Cistoadenoma mucinoso biliar: Un reto diagnóstico / Mucinous biliary cystadenoma: A diagnostic challenge

Introducción. El cistoadenoma mucinoso biliar es una neoplasia rara con alta probabilidad de malignidad. Su diagnóstico es un reto ya que se asemeja a otras masas benignas que pueden encontrarse en el hígado. Caso clínico. Mujer de 21 años con sensación de masa en hipocondrio derecho, a quien se le realizan marcadores tumorales y estudios de imágenes concluyendo que se trataba de un cistadenoma mucinoso biliar. Resultado. Se presenta el caso de una paciente con cistoadenoma mucinoso biliar, diagnosticada y tratada exitosamente con cirugía. Conclusión. El diagnóstico de cistoadenoma mucinoso biliar se confirma mediante marcadores tumorales y estudios radiológicos, y su tratamiento es quirúrgico debido al riesgo de malignidad

Introduction. Biliary mucinous cystadenoma is a rare neoplasm with a high probability of malignancy. Its diagnosis is a challenge since it resembles other benign masses that can be found in the liver. Clinical case. A 21-year-old woman with a sensation of a mass in the right hypochondrium, who underwent tumor markers and imaging studies, concluding with a diagnosis of biliary mucinous cystadenoma. Result. A case of a patient with biliary mucinous cystadenoma diagnosed and successfully treated by surgery is presented. Conclusion. The diagnosis of biliary mucinous cystadenoma is confirmed by tumor markers and radiological studies, and its treatment is surgical due to the risk of malignancy

Application value of Laennec approach in laparoscopic anatomical right hemihepatectomy / 中华消化外科杂志

Objective:To investigate the application value of Laennec approach in laparoscopic anatomical right hemihepatectomy (LARH).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 2 female patients who underwent LARH via Laennec approach in the First Affiliated Hospital of Kangda College of Nanjing Medical University from May to July 2020 were collected. The two patients were 51 and 57 years old, respectively. Observation indicators: (1) surgical situations; (2) postoperative situations and follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect post-operative survival and tumor recurrence of patients up to December 2020. Count data were repre-sented as absolute numbers.Results:(1) Surgical situations: 2 patients successfully underwent LARH via Laennec approach, without conversion to open surgery. The operation time was 180 minutes and 185 minutes, and the volume of intraoperative blood loss was 200 mL and 400 mL, respectively. No blood transfusion or gastrointestinal decompression was performed in either patient. (2) Postoperative situations and follow-up: 2 patients began to take liquid diet on the first day and out-of-bed activities on the postoperative second to third day. There was no postoperative bile fistula or bleeding, but different degrees of peritoneal and pleural effusion occurred to the 2 patients after operation. One case was improved after right-sided thoracentesis and chest tube drainage due to dyspnea, and the other case was cured after conservative therapy. There was no perioperative death. The duration of postoperative hospital stay of 2 patients was 13 days and 11 days, respectively. Results of pathological examination showed 1 case of hepatic hemangioma and 1 case of primary liver cancer, respectively. The Laennec capsule was observed on the hepatic vein branches of segment Ⅴ, Ⅵ, Ⅶ, Ⅷ, and the gap existed between the Laennec capsule and the hepatic vein. Two patients were followed up for 7 months and 5 months，respectively. They survived during the follow-up，without tumor recurrence.Conclusion:It is safe and feasible to perform LARH by Laennec approach.

Tumores hepáticos en edad pediátrica / Hepatic tumors in pediatric ages

Introducción: Los tumores del hígado representan de 1-2 por ciento de todas las neoplasias malignas de la infancia y de 15-20 por ciento de los tumores abdominales. Objetivo: Caracterizar desde el punto de vista clínico-quirúrgico a pacientes pediátricos con diagnóstico de tumor hepático. Métodos: Estudio descriptivo y transversal realizado en el hospital pediátrico Juan Manuel Márquez. Se revisaron historias clínicas, informes histopatológicos e informes operatorios en el periodo comprendido entre el 1ro. de enero de 1997 al 31 de diciembre de 2017, para obtener los datos clínicos necesarios para la investigación. La muestra quedó conformada por 63 pacientes. Se emplearon frecuencias absolutas y porcentajes para variables cualitativas. Para las variables cuantitativas, se emplearon además medidas de tendencia central y de dispersión. Resultados: Se constató que 33 (52,4 por ciento) pacientes fueron del sexo masculino. El mayor número de enfermos se concentró en el grupo de 1 a 5 años con 36 (57,1 por ciento). El tumor más frecuente fue el hepatoblastoma y dentro de este el hepatoblastoma fetal, del cual se registraron 16 pacientes (25,4 por ciento). En 34 pacientes (54 por ciento) se combinó el tratamiento médico y el quirúrgico. Conclusiones: Predominan los pacientes masculinos, entre 1 y 5 años de edad. Se identifican principalmente tumores hepáticos epiteliales, malignos en estadio III y la variedad histológica de hepatoblastoma fetal. El tratamiento más utilizado es el médico-quirúrgico según protocolo del hospital dependiente del tipo histológico(AU)

Introduction: Liver tumors represent 1-2 percent of all the malignant neoplasms in children and the 15-20 percent of abdominal tumors. Objective: To characterize from the clinical surgical perspective the pediatric patients with a diagnosis of hepatic tumor. Methods: Descriptive and cross-sectional study conducted in Juan Manuel Márquez Pediatric Hospital. There were reviewed clinical records, histopathological reports and surgical reports from January 1st, 1997 to December 31st, 2017, to obtain necessary clinical data for the research. The sample was formed by 63 patients. There were used absolute frequencies and percentages for qualitative variables. For quantitative variables, there were used central trend and diffusion measures. Results: It was verified that 33 patients (52.4 percent) were males. The biggest number of patients was in the age group from 1 to 5 years being 36 (57.1 percent). The most frequent tumor was the hepatoblastoma and within this category the fetal hepatoblastoma, with 16 (25.4 percent) patients with that condition. In 34 patients (54 percent) were combined medical and surgical approchaes. Conclusions: There was a predominance of male patients in the ages from 1 to 5 years. There were mainly identified patients with epitelial hepatic tumors, malignant tumors in stage III and the histopatological variation of fetal hepatoblastoma. The most common treatment was the medical-surgical one according to the hospital´s protocols and depending on the histologic type(AU)

Research advances in molecular classification for precision diagnosis and treatment of hepatocellular carcinoma / 中华消化外科杂志

Hepatocellular carcinoma (HCC), a highly prevalent malignancy and one of the leading cause of cancer death in China, remains a major public health problem in the next decades. Owing to the tremendous achievements in early diagnosis, precision liver surgery, molecular targeted therapy and immunotherapy, we have witnessed significant improvements in the long-time survival of HCC patients, if properly treated. However, HCC is a highly heterogeneous disease. Even for patients within the same clinical stage, their clinical outcome and treatment efficacy vary significantly. Great efforts to improve the molecular classification of HCC patients are needed to foster precision medicine, paving the way for novel therapeutic strategies. Advances in multi-omics, single-cell analysis, molecular imaging and artificial intelligence will lead to better understanding of the molecular classification and refine precision treatment in HCC, ultimately excluding this neoplasm from the risk list of our Healthy China.

