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Surgical resection in patients with advanced primary carcinoma of liver has high risks of early recurrence and incidence of portal vein tumor thrombus, caused by insufficient resi-dual liver volume after two-steps hepatotomy. At present, the treatment for patients with advanced primary carcinoma of liver is limited, thus can't satisfy the requirement of patient for treatment. The authors introduce the clinical experience of a patient with hepatocellular carcinoma and insufficient residual liver volume who underwent preventive immunotherapy plus target therapy after associa-ting liver partition and portal vein ligation for staged hepatectomy, in order to provide reference for relevant treatment.
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Along with the development of liver transplant techniques, clinical efficacy of liver transplantation has been significantly improved, and the survival of the recipients and liver grafts has been remarkably prolonged. However, the source of organ donation after citizen' s death still fails to meet the requirement of liver transplantation. The shortage of donor liver limits further development of liver transplantation. In recent years, living donor liver transplantation has been widely used in the treatment of patients with end-stage liver disease as one of the means to resolve organ shortage. As a special type of living donor liver transplantation, right posterior segmental graft liver transplantation provides a novel solution for expanding the potential donor pool for living donor liver transplantation. In this article, the development profile of living donor liver transplantation, donor selection of right posterior segmental graft for living donor liver transplantation, anatomical challenges of right posterior segmental graft procurement and surgical skills of right posterior segmental graft procurement were reviewed. Moreover, the prospect of right posterior segmental graft for living donor liver transplantation was predicted, aiming to promote the development of liver transplantation in clinical practice and bring benefits to more patients with end-stage liver diseases.
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Objective:To investigate the application value of dynamic scintigraphy single-photonemission computed tomography (SPECT) 99m-technetium-galactosyl human serum albumin diethy-lenetriamine pentaacetic ( 99Tc m-GSA) scintigraphy in assessing liver function of perihilar cholangio-carcinoma after portal vein embolization (PVE). Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 16 patients with perihilar cholangiocarcinoma who underwent 99Tc m-GSA scintigraphy after PVE in Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University from October 2019 to January 2021 were collected. There were 8 males and 8 females, aged from 46 to 78 years, with a median age of 64 years. Observation indicators: (1) liver volume after PVE; (2) liver function after PVE; (3) typical case analysis. Measurement data with normal distribution were represented as Mean± SD. Count data were represented as absolute numbers or percentages. Comparison of data of the same patient was analyzed using the paired t test. Results:(1) Liver volume after PVE:the morphological liver volume and functional liver volume for the 16 patients were (1 420±211)mL and (389±112)mL. The morphological liver volume and functional liver volume were (636±143)mL and (234±106)mL of planning reserved lobe, (784±210)mL and (151±106)mL of planning resection lobe, respectively. The functional liver density (FLD) of planning reserved lobe and planning resection lobe were 0.36±0.12 and 0.19±0.11, showing a significant difference between them ( t=3.794, P<0.05). The planning resection rate of morpholo-gical liver volume and functional liver volume were 37.8%±0.6% and 54.8%±0.2%, showing a significant difference between them ( t=?3.720, P<0.05). (2) Liver function after PVE: 13 of 16 patients completed the indocyanine green (ICG) test, and 3 patients didn't complete the ICG test due to intolerance. For the 13 patients undergoing ICG test, the total ICG-K value was (0.15±0.03)/minutes, and the ICG-K value of planning reserved lobe was (0.07±0.02)/minutes. The total GSA-K value of 16 patients was (0.14±0.10)/minutes, and the GSA-K value of planning reserved lobe was (0.08±0.06)/minutes. (3) Typical case analysis: a 46-year-old male patient with type Bismuth Ⅲa perihilar cholangiocarcinoma was planned to perform perihilar hepatectomy combined with right hepatectomy. The imaging evaluation showed that the volume of reserved liver lobe accounted for 27% of the total liver volume. The serum total bilirubin was 256 μmol/L when admitted and decreased to 118 μmol/L on the day 5 after percutaneous transhepatic biliary drainage. The right anterior and right posterior branches of PVE was performed. SPECT 99Tc m-GSA examination was performed on the day 37 after PVE. The morphological liver volume was 559 mL of planned reserved lobe and 1 461 mL of the whole liver. The planned morphological liver volume resection rate was 61.7%. ICG-K was 0.12/minutes of the whole liver, and 0.04/minutes of planned reserved lobe. The functional liver volume was 134 mL of planned reserved lobe and 309 mL of the whole liver. The planned resection rate of functional liver volume was 56.6%. The GSA-K was 0.20/minutes of the whole liver and 0.09/minutes of planned reserved lobe. R 0 resection was achieved in perihilar hepatectomy combined with right hepatectomy and no liver failure occurred. The survival time of patients was 11 months. Conclusion:Dynamic SPECT 99Tc m-GSA scintigraphy can effectively evaluate the regional function of the reserved liver lobe in patients with perihilar cholangiocarcinoma after PVE.
