Advances and challenges of conversion therapy and neoadjuvant therapy in hepatocellular carcinoma / 中华消化外科杂志

Hepatocellular carcinoma (HCC) is characterized by a low resection rate and a high postoperative recurrence rate. Conversion therapy and neoadjuvant therapy are effective stra-tegies to improve the long-term prognosis of patients with HCC. With the clinical application of new technologies and methods and the continuous emergence of new anti-tumor drugs, the conversion therapy and neoadjuvant therapy of HCC have ushered in an unprecedented development. At the same time, they are also facing many new challenges. Based on our own clinical experience and the latest progress in conversion therapy and neoadjuvant therapy of HCC, the authors classify and summarize the selection of treatment strategies and the challenges faced in HCC conversion therapy and neoadjuvant therapy.

Current status of surgery for portal hypertension in China: a national multi-center survey analysis / 中华器官移植杂志

Objective:To explore the current status of surgery for portal hypertension to grasp current status and future development of surgery in China.Methods:This study is jointly sponsored by China Hepatobiliary & Pancreatic Specialist Alliance & Portal Hypertension Alliance in China (CHESS).Comprehensive surveying is conducted for basic domestic situations of surgery for portal hypertension, including case load, surgical approaches, management of postoperative complications, primary effects, existing confusion and obstacles, liver transplantation(LT), laparoscopic procedures and transjugular intrahepatic portosystemic shunt(TIPS), etc.Results:A total of 8 512 cases of portal hypertension surgery are performed at 378 hospitals nationwide in 2021.Splenectomy plus devascularization predominated(53.0%)and laparoscopy accounted for 76.1%.Primary goal is preventing rebleeding(67.0%) and 72.8% of hospitals used preventive anticoagulants after conventional surgery.And 80.7% of teams believe that the formation of postoperative portal vein thrombosis is a surgical dilemma and 65.3% of hospitals practiced both laparoscopy and TIPS.The major reasons for patients with portal hypertension not receiving LT are due to a lack of qualifications for LT(69.3%)and economic factors(69.0%).Conclusions:Surgery is an integral part of management of portal hypertension in China.However, it is imperative to further standardize the grasp of surgical indications, the handling of surgical operation and the management of postoperative complications.Moreover, prospective, multi-center randomized controlled clinical studies should be performed.

Perioperative and long-term outcomes of laparoscopic versus open hepatectomy for hepatocellular carcinoma at specific sites of liver / 中华肝胆外科杂志

Objective:To compare the clinical efficacy of laparoscopic and open surgery in the treatment of hepatocellular carcinoma (HCC) at specific sites of liver.Methods:Data of patients with HCC undergoing hepatectomy in Mengchao Hepatobiliary Hospital of Fujian Medical University from September 2014 to May 2019 were retrospective analyzed. A total of 205 patients were enrolled, including 174 males and 31 females, aged (56.7±11.3) years. According to the surgical methods, patients were divided into laparoscopic group ( n=105) and open group ( n=100). The Child-Pugh score, maximum tumor diameter, tumor location, intraoperative blood loss, postoperative complication rate, liver function(glutamate transaminase, alanine transaminase, etc.) and length of hospital stay were compared between the two groups. Postoperative survival and recurrence were followed up. Survival curves and rates were analyzed by Kaplan-Meier and log-rank test. Results:There were no significant differences in Child-Pugh score, maximum tumor diameter, tumor location between the two groups. Compared to the open group, the laparoscopic group had a decreased blood loss [100 (50, 200) ml vs 150 (100, 200) ml], a lower incidence of postoperative complications[7.6%(8/105) vs 17.0%(17/100)], and a shorter hospital stay [(8.6±1.9) days vs (13.0±3.4) days](all P<0.05). The postoperative glutamate transaminase and alanine transaminase levels were lower in the laparoscopic group than those in the open group. The 1, 3, 5-year overall survival and recurrence-free survival were not significantly different between the two groups (χ 2=0.56, 0.21, P=0.456, 0.648). Conclusion:Laparoscopic surgery in the treatment of HCC at specific sites of liver is a safe, feasible and effective procedure.

A brief discussion of Glisson pedic-first approach in laparoscopic anatomical hepatectomy / 中华肝胆外科杂志

With the continuous in-depth understanding of liver anatomy and the progress of surgical techniques, laparoscopic hepatectomy has been developed rapidly, especially the laparoscopic anatomic hepatectomy has become the most commonly surgical method. The dissection and treatment of liver Glisson pedicle is the core techniques of laparoscopic anatomic hepatectomy. The Glisson hepatic pedicle approach has been widely used in open and laparoscopic anatomical hepatectomy, especially in laparoscopic hepatectomy. The possible advantages over the traditional approach are still under debate, and there is no standard surgical approach for pedicle dissection to date. This article introduces Glisson pedicle approach and the advantages and clinical application of laparoscopic anatomical hepatectomy with Glisson pedicle approach.

Conversion therapy strategies for hepatocellular carcinoma in the era of targeted therapy combined with immunotherapy / 中华消化外科杂志

Hepatocellular carcinoma (HCC) has an insidious onset, and most HCC patients have reached the intermediate-advanced stage when they were diagnosed, which lead to missing the opportunity for radical treatment and suffering a poor prognosis. Conversion therapy is an important tool to improve the prognosis of patients with unresectable HCC by creating resectable opportunities. With the new targeted agents, anti-vascular agents, immune agents and multi-dimensional treatment regimens bringing high objective response rate and long duration of remission in HCC treatment, conversion therapy has emerged as a hot spot in the clinical research of HCC. In the era of targeted therapy combined with immunotherapy, the connotation of conversion therapy for HCC continues to expand, with strategies constantly being updated. As such, conversion therapy for HCC has entered a rapid development period, but still faces many challenges. Combined with clinical experience and the latest research progress, based on the efficacy of systematic therapy with targeted combined immunotherapy as the core and combined local therapy in advanced HCC, the authors summarize the definition and expansion of conversion therapy and the conversion therapy strategies in oncology.

