Partial hepatic resection for ischemic graft damage after liver transplantation: a graft-saving option?

BACKGROUND: Intrahepatic biliary strictures or parenchymal infarcts may occur after liver transplantation as a complication of ischemic damage to the graft. In some selected cases the lesions appear to be confined to a part of the liver. We report our experience with partial graft resection in this setting. METHODS: From January 1984 to December 1991, 286 liver transplantations were performed in 257 recipients. Seven patients, three children and four adults, underwent partial hepatectomy 3 to 218 weeks after liver transplantation of a full-size graft. The clinical presentation included septic parenchymal infarcts (n = 4) and nonanastomotic biliary strictures (n = 3) complicating (n = 5) artery thrombosis or not (n = 2). There were four left hepatectomies, two left lobectomies, and one right hepatectomy. In four instances partial hepatectomy was performed after failed attempt at biliary reconstruction (n = 2) or arterial revascularization (n = 2). Partial graft resection was performed extrafascially without Pringle's maneuver and mobilization of the remnant liver to preserve its vascularization. RESULTS: No surgical complications occurred, and none of the patients experienced acute hepatic failure during the postoperative period. All patients were discharged home 10 to 96 days (median, 23 days) after liver resection. Two patients had recurrent ischemic cholangitis. One patient underwent successful regrafting for recurrent Budd-Chiari syndrome; one patient died of tumor recurrence. Six patients were alive with a follow-up ranging from 12 to 45 months. CONCLUSIONS: These results suggest that partial graft resection is a safe and graft-saving option after liver transplantation in selected patients with localized ischemic damage of the graft.     

Appraisal of a manual blunt dissection for an intraoperative diagnosis of extrahepatic cancer invasion

BACKGROUND/AIMS: Liver cancer extension to the adjacent organs does not necessarily indicate tumor invasion. It is very hard to diagnose extrahepatic cancer invasion to the adjacent organs using preoperative imaging. This study was undertaken, therefore, to determine the real cancer invasion using a manual dissection. METHODOLOGY: Of the 51 consecutive patients with liver cancer, 6 cases with extrahepatically growing tumors were suspected to have cancer invasion both preoperatively and intraoperatively. Thus, we diagnosed whether or not any real extrahepatic cancer invasion was present by either removing the tumour by hand or by performing a blunt gauze dissection. RESULTS: Three hepatocellular carcinomas and one metastatic cancer were stripped off from the adjacent organ using a manual blunt dissection. However, the other two tumors could not be removed in the same manner and therefore a combined resection of the invaded portion had to be performed along with the hepatectomy. A postoperative detailed pathological examination revealed no cancer cells on the surface of the adjacent organ in the former 4 tumors. Cancer invasion was recognized, however, on the outside of the liver in the latter 2 combined resected tumors. CONCLUSIONS: An accurate intraoperative diagnosis of extrahepatic cancer invasion can be made using manual blunt dissection.     

Hepatic resection for advanced carcinoma of the gallbladder

Hepatic resection for advanced carcinoma of the gallbladder must be decided upon based on the modes of cancer spread to the liver. The cystic vein through the liver bed is considered an important route of liver metastasis, because liver metastases of gallbladder carcinoma are found frequently around the liver bed. About 70% of early metastatic foci demonstrated microscopically occur in segments 4a and 5. Resection of segments 4a and 5 is considered to be an adequate range of hepatectomy for patients with subserosal invasion, because early metastatic foci are detected not only in patients with direct invasion of the liver but also in those without direct invasion. For patients with direct liver invasion, various degrees of hepatic resection are needed to comply with the depth of direct invasion. It is necessary to achieve negative surgical margins 2 cm from the tumor. Because cancer cells extend along the Glissonian sheath in patients with hilar invasion, extended right hepatectomy with caudate lobectomy is required in these patients. A future problem is to establish the safety of extended hepatectomy in these patients.     

Lysosomal enzyme beta-glucuronidase. Release from regenerating liver after partial hepatectomy

In 12 dogs, 70% hepatectomy was performed to investigate the changes in serum lysosomal enzyme beta-glucuronidase activities, and to compare them with other liver functions and with the restoration of liver mass. Three dogs died within 24 hours without recovering consciousness from anesthesia, and one died on the fourth postoperative day because of hepatic insufficiency. The other eight dogs were killed at various postoperative times up to eight weeks. Regeneration of the remaining liver occurred rapidly after operation. The peak elevation of serum glutamic oxaloacetic transaminase activity was found on the first postoperative day, with a steady return to normal within two or three weeks. To the contrary, the serum activity of beta-glucuronidase decreased during the first three days, but increased substantially between the seventh and 14th postoperative day, when regeneration was considered to be maximum. The results seem to indicate that serial determinations of lysosomal enzyme activities in the blood can be a beneficial biochemical index for detection of progressing liver regeneration following partial hepatectomy.     

