Progress on surgical treatment of intrahepatic cholangiocarcinoma / 中华外科杂志

Intrahepatic cholangiocarcinoma(ICC)is a primary liver cancer with its incidence only after hepatocellular carcinoma.Liver resection is currently the only established effective treatment for patients with ICC.However,the resectability of ICC is low and the long-term survival after surgery is far from satisfactory. With the advances in the understanding of the biological characteristics and prognostic characteristics of ICC, surgical strategy and techniques have improved in recent years, and the long-term survival has also been increased. The accurate clinical diagnosis of ICC, R0 resection, routine lymphadenectomy, effective adjuvant therapy after R0 resection, and multidisciplinary treatment including re-hepatectomy for recurrent ICC are important for achieving an optimal outcome.Down-staging management for patients with unresectable ICC may provide a chance of R0 resection in some patients. Further research on the biological heterogeneity of ICC,and the improvement of surgical treatment or the establishment of new treatment methods are the main research directions in the future.

Make great efforts to improve the levels of refined diagnosis and individualized treatment for microvascular invasion of liver cancer in China / 中华肝胆外科杂志

Recurrence after surgical resection is a bottleneck that severely restricts the long-term efficacy of patients with liver cancer, mainly referring to hepatocellular carcinoma and intrahepatic cholangiocarcinoma. As the most representative pathobiological feature of liver cancer, microvascular invasion (MVI) should be taken as an important focus to break through the bottleneck of postoperative recurrence. The new pathological diagnostic criteria and classification scheme of MVI has been written into the current " Guidelines for Diagnosis and Treatment of Primary Liver Cancer" of China. It is not only an important pathological indication for the clinical implementation of anti-recurrence therapy after operation, but also an key pathological basis for the clinical formulation of postoperative anti-recurrent therapy. Therefore, we intend to investigate how to make better use of it. From now on, multidisciplinary research should be strengthened in order to make real progress in the occurrence mechanism, migration pathway, distribution pattern, accurate identification and effective treatment of MVI in order to further improve the long-term efficacy of patients with liver cancer.

Make great efforts to improve the levels of refined diagnosis and individualized treatment for micro-vascular invasion of liver cancer in China / 中华肝胆外科杂志

Recurrence after surgical resection is a bottleneck that severely restricts the long-term efficacy of patients with liver cancer, mainly referring to hepatocellular carcinoma and intrahepatic cholangio-carcinoma. As the most representative pathobiological feature of liver cancer, microvascular invasion ( MVI) should be taken as an important focus to break through the bottleneck of postoperative recurrence. The new pathological diagnostic criteria and classification scheme of MVI has been written into the current"Guidelines for Diagnosis and Treatment of Primary Liver Cancer" of China. It is not only an important pathological indi-cation for the clinical implementation of anti-recurrence therapy after operation, but also an key pathological basis for the clinical formulation of postoperative anti-recurrent therapy. Therefore, we intend to investigate how to make better use of it. From now on, multidisciplinary research should be strengthened in order to make real progress in the occurrence mechanism, migration pathway, distribution pattern, accurate identifi-cation and effective treatment of MVI in order to further improve the long-term efficacy of patients with liver cancer.

The way of thinking decides exit and the innovation leads future: practice and implementation of Academician Lau Wan Yee's research ideas / 中华消化外科杂志

Through analysis of Lau Wan Yee's published papers,monographs,conference speeches,research designs / revisions for major hospitals in China,combined with analysis of articles revised by Academician Lau in the Eastern Hepatobiliary Surgery Hospital of the Second Military Medical University for the past decade,authors came up with 9 points in Academician Lau's research ideas.Academician Lau has played a huge and leading role in improving clinical skills and scientific research levels,as well as in development and internationalization of hepatobiliary and pancreatic surgery in China.To summarize the research ideas of Lau is of great importance to the future generations of surgeons.