Efficacy prediction of biliary drainage stenting versus primary duct closure alone after laparoscopic common bile duct exploration: a Bayesian network Meta analysis / 中华消化外科杂志

Objective:To predict the efficacy of biliary drainage stenting (BDS) versus primary duct closure (PDC) alone after laparoscopic common bile duct exploration (LCBDE)using Bayesian network Meta analysis.Methods:Databases including PubMed, MedLine, Embase, the Cochrane Library, Web of Science, CNKI, Wanfang were searched for literatures from January.1st 1990 to January. 31st 2020 with the key words of ( "Choledocholithiasis" OR "common bile duct stone" OR "CBDS" OR "extrahepatic bile duct stone" ) AND ( "laparoscopic common bile duct exploration" OR "LCBDE" ) AND ( "primary duct closure" or "PDC" ) AND ( "T-tube drainage" or "TTD" or "T-tube" ) AND ( "biliary drainage stenting or BDS" ) AND ( "clinical trials" ),胆总管结石,腹腔镜胆总管探查, T管引流,一期缝合,胆道内支架引流. The randomized controlled trials (RCTs) about comparison of efficacy among BDS, PDC alone and T-tube drainage after LCBDE were received and included. BDS group included patients who underwent BDS after LCBDE, PDC group included patients who underwent PDC alone after LCBDE, and T-tube drainage group included patients who underwent T-tube drainage after LCBDE. The primary outcomes were the incidence of postoperative overall complications, bile leakage and residual stones. GeMTC software was used for Meta analysis in the Rstudio environment. This study was conducted using the random effects model in Bayesian network. The Markov Chain Monte Carlo was used for direct evaluation and indirect prediction. The Brooks-Gelman-Rubing graphing method, tracing method and density plotting were used to evaluate the model convergence. No closed loop formed between intervention measures, so there was no need to evaluate consistency. The matrix of rank probabilities in terms of the outcomes were also calculated.Results:(1) Document retrieval: a total of 12 available RCTs were enrolled. There were 982 patients, including 190 in the BDS group, 296 in the PDC group, and 496 in the T-tube drainage group. (2) Results of Bayesian network meta analysis. ① The BDS group and PDC group had lower overall complication rate than T-tube drainage group [ odds ratio ( OR)=0.21, 0.48, 95% confidence interval ( CI): 0.06-0.52, 0.24-0.87, P<0.05]. There was no significant difference in the indirectly predicted overall complication rate between the BDS group and PDC group ( OR=0.43, 95% CI: 0.12-1.30, P>0.05). ② The BDS group had lower incidence of postoperative bile leakage than T-tube drainage group ( OR=0.18, 95% CI: 0.02-0.86, P<0.05). There was no significant difference in the incidence of postoperative bile leakage between the PDC group and T-tube drainage group ( OR=0.70, 95% CI: 0.27-1.70, P>0.05). There was no significant difference in the indirectly predicted incidence of postoperative bile leakage between the BDS group and T-tube drainage group ( OR=0.25, 95% CI: 0.03-1.60, P>0.05). ③ T-tube drainage group had no significant difference in the incidence of postoperative residual stones compared with the BDS group and PDC group ( OR=0.58, 1.40, 95% CI: 0.13-2.40, 0.41-5.50, P>0.05). There was no significant difference in the indirectly predicted incidence of postoperative residual stones between the BDS group and PDC group ( OR=0.39, 95% CI: 0.05-2.70, P>0.05). (3) Ranking of the incidence of postoperative complication among the three groups: for the BDS group, PDC group, and T-tube drainage group, the probability of ranking the first in the incidence of overall complication was 0.08%, 0.98%, 98.94%, the probability of ranking the second was 6.57%, 92.38%, 1.05%, and the probability of ranking the third was 93.36%, 6.64%, 0.01%, respectively, showing the ranking list as T-tube drainage group >PDC group >BDS group in the incidence of overall complication. The probability of ranking the first in the incidence of postoperative bile leakage was 1.25%, 18.93%, 79.82% for the BDS group, PDC group, and T-tube drainage group, the probability of ranking the second was 6.11%, 74.01%, 19.88%, and the probability of ranking the third was 92.64%, 7.06%, 0.30%, respectively, showing the ranking list as T-tube drainage group >PDC group >BDS group in the incidence of postoperative bile leakage. The probability of ranking the first in the incidence of postoperative residual stones was 10.89%, 67.37%, 21.74% for the BDS group, PDC group, and T-tube drainage group, the probability of ranking the second was 16.09%, 21.09%, 62.82%, and the probability of ranking the third was 73.02%, 11.55%, 15.44%, respectively, showing the ranking list as PDC group >T-tube drainage group >BDS group in the incidence of postoperative residual stones. Conclusions:For patients with appropriate choledocholithiasis, BDS would be recommended first after LCBDE, which can reduce duct closure related complications. This study was registered at http: //www.crd.york.ac.uk/ero/, with the registration number of CRD42019137344.