Research advances in molecular classification for precision diagnosis and treatment of hepatocellular carcinoma / 中华消化外科杂志

Hepatocellular carcinoma (HCC),a highly prevalent malignancy and one of the leading cause of cancer death in China,remains a major public health problem in the next decades.Owing to the tremendous achievements in early diagnosis,precision liver surgery,molecular targeted therapy and immunotherapy,we have witnessed significant improvements in the long-time survival of HCC patients,if properly treated.However,HCC is a highly heterogeneous disease.Even for patients within the same clinical stage,their clinical outcome and treatment efficacy vary significantly.Great efforts to improve the molecular classification of HCC patients are needed to foster precision medicine,paving the way for novel therapeutic strategies.Advances in multi-omics,single-cell analysis,molecular imaging and artificial intelligence will lead to better understanding of the molecular classification and refine precision treatment in HCC,ultimately excluding this neoplasm from the risk list of our Healthy China.

Total laparoscopic vs. open liver resection: comparative study with propensity score matching analysis / Ressecções hepáticas totalmente laparoscópicas vs. abertas: estudo comparativo com pareamento por pontuação de propensão

ABSTRACT Background: There have been an increasing number of articles that demonstrate the potential benefits of minimally invasive liver surgery in recent years. Most of the available evidence, however, comes from retrospective observational studies susceptible to bias, especially selection bias. In addition, in many series, several modalities of minimally invasive surgery are included in the same comparison group. Aim: To compare the perioperative results (up to 90 days) of patients submitted to total laparoscopic liver resection with those submitted to open liver resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM model was constructed using the following variables: age, gender, diagnosis (benign vs. malignant), type of hepatectomy (minor vs. major), and presence of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by the nearest method. Results: After matching, 120 patients were included in each group. Those undergoing total laparoscopic surgery had shorter operative time (286.8±133.4 vs. 352.4±141.5 minutes, p<0.001), shorter ICU stay (1.9±1.2 vs. 2.5±2.2days, p=0.031), shorter hospital stay (5.8±3.9 vs. 9.9±9.3 days, p<0.001) and a 45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion: Total laparoscopic liver resections are safe, feasible and associated with shorter operative time, shorter ICU and hospital stay, and lower rate of perioperative complications.

RESUMO Racional: Com a disseminação da cirurgia hepática minimamente invasiva tem-se observado nos últimos anos número crescente de trabalhos que demonstram seus potencias benefícios. No entanto, a maior parte da evidência disponível provém de estudos observacionais retrospectivos sujeitos a vieses, em especial, os de seleção. Além disso, em muitas casuísticas são incluídas no mesmo grupo diversas modalidades de operações minimamente invasivas. Objetivo: Comparar os resultados perioperatórios (até 90 dias) de pacientes submetidos a ressecções hepáticas totalmente laparoscópicas com pacientes contemporâneos por cirurgias abertas, pareados por pontuação de propensão (propensity score matching PSM), submetidos a ressecções hepáticas convencionais. Método: Foram estudados pacientes adultos consecutivos submetidos à ressecção hepática. Para homogeneização dos grupos foi utilizado pareamento por pontuação de propensão, utilizando a variável idade, gênero, tipo de doença (benigna vs. maligna), tipo de hepatectomia (maior vs. menor) e presença de cirrose. A partir disto, os grupos foram redefinidos com proporção 1:1, pelo método nearest. Resultado: Após o pareamento foram incluídos 120 pacientes em cada grupo. Os submetidos à operação totalmente laparoscópica apresentaram menor tempo cirúrgico (286,8±133,4 vs. 352,4±141,5 min, p<0,001), menor tempo de internação em unidade de terapia intensiva (1,9±1,2 vs. 2,5±2,2dias, p=0,031), menor tempo de internação hospitalar (5,8±3,9 vs. 9,9±9,3dias, p<0,001) e redução de 45% nas complicações perioperatórias (19,2 vs. 35%, p=0,008). Conclusão: As ressecções hepáticas totalmente laparoscópicas são exequíveis, seguras e associadas à menor tempo operatório, menor tempo de internação em unidade de terapia intensiva e internação hospitalar, além de diminuição nas complicações perioperatórias.

Sarcoma embrionario indiferenciado en dos pacientes pediátricos / Undifferentiated embryonal sarcoma in two pediatric patients

Resumen El sarcoma embrionario indiferenciado es un tumor hepático mesenquimal maligno infrecuente que ocupa el tercer lugar en frecuencia de las neoplasias primarias del hígado de la infancia; tiene crecimiento rápido y sus síntomas más frecuentes son dolor y sensación de masa abdominal; también puede presentarse ictericia, pérdida de peso, fiebre, emesis y hepatomegalia. El diagnóstico se realiza teniendo en cuenta los hallazgos en imágenes, estudios de inmuno-histoquímica y análisis patológico que aporta el diagnóstico definitivo. Inicialmente, su pronóstico era pobre, con tasas de supervivencia menores a un año; sin embargo, con la introducción de la quimioterapia asociada a la resección quirúrgica, la supervivencia a largo plazo ha mejorado con posibilidad de curación, directamente relacionada con el tratamiento oportuno. Se presentan dos casos de sarcoma embrionario indiferenciado en pacientes pediátricos y diagnosticados en la Fundación Cardioinfantil Instituto de Cardiología, los cuales fueron confirmados por patología. Finalmente, se discuten las características histopa-tológicas, hallazgos imagenológicos, diagnósticos diferenciales y opciones terapéuticas reportadas.

Abstract Undifferentiated embryonal sarcoma, an infrequent malignant mesenchymal liver tumor, occupies the third place in frequency of primary neoplasms of the liver in infancy. It has a fast-growing rate; the most frequent symptoms are pain and abdominal mass, also jaundice, weight loss, fever, emesis and hepatomegaly. The diagnosis is made taking into account the imaging findings, immune-histochemical studies and pathological analysis, the latter providing the definitive diagnosis. The prognosis of this tumor was initially poor, with survival rates of less than 1 year; however, with the introduction of chemotherapy associated with surgical resection, long-term survival has improved with the possibility of cure, directly related to timely treatment. In this article, two cases of undifferentiated embryonal sarcoma in pediatric patients are presented, diagnosed in the Fundación Cardioinfantil-Instituto de Cardiología, confirmed by pathology. Finally, the histopathological characteristics, imaging findings, differential diagnoses and the therapeutic options used are discussed, as reported in the literature.

Hepatitis autoinmune y cáncer de colon: una asociación inusual. Caso clínico y revisión de la literatura / A case of an unusual association of autoimmune hepatitis and colon cancer: report and literature review

Resumen Introducción: la hepatitis autoinmune idiopática (HAI) es una enfermedad crónica que predomina en mujeres, con episodios de actividad y remisión, favoreciendo la fibrosis hepática. El 40% de los pacientes presenta historia familiar de enfermedades autoinmunes. Al parecer, es mediada por la interacción antígeno-anticuerpo; sin embargo, su causa es desconocida. Se conoce la asociación frecuente de HAI con cáncer hepatobiliar; menos frecuente con linfomas, cáncer de piel y cáncer de colon; y casi inexistente con síndromes hereditarios de cáncer de colon. Este caso debutó con HAI y sangrado rectal causado por poliposis adenomatosa familiar (PAF) y adenocarcinoma de colon sigmoide. Caso clínico: mujer de 51 años con HAI de 1 año de evolución manejada con prednisolona y azatioprina. Se realizó una colonoscopia total por anemia en la que se encontraron múltiples pólipos entre 5 y 10 mm y 1 de 30 mm sésil, ulcerado, en colon sigmoide. Se realizó una polipectomía endoscópica múltiple que reportó un adenoma tubulovelloso con displasia de alto y bajo grado en varios pólipos y un adenocarcinoma de bajo grado en el pólipo del sigmoide. Los estudios de extensión fueron negativos para metástasis. Se realizó una repleción nutricional prequirúrgica, luego una colectomía subtotal y una procto-ileoanastomosis con ileostomía de protección. La patología de pieza quirúrgica mostró un adenocarcinoma de colon de bajo grado y adenomas tubulares y tubulovellosos con displasias de alto y bajo grado. Discusión y conclusiones: La asociación de HAI con PAF y cáncer colorrectal (CC) es infrecuente. Es conocida la correlación de HAI con cáncer hepatobiliar (asociado con cirrosis), linfomas, cáncer de piel y otros desórdenes autoinmunes. El pronóstico es malo y no puede establecerse una correlación clara con moduladores inmunes.

