Adjuvant treatment strategy after curative resection for hepatocellular carcinoma / 医学前沿

Hepatic resection represents the first-line treatment for patients with resectable hepatocellular carcinoma (HCC). However, the 5-year recurrence rates of HCC after surgery have been reported to range from 50% to 70%. In this review, we evaluated the available evidence for the efficiency of adjuvant treatments to prevent HCC recurrence after curative liver resection. Antiviral therapy has potential advantages in terms of reducing the recurrence rate and improving the overall survival (OS) and/or disease-free survival of patients with hepatitis-related HCC. Postoperative adjuvant transarterial chemoembolization can significantly reduce the intrahepatic recurrence rate and improve OS, especially for patients with a high risk of recurrence. The efficacy of molecular targeted drugs as an adjuvant therapy deserves further study. Adjuvant adoptive immunotherapy can significantly improve the clinical prognosis in the early stage. Randomized controlled trial (RCT) studies evaluating adjuvant immune checkpoint inhibitors are ongoing, and the results are highly expected. Adjuvant hepatic artery infusion chemotherapy might be beneficial in patients with vascular invasion. Huaier granule, a traditional Chinese medicine, has been proved to be effective in prolonging the recurrence-free survival and reducing extrahepatic recurrence. The efficiency of other adjuvant treatments needs to be further confirmed by large RCT studies.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Resección hepática extendida con vena cava inferior por colangiocarcinoma intrahepático: presentación de 2 casos / Extended hepatic resection with inferior cava vein for intrahepatic cholangiocarcinoma: presentation of two cases

Resumen Introducción: El colangiocarcinoma intrahepático (CIH) corresponde al segundo tumor hepático primario y la resección quirúrgica es la única alternativa válida para el tratamiento curativo de esta enfermedad. Reporte de casos: Describimos 2 paciente portadores de CIH con compromiso de vena cava inferior (VCI) que fueron sometidos a resección en Clínica Alemana de Santiago (CAS). Ambas pacientes son de género femenino de 39 y 47 años de edad. Ambas fueron sometidas a resección mayor hepática izquierda, asociada a resección del segmento I y extendida a VCI. La reconstrucción de la VCI fue realizada con parche pericárdico bovino y cierre primario respectivamente. El período desde el posoperatorio hasta el alta, fue de 13 y 23 días respectivamente. Discusión: Aunque la reseccion quirúrgica es la única vía para la curación en el CIH, el compromiso de estructuras vasculares hacen que esto no sea posible. El manejo multidisciplinario asociado a una técnica meticulosa realizada por un equipo quirúrgico experimentado, hacen posible lograr buenos resultados.

Introduction: Intrahepatic cholangiocarcinoma is the second most common primary liver tumor and surgical resection the only valid curative treatment. Case reports: We describe two patients harboring an intrahepatic cholangiocarcinoma with cava vein involvement who underwent resection at Clinica Alemana of Santiago. Both patients were females with ages of 39 and 47 years old. Both patients underwent left liver resection, associated to resection of segment I and of a portion of cava vein. Reconstruction of resected portion of the cava vein was performed by using a pericardium bovine patch and primary closure respectively. Postoperative period was uneventfully being discharged at 13 and 23 days respectively. Discussion: Although surgical resection is the only way to get curativeness, frequent involvement of large vascular structures make treatment unfeasible. A multidisciplinary approach associated with a meticulous technique performed by an experienced surgical team make possible to accomplish the above objective.

Effects of Different Diuretic Regimens on Related Indicators in Hepatocellular Carcinoma Patients after Hepatic Resection / 中国药房