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The concept of precision medicine has brought revolutionary changes to human health and medical treatment. In a broad sense, precision medicine is the application of advanced technologies such as gene sequencing, digital medicine, artificial intelligence, navigation technology, and biomedical engineering to clinical, basic, and public health medical research and practice. The purpose is to promote the continuous development of medical standards. The concept of precision surgery was first proposed by academician Dong Jiahong, who has played an exemplary role in the field of liver surgery for the oncology and other professional fields of surgery. The development and application of computer-assisted surgery systems have promoted the development of precision liver surgery. The digital liver three-dimensional reconstruction provides a new basis for liver vascular anatomy and liver segmentation, assists in the realization of individualized surgical planning, and the measurement of residual liver volume guarantees the safety of operation. The great progress of adult precision liver surgery has provided important help and guidance for the development of pediatric liver surgery. Compared with adults, pediatric liver tumors have their particularities. Pediatric liver tumors are often huge, complex in location, fast growing, and highly malignant. Most children do not have liver cirrhosis and are sensitive to chemotherapy. The liver volume changes greatly with age and weight. These differences determine that the treatment of liver tumors in children needs to adopt different models, and the diagnosis and treatment standards need to be improved. The authors elaborate on the topic of "from adult to child-the development and prospect of precision liver surgery" to promote precision surgery and comprehensive treatment of liver tumors.
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BACKGROUND: Multi-slice spiral CT and high-field MRI are often used in the precise treatment of the liver, to analyze the parameters related to liver parenchymal disease, Child-Pugh classification, portal hypertension and ICG retention rate. By using these two methods, reserve function of the residual liver can be relatively accurately evaluated, and safe limit of liver resection in individual patients can be determined. OBJECTIVE: To investigate the clinical superiority of three-dimensional reconstruction technology in precision liver surgery. METHODS: Randomly selected 100 primary liver cancer patients who had undergone resection at Liaoning Cancer Hospital & Institute in China were divided into a control group, in which two-dimensional CT examinations were used for empirical evaluation of tumor location, resection scope and residual liver volume and routine Pringle method was used for hepatic portal block intraoperatively, and an experimental group, in which three-dimensional reconstruction system was used preoperatively for stereoscopic imaging of intrahepatic conditions, perihepatic ducts and tumor traits and location, as well as for quantitative assessment of liver resection scope and residual volume, and selective hepatic occlusion was used intraoperatively. Postoperative liver resection volume and preoperative imaging evaluation were compared between groups, and postoperative recovery of patients was observed. The study protocol was implemented in line with the relevant ethical requirements of Liaoning Cancer Hospital & Institute. Participants and their families were fully informed of treatments and gave informed consent. RESULTS AND CONCLUSION: Resected tumor volume and planned resection volume were insignificantly different in the experimental group, but significantly different in the control group (P < 0.05). Length of hospital and incidence of postoperative complications were significantly higher in the control group than the experimental group (P < 0.05). At 1 month postoperatively, the levels of serum insulin-like growth factor II, human transforming growth factor alpha, epidermal growth factor and alpha-fetoprotein were significantly decreased in the experimental group as compared with the control group (P < 0.05). The level of alanine aminotransferase tended to be normal in the experimental group relative to the control group at 14 days postoperatively. Postoperative abdominal drainage was gradually decreased in both two groups, but the drainage volume was significantly lower in the experimental group than the control group (P < 0.05). At 1 month postoperatively, the Karnofsky scores of the two groups were significantly higher than those preoperatively (P < 0.05), and the experimental group had significantly higher scores than the control group (P < 0.05). The total effective rate of the control group was significantly lower than that of the test group (92% vs. 100%; P < 0.05). To conclude, in contrast to traditional CT imaging technology, three-dimensional liver reconstruction technology can more accurately assess tumor volume before surgery, reduce intraoperative risks, shorten hospitalization time and reduce the incidence of postoperative complications.
