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Objective:To evaluate the safety and clinical efficacy of transcatheter arterial chemoembolization (TACE) combined with portal vein embolization (PVE) and percutaneous microwave ablation liver partition with PVE for planned hepatectomy in patients with hepatocellular carcinoma (HCC) with insu-fficient remnant liver volume.Methods:The clinical data of 51 patients with initially unresectable HCC due to insufficient remnant liver volume admitted to Zhejiang Provincial Tongde Hospital and Zhejiang Provincial People’s Hospital from January 2014 to December 2021 were retrospectively analyzed, including 37 males and 14 females, aged (56.7±11.2) years old. Patients were divided into two groups according to the treatment prior to hepatectomy: percutaneous microwave ablation liver partition combined with PVE (AP group, n=12) and TACE with PVE (TP group, n=39). Patients who successfully underwent planned hepatectomy in the above two groups were marked as resectable AP group ( n=10) and the resectable TP group ( n=29), respectively. Clinical data including the waiting time for surgery and the incidence of complications were analyzed. Patients were followed up by telephone or outpatient review. Kaplan-Meier and log-rank analysis were used for survival comparison. Results:The FLR growth rate was higher in AP group [76.5% (65.3%, 81.6%)] than that in TP group [31.4% (28.2%, 41.9%), P<0.01]. The waiting time for planned hepatectomy in the resectable AP group was 12.0 (11.3, 14.5) d, shorter than that in the resec-table TP group [21.0 (15.0, 29.0) d, P<0.05]. The incidence of postoperative complications was higher in the resectable AP group than that in the resectable TP group [80.0% (8/10) vs. 27.6% (8/29), P<0.05]. There was one perioperative death in the resectable AP group. The survival rate after PVE was lower in AP group than that in TP group, and the survival rate after hepatectomy was also lower in the resectable AP group than that in the resectable TP group (all P<0.05). Conclusion:For HCC patients with insufficient FLR, TACE combined with PVE is a safe and effective method for enlargement of liver remnant, whereas percutaneous microwave ablation liver partition with PVE showed a poor prognosis, despite the higher rate of FLR enlargement and shortened the waiting time for planned hepatectomy.
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Surgery-led comprehensive treatment is an important consensus in the management of liver carcinoma. Hepatectomy and liver transplantation are the most important means for patients with liver carcinoma to achieve long-term survival. With the development of liver surgery techniques, liver surgery is no longer off-limits. Translational therapy offers the hope of surgical radical treatment for patients with initially unresectable liver carcinoma. This article discusses the conversion therapy for unresectable liver carcinoma with future liver remnant surgery, the downstaging conversion therapy of oncologically unresectable intermediate to advanced liver carcinoma, the timing of surgery after conversion, and safety and efficacy. Prospect for the formation of the standardization of translational therapy for liver carcinoma is made.
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Malignant obstructive jaundice is caused by direct invasion or compression of the biliary tract by malignant tumors of the bile duct, pancreas and other systems. Patients are often accompanied by symptoms such as malnutrition, low immune function, and organ damage. The treatments of active preoperative biliary drainage and reasonable reinfusion combined with enteral nutrition can help improve the safety of patients during the perioperative period, reduce postoperative complications, and improve the life quality of patients. This article reviewed the research progress of preoperative biliary drainage, bile recycling methods and precautions in patients with malignant obstructive jaundice, aiming to provide reference for clinical diagnosis and treatment practice.
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Surgical resection is one of the important means to achieve long-term survival for patients with liver malignant tumor. However, most of the liver malignant tumor has been diagnosed in the middle and late stage, and lose the chance of surgical treatment. For these patients who have lost the chance of surgery, some surgeons have proposed the concept of planned liver resection, which is to reduce tumor stage and increase future liver remnant (FLR) in a planned way, so as to improve the safety of surgery and prolong the survival time of patients after surgery. For patients with FLR insufficiency after prior evaluation or/and treatment, the technique of hepatic hyperplasia is an important part of planned hepatectomy, that is, to effectively increase FLR in a short period of time by various means. Portal vein ligation (PVL) and portal vein embolization (PVE), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and liver venous deprivation (LVD) are three main techniques for hepatic hyperplasia. This article reviews the principle, effect and safety of three liver augmentation techniques.
