This article aims to deepen the understanding of the role of Helicobacter pylori(H.pylori)infection in the development of cholelithiasis,initiated by the article by Yao et al,who investigated the potential link betwee...This article aims to deepen the understanding of the role of Helicobacter pylori(H.pylori)infection in the development of cholelithiasis,initiated by the article by Yao et al,who investigated the potential link between H.pylori infection and the development of cholelithiasis through a multicenter retrospective study on an Asian population of over 70000 participants.They also performed a compre-hensive analysis of previously published studies on H.pylori and cholelithiasis,finding a positive association therein[odds ratio(OR)=1.103,P=0.049].Patients positive for H.pylori also had lower levels of total and direct bilirubin,but higher levels of total cholesterol and low-density lipoprotein cholesterol compared to uninfected patients(P<0.05).Cohort studies have confirmed that H.pylori is a risk factor for cholelithiasis(P<0.0001),and aggregate analyses of case-control and cross-sectional studies have shown a positive association between H.pylori and cholelithiasis in Asia(OR=1.599,P=0.034),but not in Europe(OR=1.277,P=0.246).Moreover,H.pylori appears to be related to a higher ratio of choledocho-lithiasis/cholecystolithiasis(OR=3.321,P=0.033).The authors conclude that H.pylori infection is positively correlated with cholelithiasis,particularly with the choledocholithiasis phenotype,especially in Asia,and it is potentially related to bilirubin and cholesterol metabolism.展开更多
Biliary tract cancer(BTC)is a rare disease with few available treatment options.Tumor malignancy and surgical invasiveness vary depending on the site of the lesion.Perioperative mortality remains high,particularly in ...Biliary tract cancer(BTC)is a rare disease with few available treatment options.Tumor malignancy and surgical invasiveness vary depending on the site of the lesion.Perioperative mortality remains high,particularly in patients with hilar cholangiocarcinoma and gallbladder cancer.Benchmark cases from high-volume centers have reported high surgical complications(87%)and 3-month mortality rates(13%).Japanese studies of hepatopancreatoduodenectomy have reported that although the complication rate is higher in high-volume centers than in other institutions,the mortality rate is low;operative safety depends on adequate liver volume after resection by portal vein embolization,cholangitis reduction,and comprehensive management of postoperative complications.Robot-assisted surgery is increasingly common in patients treated with pancreaticoduodenectomy even after distal pancreatectomy.However,many challenges exist due to device and visibility issues.Recently,adjuvant chemotherapies have been developed for the treatment of BTC.The introduction of immune checkpoint inhibitors and discovery of oncogenic driver genes have increased the number of promising treatment options.Innovations in targeted drug therapy,including fibroblast growth factor receptor inhibitors and immune checkpoint inhibitors,have shown efficacy and broadened the treatment options for unresectable BTC.Therefore,a multidisciplinary treatment strategy based on surgical intervention is desirable.展开更多
AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was car...AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specifi city, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS: The D-dimer levels in the group developing postoperative PVT was signifi cantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi- quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.展开更多
AIM: To perform a systematic review and metaanalysis on robotic-assisted vs laparoscopic liver resections.METHODS: A systematic literature search was performed using Pub Med, Scopus and the Cochrane Library Central. P...AIM: To perform a systematic review and metaanalysis on robotic-assisted vs laparoscopic liver resections.METHODS: A systematic literature search was performed using Pub Med, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria:(1) studies comparing robotic and laparoscopic liver resection;(2) studies reporting at least one perioperative outcome; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.RESULTS: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time(MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.CONCLUSION: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.展开更多
The outcome after curative resection for hepatocellular carcinoma(HCC)remains unsatisfactory due to the high recurrence rate after surgery.In patients with hepatitis B virus(HBV)-related HCC,which is the majority of p...The outcome after curative resection for hepatocellular carcinoma(HCC)remains unsatisfactory due to the high recurrence rate after surgery.In patients with hepatitis B virus(HBV)-related HCC,which is the majority of patients with HCC in Asia,a high viral load is a strong risk factor for HCC recurrence.It is logical to believe that antiviral therapy may improve the postoperative outcome by promoting viral clearance and hepatocyte regeneration,as well as improving residual liver volume in HCC patients with hepatitis B.However,the effect of antiviral therapy on clinical outcomes after liver resection in patients with HBV-related HCC remains to be established.There are two main groups of antiviral treatment for HBV-oral nucleos(t)ide analogues and interferon.Interferon treatment reduces the overall incidence of HBV-related HCC in sustained re-sponders.However,side effects may limit its long-term clinical application.Nucleos(t)ide analogues carry fewer side effects and are potent in terms of viral suppression when compared to interferon and are typically implemented for patients with more advanced liver diseases.They may also improve the outcome after curative resection for HBV-related HCC.There are increasing evidence to suggest that antiviral therapy could suppress HBV,decrease the perioperative reactivation of viral replication,reduce liver injury,preserve the liver function before and after operation,and may lower the risk of HCC recurrence.After all,antiviral therapy may improve the survival after liver resection by reducing recurrence and delaying the liver damage by the virus,resulting in a higher chance of receiving aggressive salvage therapy during HCC recurrence.展开更多
