The microbiota impact on human diseases is well-known,and a growing body of literature is providing evidence about the complex interplay between microbiotaimmune system-human physiology/pathology,including cancers.Tog...The microbiota impact on human diseases is well-known,and a growing body of literature is providing evidence about the complex interplay between microbiotaimmune system-human physiology/pathology,including cancers.Together with the defined risk factors(e.g.,smoke habits,diet,diabetes,and obesity),the oral,gut,biliary,and intrapancreatic microbiota contribute to pancreatic cancer development through different pathways including the interaction with the immune system.Unfortunately,a great majority of the pancreatic cancer patients received a diagnosis in advanced stages not amenable to be radically treated and potentially cured.Given the poor pancreatic cancer prognosis,complete knowledge of these complicated relationships could help researchers better understand the disease pathogenesis and thus provide early potential noninvasive biomarkers,new therapeutic targets,and tools for risk stratification that might result in greater therapeutic possibilities and eventually in a better and longer patient survival.展开更多
AIM: To outline the feasibility, safety, adverse events and early results of endoscopic ultrasound(EUS)-radiofrequency ablation(RFA) in pancreatic neoplasms using a novel probe. METHODS: This is a multi-center, pilot ...AIM: To outline the feasibility, safety, adverse events and early results of endoscopic ultrasound(EUS)-radiofrequency ablation(RFA) in pancreatic neoplasms using a novel probe. METHODS: This is a multi-center, pilot safety feasibility study. The intervention described was radiofrequency ablation(RF) which was applied with an innovative monopolar RF probe(1.2 mm Habib EUS-RFA catheter) placed through a 19 or 22 gauge fine needle aspiration(FNA) needle once FNA was performed in patients with a tumor in the head of the pancreas. The HabibTM EUSRFA is a 1 Fr wire(0.33 mm, 0.013") with a working length of 190 cm, which can be inserted through the biopsy channel of an echoendoscope. RF power is applied to the electrode at the end of the wire to coagulate tissue in the liver and pancreas.RESULTS: Eight patients [median age of 65(range 27-82) years; 7 female and 1 male] were recruited in a prospective multicenter trial. Six had a pancreatic cysticneoplasm(four a mucinous cyst, one had intraductal papillary mucinous neoplasm and one a microcystic adenoma) and two had a neuroendocrine tumors(NET) in the head of pancreas. The mean size of the cystic neoplasm and NET were 36.5 mm(SD ± 17.9 mm) and 27.5 mm(SD ± 17.7 mm) respectively. The EUSRFA was successfully completed in all cases. Among the 6 patients with a cystic neoplasm, post procedure imaging in 3-6 mo showed complete resolution of the cysts in 2 cases, whilst in three more there was a 48.4% reduction [mean pre RF 38.8 mm(SD ± 21.7 mm) vs mean post RF 20 mm(SD ± 17.1 mm)] in size. In regards to the NET patients, there was a change in vascularity and central necrosis after EUS-RFA. No major complications were observed within 48 h of the procedure. Two patients had mild abdominal pain that resolved within 3 d. CONCLUSION: EUS-RFA of pancreatic neoplasms with a novel monopolar RF probe was well tolerated in all cases. Our preliminary data suggest that the procedure is straightforward and safe. The response ranged from complete resolution to a 50% reduction in size.展开更多
Cholangiocarcinomas are the second most frequent primary hepatic malignancy,and make up from 5% to 30% of malignant hepatic tumours.Hilar cholangiocarcinoma(HCC) is the most common type,and accounts for approximately ...Cholangiocarcinomas are the second most frequent primary hepatic malignancy,and make up from 5% to 30% of malignant hepatic tumours.Hilar cholangiocarcinoma(HCC) is the most common type,and accounts for approximately 60% to 67% of all cholangiocarcinoma cases.There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease.Neither the extension of resection,according to the sort of HCC,is a closed topic.Some authors defend limited resection(mesohepatectomy with S1,S1 plus S4b-S5,local excision for papillary tumours,etc.) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure.As there is not an ideal adjuvant therapy,R1 resection can be justified to prolong the survival rate.Morbidity and mortality rates changed along the last decade,but variability is the rule,with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%,respectively.Conclusion:Surgical resection continues to be the main treatment of HCC.Negative resection margins achieved with major hepatic resections are associated with improved outcome.Preresectional management with biliary drainage,portal vein embolization and staging laparoscopy should be considered in selected patients.Additional evidence is needed to fully define the role of orthotopic liver transplant.Portal and lymph node involvement worsen the prognosis and long-term survival,and surgery is the only option that can lengthen it.Improvements in adjuvant therapy are essential for improving long-term outcome.Furthermore,the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option,because operated patients have a longer survival rate than those who not undergo surgery.展开更多