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ObjectiveTo investigate the feasibility of a combination of gadolinium?ethoxybenzyl?diethylenetriamine pentaacetic acid (Gd?EOB?DTPA) enhanced MR T1 mapping and liver volume to standard liver volume ratio in quantitative assessment of liver function. Methods Eighty patients who underwent Gd?EOB?DTPA enhanced MR T1 mapping were prospectively enrolled, and the Child?Pugh score and the model for end?stage liver (MELD) score were evaluated and grouped. Patients were divided into three groups according Child?pugh score as follows: normal liver function (NLF, n=26), liver cirrhosis with Child?Pugh A (LCA,n=30), liver cirrhosis with Child?Pugh B+C (LCB+LCC, n=24), and were also divided into two groups according MELD, MELD≤8 (n=57) and MELD≥9 (n=23). Variable flip angle T1 mapping sequences were performed before and 20 minutes after Gd?EOB?DTPA administration. T1pre, T1 post were measured on T1 maps and ΔT1 were calculated. The images of hepatobiliary phase were transferred to the workstation to measure liver volume (LV). Standard liver volume (SLV) were calculated with the heights and weights of patients, and then liver volume to standard liver volume ratio (LV/SLV) was calculated. One?way ANOVA was used to compared the indexes (T1 post, T1 post×LV/SLV, ΔT1, ΔT1×LV/SLV) in different liver function groups of NLF,LCA,LCB+LCC. The t tests were used to compare the indexes(T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV) in MELD≤8 and MELD≥9 groups. ROC curve analysis was used to compare the diagnostic performance of T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV. Results T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV showed significant difference between different liver function groups (P<0.05). All the indexes can distinguish different groups. Multiplied by LV/SLV,the AUC of ΔT1×LV/SLV were 0.902 in the MELD≤8 and MELD≥9,which was slightly higher than that of ΔT1 (AUC=0.886). The AUCs of ΔT1×LV/SLV were 0.771, 1.000, 0.924 in the NLF and LCA, NLF and LCB+LCC, LCA and LCB+LCC groups, which were slightly higher than that of ΔT1 (0.764, 0.992, 0.904). The AUCs of T1post, T1post×LV/SLV were 0.824, 0.789 in the MELD≤8 and MELD≥9, respectively. The AUCs of T1post in the NLF and LCA, NLF and LCB+LCC, LCA and LCB+LCC groups were 0.713,0.987,0.915, respectively, and the AUCs of T1post×LV/SLV were 0.687,0.973,0.871.The AUCs of T1post×LV/SLV had a slightly lower AUC amongthe different liver function groups than T1post. Conclusion Gd?EOB?DTPA enhanced MRI T1 mapping is useful for estimating liver function. T1 relaxation times and reduction rates of T1 relaxation times with a combination of the LV/SLV may more reliably estimate liver function.
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Objective@#To investigate the feasibility of a combination of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced MR T1 mapping and liver volume to standard liver volume ratio in quantitative assessment of liver function.@*Methods@#Eighty patients who underwent Gd-EOB-DTPA enhanced MR T1 mapping were prospectively enrolled, and the Child-Pugh score and the model for end-stage liver (MELD) score were evaluated and grouped. Patients were divided into three groups according Child-pugh score as follows: normal liver function (NLF, n=26), liver cirrhosis with Child-Pugh A (LCA,n=30), liver cirrhosis with Child-Pugh B+C (LCB+LCC, n=24), and were also divided into two groups according MELD, MELD≤8 (n=57) and MELD≥9 (n=23). Variable flip angle T1 mapping sequences were performed before and 20 minutes after Gd-EOB-DTPA administration. T1pre, T1 post were measured on T1 maps and ΔT1 were calculated. The images of hepatobiliary phase were transferred to the workstation to measure liver volume (LV). Standard liver volume (SLV) were calculated with the heights and weights of patients, and then liver volume to standard liver volume ratio (LV/SLV) was calculated. One-way ANOVA was used to compared the indexes (T1post, T1 post×LV/SLV, ΔT1, ΔT1×LV/SLV) in different liver function groups of NLF,LCA,LCB+LCC. The t tests were used to compare the indexes (T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV) in MELD≤8 and MELD≥9 groups. ROC curve analysis was used to compare the diagnostic performance of T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV.@*Results@#T1post, T1post×LV/SLV, ΔT1, ΔT1×LV/SLV showed significant difference between different liver function groups (P<0.05). All the indexes can distinguish different groups. Multiplied by LV/SLV,the AUC of ΔT1×LV/SLV were 0.902 in the MELD≤8 and MELD≥9,which was slightly higher than that of ΔT1 (AUC=0.886). The AUCs of ΔT1×LV/SLV were 0.771, 1.000, 0.924 in the NLF and LCA, NLF and LCB+LCC, LCA and LCB+LCC groups, which were slightly higher than that of ΔT1 (0.764, 0.992, 0.904). The AUCs of T1post, T1post×LV/SLV were 0.824, 0.789 in the MELD≤8 and MELD≥9, respectively. The AUCs of T1post in the NLF and LCA, NLF and LCB+LCC, LCA and LCB+LCC groups were 0.713,0.987,0.915, respectively, and the AUCs of T1post×LV/SLV were 0.687,0.973,0.871.The AUCs of T1post×LV/SLV had a slightly lower AUC amongthe different liver function groups than T1post.@*Conclusion@#Gd-EOB-DTPA enhanced MRI T1 mapping is useful for estimating liver function. T1 relaxation times and reduction rates of T1 relaxation times with a combination of the LV/SLV may more reliably estimate liver function.
