Value of neutrophil-to-lymphocyte ratio in the diagnosis and prognosis evaluation of primary hepatocellular carcinoma / 肿瘤研究与临床

Objective:To investigate the value of neutrophil-to-lymphocyte ratio (NLR) in the diagnosis and prognosis evaluation of primary hepatocellular carcinoma.Methods:The clinical data of 100 patients pathologically diagnosed as primary liver cancer who were admitted to the First Medical Center of Chinese PLA General Hospital from January 2013 to December 2015 were retrospectively analyzed. Serum alpha fetoprotein (AFP), a conventional marker for hepatocellular carcinoma diagnosis was used as the control. The fourfold table diagnostic test was applied to analyze the sensitivity and specificity of serum NLR in the diagnosis of hepatocellular carcinoma, and the correlation with the degree of tumor differentiation was also analyzed.Results:The proportion of patients with high NLR (≥1.70) [56% (56/100)] was higher than the proportion of patients with positive AFP [44% (44/100)] in all 100 hepatocellular carcinoma patients, but the difference was not statistically significant ( χ2 = 2.88, P = 0.08). Among AFP-positive patients, the median survival time of patients with low and high NLR was 59 and 48 months, respectively, and the difference was statistically significant ( χ2 = 3.91, P = 0.048), and high NLR was an independent risk factor affecting the prognosis of hepatocellular carcinoma patients ( HR = 1.232, 95% CI 1.055-1.438, P = 0.008). Conclusions:The detection of NLR combined with AFP can improve the diagnostic rate of hepatocellular carcinoma before surgery. High NLR is an independent risk factor affecting the prognosis of patients with primary hepatocellular carcinoma.

Experiences in clinical management of Abernethy malformation combined with focal nodular hyperplasia / 中华肝胆外科杂志

Objective:To summarize clinical experience in the management of Abernethy malformation combined with focal nodular hyperplasia (FNH).Methods:Three patients with Abernethy malformation combined with FNH who were managed in the Department of Hepatobiliary Surgery, the First Medical Center of Chinese PLA General Hospital from January 2010 to December 2018 entered into this study. There were one male aged 35 years and two females aged 21 years and three years and nine months, respectively. Patients underwent digital subtraction angiography (DSA) with balloon dilation, shunt vasulature ligation, portal vein (PV) pressure measurement and other investigations were performed to study the changes of PV pressure before and after treatment.Results:DSA indicated that the congenital portal shunt of the patients was Abernethy deformity Ⅱ and Ⅰb, respectively, and with combined FNH diagnosed preoperatively. One patient was admitted to hospital for partial hepatectomy 5 years ago for the treatment of FNH, which presented with recurrent abdominal pain. The PV pressure increased from 8.5, 9.0, 20.0 cmH 2O(1 cmH 2O=0.098 kPa) to 15.0, 21.0, 25.0 cmH 2O after portal cavity shunt vasculature/portal vein ligation and splenic artery ligation/portal body shunt ligation, respectively. The PV blood flow into the liver increased, and DSA suggested shunt vessel occlusion. On follow-up, all patients survived well. Conclusion:Ligation or constriction of shunt vessels significantly improved the flow of PV into liver in Abernethy malformation patients with FNH. The treatment benefited long-term survival.