AIM: To study the therapeutic value of combination o cryosurgery and 125iodine seed implantation for locally advanced pancreatic cancer. METHODS: Forty-nine patients with locally advanced pancreatic cancer (males 36, ...AIM: To study the therapeutic value of combination o cryosurgery and 125iodine seed implantation for locally advanced pancreatic cancer. METHODS: Forty-nine patients with locally advanced pancreatic cancer (males 36, females 13), with a median age of 59 years, were enrolled in the study. Twelve patients had liver metastases. In all cases the tumors were considered unresectable after a comprehensive evaluation. Patients were treated with cryosurgery, which was performed intraoperatively or percutaneously unde guidance of ultrasound and/or computed tomography (CT), and 125iodine seed implantation, which was performed during cryosurgery or post-cryosurgery under guidance of ultrasound and/or CT. A few patients received regional celiac artery chemotherapy. RESULTS: Thirteen patients received intraoperative cryosurgery and 36 received percutaneous cryosurgery Some patients underwent repeat cryosurgery. 125Iodine seed implantation was performed during freezing procedure in 35 patients and 3-9 d after cryosurgery in 14 cases. Twenty patients, 10 of whom had hepaticmetastases received regional chemotherapy. At 3 mo after therapy, CT was repeated to estimate tumor response to therapy. Most patients showed varying degrees of tumor necrosis. Complete response (CR) of tumor was seen in 20.4% patients, partial response (PR), in 38.8%, stable disease (SD), in 30.6%, and progressive disease (PD), in 10.2%. Adverse effects associated with cryosurgery included upper abdomen pain and increased serum amylase. Acute pancreatitis was seen in 6 patients one of whom developed severe pancreatitis. All adverse effects were controlled by medical management with no poor outcome. There was no therapy-related mortality. During a median follow-up of 18 mo (range of 5-40), the median survival was 16.2 mo, with 26 patients (53.1%) surviving for 12 mo or more. Overall, the 6-, 12-, 24- and 36-mo survival rates were 94.9%, 63.1%, 22.8% and 9.5%, respectively. Eight patients had survival of 24 mo or more. The patient with the longest survival (40 mo) is still living without evidence of tumor recurrence. CONCLUSION: Cryosurgery, which is far less invasive than conventional pancreatic resection, and is associated with a low rate of adverse effects, should be the treatment of choice for patients with locally advanced pancreatic cancer. 125Iodine seed implantation can destroy the residual surviving cancer cells after cryosurgery. Hence, a combination of both modalities has a complementary effect.展开更多
Recently,indocyanine green(ICG)fluorescence imaging has been widely used as a substitute for cholangiography in hepatobiliary surgery,to detect hepatic tumors,for accurate anatomical hepatectomy,and to increase the sa...Recently,indocyanine green(ICG)fluorescence imaging has been widely used as a substitute for cholangiography in hepatobiliary surgery,to detect hepatic tumors,for accurate anatomical hepatectomy,and to increase the safety and accuracy of minimally invasive(laparoscopic and robotic)hepatectomy.The clinical relevance of this method has been increasing gradually,as new procedures develop in this field.Various important roles and the latest added value of ICG fluorescence imaging in liver surgery are discussed in this report.展开更多
Although vascular complications(VCs) following orthotopic liver transplantation(OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the ...Although vascular complications(VCs) following orthotopic liver transplantation(OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant(either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features(epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.展开更多
Neoplastic needle track seeding following percutaneous radiofrequency ablation(RFA)of secondary liver tumors is exceedingly rare.Reports on cutaneous tumor seeding after percutaneous RFA for colorectal liver metastasi...Neoplastic needle track seeding following percutaneous radiofrequency ablation(RFA)of secondary liver tumors is exceedingly rare.Reports on cutaneous tumor seeding after percutaneous RFA for colorectal liver metastasis are even rarer in the literature.Here we report a case of a 46-year-old female who developed an ulcerating skin lesion along the needle track of a previous percutaneous RFA site around 6 mo after the procedure.The previous RFA was performed by the LeVeen needle for a secondary liver tumor from a primary rectal cancer.The diagnosis of secondary skin metastasis was confirmed by fine needle aspiration cytology.The lesion was successfully treated with wide local excision.We believe that tumor seeding after percutaneous RFA in our patient was possibly related to its unfavorable subcapsular location and the use of an expansion-type needle.Hence,prophylactic ablation of the needle track should be performed whenever possible.Otherwise,alternative routes of tumor ablation such as laparoscopic or open RFA should be considered.展开更多
AIM: To evaluate the efficacy of sequential use of transarterial chemoembolization (TACE) and percutaneous cryosurgery for unresectable hepatocellular carcinoma (HCC). METHODS: Four hundred and twenty patients were en...AIM: To evaluate the efficacy of sequential use of transarterial chemoembolization (TACE) and percutaneous cryosurgery for unresectable hepatocellular carcinoma (HCC). METHODS: Four hundred and twenty patients were enrolled in this study. The patients, who were considered to have unresectable tumors due to their location or size or comorbidity, were divided into sequential TACE-cryosurgery (sequential) group (n = 290) and cryosurgery alone (cryoalone) group (n = 130). Patients in the sequential group tended to have larger tumors and a greater number of tumors than those in the cryo-alone group. Tumors larger than 10 cm in diameter were only seen in the sequential group. TACE was performed with the routine technique and percutaneous cryosurgery was conducted under the guidance of ultrasound 2-4 wk after TACE. RESULTS: During a mean follow-up period of 42 ± 17 mo (range, 24-70 mo), the local recurrence rateat the ablated area was 17% for all patients, 11% and 23% for patients in sequential group and cryoalone groups, respectively (P = 0.001). The overall 1-, 2-, 3-, 4and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1and 2-year survival rates (71% and 61%) in sequential group were similar to those (73% and 54%) in cryo-alone group (P = 0.69 and 0.147), while the 4and 5-year survival rates were 49% and 39% in sequential group, higher than those (29% and 23%) in cryo-alone group (P = 0.001). Eighteen patients with large HCC (> 5 cm in diameter) survived for more than 5 years after sequential TACE while no patient with large HCC (> 5 cm in diameter) survived more than 5 years after cryosurgery. The overall complication rate was 24%, and the complication rates were 21% and 26% for the sequential and cryo-alone groups, respectively (P = 0.06). The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group (P = 0.02). Liver crack only occurred in two patients of the cryoalone group. CONCLUSION: Pre-cryosurgical TACE can increase the cryoablation efficacy and decrease its adverse effects, especially bleeding. Sequential TACE and cryosurgery may be the better procedure for unresectable HCC, especially for large HCC.展开更多
Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is...Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is portal vein embolization(PVE),which does not always lead to successful hypertrophy.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been proposed to overcome the limitations of PVE.Liver venous deprivation(LVD),a technique that includes simultaneous portal and hepatic vein embolization,has also been proposed as an alternative to ALPPS.The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy,effectiveness,and safety of the three regenerative techniques.Data sources:A systematic search for literature was conducted using the electronic databases Embase,PubMed(MEDLINE),Google Scholar and Cochrane.Results:The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days,respectively.Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts.There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort,but non-significant differences were observed when compared to the LVD cohort.Notably,the LVD cohort demonstrated a significantly better FLR/body weight(BW)ratio compared to both the ALPPS and PVE cohorts.Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort.The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.Conclusions:LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy.Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.展开更多
AIM: To investigate the efficacy and safety of capecitabine and oxaliplatin (CapeOx) for extrahepatic metastasis after local treatment of hepatocellular carcinoma (HCC). METHODS: Thirty-two patients with extrahepatic ...AIM: To investigate the efficacy and safety of capecitabine and oxaliplatin (CapeOx) for extrahepatic metastasis after local treatment of hepatocellular carcinoma (HCC). METHODS: Thirty-two patients with extrahepatic metastasis of HCC after local treatment were prospectively enrolled. The CapeOx regimen consisted of capecitabine 1000 mg/m 2 taken orally twice daily on days 1-14, and oxaliplatin was administered at a total dose of 100 mg/m 2 on day 1. The treatment was repeated every 3 wk until disease progression or unaccetablle toxicity. Efficacy and safety were assessable for all enrolled patients. The primary objective of this study was to assess the overall response rate. The secondary objectives were to evaluate the overall survival (OS), the time to tumor progression (TTP) and the toxicity profile of the combined strategy. TTP and OS were assessed by the Kaplan-Meier method and differences between the curves were analyzed using the log-rank test. The statistical software SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL, United States) was used for statistical analysis. All P values were 2-tailed, with statistical significance defined byP ≤ 0.05. RESULTS: Thirty-two patients were assessable for efficacy and toxicity. The median follow-up duration was 15 mo (range, 12-20 mo). At the cut-off date of March 31, 2012, 27 patients died due to tumor progression and one patient died of myocardial infarction. Four patients were still alive (three patients with disease progression). OR was 21.9% (n = 7), the stabilization rate was 40.6% (n = 13), and the disease control rate was 62.5%. The responses lasted from 4 to 19 mo (median, 6 mo). Median TTP was 4.2 mo (95%CI: 2.5-7.4), and the median OS time was 9.2 mo (95%CI: 6.5-17.8). The 1-year survival rate was 43.6% (95%CI: 29.0-66.0). In a multivariate analysis, OS was significantly longer in patients with a Child-Pugh class A compared with class B patients (P = 0.014), with a median OS of 10.1 mo vs 5.4 mo, and there were trends towards longer OS (P = 0.065) in patients without portal vein tumor thrombosis. There were no significant effects of age, gender, performance status, cirrhosis, metastatic sites, and level of alpha fetoprotein (AFP) or hepatitis B virus-DNA on OS. Among the 22 patients with elevated AFP levels at baseline (≥ 400 ng/mL), the level fell by more than 50% during treatment in 6 patients (27.3%). The most frequent treatment-related grade 3 to 4 toxicities included leucopenia/neutropenia, transient elevation of aminotransferases, handfoot syndrome and fatigue. CONCLUSION: CapeOx showed modest anti-tumor activity in metastatic HCC. However, the manageable toxicity profile and the encouraging disease control rate deserve further study for these patients.展开更多
The robotic surgical system has been applied in liver surgery.However,controversies concerns exist regarding a variety of factors including the safety,feasibility,efficacy,and cost-effectiveness of robotic surgery.To ...The robotic surgical system has been applied in liver surgery.However,controversies concerns exist regarding a variety of factors including the safety,feasibility,efficacy,and cost-effectiveness of robotic surgery.To promote the development of robotic hepatectomy,this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts'consensus and recommendations to promote its development.Based on the World Health Organization Handbook for Guideline Development,a Consensus Steering Group and a Consensus Development Group were established to determine the topics,prepare evidence-based documents,and generate recommendations.The GRADE Grid method and Delphi vote were used to formulate the recommendations.A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings.Based on the published articles and expert panel opinion,7 recommendations were generated by the GRADE method using an evidence-based method,which focused on the safety,feasibility,indication,techniques and cost-effectiveness of hepatectomy.Given that the current evidences were low to very low as evaluated by the GRADE method,further randomized-controlled trials are needed in the future to validate these recommendations.展开更多
