ObjectiveTo identify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients. Summary Background DataBile leakage remains a common cause of major complications after hepatic resection. MethodsBetween January 1985 and June 1999, 781 hepatic resections without bilioenteric anastomosis were performed at the authors' institution. Perioperative risk factors related to postoperative bile leakage were identified using univariate and multivariate analysis. The characteristics of patients with intractable bile leakage and the effect of intraoperative bile leakage test were also examined. Management was evaluated in relation to the outcomes and the clinical characteristics of the patients with bile leakage. ResultsBile leakage developed in 31 (4.0%) of 781 hepatic resections. This complication carried high risks for surgical death (two patients [6.5%] died). The stepwise logistic regression analysis identified high-risk surgical procedure, in which the cut surface exposed the major Glisson's sheath and included the hepatic hilum (i.e., anterior segmentectomy, central bisegmentectomy, or total caudate lobectomy), as the independent predictor of the development of postoperative bile leakage. None of the 102 cases in which an intraoperative bile leakage test was performed were subsequently complicated by postoperative bile leakage, and the preventive effect of the test was statistically significant. Patients with fisterographically demonstrable leakage from the hepatic hilum and with postoperative uncontrollable ascites had poor outcomes. ConclusionPatients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis. Therefore, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, more careful surgical procedures and use of an intraoperative bile leakage test are recommended.Because of recent advances in liver surgery, hepatic resections are being performed with increasing frequency, and the surgical death rate for such resections is decreasing. [1][2][3][4][5][6][7] Bile leakage, of course, is the primary complication occurring after liver surgery, and it can not only debase the quality of the postoperative course of patients, but also can lead to hospital death. Despite a significant decrease in the overall surgical complication rate in hepatic resections, the rate of bile leakage has not changed, with an incidence of 4.8% to 7.6% reported in recent large series.2-8 The presence of bile, blood, and devitalized tissues in the dead space after hepatectomy may provide the ideal environment for bacterial growth and impair the normal host defense mechanisms.9, 10 The combination of sudden reduction in the liver volume and development of an intraperitoneal septic complication after hepatectomy (IPSCH) frequently results in live...

Preoperative administration of methylprednisolone sodium succinate can control surgical stress in patients undergoing hepatic resection. Design: A prospective randomized trial. Setting: A university hospital department of surgery. Patients: Thirty-three patients who underwent hepatic resection were classified into 2 groups: a control group (n=16) and a steroid group (n = 17) in which patients were intravenously administered 500 mg of methylprednisolone 2 hours before surgery. Main Outcome Measures: Perioperative levels of interleukin (IL)-6 and IL-10 (serum and peritoneal), immunosuppressive acidic protein, Candida antigen, and other laboratory and clinical variables were measured. Results: Postoperative levels of serum and peritoneal IL-6 and levels of C-reactive protein were significantly lower in the steroid group than in controls. Furthermore, serum and peritoneal IL-10 levels were significantly higher in the steroid group. The total bilirubin value on postoperative day 1 was significantly lower in the steroid group than in controls. Postoperative immunosuppressive acidic protein levels were also significantly lower in the steroid group, as was the positive rate of serum Candida antigen. No differences were found in the incidence of postoperative complications. Conclusions: Preoperative steroid administration significantly elevated anti-inflammatory cytokine IL-10 levels, suppressed the levels of inflammatory cytokines IL-6 and C-reactive protein, and prevented postoperative elevation of total bilirubin values. Furthermore, postoperative elevation of immunosuppressive acidic protein levels and the positive rate of Candida antigen were suppressed, indicating that the immune response was maintained by preoperative steroid administration.

Objective: Histone deacetylases (HDACs) play an important role in chromatin remodeling, gene repression and regulating cell cycle progression and differentiation. This study was designed to clarify the role of HDAC1 expression in hepatocellular carcinoma (HCC). Method: The expression of HDAC1 in 47 patients with surgically resected HCC was immunohistochemically examined and analyzed in relation to their clinicopathological factors. The patients were divided into two groups according to the expression status of HDAC1: a high HDAC1 group (n = 25) with more than 20% of positively stained cells and a low HDAC1 group (n = 22) with 20% or fewer positively stained cells. Results: A high HDAC1 expression indicated a higher incidence of cancer cell invasion into the portal vein, a poorer histological differentiation, and a more advanced TNM stage. The survival rates after a surgical resection in low and high HDAC1 patients at 1, 3, 5 and 10 years were 100, 95.5, 81.8 and 60.8% and 88.0, 60.0, 40.0 and 32.0%, respectively (p = 0.008). A multivariate analysis using the Cox regression analysis showed that a high HDAC1 expression was an independent prognostic factor of HCC in patients after hepatic resection (relative risk: 10.1, p = 0.0018). Conclusions: High HDAC1 expression might have an important role in the aggressiveness and cell dedifferentiation, and its expression status may be a useful biomarker for predicting the outcome of the patients with HCC.

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We present herein the case of a sclerosing hemangioma of the liver which was extremely difficult to differentiate from liver metastasis of rectal cancer, in a 67-year-old woman. All the radiological findings were compatible with liver metastasis; however, marginal pooling of the tumor revealed by computed tomographic angiography and magnetic resonance imaging scans was inconsistent with a diagnosis of liver metastasis. At laparotomy, the tumor was macroscopically unusual in that it was yellowish elastic-hard with a very clear margin, and thus, it did not have the appearance of a metastatic tumor. Mile's operation and a partial hepatectomy were performed, followed by an uneventful postoperative course and no signs of recurrence. The carcinoembryonic antigen (CEA) level in the peripheral blood was not elevated at any time. The postoperative pathological diagnosis was a rare hepatic tumor, namely, a "sclerosing hemangioma," based on the findings of cellular fibrous stroma containing vascular channels with flattened endothelial cells. Preoperatively differentiating between sclerosing hemangioma and a metastatic liver tumor from colorectal cancer may be very difficult; however, this case demonstrated some interesting characteristics, namely, the serum CEA level was not elevated, marginal pooling of the tumor was found in the enhanced radiological findings, and the tumor was macroscopically unusual. Therefore, the possibility of sclerosing hemangioma should be borne in mind when considering the differential diagnosis of patients suspected of having colorectal liver metastasis. A preoperative biopsy should be carried out and when a laparotomy is performed under the misdiagnosis of colorectal liver metastasis, it is advisable that either an intraoperative needle biopsy or a frozen histological analysis be undertaken to avoid unnecessary extended hepatic resection of this rare benign hepatic tumor.