ObjectivesTo systematically review the efficacy of laparoscopic hepatectomy (LH) and open hepatectomy (OH) on the hepatocellular carcinoma patients with cirrhosis.MethodsPubMed, EMbase, Web of Science, The Cochrane Library, CBM, CNKI, WanFang Data and VIP databases were searched online to collect the cohort studies of LHvs.OH on hepatocellular carcinoma patients with cirrhosis from inception to November 31st, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 15 cohort studies involving 1 720 patients were included. The results of meta-analysis showed that: compared with OH, LH had less blood loss (MD=–226.94, 95%CI –339.87 to –114.01, P<0.000 1), lower transfusion rate (OR=0.48, 95%CI 0.27 to 0.83,P=0.009), less occurrence of complications (OR=0.32, 95%CI 0.23 to 0.45, P<0.000 01), shorter postoperative hospital stay (MD=–3.66, 95%CI –5.19 to –2.14,P<0.000 01), lower mortality rate (OR=0.47, 95%CI 0.24 to 0.92,P=0.03), wider surgical margin (OR=0.78, 95%CI 0.20 to 1.36, P=0.009), higher 1, 3 and 5-year survival rate (OR=2.47, 95%CI 1.35 to 4.51, P=0.003; OR=1.62, 95%CI 1.11 to 2.36, P=0.01; OR=1.58, 95%CI 1.19 to 2.10, P=0.002, respectively) and 1-year disease free survival rate (OR=1.69, 95%CI=1.20 to 2.39, P=0.003). There were no significant differences in operation time (MD=28.64, 95%CI –7.53 to 64.82, P=0.12), tumor size (MD=–0.37, 95%CI –0.75 to 0.02, P=0.06), 3-year disease free survival rate (OR=1.14, 95%CI 0.86 to 1.51, P=0.36) and 5-year disease free survival rate (OR=0.99, 95%CI 0.77 to 1.28, P=0.97) between the two groups.ConclusionsThe perioperation and short-term postoperative outcomes of LH are significant in HCC patients with cirrhosis, and which have good long-term prognosis. Due to limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.
Objective To explore the impact of microvascular invasion (MVI) on the survival prognosis of patients after radical hepatectomy for hepatocellular carcinoma, to analyze its related risk factors and preoperative prediction methods, and to provide reference and support for the treatment of early postoperative recurrence. MethodsBy searching domestic and international medical literature databases, we screened studies related to MVI in hepatocellular carcinoma, focusing on the definition, grading, risk factors, preoperative prediction methods, and postoperative treatment strategies of MVI, and summarized the results of the existing studies. ResultsMVI was a well-established risk factor for the intrahepatic metastasis and early postoperative recurrence of hepatocellular carcinoma. Currently, various methods were employed to predict MVI, including laboratory indicators, imaging genomics, and genomics. The laboratory indicators used for prediction included alpha-fetoprotein, protein induced by vitamin K absence or antagonist-Ⅱ, hepatitis B virus, tumor diameter, vascular endothelial growth factor A, and circulating tumor cells. Imaging genomics involved preoperative MRI with irregular tumor shape and intra-voxel incoherent motion diffusion-weighted imaging D value < 1.16 × 10-3 mm2/S, CT enhancement imaging features with irregular tumor margins, multiple foci, and contrast-enhanced ultrasound portal venous and delayed phase scores. Genomics included the maximum variant allele frequency of circulating tumor DNA. In cases where MVI was detected after surgery, adjuvant therapy options had gained attention, such as transcatheter arterial chemoembolization, hepatic arterial infusion chemotherapy, targeted therapy, immunotherapy, radiation therapy, antiviral therapy, and local treatment combined with systemic treatment. ConclusionsThe study of MVI and its targeted treatment strategies are important for reducing the postoperative recurrence rate of hepatocellular carcinoma and improving patient survival. The preoperative prediction model and postoperative treatment plan should be optimized in the future to provide more effective treatment reference for patients.
ObjectiveTo investigate the role of 3D visualization technology in the laparoscopic precise hepatectomy. MethodsTo retrieve the literatures about the application of 3D visualization technology in laparoscopic precise hepatectomy, and summarize and analyzed them. ResultsThe application of 3D visualization in laparoscopic precise hepatectomy could effectively reduce the operative time, blood loss, blood transfusion rate, and total complication rate. The application of 3D visualization in preoperative evaluation of the resection surface and residual liver volume had been relatively mature. Although many organizations try to use 3D visualization in laparoscopic hepatectomy, such as laser registration and real-time intraoperative navigation, it had not been widely used in clinic because of technical limitations. ConclusionsExisting research results show that, the application of 3D visualization technology in laparoscopic precise hepatectomy can improve the resectability of lesions, increase perioperative safety, but intraoperative navigation is still need to be further developed before it is expected to be widely used in clinical practice. Existing evidence of increased benefit from laparoscopic precise hepatectomy with 3D reconstruction remains limited, and more rigorous randomized controlled trials of large cases are needed to confirm this.