In resectable colorectal liver metastasis(CRLM) the role and use of molecular biomarkers is still controversial. Several biomarkers have been linked to clinical outcomes in CRLM, but none have so far become routine fo...In resectable colorectal liver metastasis(CRLM) the role and use of molecular biomarkers is still controversial. Several biomarkers have been linked to clinical outcomes in CRLM, but none have so far become routine for clinical decision making. For several reasons, the clinical risk score appears to no longer hold the same predictive value. Some of the reasons include the ever expanding indications for liver resection, which now increasingly tend to involve extrahepatic disease, such as lung metastases(both resectable and non-resectable) and the shift in indication from "what is taken out"(e.g., how much liver has to be resected) to "what is left behind"(that is, how much functional liver tissue the patient has after resection). The latter is amenable to modifications by using adjunct techniques of portal vein embolization and the associating liver partition and portal vein ligation for staged hepatectomy techniques to expand indications for liver resection. Added to this complexity is the increasing number of molecular markers, which appear to hold important prognostic and predictive information, for which some will be discussed here. Beyond characteristics of tissue-based genomic profiles will be liquid biopsies derived from circulating tumor cells and cell-free circulating tumor DNA in the blood. These markers are present in the peripheral circulation in the majority of patients with metastatic cancer disease. Circulating biomarkers may represent more readily available methods to monitor, characterize and predict cancer biology with future implications for cancer care.展开更多
Post-hepatectomy liver failure(PHLF) is a leading cause of morbidity and mortality following major liver resection. The development of PHLF is dependent on the volume of the remaining liver tissue and hepatocyte funct...Post-hepatectomy liver failure(PHLF) is a leading cause of morbidity and mortality following major liver resection. The development of PHLF is dependent on the volume of the remaining liver tissue and hepatocyte function. Without effective pre-operative assessment, patients with undiagnosed liver disease could be at increased risk of PHLF. We report a case of a 60-year-old male patient with PHLF secondary to undiagnosed alpha-1-antitrypsin deficiency(AATD) following major liver resection. He initially presented with acute large bowel obstruction secondary to a colorectal adenocarcinoma, which had metastasized to the liver. There was no significant past medical history apart from mild chronic obstructive pulmonary disease. After colonic surgery and liver directed neo-adjuvant chemotherapy, he underwent a laparoscopic partially extended right hepatectomy and radio-frequency ablation. Post-operatively he developed PHLF. The cause of PHLF remained unknown, prompting reanalysis of the histology, which showed evidence of AATD. He subsequently developed progressive liver dysfunction, portal hypertension, and eventually an extensive parastomal bleed, which led to his death; this was ultimately due to a combination of AATD and chemotherapy. This case highlights that formal testing for AATD in all patients with a known history of chronic obstructive pulmonary disease, heavy smoking, or strong family history could help prevent the development of PHLF in patients undergoing major liver resection.展开更多
AIM: To investigate the survival impact of common pharmaceuticals, which target stromal interactions, following a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. METHODS: Data was collected retrospective...AIM: To investigate the survival impact of common pharmaceuticals, which target stromal interactions, following a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. METHODS: Data was collected retrospectively for 164 patients who underwent a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma(PDAC). Survival analysis was performed on patients receiving the following medications: angiotensin-converting enzyme inhibitors(ACEI)/angiotensin Ⅱ receptor blockers(ARB), calcium channel blockers(CCB), aspirin, and statins. Statistical analysis included Kaplan-meier survival estimates and cox multivariate regression; the latter of which allowed for any differences in a range of prognostic indicators between groups. Medications showing a significant survival benefit were investigated in combination with other medications to evaluate synergistic effects.RESULTS: No survival benefit was observed with respect to ACEI/ARB(n = 41), aspirin or statins on individual drug analysis(n = 39). However, the entire CCB group(n = 26) showed a significant survival benefit on multivariate