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Objective:To investigate the clinical efficacy of precise hepatectomy for the treatment of recurrent unilateral hepatolithiasis and prognostic factors.Methods:The retrospec-tive case-control study was conducted. The clinicopathological data of 166 patients with recurrent unilateral hepatolithiasis who were treated by precise hepatectomy in the First Affiliated Hospital of Anhui Medical University from January 2015 to January 2021 were collected. There were 51 males and 115 females, aged (58±12)years. Observation indicators: (1)diagnosis and classification; (2) surgical and intraoperative situations; (3) postoperative situations; (4) follow-up; (5) analysis of prognostic factors. Follow-up was conducted using the outpatient examination and telephone inter-view to detect final stone clearance or recurrence and survival of patients up to August 2021. Patients with T-tube were performed T-tube cholangiography or choledochoscopy to evaluate the final stone clearance rate at postoperative week 8. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. Univariate and multi-variate analyses were conducted using the Logistic regression model. Results:(1) Diagnosis and classifica-tion: 166 patients were diagnosed as hepatolithiasis by preoperative imaging examination and intraoperative evaluation, including 134 cases with common bile duct stones. Of the 166 patients, 115 cases had stones located in the left lobe of liver and 51 cases had stones located in the right lobe of liver. There were 111 cases with bile pigment stones, 31 cases with cholesterol stones, 24 cases with mixed type of stones. There were 9 cases classified as Tsunoda type Ⅰ, 89 cases as Tsunoda type Ⅱ, 65 cases as Tsunoda type Ⅲ, 3 cases as Tsunoda type Ⅳ. There were 12 cases classified as type Ⅰ, 99 cases as type Ⅱ, 47 cases as type Ⅲ, 8 cases as type Ⅳ according to Japanese classification in 2001. All the 166 patients were classified as type Ⅰ based on Chinese classification. According to the classification of author team, 166 patients were classified as type Ⅱ. (2) Surgical and intra-operative situations: 119 of 166 patients had liver lobe or segment atrophy. All the 166 patients underwent precise hepatectomy combined with different methods of drainage, of which 28 cases underwent left hemihepatectomy, 11 cases underwent right hemihepatectomy, 1 case underwent liver resection of segment Ⅰ, 5 cases underwent liver resection of segment Ⅱ, 5 cases underwent liver resection of segment Ⅲ, 8 cases underwent liver resection of segment Ⅳ (left medial lobe), 3 cases underwent liver resection of segment Ⅴ, 2 cases underwent liver resection of segment Ⅵ, 2 cases underwent liver resection of segment Ⅷ, 68 cases underwent liver resection of segment Ⅱ and Ⅲ (left lateral lobe), 3 cases underwent liver resection of segment Ⅴ and Ⅵ, 6 cases underwent liver resection of segment Ⅴ and Ⅷ (right anterior lobe), 21 cases underwent liver resection of segment Ⅵ and Ⅶ (right posterior lobe), 1 case underwent liver resection of segment Ⅱ, Ⅲ and Ⅳa, 1 case underwent liver resection of segment Ⅴ, Ⅵ and Ⅶ, 1 case underwent liver resection of segment Ⅰ, Ⅱ, Ⅲ and Ⅳ. For biliary drainage methods of 166 patients, 120 patients received T-tube external drainage, 23 cases received choledochojejunostomy, 23 cases received choledochojejunostomy combined with T-tube external drainage. The original cholangiojejunal anastomotic stenosis was found and reconstructed in 10 patients. The operation time was (258±87)minutes and intraopera-tive blood transfusion rate was 16.87%(28/166) of 166 patients. All the 166 patients underwent fiber choledochoscopy, showing 77 cases with normal function of Oddi sphincter, 38 cases with disorder, 40 cases with dysfunction. There were 11 patients undergoing choledochojejunostomy who were not evaluate the function of Oddi sphincter. There were 21.69%(36/166)of patients with intra-hepatic biliary stricture. One hundred and forty-nine of 166 patients were conducted bile culture, showing the positive rate as 75.17%(112/149). There were 22 cases