Abstract Introduction: Idiopathic autoimmune hepatitis (IAH) is a chronic disease that occurs predominately in women, has episodic activity and remission, and favors hepatic fibrosis. Forty percent of patients have family histories of autoimmune diseases. It is apparently mediated by antigen-antibody interaction, but its causes are unknown. IAH is frequently associated with hepatobiliary cancer, less frequently with lymphomas, skin cancer and colon cancer and very rarely with hereditary colon cancer syndrome. This case debuted IAH and rectal bleeding caused by familial adenomatous polyposis (FAP) and adenocarcinoma of the sigmoid colon. Clinical case: The patient was a 51-year-old woman who had had IAH for one year which had been managed with prednisolone and azathioprine. A total colonoscopy, performed because of anemia, found multiple polyps that measured 5 and 10 mm and one ulcerated 30 mm sessile polyp in the sigmoid colon. A multiple endoscopic polypectomy revealed a tubulovillous adenoma with high and low grade dysplasia in several polyps and a low grade adenocarcinoma in the sigmoid polyp. Tests and examinations for metastasis were negative. Following presurgical nutritional repletion, a subtotal colectomy was performed and an ileal pouch-anal anastomosis with protective ileostomy was created. The pathology of the surgical specimen showed low grade adenocarcinoma of the colon and tubular and tubulovillous adenomas with high and low grade dysplasia. Discussion and conclusions: Association of IAH with familial adenomatous polyposis (FAP) and colorectal cancer (CC) occurs infrequently although associations of IAH with hepatobiliary cancer associated with cirrhosis, lymphomas, skin cancer and other autoimmune disorders are well-known. The prognosis is bad and no clear correlation with immune modulators can be established.

Retrospective analysis of 116 patients and diagnostic value of 18 F-FDG PET/CT in hepatic tumor / 肿瘤

Objective: To evaluate the diagnostic value of 18F-fluorodeoxy glucose (FDG) positron emission tomography (PET)/CT in patients with hepatic tumor. Methods: One hundred and sixteen patients with clinical diagnosis of hepatic tumor (85 males, 31 females; average age was 56 years old) had undergone 18F FDG PET/CT scan before treatment from January 2010 to June 2017, and the imaging characteristics were retrospectively analyzed. The pathological results were used as a gold standard for evaluating the diagnostic value of 18F FDG PET/CT. The maximum diameter (dmax), the maximum standardized uptake value (SUVmax) and the tumor to non-tumor SUV ratio (TNR) were measured. Two-sample t test, one-way ANOVA, paired Chi-square test and receiver operating characteristic (ROC) curve were used for data analysis. Results: Of the 116 patients, 11 patients had benign tumor, and 105 patients had malignant tumor. The dmax, SUVmax and TNR of 105 patients with malignant tumor were significant higher than those of 11 patients with benign tumor (all P < 0.05). The sensitivity and specificity of visual analysis in the diagnosis of benign tumors were 84.8% and 54.5%, respectively. The sensitivity and specificity of the SUVmax method were 83.8% and 63.6%, respectively. The sensitivity and specificity of the TNR method were 57.1% and 90.9%, respectively. From the perspective of positive rate, visual analysis and SUVmax were better than TNR. The areas under receiver operating characteristic curve for diagnosis of intrahepatic cholangiocarcinoma and liver metastases by SUVmax and TNR methods were larger. Conclusion: 18F-FDG PET/CT is a useful examination in hepatic tumor, especially for intrahepatic cholangiocarcinoma and metastatic carcinoma.

Association between expression of Cullin 4B and prognosis of patients after liver transplantation / 中华消化外科杂志

Objective To investigate the effect of expression of Cullin 4B (CUL4B) on the prognosis of patients after liver transplantation for hepatocellular carcinoma (HCC).Methods The retrospective case-control study was conducted.The clinicopathological data of 79 patients who underwent liver transplantation for HCC in the First Affiliated Hospital of Sun Yat-sen University between January 1,2014 and June 30,2015 were collected.The specimens of HCC tissues were collected and embedded in paraffin,and then were detected by immunohistochemistry staining.Observation indicators:(1) expression of CUL4B in HCC tissues;(2) follow-up and survival;(3) prognostic factors analysis after liver transplantation;(4) association between expression of CUL4B and recurrence and metastasis of tumor after liver transplantation.Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence or metastasis and survival up to June 2018.Measurement data with normal distribution were represented as (x)±s.The comparison between groups of count data was done using the chi-square test.The survival curve drawn using the Kaplan-Meier method,and the survival analysis was done by Log-rank test.The univariate and multivariate analysis were respectively done using the COX regression model.The association analysis was done using the Pearson test.Results (1) Expression of CUL4B in HCC tissues:immunohistochemistry staining showed that CUL4B was mainly expressed in the cytoplasm,with a powerful brownish-yellow staining.The high expression and low expression of CUL4B in HCC tissues were detected in 64 and 15 patients,respectively.(2) Follow-up and survival:79 patients were followed up for 38-56 months,with an average time of 46 months.During the follow-up,37 patients had no tumor recurrence and 42 had tumor recurrence (32 with tumor extrahepatic metastasis and 10 with intrahepatic metastasis);36 had survival and 43 died;the 1-and 3-year overall survival rates were respectively 86.84％ and 63.25％,and 1-and 3-year tumorfree survival rates were respectively 62.31％ and 51.27％.(3) Prognostic factors analysis after liver transplantation:① Results of univariate analysis showed that preoperative alpha-fetoprotein (AFP),Child-Pugh score,maximum tumour dimension,capsular invasion,intravascular tumor thrombus,Edmonson pathological grading and expression of CUL4B were related factors affecting the 3-year overall survival rate of patients after liver transplantation for HCC [Hazard Ratio (HR) =2.17,3.36,3.66,2.43,2.19,3.36,2.84,95％ confidence interval(CI):1.17-4.04,1.53-7.42,2.10-6.42,1.33-4.17,1.08-9.04,1.58-7.59,1.17-6.32,P＜ 0.05].The preoperative alpha-fetoprotein (AFP),Child-Pugh score,maximum tumour dimension,capsular invasion,intravascular tumor thrombus,Edmonson pathological grading and expression of CUL4B were related factors affecting the 3-year tumor-free survival rate of patients after liver transplantation for HCC (HR =2.06,3.72,3.16,2.36,2.83,3.21,1.69,95％CI:1.34-4.85,1.72-8.63,1.79-7.31,1.46-4.86,1.19-8.63,1.19-7.92,1.06-4.87,P＜0.05).② Results of multivariate analysis showed that maximum tumour dimension,intravascular tumor thrombus and expression of CUL4B were independent factors affecting the 3-year overall survival rate of patients after liver transplantation for HCC [Odds ratio(OR) =3.43,3.69,2.81,95％CI:1.16-6.02,1.96-9.38,1.04-9.63,P＜0.05].The maximum tumour dimension,intravascular tumor thrombus and expression of CUL4B were independent factors affecting the 3-year tumor-free survival rate of patients after liver transplantation for HCC (OR=2.25,4.72,2.74,95％C1:1.16-4.02,1.98-9.47,1.03-7.10,P＜ 0.05).The 3-year overall survival rate in patients with high-and low-expressions of CUL4B was respectively 66.7％ and 32.8％,with a statistically significant difference (x2 =5.69,P＜0.05).The 3-year tumor-free survival rate in patients with high-and low-expressions of CUL4B was respectively 73.3％ and 18.6％,with a statistically significant difference (x2 =4.63,P＜0.05).(4) Association between expression of CUL4B and recurrence and metastasis of tumor after liver transplantation:results of Pearson test showed that expression of CUL4B was significantly associated with HCC recurrence and metastasis after liver transplantation (r =0.62,P＜0.05).The further analysis showed that expression of CUL4B was significantly associated with extrahepatic metastasis after liver transplantation (r=0.84,P ＜ 0.05).Conclusion The expression of CUL4B is associated with HCC recurrence after liver transplantation,and it can be as a predictor for HCC recurrence and distant metastasis after liver transplantation.