Intraductal cooling protection technique via PTCD tube versus via ENBD tube in percutaneous microwave ablation for HCC: a comparative study of the protective effect on bile duct thermal damage / 介入放射学杂志

Objective To compare the preventive effect on bile duct thermal damage of percutaneous transhepatic cholangial drainage (PTCD) intubation with that of endoscopic nasobiliary drainage (ENBD)intubation,through which cooling liquid is continuously infused,in treating hepatocellular carcinoma (HCC)located close to the hepatic hilum by using percutaneous microwave ablation (PMWA) therapy.Methods The clinical data of 23 patients with HCC that was located close to the hepatic hilum,who were admitted to authors' hospital during the period from September 2013 to September 2016 to receive PMWA,were retrospectively analyzed.Among the 23 patients,PTCD intubation was employed in 12 and ENBD intubation was adopted in 11,and the cooling tube was placed in the bile duct near the tumor.Through the tube 4℃ cooling saline was rapidly and continuously infused,meanwhile PMWA was carried out under the guidance of B-ultrasound.The occurrence of thermal damage of the bile duct,the cooling technique-related complications,and the recurrence of HCC were compared between PTCD ~oup and ENBD group.Results The mean follow-up time was 20 months (3.0-36.0 months),and no operation-related death occurred in all 23 patients.In each group,postoperative biloma occurred in one patient.No obvious cooling techniquerelated complications were observed in PTCD group,but in ENBD group 4 patients (36.36％) developed cooling technique-related complications,including hemorrhage after incision of duodenal papilla (n=1,9.09％) and acute pancreatitis (n=3,27.27％);the difference in the incidence of cooling technique-related complications between the two groups was statistically significant (P=0.037).No statistically significant differences in local recurrence rate,intrahepatic recurrence rate and mortality existed between the two gro ups(P=1.00,P=0.77 and P=0.61,respectively).Conclusion For the treatment of HCC located close to the hepatic hilum with radical PMWA therapy,continuous infusion of cooling liquid through PTCD intubation or ENBD intubation to prevent the thermal damage of the bile duct is clinically feasible and effective,and PTCD intubation method has less technique-related complications than ENBD intubation method.

Antiviral therapy before combined microwave ablation and chemoembolization for patients with he-patocellular carcinoma / 中华肝胆外科杂志

Objective To investigate the characteristics of hepatitis virus B ( HBV) reactivation af-ter combined percutaneous microwave ablation ( PMWA ) and transcatheter arterial chemoembolization ( TACE) in patients with hepatocellular carcinoma ( HCC) and to study the therapeutic role of preoperative antiviral therapy .Methods The data on 180 HCC patients who were treated with the combined therapy were analyzed .The antivirus group ( n=90 ) received antiviral therapy , while the control group ( n=90 ) did not.HBV-DNA was used to study the reactivation status of HBV after the combined therapy and the role of antiviral therapy .Results The incidence of HBV reactivation was significantly lower in the antivirus group (8.2%, 7/90) than the control group (20.0%, 18/90, P<0.05).A preoperative HBV-DNA level above 104 copies/ml was the only independent risk factor of HBV reactivation (P<0.05).Conclusions The HBV reactivation rate was relatively high in patients with HBV-related HCC after combined PMWA and TACE.Preoperative antiviral therapy significantly reduced HBV reactivation and thus it should be adminis -trated especially to HCC patients with a preoperative HBV-DNA level above 104 copies/ml.

Influence of repeated TACE treatment interval on the prognosis of hepatocellular carcinoma / 实用放射学杂志

Objective To investigate the effects of transarterial chemoembolization (TACE)treatment interval on the prognosis of patients with advanced hepatocellular caisinoma(HCC).Methods We retrospectively collected clinical data of 123 advanced HCC patients treated with repeated TACE.The patients were divided into two groups (group A with fixed repeated treatment interval and group B with that according to the clinical needs).Cox regression,survival curve and log-rank test were used to assess the effects of the treat-ment intervals on prognosis.Results The treatment intervals of the group A and group B were (1.1±0.3)months and (3.0±1.5) months,respectively (P <0.001).Multivariate Cox analysis showed the efficacy (P =0.024)and repetition periods (P <0.001 ) were independent prognostic factors.Conclusion TACE interval is independent risk factor for the prognosis of patients with ad-vanced HCC.Repeated TACE treatment according to clinical needs may be more favorable for prognosis of the patients.