cultured multiple kinds of bacteria. The most common bacterium was Escherichia coli (43 cases), followed by Pseudomonas aeruginosa (12 cases), Klebsiella pneumoniae (9 cases), Klebsiella oxytoca (7 cases), Enterococcus faecium (7 cases). (3) Postoperative situations. The postoperative complication rate of 166 patients was 16.87%(28/166). In the 8 patients with serious complications of Clavien-Dindo grade Ⅲ, 6 cases were performed thoracocentesis or abdominocentesis for effusion, 1 case was stopped bleeding under gastroscopy for stress ulcerbleeding, 1 case was performed surgery for adhesive intestinal obstruction. Two patients with septic shock of Clavien-Dindo grade Ⅳ were converted to intensive care unit for treatment and discharged after recovery. There were 13 patients with biliary leakage, 10 patients with pulmonary infection, 6 cases with incision infection, which were improved after conservative treatments. There was no perioperative death. The instant stone clearance rate of 166 patients was 81.93%(136/166). The duration of postoperative hospital stay of 166 patients was (11±6)days. (4) Follow-up: 166 patients were followed up for (37±17)months. The final stone clearance rate and stone recurrence rate of 166 patients were 94.58%(157/166) and 16.87%(28/166), respectively. According to Terblanche classification of prognosis, there were 91, 36, 25, 14 cases of grade Ⅰ, Ⅱ, Ⅲ, Ⅳ in 166 patients, respectively. Five of the 166 patients underwent intrahepatic secondary malignancy in which 4 cases died. (5) Analysis of prognostic factors: results of univariate analysis showed that biliary culture, the number of previous surgeries, immediate stone clearance, final stone clearance were related factors affecting the prognosis of precise hepatectomy in patients with recurrent unilateral hepatolithiasis ( odds ratio=2.29, 7.48, 2.69, 4.52, 95% confidence interval as 1.09?4.85, 2.80?19.93, 1.16?6.25, 1.15?17.77, P<0.05). Results of multivariate analysis showed that the number of previous surgeries ≥3 was an independent risk factor affecting the prognosis of precise hepatectomy in patients with recurrent unilateral hepato-lithiasis ( odds ratio=6.05, 95% confidence interval as 2.20?16.62, P<0.05). Conclusions:Precise hepatectomy is safe and effective for the treatment of patients with recurrent unilateral hepato-lithiasis. The number of previous surgeries ≥3 is an independent risk factor affecting the prognosis of precise hepatectomy in patients with recurren t unilateral hepatolithiasis.
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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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The optimal management of malignant obstructive jaundice has been the subject of much debate among hepatobiliary surgeons. However, there is currently no universal agreement in the clinical role for preoperative biliary drainage to relief the jaundice. In this current era where precision liver surgery is widely pursued, it is necessary to define the role of preoperative drainage according to the different anatomical levels of biliary obstruction so as to achieve the best outcomes and eventual prognosis.
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The application of enhanced recovery after surgery (ERAS) in hepatectomy is safe and feasible.The related researches of the clinical strategies of ERAS involved in colonic surgery instead of management of basic diseases of liver,and the influence of portal hypertension and hepatitis B virus infection on the ERAS has not been emphasized.According to the clinical strategies of ERAS in colon surgery,the basic diseases and the characteristics of liver were focused,and the clinical strategies of ERAS in the era of precision liver surgery were proposed.Through concerted efforts of the multidisciplinary team and a joint of surgeons,nurses and patients,the establishment of multicentre clinical studies under guidance of evidence-based medicine (EBM) will show clearly a development direction of the clinical strategies of ERAS in the era of precision liver surgery.