Diagnosis and treatment of iatrogenic biliary tree destruction / 中华消化外科杂志

Objective To summarize the clinicopathological characteristic,diagnosis and treatment of iatrogenic biliary tree destruction.Methods The retrospective cross-sectional study was conducted.The clinical data of 11 patients with iatrogenic biliary tree destruction who were admitted to the Chinese PLA General Hospital (9 patients) between January 1990 and December 2013 and Beijing Tsinghua Changgung Hospital (2 patients) between December 2014 and May 2017 were collected.Observation indicators:(1) causes and parts of destruction;(2) clinical manifestation;(3) imaging performance;(4) treatment;(5) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect long-term prognosis of patients up to April 2018.Measurement data with skewed distribution were described as M (range).Results (1) Causes and parts of iatrogenic biliary tree destruction:causes of iatrogenic biliary tree destruction in 11 patients:transcatheter arterial embolization for hepatic hemangioma was performed in 7 patients,high intensity focused ultrasound for hepatic hemangioma in 1 patient,arterial embolization for false aneurysm in 1 patient,sclerosant injection for hepatic echinococcosis in 1 patient,and cyberknife radiotherapy for hepatocellular carcinoma in 1 patient.Parts of biliary tree destruction of 11 patients:5,3,2 and 1 respectively involved bilateral biliary tree,right biliary tree,bilateral main biliary ducts in hepatic port and left biliary tree.(2) Clinical manifestation:11 patients had symptoms of recurrent chills and fever,and combined with different degrees of jaundice.The initial symptom occurred in 2 weeks to 3 months after iatrogenic biliary tree destruction.Of 11 patients,7 were complicated by different degrees of hepatic abscess,and abscess involving left and right half liver were detected in 4 patients,aggregating in right half liver in 2 patients and aggregating in left half liver in 1 patient.Eight patients had secondary biliary cirrhosis,portal hypertension,splenomegaly and hypersplenism during the late course of disease.(3) Imaging performance:magnetic resonanced cholangio-pancreatography (MRCP) and cholangiography examinations showed missing bile duct in necrosis area,beading-like stricture and dilation of damaged biliary tree,reducing proximal bile duct branches and associated gallbladder necrosis.CT and MRI examinations showed that structure of distribution area of damaged biliary tree disappeared or bile duct wall was thickened,and hepatic abscesses of patients were scattered and multiple.Five patients had significantly secondary liver atrophy-hypertrophic syndrome,showing atrophy of right liver and hyperplasia of left liver.Radiotherapy-induced biliary tree destruction showed a characteristic of continued progress,localized abnormality in the early stage and typical imaging changes after the damage stability in the late stage.(4) Treatment:of 11 patients,4 didn't undergo surgery,and 7 underwent 18 intentional and conclusive surgeries (1-4 times / per case).(5) Follow-up:11 patients were followed up for 2-132 months,with a median time of 73 months.During the follow-up,2,1 and 8 patients had respectively excellent,good and poor prognoses.Among 11 patients,4 died (2 died of severe infection and 2 died of biliary cirrhosis),and 7 survived.Conclusions Iatrogenic biliary tree destruction is easy to cause hepatic abscess,liver atrophy-hypertrophic syndrome or biliary cirrhosis,and it can be diagnosed by imaging examination.The definitive treatment should be followed by liver resection or liver transplantation of involving area according to the extent of damage.

ALPPS may be an effective method for the treatment of low future liver remnant HCC patients with portal vein tumor thrombus / 国际外科学杂志

Objective To provide the practical experience of association of liver partition and portal vein ligation for staged hepatectomy(ALPPS) procedure in portal vein tumor thrombosis(PVT) cases,and to explore its value in PVTT therapy.Methods Three cases of ALPPS were applied to PVTT in Department of Hepatobiliary Surgery of PLA General Hospital from 2015 to 2016.The patients data were retrieved and analyzed retrospectively,including the basic information,preoperative PVTT classification,preoperative Child-Pugh classification,ICG test results,future liver remnant (FLR),FLR growth rate between 2 phase operation,operation time,bleeding volume,postoperative complications,postoperative survival etc.We discussed the detail technology and discuss the surgical procedure combine our experience and the published papers.Results ALPPS was performed successfully in all 3 patients.According to the Cheng's Classification of PVTT,they were classified as type Ⅱ,1 case and Ⅲ type,2 cases.Preoperative liver function was Child-Pugh A grade,average ICG R15 was 7.3％ (4.2％-11.0％),and average FLR was 387 ml (333-484 ml).The mean time interval between 2 phases surgery was 24.7 days (9-50 days) and the average FLR growth rate was 50.3％ (24.4％-82.3％).Morbidity of Clavien-Dindo Ⅲ or more was recorded in 1 case,but no mortality occurred.During follow-up period,2 patients were treated with TACE for tumor recurrence.All patients survived with acceptable life quality till now.The portal vein tumor thrombosis necrosis was observed in all 3 specimens.Conclusions ALPPS is a valuable surgery for effective control of tumor thrombus and radical resection rate in well selected PVVT type Ⅱ and type Ⅲ patients.It is expected to improve the therapeutic effect in combination with TACE and other treatment methods.