CT characteristics of primary hepatic angiosarcoma / 中华消化外科杂志

Objective To summarize the computed tomography (CT) characteristics of primary hepatic angiosarcoma (PHA).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 9 PHA patients who were admitted to the Wenzhou Chinese Medicine Hospital (3 patients),Second Affiliated Hospital of Wenzhou Medical College (3 patients) and Wenzhou People's Hospital (3 patients) between January 2006 and June 2017 were collected.All 9 patients were fasting 8 hours before CT examination,and received screen scans without abdominal pressure.Scanning area was from dome of diaphragm to lower pole of the kidneys.Two associate senior doctors made images analysis.After preoperative examinations,patients selected whether or not to undergo treatment,resection,liver transplantation or chemotherapy + targeted therapy of monoclonal antibodies.Observation indicators:(1) plain scan appearances of CT;(2) enhanced scan appearances of CT;(3) results of pathological examinations;(4) follow-up and survival situations.Follow-up using outpatient,inpatient and imaging examinations was performed to detect tumor recurrence and stable condition up to December 2017.Results (1) Plain scan appearances of CT:9 patients showed solitary tumor,and tumors were respectively located in the left lobe (3 cases) and right lobe (6 cases) of the liver,including 5 with round tumors,3 with oval tumors and 1 with patchy tumor.The maximum diameter of tumor was 5.8-16.0 cm,with an average of 10.8 cm,including maximum diameter ＞ 6.0 cm in 8 patients.Tumors of 9 patients showed low-density shadow,and CT value was 32-46 HU,with an average of 41 HU,including homogeneous density in 3 patients and heterogeneous density in 6 patients;clear tumor boundary in 6 patients and unclear tumor boundary in 3 patients;tumor necrosis and cystolization in 4 patients,slightly strip-shaped high-density shadow in the center of tumor in 4 patients,and small patch-shaped intratunoral calcification in 1 patient.(2) Enhanced scan appearances of CT:① Arterial phase:tumors of 9 patients showed mild and moderate heterogeneous enhancements,with CT value of 63-76 HU and an average of 68 HU,including small patch-shaped or nodular enhancement in 3 patients and punetate or flocculent enhancement in the center of tumor in 6 patients.Tumors of 4 patients showed moderate enhancements,and tumor density was higher than that of normal liver parenchyma.Tumors of 5 patients showed mild enhancements,and tumor density was equal to or slightly less than that of normal liver parenehyma.② Portal vein phase:tumors of 9 patients showed mild and moderate,continuous and progressive enhancements,with a heterogeneous density,CT value of 56-71 HU and an average of 63 HU,including extended enhancement region in 3 patients,with a fusion and filling trend;small patch-shaped or nodular and lattice network-shaped enhancements of center and periphery of tumor in 6 patients,showing center filling and enhancement features of hepatic angiosarcoma.Tumors of 2 patients showed moderate enhancements,and tumor density was higher than that of normal liver parenchyma;tumors of 7 patients showed mild enhancements and tumor density was equal to or slightly less than that of normal liver parenchyma.③ Delayed phase:tumor enhancements of 9 patients slowly seceded,with CT value of 50-60 HU and an average of 53 HU,including density decreasing of periphery of tumor in 3 patients;partial fusion and center filling of enhancements in 6 patients,without enhancement in necrotic area.Tumor density was slightly higher than that of normal liver parenchyma in 2 patients,equal to that of normal liver parenchyma in 1 patient,and slightly less than that of normal liver parenchyma in 6 patients.(3) Results of pathological examinations:① Pathological examinations:cut surface of tumors showed grayish yellow and drab gray,and parts of surface were fish flesh shape,with internal bleeding and necrosis.Tumors were found in diffuse hyperplasia under microscopy,tumor tissues were made up of irregular and mutual matching lacuna vasorum,with infiltrating growths along hepatic sinus gap;hepatic angiosarcoma cells were spindle,round or irregular;there were slightly eosinophilia cytoplasm and deep chromatin of the nucleus,long-shaped or irregular nucleus,and different sizes of nucleolus.② Immunohistochemical staining:CD31 and CD34 were strongly positive,vimentin and Nestine were positive,and CK19,actin and creatine kinase were negative.(4) Follow-up and survival situations:of 9 patients,3 without treatment respectively died at 3,6 and 7 months;2 had recurrence at 4 and 5 months after tumor resection,with angiosarcoma invading right renal capsule,diaphragm and right pleural hemorrhage induced to haemothorax,and survived respectively for 13 and 15 months;2 respectively died of systemic metastasis at 4 and 8 months after liver transplantation;2 underwent chemotherapy + targeted therapy of monoclonal antibodies,and survived for 12 months.Conclusions CT appearances of PHA have certain characteristics.The plain scans of CT show heterogeneous low-density shadow,and enhanced scans of CT show small patch,punctate or nodular-shaped,continuous and progressive enhancements,with a clear boundary between tumor and liver parenchyma.

Application value of two-step separation approach in laparoscopic hemihepatectomy / 中华消化外科杂志

Objective To investigate the application value of two-step separation approach in laparoscopic hemihepatectomy.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 81 patients who underwent laparoscopic hemihepatectomy in the People's Hospital of Hunan Provincial between January 2015 and December 2017 were collected.Patients underwent laparoscopic hemihepatectomy using two-step separation approach after preoperative assessment.Hepatic pedicle,hepatic vein and branches were processed in the liver parenchyma,without intrathecal anatomy.Observation indicators:(1) preoperative assessment,intraand post-operative recovery;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed up to February 2018.Patients with hepatolithiasis received abdominal CT reexaminations at 5-7 days postoperatively for observing postoperative residual stones,and patients with malignant tumor were regularly followed up for 1-3 years.Measurement data with normal distribution were represented as (x)±s.Count data were described as frequency and percentage.Results (1) Preoperative assessment,intra-and post-operative recovery:81 patients underwent preoperative blood biochemistry,tumor biomarker and imaging examinations,and remaining functional liver volume and a liver model in 9 patients were respectively calculated and built using the 3D reconstruction software and 3D printing technology.Of 81 patients,68 underwent left hemihepatectomy and 13 underwent fight hemihepatectomy;77 underwent successful laparoscopic hemihepatectomy using two-step separation approach,4 were converted to open operation,with a rate of 4.9％ (4/81).Of 4 patients with conversion to open operation,1 had difficult tumor separation due to tumor invading port vein induced to close adhesion,1 had stone removal difficulties under laparoscopy due to hepatolithiasis,and 2 were converted to open operation due to severe liver cirrhosis induced to massive intraoperative bleeding.Of 81 patients,70 gained dividing line of hemiliver by intraoperatively hemihepatic blood flow occlusion,and then got effectively control of bleeding combined with Pringle blood flow occlusion,and 11 received Pringle blood flow occlusion in whole liver.Laparoscopic fluorescence imaging technology was intraoperatively used for 2 patients.Operation time,volume of intraoperative blood loss,rate of intraoperative blood transfusion and duration of hospital stay in 81 patients were respectively (206±42)minutes,(195±134)mL,11.1％(9/81) and (11.5+2.7)days.Eighty-one patients were complicated with bile leakage and were cured by conservative treatment,with a bile leakage incidence of 2.5％ (2/81),and without severe complications,such as postoperative bleeding,hepatic dysfunction and subphrenic abscess.There was no perioperative death and reoperation within 30 days postoperatively.(2) Follow-up and survival situations:55 patients with hepatolithiasis were followed up and underwent CT examinations of upper abdomen at 5-7 days postoperatively,including 52 with depletion of stones;3 with residual stones received removal of stones by choledochoscope at 3 months postoperatively,without residual stones.Seventeen patients with malignant tumor were followed up for 12-36 months,with a median time of 15 months,16 had tumor-free survival,and 1 was complicated with intrahepatic metastasis at 1 year after resection of hepatocellular carcinoma,and then underwent transcatheter arterial chemoembolization (TACE) and survived with tumor.Nine patients with benign liver diseases had good recovery during follow-up.Conclusion Two-step separation approach that is rationally used in laparoscopic hemihepatectomy is safe,effective and convenient.