Objective To study the effect of alpha fetoprotein-tumor burden score (ATS) on the long-term prognosis of hepatocellular carcinoma (HCC) after resection. MethodsThe data of 2 907 patients with HCC who underwent first hepatectomy from West China Hospital of Sichuan University, West China Ziyang Hospital/Ziyang Central Hospital, The First People’s Hospital of Neijiang, West China Yibin Hospital/the Second People’s Hospital of Yibin, and the Affiliated Hospital of Chengdu University between 2015 and 2022, were retrospectively analyzed. The X-tile software was used to calculate the optimal truncation of the ATS score. Cox proportional hazard regression model was used to explore risk factors affecting postoperative recurrence-free survival (RFS) and overall survival (OS) in HCC patients, respectively. ResultsAll patients were followed-up with a median of 37 months (1–90 months), 1 364 cases (46.9%, the recurrence time was 1–89 months after surgery) of them experienced recurrence and 847 cases (29.1%) died (the death time was 1–88 months after surgery). The 1-, 2- and 3-year OS rates were 89.3%, 81.4% and 75.9%, respectively. The 1-, 2- and 3-year RFS rates were 76.0%, 64.3% and 57.2%, respectively. The 5-year RFS rate of HCC patients with low-, medium-, and high-ATS scores were 56.4%, 45.0% and 27.2%, respectively, and patients with low ATS score had better RFS (χ2=264.747, P<0.001). The 5-year OS rates of HCC patients with low-, medium-, and high-ATS scores were 78.0%, 59.8% and 38.8%, respectively, and patients with low-ATS score had better OS (χ2=372.685, P<0.001). Multivariate Cox proportional hazard regression model suggested that, in condition of adjusting other factors, medium-ATS score [RR=1.375, 95%CI (1.209, 1.564), P<0.001] and high-ATS score [RR=2.048, 95%CI (1.764, 2.377), P<0.001] were risk factors for postoperative RFS; the medium-ATS score [RR=1.779, 95%CI (1.499, 2.112), P<0.001] and high ATS score [RR=2.676, 95%CI (2.211, 3.239), P<0.001] were also risk factors affecting postoperative OS. ConclusionATS score can predict the prognosis of HCC patients after resection, patients with high ATS score had a higher incidence of postoperative recurrence and mortality.
ObjectiveTo summarize the progress of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and evolution of surgical procedure improvement, so as to summarize experience in selecting appropriate surgical method for patients. MethodThe domestic and foreign literature on the evolution of ALPPS surgical procedure improvement in recent years was reviewed. ResultsIn the decade since the emergence of ALPPS, the ALPPS had been rapidly developed in the hepatobiliary surgery. The ALPPS promoted a rapid increase in future liver remnant during a relatively shorter period to contribute to resectability of liver tumors and reduce the rate of postoperative liver failure, the patients with intermediate to advanced and huge liver cancer could obtain the surgical radical resection. In recent years, the domestic and foreign experts had refined the ALPPS procedure, which mainly focused on the operation of hepatic section separation and hepatic artery flow restriction in stage Ⅰ surgery, including partial ALPPS, radiofrequency ablation ALPPS, tourniquet ALPPS, transcatheter arterial embolization ALPPS, hepatic artery ringed and operation ALPPS, as well as laparoscopic ALPPS and robotic ALPPS with minimally invasive approach. ConclusionsDespite the ongoing controversy over ALPPS, with the continuous progress and innovation of improved procedures and the utilization of laparoscope and robot in surgery, the trauma of ALPPS surgery has a further reduction, and the morbidity and mortality have gradually been decreased. It is believed that with the continuous advancement and improvement of ALPPS surgery technology, the indications and safety of ALPPS will be further enhanced, bringing hope to more patients with intermediate to advanced liver cancer with huge tumors.
Objective To clarify incidence and risk factors of hepatitis B reactivation during short term (one month) in hepatitis B virus (HBV) related hepatocellular carcinoma (HCC) patients receiving partial hepatectomy. Methods From January 2015 to December 2015, 214 consecutive patients with HBV-related HCC who underwent partial hepatectomy were retrospectively enrolled in this study. The risk factors affecting incidence of hepatitis B reactivation were analyzed. Results Hepatitis B reactivation happened in 7.0% (15/214) of patients within 1 month after partial hepatectomy. By univariate analysis, the preoperative HBV-DNA negativity and hepatitis B e antigen (HBeAg) positivity were significantly correlated with the occurrence of hepatitis B reactivation (P=0.023 and P=0.001, respectively). By multivariate analysis, the preoperative HBV-DNA negativity 〔OR=9.21, 95% CI (2.40, 35.45), P=0.001〕 and HBeAg positivity 〔OR=20.51, 95% CI (5.41, 77.73), P<0.001〕 were the independent risk factors for hepatitis B reactivation. Conclusions Hepatitis B reactivation is common after partial hepatectomy for HBV-related HCC during short term, especially in patients whose preoperative HBV-DNA negativity and HBeAg positivity. A close monitoring of HBV-DNA during short term after partial hepatectomy is necessary, once hepatitis B is reactivated, antiviral therapy should be given.