Clinical efficacies of different surgical palliative treatments for advanced pancreatic carcinoma / 中华肝胆外科杂志

Objective To study the clinical efficacies of different surgical palliative treatments for patients with advanced pancreatic carcinoma.Methods A retrospective analysis was conducted on the clinical data of 119 patients with advanced pancreatic carcinoma who were treated in the department of General Surgery of Linyi's Central Hospital from January 2010 to January 2016.According to the different surgical methods the patients received,they were divided into the seed group (n =38),the radiofrequency ablation (RF) group (n =52) and the control group (n =29).Patients' general data,operation data,postoperative complications and follow-up profiles were analyzed.Results There was no significant difference in the patients'general data among the three groups of patients (P ＞ 0.05).The incidences of postoperative complication in the seed group,the RF group and the control group were 55.3％,38.5％ and 20.7％,respectively.There was significant differences between the incidences of postoperative complications between the seed group and the control group (P ＜ 0.05).There was no perioperative death.The postoperative follow-up rate was 91.6％.Pain in the seed group and the RF group significantly improved,while it was not significantly improved in the control group.There were significant differences in the postoperative pain scores (P ＜0.05).The 6 months,1-year and 2-year overall survival rates were 61.3％,25.9％,8.6％ respectively.The median survival was 8 months.In the seed group,the 6 months,1-year and 2-year survival rates were 75.2％,37.8％,18.9％ respectively.The median survival was 9 months.In the RF group,the 6 months,1-year and 2-year survival rates were 60.4％,25％,6.3％ respectively.The median survival was 8 months.In the control group,the 6 months,1-year and 2-year survival rates were 53.4％,15.3％,3.8％ respectively.The median survival was 6.5 months.On log-rank test,there was no significant difference in survival rates among the three groups (P =0.145).Conclusions Patients with advanced pancreatic carcinoma had poor prognosis.I125 radioactive particles implantation and radiofrequency ablation were useful to improve patients'quality of life and prolonged their survival.

"Stepping into the ""segment"" era of the biliary surgery" / 中华消化外科杂志

Due to the theoretical and technique limitation of traditional surgery,surgical treatment of complex intrahepatic biliary diseases was left for an unresolved difficult problem of the last century.Uncertainties of the anatomical,physiological,pathological changes and surgical techniques in the intrahepatic biliary tract contribute to this complexity.Through integrated application of modern scientific technology and traditional medicine methods and systematic optimization and innovation of biliary surgical theories and techniques,authors have developed a paradigm of precision biliary surgery which is characterized by high quantification,visualization and controllability.The establishment of the precise biliary surgical system solves the difficulty in surgeries for intrahepatic biliary diseases,puts forward the biliary surgery from extrahepatic ducts,hilar ducts to intrahepatic ducts,entering a new segment era of the biliary surgery marked by precision treatment of intrahepatic biliary diseases.

Relationship between diameter of liver hemangioma and operation risk / 中华消化外科杂志

Objective To explore the relationship between diameter of liver hemangioma and operation risk.Methods The clinical data of 362 patients with liver hemangioma who were admitted to the PLA General Hospital from January 2006 to January 2014 were retrospectively analyzed.All patients were divided into the 3 groups according to diameter of gross specimen,217 with tumor diameter≥5 cm and ≤ 10 cm in the large hemangioma group,119 with tumor diameter ＞ 10 cm and ≤20 cm in the giant hemangioma group and 26 with tumor diameter≥20 cm in the extremely large hemangioma group.The operation method included open surgery and laparoscopic surgery.Hepatectomy and enucleation of liver hemangioma were major operation procedures.The operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion,number of patients with postoperative complications and duration of hospital stay were evaluated.Count data were analyzed using the chi-square test.Measurement data with normal distribution were presented as (x) ± s,and comparison among groups was analyzed using the ANOVA.Skewed distribution data were described as M (P25,P75),comparison among groups was analyzed by Kruskal-wallis test and pairwise comparison was done by the MannWhitney U test.Results All patients underwent operation successfully without perioperative death,including 315 receiving open surgery (175 in the large hemangioma group,114 in the giant hemangioma group and 26 in the extremely large hemangioma group) and 47 receiving laparoscopic surgery (42 in the large hemangioma group and 5 in the giant hemangioma group).The operation time,volume of intraoperative blood loss,number of patients with blood transfusion,number of patients with postoperative complications and duration of hospital stay were 160 minutes (125 minutes,205 minutes),300 mL (100 mL,500 mL),31,5 and 8 days (7 days,9 days) in the large hemangioma group,220 minutes (175 minutes,275 minutes),500 mL (300 mL,1 000mL),36,5 and 9 days (8 days,10 days) in the giant hemangioma group,330 minutes (280 minutes,420 minutes),1 975 mL (800 mL,4 000mL),20,7 and 11 days (9 days,13 days) in the extremely large hemangioma group,respectively,with significant differences (x2 =84.24,80.94,53.65,31.54,47.67,P ＜ 0.05).The operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion and duration of hospital stay were compared,showing significant differences between large hemangioma group and giant hemangioma group (Z =6.39,6.51,x2 =11.29,Z =4.73,P ＜ 0.05),with significant differences between large hemangioma group and extremely large hemangioma group and between giant hemangioma group and extremely large hemangioma group (Z =7.28,6.91,x2=51.22,Z =5.57,P ＜ 0.05;Z =5.33,4.86,x2=17.69,Z =3.5 1,P ＜ 0.05).Seventeen patients had postoperative complications with an incidence of 4.70％ (17/362),intra-abdominal hemorrhage were detected in 7 patients,perihepatic effusion in 4 patients,pleural effusion in 3 patients,bile leakage in 2 patients and fat liquefaction of abdominal incision in 1 patient.There was no significant difference in the number of patients with postoperative complications between large hemangioma group and giant hemangioma group (x2 =0.41,P ＞ 0.05).There were significant differences in the number of patients with postoperative complications between large hemangioma group and extremely large hemangioma group and between giant hemangioma group and extremely large hemangioma group (x2 =24.96,11.67,P ＜ 0.05).Conclusions Diameber of liver hemangioma is associated with operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion,number of patients with postoperative complications and duration of hospital stay,and there is a high risk in the surgical treatment of patients with liver hemangioma diameter≥20 cm.