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Objective: To assess the value of residual liver volume ratio measured with CT for preoperative evaluation in pediatric hepatoblastoma. Methods Totally 40 hepatoblastoma patients confirmed by pathology with the average age of (1.8±0.8)years were enrolled. All patients underwent pre-operation enhanced CT scan. The total liver volume, the predicted resected liver volume were measured, and the standard liver volume, the residual liver volume were calculated, respectively. The residual liver volume ratio was calculated with the formula of residual liver volume ratio=residual liver volume/standard liver volume×100%. The volume of the actual resected liver was measured by water immersion method and then compared with the volume of the pre-resected liver measured with CT. ROC curve was used to evaluate the efficacy of residual liver volume ratio for prediction of moderate and severe liver dysfunction. Results: The predicted resected liver volume and actual resected liver volume was (393.62±216.54)cm3 and (388.38±207.56)cm3, respectively, with no significant difference (t=1.679, P=0.101). The residual liver volume was (234.55±70.42)cm3, and the residual liver volume ratio was (63.64±13.70)%. AUC of ROC curve for prediction of moderate and severe liver dysfunction was 0.837 (P=0.016), the critical value was 56.32%, and the sensitivity and the specificity was 86.7% and 70.0%, respectively. Conclusion: The preoperative calculation of residual liver volume ratio with CT in children with hepatoblastoma is a great value in the selection of surgical option and evaluation of postoperative liver function.
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Objective: To explore the correlation between standard remnant liver volume(SRLV) and post-hepatectomy liver failure (PHLF)in patients with hepatocellular carcinoma(HCC)and cirrhotic livers.Methods:In total,181 patients who underwent hemihepa-tectomy in Affiliated Tumor Hospital of Guangxi Medical University from September 2013 to August 2016 were enrolled in the study. Total liver,tumor,remnant liver,and resected liver volumes were measured using the Myrian liver surgical planning system before sur-gery. Intraoperative resected liver volume (including resected normal liver and tumor volumes) were collected using the drainage method.The patients were divided into the PHLF(22 cases)and non-PHLF groups(159 cases)according to whether PHLF occurred based on the"50/50"criteria.The risk factors of PHLF were then explored.The cut-off of SRLV and efficiency of predicting PHLF were analyzed in the subgroup of patients with cirrhotic livers.The grade of liver cirrhosis was retrospectively analyzed using helical comput-ed tomography(CT).Results:Twenty-two of the 181 patients developed PHLF and one died of it.Preoperative total bilirubin levels and SRLV were identified as independent factors for predicting PHLF using a Logistic regression model.In total,102 patients with cirrhotic livers were selected in subgroup analysis based on postoperative cirrhotic pathology.Eighteen patients developed PHLF and one died of PHLF in the subgroup.Using receiver-operating characteristic(ROC)curve analysis,340 mL/m2was the cut-off of SRLV for patients with HCC and cirrhotic livers(area under the curve:0.861,P<0.01;sensitivity and specialty rates were 94.4% and 74.7%,respectively). Eighty-four cases were of grade Ⅰ or Ⅱ cirrhosis,18 cases were of grade Ⅲ cirrhosis,and there were no cases of grade Ⅳ cirrhosis based on retrospective analysis using helical CT.Conclusions:Patients with cirrhotic livers with an anticipated SRLV of≤340 Ml/m2after he-patic resection are at increased risk for PHLF after emihepatectomy.