OBJECTIVE:To investigate the effects of different diuretic regimens on related indicatora in hepatocellular carcino-ma patients after hepatic resection. METHODS:A total of 60 hepatocellular carcinoma patients undergoing hepatic resection were randomly divided into study group (30 cases) and control group (30 cases). After surgery,study group was given Spironolactone tablet 100 mg+Furosemide tablet 40 mg,qd,after breakfast;Control group was given Spironolactone tablet 100 mg orally,bid,af-ter breakfast and at 16:00+Furosemide tablet 20 mg,qd,after breakfast. Electrolyte,liver and renal function of 2 groups were re-checked every 3 days;diuretic regimen was adjusted according to body weight and volume of liquid intake and output. The effec-tiveness indexes of diuretic treatment were observed in 2 groups,such as the decrease of body weight,case number of effective di-uretic treatment,frequency of intravenous dieresis,frequency of hydroxyethl starch use,frequency of night arination,postoperative hospitalization stay,the time of ascites extinction;serum sodium,serum potassium,serum creatinine,blood urea nitrogen,serum al-bumin,ALT,AST,GGT,the occurrence of ADR were observed before and after treatment. RESULTS:The nocturnal micturition frequency of study group was significantly lower than that of control group,with statistical significance (P<0.05). There was no significant difference in the decrease of body weight,response rate of diuretic treatment,frequency of intravenous dieresis,frequen-cy of hydroxyethyl starch use,postoperative hospitalization stay or the time of ascites extinction between 2 groups(P>0.05). After treatment,the levels of serum sodium and serum albumin in 2 groups were decreased significantly,compared to before treatment;the levels of blood urea nitrogen,serum potassium and ALT,AST,GGT in 2 groups were significantly higher than before treat-ment,with statistical significance(P<0.05). There was no statistical significance in the levels of serum sodium,serum potassium, blood urea nitrogen,serum albumin or ALT,AST,GGT between 2 groups(P>0.05). There was no statistical significance in the incidence of ADR between 2 groups(P>0.05). CONCLUSIONS:Both two diuretic regimens can effectively avoid the occurrence of postoperative ascites formation and related complication in patients hepatocellular carcinoma after hepatic resection. The drug regi-mens of spironolactore 100 mg,qd+furosemide 40 mg,qd after breakfast can significantly reduce nocturnal micturition frequency and improve medication compliance.

Clinical value of liver transplantation for intrahepatic cholangiocarcinoma / 中华器官移植杂志

Objective To investigate the clinical value of liver transplantation for intrahepatic cholangiocarcinoma (ICC).Methods A retrospective analysis was performed on 68 patients with ICC who underwent hepatic resection or liver transplantation between January 2007 and September 2013.In the surgical treatment of ICC,overall survival and prognostic risk factors were analyzed to determine the clinical value of liver transplantation for ICC compared with hepatic resection.Results Of the patients with ICC,55 underwent hepatic resection and 13 were given liver transplantation.The 1 and 3-year survival rate was significantly higher in the liver transplantation group than in the hepatic resection group (76.9％ versus 52.7％,and 61.5％ versus 27.3％,P＜0.05).In addition,liver transplantation resulted in higher tumor recurrence-free survival rate than hepatic resection (69.2％ versus 41.8％,and 61.5％ versus 20.0％,P＜0.05).The multivariate analysis showed that tumor size larger than 5 cm was an independent risk factor and HBV infection was an independent protective factor of ICC.Conclusion The prognosis of patients who underwent liver transplantation was better than hepatic resection,suggesting that liver transplantation is perhaps a prior treatment in strictly selected and unresectable patients with ICC.

Hepatic Resection Combined with Radiofrequency Ablation versus Hepatic Resection Alone for Multifocal Hepatocellular Carcinomas: A Meta-analysis / 华中科技大学学报（医学）（英德文版）

This meta-analysis aimed to comprehensively assess the efficacy and safety of hepatic resection combined with radiofrequency ablation versus hepatic resection (HR) alone for the treatment of multifocal hepatoeellular carcinomas (HCC).A literature search was conducted from the database including MEDLINE,Embase,Cochrane Central Register of Controlled Trials (CENTRAL) and China Biology Medicine (CBM) disc.The primary outcomes included the 1-,3-,5-year overall survival (OS) and disease-free survival (DFS) rate.The secondary outcomes contained the intraoperative parameters and postoperative adverse events (AEs).These parameters were all analyzed by RevMan 5.3 software.After carefully screening relevant studies,four retrospective studies of high quality involving 466 patients (197 in the combined group and 269 in the HR group) were included in this study.The pooled results showed that the 1-,3-,5-year OS rate in the combined group were comparable with those in the HR group (OR=0.77,0.96,0.88;P=0.33,0.88,0.70,respectively).Similarly,there was no significant difference in 1-,3-,5-year DFS rate between the combined group and the HR alone group (OR=0.57,0.83,0.72;P=0.17,0.37,0.32,respectively).And the intraoperative parameters and postoperative AEs were also comparable between the above two cohorts.However,two included studies reported that tumor often recurred in the ablation site in the combined group.The present meta-analysis indicated that the HR combined with RFA could reach a long-term survival outcome similar to curative HR for multifocal HCC patients.And this therapy may be a promising alternative for these patients with marginal liver function or complicated tumor distribution.Furthermore,high quality randomized controlled trials (RCTs) are imperative to verify this conclusion.