Surgical management of giant hemangioma of the liver: enucleation versus hepatectomy / 中华普通外科杂志

Objective To compare the outcomes of giant hepatic hemangioma undergoing enucleation and hepatectomy and to summarize our experience of surgical management of liver hemangioma.Methods A retrospective study was conducted in patients undergoing giant hepatic hemangioma resection (lager than 10 cm in size) in General Hospital of PLA,during 2006 through 2014.Patients were divided into two groups according to the types of operation.Results Of 145 patients with giant liver hemangioma,81 underwent enucleation and 64 had hepatectomy.The differences of tumor size (12.0 cm vs.15.5 cm,u =3.68,P ＜0.01),time of operation (210 min vs.280 min,u =3.89,P ＜ 0.01) and the ratio of inflow control (81.5％ vs.56.3％,x2 =10.91,P ＜ 0.01) of enucleation and hepatectomy was significant.The difference of intraoperative blood loss (500 ml vs.800 ml,u =1.85,P =0.07) and the postoperative morbidity (8.6％ vs.7.8％,x2=0.03,P =0.86) was not statistically significant.There was no inhospital mortality in both groups.Conclusions Both of enucleation and hepatectomy are effective operative approaches for giant liver hemangioma,patients with liver hemangioma should be prudently chosen for surgery,and the operation type should be individualized with the guidance of precision liver surgery.

Clinical application of precise liver surgery techniques for donor hepatectomy in living donor liver transplantation / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of techniques of precise liver surgery for donor hepatectomy in living donor liver transplantation.</p><p><b>METHODS</b>Eighty-nine donors aged from 19 to 57 years were performed by the same surgical team from June 2006 to December 2013 in Chinese People's Liberation Army General Hospital.Individualized surgical program were developed according to preoperative imaging examination and hepatic functional reserve examination. The evaluation included liver function, liver volume, vascular anatomy and bile duct anatomy. According to the results after the operation, preoperative evaluation accuracy, postoperative donor liver function and postoperative complications were analyzed. ANOVA analysis was used to compare the difference of graft volume by two-dimensional, three-dimensional calculation method and actual postoperative graft weight. Pearson correlation test and linear regression analysis were used to verify the correlation between the estimated graft volume each method and actual graft postoperative weight.</p><p><b>RESULTS</b>All the 89 cases operation protocol as following, there were 5 cases with left lateral lobe graft, 10 cases with left lobe liver graft, 74 cases with right lobe graft. There were 59 cases with middle hepatic vein (MHV) harvested, and 30 cases without MHV. The mean graft volume by two-dimensional, three-dimensional calculation method and actual postoperative graft weight were (656.2±134.1) ml, (631.7±143.2) ml and (614.5±137.7) ml respectively. ANOVA analysis results showed that there were no statistically significant difference in the three methods (P>0.05). Compared to the actual postoperative graft weight, the average error rate of the two methods were 7.9% and 5.3% respectively. Pearson correlation test showed the graft volume calculated by two-dimensional and three-dimensional methods had a significantly positive correlation with actual graft weight (r=0.821, 0.890, P<0.01) and linear regression analyze showed the R2 were 0.674 and 0.792, respectively. The accuracy rate of preoperative evaluation about portal vein, hepatic vein, hepatic artery and bile duct were 100%, 100%, 97.8% and 95.5%, respectively. The preoperative plan and postoperative practical scheme coincidence rate was 95.5%. Overall donor complication rate was 7.4%. All donors were alive. Sixteen donors received right lobe hepatectomy with gallbladder preserved had a good liver function and gallbladder function.</p><p><b>CONCLUSION</b>Through the precise preoperative evaluation, surgical planning, fine operation and excellent postoperative management, precise liver surgery technique can ensure the safety of donor in living donor liver transplantation.</p>