Human erythrocyte polyamine levels after partial hepatectomy

BACKGROUND/AIM: There are various indices of liver regeneration, but no clinically useful index that reflects the current status of liver regeneration. We assayed human erythrocyte polyamine levels after partial hepatectomy to define the relationship between erythrocyte polyamine levels and liver regeneration. MATERIALS AND METHODS: Levels of human erythrocyte polyamines (putrescine, spermidine, and spermine) were assayed by high-pressure liquid chromatography in 91 patients after partial hepatectomy and in 13 patients after surgery other than partial hepatectomy (controls). Of the patients after partial hepatectomy, 37 underwent hepatectomy of 20% or more of the liver (group A), 27 underwent segmentectomy or subsegmentectomy of the liver amounting to less than 20% of the liver (group B), and 27 underwent an operation smaller in scale than sub-segmentectomy (group C). RESULTS: The greater the proportion of the liver resected, the greater was the percent increase. In groups A, B, and C, erythrocyte levels of spermidine and spermine increased after surgery compared with the base line, and were significantly higher at 7 or 14 days, decreasing later. The differences in spermidine among the three groups were significant. CONCLUSIONS: After partial hepatectomy, the erythrocyte polyamine levels, especially the level of spermidine, were related to the proportion of liver resected. They seemed to reflect the degree of liver regeneration.     

Identification of bile canalicular cell surface antigen HAM.4 as dipeptidyl peptidase IV (DPPIV) and characterization of its role in hepatic regeneration after partial hepatectomy in rats

Dipeptidyl peptidase IV (DPPIV) has been implicated in the control of cell growth and differentiation. A rat hepatocyte membrane antigen recognized by a monoclonal antibody (HAM.4) has now been shown to be identical to DPPIV by immunoblot analysis and amino acid sequencing. The amounts of DPPIV immunoreactive protein and enzymatic activity in serum increased in a manner independent of de novo protein synthesis, and without any biochemical or immunohistochemical changes in hepatic DPPIV, during liver regeneration after partial hepatectomy in rats. DPPIV purified from serum by HAM.4 antibody-based affinity chromatography lacked the NH2-terminal 36 amino acids of the membrane-bound enzyme, suggesting that proteolytic cleavage may mediate the release of DPPIV into serum. No significant differences in the restoration of liver mass or in hepatic DNA synthesis were apparent between DPPIV-deficient and normal rats after partial hepatectomy, suggesting that DPPIV may not be essential for hepatic regeneration.     

Indications for major hepatectomy in cirrhotic liver

In an investigation of the indications for major hepatic resection of the cirrhotic liver, the records of 152 consecutive patients who had undergone a right hepatic resection between April 1985 and January 1991 were reviewed. A comparison of right hepatic lobectomy and right partial hepatectomy of the liver with no cirrhotic changes, revealed that postoperative values of serum glutamic pyruvic transaminase were significantly higher after right partial hepatectomy than after right lobectomy, despite the fact that there were no significant differences with respect to preoperative laboratory data, and there was a greater blood loss and total weight of the resected liver in patients receiving a right lobectomy as compared with those undergoing partial hepatectomy. These results suggest that in order to enable a more favorable recovery from hepatic resection, it is essential to avoid both mechanical damage and ischemic injury to the residual liver during hepatic surgery. A total of 77 patients underwent a partial hepatectomy of a cirrhotic liver, and among these patients, 16 patients had values of the indocyanine green test of less than 20%, as well as a portal pressure of less than 200 mm saline. Compared with these 16 cirrhotic patients and those patients who underwent right lobectomy, there were no significant differences with regard to the pre-operative laboratory data and portal pressure. These results therefore suggest that major hepatic lobectomy could be performed on selected patients with cirrhotic livers.     

