The aim of this study was to identify the perioperative risk factors for postoperative bile leakage after hepatic resection and to propose a treatment strategy for such leakage when it does occur. Between 1992 and 2000 a total of 313 hepatic resections without choledocojejunal anastomosis were performed at our institute. Risk factors related to bile leakage were identified with univariate analysis, and strategies were evaluated in relation to the findings of postoperative fistulography. Postoperative bile leakage developed in 17 patients (5.4%). Univariate analysis identified high risk factors as advanced age, a wide surface area of the incision (bile leakage group versus no bile leakage group: 102.1 vs. 66.4 cm(2), p < 0.05), and exposure of Glisson's sheath at the cut surface (e.g., central bisegmentectomy, S4, S8 subsegmentectomy). Groupings of patients by their postoperative fistulography results showed that patients with involvement of the proximal bile duct were slower to heal than those with no demonstrable bile duct involvement. The one patient whose fistulogram demonstrated peripheral bile duct involvement had uncontrollable leakage and required reoperation. Hepatectomies with a wide surface area and those that expose the major Glisson's sheath present serious risk factors for bile leakage. When the fistulogram shows proximal bile duct involvement, endoscopic nasobiliary tube drainage is necessary; when the fistulogram shows peripheral bile duct involvement, reoperation is needed.

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This largest, multicenter, prospective study demonstrates the feasibility of SEMS placement as a BTS for malignant colorectal obstruction. SEMS serves as a safe and effective BTS with acceptable stoma creation and complication rates in patients with acute malignant colonic obstruction.

The objective of this study were to evaluate the efficacy of hepatic resection for large hepatocellular carcinomas (HCCs) and examine clinicopathologic factors influencing overall survival after resection of a large HCC. The pre-, intra-, and postoperative factors and long-term outcome of 26 patients with HCCs >10 cm who underwent hepatic resection (group A) were compared with the those of 143 patients with HCCs < or =10 cm (group B). Hepatic resection for large HCCs can be performed with a mortality rate of 3.8%, which was similar to the rate for group B (2.1%). The overall cumulative survival results for group A (1 year 41.0%, 3 years 29.3%, 5 years 29.3%; median survival 10.1 months) were markedly worse than those for group B (1 year 93.1%, 3 years 74.5%, 5 years 44.7%; median survival 53.4 months) (p < 0.0001). Multivariate analysis identified venous invasion as an independent risk factor of survival of patients with a large HCC. The overall cumulative survival results in patients with venous invasion (1 year 28.0%, 3 years 0%; median survival 6.4 months) were markedly worse than in patients without venous invasion (1 year 64.8%, 3.5 years 64.8%; median survival, 51.8 months) (p < 0.0066). We concluded that hepatic resection can be performed safely for HCCs >10 cm with a low mortality rate. It appears reasonable to believe that hepatic resection is the treatment of choice for large HCCs without venous invasion.

Abstract:Our new technique of hepatectomy in rats, avoiding inferior vena cava constriction, revealed that 5%-10% of the total liver is the minimum required volume for remnant liver, a smaller amount than previously reported. The characteristic histological findings of remnant liver in perioperative death are marked hepatocytosis and hepatocyte apoptosis, and extensive hepatocyte necrosis with sinusoid congestion, all of which are thought to be caused by hyperendotoxemia and mitochondrial energy crisis. Partial liver transplantation in rats with our new technique of hepatectomy in the donor operation showed that a graft of 20% liver was the minimum required volume for successful transplantation, also a smaller amount than previously reported. There was no difference in the rate of increase in wet weight after surgery between 20% remnant liver and 20% transplanted liver. Differences between 10% minimum volume remnant liver and 20% minimum transplanted liver appeared to be caused by ischemia-reperfusion and cold preservation injury to the transplanted liver.