cox regression; hazard ratio(HR) of 0.475(CI = 0.250-0.902, P = 0.023). Further analysis revealed that this was influenced by a group of patients who were taking aspirin in combination with CCB; median survival was significantly higher in the CCB + aspirin group(n = 15) compared with the group taking neither drug(n = 98); 1414 d vs 601 d(P = 0.029, logrank test). Multivariate cox regression revealed neither aspirin nor CCB had a statistically significant impact on survival when given alone, however in combination the survival benefit was significant; HR = 0.332(CI = 0.126-0.870, P = 0.025). None of the other medications showed a survival benefit in any combination.CONCLUSION: Aspirin + CCB in combination appears to increase survival in patients with PDAC, highlighting the potential clinical use of combination therapy to target stromal interactions in pancreatic cancer.展开更多
Enteroenteric intussusception is a condition in which full-thickness bowel wall becomes telescoped into the lumen of distal bowel. In adults, there is usually an abnormality acting as a lead point, usually a Meckels＇...Enteroenteric intussusception is a condition in which full-thickness bowel wall becomes telescoped into the lumen of distal bowel. In adults, there is usually an abnormality acting as a lead point, usually a Meckels＇ diverticulum, a hamartoma or a tumour. Duodeno- duodenal intussusception is exceptionally rare because the retroperitoneal situation fixes the duodenal wall. The aim of this report is to describe the first published case of this condition. A patient with duodeno-duodenal intussusception secondary to an ampullary lesion is reported. A 66 year-old lady presented with intermittent abdominal pain, weight loss and anaemia. Ultrasound scanning showed dilated bile and pancreatic ducts. CT scanning revealed intussusception involving the full-thickness duodenal wall. The lead point was an ampullary villous adenoma. Congenital partial （type r[） malrotation was found at operation and this abnormality permitted excessive mobility of the duodenal wall such that intussusception was possible. This condition can be diagnosed using enhanced CT. Intussusception can be complicated by bowel obstruction, ischaemia or bleeding, and therefore the underlying cause should be treated as soon as possible.展开更多
Pancreaticoduodenectomy(PD) is the standard surgical treatment for tumors of the pancreatic head,proximal bile duct,duodenum and ampulla,and represents the only hope of cure in cases of malignancy.Since its initial de...Pancreaticoduodenectomy(PD) is the standard surgical treatment for tumors of the pancreatic head,proximal bile duct,duodenum and ampulla,and represents the only hope of cure in cases of malignancy.Since its initial description in 1935 by Whipple et al,this complex surgical technique has evolved and undergone several modifications.We review three key issues in PD:(1) the initial approach to the superior mesenteric artery,known as the artery-first approach;(2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis;and(3) the extent of lymphadenectomy.展开更多
An increasing number of patients are being referred to pancreatic centres around the world due to often incidentally discovered cystic neoplasms of the pancreas.The evaluation and management of pancreatic cystic neopl...An increasing number of patients are being referred to pancreatic centres around the world due to often incidentally discovered cystic neoplasms of the pancreas.The evaluation and management of pancreatic cystic neoplasms is a controversial topic and with existing guidelines based on a lack of strong evidence there is discordance between centres and guidelines with regard to when to offer surgery and when to favour surveillance.The frequency,duration and modality of surveillance is also controversial as this is resource-consuming and must be balanced against the perceived benefits and risks involved.While there is consensus that the risk of malignancy should be balanced against the lifeexpectancy and comorbidities,the indications for surgery and surveillance strategies vary among the guidelines.Thus,the tug of war between surveillance or resection continues.Here we discuss the recommendations from guidelines with further accumulating data and emerging reports on intraductal papillary mucinous neoplasm in the literature.展开更多
Background: Pancreatic neuroendocrine tumors(PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET.Methods: A tot...Background: Pancreatic neuroendocrine tumors(PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET.Methods: A total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared.Results: Multivariate analysis found that female gender, lymph node metastases and increasing WHO2010 grade to be independently associated with reduced overall survival(P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival(AUROC: 0.699 vs 0.605;P < 0.01).Conclusions: Multi-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior.Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.展开更多
AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed.