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Objective:To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy (LPD) and to develop countermeasures in its prevention.Methods:The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed. The patients’ clinical data including gender, age, comorbidities and postoperative complications such as bleeding, pancreatic fistula, biliary fistula and intraperitoneal infection were studied, with the aims to analyze the causes, clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage (PPH) after LPD.Results:Of 215 patients, there were 132 males and 83 females, aged (60.7±10.3) years. PPH occurred in 20 patients, incidence rate was 9.30%(20/215). Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips, while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instruments or pseudoaneurysms. Among the 20 patients, 6 patients had early hemorrhage and 14 delayed hemorrhage. There was 1 patient with grade A, 10 with grade B and 9 with grade C hemorrhage. Thirteen patients developed pancreatic fistula, 1 biliary fistula, and 2 intraperitoneal infection. One patient responded well to conservative treatment. Hemostasis was successfully achieved by gastroscopy ( n=1) and interventional therapy ( n=7). Eleven patients required laparotomy for hemostasis. In this study, 14 of 20 patients survivied PPH and 6 patients died. The mortality rate was 30% (6 of 20 patients with PPH). Conclusions:Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips, while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instrument or pseudoaneurysm. Careful hemostasis, adequate protection of blood vessels, and accurate anastomosis should be performed in LPD. DSA angiography should be used for arterial hemorrhage which progressed very rapidly. Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH. Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.
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Objective:To compare the treatment outcomes between laparoscopic versus open radical resection for hilar cholangiocarcinoma (HCCA).Methods:From January 2017 to January 2020, the clinical data of 34 patients who underwent radical resection for HCCA were retrospectively collected and analyzed. These patients were divided into the laparotomy group ( n=17) and the laparoscopic group ( n=17) based on the operation they received. Clinical data including perioperative outcomes, oral re-intake time, first out-of-bed activity time, drainage tube removal time, postoperative hospital stay, 30-day and 90-day mortality rates were compared between groups. Results:Of 34 patients who underwent radical for HCCA in the study, there were 16 males and 18 females, aged (64.3±1.7) years. The mean operation time of the laparotomy group was significantly less than those in the laparoscopic group [(436.2±33.4) vs (522.1±24.0) min, P<0.05]. The 2 groups showed comparable results in extent of operation, intraoperative bleeding, incidences of portal vein reconstruction, yields of lymph nodes, and tumor diameter. The laparoscopic group showed advantage trends over the laparotomy group in incidences oral re-intake time [(4.7±0.3) vs (4.6±0.3) days], first out-of-bed activity time [(2.9±0.4) vs (2.2±0.3) days], drainage tube removal time [(12.7±1.3) vs (11.1±1.0) days] and postoperative hospital stay [(18.3±1.7) vs (15.8±1.3) days], but the differences failed to reach statistical significance ( P>0.05). Conclusion:Compared with open surgery, laparoscopic radical resection of HCCA in properly selected patients, was safe and feasible. There were comparable clinical outcomes.
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Objective:To study the technical and essential steps in laparoscopic selective devascularization with paraesophageal veins-preservation.Methods:To retrospectively analyze the clinical data of 13 cirrhotic patients who underwent laparoscopic selective pericardial devascularization for portal hypertension at the Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital from January 2019 to March 2020. There were 9 males and 4 females with age ranging from 41 to 83 years (median 51 years). The operative time, intraoperative blood loss, postoperative complications and follow-up data were analyzed.Results:All the 13 patients completed theoperation, no patient stopped the operation or transferred to laparotomy. The operation time was (170±32) min.The intraoperative bleeding was (160±30) ml. The postoperative hospital stay was (6.1±1.1) days. There were no complications, including pancreatic leakage and intra-abdominal infection. On follow-up which ranged from 1 to 15 months, one patient developed portal vein thrombosis, no upper gastrointestinal rebleeding.Conclusions:Preservation of esophageal veins in laparoscopic selective devascularization is an accurate surgery which requires close teamwork and rich experience in laparoscopic surgery. The preservation of the main trunk of the gastric coronary vein and integrity of the esophageal veins are the keys to the surgery which is safe and feasible.