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Objective To investigate the clinical value of the precision liver surgery in the liver graft procurement for pediatric living donor liver transplantation.Methods The clinical data of 58 living donors of left hepatic lobe graft who were admitted to the Renji Hospital of Shanghai Jiaotong University from December 2012 to January 2014 were retrospectively analyzed retrospectively from December 2012 to January 2014.All the donors donated voluntarily and gratuitously and were approved by the ethics committee of the hospital.All the donors received computed tomography (CT),and the two dimensional data were converted to three dimensional images for evaluating the intrahepatic bile ducts and blood vessles,and the typs of the left hepatic arteries and veins were determined.The donor's liver graft volume was assessed by CT before operation.The standard liver volume of the donors and the recipients,and the volume of liver to be reseeted and the total liver volume were measured.A virtual surgery was conducted for designing the actual surgery.The liver graft was resected with the precision liver surgery technique.Patients were followed up by the out-patient examination and phone call till April 2014.Results The results of CT angiography confirmed that 28 donors were with type Ⅰ left hepatic artery,10 with type Ⅱ left hepatic artery and 20 with type Ⅲ left hepatic artery; 35 patients were with type Ⅰ left hepatic vein and 23 with type Ⅱ left hepatic vein.The left-lobe volume estimated by CT was (243 ± 65) mL.Liver graft procurement was successfully carried out on the 58 donors,including 7 left hemihepatectomy and 51 left lateral lobectomy.Two donors received cholecystectomy concomitantly.The actual volume of liver resected was (255 ±59) mL,and the error rate of the liver volume to be resected was 4.94％.The weight of the liver graft to the body weight of the recipient was 3.3％ ± 1.0％.The operation time and the volume of blood loss were (260 ± 89) minutes and (181 ± 35)mL,respectively.One donor received red blood cell infusion of 2 U.The time for gastrointestinal function recovery was (2.0 ± 1.1) days,and the time of drainage tube pull-off was (3.0 ± 1.2) days.The duration of postoperative stay was (7 ± 3) days.The white blood cells,hemoglobin,alanine transaminase,aspartate transaminase,total bilirubin,direct bilirubin and albumin were at the normal levels at the discharge.Two donors were complicated by incisional bleeding and fat liquefaction,and they were cured by symptomatic treatment.All the donors were followed up for a median time of 8.7 months.The donors were recovered well without complications during the follow-up.Conclusions Liver graft procurement guided by precision liver surgery has the advantages of high accurate rate,little injury to the liver of the donors,few postoperative complications and quick recovery of the donors.
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The progress of liver surgery is characterized by precision,minimal invasion and effectiveness in the 21 st century.Establishment of painless liver surgery ward and implementation of pain management in the perioperative period are not only the central content of enhanced recovery after surgery,but also one of the core connotation in precision liver surgery research.Conducting training programs for medical staffs,emphasizing health education of pain,selecting the reasonable pain assessment strategy,combination of preemptive analgesia and multimodal analgesia in the perioperative period and paying attention to individualized analgesia are important contents of construction of painless liver surgery ward.To carry out multicentre clinical study energetically,explore clinical pathway for the construction of painless ward and perioperative analgesic model are the development orientation for the construction of painless liver surgery ward.
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With the wide application of liver transplantation techniques,rapid development of digital imaging medicine and continuous update of surgical implements,the theory of precision hepatectomy still keeps optimizing.Precision hepatectomy is not a surgical implement or surgical technique,but a concept of liver surgery emphasizing less bleeding,minimal invasion,fast recovery and long-term curative effect,which is updating and improving with the development of modern science.Much less intraoperative bleeding,shorter operation time,better postoperative recovery and long-term survival should be the chief pursuit and principle of precision hepatectomy.
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Continnous theoretical and technological progress in the face of increasing expectations for quality of health care and progress in medical technology has transformed the surgical paradigm.Based on the historical trends and technique advances,a novel paradigm ofPrecision Surgery has been proposed,which is featuring certainty-based practice to ensure the best results for each patient with multi-objective optimization of therapeutic effectiveness,surgical safety and minimal invasiveness.The main characteristics of precision surgery may be summarized as determinacy,predictability,controllability,integration,standardization and individualization.The strategy of precision hepatic surgery is to seek a balance of maximizing the removal of the target lesions,while maximizing the functional remnant liver and minimizing surgical invasiveness.The concept of precision surgery should be considered for wider application in liver surgery and other fields as a step toward the ultimate goal of perfect surgery.