatic failure after hepatectomy in obstructive jaundiced patients, PMN infiltration in the liver tissue was morphologically studied in autopsy cases.

Three patients with hilar bile duct carcinoma and one with gall bladder carcinoma, who developed hepatic failure after hepatectomy (more than Iobectomy), were subjected to the study and their autopsied liver sections were analayzed immunohistochemically using a monoclonal antibody against human neutrophil elastase, along with conventional stainings.

All patients showed intrahepatic cholestasis and confluent and focal liver cell necrosis, mostly located in the central zone and midzone. Intra-parenchymai PMN infiitration was also seen in all patients, preferentially in and around the area of hepatic cell necrosis. Neutrophil elastase was observed in the cytoplasm of the infiltrated PMNs and partially in extracellular site in two patients. These findings could not be demonstrated in other autopsy cases having no liver diseases.

These results suggest that hepatic failure after hepatectomy in obstructive jaundiced patients might be mediated by PMNs.

FP23 Clinicopathological Study on Mucinous Cystadenoearcinoma of the Pancreas Degree of tumor extension and prognosis

Jitsuo Hayashi, Kanji Tanigawa, Shuji Isaji, Hajime Yokoi, Yoshifurni Ogura, Takashi Noguchi, Yoshifumi Kawarada and Ryuji Mizumoto The 1st Dept. of Med. Mie Univ. Mie, Japan

Though clinicopathological features of mucinous cystadenocarcinoma of the pancreas have been recognized in recent years, the behavior of invasive tumors has not yet been fully understood, especially with regard to the degree of tumor extensionl The present study was undertaken to clarify the relationship between the degree of tumor extension and prognosis after resection of the tumor.

Materials and Methods A total of 8 cases with mucinous cystadenocarcinoma

resected for the last 16 years and 6 months were clinico- pathologically analyzed. Age of the patients ranged from 31 to 76 years (mean age of 51). There were 6 males and 2 females. The site of main tumor was head of the pancreas in 3 cases, and the body-tail in 5. These 8 cases were classified according to the present of invasion beyond the cyst wall and/or internal fistula formation to the adjacent organs.

Result Internal fistula formation between the cyst and the

adjacent organs was found in 5 cases: the stomach in 2 and the duodenum in 3. Both of 2 patients with fistula formation to the stomach underwent distal panceatectomy with gastrectomy, and histologically both cases showed cancer invasion beyond the cyst wall without lymph node metastasis: one died of local

recurrence at 1 year and 8 months after resection and the other is still alive at 5 months. The three patients with fistula formation to the duodenum underwent pancreaticoduodenectomy in 2 and pancreaticoduodenectomy with portal vein resection in 1: one patient with invasion beyond the cyst wall and lymph node metastasis died of local recurrence at 1 year and 1 month, and the other two patients without invasion beyond the cyst wall are still alive with no signs of recurrence at 2 years and 6 months and 6 years and 8 months, respectively. In the remaining 3 cases without fistula formation, the one Without cyst wall invasion is alive at 10 years and 6 months after distal pancreatectomy. The other two patients had cancer invasion beyond the cyst wall: one with direct invasion to the stomach died of liver metastasis 4 years and 5 months after distal pancreatectomy with gastrectomy, and the other with invasion to the splenic artery died of liver metastasis 3 years and 2 months after distal pancreatectomy.

Conclusion These results revealed that cancer cell invasion beyond

the cyst wall highly influenced prognosis rather than the present of internal fistula formation, and for these cases extended resection followed by aggressive adjuvant therapy should be employed to prevent tumor recurrence.

84

FP24 The examination of the long survival after hepatectomy for hepatocellular carcinoma

Hideki Nakahara, Toshimasa Asahara, Yuzo Okamoto, Makoto Ochi, Kouji Katayama, Toshiyuki Itamoto, Shinya Nomura, Seiji Marubayashi, Eiji Ono, Hiroshi Yahata, Yasuhiko Fukuda, Kiyohiko Dohi The 2nd Dept. of Surg., Hiroshima Univ., Hiroshima, Japan

We examine the condition of long survival after hepatectomy

for hepatocellular carcinoma. 195 cases of hepatectomy had

done in our hospital from 1986 to 1992. 6 cases lived more

than 5 years after hepatectomy without recurrence (group l).

4 cases lived more than 5 years after hepatectomy with

recurrence (group 2), 12 cases died from 3 to 5 years after

hepatectomy (group 3), and 31 cases died within 3 years after

hepatectomy (group 4). Age and sex are no statistically

different in any groups.

The average tumor size and the rate of capsule invasion (Fc

-inf) are statistically different between group 1 and group

4 (p < 0.05). Portal and hepatic vein invasion (Vp, Vv) is no

statistically different in any groups. But in group 4, Vp, Vv

positive rate is slightly higher than other groups. Intrahepatic

metastasis (IM) positive patients didn't survive more than

5 years except for one case.

Operational method and early post operative chemo -

lipiodization are also no statistical different in any groups.

Resection volume of group 4 is larger than other groups (p

< 0.05), because of the average tumor size of group 4 is large.

ICG-R is different between group l and group 3 (p< 0.05),

group 4 (p < 0.01), and ICG-K is also different between group

i and group 2, 3 (P < 0.05). Hepaplastin is also different

between group 1 and group 4 (p < 0.05)~ But clinical stage

are not different in any groups.

In group 3 and 4, average period from oreration to

reccurrence are shorter than group 2 (p < 0.05), and post-

reccurrence survival period in group 4 is shorter than group

2 and group 3 (p< 0.01).

In the group 4, 14 cases died from cancer, 12 cases died from

hepatic failure or rapture of esophageal varix. Liver function

disorder affects not only on post operative hepatic failure but

also operational method and post-operative combination

therapy.

The conditions of long survival of the patients of

hepatocellular carcinoma are follows; I) single tumor, 2)

tumor size is small, 3) Fc-inf is negative, 4) good liver

function, 5) early stage of combination therapy after

operation.

FP25

Usefulness of metallic stent placement for the case with benign stricture on biliary tract

Tomoyoshi Okamoto,Satoru Yanagisawa,Yoshinori Inagaki,Tsuneo Takahashi and Teruaki Aoki Dept. of Surgery(2),Jikei Univ.,Tokyo,Japan

Introduction;Endoprosthesis with metallic stents(MS) was conducted in benign stricture which was refractory to conventional treatment.As good results were obtained,the effects of this procedure are presented. Patients:Between January 1991 and April 199 3,4 patients with benign strictures in 19 patients with biliary obstruction who underwent noninvasive endoprosthesis with MS were evaluated. Patients were aged 37 to 79 and the ratio of male to female was 3;l.The causes of benign stricture were anastomotic stricture after reconstruction of biliary tract in 2,post-inflammatory change after acute cholecystitis and pericholangitis eom- plicated with ulcerative colitis.The locali- zation of stricture were bilioenteric anastomosis in 2,upper bile duct and lower bile duct.Noninvasive endoprosthesis were selected because 2 patients had been refractory to operations and the others had severe liver damage with portal hypertension.After fistula dilation following PTBD,balloon dilation on the strictured portion was carried out in each case. Neverthless,remarkable effects were not obtained.

Results:The follow-up period after MS placement was 4-68 weeks,reobstruction was obe- served in one patient.The reason for reobstruction was considered to be reactive swelling on bile duct wall after M~ placement. In this case,after tube stent was inserted first and MS was replaced again in the shape of stent-in-stent,reobstruction has not been seen.MS placement enabled all patients to be free from the external catheter tube,the period between MS placement and removal was 1-8 weeks. Cholangioscopic findings 1 week after MS insertion revealed that 50% of MS material was covered with bile duct epithelium.MS migration to intest-

inal tract was observed as a complication in one patient,but not to be developed severely.jaundice-free rate was 100%,which

was 73% in the malignant cases.

Conclusions:MS placement was useful for the cases with benign stricture as well as with malignancy because of easy procedure and improving the quality of life.

Further studies are required for a long term observation and an indication~

85

FP26

Histologioal Analysis of Advanoed Carcinoma of the Gallbladder

Shinji Noshima, Tsuyoshi Takahashi, Hidenori Shinagawa, Hiroshi hiraoka, Nobuyoshi Morita and Kensuke Esato

The ist Dept. of Surg., Yamaguchi Univ., Yamaguchi, Japan

Thirty-eight patients with carcinoma of the gallbladder underwent surgical resection from 1975 to 1992. Among them 29 patients were advanced carcinoma which has been considered to be a highly lethal disease. Advanced carcinoma was defined as follows. Cancer cells invades perimuscular connective tissue and/or extends beyond serosa or into liver. This study was designed to investigate relationship between the pathological classification and the extent of cancer and relationship between the pathological classification and the prognosis. 17 patients underwent curative operation. We defined pap or tubl as pathologically low grade malignancy (Low group; n=7) and tub2, por, ud,as or sq as pathologically high grade malignancy (High group; n=10). Statistical analysis was performed by using Chi- square method. The survival curves were calculated using the Kaplan-Meier method. Differences in survival curves were measured using the generalized Wilcoxon test. [ Results ] Lymph nodes metastases were proved 1/7 (14%) in the Low group, 6/10 (60%) in the High group. There was no significant difference between the groups. In the Low group, cancer cell invasion into liver was proved 1/7 (14%) and was significantly lower than in the High

group 8/10 (80%)(p<0.05). In the Low group, cancer cell invasion into hepato-duodenal lig. was not proved 0/7 (0%) and was significantly lower than in the High group 8/10 (80%)(p< 0.01). In the Low group, the 1,3 and 5 year survival rates were 100%, 83% and 56%, respectively. In the High group (except 4 cases of operative death), the 1,3 and 5 year survival rates were 83%, 17% and 17%, respectively. There was significant difference between groups (p< 0.05). [Conclusion ] In advanced carcinoma of gallbladder, the extent of the cancer was correlated with the pathological grade of malignancy. After curative operation, the prognosis of the pathologically low grade malignant group was better than the high grade malignant group.

FP27

Endotoxin-induced extensive hepatic cell necrosis in the Rats after partial hepatectomy : (prostaglandin I2 derivative) administration.

t he effect of OP-2507

Tomohiro Kato, Hisashi Mimnra, Keisuke Hamasaki, Hiroshi Tuge, Masanobu Mori, Keiji Koguchi and Kunzo Orita The 1st department of Surgery, Okayama Univ., Okayama, Japan

After 48 hours later of partial (70%) hepatectomy, endotoxin shock was induced in male rats by an intravenous(i.v.) injection of Escherichia coli ]ipopolysaecharide (LPS; 500#g/kg). In order to determine the effect of 0P-2507, a synthetic prostacyclin ana- logue, OP-2507 administration (100 and 300#g/kg s.c. 30 rain before LPS) was performed. ( method ) Male wistar rats weighing 250--290g were performed 70% hepatectomy under general anesthesia. 48 hours after hepatectomy, four groups were prepared as follow; A:LPS(500#g/kg i.v.) only-, B:LPS+OP2507(1OO#g/kg s.c. 30 rain before LPS), C:LPS+OP2507(300#g/kg s.c. 30 rain before LPS), D:saline only. GOT, GPT, T.Bil, Prothrombin time(PT), AT3, TAT, PIC, PAI-1, AKBt~ and TNF-alpha were measured at the time of 0, 1, 3, 6, 12 hours after LPS injection. And then survival rates were measured. ( result ) The survival rates were A:0%, B:70%, C:90%, D:100% at 8 hours, and A:0%, B:60%, C:80%, D:100% at 24 hours. The survival rates of B and C groups improved significantly compared with that of A group. Serum GOT at 6 hours was; A:2795+1540U/1, B:812• and C:800• Serum GOT of B and C groups were suppressed significantly compared with that of A group. Serum T.Bil at 6 hours was; A:3.2• B:l.7• and C: l .2• Serum T.Bil of B and C groups were lower

significantly than that of A group. Serum PT at 3 hours was; A:25.0+6.1sec, B:lS.3+l.6sec and C:17.0• and at 6 hours; A:44.5• B:19.4• a~d C:18.5• Serum PT of B and C groups were maintained well significantly. Serum AT3 at 3 hours was; A:56.2• B:65.5• and C:67.7=h7.1%, and at 6 hours; A:44.0• B:59.2• and C:59.0• AT3 of B and C groups were higher significantly than that of A group. Serum TAT of C group was suppressed significantly compared with that of A group at 3 hours. Serum PIC and PAI-1 did not show significant difference between each groups. AKBR at 6 hours was; A:0.21• B:0.35• and C:0.30• Serum TNF-alpha at 1 hour was; A:788• B:36.0• and C:16.4~=6.0JRU/ml. Serum TNF-alpha of B and C groups were low significantly( p < 02001) compared with A group. Serum TNF-Mpha at 3 hours was; A:4.9• B:0JRU/ml and C:0JP~U/ml. ( conclusion ) OP-2507 administration imprnved the fiver function and survival rates significantly in the rat model of endotoxin- induced extensive hepatic cell necrosis after partial hepatectomy. These results strongly suggest that TNF-alpfa may play an important role in the initiation of massive hepatic necrosis.