A multicenter retrospective study on clinical value of lymph node dissection in the radical resection of intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective To investigate the clinical value of lymph node dissection (LND) in the radical resection of intrahepatic cholangiocarcinoma (ICC).Methods The propensity score matching and retrospective cohort study was conducted.The clinicopathological data of 448 patients with ICC who were admitted to 12 medical centers from December 2011 to December 2017 were collected,including 279 in the Eastern Hepatobiliary Surgery Hospital of Navy Medical University,32 in the Mengchao Hepatobiliary Hospital of Fujian Medical University,21 in the First Hospital Affiliated to Army Medical University,20 in the Cancer Hospital Chinese Academy of Medical Science and Peking Union Medical College,19 in the West China Hospital of Sichuan University,18 in the Second Hospital Affiliated to Zhejiang University School of Medicine,18 in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine,16 in the Beijing Friendship Hospital Affiliated to Capital Medical University,10 in the Xuanwu Hospital Affiliated to Capital Medical University,7 in the Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology,5 in the Beijing Tiantan Hospital Affiliated to Capital Medical University,and 3 in the Affiliated Hospital of North Sichuan Medical College.There were 281 males and 167 females,aged from 22 to 80 years,with a median age of 57 years.Of the 448 patients,143 with routinely intraoperative LND were divided into LND group and 305 without routinely intraoperative LND were divided into control group,respectively.Observation indicators:(1) the propensity score matching conditions and comparison of general data between the two groups after matching;(2) intraoperative and postoperative situations;(3) follow-up;(4) survival analysis.Patients were followed up by outpatient examinafion,telephone interview and email to detect survival of patients and tumor recurrence up to October 31,2018 or death.Follow-up was conducted once every 3 months within postoperative 1-2 years,once every 6 months within postoperative 2-5 years,and once a year after 5 years.The propensity score matching was realized using the nearest neighbor method with 1∶1 ratio.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were represented as M (range),and comparison between groups was analyzed using the Mann-Whitney U test.Count data were described as absolute numbers,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Kaplan-Meier method was used to calculate survival rates and draw survival curve,and Log-rank test was used to perform survival analysis.Univariate analysis and multivaraiate analysis were conducted using the Log-rank test and COX regression model,respectively.Results (1) The propensity score matching conditions and comparison of general data between the two groups after matching:286 of 448 patients had successful matching,including 143 in each group.The number of males and females,cases with hepatitis,cases with grade A and B of Child-Pugh classification,cases with distance from margin to tumor ＜ 1 cm and ≥ 1 cm,cases with highly,moderately,and poorly differentiated tumor,cases with anatomical hepatectomy and nonanatomical hepatectomy before propensity score matching were 77,66,33,96,47,70,73,105,38,79,64 in the LND group,and 204,101,121,165,140,207,98,251,54,124,181 in the control group,respectively,showing significant differences in the above indices between the two groups (x2 =7.079,11.885,7.098,14.763,5.184,8.362,P＜0.05).After propensity score matching,the above indices were 77,66,33,96,47,70,73,105,38,79,64 in the LND group,and 79,64,29,88,55,71,72,112,31,74,69 in the control group,respectively,showing no significant difference in the above indices between the two groups (x2 =0.056,0.329,2.158,0.014,0.936,1.400,P＞0.05).(2) Intraoperative and postoperative situations:the operation time,volume of intraoperative blood loss,cases with intraoperative blood transfusion,cases with postoperative complications,and duration of postoperative hospital stay were 265 minutes (range,160-371 minutes),300 mL (range,200-500 mL),37,46,12 days (range,9-17 days) for the LND group,and 59 minutes (range,46-250 minutes),200 mL (range,100-400 mL),24,25,9 days (range,7-11 days) for the control group,respectively.There was no significant difference in the volume of intraoperative blood loss or cases with intraoperative blood transfusion between the two groups (Z =1.700,x2 =3.520,P ＞ 0.05).There were significant differences in the operation time,cases with postoperative complications,and duration of postoperative hospital stay (Z=6.520,x2=8.260,Z=4.270,P＜0.05).(3) Follow-up:143 patients in the LND group was followed up for 18-26 months.The 1-,3-,5-year survival rates were 66.9％,32.8％,25.0％,and the median survival time was 22.0 months (range,18.0-26.0 months).In the control group,143 patients were followed up for 11-32 months.The 1-,3-,5-year survival rates were 71.7％,38.0％,31.0％,and the median survival time was 22.0 months (range,11.0-32.0 months).There was no significant difference in the overall survival between the two groups (x2 =0.466,P＞0.05).(4) Survival analysis:results of univariate analysis showed that distance from margin to tumor,tumor diameter,the number of tumors,microvascular tumor thrombus,and lymph node metastasis by pathological examination were related factors for prognosis of patients undergoing radical resection of ICC (x2 =10.662,9.477,16.944,6.520,11.633,P＜0.05).Results of multivariate analysis showed that distance from margin to tumor＜ 1 cm,tumor diameter＞5 cm,multiple tumors,microvascular tumor thrombus,positive lymph node metastasis by pathological examination were independent risk factors for prognosis of patients undergoing radical resection of ICC (hazard ratio =0.600,1.571,1.601,1.750,1.723,95％ confidence interval:0.430-0.837,1.106-2.232,1.115-2.299,1.083-2.829,1.207-2.460,P＜0.05).Conclusion Lymph node metastasis is an independent risk factor affecting the prognosis of ICC patients,and it is necessary to perform LND in radical resection for patients with ICC and lymph node metastasis.

A multicenter retrospective study on clinical value of lymph node dissection in the radical resection of intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective@#To investigate the clinical value of lymph node dissection (LND) in the radical resection of intrahepatic cholangiocarcinoma (ICC).@*Methods@#The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 448 patients with ICC who were admitted to 12 medical centers from December 2011 to December 2017 were collected, including 279 in the Eastern Hepatobiliary Surgery Hospital of Navy Medical University, 32 in the Mengchao Hepatobiliary Hospital of Fujian Medical University, 21 in the First Hospital Affiliated to Army Medical University, 20 in the Cancer Hospital Chinese Academy of Medical Science and Peking Union Medical College, 19 in the West China Hospital of Sichuan University, 18 in the Second Hospital Affiliated to Zhejiang University School of Medicine, 18 in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 16 in the Beijing Friendship Hospital Affiliated to Capital Medical University, 10 in the Xuanwu Hospital Affiliated to Capital Medical University, 7 in the Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, 5 in the Beijing Tiantan Hospital Affiliated to Capital Medical University, and 3 in the Affiliated Hospital of North Sichuan Medical College. There were 281 males and 167 females, aged from 22 to 80 years, with a median age of 57 years. Of the 448 patients, 143 with routinely intraoperative LND were divided into LND group and 305 without routinely intraoperative LND were divided into control group, respectively. Observation indicators: (1) the propensity score matching conditions and comparison of general data between the two groups after matching; (2) intraoperative and postoperative situations; (3) follow-up; (4) survival analysis. Patients were followed up by outpatient examination, telephone interview and email to detect survival of patients and tumor recurrence up to October 31, 2018 or death. Follow-up was conducted once every 3 months within postoperative 1-2 years, once every 6 months within postoperative 2-5 years, and once a year after 5 years. The propensity score matching was realized using the nearest neighbor method with 1∶1 ratio. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Kaplan-Meier method was used to calculate survival rates and draw survival curve, and Log-rank test was used to perform survival analysis. Univariate analysis and multivaraiate analysis were conducted using the Log-rank test and COX regression model, respectively.@*Results@#(1) The propensity score matching conditions and comparison of general data between the two groups after matching: 286 of 448 patients had successful matching, including 143 in each group. The number of males and females, cases with hepatitis, cases with grade A and B of Child-Pugh classification, cases with distance from margin to tumor <1 cm and ≥1 cm, cases with highly, moderately, and poorly differentiated tumor, cases with anatomical hepatectomy and nonanatomical hepatectomy before propensity score matching were 77, 66, 33, 96, 47, 70, 73, 105, 38, 79, 64 in the LND group, and 204, 101, 121, 165, 140, 207, 98, 251, 54, 124, 181 in the control group, respectively, showing significant differences in the above indices between the two groups (χ2=7.079, 11.885, 7.098, 14.763, 5.184, 8.362, P<0.05). After propensity score matching, the above indices were 77, 66, 33, 96, 47, 70, 73, 105, 38, 79, 64 in the LND group, and 79, 64, 29, 88, 55, 71, 72, 112, 31, 74, 69 in the control group, respectively, showing no significant difference in the above indices between the two groups (χ2=0.056, 0.329, 2.158, 0.014, 0.936, 1.400, P>0.05). (2) Intraoperative and postoperative situations: the operation time, volume of intraoperative blood loss, cases with intraoperative blood transfusion, cases with postoperative complications, and duration of postoperative hospital stay were 265 minutes (range, 160-371 minutes), 300 mL (range, 200-500 mL), 37, 46, 12 days (range, 9-17 days) for the LND group, and 59 minutes (range, 46-250 minutes), 200 mL (range, 100-400 mL), 24, 25, 9 days (range, 7-11 days) for the control group, respectively. There was no significant difference in the volume of intraoperative blood loss or cases with intraoperative blood transfusion between the two groups (Z=1.700, χ2=3.520, P>0.05). There were significant differences in the operation time, cases with postoperative complications, and duration of postoperative hospital stay (Z=6.520, χ2=8.260, Z=4.270, P<0.05). (3) Follow-up: 143 patients in the LND group was followed up for 18-26 months. The 1-, 3-, 5-year survival rates were 66.9%, 32.8%, 25.0%, and the median survival time was 22.0 months (range, 18.0-26.0 months). In the control group, 143 patients were followed up for 11-32 months. The 1-, 3-, 5-year survival rates were 71.7%, 38.0%, 31.0%, and the median survival time was 22.0 months (range, 11.0-32.0 months). There was no significant difference in the overall survival between the two groups (χ2=0.466, P>0.05). (4) Survival analysis: results of univariate analysis showed that distance from margin to tumor, tumor diameter, the number of tumors, microvascular tumor thrombus, and lymph node metastasis by pathological examination were related factors for prognosis of patients undergoing radical resection of ICC (χ2=10.662, 9.477, 16.944, 6.520, 11.633, P<0.05). Results of multivariate analysis showed that distance from margin to tumor<1 cm, tumor diameter>5 cm, multiple tumors, microvascular tumor thrombus, positive lymph node metastasis by pathological examination were independent risk factors for prognosis of patients undergoing radical resection of ICC (hazard ratio=0.600, 1.571, 1.601, 1.750, 1.723, 95% confidence interval: 0.430-0.837, 1.106-2.232, 1.115-2.299, 1.083-2.829, 1.207-2.460, P<0.05).@*Conclusion@#Lymph node metastasis is an independent risk factor affecting the prognosis of ICC patients, and it is necessary to perform LND in radical resection for patients with ICC and lymph node metastasis.