Background: Liver transplant is a potential cure for liver failure and hepatic malignancy but there are many techniques which have been described for vascular reconstruction. This study was to compare the prevalence o...Background: Liver transplant is a potential cure for liver failure and hepatic malignancy but there are many techniques which have been described for vascular reconstruction. This study was to compare the prevalence of non-anastomotic biliary stricture and other surgical complications based on Clavien-Dindo scoring system, in initial portal reperfusion(sequential) versus simultaneous or initial artery reperfusion. Data sources: Meta-analysis of published studies comparing the outcomes of both techniques was carried out. Data search was conducted across the major databases and studies were selected under the guidance of the Cochrane guidelines for systematic reviews and meta-analysis. Results: Seven studies were included to address the primary and the secondary outcomes. No statistical difference was found in the incidence of non-anastomotic biliary strictures(OR = 0.40; P = 0.14), regardless of reperfusion technique. The pooled estimate of the Clavien-Dindo grading of complications was not significantly different between the techniques, though Clavien-Dindo II complications were higher in the simultaneous or initial artery reperfusion group than the initial portal reperfusion group(OR = 2.73; P = 0.01). Similarly, there was no difference in the operative time, hospital stay and other outcomes addressed in this report. Conclusions: The available evidence suggests that there is no significant difference demonstrated in the rate of non-anastomotic biliary strictures or other complications, between the two techniques, except for Clavien-Dindo II complications.展开更多
This paper aims to update the therapeutical strategies in liver metastasis with complete clinical response(CCR) after chemotherapy and to determine if surgery is always necessary after CCR.The aim of chemotherapy is t...This paper aims to update the therapeutical strategies in liver metastasis with complete clinical response(CCR) after chemotherapy and to determine if surgery is always necessary after CCR.The aim of chemotherapy is to achieve a good clinical response rather than CCR of liver metastasis.The CCR of liver metastasis after chemotherapy cannot be considered synonymous with a cure.The resection of the hepatic segment where there was hepatic metastases with CCR after chemotherapy theoretically prevents recurrence,improves survival and makes it possible to conf irm whether there has been a complete pathological response.However,the medical literature about this topic is scarce and sometimes contradictory.展开更多
Pancreatic cancer has an overall dismal prognosis compared to most other malignancies.In general,only about 15%-20%of patients are deemed upfront resectable at time of diagnosis,with a similar proportion presenting wi...Pancreatic cancer has an overall dismal prognosis compared to most other malignancies.In general,only about 15%-20%of patients are deemed upfront resectable at time of diagnosis,with a similar proportion presenting with either borderline or locally advanced disease[1].Novel and more effective treatment regimens including FOLFIRINOX have made yet more patients become resectable,with up to 60%reported in some centers[2].展开更多
Introduction Liver surgery for colorectal liver metastasis(CRLM)has evolved considerably over the past two decades.Novel chemotherapy regimens and effective targeted therapy,changes in the view of resectability criter...Introduction Liver surgery for colorectal liver metastasis(CRLM)has evolved considerably over the past two decades.Novel chemotherapy regimens and effective targeted therapy,changes in the view of resectability criteria and evolution of safer surgical principles have led to increasing resection rates and better overall survival for an increasing number of patients with stage IV colorectal cancer(1).展开更多
Aim:The optimal treatment for hepatocellular carcinoma(HCC)is either surgical resection or liver transplantation,but only one-third of the patients are suitable candidates for surgery.Laparoscopic radiofrequency ablat...Aim:The optimal treatment for hepatocellular carcinoma(HCC)is either surgical resection or liver transplantation,but only one-third of the patients are suitable candidates for surgery.Laparoscopic radiofrequency ablation(RFA)in selected patients is a safe,feasible technique,which has proved to be superior to the percutaneous approach in patients with severe liver disease or in lesions in which the percutaneous approach is impossible.The aim of this study is to present our experience with laparoscopic RFA and demonstrate its safety as an alternative therapeutic procedure in selected patients with HCC.Methods:This is a retrospective study of patients with HCC who underwent laparoscopic RFA between March 2009 and December 2014.Results:Thirty-two patients with 37 tumors underwent laparoscopic RFA.Median tumor size was 2.24 cm(0.7-4.45 cm).Major complications occurred in 8 patients.Initial complete ablation was achieved in 94.6%(35/37)lesions and sustained complete ablation rate was 62.85%(22/35).Overall survival rates at 1-,2-,and 3-year were 89%,67.5%,and 40%,respectively.Conclusion:Laparoscopic RFA of HCC is safe and the long-term outcomes are similar to those achieved with liver resection.Further trials combining chemoembolization and RFA are needed to improve long-term outcomes and to limit local tumor progression.展开更多
Radiological simultaneous portohepatic vein embolization(RASPE)is a relatively new technique,which aims to rapidly increase the future liver remnant(FLR)in patients with very small FLR in order to undergo major hepate...Radiological simultaneous portohepatic vein embolization(RASPE)is a relatively new technique,which aims to rapidly increase the future liver remnant(FLR)in patients with very small FLR in order to undergo major hepatectomy.展开更多