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Objective To explore the relationship between the liver volume atrophy rate,liver stiffness measurements(LSM) and Child-Turcotte-Pugh(CTP) value with the Laennec histopathological classification in the patients with hepatitis B cirrhosis and its value in the quantitative diagnosis of liver cirrhosis degree.Methods The clinicopathological data of liver biopsy tissue pathological slides,FibroScan,CT examination and hematological detection in 32 cases of hepatitis B cirrhosis were retrospectively analyzed.Liver cirrhosis was divided into mild,moderate and severe according to the Laennec liver cirrhosis histopathological classification.Then the relationship between the liver volume atrophy rate,LSM and CTP score with liver cirrhosis histopathological.Results Among 32 cases,9 cases(28.12％) were mild,12 cases(37.50％) were moderate and 11 cases(34.38％) were severe.The liver volume atrophy rates of mild,moderate and severe groups were (16.75±2.20)％,(23.11±6.67)％ and(35.55±5.70)％ respectively;LSM were(14.96±3.36),(20.21± 3.07),(37.03 ± 16.44) kPa respectively,the difference among 3 groups was statistically significant (P＜ 0.01).The CTP scores had no statistical difference among the 3 groups were(P＞0.05).The cirrhosis histopathological grade had the positive correlation with the liver volume atrophy rate and LSM(r=0.93,0.74,P＜0.01),however had no obvious correlation with the CTP scores(r=0.27,P＞0.05);the liver volume atrophy rate was positively correlated with LSM and CTP score(r=0.90,0.91,P＜0.01);while LSM had no obvious correlation with CTP score (r =0.15,P ＞ 0.05).Conclusion The more severe the cirrhosis histoathological grade,the bigger the liver volume atrophy rate and the higher the FibroScan detection value;the liver volume atrophy rate and LSM may serve as the quantitative diagnosis indicators of liver fibrosis histopathological severity.
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Objective To probe the value of both liver volume(LV)measurement and Gd-EOB-DTPA enhanced MRI to evaluate hepatic reserve function in order to obtain a better assessment method.Methods Clinical and imaging data of 42 patients with hepatic focal lesions were analyzed retrospectively.Gd-EOB-DTPA enhanced MRI scan,Child-Pugh scoring and ICG clearance tests were performed in all patients,and the liver relative enhancement (RE)and LV were used to assess the hepatic reserve function.The differences of LV, LV/standard liver volume (SLV)and RE between the Child-Pugh class A and B were compared using independent student's t-test. Spearman correlation analysis was applied to analyze the relationship of indocyanine green retention rate at 1 5 minutes (ICG-R1 5) with the LV,LV/SLV,RE,RE×LV and RE×LV/SLV.Results There was no significant difference in LV between two groups(P>0.05), whereas the RE had significant difference(P=0.039).There were no significant correlations between ICG-R15 and LV,LV/SLV(P>0.05). ICG-R1 5 was negatively correlated with RE,RE×LV and RE×LV/SLV,and RE×LV/SLV showed significant correlation with ICG-R15 (r=-0.524,P=0.000).Conclusion Gd-EOB-DTPA enhanced MRI can assess the status of hepatic reserve function, while the combination of RE with LV is a more effective method.
