Objective To compare therapeutic effects of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and transcatheter arterial chemoembolization (TACE) on patients with advanced hepatocellular carcinoma. Methods Thirty-five patients with advanced hepatocellular carcinoma admitted in the Department of Hepatobiliary and Pancreatic Surgery of Shiyan Taihe Hospital Affiliated to Hubei University of Medicine from August 1, 2014 to August 1, 2015 were randomly divided into ALPPS group and TACE group, in which 17 cases treated by the ALPPS and 18 cases treated by the TACE. The survival, changes of liver function and life quality, postoperative complications and mortality were compared in these two groups. The follow-up was performed by the telephone and the outpatient. Results ① The baselines such as the age, gender, diameter of tumor, complications had no significant differences in these two groups (P>0.05). ② The changes of liver function and life quality after operation in the ALPPS group were significantly better than those in the TACE group (P<0.05). ③ The complications after operation were observed in 5 cases (there were 2 cases of bile leakage, 1 case of intraabdominal bleeding, 1 case of peritoneal effusion, and 1 case of pulmonary infection) in the ALPPS group, which in 13 cases (there were 6 cases of nausea and vomiting, 4 cases of liver function damage, 2 cases of granulocytopenia, 1 case of fever) in the TACE group. The rate of the overall complications in the ALPPS group was significantly lower than that in the TACE group (5/17versus 13/18, P=0.018). ④ The overall survival in the the ALPPS group was significantly better than that in the TACE group (P=0.024). During follow-up period, the deaths happened in 3 cases duo to hepatocellular carcinoma and 1 case duo to traffic accident, 1 case was lost on month 8, 12 cases were still alive in the ALPPS group; the deaths happened in 10 cases duo to hepatocellular carcinoma, 1 case duo to coronary disease, and 1 case duo to cerebral infarction, 6 cases were still alive in the TACE group. Conclusion Preliminary results of limited cases in this study show that ALPPS has a better effect than TACE on patients with advanced hepatocellular carcinoma.
Objective To discuss the clinical application of two-stage hepatectomy for multiple and huge hepatic alveolar echinococcosis. Methods The clinical data of 7 patients with multiple hepatic alveolar echinococcosis treated with two-staged hepatectomy in West China Hospital of Sichuan University and The people's Hospital of Ganzi Tibetan Autonomous Prefecture of Sichuan Province from August, 2013 to June, 2016 were analyzed retrospectively. The preoperative diagnose was definite according to CT and (or) MRI, serological and life in the epidemic area. The patients, which the future liver remnant was less than 30% according to CT, received two-staged hepatectomy. Epigastric enhancement CT, liver function and blood routine examination were reviewed monthly after the first surgery, the second surgery was operated after 3 monthes, epigastric ultrasound, enhancement CT or MRI, liver function, blood routine examination and serological were adopted in 1, 6, and 12 months and each year after the second operation. Results The liver function was normal in 7 days after two operations and no complications after the first suegery, one patient developd with biliary fistula after the second surgery, no recurrence or death occurred during the followed-up period. Conclusion The two-stage hepatectomy can be operated in multiple and huge alveolar echinococcosis to reduce surgery risk and cost, shorten hospital stays and improve quality of life.
Objective To investigate the risk factors and prevention methods of the venous thromboembolism (VTE) after hepatectomy. Methods The literatures about VTE after hepatectomy in recent years at home and abroad were reviewed and summarized. Results The risk factors for postoperative VTE include tumor, male, old age, massive hepatectomy, hypercoagulability, etc. The incidence of VTE in patients with massive hepatectomy is significantly higher, which is closely related to the hypercoagulability caused by postoperative liver dysfunction. Effective prophylaxis include mechanical methods and anticoagulant drugs, the latter of which can markedly reduce the incidence of VTE. For patients who develop postoperative liver insufficiency, including those with cirrhosis and high risk of bleeding, anticoagulant VTE prophylaxis dosing decisions should be made with caution. In addition, it is rationale for extended thromboprophylaxis in high risk patients. Conclusions VTE is a common complication after hepatectomy, resulting in prolonged postoperative hospital stay and increased postoperative mortality. Therefore, it is important to determine the risk of VTE after surgery to improve the prognosis of patients after hepatectomy.