Clinical evaluation of liver stiffness by acoustic radiation force impulse imaging in patient with ischemic type biliary lesion after orthotopic liver transplantation / 中华医学超声杂志（电子版）

Objective To study the clinical value of acoustic radiation force impulse imaging (ARFI) in patients with ischemic type biliary lesion (ITBL) after orthotopic liver transplantation. Methods Between July 2012 to January 2013, forty-one patients in General Hospital of the People′s Liberation Army were enrolled in this study who were admitted for post-transplantation follow-up. Among them, 15 patients were diagnosed as ITBL by ultrasonography. Besides conventional ultrasonography, ARFI was used to detect the shear wave velocity (SWV) of liver tissue at depth of 4 cm and 5 cm respectively. Simultaneously liver function test was performed. Independent-samples t test was performed to compare the difference of SWV between ITBL and non-ITBL group at the same depth. Paired-sample t test was performed to compare the difference of SWV for the same ITBL patient. Pearson correlation analysis was used in analyzing the relation between SWV and liver function. Results The average SWV in depth of 4 cm was (1.561±0.425) m/s and (1.121±0.160) m/s in ITBL and non-ITBL group, respectively. Signiifcant differences were found among the ITBL and non-ITBL groups (t=-3.173, P=0.01). The average SWV in depth of 5 cm was (1.608±0.545) m/s and (1.175±0.173) m/s in ITBL and non-ITBL group, respectively. Signiifcant differences were found among the ITBL and non-ITBL groups (t=-2.454, P=0.034). There was no signiifcant difference between SWV measurements at different depth for the same ITBL patient. For all patients, SWV at different depths were both strongly correlated with alkaline phosphatase (r=0.656, 0.667, respectively;both P=0.000) andγ-glutamyl transpeptidase (r=0.482, P=0.007;r=0.508, P=0.004). Conclusion The liver stiffness measurement is valuable for the clinical evaluation of post-transplantation ITBL.

Liver transplantation for irresectable hilar cholangiocarcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the outcome of patients with irresectable hilar cholangiocarcinoma undergoing orthotopic liver transplantation (OLT) and to identify the prognostic factors that could influence survival.</p><p><b>METHODS</b>The data of 18 patients who underwent OLT for irresectable hilar cholangiocarcinoma between June 2003 and October 2010 were analyzed retrospectively. There were 12 male and 6 female cases with median of 52 years(range from 34 to 65 years).Fifteen patients underwent modified piggyback liver transplantation, 2 patients underwent classical orthotopic liver transplantation and 1 patient underwent living donor liver transplantation. Data were evaluated regarding tumor size, pathologic stage, overall survival, recurrence rates and prognostic factors.</p><p><b>RESULTS</b>OLT with lymphadenectomy was received by 18 patients with hilar cholangiocarcinoma. Median time until tumor recurrence was 20.5 months(range from 6.0 to 33.0 months). Seventeen patients died during follow-up.Of these, 14 patients died from recurrent or metastatic diseases, 2 patients died from multiple organ dysfunction syndrome during peri-operative period, and one patient died from other cause. The median survival time was 29.5 months(range from 3.0 to 84.0 months). The overall survival rate and recurrence-free survival rate at 1, 3, and 5 year were 16/18, 8/18, 1/18 and 13/18, 2/18, 1/18, respectively.Lymph node metastases had a statistically significant negative impact on overall survival. The 1, 3, and 5 year survival rates were 6/7, 1/7,0 and 10/11, 7/11, 1/11 (P < 0.05) in lymph node-positive and lymph node-negative patients.</p><p><b>CONCLUSIONS</b>Acceptable survival rates can be achieved by OLT for irresectable hilar cholangiocarcinoma without lymph node metastases.Strict patient selection plus multimodal chemoradiation therapy prior to OLT are recommend for patients with lymph node metastases.</p>

