Preoperative portal vein embolization (PVE) was performed in 84 patients before extensive liver resection for various diseases. By the criteria of liver volumetric determination, some patients were candidates for PVE, whereas others were not, even though the same surgical procedure, such as extended right lobectomy (ERL), was scheduled. PVE using gelatin sponge powder induced hypertrophy in the nonembolized lobe (0%-171%; median, 30%) and proportional atrophy in the embolized lobe in 2 weeks without eliciting any major inflammatory or necrotic reaction, as evidenced histologically and by the minimal elevations in the serum aspartate transaminase (AST) and alanine transaminase (ALT) values. Alterations in the total bilirubin level and prothrombin time were also insignificant and transient, indicating that hepatocyte functions were not impaired by PVE. Not all patients who undergo PVE proceed with the scheduled hepatic resection procedure, so it is a great advantage that gelatin sponge causes minimal damage compared with other embolizing materials such as cyanoacrylate and absolute ethanol, which have been reported to induce an inflammatory reaction or histological alteration. Our multiple regression analysis showed that three factors, diabetes mellitus, a high total bilirubin level at the time of PVE, and being male, each reduced the extent of hypertrophy in the nonembolized lobe (r 2 ‫؍‬ .30). By contrast, cholestasis appeared to accelerate the process of atrophy in the embolized lobe (r 2 ‫؍‬ .16). In conclusion, PVE by gelatin sponge powder is a safe and effective preoperative maneuver that induces hypertrophy of the section of the liver that will remain after partial hepatectomy. (HEPATOLOGY 1999;29:1099-1105

The surgery of living donor liver transplantation is more technically challenging than cadaveric whole liver transplantation and liver resection for the treatment of various pathological conditions. It requires a thorough understanding of the intra- and extra-hepatic anatomical relationships between the portal vein, hepatic artery, biliary tract, and hepatic vein, and also their respective contributions to liver physiology. Although a precise understanding of general anatomical principles is the key to correctly performing living donor liver transplantation procedures, anatomic anomalies are often present, and the means of detecting them and the surgical methods of coping with them represent technical challenges. In this monograph, we describe the anatomical keys and pitfalls of living donor liver transplantation surgery based on our own experience with more than 1800 hepatectomies, and 150 living donor liver transplantations. We also elaborate on techniques of selective intermittent vascular occlusion and their teleological and practical background.

Hepatectomy, if possible, is indicated in patients with hepatic metastases from colorectal carcinoma if there are no extrahepatic metastases and if the primary disease is controlled. It is indicated only in carefully selected patients with metastases from gastric carcinoma.

Benign PBD strictures, although rare, are usually indistinguishable from malignant PBD strictures by preoperative or perioperative investigation. Given the minimal morbidity, all PBD strictures should be presumed malignant and managed accordingly, even at the risk of overtreating some benign cases.

No abstract

In an attempt to determine the mechanism of cervical lymph node metastases, the authors studied the relation between lymphatic vessels in or around tumour tissue and lymph node metastases in patients with primary squamous cell carcinoma (SCC) of the oral region by enzyme histochemistry using 5′ nucleotidase‐alkaline phosphatase. The subjects consisted of 23 patients, who had biopsy proven oral SCC. After enzyme histochemical staining, the cross‐sectional dimensions of the lymphatic vessels were measured and analysed in relation to the T classification of the tumour, degree of tumour differentiation and mode of invasion. The average diameter of the lymphatic vessels in or around tumour tissue was significantly greater than that in tumour‐free tissue (P<0.01). The mode of invasion correlated significantly with the lymphatic vessel diameter (P<0.01). The diameter did not correlate significantly with the T classification (P range, 0.135–0.254) or tumour differentiation (P=0.274). The following relation was found between the incidence of cervical lymph node metastases and the mode of invasion: 40.0% of Grade 2 tumours were positive for metastases, 71.4% of Grade 3 tumours were positive, and 75.0% of Grade 4 tumours were positive (grading was according to Jakobsson’s classification). Of the factors evaluated in this study, only the mode of invasion correlated significantly with the diameter of the lymphatic vessels. Although other studies have shown that tumour thickness and perhaps even perineural and blood vessel invasion may be equally important, the findings of the current study suggest that both lymphatic vessel diameter and the mode of invasion may be important factors in the prediction of cervical lymph node metastases. Henk Tideman