ObjectiveTo study clinical practical value of multimode imaging technique in precise hepatectomy for huge hepatocellular carcinoma (HCC). MethodsThe clinicopathologic data of patients with huge HCC who underwent precise hepatectomy in Yuebei People’s Hospital from Jan. 2018 to Dec. 2020 were collected. The three-dimensional (3D) reconstruction, 3D visualization, 3D printing, and augmented reality (AR) were used to guide preoperative evaluation, surgical planning, and surgical navigation. The liver function indexes, surgical mode, operative time, intraoperative bleeding, volume of resected liver, postoperative hospitalization, and complications were analyzed. ResultsThere were 23 patients in this study, including 18 males and 5 females, with (56.8±8.1) years old. The virtual tumor volume assessed by multimodal imaging technology was (865.2±165.6) mL and the virtual resected liver volume was (1 628.8±144.4) mL. The planned operations were anatomical hepatectomy in 19 patients and non-anatomical hepatectomy in 4 patients. The actual operation included 17 cases of anatomical hepatectomy and 6 cases of non-anatomical hepatectomy, which was basically consistent with the results of AR. The operative time was (298.4±74.5) min, the median hepatic blood flow blocking time was 20 min, and the intraoperative bleeding was (330.4±152.8) mL. Compared with preoperative levels, the levels of hemoglobin and albumin decreased temporarily on the first day after operation (P<0.05), and then which began to rise on the third day and basically rose to the normal range; prothrombintime, total bilirubin, alanine aminotransferase, and aspartate aminotransferase increased transiently on the first day after operation (P<0.05), then which began to decline to the normal levels. There were no serious operative complications and no perioperative death. The median follow-up time was 18 months, the tumor recurrence and metastasis occurred in 3 cases. ConclusionFrom preliminary results of this study, it could improve surgical safety and precision of hepatectomy for huge HCC by preoperative precise assessment and operation navigation in good time of multimode imaging technology.
ObjectiveTo compare efficacy of laparoscopic or open hepatectomy in benign liver tumors patients with different difficult operations. MethodsAccording to the inclusion and exclusion criteria, the patients with benign liver tumors who underwent hepatectomy in the Affiliated Hospital of Xuzhou Medical University from September 2014 to March 2021 were collected. The enrolled patients were assigned into low, medium, and high difficulties by the Hasegawa liver resection surgical difficulty score model, then the patients were matched by propensity score matching. The liver function and inflammatory indexes, intraoperative bleeding, operative time, total hospital stay, postoperative complications, and hospitalization expenses of patients with benign liver tumors after laparoscopic (laparoscope group) or open (open group) hepatectomy were compared. ResultsA total of 209 patients who met the inclusion and exclusion criteria were enrolled in this study. According to the Hasegawa criteria, there were 59, 89, and 61 patients with low, medium, and high difficulties respectively. After 1∶1 propensity score matching, 18, 34, and 14 patients in the laparoscope group and open group were matched respectively. There were no statistic differences in the baseline data between the laparoscope group and open group (P>0.05). ① For the patients with low and medium difficulties, compared with the open group, the different values of alanine aminotransferase, aspartate aminotransferase, white blood cell count, and neutrophil percentage were lower (P<0.05), the intraoperative bleeding and total hospital stay were less or shorter (P<0.05), and the albumin were higher (P<0.05) in the laparoscope group. There were no statistic differences in these indexes among the patients with high difficulty (P>0.05). ② Compared with the open group, the operative time of the laparoscope group was shorter in the patients with low difficulty (P<0.05) and longer in the patients with high difficulty (P<0.05), and there was no statistic difference in patients with medium difficulty (P>0.05). ③ The postoperative complications had no statistic differences between the two groups for the patients with low and high difficulties (P>0.05), while which in the laparoscope group were lower than in the open group for the patients with medium difficulty (P<0.05). ④ The hospitalization expenses of the laparoscope group was higher than the open group for the patients with high difficulty (P<0.05), while which had no statistic differences between the two groups for the patients with low and medium difficulties (P>0.05). ⑤ The total hospital stay of the laparoscope group was shorter than the open group (P<0.05) no matter which difficult operation.ConclusionsAccording to results of this study, laparoscopic hepatectomy has more obvious advantages as compared with open hepatectomy for patients with low or medium difficulty, which could greatly shorten hospital stay and accelerate rehabilitation of patients. Even for patients with high difficulty, laparoscopic hepatectomy still shows an advantage of shortening hospital stay.