A comparison of hepatitis B virus reactivation rates between liver resection and radiofrequency ablation for patients with tumor ≤5 cm / 中华肝胆外科杂志

Objective To investigate the value of liver resection and radiofrequency ablation (RFA) on reactivation rates of hepatitis B virus (HBV) in hepatocellular cancer (HCC) patients with tumor ≤5 cm and determine influential factors.Methods Retrospective analysis was performed in clinical data of hepatocellular cancer patients with tumor ≤5 cm from Shengli Oilfield Centeral Hospital between July 2007 and March 2012,289 cases were assigned to liver resection group (n =157) and RFA group (n =132).Logistic regression was used to evaluate relative factors associated with HBV reactivation for univariate and multivariate analyses.The stratified x2 test was utilized to assess clinical outcomes in HBV reactivation subgroup with or without antiviral treatment.CD3 +,CD4+,CD8 +,CD4+/CD8 + and NK cell proportions were comparatively analysized.Results (1) The univariate and multivariate logistic regression analyses showed antiviral therapy,Child-Pugh grade,vascular invasion and treatment (liver resection or RFA) were significant risk factors of HBV reactivation (P ＜ 0.05).(2) HBV reactivation was lower in patients who received antiviral therapy than those who did not (10/109 vs 33/180,x2 =4.497,P ＜ 0.05).The viral reactivation rate for the liver resection group was higher than the RFA group in patients who did not receive antiviral therapy (24/98 vs 9/82,x2 =5.446,P ＜ 0.05),but the difference was not significant in patients who received antiviral therapy (6/59 vs 4/50,x2 =0.153,P ＞ 0.05).(3) The proportions of CD3 +,CD4 +,CD4 +/CD8 + and NK cell after treatment for 7 days decreased in various degrees for both the liver resection and RFA groups regardless of patients with or without antiviral therapy (P ＜ O.05).For the patients without antiviral therapy,the cell proportions in 7 days after treatment were significantly higher in the RFA group than that in the liver resection group (P ＜ 0.05),but the difference was not significant in patients with antiviral therapy (P ＞ 0.05).Conclusions For the patients with tumor ≤5 cm,the proportions of immunological cells decreased in liver resection when compared with RFA.Preoperative antiviral therapy may have partial response in immunological suppression,and lowered the incidence of HBV reactivation.

Radiofrequency ablation vs. hepatic resection for resectable colorectal liver metastases / 华中科技大学学报（医学）（英德文版）

The treatments of resectable colorectal liver metastases (CRLM) are controversial. This study aimed to evaluate the relative efficacy and safety of hepatic resection (HR) and radiofrequency ablation (RFA) for treating resectable CRLM. Between January 2004 and May 2010, the enrolled patients were given hepatic resection (HR group; n=32) or percutaneous RFA (RFA group; n=21) as a first-line treatment for CRLM. All the tumors had a maximum diameter of 3.5 cm and all patients had five or less tumors. The patient background, tumor characteristics, cumulative survival rate and recurrence-free survival rate were assessed in both groups. There were significantly more patients with comorbidities in the RFA group than those in the HR group (17 in RFA group vs. 10 in HR group; P<0.000). The mean maximum tumor diameter in the HR group and RFA group was 2.25±0.68 and 1.89±0.62 cm (P=0.054), and the mean number of tumors was 2.28±1.05 and 2.38±1.12 (P=0.744), respectively. The 1-, 3- and 5-year cumulative survival rates in the HR group were 87.5%, 53.1% and 31.3%, respectively, and those in the RFA group were 85.7%, 38.1% and 14.2%, respectively with the differences being not significant between the two groups (P=0.062). The 1-, 3- and 5-year recurrence-free survival rates in the HR group were 90.6%, 56.3% and 28.1%, respectively, and those in the RFA group were 76.1%, 23.8% and 4.8%, respectively, with the differences being significant between the two groups (P=0.036). In conclusion, as HR has greater efficacy than RFA in the treatment of resectable CRLM, we recommend it as the first option for this malignancy.