Feed-back control of cholesterol synthesis in partially hepatectomized rats

Partial hepatectomy caused a marked stimulation of cholesterol and fatty acid syntheses without affecting serum total cholesterol, total phospholipid and triacylglycerol concentrations of rats so far examined 48 h after the operation. Serum free cholesterol level, however, was increased by the treatment and the ratio of lysophosphatidylcholine to phosphatidylcholine was concomitantly decreased, suggesting the impairment of serum lecithin: cholesterol acyltransferase activity. The lipid content in the liver, especially triacylglycerol and ester cholesterol, was increased markedly by the operation. Feeding of a high cholesterol diet which elevated serum cholesterol and phospholipid levels to the partially hepatectomized rats, accelerated the accumulation of hepatic triacylglycerol and ester cholesterol by the partial hepatectomy. The weight of the regenerating liver was not influenced by cholesterol feeding, which suggested that cholesterol feeding did not inhibit the regeneration mechanism of the liver. The increase of cholesterol synthesis after partial hepatectomy was inhibited by cholesterol feeding. Therefore, it is conceivable that the negative feed-back control of cholesterol synthesis is induced by cholesterol feeding under the stimulated cell divisions of the liver after partial hepatectomy. It is suggested from the present data that a large amount of the cholesterol which is necessary for cell growth can be taken up from serum, when serum cholesterol concentration is high.     

Surgical treatment of hydatid disease of the liver: an experience from outside the endemic area

BACKGROUND/AIMS: Hydatid disease is quite rare in European countries outside the endemic area around the Mediterranean Sea. Most of the cases observed in Central and Northern Europe occur in emigrants from the endemic area, whose number has been increasing over the last decade. In Switzerland about twenty-five new cases are being diagnosed per year, an incidence of about 0.33 cases per 10(5) inhabitants. Surgery remains the principal treatment modality of hydatid liver disease. There is still debate about conservative surgery as opposed to radical surgical treatment in which the cyst is totally removed including the pericyst by total cystoperi-cystectomy, partial hepatectomy or a combination of both. Surgeons working inside the endemic area tend to favor conservative methods, whereas those outside the endemic area have the tendency to favor radical surgery. This article reviews the results of surgery for liver hydatid disease obtained in a country outside the endemic area. PATIENTS AND METHODS: In our institution 24 patients (12 female, 12 male) have been treated for liver hydatid disease from 6/1983 to 2/1995. Twenty-two patients were immigrants from the endemic area. Surgery indication was primary liver hydatid disease in 23 patients, and recurrent disease in one. RESULTS: Twenty-one patients underwent radical procedures, and three were treated by cystectomy, unroofing and omentoplasty. Radical procedures were pericystectomy in 11 patients, partial hepatectomy in five and pericystectomy combined with partial hepatectomy in five. There was no operative mortality in 23 patients operated on for primary disease, but the only patient operated upon for recurrence died from anaphylactic shock. Eighteen of the 23 surviving patients could be followed up for a median time of 6.5 years (eight months to 12.5 years). Sixteen of 18 patients have remained free of recurrence. One has been reoperated for a retrocaval recurrence four years after right hepatectomy, and one patient is being observed for suspected recurrence after unroofing and omentoplasty. CONCLUSIONS: The policy of applying radical surgery whenever feasible can be followed with acceptable morbidity and near zero mortality. Radical surgery has, however, to be applied judiciously, and there is still an important role for conservative surgery.     

CD45 isoform expression on human haemopoietic cells at different stages of development

Modified retroperitoneal lymph node dissection for stage I testicular tumors has been described by Weissbach. For performing laparoscopic retroperitoneal lymphadenectomy within these boundaries, we have developed a two-step procedure. In the first step, a ventral approach is used. The colon is dissected free, then the spermatic vein is excised, and the borders of dissection are defined. Removal of retroaortic and retrocaval nodal tissue is technically not feasible from the ventral approach. Therefore, in the second step, a lateral approach is employed, which is the key to success since it allows for easy transection of the lumbar vessels. Thus complete lymph node dissection can be realized. Between August 1992 and June 1993 this procedure was performed in 11 patients. In 7 patients, the tumor was on the right side and in 4 on the left. Conversion to open surgery was necessary in two patients because of uncontrollable bleeding and a large metastasis, respectively. Microscopic metastases were detected in two other patients. No major complications occurred; no blood transfusions were required. So far, the results have been encouraging.     