Surgical efficacy of benign tumor of liver in the caudate lobe / 中华消化外科杂志

Objective To evaluate the surgical efficacy of benign tumor of liver in the caudate lobe.Methods The clinical data of 112 patients with benign tumor of liver in the caudate lobe who were admitted to the Eastern Hepatobiliary Surgery Hospital from January 2003 to April 2014 were retrospectively analyzed.The leftsided approach,right-sided approach,bilateral approach,central anterior approach and retrograde caudate lobectomy were selected according to the location and size of the tumor.All the patients were followed up by outpatient examination and telephone interview up to October 2014.Results Of all the 112 patients who received complete resection of tumor,33 patients received caudate lobectomy (22 by bilateral approach,11 by left-sided approach),28 received left hemihepatectomy + caudate lobectomy (by left-sided approach),21 received mesohepatectomy + caudate lobectomy (by central anterior approach),19 received partial right hepatectomy + caudate lobectomy (by right-sided approach),11 received right hemihepatectomy + candate lobectomy (9 by right-sided approach,2 by retrograde caudate lobectomy).During the operation,72 patients received vascular inflow occlusion,29 received vascular inflow occlusion combined with hepatic veins occlusion,6 received total hepatic vascular exclusion and 5 did not receive vascular inflow occlusion.The operation time,mean time of vascular inflow occlusion,mean volume of intraoperative blood loss,cases of blood transfusion,mean volume of blood transfusion and duration of postoperative hospital stay were (192 ± 69)minutes,28 minutes (range,0-94 minutes),590 mL (range,100-12 000 mL),68,600 mL (range,200-10 000mL) and (8.2 ± 2.7) days,respectively.Thirty-one patients had postoperative complications,including 21 with bile leakage,7 with medium and above volume of pleural effusion,2 with postoperative bleeding and 1 with hepatic failure.The complications were cured after symptomatic treatment.No patient died perioperatively.All the 112 patients were followed up for a median time of 12 months (range,6-24 months).All patients were survived well and without tumor recurrence during the follow-up.Conclusions Surgical treatment is an effective method for benign tumor of liver in the caudate lobe,with the good recovery of patients and definitive surgical efficacy.The key factors of surgical treatment include strictly following operative indication,rationally optimizing surgical approach,suitably selecting vascular inflow occlusion and the accurate operation.

Preventation of excessive treatment for benign tumors of liver / 中华消化外科杂志

Currently,since a single treatment standard of benign tumors of liver is not established,many serious out-comes due to the excessive treatment of benign tumors of liver still happen sometimes.We should pay attention to composing the guideline on the treatment for the different types of benign tumors of liver on the basis of the multidisciplinary cooperation and the randomized controlled trials,and achieving the goals of an unified standard and the standardized therapy,meanwhile,avoiding the pain and burden of excessive treatment on the patients.

Effective ways to improve the prognosis of advanced stage (BCLC stage C) hepatocellular carcinoma / 中华外科杂志

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) or lymphatic/extrahepatic metastasis is classified as advanced stage (Stage C of Bacelona Clinic Liver Cancer Staging). There is few effective therapy for the advanced stage HCC, leading to an extremly poor prognosis. For these patients, Sorafinib is recommended as the only therapy by European and American guidelines, which has limited clinic effect. In China, besides Sorafinib, various therapies have also been suggested, including surgery, trans-arterial chemoembolization (TACE), radiotherapy, as well as traditional Chinese medicine. Recently, it is reported that several therapies may be effective in treating HCC with PVTT which is classified based on Cheng's classification, including surgery after "down-stage" radiotherapy, early use of sorafinib postoperatively, as well as postoperative antivirus treatment. The modified Folfox4 chemotherapy, is also a potential effective way to improve the prognosis of advanced stage HCC with lymphatic/extrahepatic metastasis. Mutiple disciplinary team which could faciliate the process of diagnosis and treatment of advanced stage HCC, is expected to favor the prognosis of these patients.