Gallbladder cancer is the most common tumor of the biliary tract and it is associated with a poor prognosis.Unexpected gallbladder cancer is a cancer incidentally discovered,as a surprise,at the histological examinati...Gallbladder cancer is the most common tumor of the biliary tract and it is associated with a poor prognosis.Unexpected gallbladder cancer is a cancer incidentally discovered,as a surprise,at the histological examination after cholecystectomy for gallstones or other indications.It is a potentially curable disease,with an intermediate or good prognosis in most cases.An adequate surgical strategy is mandatory to improve the prognosis and an adjunctive radical resection may be required depending on the depth of invasion.If the cancer discovered after cholecystectomy is a pTis or a pT1a,a second surgical procedure is not mandatory.In the other cases(pT1b,pT2 and pT3 cancer) a re-resection(4b + 5 liver segmentectomy,lymphadenectomy and port-sites excision in some cases) is required to obtain a radical excision of the tumor and an accurate disease staging.The operative specimens of re-resection should be examined by the pathologist to find any "residual" tumor.The "residual disease" is the most important prognostic factor,significantly reducing median disease-free survival and disease-specific survival.The other factors include depth of parietal invasion,metastatic nodal disease,surgical margin status,cholecystectomy for acute cholecystitis,histological differentiation,lymphatic,vascular and perineural invasion and overall TNM-stage.展开更多
We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular...We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular carcinoma(HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo(range, 6-21 mo). The median Child-Pugh score at the onset of perforation(8.2) was significantly higher compared to the median Child-Pugh score just after RFA(6.5)(P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.展开更多
Diffusion-weighted imaging(DWI), dynamic contrastenhanced magnetic resonance imaging(DCE-MRI) and perfusion computed tomography(CT) are technical improvements of morphologic imaging that can evaluate functional proper...Diffusion-weighted imaging(DWI), dynamic contrastenhanced magnetic resonance imaging(DCE-MRI) and perfusion computed tomography(CT) are technical improvements of morphologic imaging that can evaluate functional properties of hepato-bilio-pancreatic tumors during conventional MRI or CT examinations.Nevertheless, the term "functional imaging" is commonly used to describe molecular imaging techniques, as positron emission tomography(PET)CT/MRI, which still represent the most widely used methods for the evaluation of functional properties of solid neoplasms; unlike PET or single photon emission computed tomography, functional imaging techniques applied to conventional MRI/CT examinations do not require the administration of radiolabeled drugs or specific equipments. Moreover, DWI and DCE-MRI can be performed during the same session, thus providing a comprehensive "one-step" morphological and functional evaluation of hepato-bilio-pancreatic tumors. Literature data reveal that functional imaging techniques could be proposed for the evaluation of these tumors before treatment, given that they may improve staging and predict prognosis or clinical outcome. Microscopic changes within neoplastic tissues induced by treatments can be detected and quantified with functional imaging,therefore these techniques could be used also for posttreatment assessment, even at an early stage. The aim of this editorial is to describe possible applications of new functional imaging techniques apart frommolecular imaging to hepatic and pancreatic tumors through a review of up-to-date literature data, with a particular emphasis on pathological correlations,prognostic stratification and post-treatment monitoring.展开更多
AIM: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.METHODS: This is an observational database study conducted in ...AIM: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.METHODS: This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography(ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded. RESULTS: During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d(interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23(77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy(median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed andthe biliary stent was removed on gastroscopy. In seven(23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d(interquartile range, 28-43 d). Among the patients included in the follow-up(median 30.5 mo, range 7-59 mo), four patients(14.8%) died of severe underlying comorbid illnesses.CONCLUSION: Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.展开更多
AIM:To investigate the significance of the surgical approaches in the prognosis of hepatocellular carcinoma(HCC) located in the caudate lobe with a multivariate regression analysis using a Cox proportional hazard mode...AIM:To investigate the significance of the surgical approaches in the prognosis of hepatocellular carcinoma(HCC) located in the caudate lobe with a multivariate regression analysis using a Cox proportional hazard model.METHODS:Thirty-six patients with HCC underwent caudate lobectomy at a single tertiary referral center between January 1995 and June 2010.In this series,left-sided,right-sided and bilateral approaches were used.The outcomes of patients who underwent isolated caudate lobectomy or caudate lobectomy combined with an additional partial hepatectomy were compared.The survival curves of the isolated and combined resection groups were generated by the Kaplan-Meier method and compared by a log-rank test.RESULTS:Sixteen(44.4%) of 36 patients underwent isolated total or partial caudate lobectomy whereas 20(55.6%) received a total or partial caudate lobectomy combined with an additional partial hepatectomy.The median diameter of the tumor was 6.7 cm(range,2.1-15.8 cm).Patients who underwent an isolated caudate lobectomy had significantly longer operative time(240 min vs 170 min),longer length of hospital stay(18 d vs 13 d) and more blood loss(780 mL vs 270 mL) than patients who underwent a combined caudate lobectomy(P < 0.05).There were no perioperative deaths in both groups of patients.The complication rate was higher in the patients who underwent an isolated caudate lobectomy than in those who underwent combined caudate lobectomy(31.3% vs 10.0%,P < 0.05).The 1-,3-and 5-year disease-free survival rates for the isolated caudate lobectomy and the combined caudate lobectomy groups were 54.5%,6.5% and 0% and 85.8%,37.6% and 0%,respectively(P < 0.05).The corresponding overall survival rates were 73.8%,18.5% and 0% and 93.1%,43.6% and 6.7%(P < 0.05).CONCLUSION:The caudate lobectomy combined with an additional partial hepatectomy is preferred because this approach is technically less demanding and offers an adequate surgical margin.展开更多
Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patient...Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.展开更多
文摘This article aims to deepen the understanding of the role of Helicobacter pylori(H.pylori)infection in the development of cholelithiasis,initiated by the article by Yao et al,who investigated the potential link between H.pylori infection and the development of cholelithiasis through a multicenter retrospective study on an Asian population of over 70000 participants.They also performed a compre-hensive analysis of previously published studies on H.pylori and cholelithiasis,finding a positive association therein[odds ratio(OR)=1.103,P=0.049].Patients positive for H.pylori also had lower levels of total and direct bilirubin,but higher levels of total cholesterol and low-density lipoprotein cholesterol compared to uninfected patients(P<0.05).Cohort studies have confirmed that H.pylori is a risk factor for cholelithiasis(P<0.0001),and aggregate analyses of case-control and cross-sectional studies have shown a positive association between H.pylori and cholelithiasis in Asia(OR=1.599,P=0.034),but not in Europe(OR=1.277,P=0.246).Moreover,H.pylori appears to be related to a higher ratio of choledocho-lithiasis/cholecystolithiasis(OR=3.321,P=0.033).The authors conclude that H.pylori infection is positively correlated with cholelithiasis,particularly with the choledocholithiasis phenotype,especially in Asia,and it is potentially related to bilirubin and cholesterol metabolism.
文摘Biliary tract cancer(BTC)is a rare disease with few available treatment options.Tumor malignancy and surgical invasiveness vary depending on the site of the lesion.Perioperative mortality remains high,particularly in patients with hilar cholangiocarcinoma and gallbladder cancer.Benchmark cases from high-volume centers have reported high surgical complications(87%)and 3-month mortality rates(13%).Japanese studies of hepatopancreatoduodenectomy have reported that although the complication rate is higher in high-volume centers than in other institutions,the mortality rate is low;operative safety depends on adequate liver volume after resection by portal vein embolization,cholangitis reduction,and comprehensive management of postoperative complications.Robot-assisted surgery is increasingly common in patients treated with pancreaticoduodenectomy even after distal pancreatectomy.However,many challenges exist due to device and visibility issues.Recently,adjuvant chemotherapies have been developed for the treatment of BTC.The introduction of immune checkpoint inhibitors and discovery of oncogenic driver genes have increased the number of promising treatment options.Innovations in targeted drug therapy,including fibroblast growth factor receptor inhibitors and immune checkpoint inhibitors,have shown efficacy and broadened the treatment options for unresectable BTC.Therefore,a multidisciplinary treatment strategy based on surgical intervention is desirable.
基金Supported by Technology Support Fund of Guangdong Province, No. 2004B35001007
文摘AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specifi city, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS: The D-dimer levels in the group developing postoperative PVT was signifi cantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi- quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.
文摘AIM: To perform a systematic review and metaanalysis on robotic-assisted vs laparoscopic liver resections.METHODS: A systematic literature search was performed using Pub Med, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria:(1) studies comparing robotic and laparoscopic liver resection;(2) studies reporting at least one perioperative outcome; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.RESULTS: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time(MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.CONCLUSION: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.
文摘The outcome after curative resection for hepatocellular carcinoma(HCC)remains unsatisfactory due to the high recurrence rate after surgery.In patients with hepatitis B virus(HBV)-related HCC,which is the majority of patients with HCC in Asia,a high viral load is a strong risk factor for HCC recurrence.It is logical to believe that antiviral therapy may improve the postoperative outcome by promoting viral clearance and hepatocyte regeneration,as well as improving residual liver volume in HCC patients with hepatitis B.However,the effect of antiviral therapy on clinical outcomes after liver resection in patients with HBV-related HCC remains to be established.There are two main groups of antiviral treatment for HBV-oral nucleos(t)ide analogues and interferon.Interferon treatment reduces the overall incidence of HBV-related HCC in sustained re-sponders.However,side effects may limit its long-term clinical application.Nucleos(t)ide analogues carry fewer side effects and are potent in terms of viral suppression when compared to interferon and are typically implemented for patients with more advanced liver diseases.They may also improve the outcome after curative resection for HBV-related HCC.There are increasing evidence to suggest that antiviral therapy could suppress HBV,decrease the perioperative reactivation of viral replication,reduce liver injury,preserve the liver function before and after operation,and may lower the risk of HCC recurrence.After all,antiviral therapy may improve the survival after liver resection by reducing recurrence and delaying the liver damage by the virus,resulting in a higher chance of receiving aggressive salvage therapy during HCC recurrence.