Objective To systematically evaluate safety and effectiveness of using fast track surgery (FTS) protocol in perioperative management of hepatectomy. Methods The studies were collected by searching the PubMed, Web of Science, Cochrane Library, CNKI, Wanfang Data, and VIP databases by two researchers. The FTS management was used in the FTS group and the traditional perioperative management was used in the traditional group. The meta analysis was performed using the RevMan 5.3 software. Results A total of 28 articles were included in the study, of which 1 632 patients in the FTS group and 1 820 patients in the traditional group; 14 RCTs, 14 CCTs. The results of meta analysis showed: Compared with the traditional group, the FTS not only could reduce the pain of patients during 24 and 48 hours after the surgery [24 h: WMD=–0. 92, 95%CI (–1.05, –0.79), P<0.000 01; 48 h:WMD=–0.73, 95%CI (–0.90, –0.56), P<0.000 01], but also shorten the first postoperative flatus time of patients [WMD=–17.36, 95%CI (–23.16, –11.56), P<0.000 01] and the length of hospital stay [WMD=–2.42, 95%CI (–3.02, –1.63), P<0.000 01] and reduce the hos-pitalization expenses [WMD=–0.52, 95%CI (–0.64, –0.41, P<0.000 01]; While the incidences of pulmonary comp-lications [OR=0.51, 95%CI (0.32, 0.81), P=0.005], total complications [OR=0.57, 95%CI (0.38, 0.87), P=0.008], and nausea and vomiting [OR=0.45, 95%CI (0.31, 0.65), P<0.000 1] were significantly decreased. The RCT group and CCT group showed the same conclusions with the overall study (except incidence of postoperative pulmonary complications between the two groups in the CCT study). Conclusion For patients with elective hepatectomy, it seems feasible to use FTS protocol, which could promote postoperative bowel recovery, shorten length of hospital day, and save medical resources.
ObjectiveTo evaluate whether radiofrequency-assisted associating liver partition and portal vein ligation for staged hepatectomy (RALPPS) is a safer and more effective modified treatment for patients with cirrhosis-related hepatocellular carcinoma (HCC). MethodsRALPPS were performed in patients with HCC and insufficient volume of future liver remnant (FLR<40%). Data of the patients during perioperative period such as operative morbidity, mortality, operative time, blood loss, percent increase in FLR, and interval between operations, were analyzed to assess the effectiveness and safety of the operation. ResultsA total of 8 patients were performed the RALPPS operation, and 6 cases completed both stages, 2 cases of postoperative complications or tumor metastasis did not complete the two phase of surgery. The average first and second stages operative time was (214.3±35.7) min, (266.7±46.0) min, respectively, and the average two stages blood loss during the operation was (218.8±113.2) mL,(501.7±224.5) mL, respectively. The mean preoperative FLR was (26.4±7.1)%, and the mean FLR before the second stage was (46.2±4.6)%. The average percentage increase in FLR during the interval time was 35%-113%, and the mean time interval between operations were (22.2±6.4) days. One case died of renal failure and severe pulmonary infection after two operation. Seven patients were followed-up (11.6+2.0) months (8-15 months). Two patients who had not completed the two-stage operation died within 3 months after discharge. Three patients who had completed the two-stage operation were tumor recurrence in 3-9 months after discharged from hospital and supplemented interventional therapy, 1 of them died,and 2 patients were followed-up to now without recurrence. ConclusionsRALPPS is equivalent to ALPPS for treating patients with cirrhosis-related HCC and insufficient FLR volume.
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 explore the curative effect of precise hepatectomy techniques in hepatolithus. MethodsTotally 132 patients underwent precise hepatectomy and 52 patients underwent irregular hepatectomy were retrospectively analyzed, and the intraoperative and postoperative indexes such as operation time, blood loss, postoperative complications, hospitalization time, clearance rate of calculus, and cost of hospitalization were analyzed. ResultsCompared with the patients in irregular hepatectomy group, although the operative time was longer in precise hepatectomy group 〔(364.6±57.8) min vs. (292.9±44.7) min, Plt;0.001〕, but the patients in precise hepatectomy group had less blood loss 〔(558.3±90.6) ml vs. (726.7±88.7) ml, Plt;0.001〕, less postoperative complications (11.4% vs. 23.1%，P=0.004 3), and higher clearance rate of calculus (89.4% vs. 73.1%, P=0.005 5). Thus, the patients in precise hepatectomy group had shorter hospital stay 〔(22.9±4.4) d vs. (28.8±3.5) d, Plt;0.001〕 and less cost of hospitalization 〔(1.8±0.7)×104 yuan vs. (2.1±0.9)×104 yuan, P=0.016 5〕. Conclusion Precise hepatectomy is better than irregular hepatectomy in treatment for hepatolithus.