Optimizing plan for right lobe living donor hepatectomy based on the territorial volume drained by the middle hepatic vein / 中华普通外科杂志

Objective To optimize plan for right lobe living donor hepatectomy based on the territorial volume drained by the middle hepatic vein (MHV) as shown by preoperative MR image in donors.Methods Utilizing preoperative MR dynamic enhancement scanning image,virtually plot three types of hepatic parenchyma transsection plane based on the variation of including MHV for right lobe graft procurement. Results From June 2006 to May 2010,65 adult-to-adult right lobe living donor liver transplantations was performed at General Hospital of Chinese PLA,in which there were 43 grafts including MHV (66.2％,43/65 ), eight grafts including partial MHV which was dissected before the V4b abouchement ( 12.3％,8/65) and 14 grafts not including MHV (21.5％,14/65). There was no postoperative death in donors and the postoperative complications developed in 10.76％ (7/65). The recipients' perioperative mortality was 7.69％ (5/65). Ttwenty-one complications developed in 18 recipients,and the morbidity was 32.31％. The cumulative survival rates were 86％,77％ and 68％respectively for 1,2 and 3 years. Conclusions The optimizing liver resection plane could be practically designed preoperatively for right lobe graft procurement based on the territorial volume drained by MHV.

Application of a computer-assisted operation planning system in curative hepatectomy for complex hilar cholangiocarcinoma / 中华消化外科杂志

ObjectiveTo evaluate a computer-assisted operation planning system in curative hepatectomy for complex hilar cholangiocarcinoma.MethodsThe clinical data of 15 patients with complex hilar cholangiocarcinoma who were admitted to the Chinese PLA General Hospital from January 2008 to December 2009 were retrospectively analyzed.Based on triple-phase contrast-enhanced computed tomography inages,a computer-assisted operative planning system was used to evaluate the anatomic relationship between the tumor and its adjacent vessels,liver volume,operative feasibility,and the potential surgical approaches.The accuracy of three-dimensional reconstruction was tested by comparison to actual intraoperative findings.The correlation between actual liver resection volumes and predicted liver resection volumes was analyzed by calculating a Pearson correlation coefficient.Differences in liver volumes calculated by two-dimensional techniques versus three-dimensional reconstruction were analyzed using the paired t test,and the error rate was compared using the chi-squarc test. Results Fifteen patients received curative hepatectomy,including extended hemihepatectomy in 8 patients and trisectionectony in 7 patients.Preoperative evaluation of the hepatic anatomy based on three-dimensional reconstruction imaging was confirmed with operative findings.The sensitivity,specificity and accuracy rates were 100.0％,72.7％ and 72.7％ for patients with portal invasion and 100.0％,78.6％ and 78.6％ for patients with hepatic arterial invasion,respectively.The actual liver resection volume was positively correlated with the predicted liver resection volume ( r =0.974,P ＜ 0.05 ).The mean liver volumes calculated by the three-dimensional reconstruction and the two-dimen-sional techniques were (458 ±86)ml and (491 ± 103 )ml,respectively,with no significant difference (t =-1.911,P ＞0.05 ).The error rates of the three-dimensional reconstruction and the two-dimensional techniques were 4.7％ and 7.2％,respectively,with no significant differnece ( x2 =2.381,P ＞ 0.05 ).Five patients had postoperative complications,and each was cured with conservative or interventional management. Conclusion The application of a computer-assisted operation planning system may improve the safety and accuracy of curative resection for complex hilar cholangiocarcinoma.

