Hepatic resection: an analysis of the impact of operative and perioperative factors on morbidity and mortality rates in 2008 consecutive hepatectomy cases / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Hepatectomy is a standard hepatic surgical technique. The safety of hepatectomy has been improved in line with improvements in surgical techniques. This study analyzed the operative and perioperative factors associated with hepatectomy.</p><p><b>METHODS</b>A total of 2008 patients who underwent consecutive hepatectomies between January 1986 and December 2005 were investigated retrospectively. Diagnoses were made based on pathological findings.</p><p><b>RESULTS</b>Malignant and benign liver diseases accounted for 58.5% and 41.2%, respectively, of the conditions requiring resections. Primary liver cancers accounted for 76.1% of the malignant tumors, while hilar cholangiocarcinomas accounted for 6.7%. Hemangiomas (41.7%) and hepatolithiasis (29.6%) were the most common of the benign conditions. Microwave in-line coagulation was used in 236 of our liver resection cases. The overall postoperative complication rate was 14.44%, of which 12.54% of resections were performed for primary liver cancer, 16.40% for secondary liver cancer, and 16.32% for hepatolithiasis. The overall hospital mortality was 0.55%, and that for malignant liver disease was 0.51%. A high mortality (2.53%) was associated with extensive liver resections for hilar cholangiocarcinomas (two deaths in 79 cases). Microwave in-line pre-coagulation resection, Child-Pugh grading, operating time, postoperative length of stay, and preoperative serum albumin level were independent predictors of morbidity. Blood loss, Child-Pugh grading, operating time and preoperative serum albumin level were independent predictors of mortality.</p><p><b>CONCLUSIONS</b>Hepatectomy can be performed safely with low morbidity and mortality, provided that it is carried out with optimal perioperative management and innovative surgical techniques.</p>

Liver resection: single center experiences of 2008 consecutive resections in 20 years / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze operative and perioperative factors associated with hepatectomy.</p><p><b>METHODS</b>2008 consecutive patients undergoing hepatectomy from January 1986 to December 2005 at Chinese People's Liberation Army General Hospital were investigated retrospectively according to their medical documentation. Diagnoses were made on basis of pathological results.</p><p><b>RESULTS</b>Malignant and benign liver diseases accounted for 58.5% and 41.2%, respectively. In the former, primary liver cancer accounted for 76.1% and hilar cholangiocarcinoma for 6.7%. Hemangioma (41.7%) and hepatolithiasis (29.6%) were listed in the first two in the latter group with relatively more patient ratios. Isolated caudate lobe resection was performed in 25 patients and micro-wave inline coagulation was induced in 236 cases of liver resection. In all cases, those with blood loss less than 200 ml accounted for 50.5% (1015/2008), whereas those with more than 400 ml accounted for 28.4% (570/2008). In patients performed micro-wave inline coagulation liver resection, those with blood loss less than 200 ml and more than 400 ml accounted for 60.6% (143/236) and 19.9% (47/236), respectively, which differed significantly from the average level (P < 0.05). The postoperative complication incidence was 14.44% for all cases, 12.54% for primary liver cancer, 16.40% for secondary liver cancer, and 16.32% for hepatolithiasis. Complication incidence of primary liver cancer with tumor size smaller than 5 cm was 11.65% and that with tumor larger than 10 cm was 14.69%. There was no significant difference between the two groups. All-case hospital mortality was 0.55% and that for liver malignant disease was 0.60%, hilar cholangiocarcinoma 2.53%.</p><p><b>CONCLUSION</b>Hepatectomy can be performed safely with low mortality and low complication incidence, provided that it is carried out with optimized perioperative management and innovative surgical technique.</p>