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Pancreatic duct stone is a rare pancreatic disease in clinic, which is often associated with chronic pancreatitis, and could seriously damage the quality of life of patients, and even induce pancreatic cancer. The diagnosis is mainly based on imaging examination, and the treatment methods are diverse. It is necessary to follow the principle of individualized treatment and treat it as soon as possible. This article reviewed the etiology, mechanism, diagnosis, classification and treatment of the disease.
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OBJECTIVE@#To investigate the regulatory effect of metformin on regulatory T cells (Treg) in acidic environment.@*METHODS@#CD4 CD25 Treg cells were obtained by magnetic bead sorting. Treg and conventional T cells (Tcon) cells were cultured for 24-72 h in pH 7.4 or pH 6.7 medium, and the cell proliferation, apoptosis and Foxp3 expression were detected by flow cytometry. Real-time PCR was used to detect the expression levels of the genes related with glucose metabolism. Thirty-two C57BL/6 male mouse models bearing subcutaneous prostate cancer xenograft derived from RM-1 cells were randomized into 4 equal groups for treatment with PBS, metformin, tumor vaccine, or both metformin and the vaccine. The treatment started on the 4th day following tumor cell injection, and metformin (100 mg/kg) or PBS was administered by intraperitoneal injection on a daily basis; the vaccine was intramuscularly injected every 4 days. The tumor size was continuously monitored, and the mice were euthanized on day 25 after tumor implantation to obtain tumor and blood samples. Flow cytometry was used to detect the changes in CD4, CD8, CD4Foxp3 cell subsets in the tumor tissue and peripheral blood.@*RESULTS@#Treg cells showed significantly enhanced proliferation ( < 0.05) while the proliferation of Tcon cells was suppressed in acidic medium ( < 0.001). Treg cells cultured in acidic medium showed significantly increased expressions of OXPHOS-related genes pgc1a ( < 0.001) and cox5b ( < 0.01), which did not vary significantly in Tcon cells in acidic medium. Treg cells exhibited significantly decreased apoptosis in acidic medium ( < 0.01) with increased Foxp3 cells ( < 0.001) and intracellular alkaline levels ( < 0.01). Metformin obviously reversed the acid tolerance of Treg cells without producing significant effect on Tcon cells. In the animal experiment, both metformin ( < 0.05) and vaccine ( < 0.01) alone reduced the tumor volume, but their combined treatment more potently reduced the tumor volume ( < 0.001). Metformin alone did not obviously affect CD4 cells or CD8 cells but significantly decreased the percentage of CD4Foxp3 ( < 0.05); the vaccine alone significantly increased CD4 cells and CD8 cells ( < 0.001) and also the percentage of CD4Foxp3 cells ( < 0.05). The combined treatment, while reducing the percentage of CD4Foxp3cells to a level lower than that in the vaccine group ( < 0.01), produced the strongest effect to increase CD4 cells and CD8 cells ( < 0.01).@*CONCLUSIONS@#Metformin can inhibit the proliferation and function of regulatory T cells in an acidic environment and enhance the effect of tumor vaccine by reducing the proportion of Treg cells to achieve the anti-tumor effect.