Living donor liver transplantation for hepatocellular carcinoma / 中华器官移植杂志

Objective To evaluate the outcome of living donor liver transplantation(LDLT)for hepatocellular carcinoma(HCC).Methods We retrospectively analyzed the clinical data of 180 patients,who had received LDLT(n=34)or deceased donor liver transplantation(DDLT,n=146)for HCC,compared overall and recurrence-free survival between LDLT and DDLT,and identified the risk factors of tumor recurrence and prognosis by univariate and multivariate analysis.Results The 5-year overall survival and recurrence-free survival rate were 53 % and 58 %,respectively,in DDLT group,and 60 % and 60 %,respectively,in LDLT group.There was no significant difference in overall (P=0.85)and recurrence-free(P=0.89)survival between these two groups.The tumor recurrence rate was 26.5 % in LDLT group,and 17.8 % in DDLT group,respectively(P=0.25).Multivariate COX regression model analysis identified vascular invasion(relative risk 2.118,95 % confidential interval 1.201-4.353,P=0.032)and tumor beyond UCSF criteria(relative risk 3.490,95 % confidential interval 1.862-8.207,P=0.015)as independent risk factors of tumor recurrence,and tumor beyond UCSF criteria(relative risk 8.573,95 % confidential interval 3.016-18.261,P=0.006)as independent predictors of prognosis.Conclusion LDLT is a safe and effective procedure for patients with HCC,but further studies are required for selection criteria of recipients and higher HCC recurrence rate after LDLT.

Ex-vivo liver resection combined liver autotransplantation for the treatment of hepatic alveolar echinococcosis / 中华消化外科杂志

Ex-vivo liver resection and liver autotransplantation offers a chance to cure extensive regional liver diseases which are otherwise deemed untreatable in selected cases. A 33-year-old male patient with advanced alveolar echinococcosis (AE) which invaded the right lobes and adjacent retrohepatic inferior vena cava, while the left lobes were free from lesion and had proliferated to over 1200 ml in size except for a 1 cm × 1 cm solid lesion in the segment Ⅳ. No extrahepatic metastases were found in this patient. A lesion with a size of 4300 ml and other small lesions in the right lobes were removed extracorporeally,and the retrohepatic vena cava was repaired, then the remaining AE-free left lobes (more than 700 ml in size) and the retrohepatic inferior vena cava were re-implanted in situ. A temporary end-to-end cavo-caval shunt with interposition of a blood vessel prosthesis and end-to-side portocaval shunt were established to keep the blood flow during the four-hour anhepatic phase. The patient was followed up for six months, and he had no signs of residual liver disease with good hepatic function.

Arterial plasty and reconstruction of variant hepatic arteries in live donor liver transplantation / 中华器官移植杂志

ObjectiveTo share the experience of arterial plasty and reconstruction of variant arteries in living donor liver transplantation. MethodsFrom September 2006 to May 2010, 73 living donor liver grafts (64 cases using the right lobe,9 cases using left lobe) were used in patients with end-stage liver disease. The hepatic arteries were evaluated preoperatively with computed tomography and magnetic resonance angiography. Back-table arterial plasty was performed under a microscope or a loupe according to arterial variation. We described technical points based on anatomic variations. There were 13 (17. 8 ％) liver grafts with anatomic hepatic arterial variations and all of these cases were subjected to back-table reconstruction with interrupted 8-0 or 9-0 nonabsorbable nylon monofilament sutures according to the diameter of artery. ResultsIn 3 cases, the associate right hepatic arteries that were arisen from superior esenteric arteris (SMA) were reconstructed to cystic arteries. In 2 cases with the associate right hepatic arteries arisen from the abdominal trunk, the right hepatic arteries and associate right hepatic arteries of donors were anastomosed with right hepatic arteries and left hepatic arteries in recipients respectively. In 2 donors, hepatic arteries had branches, which were reconstructed. All of the arterial plasty were conducted on a back table. No arterial thrombosis was found during a postoperative follow-up period of 6 months. ConclusionLive donor liver transplantation using the right lobe with hepatic artery variation can be performed safely, but there is a potential operative risk of severe complication after transplantation. Tominimize operative difficulties and complications, back-table reconstruction should be applied and proper treatment is given according to individual situations to ensure a safe and satisfactory outcome

Application of computer-assisted operation planning system in precise hepatectomy / 中华消化外科杂志

Objective To investigate the clinical value of computer-assisted operation planning system for precise hepatectomy.Methods The clinical data of 45 patients who had undergone precise hepatectomy at General Hospital of PLA from November 2006 to November 2009 were retrospectively analyzed.The 3-dimensional imaging of liver was constructed by computer-assisted operation planning system,and the anatomic relationship between hepatic vasculature and tumor Was analyzed.Volume of hepatic segments,total liver volume,tumor volume,predicted resection volume and the remnant liver volume were calculated before operation.Virtual liver resection was performed in order to select the best operative procedure.The predicted resection volume Was compared with the hepatic segment resected.All data were analyzed by t test,Pearson rank correlation analysis and chi-square test.Results The predicted resection volume calculated based on the 2-dimensional imaging was similar to that calculated based on the 3-dimensional imaging(t=2.125,P>0.05).The three-grade branches of the hepatic artery,portal vein and hepatic vein were clearly shown in the computer-assisted operation planning system.The anatomic relationship between tumor and adjacent vessels was quantitatively analyzed.There was a positive correlation between the predicted resection volume and the resected liver volume(r=0.999,P<0.05),and the error rate Was 5.1%.All patients received anatomical hepatectomy,and the incidence of postoperative complications was 20%(9/45).No liver failure or perioperative mortality was observed.Conclusion Computer-assisted operation planning system may facilitate and promote precise hepatectomy.