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Objective Toidentify factors contributing to posthepatectomy liver dysfunction (PHLD),focusing on the Functional remnant liver volume to spleen volume ratio (FreLSVR).Methods The clinical data of 74 patients undergoing precise liver resection from January 2016 to October 2017 were retrospectively analyzed.IQQA liver system was used to reconstruct the liver and spleen 3D image by using patients' preoperative abdominal CT image data.Tumor volume,3D estimated functional residual liver volume,spleen volume and FreLSVR were measured and calculated.Preoperative and postoperative liver function test,blood coagulation function test,operation time,intraoperative blood loss,and the volume of daily postoperative abdominal drainage were recorded.Correlations between multiple parameters and PHLD were analyzed.Results PHLD occurred in 16 (21.6％).Single factor analysis revealed that the standardized residual liver volume ratio (P＜0.05),FreLSVR (P＜0.05) and preoperative AST value (P＜0.05) were correlated with postoperative hepatic insufficiency.Multivariate regression analysis showed that FreLSVR (OR=0.535,95％CI=0.305～0.936,P＜0.05) was the only independent factor of PHLD.In the ROC curve analysis for FreLSVR,a cut-off value of 2.56 (AUC=0.824,Sensitivity 81.1％,specificity 71.7％.) was the appropriate value for predicting the risk of PHLD according to Youden index.Then the patients were regrouped according to this cut-off value.Compared with the FreLSVR＞2.56 group (53 cases),the highest postoperative INR value (1.46± 0.19 to 1.29± 0.29,t=-2.405,P＜0.05) was higher that of FreLSVR≤2.56 group,and the amount of average daily abdominal drainage in one and two weeks after operation was higher,(188.0(79.2 ～ 375.1)ml to 96.0(46.5 ～ 179.3)ml,P＜0.05) and (207.2(125.6 ～ 827.1)ml to71.8(14.0 ～ 179.8) ml,P＜0.05),respectively.Conclusion FreLSVR has significant correlation with postoperative hepatic dysfunction,and provides guidance for the safety of liver resection in the future.
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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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PURPOSE: The present study developed formulas for estimation of standard liver volume (SLV) with high accuracy for the Korean population. MATERIALS AND METHODS: SLV estimation formulas were established using gender-balanced and gender-unbalanced measurements of anthropometric variables, body composition variables, and abdominal geometry of healthy Koreans (n=790). Total liver volume excluding blood volume, was measured based on CT volumetry. RESULTS: SLV estimation formulas as preferred in various conditions of data availability were suggested in the present study. The suggested SLV estimation formulas in the present study were found superior to existing formulas, with an increased accuracy of 4.0–217.5 mL for absolute error and 0.2–18.7% for percentage of absolute error. CONCLUSION: SLV estimation formulas using gender-balanced measurements showed better performance than those using gender-unbalanced measurements. Inclusion of body composition and abdominal geometry variables contributed to improved performance of SLV estimation.
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Blood Volume , Body Composition , LiverABSTRACT
Objective To classify the types of hepatic vein and to measure their corresponding liver venous drainage volumes based on analysis of data obtained from a computer-assisted surgery system with an aim to provide an anatomical basis on individualized anatomical hepatectomy.Methods Thin-layer computed tomography (CT) imaging on 570 patients were reconstructed using the Hisense CAS.The types of hepatic vein were classified according to their anatomical variations.The margins of the hemilivers or sectors and their corresponding hepatic venous drainage volumes were displayed.Results The major hepatic veins were classified into three types:Type Ⅰ (270/570,47.4％),type Ⅱ (294/570,51.6％),and type Ⅲ (6/570,1.0％).The left hepatic vein (LHV) was classified as type Ⅰ in 190/570 (33.3％),type Ⅱ in 79/570 (13.9％),and type Ⅲ in 301/570 (52.8％).The middle hepatic vein (MHV) was classified as type Ⅰ in313/570 (54.9％),type Ⅱ in 174/570 (30.5％),and type Ⅲ in 83/570 (14.6％).The right hepatic vein (RHV) was classified as type Ⅰ in 456/570 (80.0％),type Ⅱ in 79/570 (13.9％),and type Ⅲ in 35/570 (6.1％).Type Ⅰ was further classified into four subtypes of A (26/456,5.7％),B (404/456,88.6％),C (20/456,4.4％),and D (6/456,1.3％).The LHV volume was (25.0± 6.6) ％,the MHV volume was (34.8 ± 9.5) ％ and the RHV volume was (25.1 ± 11.6) ％ in 63 patients with inferior right hepatic veins (IRHV).The IRHV and other branches volumes were (14.7 ± 7.4) ％.The RHV volume was (40.7 ± 8.6) ％ in 68 patients without IRHV.Conclusions Hepatic venous variations are complex.Significant differences existed in the hepatic venous drainage volumes.The Hisense CAS clearly delineated the relationship between the intrahepatic vascular structures and the liver carcinoma which hopefully can lead to improvement in the success rate of complex hepatectomy.