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Animals , Male , Mice , Cell Proliferation , Forkhead Transcription Factors , Metformin , Mice, Inbred C57BL , T-Lymphocytes, RegulatoryABSTRACT
Objective To study the safety and feasibility of laparoscopy combined with holmium laser in the treatment of chronic pancreatitis complicated with pancreatic ductal stones.Methods To compare the clinical data in patients who underwent laparoscopy combined with holmium laser (10 patients,group A) with those who underwent laparoscopy only (21 patients,group B) at Zhejiang Provincial People' s Hospital from January 2012 to August 2018.The operation time,intraoperative blood loss,intraoperative conversion rate,pancreatic ductal incision length,postoperative pancreatic fistula rate,length of postoperative hospital stay,residual stone rate and relief of postoperative abdominal pain rate of the two groups were documented and analyzed.Results Three of 31 patients were converted to open surgery.The remaining patients in the two groups were discharged home without any perioperative death.Group A and B were significant differences in the pancreatic ductal incision length (5.0±0.8 vs.6.5±1.0) cm,operation time (289.3±51.6 vs.349.5± 34.7) min,and postoperative hospital stay (8.0± 1.2 vs.10.2± 1.6) d between the two groups (P＜0.05).There were no significant differences in the intraoperative conversion to open rate,intraoperative blood loss,postoperative pancreatic fistula rate,residual stone rate and relief of postoperative abdominal pain rate between the two groups (P ＞ 0.05).Conclusions It was safe and feasible to treat chronic pancreatitis complicated with pancreatolithiasis by laparoscopy.Laparoscopy combined with holmium laser had the added advantages of easy access through the pancreaticojejunostomy,shorter operation time,and less intraoperative blood loss.
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Objective To explore the value of transcatheter arterial chemoembolization (TACE) combined with portal vein embolization (PVE) prior to laparoscopic right hemihepatectomy (LRH) in the treatment of large liver tumor.Methods A retrospective study was conducted based on the clinical data of 8 patients with large liver tumor undergoing PVE combined with TACE before scheduled LRH,with 4 cases receiving simultaneous TACE + PVE and the other 4 cases doing sequential TACE + PVE.Results The interval between TACE and PVE was 14-29 d in sequential group,and the interval between PVE and surgery was 13-30 d.Patients in simultaneous treatment group encountered more prominent elevation of transaminase after PVE and TACE,but they recovered to comparable levels with the sequential group before surgery.The average standard future liver remnant (sFLR) increased from 35.3％ ± 4.9％ to 48.7％ ± 5.1％ before surgery.LRH was performed sucessfully in all patients with no conversion and perioperative death.Complications occurred in 2 cases,including pulmonary infection and bile leakage.The median hospital stay was 36 days.All patients were survival in the 25 months median follow up time including 2 recurrence cases.Conclusions TACE combined with PVE prior to LRH in the treatment of large liver tumor is safe and feasible.
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Objective To explore the safety and feasibility of laparoscopic hepatectomy combined with radiofrequency ablation for primary liver cancer difficult to manage.Methods A retrospective study was conducted to analyze the clinical data of 16 patients who underwent laparoscopic hepatectomy combined with radiofrequency ablation in the Zhejiang Provincial People's Hospital from Apr 2015 to Dec 2017.Results 2 more tumors were found by intraoperative laparoscopic ultrasound.All patients underwent laparoscopic hepatectomy combined with radiofrequency ablation successfully.There were 2 laparoscopic left hepatectomy combined with radiofrequency ablation,2 laparoscopic right hepatectomy combined with radiofrequency ablation,6 laparoscopic left lateral lobectomy combined with radiofrequency ablation,4 laparoscopic right postrior lobectomy combined with radiofrequency ablation and 2 irregular laparoscopic hepatectomy combined with radiofrequency ablation.The intraoperative blood loss ranged from 100-800 ml.The average operative time was (283 ± 112) min.The length of postoperative hospital stay ranged from 5 to 12 days.The tumor-free survival rate after operation is 100％ (16/16) on 6 to 38 months follow up.Conclusion It is safe and feasible to carry out laparoscopic hepatectomy combined with radiofrequency ablation in difficult to manage primary liver cancer.
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Objective To analyze the initial experience of total laparoscopic radical resection for patients with Bismuth type Ⅲa hilar cholangiocarcinoma.Methods A retrospective study was conducted to analyze the clinical data of three patients with Bismuth type Ⅲa hilar cholangiocarcinomatotal who underwent laparoscopic radical resection in Zhejiang Provincial People's Hospital from February to May in 2017.Results The three patients all underwent the operations successfully.The operation time ranged from 490.0 to 580.0 min.The intraoperative blood loss ranged from 300.0 ml to 1 200.0 ml.There was no severe perioperatire complication or death.One patient developed biliary leakage which responded to drainage without reoperation.Another patient developed pleural effusion treated with minimal invasive drainage.The length of postoperative hospital stay ranged from 10.0 to 18.0 days.Histopathology showed two patients with well-differentiated adenocarcinomas and one patient with poorly differentiated adenocarcinoma.The number of lymph nodes harvested ranged from 8 ～ 13.Two patients had no regional lymph node metastasis and one patient had regional lymph node metastasis (1/13).The hilar bile duct resection margins of the three patients were all negative.There was no evidence of tumor recurrence on following up for 7 ～ 10 months.Conclusions It was safe and feasible to carry out total laparoscopic radical resection in selected patients with Bismuth type Ⅲa hilar cholangiocarcinoma.More patients and longer follow-up are required to study the long term oncological results.