In neuroendocrine tumors(NETs),liver metastases(LM)represent the most crucial prognostic factor,irrespective of the primary tumor site.At diagnosis,about 65-95%of gastroenteropancreatic neuroendocrine tumors(GEP-NETs)...In neuroendocrine tumors(NETs),liver metastases(LM)represent the most crucial prognostic factor,irrespective of the primary tumor site.At diagnosis,about 65-95%of gastroenteropancreatic neuroendocrine tumors(GEP-NETs)show hepatic metastasis.Management strategies of LM are heterogeneous and range from systemic therapy to liver-directed procedures.The type of systemic therapy used is dependent on the grade and proliferation of the tumor and includes somatostatin analogues,interferon,m-Tor and tyrosine kinase inhibitors,and chemotherapy.Angiographic liver-directed techniques,such as transarterial embolization/chemoembolization and selective internal radiation therapy,offer excellent palliation for patients with liver-predominant disease.In highly selected cases,liver transplantation and peptide receptor radionuclide therapy are considered.The relatively low disease incidence and the diversity of presentation have led to a lack of well-conducted randomized controlled trials comparing the efficacy of different treatment options.Experience indicates that surgery is the only treatment that offers potential for cure.For unresectable lesions,the absence of data from rigorous trials limits the validity of many publications that detail management.In this review we will discuss the existing approaches for hepatic metastases from GEP-NETs.展开更多
Pancreatic ductal adenocarcinoma(PDAC)is a disease with a particular aggressive cancer biology and,unfortunately,a very poor prognosis for most patients.There is no question about the lethality of pancreatic cancer.Ho...Pancreatic ductal adenocarcinoma(PDAC)is a disease with a particular aggressive cancer biology and,unfortunately,a very poor prognosis for most patients.There is no question about the lethality of pancreatic cancer.However,the question why this malignancy is so deadly remains a biological puzzle both to investigators and caretakers alike.Staging of pancreatic cancer undergoing resection-while important to compare cohorts across studies and trials-also allows for a clinical clue about the progress of the disease.展开更多
Acute pancreatitis(AP)represents a common clinical challenge,with increasing incidence globally and with continued rates of high mortality in patients progressing to severe AP despite improvements in the evidence base...Acute pancreatitis(AP)represents a common clinical challenge,with increasing incidence globally and with continued rates of high mortality in patients progressing to severe AP despite improvements in the evidence base for early management(1).Timely management from the initial presentation is crucial,underscoring the need for evidence-based guidelines in this field.Tenner et al.recently published evidence-based clinical guidelines for the management of AP(2),providing valuable recommendations for clinicians based on a systematic review of current evidence.We would like to add to this important work by offering some additional considerations for optimizing the management of AP.展开更多
文摘The microbiota impact on human diseases is well-known,and a growing body of literature is providing evidence about the complex interplay between microbiotaimmune system-human physiology/pathology,including cancers.Together with the defined risk factors(e.g.,smoke habits,diet,diabetes,and obesity),the oral,gut,biliary,and intrapancreatic microbiota contribute to pancreatic cancer development through different pathways including the interaction with the immune system.Unfortunately,a great majority of the pancreatic cancer patients received a diagnosis in advanced stages not amenable to be radically treated and potentially cured.Given the poor pancreatic cancer prognosis,complete knowledge of these complicated relationships could help researchers better understand the disease pathogenesis and thus provide early potential noninvasive biomarkers,new therapeutic targets,and tools for risk stratification that might result in greater therapeutic possibilities and eventually in a better and longer patient survival.
文摘AIM: To outline the feasibility, safety, adverse events and early results of endoscopic ultrasound(EUS)-radiofrequency ablation(RFA) in pancreatic neoplasms using a novel probe. METHODS: This is a multi-center, pilot safety feasibility study. The intervention described was radiofrequency ablation(RF) which was applied with an innovative monopolar RF probe(1.2 mm Habib EUS-RFA catheter) placed through a 19 or 22 gauge fine needle aspiration(FNA) needle once FNA was performed in patients with a tumor in the head of the pancreas. The HabibTM EUSRFA is a 1 Fr wire(0.33 mm, 0.013") with a working length of 190 cm, which can be inserted through the biopsy channel of an echoendoscope. RF power is applied to the electrode at the end of the wire to coagulate tissue in the liver and pancreas.RESULTS: Eight patients [median age of 65(range 27-82) years; 7 female and 1 male] were recruited in a prospective multicenter trial. Six had a pancreatic cysticneoplasm(four a mucinous cyst, one had intraductal papillary mucinous neoplasm and one a microcystic adenoma) and two had a neuroendocrine tumors(NET) in the head of pancreas. The mean size of the cystic neoplasm and NET were 36.5 mm(SD ± 17.9 mm) and 27.5 mm(SD ± 17.7 mm) respectively. The EUSRFA was successfully completed in all cases. Among the 6 patients with a cystic neoplasm, post procedure imaging in 3-6 mo showed complete resolution of the cysts in 2 cases, whilst in three more there was a 48.4% reduction [mean pre RF 38.8 mm(SD ± 21.7 mm) vs mean post RF 20 mm(SD ± 17.1 mm)] in size. In regards to the NET patients, there was a change in vascularity and central necrosis after EUS-RFA. No major complications were observed within 48 h of the procedure. Two patients had mild abdominal pain that resolved within 3 d. CONCLUSION: EUS-RFA of pancreatic neoplasms with a novel monopolar RF probe was well tolerated in all cases. Our preliminary data suggest that the procedure is straightforward and safe. The response ranged from complete resolution to a 50% reduction in size.