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Objective To compare the clinical efficacy and postoperative liver function in patients with primary hepatic carcinoma treated by transcatheter arterial chemoembolization(TACE) or TACE combined with portal vein chemoembolization.Methods 48 patients with primary hepatic carcinoma, randomly divided into 2 groups (hepatic artery group in 25 cases and dual interventional group in 23 cases),underwent interventional treatment.The hepatic artery group underwent conventional hepatic artery interventional therapy, while the dual interventional group underwent hepatic artery and portal vein interventional treatment.The postoperative clinical efficiency, liver volume and liver function between the two groups'' patients were compared.Results To the endpoint of observation,the clinical efficacy and tumor reduction degree of dual interventional group were better than that of hepatic artery group.Compared with hepatic artery group, the postoperative ALT, AST and TBIL of dual interventional group were higher on the first and third days.On the seventh and fourteenth days, the statistical difference was not significant.The volume of non-embolization part in dual interventional group was larger than that in preoperative volume to different degrees.The most obvious change of liver volume happened in the 4th weeks after treatment.There was no treatment-related death or severe adverse reaction in two groups.Conclusion The treatment of TACE combined with portal vein chemoembolization is a safe and effective method, which may effectively inhibit the growth and reduce the volume of tumor, and result in compensatory hypertrophy of non-embolization part.
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Objective:To investigate the value of indocyanine green retention rate at 15 minutes (ICG R15) on postoperative day 3 combined with standard remnant liver volume (SRLV) in predicting the occurrence of liver dysfunction after hepatectomyin hepatocellular carcinoma (HCC).Methods:The clinical data of 61 HCC patients undergone hepatectomy in Xiangya Hospital of Central South University from January 2015 to February 2016 were collected and analyzed.The patients were divided into 2 groups:a normal liver function group (n=40) and a liver dysfunction group (n=21).Univariate analysis was used to evaluate the risk factors for postoperative liver dysfunction.Logistic regression was used to assess the independent risk factors for postoperative liver dysfunction,and the regression equation between independent risk factors and postoperative liver dysfunction was established,The receiver operating characteristic (ROC) curve was used to examine the regression equation and compare the value difference in predicting postoperative liver dysfunction between single and combined independent risk factors.Results:Postoperative liver dysfunction occurred in 21 of the 61 patients,with an incidence rate at 34.4％.There was no significant difference in the time of operation,time of hepatic portal occlusion,volume of tumor and volume of resected liver between the 2 groups (all P＞0.05),but there were significant differences in the ICG R15 on postoperative day 3,intraoperative blood loss and SRLV between the 2 groups (all P＜0.05).The ICG R15 on postoperative day 3,intraoperative blood loss,SRLV were the risk factors for postoperative liver dysfunction.Logistic regression analysis showed ICG R15 on postoperative day 3 and SRLV were the independent risk factors for postoperative liver dysfunction,and the regression equation between independent risk factors and postoperative liver dysfunction was as follows:logit(P)=1.277+0.140×ICG R15 on postoperative day 3-5.125×SRLV.The area under the ROC curve ofICG R15 on postoperative day 3 combined with SRLV was more than that of single ICG R15 and single SRLV.Conclusion:ICG R15 on postoperative day 3 and SRLV are the independent risk factors for postoperative liver dysfunction.The regression equation,which is established by combination of ICG R15 with SRLV,can predict the occurrence of postoperative liver dysfunction.The accuracy of ICG R15 on postoperative day 3 combined with SRLV is better than that of single ICG R15 or single SRLV.
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Objective To evaluate the feasibility and efficacy of preoperative sequential transcatheter arterial chemoembolization (TACE) followed by selective portal venous embolization (PVE) in patients with marginally resectable hepatocellular carcinoma (HCC).The aim was to find out whether this combined procedure helped to increase the rate of extended radical liver resection.Methods From March 2009 to November 2016,29 patients with HCC which were marginally resectable underwent preoperative TACE combined with PVE were included into this study.All these patients were subsequently assessed to undergo radical hepatectomy.The complications,laboratory results,volume changes of each liver lobe and patient survival were analyzed.Results TACE combined with PVE was successful in all the 29 patients.There were no major complications.After the procedure,the volumes of the tumor and the part of the liver to be resected decreased to certain degree.The remnant liver volume (RLV) increased remarkably.The RLV were (395.4 ±58.7) cm3 and (599.2 ±75.2) cm3 before and after the procedure,respectively.The difference was significant (P ＜ 0.05).19 patients underwent radical hemihepatectomy or trisectionectomy,with a resection rate of 65.5％ (19/29).There were sufficient surgical margins in all the resected tumors.After operation,the 1-,3-,and 5-year survival rates were 58.8％,35.5％ and 17.6％,respectively.Conclusion For HCC patients who had marginally resectable HCC,preoperative TACE combined with PVE efficiently controlled the growth of the tumors,decreased the volume of the liver lobe with tumor,increased the RLV,and made it possible for a planned two-stage radical hepatectomy with sufficient surgical margin and better survival in a significant proportion of patients.