Da Vinci surgical system-assisted precise hepatectomy / 中华消化外科杂志

Objective To assess the feasibility,safety and advantages of robotic-assisted precise hepatectomy.Methods Between April and July 2009,13 consecutive patients underwent robotic-assisted hepatectomy for hepatic diseases.The clinical data were analyzed retrospectively.Results All 13 Da Vinci surgical systemassisted precise hepatectomies were successfully performed without conversion to laparotomy.Major hepatectomies were performed in 9 patients,left lateral segmentectomies in 4 patients.All the Da Vinci surgical system-assisted hepatectomies were performed anatomically with hilum dissection.Prior to the parenchymal transaction,vascular control of the portal vessels was carried out whenever possible.The mean operative time was 338 minutes(range,150-720 minutes).The mean blood loss was 208 ml(range,50-800 ml).No patient required blood transfusion,and no mortality,transient bile leakage was observed in patients with hilar cholangiocarcinoma.The mean postoperative stay was 7 days(range,2-13 days).Conclusions These preliminary results show that Da Vinci surgical system-assisted precise hepatectomy is safe and feasible with potential benefits of a minimally invasive approach.Da Vinci surgical system may broaden the indications for laparoscopic hepatactomy,and it enables surgeons to perform precise laparoscopic hepatectomy which required hilum dissection,hepatocaval dissection,endoscopic suturing and microanastamosis.

MRI findings of multiple focal nodular hyperplasia of the liver / 中华放射学杂志

Objective To assess the diagnostic value of MRI on multiple focal nodular hyperplasia (FNH) of the liver. Methods MR images of 9 cases with pathological-confirmed multiple FNH were retrospectively analyzed. MRI features of the lesions were correlated with pathological findings. Results Multiple FNH was considered in all these 9 cases. Among them, the primary diagnosis was FNH in 5,hepatic adenoma in 3 and fibrolamellar hepatocellular carcinoma in 1 case. A total of 31 lesions were detected in the 9 cases. On T2WI, 19 lesions presented slightly high-signal intensity, and the other 12 presented iso-signal intensity. On T1WI, 12 lesions presented slightly low-signal intensity, 7 presented iso-signal intensity, and the other 12 presented high-signal intensity. On opposed-phase, the signal intensity of 1 lesion dropped unevenly. After bolus injection of contrast agent Gd-DTPA, in hepatic arterial phase 18 lesions showed mild to marked heterogeneous enhancement, 11 showed marked homogeneous enhancement, 1 showed moderate ring-like enhancement, and the last one did not have obvious enhancement In portal venous and delayed phase, all the lesions turned to iso- or slightly high-signal intensity gradually. Sixteen of 31 lesions presented central scar, which demonstrated mild star-like enhancement in delayed phase. Conclusion Multiple FNH presented certain MRI features, which contributed to the preoperative diagnosis.

Right hepatic resection using anterior approach for large right hepatic tumor / 中华肝胆外科杂志

Objective To analyze the advantages of right hepatic resection using the anterior approach for large right hepatic tumors. Methods After initial control of the right liver hilum, liver parenchyma was transected along the ischemic plane down to the anterior surface of the inferior vena cava. All the small caval branches were individually ligated and divided. The right hepatic vein was then isolated, divided and sutured. Sequentially, the right hepatic lobe and tumor were mobilized from the right abdominal cavity in the usual manner and delivered. Results The anterior approach was used for right hepatic resection in 24 patients with huge right hepatic tumors from January 2000 to December 2006 in our hospital. The median size of the tumors was 15.7 cm. Intraoperative blood loss and blood transfusion volume were 734 ml and 620 ml, respectively. No major postoperative complications or hospital death occurred. Conclusion The anterior approach is a preferred technique for huge right hepatic tumors that are very difficult to resect in the conventional manner.