基金The Science-development Grand of Science-technology Department of Guangdong Province Grand of Health Department of Guangdong Province
文摘AIM: To study the therapeutic value of combination o cryosurgery and 125iodine seed implantation for locally advanced pancreatic cancer. METHODS: Forty-nine patients with locally advanced pancreatic cancer (males 36, females 13), with a median age of 59 years, were enrolled in the study. Twelve patients had liver metastases. In all cases the tumors were considered unresectable after a comprehensive evaluation. Patients were treated with cryosurgery, which was performed intraoperatively or percutaneously unde guidance of ultrasound and/or computed tomography (CT), and 125iodine seed implantation, which was performed during cryosurgery or post-cryosurgery under guidance of ultrasound and/or CT. A few patients received regional celiac artery chemotherapy. RESULTS: Thirteen patients received intraoperative cryosurgery and 36 received percutaneous cryosurgery Some patients underwent repeat cryosurgery. 125Iodine seed implantation was performed during freezing procedure in 35 patients and 3-9 d after cryosurgery in 14 cases. Twenty patients, 10 of whom had hepaticmetastases received regional chemotherapy. At 3 mo after therapy, CT was repeated to estimate tumor response to therapy. Most patients showed varying degrees of tumor necrosis. Complete response (CR) of tumor was seen in 20.4% patients, partial response (PR), in 38.8%, stable disease (SD), in 30.6%, and progressive disease (PD), in 10.2%. Adverse effects associated with cryosurgery included upper abdomen pain and increased serum amylase. Acute pancreatitis was seen in 6 patients one of whom developed severe pancreatitis. All adverse effects were controlled by medical management with no poor outcome. There was no therapy-related mortality. During a median follow-up of 18 mo (range of 5-40), the median survival was 16.2 mo, with 26 patients (53.1%) surviving for 12 mo or more. Overall, the 6-, 12-, 24- and 36-mo survival rates were 94.9%, 63.1%, 22.8% and 9.5%, respectively. Eight patients had survival of 24 mo or more. The patient with the longest survival (40 mo) is still living without evidence of tumor recurrence. CONCLUSION: Cryosurgery, which is far less invasive than conventional pancreatic resection, and is associated with a low rate of adverse effects, should be the treatment of choice for patients with locally advanced pancreatic cancer. 125Iodine seed implantation can destroy the residual surviving cancer cells after cryosurgery. Hence, a combination of both modalities has a complementary effect.
基金supported by a grant from the Grants-in-Aid for Research from the National Center for Global Health and Medicine(21A1019 to N.T.)。
文摘Recently,indocyanine green(ICG)fluorescence imaging has been widely used as a substitute for cholangiography in hepatobiliary surgery,to detect hepatic tumors,for accurate anatomical hepatectomy,and to increase the safety and accuracy of minimally invasive(laparoscopic and robotic)hepatectomy.The clinical relevance of this method has been increasing gradually,as new procedures develop in this field.Various important roles and the latest added value of ICG fluorescence imaging in liver surgery are discussed in this report.
文摘Although vascular complications(VCs) following orthotopic liver transplantation(OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant(either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features(epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.
文摘Neoplastic needle track seeding following percutaneous radiofrequency ablation(RFA)of secondary liver tumors is exceedingly rare.Reports on cutaneous tumor seeding after percutaneous RFA for colorectal liver metastasis are even rarer in the literature.Here we report a case of a 46-year-old female who developed an ulcerating skin lesion along the needle track of a previous percutaneous RFA site around 6 mo after the procedure.The previous RFA was performed by the LeVeen needle for a secondary liver tumor from a primary rectal cancer.The diagnosis of secondary skin metastasis was confirmed by fine needle aspiration cytology.The lesion was successfully treated with wide local excision.We believe that tumor seeding after percutaneous RFA in our patient was possibly related to its unfavorable subcapsular location and the use of an expansion-type needle.Hence,prophylactic ablation of the needle track should be performed whenever possible.Otherwise,alternative routes of tumor ablation such as laparoscopic or open RFA should be considered.