86

FP28

Operative Indications for Polypoid Lesions of the Gallbladder

Hiroshi Isozaki, Kunio Okajima, Takashi Ishibashi, Shinsho Morita, Hitoshi Hara, Masakazu Tanimura, Kiyotaka Tezuka, Hiroshi Akimoto, Masami Niki, Junji Okuda Department of Surgery, Osaka Medical College, Osaka, Japan

Treatment for polypoid lesions of the gallbladder discovered by ultrasonography or cholecystogram is one of the clinical problems of gallbladder diseases. Operative indications for polypoid lesions were clarified in the present study. PATIENTS AND METHODS 62 patients underwent cholecystectomy for polypoid lesions of gallbladder in the department of surgery, Osaka Medical Col- lege between 1978 and 1992. Relationship between pathologic characteristics of the polyps and clinical data such as age and sex or preoperative diagnosis was studied. RESULTS I) Histological type, sex and age: There were 45 patients (20 women (F) and 25 men (M)) with cholesterol polyp (CP), 9 patients (7 F and 2 M) with carcinoma, 5 patients (2 F and 3 M) with adenoma, 2 patients (I F and I M) with hyperplastic polyp and I patient (F) with inflammatory polyp. Carcinoma (CA) was frequently detected in women. Moreover, mean age of women with CA (62 y.o.) was significantly higher than that of women with CP (51 y.o.)[p=0.03].

2) Largest diameter, number of polyps: CP were 9mm or less in 39 patients, from 10mm to 15mm in 6 patients (average 7.4mm), CA were 6mm, 9mm, 15mm, 18mm and 20mm or more in 5 patients (average 28mm), and all of the other polyps was less than 12mm in diameter. Multiple polyps were demonstrated in the gallbladder in 80% with CP patients, but only one polyp was recognized in 8 out of 9 CA patients. 3) Preoperative diagnosis: When the diameter of polyp was less than 15mm, preoperative differential diagnosis was difficult to establish. CONCLUSION Considering the possiblity of carcinoma, operative indications for polypoid lesion of gallbladder should be as follows: I) old woman 2) single polyp 3) 6mm or more in largest diameter.

FP29

The meaning of the furrow of caudate lobe

Kimitaka Kogure, Masatoshi Ishizaki, Masaaki Nemoto, Mitsugu Muratani Department of Surgery, Gunma UniversiIy, School of Medicine., Maebashi, Japan

[Purpose] There are some furrows in liver and each furrow has the meaning, for example, a major furrow between left lateral lobe and left median lobe is an umbilical fissure, along which round ligament ascends to reach portal vein. In the half of the caudate lobes variable development of furrows can be observed. However, a definite explanation for the furrow of caudate lobe has not been propounded. To investigate the meaning of the furrow of caudate lobe the research was carried on.

[Mater ia l s and methods] Fifty livers from cadavers were examined by the technique of dissection method. The number of the portal branches and the branching patterns were analyzed on caudate lobes and the correlation between the branching patterns and the furrows were simultaneously inquired.

[Resul ts ] 1 , All caudate lobes were divided into two territories, right (para caval portion) and left (a so called, Spiegel lobe).

2 . A furrow was observed in 22 caudate lobes (47 %) and there were 25 caudate lobes (53 %) which had no furrow in them. The residual three livers couldn't be analyzed the furrow of caudate lobe because of the artificial des t ruc t ion . 3 .These 47 caudate lobes were vascularized by 146 portal branches (average 3.1 branches). Six kind of supplying patterns of portal branches, viz, 1, 2, 3, 4, 5 and 6 branches were observed in 3, 11, 11, 14, 4 and 2 caudate lobes, respectively, and these branches could be separated into two groups, viz, branches of para caval portion (right) and branches of Spiegel lobe (left). This portal segmentation into two territories corresponded to the hepatic venous segmentation. 4 .The furrows existed on the border which separated the portal branches into two groups,

[ C o n c l u s i o n ] It may be concluded that the furrow is an external index of the boundary which divides caudate lobe into two territories, viz, para caval portion (right) and Spiegel lobe (left).

F P 3 0

A Case of an Isolated Caudate Lobe (Segment I) Resection

Mitsuyo Kosugi, Kaoru Kiyohara

Dept., of Surg., Tonami General Hospital, Toyama, Japan

Some authors have reported various hepatic segmentectomies

with caudate lobectomy for bile duct carcinoma of the hepatic

hilus or hepatocellular carcinoma. As compared with a com-

bined resection, an isolated caudate lobectomy is uncommon

because of anatomical, technical or carcinologic reasons and

low incidence of an isolated tumor.

An ultrasound examination revealed a liver tumor in, a 61-year-

old female, who had gastrectomy for an originating leiomyosar-

coma in 1980, and underwent crater removal of a tumor from the

S IV, metastasized in 1987. CT scan and MR image showed a

large mass, in the S I. Celiac angiogram demonstrated a hyper-

vascular tumor with abundant neovascularity which was fed

from the right posterior and left hepatic, and diaphragmatic ar-

teries.

She underwent caudate lobectomy in March 1993 electively.

On the laparotomy the tumor lay between the inferior vena cava,

the ligamentum venosum,the hepatoduodenal ligament and the

main portal trunk. It was precisely in the S I alone.

I think that the isolated caudate tumor resembles a cube or die.

for a Metastatic Leiomyosarcoma

The left and inferior sides are free. Four sides the right, ante-

rior, superior and posterior are surrounded primarily by the he-

patic hilar structure,S 1V and IVC. Since a large caudate tumor

hugs and compresses the IVC, it is dangerous to divide the pos-

terior plane from the left. The hepatoduodenal ligament and the

portal trunk obstruct the mass.

After anterior division from the tigamentum venosum to the S

IV, ligation of the short hepatic veins was done step by step,

which exposed the IVC surface from the inferior toward the

superior. On the right side,where is important to the caudate

resection, at the transparenchymal transection between the S I

and S VI, IV, a dissecting procedure was performed to figate the

branches of portal trunk supplying the S I. The superior poste-

rior side separation maintains a risk and is the key point of seg-

mentectomy L The supreme short hepatic vein ruptures eas-

ily. Total blood loss was 1900ml and the operation lasted for

6 hours. The resected specimen, measured 9 x 7 x 6.8 cm,

and weighed 228Gm.

The patient was discharged uneventfully.

87

FP31

Proliferative Activity and Oncoprotsin Expression in Cystic Neoplasms of the Pancreas

Takashi Yano, Toshio Iida, Hideya Kida, Yoshikazu Akasaka, Kazuya Amano, Kenji Fujimori, Akinori Ishihara* Department of Surgery, Saiseikai Matsusaka General Hospital * Division of Clinical Pathology, Matsusaka Chuo Hospital

Plural oncogenes and anti-oncogenes have proved to play [Results]

an essential role in multistep carcinogenesis. Lately, some (A) Cystadenoma of the pancreas (n=3)

of the oncoprotein can be identified immunohistochemically. No positive staining for the c-erbB-2 and p53 oneoprotein

In the present study, immunohistochemieal staining was was observed in both serous and mucinous cystadenoma.

performed on cystic neoplasms of the pancreas (n=6) Both serous and mucinous cystadenoma showed a low

to evaluate over-expression of the c-erbB-2 and p53 proliferative activity with PCNA labeling index of less

oncoprotein, than 7 %.

Furthermore, proliferative activity was investigated (B) Intraductal mucin-producing tumors (n=3) in these tumors with PCNA (Proliferative Cell Nuclear c-erbB-2 and p53 oncoprotein were not stained in all of 3

Antigen). tumors. PCNA labeling index ranged between 4 % to 17% [Materials and Methods] in these tumors. This study was done on 6 cystic tumors of the pancreas. [Conclusion]

Histological diagnosis was as follows: serous cystadenoma An over-expression of c-erbB-2 and p53 oncoprotein was in one, mucinous cystadenoma in 2, and so-called intraductal not detected in both cystadenoma and intraductal mucin~producing tumor in 3 (adenoma in one, ductal mucin-producing tumor of the pancreas. Although most

hyperp]asia in 2). of these tumors showed a low proliferative activity with Using specific antisera to the c-erbB-2 and to the p 53 PCNA labeling index, some of mucin-producing tumor oncoprotein, the tumors were stained immunohistochemically, demonstrated a moderate proliferative activity. All of these tumor samples were taken from routine paraffin-embedded tissue. Proliferative activity of these tumors w e r e examined by PCNA labeling index.

88

FP32 Hepat ic Resect ion for Metastatic Cancer

Kenj i Kakizaki , Hidemi Yamauchi

Depar tment of Surgery , Sendai Nat ional Hosp i ta l , Sendai,

Resect ion of hepatic metastases from colorecta l cancer seems to be of benefit to the pat ients . However , the role of hepatic resect ion for non- colorectal metstases has not been defined. We repor t our exper ience of hepatic resect ion for metastat ic cancer, espec ia l ly for those of non-co lorec ta l hepat ic metastases . (Pat ients) Between 1986 and 1992, 34 hepat ic resect ions for metastat ic tumor were per formed at our ins t i tu t ion .Twenty-e igh t resect ion were for colorectal metastases (25 pa t ien ts ) ,and each one for hepat ic metastases of gastr ic cancer, pancreat ic carcinoma, bile duct carcinoma, carcinoma of Papi l laVater , b reas t cancer and carcinoid of the breast . Pat ient charts were reviewed and fo l low-up evaluat ion was carr ied out. (Resul ts) 1) Fo r the group of 25 patients with hepatic metastases from colorectal cancer, the 3- year surv iva l was 49 %. 2) Each pat ient with pancreat ic and bile duct carcinoma died of recurrence 8 months after the hepatic resect ion. The patient , who had r ight hemilobectomy and par t ia l resect ion of the lateral segment of the l iver for the

Japan

metastases of the breas t cancer, surv ived for 4 years without any sign of r ecur rence .So do the one who had part ia l resect ion o f $8 with combined resect ion of the d iaphragma for metastasis of carcinoma ot papi l la of Vater for 2 yea rs .The fo l low-up per iod of the patiens of gastr ic cancer and carcinoid of the breas t are 4, 10 months , r e spec t ive ly .Those two are alive, but the one with carc inoid tumor has recurrence on the bone. (Summary) Occasional long term survivors are found after hepatic resect ion for non-colorecta l hepatic metasases in both our experience and the l i terature rev iew.Terefore , hepatic resect ion could benefi t some patiens with hepat ic metastases from non-colorecta l cancer. Specia l guidl ines for select ion of the patientts are necessary .