Markers of hepatitis B virus infection：current application and prospect / 中华检验医学杂志

The natural history of chronic HBV infection is diverse and variable, ranging from inactive carriers to progressive chronic hepatitis B ( CHB), cirrhosis and hepatocelluar carcinoma.It is estimated that 93 million people are chronically infected with HBV and 20 million cases suffering from chronic hepatitis B in China.Hepatocelluar carcinoma has been the second leading cause of death for male in China.Liver cirrhosis and HCC which have high mortality and morbidity have become the heavy burden for the limited medication resource of China.Here the current clinical applications and consensus progression based on antigen and nuclear acid detection were acknowledged.The reasonable application as well as appropriate clinical interpretation are emphasized indicating that laboratory medicine practitioners should be more actively involved in clinical diagnosis and treatment.More efforts and contributions should be made by the laboratory medicine practitioner for optimizing clinical management of HBV-related diseases in future.

Persistent care should be taken to the research on HBV genomic viability and its clinical translation / 中华检验医学杂志

China is among the middle-high endemic regions of HBV infection.The pathological outcomes of chronic HBV infection have been shown to be greatly influenced by several important factors,including HBV genotype,sub-genotype and gene viability mutation.HBV genome mutation,on the one hand,could alter its replication and secretion and thus change viral pathogenicity.In addition,host immune microenvironment and host-virus interaction,disease progression and the effect of antiviral therapy could be adapted at the same time.The detection of HBV genotypes,genetic subtypes and the key hotspot mutation is helpful to clinical risk assessment and prognosis prediction of HBV-related end-stage liver diseases (cirrhosis and hepatocellular carcinoma),it is also helpful to auxiliary predict the liver diseases recurrence and metastasis after treatment.Thus persistent care should be taken on the HBV mutation and its clinical translation so as to provide solid evidences for the personalized,standardized and fine management of HBV-related liver diseases.

Prognosis after resection of early hepatocellular carcinoma in HBV-related cirrhotic patients / 中华肝胆外科杂志

Objective To identify clinicopathologic factors which predict survival following hepatectomy in HBV-related cirrhotic patients with early hepatocellular carcinoma (HCC).Methods A database was used to identify patients with histologically confirmed early HCC (≤5 cm,no nodal involvement,metastases,or major vascular invasion) who underwent surgical resection (excluding ablation or transplantation).Among 20 700 patients with HCC who were diagnosed at the Eastern Hepatobiliary Surgery Hospital from April 2005 to November 2010,537 (2.6％) patients with early HCC were studied retrospectively.Prognostic factors were evaluated using the Kaplan-Meier curves,Cox proportional hazards models and the receiver operating characteristic (ROC) curves.Results The study included 537 patients.The median tumor size was 2.9 cm,and 33％ of patients had tumors ≤2 cm.Most HCC lesions were solitary (63％) and had no evidence of vascular invasion (64％).Following surgery,the overall median and 5-year survival were 45 months and 33％ respectively.After adjusting for demographic factors and histological grade,tumor size ＞2 cm (hazard ratio [HR]:1.56),multifocal tumors (HR:1.34),and vascular invasion (HR:2.03) remained independent predictors of poor survival (all P ＜ 0.05).Based on these findings,a prognostic scoring system was developed that allotted 1 point each for these factors.Patients with early HCC could be stratified into 4 distinct prognostic groups (median and 5-year survival,respectively):0 points (97 months,96％),1 point (85 months,76％),2 points (76 months,54％),3 points (56 months,39％) (P ＜0.01).Conclusions The present study emphasized the importance of pathologic staging even in patients with small HCC.Anatomical resection of HCC should be the preferred surgical procedure in cirrhotic patients.