ObjectiveTo compare the diagnostic accuracies of Lipiodol computed tomography (CT) and helical biphasic CT as preoperative imaging modalities for hepatocellular carcinoma (HCC). Summary Background DataLipiodol CT after digital subtraction angiography has long been used as a highly sensitive imaging modality for HCC. The recent advent of helical CT has allowed scanning the entire liver during both the arterial and portal venous phase of contrast enhancement. MethodsThe authors analyzed data from 164 patients who underwent hepatic resection for HCC to calculate the sensitivity and specificity of these modalities. Findings of intraoperative ultrasonography followed by histologic confirmation were set as the gold standard. ResultsAlthough sensitivity decreased with both modalities as tumors became small and well differentiated, helical CT showed a higher sensitivity than Lipiodol CT in detecting well-differentiated HCC nodules smaller than 2 cm. In contrast, Lipiodol CT was superior to helical CT for the detection of small but moderately to poorly differentiated nodules. The overall sensitivity of helical CT was higher than that of Lipiodol CT. These findings suggest that helical CT is superior in delineating early HCC, whereas Lipiodol CT is specific to the detection of intrahepatic metastases. In terms of specificity, helical CT was superior to Lipiodol CT. ConclusionsHelical CT and Lipiodol CT are complementary modalities. At present, helical biphasic CT does not obviate the need for invasive techniques such as angiography and Lipiodol CT as preoperative examinations for HCC.Advances in various imaging modalities including ultrasonography and computed tomography (CT) have facilitated the detection of hepatocellular carcinoma (HCC) in a preclinical stage.1 As a result, the resectability of HCC has markedly increased, thereby significantly improving survival during the past two decades.2-5 HCC nodules are often multifocal and frequently accompanied by intrahepatic metastatic nodules.6 -8 Underestimation of these lesions may lead to inappropriate surgical resection. Therefore, accurate preoperative imaging evaluation of HCC nodules is essential for selecting appropriate patients for surgical intervention and for determining the extent of hepatectomy. Because typical HCCs are hypervascular tumors that have only an hepatic arterial blood supply (i.e., there is no portal venous

BackgroundSolitary metastasis of a malignancy to the spleen is rare, particularly for gastric cancer. Only a few case reports have documented isolated splenic metastasis from early gastric cancer. We describe a case of splenic metastasis from early gastric cancer.Case presentationA 60-year-old man underwent a distal gastrectomy for early gastric cancer. It infiltrated the submucosa with pathological nodal involvement (pT1bN2M0, stage IIB). One year after the gastrectomy, an abdominal computed tomography scan showed a low-density lesion, 17 mm in diameter, at the upper pole of the spleen. Positron emission tomography/computed tomography showed focal accumulation of fluorine-18 fluorodeoxyglucose in the spleen without extrasplenic tumor dissemination or metastasis. We diagnosed splenic metastasis of gastric cancer, and performed a splenectomy. Histological examination confirmed moderately differentiated tubular adenocarcinoma and poorly differentiated adenocarcinoma (solid type) that was consistent with the features of the primary gastric cancer. The splenic tumor was pathologically and immunohistochemically diagnosed as a metastasis from the gastric carcinoma. More than 18 months after the splenectomy, the patient has had no evidence of recurrent gastric cancer.ConclusionWhen solitary metastasis to the spleen is suspected during the postoperative follow-up of a patient with gastric cancer, a splenectomy is a potentially effective treatment.