Application of contemporary reconstructive techniques in head and neck surgery for anterior oral-facial cancers

One hundred and seventy-eight patients underwent surgical therapy for oral and cervical cancers from 1964 to 1975. About 25 percent of the patients underwent neck dissection and/or "pull-through" procedures. However, majority of patients required a spectrum of reconstructive techniques extending from marginal mandibulectomy with or without skin flaps (39), partial mandibulectomy with immediate prosthetic mandible reconstruction (36), to extended resections with skin flaps or staged reconstructive procedures (48). The advantages and disadvantages of each reconstructive procedure have been observed and a scheme of graded management has been developed. The therapeutic goal is to maximize functional oral reconstruction without compromising tumor cure. There were two operative deaths--one from myocardial infarction after operation and one from halothane hepatitis. The tumors were grouped according to TNM classification. In the follow-up of the 178 patients, 47 per cent are known to be alive and free of tumor. The better results (greater than 70% free of tumor) are in the group with smaller tumors (less than 2 cm.) and no node involvement, and there are less favorable rates for those patients with larger tumors and nodal metastasis or invasion of adjacent structures. There was a 49 percent 2 year survival rate and 12 of the deaths were from nontumor causes. Ninety percent of these patients smoked more than one pack of cigarettes per day, accounting for the high rate of synchronous or subsequent oroairway cancers (7 percent). Seventy-five percent were considered to be "heavy alcoholics" with evidence of cirrhotic liver disease. These two factors significantly decreased the survival from rate 54 to 47 percent. The series shows that planned primary reconstructive surgery can be done at a low risk, that it can enhance resectability of head and neck cancers, and that it does improve oral function after operation.     

Microwave coagulation therapy for hepatocellular carcinoma

BACKGROUND & AIMS: Surgical resection is not always feasible in patients with hepatocellular carcinoma. Microwave coagulation therapy has been used as an alternative to resection, and its efficacy has been evaluated. METHODS: Nineteen patients with unresectable hepatocellular carcinoma underwent microwave coagulation therapy through laparotomy (n = 12), laparoscopy (n = 5), or thoracotomy (n = 2) because of advanced liver cirrhosis and/or intrahepatic metastases. One nodule was treated in 13 patients, tumor size ranged from 5 to 90 mm. Patient outcomes were studied. RESULTS: Microwave coagulation therapy created a reproducible regional necrosis. Fourteen patients underwent potentially curative treatment; the remaining 5 patients underwent palliative treatment (n = 4) or incomplete tumor coagulation (n = 1). Of the 31 nodules treated, 28 underwent complete tumor ablation. Only 2 patients undergoing laparoscopic microwave coagulation therapy developed local recurrence. The coagulated area subsequently shrank. Patients showed rapid recovery without hepatic dysfunction. Thirteen patients, including 2 long-term survivors, are alive either without tumor (n = 10; 14-64 months) or with tumor (n = 3; 17-22 months). Six patients died of hepatocellular carcinoma (n = 4) or liver insufficiency (n = 2). CONCLUSIONS: This preliminary study suggests the efficacy of microwave coagulation therapy, including safety and potential curability, in patients with hepatocellular carcinoma with advanced liver cirrhosis and multifocal or central tumors.     

The effect of WIC participation on small-for-gestational-age births: Michigan, 1992

Portal thrombectomy with extended hepatectomy for extensively progressive primary liver cancer (Vp 3), in which the tumor thrombus has spread beyond the first portal branches, will make other non-surgical treatments possible and improve patients quality of life. We have performed extensive resections in 15 cases of such Vp 3 liver cancer. One patient with huge HCC involving retrohepatic IVC underwent in situ extended left hepatectomy without reconstruction of IVC, resulting in postoperative renal failure because of thrombosis in the bilateral renal veins, but 14 other patients' postoperative courses were uneventful. Ten of 14 patients relapsed within one year, but these patients underwent non-surgical treatments, resulting in improvement in the quality of life. The 1-, and 3-year survival rates were 55.6% and 32.5%, respectively.     

Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors

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.     

Mitochondrial oxidative alterations following partial hepatectomy

Mitochondria, isolated from rat livers during the early phase of liver regeneration (7-24 h after partial hepatectomy), show: (i) decrease in the rate of ATP synthesis; (ii) increase of malondialdehyde and of oxidized protein production; (iii) decrease of the content of intramitochondrial glutathione and of protein thiols on mitochondrial proteins; (iv) increase of the glutathione bound to mitochondrial proteins by disulfide bonds. These observations suggest an increase of production of oxygen radicals in liver mitochondria, following partial hepatectomy, which can alter the function of the enzymes involved in the oxidative phosphorylation. Blue-native gel electrophoresis of rat liver mitochondria, isolated after partial hepatectomy, shows, during the early phase of liver regeneration (0-24 h after partial hepatectomy), a progressive decrease of the content of F0F1-ATP synthase complex. The amount of glutathione bound to the F0F1-ATP synthase, electroeluted from the blue-native gels, progressively increased during the early phase of liver regeneration. It is concluded that partial hepatectomy causes mitochondrial oxidative stress that, in turn, modifies proteins (such as F0F1-ATP synthase) involved in the mitochondrial oxidative phosphorylation.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Ventilatory response to severe acute hypoxia in guinea-pigs and rats with high hemoglobin-oxygen affinity induced by cyanate