Combined postoperative adjuvant transarterial chemoembolization and portal vein chemotherapy to treat patients with hepatocellular carcinoma and portal vein tumor thrombosis: a meta-analysis / 中华肝胆外科杂志

Objective:To systematically review the clinical effectiveness of combined postoperative adjuvant transcatheter arterial chemoembolization (TACE) with portal vein chemotherapy (PVC) versus TACE alone in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).Methods:Databases including PubMed, Embase, Cochrane Library, Medline, Web of Science, CNKI, China Biology Medicine, Wan Fang and VIP were searched from Jan 1st 2000 to Jun 30th 2019 for eligible studies on clinical effectiveness of combined postoperative adjuvant TACE with PVC versus TACE alone in patients with HCC and PVTT. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoint was adverse events. These endpoints were evaluated by odds ratio ( OR) and 95% confidence interval ( CI) using Review Manager 5.3 software. Results:Nine studies with 642 patients were enrolled in this meta-analysis. There were 323 patients in the TACE group and 319 patients in the TACE plus PVC group. The pooled OR for the 1-, 2-, and 3-year OS were all significantly better in the TACE plus PVC group than the TACE group (1-year OS, OR=2.20, 95% CI: 1.53-3.17; 2-year OS, OR=2.44, 95% CI: 1.69-3.53; 3-year OS, OR=2.30, 95% CI: 1.52-3.46) (all P<0.05). Similarly, significantly better results were observed in the pooled OR for the 1-, 2-, and 3-year DFS (1-year DFS, OR=2.56, 95% CI: 1.70-3.86; 2-year DFS, OR=2.27, 95% CI: 1.19-4.32; 3-year DFS, OR=3.03, 95% CI: 1.55-5.92) (all P<0.05). There were no significant differences in the incidences of adverse events between the two groups (all P>0.05). Conclusion:Postoperative adjuvant TACE combined with PVC for patients with HCC and PVTT was safe and effective, and was significantly better than TACE alone in long-term prognosis. Large-scale, multi-center, prospective studies are needed to support the conclusion.

Pilot study of the relationship between clinical classification of gallbladder cancer and prognosis: a retrospective multicenter clinical study / 中华外科杂志

Objectives@#To propose a novel clinical classification system of gallbladder cancer, and to investigate the differences of clinicopathological characteristics and prognosis based on patients who underwent radical resection with different types of gallbladder cancer.@*Methods@#The clinical data of 1 059 patients with gallbladder cancer underwent radical resection in 12 institutions in China from January 2013 to December 2017 were retrospectively collected and analyzed.There were 389 males and 670 females, aged (62.0±10.5)years(range:22-88 years).According to the location of tumor and the mode of invasion,the tumors were divided into peritoneal type, hepatic type, hepatic hilum type and mixed type, the surgical procedures were divided into regional radical resection and extended radical resection.The correlation between different types and T stage, N stage, vascular invasion, neural invasion, median survival time and surgical procedures were analyzed.Rates were compared by χ2 test, survival analysis was carried by Kaplan-Meier and Log-rank test.@*Results@#Regional radical resection was performed in 940 cases,including 81 cases in T1 stage,859 cases in T2-T4 stage,119 cases underwent extended radical resection;R0 resection was achieved in 990 cases(93.5%).The overall median survival time was 28 months.There were 81 patients in Tis-T1 stage and 978 patients in T2-T4 stage.The classification of gallbladder cancer in patients with T2-T4 stage: 345 cases(35.3%)of peritoneal type, 331 cases(33.8%) of hepatic type, 122 cases(12.5%) of hepatic hilum type and 180 cases(18.4%) of mixed type.T stage(χ2=288.60,P<0.01),N stage(χ2=68.10, P<0.01), vascular invasion(χ2=128.70, P<0.01)and neural invasion(χ2=54.30, P<0.01)were significantly correlated with the classification.The median survival time of peritoneal type,hepatic type,hepatic hilum type and mixed type was 48 months,21 months,16 months and 11 months,respectively(χ2=80.60,P<0.01).There was no significant difference in median survival time between regional radical resection and extended radical resection in the peritoneal type,hepatic type,hepatic hilum type and mixed type(all P>0.05).@*Conclusion@#With application of new clinical classification, different types of gallbladder cancer are proved to be correlated with TNM stage, malignant biological behavior and prognosis, which will facilitate us in preoperative evaluation,surgical planning and prognosis evaluation.