FP33

Effects of Rat Serum Induced by Freezing-thawing Hepatic Tissue on Prolifiration of Intrasplenic and/or Cultured Hepatocytes.

Satomi Uno, Shinji Osada, Akihiro Kanno, Motohisa Katou, Yasuyuki Sugiyama, Kiichi Miya and Shigetoyo Saji The 2nd Dept. of Surg., Gifu Univ. Sch.of Med., Gifu Japan

It has been considered that some kinds of tumor enhancement was observed in some cases following cryosurgery for malignant tumor and was caused by increase of immunosuppresive activity induced from the freezing-thawing malignant tumor tissue. From the poin of this phenomenon, it was suggested that proliferation of the engrafted intrasplenic hepatocytes or primary cultured hepatocytes might be accelated by the serum obtained from pre- sensitized rats with freezing-thawing hepatic tissue(FTHT). In present investigation, usefullness of FTHT for proliferative activity was examined and compared with the serum obtained from the rats underwent 70% partial hepatectomy before 24 hrs(PRGF) and normal rats(NR). Results:(1)2g of FTHT was inoculated into the back of male Fisher 344 rats, and serem was obtained at day 14, and collected together as pooled serum from 30 rats(RHGF). (2)When 5Xl0bhepatocytes were inoculated into the spleen on day 7 or 14 after intraperitoneal administration of 2.0ml of RHGF, the growth area of

engrafted hepatocytes calculated by use of image analyzer was significantly increased at day 14 and 28 as compared with that of NR. 3)The produced DNA synthesis activity of primary cultured hepatocytes evaluated by3H -thymidine uptake was significantly increased after the addition of RHGF or PRGF into culture medium than that of NR. 4)The distribution of RHGF fraction(Fr.35) at 14-25% of Na+analysed by Mono-Q column showed different pattern from those of PRGF and NR. Moreover, the produced DNA synthesis activity was shignificantly increased by Fr.35 than conventional RHGF. 5)The growth area of engrafted hepatocytes into the spleen was significantly increased by RHGF or PRGF administration at day 1,8,15 and 22, while it showed no enhancement activity by NR administration. Conclusion:It was suggested that rats serum induced by inoculation of freezing- thawing hepatic tissue played as a some kind of hepatocyte growth factor, and was considered that its characterization was slight different from human haptocyte growth factor so on.

89

FP34

Successful resection of the pancreatic carcinoma with cavernous transformation : Reconstruction of the portal vein follwing pancreatico-duodenectomy

Tadashi Horimi, Tadanori Ishikawa, Motohiro Takasaki, Sojiro Morita, Tohru Nakamura Dept. of Surgery, Kochi Municipal Central Hospital, Kochi, Japan

Two cases of the pancreatic head carcinoma which

have obstruct ion of the portal vein with cavernous

transformation were resected and the reconstruction of

the portal vein was performed.

Case 1 was a 37-year-old male with obstructive jaundice

under FTCD. To resect the pancreatic head and the

portal vein included cavernous t ransformat ion, the

bypass-catheter between umbilical vein: and super ior

mesenteric vein was used under pumping of plasma

exchange machine.

Case 2 was a 71-year-old female without jaundice. As

giving attention to preserve the hepatic artery and a

couple of collateral vein of cavernous transformation,

bypass-catheter such as forementioned was not used.

Both patients were discharged from hospital with no

complication. Case 1 was survived for 16 months and

case 2 was still alive on 4 months postoperatively.

Cavernous transformation of the portal vein causes

following the obstruction of extra-hepatic portal vein,

b u t t he s u c c e s s f u l r e p o r t of t he r e s e c t i o n and

reconstruction for the pancreatic head carcinoma and

the portal vein with cavernous transformation was not

found on the liteartures.

We will describe herein the success of two cases and

the extracorporeal circulation.

FP35

Inhibition of Liver Metastasis of VX2 Carcinoma in Rabbits by Anti-angiogenic Agent, TNP-470.

Hiroki Tanaka, Toshio Takahashi, Hiroki Taniguchi, Kazumi Takeuchi, Yasushi Suganuma, Keigo Miyata, Hiroshi Koyama First Department Surgery,Kyoto Prefectural University of Medicine

Tumors induces neovascularization for its growth. Inhibition of angiogenesis has a potency of anti-tumor effect. TNP- 470(O-(chloroacetyl-carbonyl)fumagillol) exhibits potent inhibitory activity on endothelial cell. The agent is a new synthetic analog of fumagillin that is a natural product of Asprgillus fumigatus. TNP-470 inhibit DNA synthesis of endothelium. In Tumor tissue, the agent suppresses only tumor-indused endothelial cell proliferation not tumor cell itself then causes anti-tumor effect. The inhibitory activity of this product was explored on a VX2 carcinoma metastasized to the liver in rabbits.

MATERIALS AND METHODS Fourteen Japanese white rabbits were used for this study. The fresh 1.0x106 of VX2 carcinoma ceils in Hank's balanced salt solution were injected into the parenchyma of the spleen to cause liver metastasis via portal vein. Fourteen rabbits were classified into 2 groups Group A(7rabbits): 5.0mg of the agent was administrated intravenously everyday from the day of tumor plantation (day 0) to the sixth day (day 6). GroupB(7rabbits): No agent was administrated for control. On the day 14, rabbits were sacrificed and the number of the minor metastasized tumor on the surface of the liver was

counted. RESULTS The number of tumor in group A was less than in the group B(p<0.05). DISCUSSION Neoplasm induces neovascularization for growth. The concept that "tumor growth is angiogenic dependent" was first proposed in 1971 by Folkman et al. If angiogenesis is suppressed in early phase of tumor implantation, metastasis will be inhibited.

We made up the liver metastasis model of rabbits, which was inhibited by TNP-470. TNP-470 is defferent from other anti-tumor agent in following point. 1)The agent is expected to have no specificity on any cancer, because the target of the agent is the endotherium of tumor vessels not tumor itself. 2)At an early phase of tumor metastasis, the metastatic liver tumor is supplied by both arterial and portal systems. This agent wi|l be expected to have no specificity on the route of administration, because this agent will inhibit neovascuralization of both systems.

90

FP36

Portal vein thrombi accompanied with liver metastases seen at cancer resection

angio-CT in the early postoperative period of colorectal

Hideki Aoki, Kazuo Hatsuse, Shintaro Terahata*, Toshiyuki Irie**, Michinori Murayama, Tsukasa Aihara, Shoetsu Tamakuma The 1st Department of Surgery, Clinical Laboratory*, Radiology**, National Defense Medical College, Tokorozawa, Japan

Angio-CT is now considered the most sensitive technique for detecting small hepatic lesions and defining the relationship of each lesion to adjacent intrahepatic vascular structures. So it is of great value in the evaluation of patients being considered for surgical resection of hepatic tumors. A simultaneous combination of CTAP (CT during arterial portography) and CrHA ( c r during hepatic arteriography) is also useful in the detection of the hemodynamics of hepatic lesions.

2 patients underwent colorectal surgery and liver metastases were found by intraoperative palpation. To determine the resectability of hepatic lesions, we performed angio-CT in the early period after original operation. Angio-CT revealed metastatic lesions and portal vein thrombi characteristic of wedge-shaped defect in CTAP and wedge-shaped enhancement in CrHA Resected specimens were pathologically studied; besides metastatic lesions, two different types of thrombi were found.

Case 1 underwent left colectomy for descending colon cancer (moderately differentiated adenocarcinoma: depth ss lyl v2 nO inf2). Angio-CT was done 20 days after first

operation and it showed liver metastases ($5, $6, $7) and portal vein thrombi ($6, $7). We perfmmed an extended right hepatectomy 31 days after angio-CT. Portal vein thrombus was not found by intraoperative ultrasound or angiography of resected specimen. Microscopically, portal vein thrombi were tumor thrombi and cancer cells were 'showered' on the peripheral area. Case 2 underwent anterior resection for rectal cancer (moderately differentiated adenocarcinoma: depth ss ly2 vl n2 inf , ) . Angio-CT was done 29 days after first operation and it showed solitary liver metastasis ($7) and portal vein thrombus ($5-6). We performed a right hepatectomy 25 days after angio-CT. An obscure cutoff of portal vein (P5) was found by intraoperative ultrasound. Microscopically, portal vein thrombus was thrombus without cancer ceils.

Angio-CT performed for metachronous liver metastasis never shows these wedge-shaped portal vein thrombi. These facts remind us of following questions: 1)Does colorectal liver metastasis occur in form of portal vein tumor thrombus at first? 2)Does operative procedure easily cause portal thrombus? 3)How do we decide timing and the extent of liver resection when we find these thrombi?

FP37 A Case of Endocrine Cell Carcinoma of Papil!a Vater

Ichiro Uyama, Shuhei Iida, Hiroyuki Ogiwara, Kaichiro Kikuchi, Tetsuya Takahara,

Katou Department of Surgery, Nerima General Hospital, Tokyo, Japan

and Yutaro

Endocrine cell carcinoma with similar histological findings to carcinoid tumor is very rare. We report a patient with endocrine cell carcinoma of papilla Vater who died due to liver metastasis. Case Report

A 86-year-old male underwent upper abdominal computed tomography for liver dysfunction in June 1991 and was found to have a dilatation of intrahepatic billiary duct, choledochus, and swelling of gallbladder. He was admitted to the hospital for the detailed examination. On physical examination he had no jaundice, no right hypochon- tralgia. Hemoglobin level was 13.6 mg/dl, leukocytes count was 4300/mm 3 , patelets count was 188000/mm 3 serum total biliruibin level was 1.0 mg/dl, GOT level was 49 IU/I, GPT level was 58 IU/I, LAP level was 287 IU/I, ALP level was 1237 IU/I, serum-AMY level was 288 IU/I, CA19-9 level was 76 U/ml.

Percutaneous transhepatic cholangiogram revealed choledocholithiasis, choledochotomy and cholangioscopy were underwent, but there was no stone in choledochus. Therefore, duodenotomy was performed and was found to have a tumor in pappila Vater.

The surface of the tumor was irregular, and was accompanied with a ulcer. And then pappilectomy was underwent. Histological examination showed positive Grimelius stain and rosette formation, and high grade of atypism. Histological diagnosis was endocrine cell carcinoma. The postoperative course was uneventful and he was discharged one month after the operation.

Six months after the operation, he was readmitted due to the obstructive jaundice resulting from liver metastasis.

Percutanous transhepatic biliary drainage was underwent, however, the patient died 9 months after the operation. Percutanous needle biopsy was underwent and revealed liver meatstasis of endocrine cell carcinom~

91

FP38 A Three-dimensional Reconstruction using Spiral CT for Hepato-bilio-panceatic Surgery

A-Hon Kwon, Shoji Uetsuji, Osamu Yamada, Tomohisa Inoue, Shuji Kurimoto, Hisanao Komada, Yasuo Kamiyama, Tsunehide Boku*. The Ist Dep. of Surg. and 2nd Dep. of Surg*., Kansai Med. Univ., Osaka, Japan

A spiral CT (SCT) scanning is a recently introduced scanning technique which continuous table transportation. This technique allows to scan one large volume with no interscan interval. And three dimensional reconstruction using SCT is emerging as an effective means of showing complex anatomical relationships. In this study we analyzed the possible advantages of this new technique regarding hepato- bilio-panceratic lesion. We investigate the 68 cases of cholecystolithiasis (after enhancement of drip infusion cholangiography :DIC-SCT), 12 cases of choledocholithiasis (endoscopic retrograde cholangiography :ERC-SCT), and 4 cases of the carcinoma in the biliary tract (through a endoscopic retrograde biliary drainage :ENBD-SCT or percutaneous transhepatic cholangiography :PTC-SCT), 3 cases of pancreatic cancer (angiography: Angio-SCT) , and 6 cases with hepatocellular carcinoma (rapid single bolus injection: Bolus-SCT). All examinations are done on a Somatom Plus scanner (Siemens AG, Erlangen West Germany) in which the available spiral CT

scanning software and hardware have been implemented. Three dimensional surface reconstruction of biliary tract (DIC-SCT) is useful in the diagnosis of anatomical relationships between cystic duct and common bile duct (84.2% of cases can be seen). The rate of contrast enhancement of DIC-SCT is not different in comparison with conventional ERC. The ENBD-SCT and PTC-SCT provide three dimensional, anatomical informations on hepatic duct. And the Angio-SCT and Bolus-SCT can assist in studies of cancer invasion and anatomical arterial relationships. We conclude the SCT scanning technique is useful for the preoperative assessment of hepatic, biliary and pancreatic surgery using three dimensional reconstructions, as well as for thin-section scans and multiplanar reconstructions.