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Objective To classify the types of hepatic vein and to measure their corresponding liver venous drainage volumes based on analysis of data obtained from a computer-assisted surgery system with an aim to provide an anatomical basis on individualized anatomical hepatectomy.Methods Thin-layer computed tomography (CT) imaging on 570 patients were reconstructed using the Hisense CAS.The types of hepatic vein were classified according to their anatomical variations.The margins of the hemilivers or sectors and their corresponding hepatic venous drainage volumes were displayed.Results The major hepatic veins were classified into three types:Type Ⅰ (270/570,47.4％),type Ⅱ (294/570,51.6％),and type Ⅲ (6/570,1.0％).The left hepatic vein (LHV) was classified as type Ⅰ in 190/570 (33.3％),type Ⅱ in 79/570 (13.9％),and type Ⅲ in 301/570 (52.8％).The middle hepatic vein (MHV) was classified as type Ⅰ in313/570 (54.9％),type Ⅱ in 174/570 (30.5％),and type Ⅲ in 83/570 (14.6％).The right hepatic vein (RHV) was classified as type Ⅰ in 456/570 (80.0％),type Ⅱ in 79/570 (13.9％),and type Ⅲ in 35/570 (6.1％).Type Ⅰ was further classified into four subtypes of A (26/456,5.7％),B (404/456,88.6％),C (20/456,4.4％),and D (6/456,1.3％).The LHV volume was (25.0± 6.6) ％,the MHV volume was (34.8 ± 9.5) ％ and the RHV volume was (25.1 ± 11.6) ％ in 63 patients with inferior right hepatic veins (IRHV).The IRHV and other branches volumes were (14.7 ± 7.4) ％.The RHV volume was (40.7 ± 8.6) ％ in 68 patients without IRHV.Conclusions Hepatic venous variations are complex.Significant differences existed in the hepatic venous drainage volumes.The Hisense CAS clearly delineated the relationship between the intrahepatic vascular structures and the liver carcinoma which hopefully can lead to improvement in the success rate of complex hepatectomy.
ABSTRACT
Objective To investigate the effect of portal vein ligation combined with in situ splitting on liver regeneration in rats .Methods Seventy-five healthy male Sprague-Dawley rats were selected and randomly assigned into sham operation group ( S) , portal vein ligation group ( PVL) and portal vein ligation combined with in situ splitting group ( ALPPS) .On 1 d, 3 d, 7 d, 10 d, 14 d after operation , the hepatic regeneration rate ( HRR) of right median lobe was calculated , the serum alanine aminotransferase ( ALT) , aspartate aminotransferase (AST), IL-6, HGF, VEGF were detected.mRNA of IL-6, HGF, TNF-α, TGF-βwas assayed by real-time PCR, and the hepatic proliferating cell nuclear antigen ( PCNA) labeling index was evaluated by immunohistochemistry .Results Comparing with PVL group , the HRR of the right median lobe obviously increased on day 3, 7, 10 and 14 in ALPPS group (P<0.05), and ALT and AST level were increased on 1 d (P<0.05).On day 1 and 3, the content of serum IL-6, HGF and VEGF were all in-creased in ALPPS group [(70.7 ±14.6) pg/ml vs.(134.2 ±31.4) pg/ml; (0.70 ±0.04) ng/ml vs. (0.74 ±0.02) ng/ml;(82.1 ±12.6) pg/ml vs.(103.5 ±14.7) pg/ml], respectively (P<0.05).The mRNA expression of IL-6, HGF, TNF-α, TGF-βand the PCNA labeling index were also increased in ALPPS group in comparison with those in PVL group on day 1 and 3 (P<0.05).All the indexes in the two groups were all higher than those in the group S ( P<0 .05 ) .Conclusions Portal vein ligation combined with in situ splitting could significantly enhance liver regeneration .The possible mechanisms were related to the inflammation reaction and stress response caused by in situ splitting and up-regulation of cytokines in the regenerating lobe after portal vein ligation combined with in situ splitting , especially IL-6, HGF and TNF-α.