文摘Cholangiocarcinomas are the second most frequent primary hepatic malignancy,and make up from 5% to 30% of malignant hepatic tumours.Hilar cholangiocarcinoma(HCC) is the most common type,and accounts for approximately 60% to 67% of all cholangiocarcinoma cases.There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease.Neither the extension of resection,according to the sort of HCC,is a closed topic.Some authors defend limited resection(mesohepatectomy with S1,S1 plus S4b-S5,local excision for papillary tumours,etc.) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure.As there is not an ideal adjuvant therapy,R1 resection can be justified to prolong the survival rate.Morbidity and mortality rates changed along the last decade,but variability is the rule,with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%,respectively.Conclusion:Surgical resection continues to be the main treatment of HCC.Negative resection margins achieved with major hepatic resections are associated with improved outcome.Preresectional management with biliary drainage,portal vein embolization and staging laparoscopy should be considered in selected patients.Additional evidence is needed to fully define the role of orthotopic liver transplant.Portal and lymph node involvement worsen the prognosis and long-term survival,and surgery is the only option that can lengthen it.Improvements in adjuvant therapy are essential for improving long-term outcome.Furthermore,the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option,because operated patients have a longer survival rate than those who not undergo surgery.
文摘In resectable colorectal liver metastasis(CRLM) the role and use of molecular biomarkers is still controversial. Several biomarkers have been linked to clinical outcomes in CRLM, but none have so far become routine for clinical decision making. For several reasons, the clinical risk score appears to no longer hold the same predictive value. Some of the reasons include the ever expanding indications for liver resection, which now increasingly tend to involve extrahepatic disease, such as lung metastases(both resectable and non-resectable) and the shift in indication from "what is taken out"(e.g., how much liver has to be resected) to "what is left behind"(that is, how much functional liver tissue the patient has after resection). The latter is amenable to modifications by using adjunct techniques of portal vein embolization and the associating liver partition and portal vein ligation for staged hepatectomy techniques to expand indications for liver resection. Added to this complexity is the increasing number of molecular markers, which appear to hold important prognostic and predictive information, for which some will be discussed here. Beyond characteristics of tissue-based genomic profiles will be liquid biopsies derived from circulating tumor cells and cell-free circulating tumor DNA in the blood. These markers are present in the peripheral circulation in the majority of patients with metastatic cancer disease. Circulating biomarkers may represent more readily available methods to monitor, characterize and predict cancer biology with future implications for cancer care.
文摘Post-hepatectomy liver failure(PHLF) is a leading cause of morbidity and mortality following major liver resection. The development of PHLF is dependent on the volume of the remaining liver tissue and hepatocyte function. Without effective pre-operative assessment, patients with undiagnosed liver disease could be at increased risk of PHLF. We report a case of a 60-year-old male patient with PHLF secondary to undiagnosed alpha-1-antitrypsin deficiency(AATD) following major liver resection. He initially presented with acute large bowel obstruction secondary to a colorectal adenocarcinoma, which had metastasized to the liver. There was no significant past medical history apart from mild chronic obstructive pulmonary disease. After colonic surgery and liver directed neo-adjuvant chemotherapy, he underwent a laparoscopic partially extended right hepatectomy and radio-frequency ablation. Post-operatively he developed PHLF. The cause of PHLF remained unknown, prompting reanalysis of the histology, which showed evidence of AATD. He subsequently developed progressive liver dysfunction, portal hypertension, and eventually an extensive parastomal bleed, which led to his death; this was ultimately due to a combination of AATD and chemotherapy. This case highlights that formal testing for AATD in all patients with a known history of chronic obstructive pulmonary disease, heavy smoking, or strong family history could help prevent the development of PHLF in patients undergoing major liver resection.
文摘AIM: To investigate the survival impact of common pharmaceuticals, which target stromal interactions, following a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. METHODS: Data was collected retrospectively for 164 patients who underwent a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma(PDAC). Survival analysis was performed on patients receiving the following medications: angiotensin-converting enzyme inhibitors(ACEI)/angiotensin Ⅱ receptor blockers(ARB), calcium channel blockers(CCB), aspirin, and statins. Statistical analysis included Kaplan-meier survival estimates and cox multivariate regression; the latter of which allowed for any differences in a range of prognostic indicators between groups. Medications showing a significant survival benefit were investigated in combination with other medications to evaluate synergistic effects.RESULTS: No survival benefit was observed with respect to ACEI/ARB(n = 41), aspirin or statins on individual drug analysis(n = 39). However, the entire CCB group(n = 26) showed a significant survival benefit on multivariate cox regression; hazard ratio(HR) of 0.475(CI = 0.250-0.902, P = 0.023). Further analysis revealed that this was influenced by a group of patients who were taking aspirin in combination with CCB; median survival was significantly higher in the CCB + aspirin group(n = 15) compared with the group taking neither drug(n = 98); 1414 d vs 601 d(P = 0.029, logrank test). Multivariate cox regression revealed neither aspirin nor CCB had a statistically significant impact on survival when given alone, however in combination the survival benefit was significant; HR = 0.332(CI = 0.126-0.870, P = 0.025). None of the other medications showed a survival benefit in any combination.CONCLUSION: Aspirin + CCB in combination appears to increase survival in patients with PDAC, highlighting the potential clinical use of combination therapy to target stromal interactions in pancreatic cancer.