FP39 Significance of Serum Thymidine Kinase Activity after Hepatic Resection in Humans

Hitoshi Kohno, Naofumi Nagasue, Takafumi Hayashi, Akira Yamanoi, Masaaki Uchida, u Takemoto, Yoshinari Makino, Takashi Ono, Junko Hayashi and Teruhisa Nakamura The 2nd Dept. of Surg., Shimane Med. Univ., Izumo, Japan

Major hepatic resection in patients has some risk of liver failure even now. During the early postoperative period, it would be worthwhile to know whether remnant liver has started to regenerate or not. Thymidine kinase (TK, EC 2.7.1.21) increases at the G1-S boundary, and remains high during S and G~ in cell cycle. Thus, TK in the liver

Z , , ,

reflects hepatocytes dlvlslon and DNA synthesis of regenerating liver in animal experiments. To know whether serum TK could be a clinically useful marker of hepatocytes division after hepatic resection, serum TK activity (radioenzyme assay) was measured serially after operation in 25 patients, as follows. Group I (n=5) was non-liver surgery group (4 gastrectomies and 1 cholecystectomy). Group II (n=8) was minor hepatectomy group (Wedged resections were done in patients with hepatoceliular cancer and cirrhosis). Group III (n=5) was of major hepatectomy of normal liver (i left lobectomy, 2 right lobectomies and 2 extended right lobectomies against metastatic cancer in 2, cholangioma in i, gall-bladder cancer in i, and hepatocellular cancer in i). Group IV (n=7) was of

major hepatectomy of 'cirrhotic or hepatitic liver (i left lobectomy, 5 right lobectomies and 1 extended right lobectomy against hepatocellular cancer). Normal control (n=9, healthy volunteers) was 3.5 + 1.0 U/l.

Table. Serial changes of serum TK Group Postoperative Day

0 1 3 5 7 14 I 3.3 2.3 3.4 4.8 5.5 5.8

(2.2) (1.4) (2.8) (3.1)(2.5)~(3.0) II 4.9 3.9 4.2 11.7 17.7 6 6

(2.5) (1.8) (I.0) (9.1) (7.6) (1.8) III 5.2 3.6 4.1 10.9 14.3 7.2

(3.6) (1.7) (2.8) (6.3) (9.5) (2.9) IV 6.6 ~ 5.4 ~ 7.1 14.6 17.9 ~ 6.8

(2.9) (2.7) (5.7) (15.0) (9.2) (2.5)

Data was shown as mean (S.D.) and asterisk or asterisks indicates p<0.05 or p<0.01, as compared with Group I. Considering liver regeneration was confirmed on CT in Groups III and IVy while not in Group II, serum TK does not seem to reflect only liver cell division. Serum TK may not be a useful marker of liver regeneration, and elevation of serum TK does not necessarily ensure liver regeneration in patients.

92

FP40

P r e o p e r a t i v e D i a g n o s i s and T r e a t m e n t o f C h o l a n g i o c e l l u l a r C a r c i n o m a

Hodaka Amano, T o s h i y u k i K i k u c h i , Tohru N a g a s h i m a , S h i n - i c h i Okazumi , K o u t a r o u I w a s a k i , Ha ru fumi Makino , T a k e h i d e Asano and K a i c h i I s o n o The 2nd Dept. of S u r g . , C h i b a U n i v . , C h i b a , J a p a n

To improve the prognosis of c h o l a n g i o c e l l - ular c a r c i n o m a (CCC), appropriet s u r g i c a l procedures depended on accurate diagnosis a r e i m p o r t a n t . Preoperative d i a g n o s t i c p r o c e d u r e s in ou r h o s p i t a l a r e d e s c r i b e d , w i t h c l i n i c o p a t h o l o g i c a l a s p e c t of t h e r e s e c t e d c a s e s . From 1981, 31 c a s e s of CCC were r e s e c t e d and t h e y were d i v i d e d i n t o f o u r t y p e s a s f o l l o w s , I . m a s s i v e and l o c a l i z e d t y p e (6 c a s e s ) , E . m a s s i v e and i n v a s i v e t y p e ( 1 5 ) , m. d u c t a l and i n v a s i v e t y p e ( 9 ) and N . d u c t a l and l o c a l i z e d t y p e ( 1 ) . These t y p e s a r e d i v i d e d to m a s s i v e and d u c t a l t y p e by mass f o r m a t i o n in t h e l i v e r and to l o c a l i z e d and i n v a s i v e t y p e by infiltration along the major intrahepatic bile duct . Hepatic resection of two or more segment were performed in 24 cases. Caudate lobe resection in 25 cases for ~, N and N. Intrahepaticojejunostomy in 25 cases for ~, �9 and N except i case. Portal vein resection in 8 cases for I and m.

Cumulatve survival rate of one-year is 65%, 3-year 31% and 5-year 26%, exclude 3 operative death. Longest survival of I is lOylOm, E 5y2m, ~ 4y2m, N ?y6m and a l l of them a r e a l i v e . D i f f e r e n t i a l d i a g n o s i s i s important in I and d i a g n o s i s of portal vein i n v a s i o n i s important in E and m , D-CT i s u s e f u l in b o t h . M[I i s s u p e r i o r in d e t e c t i n g tumors. D-OT is use fu l in de tec - t i n g iymphnode m e t a s t a s e s . In ~ , N and N , diagnosis of bile duct invasion is important, stereo-bipane cholangiography, Cholangio-CT and 3D-CT is useful. To improve the postoperative prognosis, accurate diagnosis using various diagnostic modalities is impor tant .

FP41

Sonoradiographie Diagnosis and Gross Appearance of Cholangiocellular Carcinoma

Syuiehi Niimoto, Kazurou Hirose, Hiroaki Seki, Yoshiaki Isobe, Akio Yamaguchi, Gizou Nakagawara The Ist Dept. of med., s Medical School, Fukui, Japan

Cholangiocellular carcinoma (i.e. CCC) is a poor prognostic disease because of the difficulty to diag- nose in early stage. This study was investigated about the sonoradiographic diagnosis and the gross appearance of CCC. Patients and results;iS CCC cases were studied, which classified no patients in stage I ,one patient in If, 4 patients in Ill,and 11 patients in IV. (male:female = 5:11, 35y. o. --~85y.o.,ave. 65y. o.) For these patients sonography, CT scan, cholangiography (ERC or PTC) and angiography were examined and these findings were compared with gross appearanse of CCC. Sonography; They may be hypoechoic, isoechoic(93.8%) and either than homogeneous, the border of mass is obscure or wave like (81.3%). Usually biliary tree dilatation acompanied the mass (50%). Only one case formed halo. CT scan; They were hypodense with slightly irregular internal component, but without mosaic structure or central necrosis. In 37% of cases, the margin of mass was enhansed on contrast scan.

or obstructed in all cases. Intra!uminal mass, or an irregular stricture was present at the point of obstruction. In 3 cases, obstructive jaundise was obserbed. Angiography; They usually have hypovascular tumor vessels (66.7%), small arterial encasement (80%), and obstruction or stenosis of intrahepatic portal vein (66.?%). But there was no arterievenous nor arterio- portal shunt. Gross appearance; 25% of cases was nodular type, ?5% was massive type and no eases was diffuse type. All cases didn't formed capsule, grew invasively to peripheral normal liver and biliary tree, but had no septal formation nor central necrosis. These findings corresponded with the imaging features. 2 cases complicated with intrahepatic stones. Conclusion; In comparison with imaging features and gross appearance, CCC is usually detected as low echoic, hypodense, poorly marginated~ ,kypovascular mass with infiltration to biliary trees.

93

FP42 Two Cases of Mucoepidermoid Carcinoma of the Liver

Michinori Murayama i, Kazuo Hatsuse 1, Shintaro Terahata z, Hideki Aoki 1, Nozomi Idota 1, Satoshi Shono 1 Tsukasa Aihara 1, Yoshihiro Sakai a, Minoru Kakihara ~, Shoetsu Tamakuma The 1st Department of Surgery%Clinical Laboratory 2, National Defense Medical College, Tokorozawa, Japan

Mucoepidermoid carcinoma is defined as a tumor characterized by the presence of squamous cells, mucus-producing cells, and ceils of intermediate type. We report two cases mucoepidermoid carcinoma of the liver, That is very rare in the liver, although relatively common in the salivary glands.

Case !: A 33-year-old male complained jaundice and upper abdominal pain. Abdominal ultrasonography revealed obstructive jaundice with tumor of the liver hilum. Cholangiography, computerized tomography, magnetic resonance imaging and angiography suggested hilar cholangiocarcinoma. We performed a left trisegmentectomy with resection of common bile duct and the portal vein. 45 Gy postoperative radiation to the site of anastomosis was performed. The intrahepatic tumor invaded into the liver hilum, measuring 3.0 x 2.3 x 4.5 cm. The cut surface showed gray-white, round in shape and a cystic lesion in the center of the tumor. Microscopically, the center of the tumor with cyst was mucoepidermoid carcinoma, accompanied with the feature of adenocarcinoma at the peripheral site.

Case 2: A 77-year-old male was incidentally found to have an elevated value of serum alkaline phosphatase by his home doctor. An ultrasonographic examination of the abdomen disclosed a tumor of the liver. Endoscopic retrograde cholangiography, computerized tomography and angiography provided the diagnosis of intrahepatic cholangiocarcinoma. We performed extended right hepatectomy with resection of the common bile duct. 45 Gy postoperative radiation to the site of anastomosis was performed. The specimen contained a gray-white minor measuring 3.8 cm in diameter. Microscopically, it consists of squamoid cells with intercellular bridge, mucus- containing goblet cells and intermediate type ceils.

Mucoepidermoid carcinoma of the liver is regarded as a variant of cholangiocarcinoma. But the tumors of the other organ (salivary glands, lung, esophagus) are regarded as secretfiry gland origin. Similarly, the tumors of the liver may arise from the glandular elements around the intrahepatic bile duct. The prognosis is seemed to be poor in the previous report, but case 1 is alive 2 years after surgery and has no sign of recurrence. Radiation therapy may be effective, like the tumor of the salivary glands.

FP43 A case of advanced carcinoma of the hepatic hilus radically resected by left hepatic trisegmentectomy with caudate lobectomy and combined portal vein resection.

Hideaki Suzuki, Yuji Nimura, Junichi Kamiya, Masato Nagino, Michio Kanai, Masahiko Miyachi, Katsuhiko Uesaka

A 65-year-old female patient was admitted to her local hospital with jaundice and fever. After percutaneous transhepatic biliary drainage(PTBD) in the right anterior segmental duct, she was referred to our hospital for further investigations and treatments. Multiple PTBD, two in the left lateral segmental ducts and one in the right posterior segmental duct, was additionally performed. Selective cholangiography revealed advanced cholangiocarcinoma which devided the bile ducts into multiple units at the hepatic hilus. Percutaneous transhepatic portography demonstrated complete obstruction of the left portal vein and stenosis of the right portal vein. Celiac arteriography revealed the tumor encasements of the right hepatic artery, the right anterior hepatic artery, and the middle hepatic artery. The right posterior hepatic artery, originating from the superior mesentric artery, had no eneasement on superior mesentric arteriogram. After improving jaundice and cholangitis, left hepatic trisegmentectomy with caudate lobectomy and combined portal vein resection were performed to suit the above findings on November 17, 1992. Portal vein reconstruction was performed by end to end anastomosis between the main trunk and the right posterior branch. Bilioenteric continuity was established by Roux-en-Y jejunal loop.