基金Supported by Scientific Foundation of Science Technology Department and Health Department of Guangdong Province
文摘AIM: To evaluate the efficacy of sequential use of transarterial chemoembolization (TACE) and percutaneous cryosurgery for unresectable hepatocellular carcinoma (HCC). METHODS: Four hundred and twenty patients were enrolled in this study. The patients, who were considered to have unresectable tumors due to their location or size or comorbidity, were divided into sequential TACE-cryosurgery (sequential) group (n = 290) and cryosurgery alone (cryoalone) group (n = 130). Patients in the sequential group tended to have larger tumors and a greater number of tumors than those in the cryo-alone group. Tumors larger than 10 cm in diameter were only seen in the sequential group. TACE was performed with the routine technique and percutaneous cryosurgery was conducted under the guidance of ultrasound 2-4 wk after TACE. RESULTS: During a mean follow-up period of 42 ± 17 mo (range, 24-70 mo), the local recurrence rateat the ablated area was 17% for all patients, 11% and 23% for patients in sequential group and cryoalone groups, respectively (P = 0.001). The overall 1-, 2-, 3-, 4and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1and 2-year survival rates (71% and 61%) in sequential group were similar to those (73% and 54%) in cryo-alone group (P = 0.69 and 0.147), while the 4and 5-year survival rates were 49% and 39% in sequential group, higher than those (29% and 23%) in cryo-alone group (P = 0.001). Eighteen patients with large HCC (> 5 cm in diameter) survived for more than 5 years after sequential TACE while no patient with large HCC (> 5 cm in diameter) survived more than 5 years after cryosurgery. The overall complication rate was 24%, and the complication rates were 21% and 26% for the sequential and cryo-alone groups, respectively (P = 0.06). The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group (P = 0.02). Liver crack only occurred in two patients of the cryoalone group. CONCLUSION: Pre-cryosurgical TACE can increase the cryoablation efficacy and decrease its adverse effects, especially bleeding. Sequential TACE and cryosurgery may be the better procedure for unresectable HCC, especially for large HCC.
文摘Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is portal vein embolization(PVE),which does not always lead to successful hypertrophy.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been proposed to overcome the limitations of PVE.Liver venous deprivation(LVD),a technique that includes simultaneous portal and hepatic vein embolization,has also been proposed as an alternative to ALPPS.The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy,effectiveness,and safety of the three regenerative techniques.Data sources:A systematic search for literature was conducted using the electronic databases Embase,PubMed(MEDLINE),Google Scholar and Cochrane.Results:The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days,respectively.Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts.There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort,but non-significant differences were observed when compared to the LVD cohort.Notably,the LVD cohort demonstrated a significantly better FLR/body weight(BW)ratio compared to both the ALPPS and PVE cohorts.Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort.The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.Conclusions:LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy.Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.
基金Supported by Shanghai Municipal Health Bureau Outstanding Young Clinical Personal Training Project, No. ZYSNXD-YLYSZK025
文摘AIM: To investigate the efficacy and safety of capecitabine and oxaliplatin (CapeOx) for extrahepatic metastasis after local treatment of hepatocellular carcinoma (HCC). METHODS: Thirty-two patients with extrahepatic metastasis of HCC after local treatment were prospectively enrolled. The CapeOx regimen consisted of capecitabine 1000 mg/m 2 taken orally twice daily on days 1-14, and oxaliplatin was administered at a total dose of 100 mg/m 2 on day 1. The treatment was repeated every 3 wk until disease progression or unaccetablle toxicity. Efficacy and safety were assessable for all enrolled patients. The primary objective of this study was to assess the overall response rate. The secondary objectives were to evaluate the overall survival (OS), the time to tumor progression (TTP) and the toxicity profile of the combined strategy. TTP and OS were assessed by the Kaplan-Meier method and differences between the curves were analyzed using the log-rank test. The statistical software SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL, United States) was used for statistical analysis. All P values were 2-tailed, with statistical significance defined byP ≤ 0.05. RESULTS: Thirty-two patients were assessable for efficacy and toxicity. The median follow-up duration was 15 mo (range, 12-20 mo). At the cut-off date of March 31, 2012, 27 patients died due to tumor progression and one patient died of myocardial infarction. Four patients were still alive (three patients with disease progression). OR was 21.9% (n = 7), the stabilization rate was 40.6% (n = 13), and the disease control rate was 62.5%. The responses lasted from 4 to 19 mo (median, 6 mo). Median TTP was 4.2 mo (95%CI: 2.5-7.4), and the median OS time was 9.2 mo (95%CI: 6.5-17.8). The 1-year survival rate was 43.6% (95%CI: 29.0-66.0). In a multivariate analysis, OS was significantly longer in patients with a Child-Pugh class A compared with class B patients (P = 0.014), with a median OS of 10.1 mo vs 5.4 mo, and there were trends towards longer OS (P = 0.065) in patients without portal vein tumor thrombosis. There were no significant effects of age, gender, performance status, cirrhosis, metastatic sites, and level of alpha fetoprotein (AFP) or hepatitis B virus-DNA on OS. Among the 22 patients with elevated AFP levels at baseline (≥ 400 ng/mL), the level fell by more than 50% during treatment in 6 patients (27.3%). The most frequent treatment-related grade 3 to 4 toxicities included leucopenia/neutropenia, transient elevation of aminotransferases, handfoot syndrome and fatigue. CONCLUSION: CapeOx showed modest anti-tumor activity in metastatic HCC. However, the manageable toxicity profile and the encouraging disease control rate deserve further study for these patients.
基金Supported by National Key Research and Development Program of China,No.2017YFC0110405National Natural Science Foundation of China,No.81500499
文摘The robotic surgical system has been applied in liver surgery.However,controversies concerns exist regarding a variety of factors including the safety,feasibility,efficacy,and cost-effectiveness of robotic surgery.To promote the development of robotic hepatectomy,this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts'consensus and recommendations to promote its development.Based on the World Health Organization Handbook for Guideline Development,a Consensus Steering Group and a Consensus Development Group were established to determine the topics,prepare evidence-based documents,and generate recommendations.The GRADE Grid method and Delphi vote were used to formulate the recommendations.A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings.Based on the published articles and expert panel opinion,7 recommendations were generated by the GRADE method using an evidence-based method,which focused on the safety,feasibility,indication,techniques and cost-effectiveness of hepatectomy.Given that the current evidences were low to very low as evaluated by the GRADE method,further randomized-controlled trials are needed in the future to validate these recommendations.