文摘Enteroenteric intussusception is a condition in which full-thickness bowel wall becomes telescoped into the lumen of distal bowel. In adults, there is usually an abnormality acting as a lead point, usually a Meckels＇ diverticulum, a hamartoma or a tumour. Duodeno- duodenal intussusception is exceptionally rare because the retroperitoneal situation fixes the duodenal wall. The aim of this report is to describe the first published case of this condition. A patient with duodeno-duodenal intussusception secondary to an ampullary lesion is reported. A 66 year-old lady presented with intermittent abdominal pain, weight loss and anaemia. Ultrasound scanning showed dilated bile and pancreatic ducts. CT scanning revealed intussusception involving the full-thickness duodenal wall. The lead point was an ampullary villous adenoma. Congenital partial （type r[） malrotation was found at operation and this abnormality permitted excessive mobility of the duodenal wall such that intussusception was possible. This condition can be diagnosed using enhanced CT. Intussusception can be complicated by bowel obstruction, ischaemia or bleeding, and therefore the underlying cause should be treated as soon as possible.
文摘Pancreaticoduodenectomy(PD) is the standard surgical treatment for tumors of the pancreatic head,proximal bile duct,duodenum and ampulla,and represents the only hope of cure in cases of malignancy.Since its initial description in 1935 by Whipple et al,this complex surgical technique has evolved and undergone several modifications.We review three key issues in PD:(1) the initial approach to the superior mesenteric artery,known as the artery-first approach;(2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis;and(3) the extent of lymphadenectomy.
文摘An increasing number of patients are being referred to pancreatic centres around the world due to often incidentally discovered cystic neoplasms of the pancreas.The evaluation and management of pancreatic cystic neoplasms is a controversial topic and with existing guidelines based on a lack of strong evidence there is discordance between centres and guidelines with regard to when to offer surgery and when to favour surveillance.The frequency,duration and modality of surveillance is also controversial as this is resource-consuming and must be balanced against the perceived benefits and risks involved.While there is consensus that the risk of malignancy should be balanced against the lifeexpectancy and comorbidities,the indications for surgery and surveillance strategies vary among the guidelines.Thus,the tug of war between surveillance or resection continues.Here we discuss the recommendations from guidelines with further accumulating data and emerging reports on intraductal papillary mucinous neoplasm in the literature.
文摘Background: Pancreatic neuroendocrine tumors(PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET.Methods: A total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared.Results: Multivariate analysis found that female gender, lymph node metastases and increasing WHO2010 grade to be independently associated with reduced overall survival(P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival(AUROC: 0.699 vs 0.605;P < 0.01).Conclusions: Multi-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior.Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.
文摘AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed.
文摘Background: Liver transplant is a potential cure for liver failure and hepatic malignancy but there are many techniques which have been described for vascular reconstruction. This study was to compare the prevalence of non-anastomotic biliary stricture and other surgical complications based on Clavien-Dindo scoring system, in initial portal reperfusion(sequential) versus simultaneous or initial artery reperfusion. Data sources: Meta-analysis of published studies comparing the outcomes of both techniques was carried out. Data search was conducted across the major databases and studies were selected under the guidance of the Cochrane guidelines for systematic reviews and meta-analysis. Results: Seven studies were included to address the primary and the secondary outcomes. No statistical difference was found in the incidence of non-anastomotic biliary strictures(OR = 0.40; P = 0.14), regardless of reperfusion technique. The pooled estimate of the Clavien-Dindo grading of complications was not significantly different between the techniques, though Clavien-Dindo II complications were higher in the simultaneous or initial artery reperfusion group than the initial portal reperfusion group(OR = 2.73; P = 0.01). Similarly, there was no difference in the operative time, hospital stay and other outcomes addressed in this report. Conclusions: The available evidence suggests that there is no significant difference demonstrated in the rate of non-anastomotic biliary strictures or other complications, between the two techniques, except for Clavien-Dindo II complications.