Objective To evaluate application of anterior approach combined with selective hepatic vein(s) occlusion in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for giant hepatocellular carcinoma (HCC) in right lobe. Method The clinical data of 9 patients underwent the ALPPS in the First Affiliated Hospital of Guangxi Medical University from January 2017 to September 2017 were retrospectively analyzed. Results Six cases underwent the complete ALPPS, 3 cases lost because it couldn’t match the standard for the second step. After the first step, The average increased volume of the future liver remnant (FLR) was 139.1 cm3 (46.4–291.6 cm3), and the average increased volume rate of FLR was 37.8% (15.1%–76.2%). The average blood loss was 356 mL (200–600 mL). In the second step, 4 cases underwent the right hemihepatectomy and 2 cases underwent the extend right hemihepatectomy, the average blood loss was 617 mL (300–1 400 mL). There was no bile fistula, liver failure, and death. Conclusions Preliminary results of limited cases in this study show that application of anterior approach combined with selective hepatic vein(s) occlusion is a safe and feasible strategy in ALPPS for giant HCC in right lobe. This strategy is conformity with the " no touch” principle of oncology surgery, and reduces blood loss and decreases complications. Long-term oncological result of ALPPS in HCC patients with cirrhosis is unknown.
ObjectiveTo understand the incidence and mechanism of posthepatectomy acute pancreatitis (PHAP) after liver resection, and to explore diagnosis, treatment, and preventive strategies to enhance prognosis for the patients with PHAP. MethodThe literature on studies relevant PHAP both domestically and internationally was retrieved and reviewed. ResultsThe incidence rate of PHAP was approximately 0.7% by the literature. The exact etiology was still unclear. According to the existing research results, it was speculated that the pathogenesis might be related to the portal vein congestion, reactive oxygen species, surgical trauma, and other factors. At present, there were no comprehensive guidelines for the diagnosis and treatment of PHAP after liver resection both domestically and internationally. The diagnosis was mainly based on the clinical manifestations, early signs and symptoms, biochemical examination and imaging evaluation. The treatment principle of the PHAP was similar to that of common acute pancreatitis. The symptomatic supportive treatment was performed for the patients with mild to moderate PHAP, while the surgical treatment and minimally invasive surgery were chosen for the severe PHAP. The best way prevented for PHAP was the preoperative comprehensive evaluation of patients, and quit smoking and drinking, and so on. The careful operation should be performed during the surgical process to minimize portal vein congestion and reduce reactive oxygen species in blood vessels.The blood biochemistry, hematuric amylase, pancreatic function, and relevant infection indicators should be closely monitored after surgery, and abdominal ultrasound should be repeated several times to achieve early identification and timely treatment. ConclusionsAlthough the incidence rate of PHAP is not high, it is a serious surgical complication. The prevention, early detection, and early treatment should be strengthened for PHAP, and we should focuse on earlier and more accurate prediction model in future.
ObjectiveTo investigate feasibility and safety of laparoscopic liver resection with vascular variation.MethodsThe clinical data of one patient with preoperative diagnosis of primary liver cancer, who was admitted into the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Army Military University in October 2017, were analyzed retrospectively. The three-dimensional (3D) reconstruction was completed basing on the preoperative CT data, then the liver volume was calculated and the preoperative planning was made, finally the subsequent surgery was performed.ResultsThe results of the 3D reconstruction suggested that the tumor was situated in the central of the right liver, including the segment Ⅴ, Ⅵ, Ⅶ, and Ⅷ. There was a type Ⅱ portal vein variation, the right anterior branch of the portal vein divided a branch into the left medial lobe. The right hepatic vein was divided into the ventral and dorsal branches. There was a thick right posterior inferior vein in this case. The preoperative planning was that the right posterior lobectomy or right anterior lobectomy could not completely remove the tumor. According to the standard right hemihepatectomy, the remaining liver volume accounted for 27% of the standard liver volume. If preserving the right anterior branch of the portal vein for the right hemihepatectomy, the remaining liver volume accounted for 41% of the standard liver volume. According to the concept of precise hepatectomy, the laparoscopic partial right hepatectomy with preservation of the main branch of the right anterior portal vein was performed smoothly. The liver function recovered well after the surgery. The right pleural effusion appeared after the surgery, then was relieved by the thoracentesis.ConclusionFor primary liver cancer patient with vascular variation, laparoscopic liver resection is feasible and safe basing on guide of 3D reconstruction technology.