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Surgical resection is the first choice for liver cancer therapy.In order to transform the unresectable part into resectable one,surgeons manage to ensure adequate liver reserves by making the wanted liver tissue become hypertrophy and let the unwanted one become atrophy.However,though ALPPS (associating liver partition and portal vein ligation for staged sepatectomy) as an alternative operation plan in its initial developing stage now becomes a hot topic,it is still under great controversy.The author believes that it is imperative to draw up a personalized plan and carry out a strict and reasonable multicenter-clinical trial for those patients to get an opportunity to conduct a safe and effective operation.
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Objective To study the surgical treatment of xanthogranulomatous cholecystitis (XGC).Methods We retrospectively analyzed the clinical data of 56 patients with XGC who underwent surgical treatment at the Zhejiang Provincial People's Hospital from May 2010 to May 2017.Results The diagnosis of XGC was confirmed by histopathology.On preoperative examination of the 56 patients,42 patients had various degrees of increase in the CA19.9 levels,41 patients (73.2％) had thickened gallbladder walls with continuous mucosal linings on ultrasonography,CT,or MRI,and 18 patients (32.1％) had thickening of gallbladder walls with low density nodules.Gallbladder stones were present in 51 patients (91.1％) and 4 patients (7.2％) presented with Mirizzi syndrome.The 41 patients (73.2％) who were diagnosed as XGC before operation under laparoscopic surgery and 7 patients (17.1％) were converted to open surgery.The remaining 15 patients (26.8％) underwent open operation directly because of uncertainty in the diagnosis.All the patients had frozen section during operation.The postoperative pathological results included 21 localizedtype (37.5％) and 35 diffuse type (62.5％) of XGC.All 56 patients had no long-term complications on followed-up for 0.5～ 6 years.Conclusions XGC is a special kind of chronic cholecystitis.There is difficulty in differentiating from gallbladder cancer before surgery.The diagnosis of XGC mainly depends on ultrasonography,CT or MRI.Cholecystectomy is the treatment for XGC.Laparoscopic surgery is the first line treatment for XGC.
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The paper probed into key challenges in talents introduction of hospitals ,especially introduction strategy and practical considerations.In its"MVPPS"(Money ,Value ,Platform ,Promise , Service)theory framework ,V(value)is the core ,and P(platform)is the key ,while P(promise)and M (money ,remuneration)are the cornerstone.The hospital can attract excellent talents by means of common value ,reasonable material conditions ,ideal development platform and service ,and promises fulfilled ,thus achieving fast disciplines development .
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Objective To evaluate intraoperative ultrasound combined with near-infrared imaging in laparoscopic liver tumor resection.Methods 15 cases undergoing laparoscopic hepatectomy at our department from Ju12017 to Sep 2017 were enrolled in this study.We observed the volume of resected liver,ICG test,the ability of detected lesion overlooked by preoperative imaging,operation time,blood loss,hospital stay,postoperative complication,final pathological result,and tumor margin.Results We have done laparoscopic hepatectomy in 15 cases by intraoperative ultrasound and near-infrared imaging.There was no conversion to open surgery,blood loss was (220 ± 159) rnl,operation time was (136 ±6) min,hospital stay was (8.6 ± 2.1) d,tumor margin was (1.6 ± 1.1) cm,all were tumor negative.There was no major complications such as postoperative bleeding,nor perioperative death.There were pleuraleffusion in 3 cases and bile leakage in one,all were cured by drainage.Conclusion Intraoperative ultrasound combined with near-infrared imaging during the process of laparoscopic hepatectomy helps in assuring safe tumor margin and preserving normal liver parenchyma.