Clinical efficacy of laparoscopic hepatectomy for intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective To investigate the clinical efficacy of laparoscopic hepatectomy for intrahepatic cholangiocarcinoma (ICC).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 62 patients with ICC who were admitted to Mengchao Hepatobiliary Hospital of Fujian Medical University (32 patients) and the First Hospital Affiliated to Army Medical University (30 patients) between January 2013 and January 2018 were collected;there were 35 males and 27 females,aged from 25 to 77 years,with an average of 60 years.According to the preoperative and intraoperative situations,lymph node dissection was performed,and anatomical or non-anatomical laparoscopic hepatectomy were performed based on tumor size and location.Observation indicators:(1) surgical and postoperative recovery;(2) pathological examination results;(3) follow-up and survival situations.Follow-up was conducted by telephone interview and outpatient examination once every 3 months to detect tumor-free survival and overall survival of patients up to June 2018.Measurement data with normal distribution were represented as Mean±SD.Measurement data with skewed distribution were represented as M (range).Count data were described as absolute number and percentage.The survival curve and rate were drawn and calculated by the Kaplan-Meier method.Results (1) Surgical and postoperative recovery:all the 62 patients received successful laparoscopic hepatectomy,without conversion to open surgery or preoperative death,including 40 with anatomical hepatectomy and 22 with non-anatomical hepatectomy.There were 18 patients undergoing regional lymph node dissection.The operation time of 62 patients was (217±86)minutes.Of 62 patients,12 had hepatic vascular occlusion using the Pringle method with a total occlusion time of (14±7)minutes,45 received selective hepatic vascular occlusion and 5 did not receive hepatic portal occlusion.The volume of intraoperative blood loss was 282 mL (range,20-2 500 mL).Four patients had intraoperative infusion of suspended red blood cells.The time for out-of-bed activity,time to initial anal exsufflation,time of abdominal drainage-tube removal,recovery time of liver function to normal level were 1 day (range,1-3 days),2.5 days (2.0-4.0 days),(4.4±1.3)days,(6.8±1.6) days.There was no liver failure.Six of 62 patients had postoperative complications,including 5 with thoracic and abdominal effusion,3 with abdominal infection,2 with pulmonary infection,2 with bile leakage,1 with intraperitoneal hemorrhage,1 with urinary retention,1 with postoperative incision infection,multiple complications might occur in the same patient.Two of 6 patients with complications of Clavien-Dindo Ⅲ were improved by symptomatic treatment.The other patients had no clear complications.The duration of postoperative hospital stay was (13±9) days.Thirteen patients received preventive TACE treatment after surgery,9 received 4-6 courses of chemotherapy,2 received both TACE and chemotherapy with chemotherapy drug of Tegafur or gemcitabine combined with cisplatin.(2) Pathological examination results:the tumor diameter of 62 patients was (5.4±3.3)cm,including 38 with the diameter ≤ 5 cm and 24 with the diameter ＞5 cm.There were 56 patients of mass-forming type,4 of intraductal growth type and 2 of periductal infiltrating type.High-,moderate-,poor-differentiated adenocarcinoma were respectively detected in 10,37 and 15 of 62 patients.The distance of surgical margins to tumor was ＞ 1.0 cm in 57 patients.There were 60 patients with negative surgical margin,1 patient of intraductal growth type and 1 of periductal infiltrating type with positive margin.Lymph node dissection was performed in 18 patients,among which 11 were pathologically positive,otherwise,there were 16 patients with microvascular invasion,and 4 patients with peripheral nerve infiltration.TNM stages of 62 patients:stage Ⅰ A,stage Ⅰ B,stage Ⅱ and stage ⅢB were respectively detected in 14,23,14 and11 patients.(3) Follow-up and survival situations:62 patients were followed up for (22± 12) months.The 1-and 3-year disease-free survival rates were 65.2％ and 39.8％ respectively.The 1-and 3-year overall survival rates were 89.6％ and 52.5％ respectively.During the follow-up,2 of 44 patients without lymph node dissection had liver portal lymph node metastasis,1 had extensive lymph node metastasis,2 died of other causes at 6 months and 18 months after operation.Conclusion Routine laparoscopic radical resection of intrahepatic cholangiocarcinoma with regional lymph node dissection is safe and effective,however,laparoscopic hepatectomy should be carefully selected for intraductal growth type and periductal infiltration type.

Effects analysis between laparoscopic radical resection combined with radiofrequency ablation and open radical resection for colorectal liver metastases / 中华消化外科杂志

Objective To compare the clinical effects between laparoscopic radical resection combined with radiofrequency ablation (RFA) and open radical resection for colorectal liver metastases.Methods The retrospective cohort study was conducted.The clinicopathological data of 120 colorectal liver metastases patients who were admitted to the Mengchao Hepatobiliary Hospital of Fujian Medical University (80 patients) and the Third Mfiliated Hospital of Chongqing Medical University (40 patients) between September 2012 and April 2017 were collected.Sixty patients undergoing laparoscopic radical resection of colorectal cancer combined with RFA of liver metastases were allocated into the laparoscopy with RFA group,and 60 undergoing open radical resection of colorectal liver metastases were allocated into the open group.Observation indicators:(1) surgical and postoperative situations;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to May 2017.Measurement data with normal distribution were represented as x±s,and comparisons between groups were analyzed using independent-sample t test.Measurement data with skewed distribution were described as M (range).Comparisons of count data were analyzed using chi-square test or Fisher exact probability.The repeated measures data were analyzed using the repeated measures ANOVA.The survival curve and rate were respectively drawn and calculated by the Kaplan-Meier method,and the Log-rank test was used for survival analysis.Results (1) Surgical and postoperative situations:① All the patients underwent successful surgery,without conversion to open surgery in the laparoscopy with RFA group.Operation time,volume of intraoperative blood loss,cases with overall complications,death,abdominal pain,nausea and vomiting,liver dysfunction,pleural effusion,non-calculus cholecystitis and peptic ulcer and duration of postoperative hospital stay were respectively (135±34)minutes,(451±197)mL,31,0,18,6,6,4,3,2,(13±4)days in the laparoscopy with RFA group and (165±49)minutes,(794±204)mL,42,1,15,9,10,11,5,5,(19±4)days in the open group,with statistically significant differences in operation time,volume of intraoperative blood loss,cases with overall complications and duration of postoperative hospital stay between groups (t =3.983,9.394,x2 =4.232,t =9.148,P＜0.05),and no statistically significant differences in cases with death,abdominal pain,nausea and vomiting,liver dysfunction,pleural effusion,non-calculus cholecystitis and peptic ulcer between groups x2 =0.376,0.686,1.154,3.733,0.134,0.607,P＞0.05).() Levels of alanine aminotransferase (ALT),total bilirubin (TBil) and prothronbin time (PT) before operation,at day 1 and 3 postoperatively were respectively (70±9)U/L,(399±36)U/L,(231±19) U/L,(21±3) μmol/L,(26±3) μmol/L,(23±5) μmol/L,(17.3±2.4) seconds,(20.2-±4.4) seconds,(18.9±2.8) seconds in the laparoscopy with RFA group and (68± 8) U/L,(412±39)U/L,(253±22)U/L,(21±4)μmol/L,(28±4)μmol/L,(27±8)μmol/L,(16.6±3.0)seconds,(22.1±5.2) seconds,(20.1± 4.4)seconds in the open group,with statistically significant differences in the levels of ALT,TBil and PT before operation,at day 1 and 3 postoperatively between groups (F=16.727,13.115,4.194,P＜0.05).(2) Follow-up and survival situations:120 patients were followed up for 7-24 months,with a median time of 20 months.The postoperative 1-and 2-year tumor-free survival rates,1-and 2-year overall survival rates were respectively 23.3％,11.9％,85.0％,40.0％ in the laparoscopy with RFA group and 20.0％,12.8％,83.3％,38.3％ in the open group,with no statistically significant difference in above indicators between groups (x2 =0.145,0.069,0.012,0.196,P＞0.05).Further analysis showed that postoperative 2-year overall survival rate of patients with 1,2,3 and ＞3 liver metastasis lesions were respectively 53.3％,38.2％,40.0％,16.7％ in the laparoscopy with RFA group and 50.0％,35.7％,40.0％,15.4％ in the open group,with a statistically significant difference in 2-year survival rate of patients with different liver metastasis lesions in the laparoscopy with RFA group (x2 =20.949,P＜0.05) and in the open group (x2 ＝ 21.349,P＜0.05).Conclusion There are some advantages of fewer traumas,less complications,faster postoperative recovery and minimally invasive in laparoscopic radical resection combined with RFA for colorectal liver metastases,meanwhile,less liver metastasis lesions and better prognosis are found.