Percutaneous radiofrequency ablation for the treatment of portal vein tumor thrombus：experience of 15 cases / 介入放射学杂志

Objective To investigate the safety and clinical effect of endovascular radiofrequency ablation (RFA) catheter, the HabibTM VesOpen, in treating portal vein tumor thrombus. Methods Fifteen patients of hepatocellular carcinoma associated with portal vein thrombus causing obstruction of blood flow were enrolled in this study. Guided by ultrasound percutaneous portal catheter implantation was performed, then, under DSA guidance RFA catheter was placed at portal vein tumor thrombus. RF generator (RITA) was connected to the electrodes, the power was set at 10 W for 2 - 10 minutes. The technical success rate, the postoperative complications, the hepatic and renal functions as well as routine blood tests, portal vein blood flow and the ablation extent of portal vein tumor thrombus were evaluated, and the results were analyzed. Results The procedure was successfully accomplished in all patients. No technique-related complications, such as hemorrhage, vessel perforation, bile leak complicated by infection, liver abscess, abdominal bleeding occurred. Direct portography performed immediately after RFA showed that the portal vein was re-opened. Laboratory examinations performed 4 weeks after RFA showed that no obvious changes in hepatic functions and routine blood tests were observed. Doppler ultrasound examinations revealed that flowing blood was obviously displayed within previously obstructed portal vein. CT scanning was carried out in some patients with portal vein thrombus, and it indicated that the portal vein tumor thrombus was reduced in size or even disappeared. Conclusion For the treatment of portal vein tumor thrombus in patients with hepatocellular carcinoma, endovascular radiofrequency ablation is technically feasible, and the initial results indicate that this technique is an effective treatment.

Risk factors for postoperative liver failure of patients with hepatocellular carcinoma and bile duct tumor thrombus / 中华消化外科杂志

Objective To investigate the risk factors for postoperative liver failure of patients with hepatocellular carcinoma (HCC) and bile duct tumor thrombus through a risk evaluation model.Methods The clinical data of 107 patients with HCC and bile duct tumor thrombus who received hepatic resection at the Eastern Hepatobiliary Surgery Hospital from March 2002 to February 2011 were retrospectively analyzed.All patients were divided into the non-liver failure group (98 patients) and liver failure group (9 patients).Risk factors associated with liver failure were analyzed and a risk evaluation model was established.All data were analyzed using the bivariate regression model,and factors with significance were further analyzed using the multivariate regression model.Results Of the 107 patients,105 received hepatic resection + choledochotomy + thrombectomy and 2 received hepatic resection + extrahepatic bile duct resection + cholangiojejunostomy.The operation time was 2.0-5.5 hours,and the intraoperative blood loss was 200-3500 ml.In the non-liver failure group,5 patients had pleural and peritoneal effusion,3 had biliary bleeding,2 had incisional infection,1 had biliary infection,1 had bile leakage,1 had stress-induced ulcer of upper digestive tract and 1 had thoracic epidural hematoma.The bleeding of the patients with thoracic epidural hematoma was stopped after thoracic spinal decompression,but subsequent paraplegia occurred.In the liver failure group,2 patients died of postoperative acute liver failure,and 7 patients died of postoperative subacute liver failure (death caused by tumor recurrence or medicine was excluded).The results of univariate analysis showed that preoperative total bilirubin,albumin,pre-albumin,albumin/globulin ratio,distribution of tumor thrombus,operative blood loss and ratio of postoperative residual liver volume to the total liver volume were correlated with the postoperative liver failure in patients with HCC and bile duct tumor thrombus (OR =3.017,0.191,0.248,2.681,9.048,4.759,13.714,P ＜ 0.05).The results of multivariate analysis showed that preoperative total bilirubin ＞ 256.5 μmol/L,albumin/globulin ratio ≤ 1.3 and postoperative residual liver volume ＜ 50％ were the independent risk factors of postoperative liver failure (OR =5.537,11.107,172.450,P ＜ 0.05).The risk evaluation model was Z =1.77 × preoperative total bilirubin + 2.408 × preoperative albumin/globulin ratio + 5.150 × ratio of postoperative residual liver volume to the total liver volume-17.288.The risk of postoperative liver failure increased as the increase of Z value.The risk of postoperative liver failure ＞ 50％ when the Z value ＞ 0.Conclusions Preoperative total bilirubin ＞ 256.5μmol/L,albumin/globulin ratio ≤ 1.3 and postoperative residual liver volume ＜ 50％ were the independent risk factors of postoperative liver failure.Risk evaluation model is helpful in screening the risk factors so as to decrease the incidence of postoperative liver failure.