Laparoscopic pelvic lymph node dissection has been applied as a minimally invasive staging technique for men with prostate cancer. This procedure has been shown to shorten markedly postoperative hospitalization, decrease analgesic requirements and shorten convalescence period compared to open pelvic node dissection. However, the laparoscopic procedure takes longer to perform and many disposable instruments are used, thus increasing the cost. We determine the overall cost of laparoscopic versus open pelvic lymph node dissection. Between January 1989 and April 1992, 61 men underwent only staging pelvic lymph node dissection for cancer of the prostate at a single university teaching hospital. Of these patients 11 and 50 underwent open and laparoscopic pelvic lymph node dissection, respectively. Information from the hospital business office was reorganized into preoperative, intraoperative and postoperative expenses. All individual charges were transformed up or down to the dollar amounts of the 1990 to 1991 fiscal year so as to correct for inflationary changes. Preoperative costs were not significantly different between the 2 operative approaches. Intraoperative expenses were 52% greater if laparoscopic pelvic lymph node dissection was performed and can be explained by the longer operative times and use of disposable instrumentation. However, the postoperative period lasted an average of 1.61 days following laparoscopic pelvic lymph node dissection. Postoperative nursing and analgesic requirements were significantly more for patients undergoing open pelvic lymph node dissection. The overall postoperative costs following open pelvic lymph node dissection were 280% more expensive than for the laparoscopic procedure. The overall total costs were approximately $1,250 more for laparoscopic pelvic lymph node dissection. Wages lost or earned during this period and rapid return to normal activity following laparoscopic pelvic lymph node dissection would, in our opinion, justify this additional cost.     

Cross-species interaction of porcine and human integrins with their respective ligands: implications for xenogeneic tolerance induction

OBJECTIVES: To determine the resectability rate for hilar cholangiocarcinoma, to analyze reasons for unresectability, and to devise a presurgical clinical T-staging system. METHODS: Ninety patients with hilar cholangiocarcinomas seen between March 1, 1991, and April 1, 1997, were evaluated. Accurate patterns of disease progression and therapy were evaluable. Disease was staged in 87 patients using extent of ductal tumor involvement, portal vein compromise, and liver atrophy. RESULTS: In 21 patients, disease was deemed unresectable for cure at presentation. In 39 patients, disease was found to be unresectable at laparotomy, 23 secondary to nodal (N2) or distant metastases. Unresectability was the result of metastases in 52% and of locally advanced disease in 28%. Thirty patients (33%) had resection of all gross disease, and 25 of these (83%) had negative histologic margins. Twenty-two patients underwent partial hepatectomy. The 30-day mortality rate was 7%. Projected survival is greater than 60 months in those with a negative histologic margin, with a median follow-up of 26 months. A presurgical T-staging system allows presurgical selection for therapy, predicts partial hepatectomy, and offers an index of prognosis. CONCLUSIONS: In half the patients, unresectability is mainly the result of intraabdominal metastases. Presurgical imaging predicts unresectability based on local extension but is poor for assessing nodal metastases. In one third of patients, disease can be resected for cure with a long median survival. Curative resection depends on negative margins, and hepatic resection is necessary to achieve this. The T-staging system correlates with resectability, the need for hepatectomy, and overall survival.     

Nonparasitic cysts of the liver: results and options of surgical treatment

Nonparasitic cysts of the liver (NPHC) are highly variable in respect to appearance and therapeutic approach. The treatment of these cysts varies according to the nature and appearance of the disease. Based on the variable nature of disease and the various therapeutic options, all of which were attempted in our patients, the most suitable mode of treatment for different forms of NPHC are discussed. Ninety-one patients with NPHC who had been treated surgically from 1977 through 1995 were examined retrospectively. Asymptomatic peripheral cysts measuring up to 10 cm do not require further treatment. Computed tomography (CT)-guided aspiration (n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically (n = 10) or by the conventional surgical mode (n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver (n = 9) was successfully performed in cases of polycystic disease (n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver (n = 4). In patients in whom we found that the cysts communicated with the ductal system (n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.