ObjectiveTo evaluate the effects of indocyanine green (ICG) fluorescence imaging in laparoscopic anatomic hepatectomy. MethodsThe clinical data of 26 patients who underwent ICG fluorescence-guided laparoscopic anatomic hepatectomy in the Department of Hepatobiliary Surgery at Affiliated Hospital of North Sichuan Medical College from March 2019 to May 2023 were retrospectively analyzed. ICG staining methods included combined lipiodol-ICG (SHIFT&nanoICG) hepatic artery embolization (anterograde staining) and (or) portal vein retrograde staining. Patient demographics, pathological characteristics, intraoperative outcomes (ICG staining method and results, operation time, intraoperative blood loss, transfusion rate, conversion to open surgery), and postoperative outcomes [alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin (ALB), total bilirubin (TB) levels on postoperative day 3, hospital stay, complications] were analyzed. Quantitative data conforming to a normal distribution were described as mean ± standard deviation, while skewed distributions were described as median (interquartile range). The significance level was set at α=0.05. ResultsAmong 26 patients, 6 received combined anterograde (SHIFT&nanoICG) + retrograde staining (referred to as the “dual-staining group”), while 20 received retrograde staining alone (referred to as the “single-staining group”). One case (3.8%) in the single-staining group required conversion to open surgery. All resection margins were negative. No statistically significant differences were observed between the dual-staining group and the single-staining group for the following parameters: Tumor diameter [5.0 (4.4) cm vs. 4.0 (4.2) cm, P=0.483], operative time [307.0 (146.0) min vs. 250.0 (137.5) min, P=0.831], intraoperative blood loss [250.0 (225.0) mL vs. 225.0 (338.0) mL, P=0.756], postoperative hospital stay [(12.3±2.1) d vs. (10.9±2.7) d, P=0.232]. Furthermore, no significant differences were found in ALT, AST, ALB, and TB levels on postoperative day 3 (P>0.05). Regarding postoperative complications (classified according to the Clavien-Dindo system): One patient with grade Ⅰ complication was recorded in the dual-staining group, 3 with grade Ⅰ and 3 with grade Ⅱ complications were recorded in the single-staining group, no grade Ⅲ or higher complications occurred in either group. Comparison of complication rate between the two groups showed no statistically significant difference (P=0.600). ConclusionsBoth conventional ICG and SHIFT&nanoICG provide effective fluorescence guidance for laparoscopic anatomic hepatectomy. For patients with hepatocellular carcinoma who are ineligible for primary radical resection or have lost the opportunity for initial curative surgery, SHIFT&nanoICG provides superior intraoperative fluorescence visualization following transarterial embolization-assisted conversion therapy.
Objective To assess the influence of hepatic artery ligation on survival, hepatocyte apoptosis and regeneration of rats with obstructive jaundice. Methods Eighty adult male Wistar rats were divided into four groups: group A, suffered 70% hepatectomy+hepatic artery ligation+biliary drainage after 3 days of establishing obstructive jaundice model; group B, suffered 70% of hepatectomy+biliary drainage after 3 days of establishing obstructive jaundice model; group C, suffered 70% of hepatectomy+hepatic artery ligation after 3 days of sham operation; group D, suffered 70% of hepatectomy after 3 days of sham operation. Five rats of each group were sacrificed on 1, 2, 3, and 6 days after second operation. Liver function, hepatocyte apoptosis and liver regeneration were detected. Results Postoperative survival rates were not significantly different between group A and group B, similarly between group C and group D (allP＞0.05). There was no significantly different in liver function of group Aversus group B, and group Cversus group D (P＞0.05), but the synthesis of album on 1 d or 3 d after operation were significant difference (group Aversus group B,P＜0.05; group Cversus group D,P＜0.05). Both of the group A, group B and group C had the highest apoptotic index on 1 d after operation, whereas the group D had the lowest hepatic apoptotic index among four group after the surgery. The regeneration indexes were as follow: group D＞group C＞group B＞group A (allP＜0.05). On y 6 d after operation, the regeneration indexes of group A and group B did not increase, while those of group C and group D decreased remarkably. However, the regeneration indexes of four groups were lower than the mean level. Conclusions Hepatic artery ligation will increase hepatocyte apoptosis and weaken liver regeneration. However, for rats with obstructive jaundice, hepatic artery ligation didn't increase the risk of postoperative mortality.