文摘This paper aims to update the therapeutical strategies in liver metastasis with complete clinical response(CCR) after chemotherapy and to determine if surgery is always necessary after CCR.The aim of chemotherapy is to achieve a good clinical response rather than CCR of liver metastasis.The CCR of liver metastasis after chemotherapy cannot be considered synonymous with a cure.The resection of the hepatic segment where there was hepatic metastases with CCR after chemotherapy theoretically prevents recurrence,improves survival and makes it possible to conf irm whether there has been a complete pathological response.However,the medical literature about this topic is scarce and sometimes contradictory.
文摘Pancreatic cancer has an overall dismal prognosis compared to most other malignancies.In general,only about 15%-20%of patients are deemed upfront resectable at time of diagnosis,with a similar proportion presenting with either borderline or locally advanced disease[1].Novel and more effective treatment regimens including FOLFIRINOX have made yet more patients become resectable,with up to 60%reported in some centers[2].
文摘Introduction Liver surgery for colorectal liver metastasis(CRLM)has evolved considerably over the past two decades.Novel chemotherapy regimens and effective targeted therapy,changes in the view of resectability criteria and evolution of safer surgical principles have led to increasing resection rates and better overall survival for an increasing number of patients with stage IV colorectal cancer(1).
文摘Aim:The optimal treatment for hepatocellular carcinoma(HCC)is either surgical resection or liver transplantation,but only one-third of the patients are suitable candidates for surgery.Laparoscopic radiofrequency ablation(RFA)in selected patients is a safe,feasible technique,which has proved to be superior to the percutaneous approach in patients with severe liver disease or in lesions in which the percutaneous approach is impossible.The aim of this study is to present our experience with laparoscopic RFA and demonstrate its safety as an alternative therapeutic procedure in selected patients with HCC.Methods:This is a retrospective study of patients with HCC who underwent laparoscopic RFA between March 2009 and December 2014.Results:Thirty-two patients with 37 tumors underwent laparoscopic RFA.Median tumor size was 2.24 cm(0.7-4.45 cm).Major complications occurred in 8 patients.Initial complete ablation was achieved in 94.6%(35/37)lesions and sustained complete ablation rate was 62.85%(22/35).Overall survival rates at 1-,2-,and 3-year were 89%,67.5%,and 40%,respectively.Conclusion:Laparoscopic RFA of HCC is safe and the long-term outcomes are similar to those achieved with liver resection.Further trials combining chemoembolization and RFA are needed to improve long-term outcomes and to limit local tumor progression.
文摘Radiological simultaneous portohepatic vein embolization(RASPE)is a relatively new technique,which aims to rapidly increase the future liver remnant(FLR)in patients with very small FLR in order to undergo major hepatectomy.
文摘In neuroendocrine tumors(NETs),liver metastases(LM)represent the most crucial prognostic factor,irrespective of the primary tumor site.At diagnosis,about 65-95%of gastroenteropancreatic neuroendocrine tumors(GEP-NETs)show hepatic metastasis.Management strategies of LM are heterogeneous and range from systemic therapy to liver-directed procedures.The type of systemic therapy used is dependent on the grade and proliferation of the tumor and includes somatostatin analogues,interferon,m-Tor and tyrosine kinase inhibitors,and chemotherapy.Angiographic liver-directed techniques,such as transarterial embolization/chemoembolization and selective internal radiation therapy,offer excellent palliation for patients with liver-predominant disease.In highly selected cases,liver transplantation and peptide receptor radionuclide therapy are considered.The relatively low disease incidence and the diversity of presentation have led to a lack of well-conducted randomized controlled trials comparing the efficacy of different treatment options.Experience indicates that surgery is the only treatment that offers potential for cure.For unresectable lesions,the absence of data from rigorous trials limits the validity of many publications that detail management.In this review we will discuss the existing approaches for hepatic metastases from GEP-NETs.
文摘Pancreatic ductal adenocarcinoma(PDAC)is a disease with a particular aggressive cancer biology and,unfortunately,a very poor prognosis for most patients.There is no question about the lethality of pancreatic cancer.However,the question why this malignancy is so deadly remains a biological puzzle both to investigators and caretakers alike.Staging of pancreatic cancer undergoing resection-while important to compare cohorts across studies and trials-also allows for a clinical clue about the progress of the disease.
文摘Acute pancreatitis(AP)represents a common clinical challenge,with increasing incidence globally and with continued rates of high mortality in patients progressing to severe AP despite improvements in the evidence base for early management(1).Timely management from the initial presentation is crucial,underscoring the need for evidence-based guidelines in this field.Tenner et al.recently published evidence-based clinical guidelines for the management of AP(2),providing valuable recommendations for clinicians based on a systematic review of current evidence.We would like to add to this important work by offering some additional considerations for optimizing the management of AP.