Effect and mechanism of liver X receptor agonist T0901317 on angiogenesis phenotype of liver cancer / 中华消化外科杂志

Objective To explore the effect and mechanism of liver X receptor agonist T0901317 on angiogenesis phenotype of liver cancer.Methods The experimental study was conducted.Hepatocellular carcinoma MHCC97-H and Huh7 cells and human umbilical vein endothelial cells (HUVEC) were cultured in vitro.Each cell line was divided into 3 groups:control group (non-treated),low concentration group (treated using 1 μmot/L T0901317) and high concentration group (treated using 3 μmol/L T0901317).Cell proliferation was counted with a CCK-8 assay.Quantitative real-time polymerase chain reaction (PCR) was applied to confirm the relative mRNA expression of fatty acid synthetase (FAS) of liver X receptor target genes in 3 groups.Subcutaneous xenograft tumor volume and body mass were measured in MHCC97-H nude mice model.Then mice were sacrificed and tumor tissues were analyzed for CD31 relative expression by immunohistochemistry (IHC) staining.Migration and vessel angiogenesis of HUVEC were determined by Transwell method.Observation indicators:(1) effects of T0901317 on MHCC97-H,Huh7 and HUVEC cells proliferation,(2) effects of T0901317 on liver X receptor with MHCC97-H,Huh7 and HUVEC cells,(3) effects of T0901317 on subcutaneous xenograft tumor growth in MHCC97-H nude mice model,(4) effects of T0901317 on CD31 relative expression in subcutaneous xenograft tumor tissues of MHCC97-H nude mice model,(5) effects of T0901317 on migration of HUVEC,(6) effects of T0901317 on vessel angiogenesis of HUVEC.Measurement data with normal distribution were represented as x±s,and comparisons between groups were analyzed by the t test.Results (1)Effects of T0901317 on MHCC97-H,Huh7 and HUVEC cells proliferation:results of CCK-8 assay showed that percentage of living cells was respectively 100.0％± 1.7％,101.0％±0.7％ and 104.6％± 1.9％ in MHCC97-H control,low concentration and high concentration groups,with no statistically significant difference (F =2.632,P＞0.05).Percentage of living cells was respectively 100.0％ ± 2.7％,97.6％ ± 2.4％ and 103.7％ ± 2.8％ in Huh7 control,low concentration and high concentration groups,with no statistically significant difference (F =1.404,P＞0.05).Percentage of living cells was respectively 100.0％ ±0.7％,100.7％± 1.2％ and 101.3％ ±0.8％ in HUVEC control,low concentration and high concentration groups,with no statistically significant difference (F=0.471,P＞0.05).(2) Effects of T0901317 on liver X receptor with MHCC97-H,Huh7 and HUVEC cells:results of quantitative real-time PCR showed that relative mRNA expressions of FAS in MHCC97-H control,low concentration and high concentration groups were respectively 100.0 ％±2.2％,658.5％±7.7％ and 1 241.0％± 106.8％,with a statistically significant difference among groups (F=46.227,P＜0.05),and with a statistically significant difference between MHCC97-H control group and MHCC97-H low concentration and high concentration groups (t =70.025,8.274,P ＜ 0.05) and between MHCC97-H low concentration and high concentration groups (t =4.222,P ＜ 0.05).Relative mRNA expressions of FAS in Huh7 control,low concentration and high concentration groups were respectively 100.0％ ± 15.8％,1 225.0％ ± 26.7 ％ and 2 015.0％ ± 215.1％,with a statistically significant difference among groups (F =49.402,P＜ 0.05),and with a statistically significant difference between Huh7 control group and Huh7 low concentration and high concentration groups (t=39.460,8.879,P＜0.05) and between Huh7 low concentration and high concentration groups (t =2.836,P ＜ 0.05).Relative mRNA expressions of FAS in HUVEC control,low concentration and high concentration groups were respectively 100.0％ ± 19.6％,790.8％ ± 116.5％ and 1 756.0％ ± 55.0％,with a statistically significant difference among groups (F=185.395,P＜0.05),and with a statistically significant difference between HUVEC control group and HUVEC low concentration and high concentration groups (t =7.639,34.375,P＜0.05) and between HUVEC low concentration and high concentration groups (t =7.488,P＜0.05).(3) Effects of T0901317 on subcutaneous xenograft tumor growth in MHCC97-H nude mice model:results of assay showed that subcutaneous xenograft tumor volume in MHCC97-H control group and MHCC97-H T0901317 group were respectively (935±72)mm3 and (552 ± 47)mm3,with a statistically significant difference between groups (t=4.449,P＜0.05).Body masses of nude mice model in MHCC97-H control group and MHCC97-H T0901317 group were respectively (23.8±0.8) g and (21.7± 1.7) g,with no statistically significant difference between groups (t =1.059,P＞0.05).(4) Effects of T0901317 on CD31 relative expression in subcutaneous xenograft tumor tissues of MHCC97-H nude mice model:results of IHC staining showed that CD31 relative expression in subcutaneous xenograft tumor tissues of MHCC97-H nude mice model was 100％±11％ and 35％±7％ in MHCC97-H control group and MHCC97-H T0901317 group,with a statistically significant difference between groups (t =4.919,P＜0.05).(5) Effects of T0901317 on migration of HUVEC:results of Transwell method showed that percentages of membrane cells in HUVEC control,low concentration and high concentration groups were respectively 100.0％±4.0％,57.3％±1.5％ and 32.7％± 1.7％,with a statistically significant difference among groups (F=163.944,P＜0.05),and with statistically significant differences between HUVEC control group and HUVEC low concentration and high concentration groups (t =9.998,15.434,P＜0.05) and between HUVEC low concentration and high concentration groups (t =10.801,P ＜ 0.05).(6) Effects of T0901317 on vessel angiogenesis of HUVEC:results of vessel angiogenesis assay showed that length of vessel angiogenesis in HUVEC control,low concentration and high concentration groups were respectively 100.0％±3.4％,68.4％ ±3.5％ and 44.7％± 0.5％,with a statistically significant difference among groups (F =38.964,P ＜ 0.05),and with statistically significant differences between HUVEC control group and HUVEC low concentration and high concentration groups (t=6.268,9.831,P＜0.05) and between HUVEC low concentration and high concentration groups (t =3.460,P＜0.05).Conclusion Liver X receptor agonist T0901317 can inhibit vessel angiogenesis of liver cancer.