The operation time was 11 hours and 57 minutes with the intraoperative blood loss of 5600 gram. The resected specimen revealed that the tumor had originated in left hepatic duct and had infiltrated to Glisson's sheath and hepatic parenchma. Histologically, the tumor was moderately differentiated tubular adenocarcinoma with moderate proliferation of interstitional connective tissue. Portal vein infiltration, marked perineural invasion, and positive paraaortic lymphnode were observed. No postoperative complication was occurred and the patient discharged the hospital on the 35 postoperative day and has enjoyed her social life for 4 months without any sign of recurrent tumor.

94

FP44

A Case of Cholangiocarcinoma with Intra Bile Duct Papillaly Growth

Masaru Konishi, Munemasa Ryu, Yoshiyuki Shimamura, Taira Kinoshita, Noriaki Kawano, Hiroshi Tanizaki and Yoshihide Arai Dept. of Surg., National Cancer Center Hospital East

We report a case of cholangiocarcinoma or iginat ing in the posterior segment wi th in t ra bile duct papil laly growth. The patient, a 60 year-old woman, suffered from epigastralgia. A liver tumor, measur ing 10cm, in the posterior segment with dilatat ion of peripheral bile duct was revealed by CT and ul t rasongraphy. We made a diagnosis of cholangiecarcinoma and performed r ight lobectomy, caudate lobectomy and resection of the bile duct. The resected specimen contained a solid tumor, measuring 3 era, in the posterosuperior subsegment and a papillaly tumor widely spreading into the posterior hepatic duct. Histologically, the major par t of the tumor consisted of a papillaly adenocarcinoma, even though the papillaly tumor in the bile duct revealed necrotic change.

Until now the definition of eholangiocarcinoma has been confusing. Grossly, it is usually classified into two types : mass - fo rming type, developing an apparent t u m o r ; a n d infi l trat ing type, spreading along the bile duct. This case is in teres t ing in the sense t ha t this tumor showed not only t u m o r - f o r m i n g growth but also in t ra bile duct papillaly growth.

FP45 Immunohistochemical Evaluation of Proliferating Activity in Intrahepatic Cholangiocarcinoma

Kazuo Ohashil), Yoshiyuki Nakajimal), Tsutsumi Masahiro2), Hiromiti Kanehiro 1), Toshiyuki Fukuokal), Azusa Naito 1), Yoichi Konishi2) and Hiroshige Nakano 1) 1)The 1st Dept. of Surg.,2)Dept of Oncol. Pathol., Nara Med. Univ., Nara, Japan

The history of intrahepatic cholangiocarcinoma (ICC) is dismal in

spite of the refinement in operative techniques. Gross classification

of ICC has been confusing because of the rarity and the multiplicity

of gross appearance. In the light of palliation of ICC, gross

classification which refelects biological behavior including its'

proliferating activity must be viewed and the treatment fit for each

type must be discussed. In this study, to analyze the proliferating

activity of ICC, proliferating cell nuclear antigen (PCNA) staining

was applied to 12 cases who underwent surgical treatment in the 1 st

Dept. of Surg., Nara Med. Univ. The gross classification are divided

into the following three types. Mass forming (MF) type (n=3): The

tumor is nodular shape and the borders between the cancerous and

non-cancerous portions are relatively clear. Peri-ductal extension

(PD) type (n=3): The tumor extends along peru-bile duct area without

forming a large nodular shape. Spicula formation (SF) type (n=6):

The tumor is nodular shape and the border between the cancerous

and non-cancerous portions are unclear and irregular.

Four-micrometer paraffin sections of forrnalin fixed specimen were

immunostained with the LSAB technique using PCNA antibody

(Dako). PCNA labelling index (LI) was calculated as the percentage

of PCNA positive tumor cells in relation to the 1000 of the tumor

cells. PCNA LI were 17.3 • 3.2%, 51.2 +-- 11.7%, 58.3 • 12.3% in

MF, PD and SF type, respectively (Table). These differences

between MF and other groups are statistically significant.

Furthermore, it would seem that patients in high PCNA LI (PD,SF)

group have limited lifespans.

Table Labeling index of PCNA by gross classifications in 12 intrahepatic cholangiocarcinoma.

Gross Number classification of cases Labeling index

MF type 3 17.3 • 3.2

PD type 3 51.2_+ t l .7

SF type 6 58.3 • 12.3

.

95

FP46 Clinicopathological Evaluation of Cholangiocellular Carcinoma after Hepatic Resection

Hiroshi Kawamura, Shuichi Ishiyama, Nobuo Seo~ Akira Fuse, Hiroshi Kuzu, Koichi Sutoh and Masaru Tsukamoto The !st Dept. of Surg., Yamagata Univ., Yamagata, Japan

We have 8 patients with cholangiocellular carcinoma(CCC), and 5 of them underwent hepatic resection. The records of these 5 patients were reviewed. We classified them by the general rules of Liver Cancer Study Group of Japan for primary liver cancer. The clinical stages were II(3 cases), III(l case) and IV-A(1 case).

In 3 cases, tumors were found near the hepatic hilus (Central Type), and in the other cases they were found in the periphery of the liver (Peripheral Type). There was one case of central type with hepatolithiasis. In all 3 cases of central type, we added caudate lobectomy, and there was one case needed partial resection of the portal vein. We performed bisegmentectomy for 4 cases and trisegmentectomy for I case.

operation. There was one case which had no metastasis in the regional lymph node at the operation showed the lymph node recurrence. We have one peripheral type who is alive for 2.5 years without recurrence.

In order to improve the prognosis of CCC, extended operation which is brought by the investigations of the prevention of the intrahepatic recurrence and the method of lymph node dissection will be proposed.

We achieved relative non curative resection for 4 cases and absolute non curative resection for 1 case because of the positive TW. Recurrence in the residual liver after hepatectomy was found in 1 case that had intrahepatic metastasis at the

FP47 A Study of Surgical Treatment of Cholangiocel!ular Carcinoma

Shigeru Takamori, Shunji Futagawa, Tomoe Beppu, Masaki Fukazawa, Kuniaki Kojima, Isamu Watanabe, Kouichi Okuyama and Shin Watanabe The 2nd Dept. of Surgery Faculty of Medicine Juntendo Univ., Tokyo, Japan

We had 6 patiens with cholangiocellular carcinoma, one patient with a hilar type and 5 with a peripheral type from October 1979 to March 1993; these cases accounted for 4.1% of 148 patients who had surgery for primary liver cancer. The ratio of men to women was I:i, and the average age was 58.3 years~ Upper abdominal pain was the most frequent initial symptom. The level of carcinoembyroic antigen was elevated in 4 patients (67%), and that of CA19-9 in S (83%). Hypovascularity of the tumor and dilatation of the bile duct in the peripheral site of the tumor were preoperatively obtained by image diagnosis. No patients had either liver cirrhosis or intrahepatic stones. The maximum diameter of the tumor was 6.9cm on the average. Surgery was performed in all patients: hepatic lobectomies in 2, and extended hepatic lobectomies in 4. Lymph node metastases were found in 3 patients. Histologically all cases were tubular adenocarcinoma. All patients were regarded as non-curative by the Japanese general rules of primary liver cancer. Five patients died within

8 months after hepatectomy. However, there were no operative deaths, and one case (40-year-old female, peripheral type) has survived postoperatively without recurrence beyond 6 years. Our cases of cholangiocellular carcinoma were already advanced at the time of diagnosis except one, and had poor prognoses.

96

FP48

CholangioceUular carcinoma - Our Experiences -

Susum u T a k a m a t s u , N a r i h i d e G o s e k i , K e n i c h i T e r a m o t o , S h o u i c h i K a t o h , Y u z u r u H a m , Y a s u y u k i D o b a s h i , M i t s u o E n d o h T h e 1 s t D e p a r t m e n t o f S u r g e r y o f T o k y o M e d i c a l & D e n t a l U n i v e r s i t y

From January 1885 to April 1993, 7 patients (5 males and 2 females, a mean age 61.7 ;range 44 to 72 years) with cholangiocel lular carcinoma were treated in our department . The tumor mainly existed segment 4 in 6 patients, and segment 6 in 1 patient. The size of tumor were ranged from 1.9cm to 9cm (mean 4.6cm) in 6 pat ients (1 pat ient , whose tumor was no t resectable, was unknown) . 1 patient had liver cirrhosis, and 1 pat ient had hepatol i thias is . According to the general rules for the clinical and pathologica l s tudy of primary l iver cancer, staging of the cancer were Stage II in 2 patients, Stage III in 3 patients , and Stage IV-A in 2 patients. In the gross classification, 4 cases were nodular type, and 2 cases were massive type. PathologicaUy, 4 cases were moderately, 1case was poorly differentiated adenocarcinoma, and 2 cases were unknown. We performed expanded right l obec tomy and caudal l obec tomy for 1 patient, expanded left lobectomy for 2 patients, left lobectomy and subtotal caudal lobectomy for

1 patient, enucleation for 1 patient, resection of the segment 4 and 5 for 1 patient, and ligation of the left hepatic artery and cannulat ion to right hepatic artery for 1 patient. The prognosis of our 7 pa t i en t s is fo l lowing; 2 pa t i en t s d i ed perioperatively, two died of cancer recurrence ( 4 months and 2.5 years after surgery), one died of other disease with no recurrence of cancer ( 4.5 years after operation), and two are alive up to date ( 3 months and 6 months after surgery).

FP49

Retrospective Analysis of S u r g i c a l T r e a t m e n t fo r C h o l a n g i o c e l l u l a r C a r c i n o m a (CCC)

Kyosuke Ohta, Taich Kanamaru, Makoto Usami, Kazuya Sakata, Seiji Haji, Jorge Kotani, Atsunori Iso, Hiroshi Kasahara, Eisei Ku, Masahiro Yamamoto and Yoichi Saitoh The 1st Dept. of Surgery, Kobe Univ., Hyogo, Japan

Ret rospect ive analysis of surgical t rea tment for

cho lang ioce l lu la r ca rc inoma was per formed in 9 patients who

underwen t hepa tec tomy from 1977 to 1992 in our depertment .