Clinical analysis of 110 patients with primary gallbladder carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the clinical characteristics of primary gallbladder carcinoma.</p><p><b>METHODS</b>The data of clinical manifestations, image characteristics, diagnosis and treatment of 110 patients with primary gallbladder carcinoma were analyzed.</p><p><b>RESULTS</b>The rate of diagnosis as early primary gallbladder carcinoma was only 8.2% (9/110) in this series. The majority of the patients were females (63/110) with an age ranging from 31 to 80 years. Clinical manifestations were not specific, and diagnosis was made mainly on image examination. Radical resection was performed for 57 patients, palliative resection for 41, the rest 12 patients failed to receive operation on reasons of distant metastasis, age or other reasons. Only 88 patients were followed with a mean survival time of 196 days ranging from 15 days to 5 years and 11 months.</p><p><b>CONCLUSION</b>The primary gallbladder carcinoma is quite difficult to diagnose at the early stage, and its prognosis is usually poor. The diagnosis is made mainly depending on the medical history and image examinations.</p>

Surgical treatment of 402 consecutive cases for hilar cholangiocarcinoma: Chinese single center experience / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze clinical typing, pathologic characteristics of hilar cholangiocarcinoma (HCCA) and surgical strategies and their effects on HCCA, and to explore the factors that influence the surgical outcomes and long-term survival.</p><p><b>METHODS</b>The data of the 402 patients with HCCA admitted between January 1993 and December 2004 was investigated retrospectively. Primary outcomes examined included clinical typing, pathologic characteristics, surgical procedures and follow-up results. On the basis of Bismuth-Corlette typing, we defined the tumor originated from intrahepatic large bile duct (LBD) as type V (type Va and Vb).</p><p><b>RESULTS</b>Among the 402 patients with HCCA, 198 cases accepted curative resection, 102 (51.5%) for radical resection and 96 (48.5%) for palliative resection. Of the rest patients, 8 received orthotopic liver transplantation (OLT), 161 received simple drainage and 35 were not operated on. The resection rates for type I, II, IIIa, IIIb, IV, Va and Vb were 69.4%, 55.5%, 57.4%, 71.7%, 19.6%, 100% and 34.6%, respectively. The one-year survival rates for radical resection, palliative resection, simple drainage and untreated were 80.3%, 53.2%, 26.7% and 9.8%, respectively. And the three-year and five-year survival rates in the four groups were 41.9% and 33.3%, 19.6% and 14.7%, 3.3% and 0, 0 and 0, respectively. Significant difference was found in survival rates between the radical and palliative resection. In the patients who received tumor resection, the ones without lymph nodes metastasis (LNM) survived much longer than those with LNM (P < 0.05). Complications were found in 36.1% of the patients and the mortality rate was 0.3%.</p><p><b>CONCLUSIONS</b>HCCA type V originated from intrahepatic LBD has higher resection rate and better prognosis. The tumor differentiation is significantly correlated with the prognosis after operation. With HCCA, resection is still the major treatment selection. Curative resection carries the best effect. Extended radical resection of liver lobes, blood vessels, lymph nodes can prolong survive. The problem of high recurrence rate after OLT for HCCA has not been solved yet.</p>

Experience of diagnosis and treatment of carcinoma arising from congenital biliary duct cyst / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience in diagnosis, prevention and treatment of carcinoma arising from congenital biliary duct cyst.</p><p><b>METHODS</b>The clinical and pathological data of 185 patients with congenital biliary duct cyst admitted to Chinese PLA General Hospital were analyzed retrospectively.</p><p><b>RESULTS</b>Among 185 patients, twenty-seven cases had carcinomas arising from congenital biliary duct cyst, and the frequency of malignant transformation was 14.6%, which closely related to the age (P < 0.001). The incidences of malignancy for different age groups were: 0 for 0-9 age group, 5.1% for 0-19, 9.1% for 20-29, 16.2% for 30-39, 26.7% for 40-49, 33.3% for 50-59, and 50% for over 60, respectively. Six patients had the history of cyst-enterostomy. Abdominal pain, fever, jaundice and weight loss were the main clinical manifestations. Abdominal ultrasonography, CT, MRI or magnetic resonance cholangiopancreatography, MRCP and endoscopic retrograde choledochopancreatography (ERCP) were the main diagnostic methods. For twenty patients (74.1%), a definite diagnosis was made preoperatively, but it's hard to make an early diagnosis. Nine patients (33.3%) underwent curative resection.</p><p><b>CONCLUSIONS</b>Congenital biliary duct cyst is a premalignant lesion, and the incidence of carcinogenesis increases remarkably with age. The most effective method for prevention of carcinogenesis in choledochal cyst is complete excision of choledochal cyst during childhood, and the prognosis is poor for patients with biliary malignancy.</p>