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Objective To investigate the effects of miRNAs-107 (miR-107) on pancreatic cancer proliferation,senescence and invasion.Methods MiR-107 expression levels in 3 pancreatic cancer cell lines PANC-1,ASPC-1,BXPC-3 and normal pancreatic HTERT-HPNE cells were studied by quantitative reverse transcription-polymerase chain reaction (qRT-PCR).PANC-1 cells were transfected with 50 nmol/L anti-miR-107 or negative control using Lipofectamine 2000.After transfection,the miR-107 expression was measured by qRT-PCR.Cell proliferation was tested by methylthiazol tetrazolium (MTT) assay.Cell senescence was detected by β-galactosidase staining.The expression levels of PCNA,P16INK4A and MMP2 were measured by qRT-PCR.Results Compared with the HTERT-HPNE cells,the expression level of miR-107 in 3 pancreatic cancer cell lines was significantly increased (P ＜ 0.01).After transfected with 50 nmol/L anti-miR-107,cell proliferation was inhibited,and cell senescence were increased in PANC-1 cells (P ＜ 0.05),and there was no obvious change in cell invasion.Compared with the HTERT-HPNE cells,after transfected with anti-miR-107,the PCNA expression was significantly decreased and P16INK4A was significantly increased,but expression of M MP2 didn't change significantly.Conclusions These results demonstrate that miR-107 promotes the proliferation and escapes cell senescence in PANC-1 cells by targeting PCNA and P16INK4A.But it has no obvious effects on cell invasion.Therefore,it may be a new target for the biologic therapy for pancreatic cancer.
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Objective To discuss the surgical treatment of intraductal papillary mucinous neoplasms of the pancreas (IPMN).Methods The clinical data of 42 IPMN cases undergoing surgical treatment in our hospital during the past 4 years were analyzed retrospectively.Results Routine CT or MRI examination was made in 42 cases,ERCP in 6 cases,ultrasonic endoscopy in 12 cases,fine needle biopsy by endoscopic ultrasonography in 4 cases.There were 12 cases of the main duct IPMN,24 cases of branch duct IPMN,6 cases of mixed IPMN.Pancreatoduodenectomy was performed in 24 cases;6 cases underuent laparoscopic central pancreatectomy;10 cases did distal pancreatectomy,2 cases did total pancreatectomy.Postoperative pathology revealed that the malignant transformation rate of main pancreatic duct type was 66.7％,that of BD-IPMN was 12.5％ and 66.7％ of Mix-IPMN.The postoperative complication rate was 26.2％.All cases were followed up for 1 month to 4 years,with no tumor recurrence.Conclusions Imaging examination combined with endoscopic ultrasonography is the main method for clinical diagnosis of IPMN.The malignant transformation rate of MD-IPMN and Mix-IPMN is high.Most of the BD-IPMN is hyperplasia and adenoma.
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Objective To explore the feasibility and safety of laparoscopic right hemihepatectomy (LRH) via anterior approach for larger tumors in the right lobe of the liver.Methods A retrospective study was conducted based on the clinical data of ten consecutive patients with large right liver cancer undergoing LRH through anterior approach and thirty-seven patients undergoing open hemihepatectomy by anterior approach in recent 6 years.Results Between the two groups there were no significant difference in gender,average age,the mean tumor size,preoperative liver reserve function,cut margin and intraoperative blood transfusion.The LRH group had less average intraoperative blood loss [(408 ± 158)ml vs.(520 ± 153)ml,t =2.047,P =0.046] and shorter postoperative hospital stay [(11.5 ±2.8)d vs.(16.2 ±4.6) d,t=3.091,P=0.003],longer operation time [(302 ±38)min vs.(251±55)min,t=2.732,P=0.009].There was no perioperative death and no significant difference in complications (20.0％ vs.35.1％,x2 =0.812,P =0.367) and similar median survival time (36 mon vs.29 mon,x2 =1.266,P =0.261).Conclusions LRH via anterior approach for larger tumors in the right lobe of the liver is safe and feasible.