Risk factor analysis of acute kidney injury after orthotopic liver transplantation / 中华消化外科杂志

Objective To investigate the risk factors and prognosis of acute kidney injury (AKI) after orthotopic liver transplantation (OLT).Methods The retrospective case-control study was conducted.The clinical data of 127 patients who underwent OLT in the First Affiliated Hospital of Xi'an Jiaotong University from January 2013 to December 2015 were collected.Of 127 patients,24 were complicated with postoperative AKI,including 17 in grade 1,5 in grade 2 and 2 in grade 3,and 103 were not complicated with AKI.AKI after OLT was treated according to the diagnostic criteria of AKI from 2012 guidelines of Kidney Disease:Improving Global Outcomes (KDIGO).Observation indicators:(1) risk factors analysis affecting AKI after OLT;(2) comparison of postoperative recovery in patients with different AKI grade;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed up to July 2017.Measurement data with nornal distribution were represented as x±-s,and measurement data with skewed distribution were described as M (range).Univariate analysis was done using the t test and rank sum test.Comparisons of count data and univariate analysis were done using chi-square test or Fisher exact probability.Multivariate analysis was done using the logistic regression model.The survival rate and curve were respectively calculated and drawn by the KaplanMeier method,and Log-rank test was used for survival analysis.Results (1) Risk factors analysis affecting AKI after OLT:results of univariate analysis showed that age,combined hypertension,preoperative Child-Pugh score,preoperative model for end-stage liver disease score (MELD),preoperative hemoglobin,preoperative serum albumin,preoperative blood urea nitrogen,preoperative glomerular filtration rate,preoperative prothrombin time,operation time,inferior vena cava occlusion time,duration of anhepatic phase,volume of intraoperative blood loss,total volume of intraoperative blood transfusion,volumes of intraoperative plasma and red blood cells transfusion,duration of postoperative ICU stay,use time of postoperative vasoactive drugs,time of postoperative mechanical ventilation,cases with postoperative infection,body mass index of donor and donor liver cold-ischemia time were related factors affecting occurrence of AKI after OLT (t =4.154,x2 =8.482,t =5.129,3.694,1.294,9.223,5.418,Z=4.287,t=2.105,5.168,8.182,10.042,Z=1.074,0.664,6.274,3.712,1.289,t=1.056,x2 =10.617,t=2.447,3.371,1.476,P＜0.05).Results of multivariate analysis showed that age,preoperative MELD score,preoperative serum albumin,volume of intraoperative blood loss and donor liver cold-ischemia time were independent factors affecting occurrence of AKI after OLT [odds ratio (OR) =0.812,0.866,1.392,1.001,0.516,95％ confidence interval:0.717-0.919,0.751-0.997,1.104-1.755,1.000-1.001,0.282-0.944,P＜0.05].(2) Comparison of postoperative recovery in patients with different AKI grade:cases with complete recovery,partial recovery and chronic renal failure were respectively 14,3,0 in 17 patients with grade 1 of AKI and 3,2,0 in 5 patients with grade 2 of AKI and 0,1,1 in 2 patients with grade 3 of AKI,with a statistically significant difference (x2=14.140,P＜0.05).(3) Follow-up and survival situations:127 patients were followed up for 9-44 months,with a median of 23 months.The 1-year overall survival rate of 127 patients was 95.3％.During the follow-up,22 patients died,including 9 with multiple organ failure,8 with primary disease recurrence and 5 with respiratory complication.The median overall survival time after OLT was 36 months in 24 patients with AKI and 40 months in 103 patients without AKI,with no statistically significant difference (x2=3.033,P＞0.05).Conclusion Age,preoperative MELD score,preoperative serum albumin,volume of intraoperative blood loss and donor liver cold-ischemia time are independent factors affecting occurrence of AKI after OLT,and there is better recovery in patients with grade 1 of AKI.

Effect of microvascular invasion on prognosis of patients with hepatocellular carcinoma after hepatectomy / 中华消化外科杂志

Objective To investigate the effect of microvascular invasion (MVI) on tumor recurrence of hepatocellular carcinoma (HCC) patients after hepatectomy,the efficacy of sequential transcatheter arterial chemoembolization (TACE) on positive MVI patients after hepatectomy,and the effect of comprehensive treatment on the prognosis of patients with tumor recurrence.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 136 HCC patients who underwent hepatectomy in the First Affiliated Hospital of Air Force Medical University from February 2015 to December 2016 were collected.Patients were treated with TACE,radiofrequency ablation (RFA) and molecular-targeted drugs after hepatectomy,and patients with tumor recurrence selected 1 or 2 above treatments.The patient received postoperatively outpatient reexaminations every 3 months to detect tumor recurrence and survival.Follow-up was from the day of the surgery to death or December 2017.Observation indicators:(1) treatment after hepatectomy;(2) effect of MVI on tumor recurrence of HCC patients after hepatectomy:clinicopathological features and tumor recurrence rate between positive and negative MVI patients;(3) efficacy of TACE on positive MVI patients:clinicopathological features and tumor recurrence rate in positive MVI patients with or without TACE;(4) effect of comprehensive treatment on the prognosis of patients with tumor recurrence.Measurement data with normal distribution were represented as x±s and analyzed using the independent-samples t test.Comparisons of count data were analyzed using chi-square test or Fisher exact probalility.The tumor recurrence rate and survival rate were calculated by the Kaplan-Meier method,and Log-rank test was used for survival analysis.Results (1) Treatment after hepateetony:of 136 patients undergoing hepatectomy,117 underwent single hepatectomy and 19 combined sequential TACE;59 had HCC recurrence,including 22 receiving comprehensive treatment.(2) Effect of MVI on tumor recurrence of HCC patients after hepatectomy:① Clinicopathological features:of 117 patients undergoing single hepatectomy,positive MVI was detected in 49 patients,including 44 males and 5 females,with an age of (52-± 10)years old;49 patients were in Child-Pugh grade A,including 36 combined with liver cirrhosis and 13 without liver cirrhosis;positive and negative alpha-fetoproteins (AFPs) were respectively detected in 34 and 15 patients.Negative MVI was detected in 68 patients,including 54 males and 14 females,with an age of (55± 11)years old;65 and 3 patients were respectively in Child-Pugh grade A and B,including 52 combined with liver cirrhosis and 16 without liver cirrhosis;positive and negative AFPs were respectively detected in 39 and 29 patients.There was no statistically significant difference in gender,age,Child-Pugh score of liver function,liver cirrhosis and comparison of AFP between positive and negative MVI patients (x2 =2.258,t =-1.626,x2 ＝ 0.804,0.138,1.758,P＞0.05).② Tumor recurrence rate:The 6-month and 1-year tumor recurrence rates after hepatectomy were respectively 30.77％,30.61％ in 117 patients undergoing single hepatectomy and 42.86％,51.02％ in 49 of 117 patients with positive MVI and 22.06％,27.94％ in 68 of 117 patients with negative MVI,showing statistically significant differences in 6-month and 1-year tumor recurrence rates between positive and negative MVI patients (x2 =5.738,6.465,P＜0.05).(3) Efficacy of TACE on positive MVI patients:① Clinicopathological features of 56 patients with positive MVI,7 received postoperatively sequential TACE,including 7 males,with an age of (50±4) years old;56 patients were in Child-Pugh grade A,including 5 combined with liver cirrhosis and 2 without liver cirrhosis;positive and negative AFPs were respectively detected in 2 and 5 patients.Forty-nine patients didn't combine sequential TACE,including 44 males and 5 females,with an age of (52± 10)years old;49 patients were in Child-Pugh grade A,including 36 combined with liver cirrhosis and 13 without liver cirrhosis;positive and negative AFPs were respectively detected in 34 and 15 patients.There was no statistically significant difference in gender,age,Child-Pugh score of liver function,liver cirrhosis and comparison of AFP between patients with and without sequential TACE (x2 =0.784,t =-0.512,x2 =0.013,2.844,P＞0.05).② Tumor recurrence:the 6-month and 1-year tumor recurrence rates after hepatectomy were respectively 0,28.57％ in 7 positive MVI patients with sequential TACE and 42.86％,51.02％ in 49 positive MVI patients without sequential TACE,showing a statistically significant difference in 6-month tumor recurrence rate (x2=4.800,P＜0.05) and no statistically significant difference in 1-year tumor recurrence rate (x2 =1.236,P ＞ 0.05).(4) Effect of comprehensive treatment on the prognosis of patients with tumor recurrence:of 59 patients with tumor recurrence,37 didn't receive comprehensive treatment,34 of 37 died within 1-year postoperatively,including 30 deaths within 6-month postoperatively,and 1-year survival rate was 8.10％;22 received comprehensive treatment,including 4 deaths within 1-year postoperatively,and 1-year survival rate was 81.80％,showing a statistically significant difference in 1-year survival rate (x2=32.698,P＜0.05).Conclusions MVI is one of the important risk factors affecting HCC recurrence and metastasis after hepatectomy.The combined TACE after hepatectomy can reduce the HCC recurrence rate of MVI positive patients,and active comprehensive treatment after HCC recurrence can significantly prolong the survival time of patients.