Protective effects of lidocaine injected into the hepatoduodenal ligament on warm ischemia-reperfusion injury to the rat liver / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Ischemia-reperfusion (IR) injury to the liver is still a critical and daunting problem in the field of hepatobiliary surgery. Ischemic preconditioning (IP) of the liver serves as an effective approach against IR injury. This study was to develop a novel procedure that could mimic IP, but might be more feasible than IP during surgery.</p><p><b>METHODS</b>Eighty-two SD rats were randomly divided into 5 groups. L group (n = 21): 0.4% lidocaine (10 mg/kg) was injected into the hepatoduodenal ligament 10 minutes before a 40-minute hepatic IR. IP group (n = 16): a 5-minute ischemia was followed by a 10-minute reperfusion prior to a 40-minute hepatic IR. ILR group (n = 15): after a 40-minute ischemia of the liver, 0.4% lidocaine (10 mg/kg) was injected into the hepatoduodenal ligament 10 minutes prior to a 40-minute reperfusion of the liver. IR group (n = 15): the liver of the rat was subjected to a 40-minute IR. Control group (n = 15): 0.9% sodium chloride was injected into the hepatoduodenal ligament without other treatments. The levels of plasma alanine transaminase (ALT) and aspartate transaminase (AST) were determined for each group after treatment.</p><p><b>RESULTS</b>The mean concentrations of ALT and AST were (379.80 +/- 141.69) U/L and (606.05 +/- 220.26) U/L for the L group, (334.64 +/- 141.94) U/L and (625.68 +/- 267.06) U/L for the IP group, (523.36 +/- 170.35) U/L and (765.47 +/- 238.45) U/L for the ILP group, (524.29 +/- 163.59) U/L and (764.63 +/- 246.79) U/L for the IR group, and (150.90 +/- 27.05) U/L and (298.15 +/- 47.68) U/L for the control group (standard error of the mean).</p><p><b>CONCLUSION</b>A significant decrease in ALT and AST levels was observed in the L and IP groups when compared to the ILR and IR groups (P < 0.05), but no significant difference in ALT and AST levels was observed in the L group when compared to the IP group (P > 0.05). These results suggest that pretreatment with lidocaine injected into the hepatoduodenal ligament prior to IR provides effective protection against subsequent IR injury to the liver. The novel approach of blocking innervation with lidocaine mimics hepatic IP, but is more convenient than IP at the time of liver surgery.</p>

An inquiry into blood loss in laparoscopic liver resections / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the potential causes and preventive measures for blood loss in laparoscopic liver resection.</p><p><b>METHODS</b>The candidates for laparoscopic liver resections were 21 patients with liver lesions, including 13 patients with primary liver cancer, 2 patients with liver abscess, 3 patients with liver hemangioma, 1 patient with hepatic cellular adenoma, 1 patient with hepatic focal nodular hyperplasia, and 1 patient with infected liver cyst. They were classified as Child A in 16 and B in 5 patients.</p><p><b>RESULTS</b>Twenty-one patients with liver lesions underwent 23 laparoscopic resections uneventfully. Operating procedures included partial liver resection in 12 patients, segment IV in 1 case and anatomical left liver resections in 8 patients. Operation duration was 80 - 320 (mean 193.8 +/- 78.3) minutes. The blood loss in operation was 100 - 1000 (mean 333.1 +/- 291.4) ml. The postoperative hospital stay averaged 6.3 +/- 1.5 days, which was markedly shortened in comparison to conventional laparotomy liver resections. In addition, there was no complication in this series.</p><p><b>CONCLUSIONS</b>Based on these preliminary results, occlusion of hepatic vessels with clamp is very important for partial liver resection. The key technique is to control the blood loss in operation. We conclude that laparoscopic liver resection is a prospective minimally invasive technique. These experiences suggest that laparoscopic procedures could be employed both in the treatment of benign and malignant tumors in selected cases.</p>