Application value of 3D reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma / 中华消化外科杂志

Objective To investigate the application value of three-dimensional (3D) reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma.Methods The retrospective crosssectional study was conducted.The clinical data of 36 patients with hilar cholangiocarcinoma who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2014 and September 2017 was collected.Before operation,images of 3D virtual surgery planning were respectively reconstructed and determined using IQQA-Liver imaging analysis system,and then precise resection of tumor was performed based on results of virtual surgical planning and intraoperative conditions.Observation indicators:(1) virtual surgical planning;(2) surgical and postoperative situations;(3) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and tumor recurrence or metastasis up to November 2017.Measurement data with normal distribution were represented as (x)±s.Comparison between indicator of preoperative virtual surgical planning and surgical indicators was analyzed by the t test.The postoperative survival time was calculated by the Kaplan-Meier method.Results (1) Virtual surgical planning:36 patients accomplished 3D visualization reconstruction and virtual surgical planning.Three D visualization reconstruction clearly showed adjacent relationship between tumor size and surrounding vessels or bile duct space.Type Ⅱ,Ⅲ a,Ⅲb and Ⅳ of Bismuth-Corlette Classification were detected in 2,13,14 and 7 patients by 3D visualization system,respectively.The tumor volume,whole liver volume,predicted liver resection volume and remnant liver volume were respectively (76± 26) mL,(1 319± 306) mL,(588± 128) mL and (731± 269) mL.(2) Surgical and postoperative situations:of 36 patients,16,12,5 and 3 patients underwent left hemigepatectomy,right hemigepatectomy,extended left hemigepatectomy and extended right hemigepatectomy,respectively,and all of them were combined with caudate lobectomy of liver.Combined resection and reconstruction of hepatic artery,combined wedge resection and repair of the portal vein and combined end-to-end anastomosis after resection of the portal vein were detected in 1,2 and 1 patients,respectively.Operation time and volume of intraoperative blood loss of 36 patients were respectively (368± 134)minutes and (474±288)mL.Thirty-six patients with postoperative complications were cured by conservative treatment,including 3 with pulmonary infection,3 with intra-abdominal infection and 2 with intra-abdominal lymphatic fistula.Duration of hospital stay of 36 patients was (19±7) days.Type Ⅱ,Ⅲ a,Ⅲ b and Ⅳ of postoperative Bismuth-Corlette Classification were detected in 2,11,13 and 10 patients,respectively.Accuracy of tumor classification through 3D visualization reconstruction was 91.7％ (33/36).Actual liver resection volume of 36 patients was (551± 141)mL,and was not significantly different from predicted liver resection volume (t =1.148,P＞0.05).(3) Follow-up and survival:31 of 36 patients were followed up for 2-39 months after surgery,with a median time of 16 months.The postoperative median survival time was 13 months,and 9 patients had tumor recurrence or metastasis during the follow-up.Conclusion The 3D reconstruction virtual surgery planning can accurately complete the preoperative evaluation,meanwhile,it can also provide important reference for the surgical therapy of hilar cholangiocarcinoma.

Clinical efficacies of free endoscopic nasobiliary drainage in primary duct closure following laparoscopic common bile duct exploration: a multicenter retrospective study (A report of 312 cases) / 中华消化外科杂志

