The respective volumes of hepatic tumors and nontumorous parenchyma of 50 patients requiring hepatectomy of more than one segment of Healey for tumor removal were measured using computed tomography (Vol-CT). The volume estimated by Vol-CT was found to correlate with the real weight resected (P < .0001) with a mean absolute error of 64.9 mL. The ratio of the nontumorous parenchymal volume of the resected liver to that of the whole liver (R2) in 15 patients who underwent right or extended right hepatic lobectomy was 43% +/- 15%. Eight of 15 patients with R2s < 60% underwent the procedures without right portal vein embolization (PE). The other seven with R2s exceeding 60% or an indocyanine green retention rate after 15 minutes (ICG15) of 10% to 20% underwent PE: in six of seven, the nontumorous parenchyma of the right hepatic lobe became atrophic and in all seven, the volume of the remaining left hepatic lobe increased with a decrease in the mean R2 from 62% +/- 14% to 55% +/- 8% (P = .0006). In the remaining 35 who underwent other hepatectomy procedures, R2s also remained <60%. Overall, at surgery, in 27 with normal liver function (ICG15 < 10%), R2s exceeded 60% in one, remained at 50% to 60% in five, and <50% in 21, whereas 23 patients except for one with an ICG15 exceeding 10%, had R2s of <50%. The postoperative serum total bilirubin levels in 84% of the patients remained within the normal range and there was no surgery-related mortality. In conclusion, 1) Vol-CT can accurately assess the extent of liver resection, 2) individuals with normal liver function can undergo resection of up to 60% of the nontumorous parenchyma without the need for PE, and 3) PE can be used to reduce the size of the resected tissue and increase the volume of the remnant liver to approximate the target limits in individuals with large tumors or minimally abnormal liver function.

Fluorescent cholangiography enabled real-time identification of the extrahepatic bile ducts during SILC without necessitating catheterization of the bile duct. Such properties of fluorescent cholangiography are expected to be helpful for ensuring the safety of SILC and expanding the indications for the procedure.

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Hemihepatic portal vein embolization (PVE) concomitantly induces atrophy in embolized and compensatory hypertrophy in nonembolized hepatic lobes. The aim of the present study was to evaluate the involvement of growth stimulatory and inhibitory factors in these hepatic lobes after PVE. Liver specimens from the embolized and nonembolized lobes of ten patients who underwent hepatectomy (8-22 days) after undergoing PVE were obtained. Proliferation and apoptosis were examined immunohistochemically using Ki-67 and the Tdt-mediated dUTP-biotin nick end-labeling method. The expression of transforming growth factor-alpha (TGF-alpha) and transforming growth factor-beta (TGF-beta) was also examined by immunohistochemical staining. PVE induced hepatocyte apoptosis in the embolized lobe and hepatocyte proliferation in the nonembolized lobe. TGF-alpha expression in the hepatocytes of the nonembolized lobe was markedly increased, whereas TGF-alpha was also overexpressed, albeit moderately, in the embolized lobe. In contrast, TGF-beta expression in the hepatocytes of the embolized lobe was significantly increased, and TGF-beta expression was also increased, although to a lesser extent, in the nonembolized lobe. The degree of volume changes of the nonembolized lobe and the embolized lobe after PVE was statistically correlated with the ratios of TGF-alpha and TGF-beta expression in these lobes (r = 0.886, P < .0001). In conclusion, these findings indicate that TGF-alpha and TGF-beta expression (assessed by immunohistochemical staining) increase in relation to hepatocyte proliferation and apoptosis, respectively, after PVE in humans and the balance of the two factors may contribute to hepatic atrophy and hypertrophy concomitantly observed in this model.

Introduction: Laparoscopic hepatectomy has disadvantages in intraoperative diagnosis, because it offers limited visualization and palpability of the liver surface. Recently, we developed a novel fluorescent imaging technique using indocyanine green (ICG), which would enable identification of liver cancers during open hepatectomy. However, this technique has not yet been applied to laparoscopic hepatectomy. Materials and Surgical Technique: A patient with a hepatocellular carcinoma (HCC) located in Couinaud's segment II was administered ICG (0.5 mg per kg body weight) intravenous injection 5 d before surgery, as a routine liver function test. The prototype fluorescent imaging system was composed of a xenon light source and a laparoscope with a charge-coupled device camera that could filter out light with wavelengths below 810 nm. Intraoperatively, fluorescent imaging of the HCC was performed by changing color images to fluorescent images with a foot switch. Then, the fluorescing tumor was clearly identified on the visceral surface of segment II during mobilization of the left liver for resection of segments II and III. On the cut surface of the specimen, the tumor showed uniform fluorescence and was microscopically diagnosed as a well-differentiated HCC. Discussion: Laparoscopic fluorescent imaging using preoperative injection of ICG enabled real-time identification of HCC. This technique may be an easy and reliable tool to enhance the accuracy of intraoperative diagnosis during laparoscopic hepatectomy.Asian J Endosc Surg

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IntroductionA liver abscess in Crohn’s disease is a rare but important entity that is associated with a poor prognosis and high mortality when treatment is delayed. We report a case of successful liver segmentectomy for a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn’s disease under infliximab treatment.Case presentationA 31-year-old Japanese man, who had been treated with infliximab infusions for Crohn’s disease, was referred to our hospital presenting with an abrupt onset of high fever and an elevated white blood cell count and serum C-reactive protein level. Computed tomography revealed a liver abscess occupying segment 8. The limited effect of percutaneous transhepatic abscess drainage and antibiotics led us to perform radical resection of the abscess. The patient recovered quickly after surgery and the postoperative course was uneventful.ConclusionThe present case suggests that surgical removal of an abscess should be considered for patients under immunosuppression or refractory to conventional treatment.