Retrograde caudate lobectomy combined with right hemi-hepatectomy / 中华消化外科杂志

Retrograde caudate lobectomy is a proper technique to resect the tumor in caudate lobe when the tumor is too big or closely adherent to the inferior vena cava.A male patient aged 44 years was admitted to the Eastern Hepatobiliary Surgery Hospital in November 2007.The ligaments around the liver were firstly dissected to mobilize the whole liver,and the right hepatic pedicle was dissected and ligated,then the liver was splited anteriorly along the Cantlie's line.The tumor was opposed in the sight and then it was dissected from the liver parenchyma.The short hepatic veins were ligated and the tumor was detached from the inferior vena cava.The inflow blood was occluded for 19 minutes,and the total blood loss was 4500 ml.The technique of retrograde caudate lobectomy can improve the success rate and safety of caudate lobectomy when the tumor in the caudate lobe is too large or adherent to the inferior vena cava.

Total caudate lobectomy via anterior hepatic transection / 中华消化外科杂志

Total caudate lobectomy via anterior hepatic transection is still a new technique to resect the tumor in the caudate lobe,which is mastered only by few surgeons.The procedure was successfully performed on a 21-year old patient with focal nodular hyperplasia in caudate lobe.The right and left lobes were first mobilized,then the short hepatic veins were dissected to detach the caudate lobe from the retrohepatic vena cava.Then the liver was split anteriorly and the partial middle lobe was resected.With this process,the tumor was in the sight and we dissected it from the liver parenchyma.The inflow blood was occluded 3 times with a period of 29,27 and 27 minutes,respectively,with an interval of 5 minutes.The total blood loss during operation was 1000 ml.The patient recovered quickly without any complications.The technique for caudate lobectomy via anterior hepatic transection can improve the success rate and safety of caudate lobectomy and deserve clinical consideration.

Some thoughts on the development of surgical pathology for hepatobiliary tumors / 中华肝胆外科杂志

Surgical-oncological pathology is one of the most important supporting discipline for hepatobiliary surgery.With rapid development in modern hepatobiliary surgery,the traditional model of morphological diagnosis can no longer meet the needs of oncological surgery.To improve the level of pathological diagnosis, better understand clinical concerns,update the mode of pathological diagnosis,introduce new technologies,expand the connotations of pathological diagnosis,provide a new indexing system for clinical treatment programs,and focus on interdisciplinary collaborative research are the most important issues in the development of surgical pathology for hepatobiliary tumors.

Laparoendoscopic rendezvous in cholecystocholedocholithiasis / 中华肝胆外科杂志

Cholecystocholedocholithiasis is a common disease. The traditional treatment is open surgery which has its inherent invasiveness and slow recovery. The advent of laparoscopic and endoscopic techniques change surgery in many ways. Laparoscopic cholecystectomy is now the gold standard for cholecystitis, while endoscopic procedure is a treatment of choice for choledocholithiasis. To combine them as a laparoendoscopic rendezvous procedure treats cholecystitis and choledocholithiasis in a single stage, and results in a safe, effective and minimal invasive procedure.

Hepatic vein occlusion in hepatectomy for liver tumor involving second hepatic hilum / 中华消化外科杂志

Hepatic vein hemorrhage and air embolism are easily caused during the resection of the tumor involving the second hepatic hilum.Hepatic vein occlusion has been proven to decrease this risk,while classic selective hepatic vein occlusion with tourniquet is technique demanding.We modified the classic method by using Satinsky clamp in hepatic vein dissection and occlusion.Based on the clinical data of 220 patients who received hepatic vein occlusion with tourniquet and 330 patients with Satinsky clamp,we proved that hepatic vein occlusion with Satinsky clamp is simpler,safer and with high success rate.