Objective To investigate the clinical efficacies of free endoscopic nasobiliary drainage (ENBD) in primary duct closure (PDC) following laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis.Methods The retrospective cohort study was conducted.The clinical data of 312 patients with extrahepatic bile duct stones accompanied with or without cholecystolithiasis who were admitted to the 11 medical centers [86 in the Affiliated Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,62 in the Second Affiliated Hospital of Zhejiang University School of Medicine,44 in the West China Hospital of Sichuan University,29 in the First Affiliated Hospital of Xi'an Jiaotong University,27 in the First Hospital Affiliated to Army Medical University (Third Military Medical University),25 in the Hunan Provincial People's Hospital,17 in the Beijing Friendship Hospital of Capital Medical University,10 in the First Affiliated Hospital of Hainan Medical University,5 in the Henan Provincial People's Hospital,4 in the Beijing Tian Tan Hospital of Capital Medical University,3 in the First Affiliated Hospital of Fujian Medical University] from January 2011 to June 2017 were collected.All patients underwent LCBDE+PDC,and 81 and 231 patients with and without ENBD were respectively allocated into the ENBD group and PDC group.Observation indicators:(1) comparisons of operation situations;(2) comparisons of postoperative recovery;(3) comparisons of postoperative complications;(4) follow-up situations.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative complications up to June 2017.Measurement data with normal distribution were represented as x±s.Comparison between groups was analyzed by the t test.Measurement data with skewed distribution were represented M [interquartile range (IQR)],and comparison between groups was analyzed by the nonparametic test.Comparisons of count data were analyzed using the chi-square test and Fisher exact probability.Results (1) Comparisons of operation situations:all the 312 patients underwent successful laparoscopic LCBDE + PDC,without conversion to open surgery,including postoperative death of 1 patient in the PDC group.The common bile duct diameter,cases using interrupted sutures,continuous sutures,absorbable threads and nonabsorbable threads were respectively (1.2±0.4)cm,106,125,195,36 in the PDC group and (1.1±0.5)cm,76,5,79,2 in the ENBD group,with statistically significant differences between groups (t =2.497,x2 =56.706,8.457,P＜0.05).The numbers of stones,stone diameter,cases with common bile duct wall (≤ 3 mm and ＞3 mm),normal and abnormal Oddi sphincter contraction function,volume of intraoperative blood loss and operation time were respectively 2.1±1.7,(1.1-±0.6)cm,148,83,226,5,20 mL (10-45 mL),(116± 49)minutes in the PDC group and 1.9±1.6,(1.0±0.6)cm,49,32,75,6,20 mL (15-30 mL),(113± 23)minutes in the ENBD group,with no statistically significant difference between groups (t =1.021,0.329,x2 =0.329,3.428,Z=1.147,t=0.521,P＞0.05).The further analysis:of 312 patients,cases and time using interrupted sutures and continuous sutures were respectively 182,130 and (133±.49) minutes,(103±34) minutes,with a statistically significant difference between groups (t =-6.605,P＜0.05).The volume of intraoperative blood loss and cases with postoperative complications using interrupted sutures and continuous sutures were respectively 20 mL (15-31 mL),21 and 20 mL (10-45 mL),18,with no statistically significant difference between groups (Z =-0.285,x2 =0.369,P＞ 0.05).Of 312 patients,cases,operation time,volume of intraoperative blood loss and postoperative complications using absorbable threads and non-absorbable threads were respectively 274,(116±44)minutes,20 mL (15-40 mL),33 and 38,(115±35) minutes,18 mL (10-26 mL),6,with no statistically significant difference between groups (Z =0.971,t =0.023,x2 =0.154,P＞ 0.05).(2) Comparisons of postoperative recovery:recovery time of gastrointestinal function,time of abdominal drainage-tube removal,using time of antibiotics and duration of hospital stay were respectively (2.0± 1.5) days,(4.0 ± 2.4) days,(4.0±2.8) days,(5.5±3.0) days in the PDC group and (4.0±1.9) days,(6.9±3.5) days,(10.0± 3.9) days,(11.1±3.7)days in the ENBD group,with statistically significant differences between groups (t =-9.507,-8.258,-15.103,-13.575,P＜0.05).The total expenses of hospital stay in the Affiliated Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology were respectively (5.1 ±0.6)× 104 yuan in the PDC group and (6.5-±0.5)× 104 yuan in the ENBD group,with a statistically significant difference between groups (t =-9.516,P＜0.05).(3) Comparisons of postoperative complications:incidence of complications in the PDC group was 14.29％ (33/231),including 16 with biliary fistula,11 with biliary tract infection,3 with wound infection,1 with biliary tract bleeding,1 with residual stones of common bile duct and 1 with death;incidence of complications in the ENBD group was 6.17％ (5/81),including 2 with biliary fistula,2 with biliary tract infection and 1 with biliary tract bleeding,showing no statistically significant difference between groups (x2 =3.151,P＞0.05).(4) Follow-up situations:of 312 patients,252 were followed up for 2-67 month,with a median time of 15 months,including 175 in the PDC group and 77 in the ENBD group.During the follow up,there was no occurrence of jaundice,cholangitis and pancreatitis,and stone recurrence and postoperative cholangiostenosis were not detected by abdominal color Doppler ultrasound or CT or magnetic resonanced cholangio-pancreatography.Conclusion On the basis of grasping operative indication strictly,ENBD in PDC following LCBDE for choledocholithiasis is safe and effective.

The impact and the risk factors of different preoperative biliary drainage procedures for patients with malignant obstruction jaundice on overall survival : a Meta-analysis / 中华肝胆外科杂志

Objective To determine the impact and the risk factors of different methods of preoperative biliary drainage (PBD) for malignant obstruction jaundice (MOJ) on overall survival (OS).Methods Databases including the PubMed,Medline,Web of Knowledge,and other databases were searched up to 30th April,2018 for clinical studies which compared the OS rates between percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD) for MOJ.Hazard ratio (HR) and Odds Ratio (OR) with 95％ confidence interval (CI) were performed using the Review Manager 5.3 software to synthesize the results.Results Nine studies were enrolled in this meta-analysis,which included 818 patients in the PTBD group and 1253 patients in the EBD group.EBD was shown to be superior to PTBD in OS (HR=0.63,95％ CI:0.51～0.77,P＜0.05).Risk factors analysis showed that patients in the EBD group had a higher rate of early tumor stage (P＜0.05) and a lower rate of lymphatic metastasis (P＜0.05).When compared with the PTBD group,the EBD group had a lower rate of intraoperative bleeding (P＜0.05),and a higher rate of adjuvant therapy (P＜0.05).Conclusion In PBD for patients with resectable MOJ,there was insufficient evidence to support EBD to be superior to PTBD in OS.

Effect of abdominal lymphadenectomy on prognosis of intrahepatic cholangiocarcinoma: a systematic review and Meta analysis / 中华消化外科杂志

Objective To systematically review the prognostic factors of intrahepatic cholangiocarcinoma (ICC) and clinical significance of abdominal lymphadenectomy.Methods PubMed was queried with the terms of intrahepatic cholangiocarcinoma,survival,surgery,lymph or vascular invasion to find all studies published from January 2005 to December 2015.Authors were contacted by letters for the publications that were initially ineligible due to insufficient information for data extraction,responses were received,so these publications were included.Data were analyzed and evaluated by 2 independent researchers.Prognostic factors of ICC (vascular invasion,bile duct invasion,lymphatic vessel invasion,lymph node metastasis and peripheral nerve invasion) and related-factors of surgical method (R0 resection and lymph node dissected) were analyzed.The 3-,5-year survival rate,tumor-free survival rate and effect of lymph node dissected for prognosis of patients were extracted.Heterogeneity was analyzed by the chi-squared test and I2 test.The hazard ratio (HR) and 95％ confidence interval (CI) were transformed to Log (HR) and standard errors (SE) Log (HR).HR and 95％ CI of clinical factors associated with outcomes were done using univariate COX regression models.Publication bias was evaluated by the Egger's method,visualizing with funnel plot.Results A total of 48 publications including 7 868 patients with ICC were eligible to be included in this analysis,12 of 48 publications were included in the Mata analysis.Of 7 868 patients with ICC,vascular invasion,bile duct invasion,lymphatic vessel invasion,lymph node metastasis,peripheral nerve invasion,R0 resection and lymph node dissected were detected in 30％ (5％-98％),40％ (11％-59％),45％ (35％-65％),28％ (9％-100％),25％ (7％-55％),79％ (35％-100％) and 64％ (9％-100％),respectively.The 3-,5-year survival rate and 3-,5-year tumor-free survival rate were 39％ (16％-65％),29％(5％-60％) and 34％ (3％-60％),23％ (0-52％),respectively.The results of meta-analysis showed that lymph node metastasis and vascular invasion were factors affecting the prognosis of patients with ICC (HR =2.30,1.92,95 ％ CI:1.94-2.73,1.64-2.25,P ＜ O.05).Among the patients without lymph node metastasis,5-year survival rate in patients with and without lymphadenectomy was 17％-64％ and 15％-64％,respectively,showing no statistically significant difference (P ＞ 0.05).Among the patients with lymph node metastasis,5-year survival rate in patients with and without lymphadenectomy was 48％ and 11％,respectively,showing a statistically significant difference (P＜0.05).Conclusions Lymph node metastasis and vascular invasion are the risk factors affecting the prognosis of patients with ICC.Routine lymphadenectomy for ICC cannot show survival benefit,while routine lymphadenectomy should be applied to patients with ICC and uncertain lymph node metastasis.