Methods of resect ion, pa thologica l f indings and prognosis

were evaluated. The mean age of 9 pat ients(4 male; 5 female)

was 63.2 years old. The max diameter of tumors was between

4.1 to 15 cm and the mean value was 7.8 cm. 3 out of 9 eases

(33.3%) had multiple tumors. Staging system fol lowing the

general rules for the clinical and pa tho log ica l study of

p r imary liver cancer by liver cancer study group of Japan

s h o w e d S t a g e I I i n 7 c a s e s , S t a g e I I I i n 1 c a s e a n d S t a g e I V - A i n 1

case. Methods of hepatic resect ion showed Hr l in 1 case, Hr2

in 7 cases and Hr3 in 1 case. All cases underwent major

hepatic surgery without lethal complicat ion, because they did

not have any other chronic liver diseases. 8 out of 9 cases in

our hospital unde rwen t left lobectomy. Concern ing the

curabil i ty o f hepatic resection, all 3 cases underwent absolute

noncura t ive resect ion, because tumors existed near hepatic

hilus and the portal vein. 2 out of 3 cases were per formed

t r ansa r t e r i a l c h e m o t h e r a p y or radiat ion. Rates of r e cu r r ence

in 6 cases after curat ive and relat ive noncura t ive resect ion

were as follows; 2 / 5 TW(-) cases (40%), 1 / 1 TW(+) case

(100%), 2 / 4 N ( - ) cases (50%), I / 2 N(+) case (50%), 0 / 1 B2

(0%), 3 / 5 B1 cases (60%). Histological f indings of fc(-) and z0

showed no re la t ionsh ip with recur rence . 3 absolute

n o n c u r a t i v e r e s e c t i o n c a s e s w e r e a l l d ied w i t h i n o n e y e a r a n d

1 relat ive noncu ra t i ve resect ion case developed in t rahepa t i c

metastasis but he was still alive at 16 months after the

operat ion. The survival rates of 5 relat ive curat ive resect ion

cases were 80.0% at 1-year, 80.0% at 3-year, 53.3% at 5-year,

There were 2 long term survival cases, one died from other

disease after 174 months and another case passed 151 months

without r ecur rence . In conclus ion, major hepatic resect ion

should be pe r fo rmed for removal of (3(3C including cases who

develop lymphnode metastasis or tumor growth within the

bile duct of ex t rahapat ie lesion for possibil i t ies of longer

survival. But prognosis is poor after absolute noncura t ive

r e s e c t i o n .

FP50

Clinical Study of Cholangiocellular carcinoma

Satoshi Hirano, Hiroyuki Katoh, Susumu Okajima, Yuji Miyasaka, Toshiya Nishibe, Yoshiaki Narita, Mitsuru Doke, Shunichi 0kushiba, Eiji Shimozawa The 2nd Dept. of Surgery, Hokkaido Univ., Sapporo, Japan

97

The result of surgical treatment for the cholangiocellular carcinoma (CCC) still have been poor. To clarify the factors provide such an unsatisfactory outcome, recent cases experienced at our department were evaluated.

PATIENTS; From 1987 to 1992, ten patients suffered from CCC were treated at our department. Of i0 cases 7 were male and 3 were female. Their ages varied from 47 to 79, and the average was 61.4 years old. The clinical staging of them were stage-III (n=2),IV-a(6) and IV-b(2).

RESULT; Most common clinical symptom was epigastralgia and back pain (n=5). Liver dysfunction and jaundice were complained in 3 cases each. Preoperative hepatic reserve was relatively good, as was indicated by the average of ICG K-value 0.13+0.06. For tumor markers, 80% of CA19-9 reveTed high range. In regard to diagnosis with US, tumors demonstrated various echo level in thair center, and comparative low echo in thair lateral portion. With CT, the central part cf the tumor showed low density in all the cases. Seven of I0 patients were operated, and 5 tumors were resectedby hepatic lobe-

ctomy. The resectability rate was 71.4%. For the radicality,only 2 cases (40%) were curative,and the other 3 resulted in absolute non-curative operation,owing to positive resected margin of the liver. At present,only 2 cases survived and one is alive over 4 years without any evidence of recurrence. Howevec, the mean survival of unresectable and non-curative cases are 267+147 and 285+114 days, respectively.

CONCLUSION; As almost all the CCC cases have been advanced at the time of diagnosis. and tend to be given non-curative resection followed by poor prognosis,so extended hepatic resection should be performed positively to aim better curative rate.

FP51

The regenerating rate of the remnant liver correlates with the area under the curve(AUC) of serum hHGF.

Keigo Miyata, Hiroki Taniguchi, Hiroki Tanaka, Hkoshi Koyama, Kazumi Takeuchi, Toshio Takahashi First Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan

The liver actively regenerates after partial hepatectomy, but the mechanisms responsible for this proliferation are not fully understood. Human HGF is the strongest growth stimulator of both human and rat hepatocytes in primary culture, and the hHGF level increases after partial hepatectomy. We compared the regenerating rate of the remnant liver and postoperative area under the curve(AUC) of serum hHGF.

MATERIALS AND METHODS Nine patients who underwent liver surgery were studied. Eight patients had metastatic liver tumors and 1 patient had hemangioma of the liver. The weight of the resected liver was measured postoperatively as soon as possible. Blood sample was taken before and 7 days after the operation. Human HGF was measured by ELISA assay.(Otsuka Assay Laboratories) Preoperative and 6 months postoperative liver volume were approximated from the images of computed tomography. The Speamann's rank correlation test was used to compare the AUC and regenerating rates. The AUC was calculated trapezoidally. A value of p<0.05 was considered to be statistically significant. All values are reported as means•

RESULTS The mean value of regenerating rate [ (.postoperative liver

volume)/(preoperative liver volume-liver weight resected)-i ] was 0.83• The serum AUC was 86.55• h/ml). There was a positive linear correlation between them [Y=0.029X-1.68 X:AUC(ng h/ml) Y:regenerating rate]

DISCUSSION The serum hHGF level increases immediately postoperatively and followed by a decline, and the serum hHGF concentration 12 hours postoperatively correlates with the amount of the liver resected. However, little is known about the relationship between the regenerating rate of the remnant liver and the serum hHGF level. In this study, the remnant liver regenerated actively, and the regenerating rate ~orrelated with the serum AUC. Although the control mechanism responsible for hHGF production during liver damage is not fully understood, our finding provides direct evidence that hHGF stimulates the remnant liver to proliferate postoperatively.

ACKNOWLEDGEMENTS Thanks are due to Dr.Masayoshi Kimoto (Second Department of Internal Medicine, Faculty of Medicine, Kagoshima University) and Dr.Hirohito Tsubouchi (Professor of Second Department of Internal Medicine, Miyazaki Medical College) for measuring the serum hHGF level.

98

FP52 Primary closure of the common bile duet by using intraoperative transpapillary decompression tube for choledocholithiasis

Takeshi Mitsui,Shoji Miura,Yoshinori Munemoto,Yasuyuki Asada,Yoshio Kasahara, Atsushi Nagasato,Yoshiro lida,Hideo Saito,Masakiyo Fujisawa Dept.of Surg.,Fukuiken Saiseikai Hosp.,Fukui,Japan

Primary closure of the common bile duet using transpapillary decompression tube was performed in I0 patients of choledocholithiasis.0perative procedure was chole- doeholithotomy after cholecystectomy and eholangiography via cystic duct followed by insertion of decompression tube with 2 side flaps and 4 side holes from choledocho tomied portibn into the CBD. This tube was reformed from ERBD tube with size of 7 Fr. 9cm. After passage of tip and the distal flap of the tube into the duodenum transpapillary,the CBD was closed by using 6-0 PDS. Mean operationtime was i hr.35 min., and mean intraoperative bleeding was 128g. This tube was removed about 14 postoperative day endoscopically. In one of I0 patients,mild bile leakage from drain for 6 postoperative days was recognized. And another patient revealed transient elevation of serum amylase. But no other postoperative complications were recognized. Postoperative hospital stay was 26{8.7(mean +S.D.) days. This period was shorter than those of T-tube drainage patients of ehole- docholithiasis. We concluded that primary

closure of the CBD by using transpapillary decompression tube was effective and safe procedure.

FPS3

Interleukin-6 and granulocytic elastase levels after laparoscopic cholecystectomies

Shoichi Hazama, Masaaki Oka, Kazuhisa Hiwaki, Sakurao Hiraki, Akira Tangoku, Kouji Shimoda, ~ichinari Suzuki Norio Iizuka, Kenji Wadamori, Takashi Suzuki

Dept. of Surg. II, Yamaq~chi Univ., Ube, Japan

Background: Interleukin-6 ( IL-6 ) levels are well

correlated with the magnitude of surgical tratmm.

Patients and Method: Serum IL-6 and plasma granulocy~

tic elastase levels were determined in twelve patients

undergoing maj or surgery ( 5-esophageal cancer,

3 gastric cancer and 4 coloreetal cancer) (MS group)

and 17 patients undergoing laparoscopic cholecystec-

tomy (LC group) to compare these two groups.

Results: The duration of the surgery in MS group

was significantly longer than that in LC group

(p<0.01). Blood loss in MS group was significantly

greater than that in LC group (p< 0.01). IL-6

levels was significantly correlated with the dura-

tion of the surgery (R=0.675, p< 0.01) and intra-

operative blood loss (R=0.537, p< 0.02). However,

there was no significant correlation between granu-

locytie elastase and the duration of surgery or

blood loss. Plasma IL-6 levels in LC group (21

• 3 pg/ml) was significantly lower than those in

MS group (186 --+ 36 pg/ml) (p<0,01). However, there

was no significant difference in granulocytic elastase

levels between LC group (318 + -- 81 ~g/l) and MS group

(701--+ 344 ~g/l).

Conclusion: IL-6 is well correlated with the

magnitude of the surgery. The low IL-6 levels

may elucidate the low surgical stress of laparo-

scopic cholecys tectomy.

99

FP54 Study on Surgical Anatomy for Duodenum Preserving Resection of the Head of the Pancreas

~ataru Kimura I, Hideo Nagai 2, Tetsuichiro Muto I, Gyotaro Kanazawa 2 First Department of Surgery, University of Tokyo 2Department of Gastroenterological and General Surgery, Jichi Medical University, Tokyo, Japan

[Aim] To precisely examine the topography of the duodenum, pancreas, bile duct and supplying vessels. [Materials and Methods] Among the cases autopsied in the Tokyo Metropolitan Geriatric Hospital, forty cases were studied in which the pancreas head was well preserved and no pathological lesion was found. [Results] I) The arcade formation between the anterior superior pancreaticoduodenal artery (ASPD) and the anterior inferior pancreaticoduodenal artery (AIPD) was found in all of the cases. ASPD ran toward the point 1.5 cm below the papilla of Vater, then turning around to the posterior aspect of the pancreas to join AIPD. Thus, to the contrary to the prevailing notion, AIPD was found on the "posterior" surface of the pancreas. 2) In 88% of the cases was the arcade demonstrated between the posterior superior pancreaticod- uodena! artery (PSPD) and posterior inferior pancreaticoduodenal artery (PIPD). 3) No case was found, in which ASPD, AIPD, PSPD, PIPD, and their branches were completely buried in the pancreatic parenchyma. ASPD and its branches to the duodenum were rather deeply buried in a number of the cases. 4) It was

generally easy to dissect the pancreas from the duodenum because of the loose connection. Nevertheless, we had to remove a part of the duodenal wall in 88% of the cases in order to completely extirpate the pancreatic tissue, because the pancreatic parenchyma "invaded" the submucosal or muscular layer of the duodenum in the neighborhood of the accessory papilla. [Conclusion] It seemed possible to remove the head of the pancreas preserving the vascular arcades and their blanches to the duodenum, the bile duct and the papilla of Vater. Near the accessory papilla, however, the dissection of the vessels was tedious, and pancreatic parenchyma was sometimes found in the wall of the duodenum. It might be better in such cases to leave this portion and to perform the subtotal resection of the head of the pancreas.

FP55

Good control for the postoperative indigestion by our new operative technique "sphincter creating pancreatoduodenectomy"

Kazunari Mori, Katsuyoshi Tabuse, Seiki Yamamoto, Yoshihiro Sugimoto, Masami Oka, Satoshi Asano and Hiroyuki Kinoshita Dept. of Surgery, Osaka-Minami National Hospital, Osaka, Japan

Formation of substitute pyloric muscle was made at the reconstruction of digestive tract after extended pancreatoduodenectomy for 5 cases of the cancer of pancreatic head area, 2 cases of bile duct cancer in the middle portion, 2 cases of gastric cancer and one case of the retroperitoneal tumor. Our method is the modification of the Imanaga's Bilroth I reconstruction after pancreatoduodenec tomy, but the characteristic operative procedure is used when the gastrectomy and gastrojejunostomy is performed, ie, the sero-muscular layers of the triangular portion of the greater curvature of the residual stomach are used to patch the site of the anastomosis in the hope they would have function as a sphincter, controlling empty from the stomach and preventing bile reflux into the stomach.