文摘Gallbladder cancer is the most common tumor of the biliary tract and it is associated with a poor prognosis.Unexpected gallbladder cancer is a cancer incidentally discovered,as a surprise,at the histological examination after cholecystectomy for gallstones or other indications.It is a potentially curable disease,with an intermediate or good prognosis in most cases.An adequate surgical strategy is mandatory to improve the prognosis and an adjunctive radical resection may be required depending on the depth of invasion.If the cancer discovered after cholecystectomy is a pTis or a pT1a,a second surgical procedure is not mandatory.In the other cases(pT1b,pT2 and pT3 cancer) a re-resection(4b + 5 liver segmentectomy,lymphadenectomy and port-sites excision in some cases) is required to obtain a radical excision of the tumor and an accurate disease staging.The operative specimens of re-resection should be examined by the pathologist to find any "residual" tumor.The "residual disease" is the most important prognostic factor,significantly reducing median disease-free survival and disease-specific survival.The other factors include depth of parietal invasion,metastatic nodal disease,surgical margin status,cholecystectomy for acute cholecystitis,histological differentiation,lymphatic,vascular and perineural invasion and overall TNM-stage.
文摘We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular carcinoma(HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo(range, 6-21 mo). The median Child-Pugh score at the onset of perforation(8.2) was significantly higher compared to the median Child-Pugh score just after RFA(6.5)(P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.
文摘Diffusion-weighted imaging(DWI), dynamic contrastenhanced magnetic resonance imaging(DCE-MRI) and perfusion computed tomography(CT) are technical improvements of morphologic imaging that can evaluate functional properties of hepato-bilio-pancreatic tumors during conventional MRI or CT examinations.Nevertheless, the term "functional imaging" is commonly used to describe molecular imaging techniques, as positron emission tomography(PET)CT/MRI, which still represent the most widely used methods for the evaluation of functional properties of solid neoplasms; unlike PET or single photon emission computed tomography, functional imaging techniques applied to conventional MRI/CT examinations do not require the administration of radiolabeled drugs or specific equipments. Moreover, DWI and DCE-MRI can be performed during the same session, thus providing a comprehensive "one-step" morphological and functional evaluation of hepato-bilio-pancreatic tumors. Literature data reveal that functional imaging techniques could be proposed for the evaluation of these tumors before treatment, given that they may improve staging and predict prognosis or clinical outcome. Microscopic changes within neoplastic tissues induced by treatments can be detected and quantified with functional imaging,therefore these techniques could be used also for posttreatment assessment, even at an early stage. The aim of this editorial is to describe possible applications of new functional imaging techniques apart frommolecular imaging to hepatic and pancreatic tumors through a review of up-to-date literature data, with a particular emphasis on pathological correlations,prognostic stratification and post-treatment monitoring.
文摘AIM: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.METHODS: This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography(ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded. RESULTS: During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d(interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23(77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy(median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed andthe biliary stent was removed on gastroscopy. In seven(23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d(interquartile range, 28-43 d). Among the patients included in the follow-up(median 30.5 mo, range 7-59 mo), four patients(14.8%) died of severe underlying comorbid illnesses.CONCLUSION: Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.
文摘AIM:To investigate the significance of the surgical approaches in the prognosis of hepatocellular carcinoma(HCC) located in the caudate lobe with a multivariate regression analysis using a Cox proportional hazard model.METHODS:Thirty-six patients with HCC underwent caudate lobectomy at a single tertiary referral center between January 1995 and June 2010.In this series,left-sided,right-sided and bilateral approaches were used.The outcomes of patients who underwent isolated caudate lobectomy or caudate lobectomy combined with an additional partial hepatectomy were compared.The survival curves of the isolated and combined resection groups were generated by the Kaplan-Meier method and compared by a log-rank test.RESULTS:Sixteen(44.4%) of 36 patients underwent isolated total or partial caudate lobectomy whereas 20(55.6%) received a total or partial caudate lobectomy combined with an additional partial hepatectomy.The median diameter of the tumor was 6.7 cm(range,2.1-15.8 cm).Patients who underwent an isolated caudate lobectomy had significantly longer operative time(240 min vs 170 min),longer length of hospital stay(18 d vs 13 d) and more blood loss(780 mL vs 270 mL) than patients who underwent a combined caudate lobectomy(P < 0.05).There were no perioperative deaths in both groups of patients.The complication rate was higher in the patients who underwent an isolated caudate lobectomy than in those who underwent combined caudate lobectomy(31.3% vs 10.0%,P < 0.05).The 1-,3-and 5-year disease-free survival rates for the isolated caudate lobectomy and the combined caudate lobectomy groups were 54.5%,6.5% and 0% and 85.8%,37.6% and 0%,respectively(P < 0.05).The corresponding overall survival rates were 73.8%,18.5% and 0% and 93.1%,43.6% and 6.7%(P < 0.05).CONCLUSION:The caudate lobectomy combined with an additional partial hepatectomy is preferred because this approach is technically less demanding and offers an adequate surgical margin.
文摘Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.