Clinical evaluation of laparoscopic hepatectomy for liver tumors in Couinaud Ⅰ, Ⅳa, Ⅶ, and Ⅷ / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical experience of laparoscopic hepatectomy (LH) for liver tumors in Couinaud Ⅰ, Ⅳa, Ⅶ, and Ⅷ segment.</p><p><b>METHODS</b>Fifty-six patients with tumor in Couinaud Ⅰ, Ⅳa, Ⅶ, or Ⅷ segment underwent LH in Department of Hepatobiliary Surgery, the First Affiliated Hospital of Fujian Medical University from July 2009 to December 2014.The pathological diagnoses were hepatic hemangioma(5 patients), colorectal cancer metastasis to the liver(4 patients), hepatic adenoma (6 patients), hepatocellular carcinoma(32 patients), focal nodular hyperplasia(8 patients) and liver harmatoma(1 patient). The liver function of all patients was Child-Pugh class A. All patients were followed up by several kinds of methods which included outpatient or inpatient review, telephone and mail until January 2015.</p><p><b>RESULTS</b>LH was converted to open hepatectomy in one patient, and tumor resection by LH was successful in other patients.The mean diameter of tumor was (5.7±3.4)cm (range 3-9 cm). The mean operative time was (115±46)min (range 55-260 min). And the mean estimated intraoperative blood loss was (181±135)ml (range 20-550 ml). The postoperative hospital stay was (7.1±1.5)days (range 5-10 days). Postoperative complications occurred in 4 patients(7.1 percent) and resolved with conservative management. There was no perioperative deaths. At the 1-month follow-up, 47 patients had returned to full-time work. A total of 9 patients had evidence of recurrence after operation. The one-year overall and disease-free survival rates of patients with malignant tumor were 100 percents and 87.5 percents, respectively.</p><p><b>CONCLUSION</b>LH for tumors in segment Ⅰ, Ⅳa, Ⅶ, and Ⅷ is safe and effective.</p>

Efficacy of laparoscopic hepatectomy for hepatic neoplasms: a report of 258 cases / 中华消化外科杂志

Objective To investigate the clinical efficacy of laparoscopic hepatectomy.Methods The clinical data of 258 patients who received laparoscopic hepatectomy at the First Affiliated Hospital of Fujian Medical University from March 2010 to January 2013 were retrospectively analyzed.There were 196 patients with primary hepatic cancer,45 with hepatic hemangioma,13 with hepatic focal nodular hyperplasia,2 with hepatic metastatic cancer,1 with carcinoma of gallbladder and 1 with hepatic hamartoma.All patients were followed up via phone call or out-patient examination till March 2013.Results A total of 142 patients received single hepatic segmentectomy,98 received multiple hepatic segmentectomy,18 received multiple lesions resection.Fifty-one patients received hepatic tumorectomy + cholecystectomy.All the operations were successfully done under laparoscope without conversion to the open surgery.The mean tumor diameter and the operation time were (5 ± 3) cm (range,1.0-11.5 cm) and (113 ± 56) minutes (range,50-310 minutes),respectively.Intraoperative hepatic portal occlusion was performed on 122 patients,and the time for hepatic portal occlusion was (15 ± 7)minutes.The volume of intraoperative blood loss was (211 ± 195)mL (range,10-650 mL),and blood transfusion was not needed.The capsule of the tumor was complete.The distance between the resection margin and the malignant tumor was above 1.5 cm,and there was no residual tumor in the resection margin.The hepatic function was back to the normal level in 1 week after the operation,and no patient had hepatic failure.The duration of postoperative hospital stay was (7.2 ± 1.3)days (range,5-10 days).One patient was complicated with bile leakage,6 with slight peritoneal effusion,and other patients had no postoperative complications.The rate of follow-up was 91.47％ (236/258),and the time of follow-up was (16 ± 10) months.A total of 199 patients with malignant hepatic tumors were followed up.During the follow-up,180 patients had tumor-free survival; 18 patients had postoperative tumor recurrence; 1 patient had omental metastasis and received surgical resection.Thirty-seven patients with benign hepatic tumor survived without complication during the follow-up.Conclusion Laparoscopic hepatectomy is effective for the treatment of hepatic tumors.Multiple hepatic inflow occlusion under laparoscope in a short time may improve the safety of surgery,without prolonging the recovery time of patients.

Correlated factors of pulmonary metastasis of hepatocellular carcinoma / 中华消化外科杂志

Objective To investigate the correlated factors of pulmonary metastasis of hepatocellular carcinoma (HCC),so as to provide theoretical evidences for the prevention and treatment.Methods The clinical data of 862 patients with HCC who were admitted to the First Affiliated Hospital of Fujian Medical University from January 2008 to March 2012 were retrospectively analyzed.There were 107 patients with pulmonary metastasis.Factors including serum alpha fetoprotein (AFP) level,serum gamma-glutamyl transpeptidase (GGT) level,hepatitis B virus (HBV) infection,presence and treatment of intrahepatic tumor were analyzed to screen out relevant factors of pulmonary infection of HCC.Univariate and multivariate COX regression model analysis were performed for data analysis.Results The results of univariate analysis showed that high level of AFP (≥400 μg/L),ultra-high level of GGT (≥ 150 U/L),presence of HBV infection,the number of intrahepatic tumors ≥2,no radical resection (or radiofrequency ablation) for intrahepatic tumors,combining with tumor thrombi in the vessels,lymph node metastasis were risk factors of pulmonary metastasis of HCC (RR =1.986,3.653,0.365,3.675,0.252,0.379,0.352,P ＜ 0.05).The results of multivariate analysis showed that high level of AFP (≥400 μg/L),HBV infection,the number of intrahepatic tumors ≥2,no radical resection (or radiofrequency ablation) for intrahepatic tumors,combining with tumor thrombi in the vessels were risk factors of pulmonary metastasis of HCC (RR =2.391,3.462,3.425,3.396,2.418,0.638,P ＜ 0.05).Conclusions AFP ≥400 μg/L,HBV infection,the number of intrahepatic tumors ≥ 2,no radical resection (or radiofrequency ablation),tumor thrombi in the vessels and lymph node metastasis are risk factors of pulmonary metastasis of HCC.Anti-hepatitis virus treatment and early treatment are helpful for the prevention and treatment.