Postoperative gastrofiberscopy(1 case) revealed no bile in the gastric contents, and closed state of the anastomotic stoma, but easy passage of an endoscopy through it. Postoperative scintigraphies to examine the gastric emptying and bile secretion (2cases) revealed 20 minutes elapse

for bile to mix with food. After 5 to 30 months postoperative

follow up, no diarrhea was observed, the body weight began increase in the 3 months after operation, and the serum albumin level increased more than 10 percent in each cases.

Therefore, it was considered that this method was useful for good control for the postoperative indigestion after pancreatoduodenectomy.

100

FP56 Delayed gastric empty and H2-reeeptor antagonist, and selective musearinic receptor antagonist.

-a randomized control study-

T. IWAGAKI, T. TAKADA, H. YASUDA, K. UCHIYAMA, H. HASEGAWA, H. USHITANI, Y. YAMAKAWA First Department of Surgery Teikyo University, School of Medicine

Gastric stasis in the early postoperative period is one of the problems in the cases performed pylorus preserving pancreatoduodenectomy (PPPD). A randomized controlled study was performed as to the surpressive effect of H2-receptor antagonist and selective muscarinic receptor antagonist upon the gastric empty in the early period after PPPD. [Subject and Method] 20 cases performed PPPD were

divided 4 groups by the envelope method and each of them included 5 cases. Group I was administrated neither H2-receptor antagonist nor selective muscarinic receptor antagonist. Group ~ was administrated ranitidin as a H2-receptor antagonist. Group ~ was prescribed pirenzepine as a selective musearinic receptor antagonist. Group IV was prescribed H2- receptor antagonist and selective muscarinic receptor antagonist jointly. The daily volume and the total acidity of the gastric involvements via naso-gastric tube from the Ist until 13th post operative day were measured. Serum gastrin and secretin level also measured preoperatively and post operative 3rd, 7th, 14th and 28th days. [Conclusion] The daily mean discharge volume from the naso-gastric tube was amount to i121• on the 3rd post operative day and gradually reduced after the 5th postoperative day in group I, however it was still over 550mi on the 13th postoperative day. In group E, the maximum volume of

Video presentation

VF1

575• was recorded on the 4th postoperative day and about 300ml were recorded after the 5th postoperative day. As for group ELI, the maximum volume of 574• was recorded on the 3rd postoperative day and about 300ml were recorded after the 5th postoperative day. And in group IV~ the maximum volume was surpressed to 242• and about 180ml of discharge wererecorded after the 5th postoperative day. there were stastical difference about the daily volume of gastric discharge between group I and the other groups respectively. The total acidity of the gastric involvements, while its mean preoperative value was 81mEq/l, was higher, twice as mch as the preoperative mean value in group I. The acidity were almost same as the preoperative value in the group and ~. The acidity showed lower than the preoperative value in group IV and there was a statistical difference about the total acidity between group I and IV. Serum gastrin and secretin levels changed within normal range pre and postoperatively. These results supported that postoperative adminis-

tration of ran•177 pirenzepine or joint use of them were surpressed the volume of gastric discharge and the acidity of involvements. And in group I, the gastric acidity was higher and the volume of gastic discharge was abundant with any concern with gastrin nor secretin levels.

Right hepatectomy with removal of tumor thrombus in the inferior vena eava under oblique clumping of the inferior vena eava with preserving perfusion of left hepatic lobe for hepatoeellular carcinoma Shoichi Fujii, Shigeo Ooki, Akira Sugita, Shinji Togo, Shinsuke Imai,Hiloshi Sekido, Shingo Fukazawa, Shiniehi Ishihara, Hidenobu Masui,Masayoshi

Yamamoto, Kouhei Yoda, Akira Nakano, Hiroshi Shimada

The Zud Dept of Surgery.,Yokohama City Univ.,Yokohama,Japan

The patient was a 43-year-old woman with hepatocellular

carcinoma occupying the right lobe, 8cm in diameter.

Tumor thrombi was detected in the right portal branch and

the inferior vena cava by CTscan, MRI, abdominal

angiogram and abdominal ultrasonogram preoperatively.

Operative procedure : Following the skeletonization of the

hepatoduodenal ligament with separation of the arteries,

portal veins and biliary ducts to each lobes, right

hepatectomy was performed by anterior approach after

transection of the fight vessels and biliary ducts. A tumor

thrombus invaded into the inferior vena cava through the

inferior right hepatic vein. Its upper edge was below the

root of the right hepatic vein. We performed veno-venous

bypass with a cetrifugal blood pump from the right femoral

vein to the left axillary vein. Then, we applied upper

inferior vena cava clump above the right hepatic vein and

below the middle and left hepatic vein obliquely in order to

preserve a perfusion of the left hepatic lobe. The inferior

vena cava was incised at the root of the inferior fight

hepatic vein, and the tumor thrombus was removed from the

inferior vena cava. The incised portion of the inferior vena

cava was closed by continuous suture with 5-0 Proline. The

resected liver weight was 750g. The exclusin time was

19min 20seconds. The postoperative course was uneventful.

The hospital stay was 30days.

101

VF2 Hepatic Right Trisegmentectomy with Portal Vein Reconstruction for Hepatocellular Carcinoma with Extensive Portal Vein Tumor Embolism Katsuhiko Yanaga, Mitsuo Shimada, Hidefumi Higashi, Akinobu Taketomi, Takashi Matsumata, Keizo Sugimachi The 2nd Dept. of Surgery, Kyushu University Faculty of Medicine, Fukuoka, Japan

For advanced hepatocellular carcinoma (HCC) with tumor embolism of the main portal vein (PV), hepatic resection with embolectomy could prevent variceal hemorrhage and achieve palliation as well as avoidance of tumor rupture. We herein present a 35-year-old hepatitis B carrier who successfully underwent right trisegmentectomy with PV embolectomy for such a pathological condition. Preoperative imaging studies revealed massive HCC of the right lobe with multiple small intrahepatic metastases (IM) and a PV embolus which extended into the mid- portion of the main trunk as well as the horizontal portion of the left branch. IM were controlled by transcatheter arterial embolization (TAE) x 2. His preoperative liver function was as follows: ICG at 15min 24.6% (0-i0), Total bil. 1.6mg/dl, A l b u m i n 2 . 8 g / d l , g a m m a - g l o b u l i n 2 7 . 6 % , plt. 127x103/cmm, AFP 418,180ng/ml. On Jan. 21, 1993, he was taken to the operating room and the abdomen was entered via a bilateral subcostal incision with an upper midline extension. The PV pressure was 255mmH20.

After cholecystectomy, parenchymal dissection was commenced to the right of the falciform ligament. The right hepatic artery and duct were divided. Under PV inflow occlusion and balloon obliteration of the umbilical portion, the right PV branch was incised hemicircumferentially at its origin, and the embolus was removed. The venotomy site was closed with a 5-0 Prolene| running suture. The PV occlusion time was 16min. Right trisegmentectomy was completed by dividing the middle and right hepatic veins. The operation time was 7hr 25min, and 1,680ml of packed red cells were transfused. Postoperatively, the liver function normalized rapidly; the highest Total bil. and SGPT were 2.1mg/dl and 55IU/L on postoperative day (POD) i, respectively. PV patency was confirmed by enhanced CT on POD 49. After another TAE, he was discharged on POD 57 with normal liver function and AFP of 4,661ng/ml. Three months after surgery, the patient remains well with normal liver function and last endoscopy demonstrated only mild esophageal varices (FICw).

VF3

Total Replacement of the Inferior Vena Cav~ with an oPTFE in Radical Resection for Primary Liver Cancer Minekatsu Nishida , Takashi Yagyu, Kazutaka Nakashima, Ryoichi Sh imizu , Te t sush i Uchiyama, Takashi Suzuki

Dept. of Surg.][ , Yamaguchi Univ. School of Med., Yamaguchi, Japan

Cons iderab le advances have been made in l ive r surgery in the pas t decade. Much of t h i s p rog re s s has been achieved because of increased r ecogn i t i on of l i ve r func t ions and an improvement of su rg ica l techniques , which is ma in ly due to a p p l i c a t i o n of techniques for l i ve r t r a n s p l a n t a t i o n . None the less , r e s e c t i o n of a l i ve r tumor involv ing the i n f e r i o r vena cava remains to be chal lenged, s ince the large d iamete r autogenous condui ts are not r e ad i l y available, and pros thet ic g r a f t s in the venous sys tem have low potency r a t e s i n f e r i o r to those obtained in a r t e r i a l r econs t ruc t ions . I n addition, ex te rna l compression in c r i t i c a l a reas like the r e t r o h e p a t i c IVC may a l so c o n t r i b u t e to f a i l u r e of the g r a f t s . We here in repor t a pa t i en t wi th c h o l a n g i o c e l l u l a r c a r c i n o - ma involving the I V C who s u c c e s s f u l l y underwen tex- s i t u r i gh t t r i s e g m e n t e c t o m y and to t a l replacement of the i n f e r i o r vena cava wi th ringed expanded lmlytetrafluotoethylene. C A S E . A 5 0 year old female was admi t ted to our hosp i t a l for t rea tment of c h o l a n g i o c e l l u l a r carcinoma in the r i gh t !obe. Magnetic resonance imaging revealed that a l i ve r tumor, which probably o r i g i n a t e d f rom the caudate lobe, occupied in the r i gh t lobe and the l e f t median segment . The l e f t l a t e r a l segment remained i n t a c t , b u t the tumor invaded d i r e c t l y to the three major hepatic ve ins .

Angiography showed encasements of the po r t a l vein and the hepa t ic a r t e r y at the confluence of the i r l e f t hepa t i c branches. Right t r i s egmen tec tomy concomitant w i t h replacement of the r e t rohepa t i c IVC and r e c o n s t r u c t i o n o f the l e f t hepatic vein as well as the lef t hepa t i c a r t e r i a l

mad por ta l branches were recommended, so we decided to use ex s i t u techniques . She was taken to the ope ra t ing room Jan. 18, 1993. A f t e r to ta l hepatectomy, ex s i t u hypothermic pe r fus ion us ing a U n i v e r s i t y - W i s c o n s i n so lu t i on was c a r r i e d o u t . Tr i segmentec tomy w i t h r e s e c t i o n of the re t rohepa t ic I V C was performed, and the l e f t hepatic vein was anastomosed in an e n d - t o - s i d e fashion to the 20ram r inged e P T F E w i t h running m a t t r e s s ( 4 - 0 N e s p i r e n e ) s u t u r e s . The r e i m p l a n t a t i o n of the remnant l i ve r followed the pr inc ip le of l i ve r t r a n s p l a n t a t i o n , except for r ep l acemen t of t he IVC in an e n d - t o - e n d fashion w i t h g ra f t , 7cm in l eng th , w i t h r u n n i n g m a t t r e s s ( 3 - 0 N e s p i r e n e ) s u t u r e s . Theost ium of the l e f t hepatic vein was 3cm below the anastomosis of suprahepa t ic I V C . Recons t ruc t ion of the b i l i a r y sys tem was performed as e n d - t o - e n d b i l e duct anas tomos i s w i t h T - t u b e . P o s t o p e r a t i v e l y , the pa t i en t had an uneventful recovery and discharged 51 days a f t e r the o p e r a t i o n . She is g e t t i n g we l l w i t h no evidence of recur rence . The e P T F E g r a f t was proved to be patent by vena cavogm#ly at 3 months, and enlargement of t h e r e m n a n t l ive r was a l so de mons t r a t e d .