Value of the preoperative Child-Pugh score and albumin-bilirubin score predicting posthepatectomy liver failure and prognosis of patients with hepatocellular carcinoma / 中华消化外科杂志

Objective To investigate the value of the preoperative Child-Pugh score and albuminbilirubin (ALBI) score predicting posthepatectomy liver failure (PHLF) and prognosis of patients with hepatocellular carcinona (HCC).Methods The retrospective cohort study was conducted.The clinical data of 226 HCC patients who were admitted into the People's Hospital of Peking University between January 2010 and October 2014 were collected.After preoperative related examinations,feasibility and extent of liver resection were discussed according to patients' conditions by muhidisciplinary team,and then surgery was performed.Observation indicators:(1) surgical situations;(2) factors analysis affecting PHLF of HCC patients;(3) receiver operating characteristic (ROC) curve analysis of Child-Pugh and ALBI scores predicting PHLF;(4) follow-up and survival situations;(5) prognosis analysis of HCC patients after hepatectomy.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to August 2016.Measurement data with normal distribution were represented as-±s.Measurement data with skewed distribution were described as M (P25,P75).The survival curve was drawn by the Kaplan-Meier method,and the Log-rank test was used for survival analysis.The influencing factors of PHLF were analyzed using the logistic regression model.The prognostic factors were analyzed by the COX regression model.ROC analysis was used for predictive value of Child-Pugh and ALBI scores.Results (1) Surgical situations:226 patients underwent successful surgery,including 171 receiving localized liver resection (＜ 3 Couinaud hepatic segments resection) and 55 receiving extensive liver resection (≥ 3 Couinaud hepatic segments resection).Volume of intraoperative blood loss of 226 patients was 1-22 550 mL,with a median of 800 mL.Of 226 patients,89,9,4,4,3 and 1 were complicated with liver failure,pulmonary infection,bile leakage,gastrointestinal henorrhage,incision infection and infectious shock,respectively,they were cured and discharged from hospital by life-sustaining treatment and symptomatic treatment.Duration of hospital stay was 2-49 days,with a median of 12 days.(2) Factors analysis affecting PHLF of HCC patients:results of univariate analysis showed that gender,total bilirubin (TBil),albumin (Alb),prothrombin time (PT),international normalized ratio (INR),platelet (PLT),peritoneal effusion,volume of intraoperative blood loss,Child-Pugh score and ALBI score were related factors affecting PHLF of HCC patients [Odds ratio (OR) =O.490,1.077,0.763,1.613,26.342,0.990,2.458,5.052,2.875,34.570,95％ confidence interval (CI):0.248-0.971,1.030-1.127,0.699-0.833,1.248-2.087,2.722-254.936,0.985-0.995,1.386-4.361,2.467-10.347,1.807-4.576,11.674-102.376,P＜0.05].Child-Pugh score and ALBI score in the multivariate analysis were respectively analyzed using the logistic regression model for avoiding multicollinearity.Excluding TBil,Alb,PT and peritoneal effusion,logistic regression model of Child-Pugh score showed that PLT,volume of intraoperative blood loss and Child-Pugh score were independent factors affecting PHLF of HCC patients (OR=0.991,4.462,2.412,95％CI:0.986-0.996,2.090-9.527,1.479-3.934,P＜0.05).Excluding TBil and Alb,Logistic regression model of ALBI score showed that PLT,volume of intraoperative blood loss and ALBI score were independent factors affecting PHLF of HCC patients (OR=O.990,4.867,42.947,95％CI:O.984-0.995,2.088-11.346,12.409-148.637,P＜ 0.05).(3) ROC analysis of Child-Pugh and ALBI scores predicting PHLF:area under the ROC was respectively 0.652 (95％CI:0.577-0.727) in the Child-Pugh score and 0.801 (95％CI:0.741-0.861) in the ALBI score,with a statistically significant difference (Z=3.590,P＜0.05).The best critical value,sensitivity and specificity of PHLF that were predicted by ALBI score were-2.58,68.5％ and 86.9％,respectively.Further analysis showed that area under the ROC was respectively 0.642 (95％CI:0.554-0.731) in Child-Pugh score and 0.813 (95％CI:0.744-0.882) in ALBI score,excluding factors of extensive liver resection affecting PHLF,with a statistically significant difference (Z=3.407,P＜0.05).(4)Follow-up and survival situations:of 226 patients,217 were followed up for 1.3-79.5 months,with a median time of 29.5 months.During the follow-up,134 patients had survival and 92 died.(5) Prognosis analysis of HCC patients after hepatectomy:results of univariate analysis showed that Alb,PLT,alpha-fetoprotein (AFP),peritoneal effusion,tumor diameter,extent of resection,combined portal vein tumor thrombus (PVTT),combined vascular tumor thrombus and Child-Pugh score were related factors affecting prognosis of HCC patients [Hazard Ratio (HR)=0.954,1.003,2.958,1.698,1.155,1.785,2.326,3.001,1.324,95％CI:0.911-0.999,1.000-1.005,1.955-4.476,1.115-2.585,1.103-1.209,1.138-2.802,1.310-4.130,1.983-4.546,1.037-1.690,P ＜ 0.05].Excluding Alb and peritoneal effusion for avoiding multicollinearity,results of multivariate analysis showed that AFP,tumor diameter,combined vascular tumor thrombus and Child-Pugh score were independent factors affecting prognosis of HCC patients (HR =2.237,1.080,2.122,1.309,95％ CI:1.439-3.476,1.028-1.134,1.362-3.305,1.010-1.697,P＜0.05).Further analysis of Kaplan-Meier curve showed that median survival time in patients with grade A and B of Child-Pugh score were respectively 30.6 months and 25.2 months,with a statistically significant difference in survival (x2 =4.491,P＜0.05).The median survival time in patients with grade 1 and 2 of ALBI score were respectively 29.6 months and 31.0 months,with no statistically significant difference in survival (x2 =0.539,P＞0.05).Conclusion Preoperative ALBI score in predicting PHLF is superior to that of Child-Pugh score,but ALB1 score is not independent factor affecting prognosis of HCC patients.