102

VF4

Extended Right Hepatectomy with Portal Vein Resection and Reconstruction for a Carcinoma of the Hepatic Duct Confluence

Masaru Miyazaki, I-Iiroshi Itoh, Takashi Kaiho, Katsuhiko Andoh, Satoshi Ambiru, Shinichi Hayashi, Eiji Gohchi, Kijuro Takanishi, Motoki Nagai, Akira Togawa, Masayuki Ohtsuka, Kazuhiro Sasada, Masayuki Shiobara, Yoshiaki Shimizu, Shigeru Yoshioka, Hiroyuki Yoshitome, Atsushi Katoh, Shunta Nakamura, Nobuyuki Nakajima, Yoshiaki Sano*, Toshikazu Suwa*. The 1st Dept. of Surgery, Chiba University, Chiba Japan, * Ohmiya Red Cross Hospital, Ohmiya, Japan.

Hepatic hilar vascular involvement has been considered

to be crucial for a judgement of resectabi l i ty in a

carcinoma of the hepatic duct confluence. Heptic hilar

vascular resection, and reconstruction has been reported

to induce high operative morbidity and mortality rates.

However we have applied the more aggressive surgical

approaches of hepatic hilar vascular resection and

reconstruction to the disease. Eightteen patients of

hepatic hilar ductal carcinoma had surgical resection

with portal vein resection and reconstruction. In six

of 18 pat ients the hepatic ar tery feeding remnant

l iver after hepatectomy were also resected and

reconstructed. Two hospital deaths ( 1 3 % ) o c c u r r e d

following surgical resection with hepatic hilar vascular

resection and reconstruction. Similarly four hospital

deaths (13%) in thir ty four resected patients without

vascular resection. This video shows a procedure of

extended right hepatectomy with portal vein resection

and reconstruction for a 58 -y r -o ld woman of hepatic

hilar ductal carcinoma.

VF5 Vascular Reconstruction in biliary tract Cancer --- Umbilical Vein Patching for Portal Vein and Replacing Right Hepatic Artery with Gastroduodenal Artery ---

Takeshi Todoroki, Kenji Yuzawa, Masaaki Otsuka, Kazuo Oriif Mutsumi Nozuer Toru Kawamoto, Shuji Kate, Katashi Fukao, Kenmei Kuramoto* and Yukihisa Saida* Dept. of Surg. and *Radiol., Inst. of Clin. Med. r Univ. of Tsukuba, Tsukuba, JAPAN

Twenty-one patients with advanced biliary tract cancer (hilar bile duct for 12, distal duct for one and gallbladder for 8) received vascular reconstruction for portal vein and/or hepatic artery. 14 patients had reconstruction for portal vein (ii for trunk and 3 for right or left main branch) and II had for hepatic artery (i0 for the right and one for the common hepatic). This video will present our techniques for reconstruction both of portal vein and rt. hepatic artery. By way of example, umbilical vein patching for portal vein reconstruction and replacement of right hepatic artery with the gastroduodenal artery will be demonstrated in detail. Rotating video cholangiography of a 72-year old male patient showed complete obstruction at the primary bifurcation of the main hepatic ducts and the stenosis extended along the right and left hepatic ducts up to the 2nd bifurcation of the intrahepatic bile duct. Cholangioscope, which was replaced with PTCD tube, showed that malignant stenotic findings on the confluence of the posterior and anterior segmental bile duct and two calculus at the end

of it. Angiogram demonstrated cancerous involvement of the rt. hepatic and cystic arteries at the liver hilum. The slight shift to the left side in the portal vein from the rt. primary branch to the trunk also suggested cancer involvement. Briefly~ after amputation of the choledochus and taking out stones, blunt dissection of the hepatic arteries and portal vein was proceeded to the severely adhered portion of the portal hepatis. Hepatic segmentectomy of IVb~ and V with gallbladder was performed using Aqua-jet | dissector. Following amputations of the each hepatic duct branches for the remaining segments and cutting hepatic arteries close to the duct stump, a lump of the cancerous lesion was extripated with the anterior wall of the portal vein from middle portion of the trunk up to the bilateral primary branches. The protal vein was reconstructed by the 5cm umbilical vein patch using 5-0 Nespilen | sutures. A posterior segmental branch of the right hepatic artery was anastomosed to the gastroduodenal artery under a x 2.5 binoculars using 7-0 Nespilen @ suture.

103

VF6

Combined Resection of Portal Vein for Carcinoma of the Biliary Tract

Naokazu Hayakawa, Yuji Nimura, Junichi Kamiya, Satosi Kondo, Masato Nagino, Masahiko Miyachi , and Michio Kanai First Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan

Because of anatomical relat ion between the biliary and portal

sy s t e m , a d v a n c e d c a r c i n o m a of t he b i l i a r y t r a c t o f t e n

involeves the portal vein system. Combined resect ion of the

portal vein is necessary for radical resection of such tumour.

<Patients and m e t h o d s > F r o m Octover 1975 to March 1993,

52 pa t ien ts wi th advanced carc inoma of the b i l ia ry t r ac t

underwent eon-lbined resect ion of the portal vein. Th i r ty of

52 had bile duct carcinoma and remaining 22 had gal lbladder

carcinoma. Fi f ty one of 52 cases underwent several types of

liver resect ion. Segmenta l excis ion of the por ta l ve in was

performed in 33 cases and wedge resection of the vessel wall

in 19 cases. An end-to-end anastomosis had been per formed

by a cont inuous ex t ra lumina l over-and-over su tu re of 5 / 0

polypropylene us ing two guy st i tches. In the r ecen t cases,

however , we p r e f e r to u se one guy s t i t c h t e c h n i q u e to

provide a large lumen for end-to-end anas tomosis us ing a

continuous intraluminal su ture at posterior anastomosis. Af te r

wedge resection of the por ta l vein, the side wall was su tured

para l led or long i tud ina l ly to t he axis in 17 cases and a

saphenous vein pa tch was used in two cases. <Results> Six

of 19 pat ients who developed postoperat ive liver failure died

within 30 days after the operation (operative morta l i ty ra te

of 12 %). Actuarial survival rates at 1, 3, and 5 years were

: 59 %, 28 %, and 5 % in pat ients wi th bile duct carcinoma ;

18%, 0 %, a n d 0 % in p a t i e n t s w i t h c a r c i n o m a of t h e

g a l l b l a d d e r , r e s p e c t i v e l y . T h e s e s u r v i v a l r a t e s w e r e

s igni f icant ly be t t e r t han those for respec t ive pa t ients wi th

unresec table carcinoma. <Case repor t> We p resen t combined

liver and por ta l vein resect ion(end-to-end anastomosis using

continuous intrahiminal technique by one guy stitch) for two

cases of a d v a n c e d c a r c i n o m a of t he h e p a t i c hihis . One

p a t i e n t s was 65-year -o ld f ema le u n d e r w e n t l e f t h e p a t i c

t r i s e g m e n t e c t o m y w i t h c a u d a t e l o b e c t o m y . As a f i n a l

procedure of the liver transection, portal vein resection and

r e c o n s t r a c t i o n b e t w e e n t h e m a i n t r a n k a n d t h e r i g h t

pos te r io r b r a n c h were pe r fo rmed . Ano the r was 59-year-old

female u n d e r w e n t por ta l ve in resec t ion and recons t rac t ion

between the main t rank and left portal vein before extended

r ight hepat ic lobectomy with caudte lobeetomy. <Conclusion>

Combined resect ion of por ta l vein isto be recommended as

a r ea sonab l e su rg ica l app roach to se lec ted pa t i en t s w i th

advanced carc inoma of the bi l iary t rac t .

VF7

Experience of pancreatoduodenectomy associated with resection of the caudate lobe and portal vein Mitsuhi ro Mukaiya, Kazuhi ro Yamashi ro , Shinji Koide, Katsuji Tor imoto , Tadashi Katsuramaki , Rhyuichi D e n n o and Koichi Hira ta First D e p a r t m e n t o f Surgery, Sapporo Medica l University, Sapporo , Japan.

( Introduction )

Although imaging diagnosis has been greatly advanced, it is difficult

in many patients with malignant tumor of the biliary tract to examine

the depth and extension of cancer invasion for determination of

dissection range. In a patient with malignant tumor mainly occupying

the middle to the superior bile duct, absolute curative operation

by hepatopanereatoduodenectomy associated with the resection of

portal vein should be selected. Now, our experience is introduced.

( Patient )

A 6 5 - year old women was diagnosed as gallbladder calculus and

obstructive jaundice due to the cancer of the middle bile duct on

February 2, 1992. On cholangiography, the left branch of caudate

lobe was not visualized, which was suggestive of cancer infiltration

into the left branch of caudate lobe. Percutaneous transhepatic

portograpy reveled that the anterior wall of the main portal vein

had somewhat irregular contour, which could not deny infiltration.

( Surgical technique } The second portion of duodenum was mobilized by Kocher method

and the ventral serosa of the mesocolon was stripped off. Division of

the stomach was carried out along the lines of hemigastrectomy. The

proximal jejunum just distal to the ligament of Treitz was divided.

The neck of the pancreas was divided at the level of the portal vein.

Regional lymphnodes were dissected ( R 2 ) , and the left caudate

lobe was mobilized. Then, the left and right hepatic ducts were cut

just before branching and subjected to intraoperative frozen section

examination. The left caudate lobe was passed between bifurcation

of hepatic hilar portal vein and en bloc dissected together with the

portal vein. For the reconstruction of the portal vein, a bypass from

superior mesenteric vein to the hepatic teres ligamentum was

prepared in order to avoide the congestion of the blood flow in the

mesenteric vein. The portal vein was anastomosed by intraluminal

technique by holding 2 points with 6 - 0 proline sutures.

The histological depth of wall invasion was limited to the fibrous

muscle ( f m ) , lymph node metastasis was n ( - ) , and cancer

infiltration at the resection margin was ew (-) .

( Conclusion ) We think it reasonable to apply extensive operation including

heoatopancreatoduodenectomy ( H P D ) to malignant tumor of the

biliary tract in which infiltration into the proximal portal vein or

caudate lobe.

104

VF8 He~Bt~l~nal lig~m~ntectomy and vasollar reconstruction for cholangiocarcinoma using the double-catheter

Hiromu Tsuge, Hisashi Mimura, Keisuke Hamazaki, Masanobu Mori, Noriyuki Kawata and Kunzo Orita The Ist Dept. of Surg., Okayama Univ., Okayama, Japan

Radical surgery for cholangiocarcinoma should be designed to remove the whole hepatoduodenal ligament, because this cancer tends to extensively invade the ligament along the lymphatics and the perineural spaces. Double-catheter bypass (pump- controlled bypass from the left femoral artery to the umbilical portion of the left portal vein branch or the right portal vein branch, and pressure gradient bypass from the superior mesenteric vein to the femoral vein) was used to maintain hepatic circulation and prevent portal congestion during temporary occlusion of the hepatic artery and portal vein. The operative procedure used in two patients will be demonstrated on video. The first patient was a 53-year-old man with hilar cholangiocarcinoma which principally involved the left lobe of the liver and the caudate lobe was performed. Then the hepatic artery and portal vein were reconstructed by interposing a left saphenous vein graft between the common and right hepatic arteries, and interposing a right common iliae vein graft between the portal vein and the right portal vein branch. The second patient was a 58-year-old woman with hilar cholangiocarcinoma which principally involved the right hepatic bile duct. Resection of hepatoduodenal ligament plus resection of the

right lobe of the livers the caudate lobe; and the head of the pancreas was performed. Then the hepatic artery and portal vein were reconstructed by direct anastomosis between the common and left hepatic arteries, and by interposing an external iliac vein graft between the portal vein and the left portal vein branch. We performed hepatoduodenal ligamentectomy in 15 patients, and histological evidence of tumor invasion into the ligament was detected in 13 patients. In 7 of them, the hepatic artery and portal vein were also involved. Double-catheter bypass was an effective support method during en bloc resection of the hepatoduodenal ligament and vasucular reconstruction~

5th Japanese Association of Hepato-Biliary-Pancreatic Surgery

Documents