Application value of the liver stiffness measurement on complications after hepatectomy / 中华消化外科杂志

Objective To explore the application value of the liver stiffness measurement (LSM) on complications after hepatectomy.Methods The retrospective case-control study was conducted.The clinical data of 121 hepatocellular carcinoma (HCC) patients who underwent hepatectomy in the Mianyang Central Hospital from January 2011 to April 2017 were collected.All 121 patients received LSM using Fibro Scan,and 81 undergoing laparoscopic liver resection (LR) and 40 undergoing open liver resection (OR) were respectively allocated into the LR and OR groups.Observation indicators:(1) comparisons of intra-and post-operative situations;(2) risk factors analysis affecting postoperative complication of HCC patients;(3) area under the curve (AUC) of LSM and postoperative complications;(4) comparisons of intra-and post-operative situations,when LSM ≤17.5 kPa;(5) comparisons of intra-and post-operative situations,when LSM ＞ 17.5 kPa;(6)comparisons of intra-and post-operative situations between patients with LSM ≤ 17.5 kPa and LSM ＞ 17.5 kPa in the LR group.Measurement data were represented as x±s,and mean comparisons between groups were done using the t test.Comparisons of count data and univariate analysis were analyzed using the chi-square test and Fisher exact probability.The multivariate analysis was done using the logistic regression model,using P＜0.01 as a inclusion criteria in the univariate analysis.The critical value of postoperative complication was calculated using the receiver operating characteristic curve (ROC).Results (1) Comparisons of intra-and post-operative situations:all the 121 patients underwent successful surgery,including 4 with conversion to open surgery in the LR group.Cases with Pringle manner were 51 in the LR group and 17 in the OR group,with a statistically significant difference (x2 =4.555,P＜0.05).Operation time,volume of intraoperative blood loss,case with intraoperative blood transfusion,Ishak score of 1-3 and 4-6 scores,postoperative complications and duration of hospital stay were respectively (248±78)minutes,(292±229)mL,14,14,67,29,(12±7)days in the LR group and (221±78)minutes,(281± 194)mL,9,9,31,10,(13±6)days in the OR group,with no statistically significant difference between groups (t =1.843,0.282,x2 =0.473,0.473,1.431,t =0.075,P＞0.05).(2) Risk factors analysis affecting postoperative complication of HCC patients:39 of 121 patients had postoperative complications.Results of univariate analysis showed that retention 15-minute rate of indocyanine green (ICG R15),LSM,volume of intraoperative blood loss and Ishak score were risk factors affecting postoperative complication of HCC patients (x2 =7.161,32.490,7.725,2.863,P＜0.l).Results of multivariate analysis showed that LSM ＞ 15.0 kPa was an independent risk factor affecting postoperative complication of HCC patients [odds ratio (OR) =6.906,95％ confidence interval (CI):2.307-20.672,P＜0.05].(3) AUC of LSM and postoperative complication:when LSM of postoperative complication ＞ 17.5 kPa,sensitivity,specificity and AUC were respectively 64.1％,85.4％ and 0.749 (95％CI:0.662-0.824,P＜0.05).(4) Comparisons of intra-and post-operative situations,when LSM ≤ 17.5 kPa:duration of hospital stay was respectively (10±5) days in the LR group and (13±7) days in the OR group,with a statistically significant difference between groups (t--2.389,P＜0.05).(5) Comparisons of intra-and post-operative situations,when LSM ＞ 17.5 kPa:operation time,volume of intraoperative blood loss,cases with postoperative complications and hepatic dysfunction were respectively (277±76)minutes,(505±232)mL,21,17 in the LR group and (212-± 109) minutes,(328±250) mL,4,2 in the OR group,with statistically significant differences between groups (t=2.060,2.057,P＜0.05).(6) Comparisons of intra-and post-operative situations between patients with LSM ≤ 17.5 kPa and LSM ＞ 17.5 kPa in the LR group:operation time,volume of intraoperative blood loss,cases with postoperative complications and hepatic dysfunction and duration of hospital stay were respectively (236±76)minutes,(197± 153)mL,8,3,(10±5)days in the LR group and (277± 76)minutes,(505±232) mL,21,17,(16±9)days in the OR group,with statistically significant differences between groups (t=0.657,3.398,x2 =36.547,36.475,t=17.414,P＜0.05).Conclusion LSM is an independent risk factor affecting postoperative compfications after hepatectomy,when LSM ＞ 17.5 kPa,LR is associated with higher incidence of postoperative complications compared with OR.

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 of ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in anatomical segmentectomy / 中华消化外科杂志

Objective To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy.Methods The retrospective cross-sectional study was conducted.The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected.The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed,laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment,and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization,finally laparoscopic anatomical segmentectomy was performed.Observation indicators:(1) intraoperative situations:success rate of portal vein puncture,targeted hepatic segment,effect of ICG fluorescence staining,intraoperative complications,operation time,volume of intraoperative blood loss,blood transfusion,conversion to open surgery,tumor diameter,the minimum resection margin to tumor;(2) postoperative situations:postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay;(3) follow-up situations:cases with follow-up,follow-up time and postoperative tumor recurrence.Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018.Measurement data with normal distribution and count data were respectively described as average (range) and percentage.Results (1) Intraoperative situations:a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0％ (26/26),and punctures in S8,S7,S2,S3,S6,S5 and S4 of the liver were respectively performed to 7,6,4,3,3,2 and 1 patients.Of 26 patients,22 achieved expected effect of ICG fluorescence staining,with a statisfaction of 84.6％ (22/26) and 4 failed to get expected effect,including 2 with uneven dying,1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary.All the 26 patients were not complicated with ICG injection induced to allergy.Average operation time and volume of intraoperative blood loss were 184 minutes (range,60-315 minutes) and 97 mL (range,10-400 mL),without intraoperative blood transfusion and conversion to open surgery.Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range,1.2-10.0 cm) and 1.5 cm (range,0.4-3.0 cm).(2) Postoperative situations:of 26 patients,2 with grade Ⅰ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion),no patient had grade Ⅲ and above complications,and there was no bile leakage,infection and hepatic dysfunction.Average duration of hospital stay in 26 patients was 6.9 days (range,5.0-14.0 days).(3) Follow-up situations:26 patients were followed up for 0.3-17.0 months,with a median time of 6.0 months.During the follow-up,1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival.Conclusion Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approaeh is safe and feasible,especially suitable in posterosuperior liver segments.

Targeted therapy for hepatocellular carcinoma / 中华消化外科杂志

Hepatocellular carcinoma (HCC) is the world's fifth common malignant tumor,ranks as the second and sixth leading causes of cancer death in nale and female.In a majority of the cases,HCC is diagnosed in advanced stage of disease when curative treatment options are not applicable.In 2007,sorafenib was approved for the first-line treatment of advanced HCC.Targeted therapy,which could improve the overall survival and qualities of life,brought a new hope for patients with advanced HCC.Unfortunately,in the past 10 years,various drugs tested in numerous different trials failed to denonstrate any benefit.Recent studies have demonstrated the efficacy of two molecular targeted agents,the second-line agent regorafenib and the first-line agent lenvatinib.Furthermore,preliminary results of immune checkpoint inhibitors such as anti-PD-1/PD-L1 or CTLA-4 antibodies were quite encouraging.These new drugs brought dawn of targeted therapy of HCC.