Survival outcomes of hepatic resection compared with transarterial chemoembolization or sorafenib for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND/AIMS: Treating hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains controversial. We compared the outcomes of hepatic resection (HR), transarterial chemoembolization (TACE), and sorafenib therapy as treatments for HCC with PVTT. METHODS: Patients diagnosed as HCC with PVTT between January 2000 and December 2011 who received treatment with sorafenib, HR, or TACE were included. Patients with main PVTT, superior mesenteric vein tumor thrombosis, or Child-Turcotte-Pugh (CTP) class C were excluded. The records of 172 patients were analyzed retrospectively. HR, TACE, and sorafenib treatment were performed is 40, 80, and 52 patients respectively. PVTT was classified as either involving the segmental branch (type I) or extending to involve the right or left portal vein (type II). RESULTS: The median survival time was significantly longer in the HR group (19.9 months) than in the TACE and sorafenib groups (6.6 and 6.2 months, respectively; both p<0.001), and did not differ significantly between the latter two groups (p=0.698). Among patients with CTP class A, type I PVTT or unilobar-involved HCC, the median survival time was longer in the HR group than in the TACE and sorafenib groups (p=0.006). In univariate analyses, the initial treatment method, tumor size, PVTT type, involved lobe, CTP class, and presence of cirrhosis or ascites were correlated with overall survival. The significant prognostic factors for overall survival in Cox proportional-hazards regression analysis were initial treatment method (HR vs. TACE: hazard ratio=1.750, p=0.036; HR vs. sorafenib: hazard ratio=2.262, p=0.006), involved lobe (hazard ratio=1.705, p=0.008), PVTT type (hazard ratio=1.617, p=0.013), and CTP class (hazard ratio=1.712, p=0.012). CONCLUSIONS: Compared with TACE or sorafenib, HR may prolong the survival of patients with HCC in cases of CTP class A, type I PVTT or unilobar-involved HCC.

Changes in the types of liver diseases requiring hepatic resection: a single-institution experience of 9016 cases over a 10-year period

BACKGROUNDS/AIMS: To understand the changing demands for hepatic resection (HR), we collected data regarding HR performed in a tertiary centre over a period of 10 years. METHODS: We carried out extensive search of institutional databases to identify HR cases performed between January 2005 and December 2014. A study cohort of 9,016 patients were divided into 5 disease categories, namely hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), intrahepatic duct stone disease (IHDS), colorectal cancer liver metastasis (CRLM), and uncommon/rare diseases (URD). RESULTS: There were 5,661 (62.8%) HCC cases, followed by 1441 (16.0%) CRLM, 942 (10.5%) ICC, 638 (7.1%) IHDS and 334 (3.7%) URD. The number of annual HR cases gradually increased from 443 in 2005 to 1,260 in 2015. Annual HCC cases also gradually increased, but the annual proportion of HCC cases fluctuated narrowly between 58.3% and 70.2%. Annual CRLM cases increased rapidly, and their proportion increased progressively from 4.7% to 20.5%. Annual ICC cases increased slowly, and their annual proportion fluctuated between 7.2% and 15.6%. Annual IHDS cases decreased slowly, and their annual proportion decreased progressively from 17.2% to 3.4%, while annual URD cases fluctuated, with annual proportions varying between 2.3% and 5.6%. CONCLUSIONS: Annual cases of HR increased over the last 10 years in a tertiary center probably due to a center-specific centralization effect. The number of CRLM cases increased rapidly; those of HCC and ICC increased gradually, and those of IHDS declined gradually. We believe that these results reflect real changes in the types of liver disease requiring HR.

Effects ofαInterferon on Long-term Survival Rate and Tumor Recurrence After Radical Hepatic Resection / 中国药房

OBJECTIVE:To investigate the effect of α-interferon on long-term survival rate and tumor recurrence after radical hepatic resection. METHODS:104 patients with primary hepatocellular carcinoma underwent radical hepatic resection were divided into observation group(62 cases)and control group(42 cases). Observation group was treated with IFN-α for 18 months 4-6 weeks after surgery;control group received rountine treatment. Total survival rate and disease-free survival rate after surgery were com-pared between 2 groups. RESULTS:In observation group after surgery,1-year survival rate was 82.26%(51/62),3-year survival rate 61.29%(38/62),and 5-year survival rate 24.19%(15/62);in control group after surgery,1-year survival rate was 41.94%(26/62),3-year survival rate 28.57%(12/42)and 5-year survival rate 9.52%(4/42);there was statistically significant difference in postoperative survival rate between 2 groups (P<0.05). In observation group after surgery,1-year disease-free survival rate was 61.29%(38/62),3-year disease-free survival rate 40.32%(25/62),and 5-year disease-free surial rate 17.74%(11/62);in control group after surgery,1 year disease-free survival rate was 43.55%(27/62),3 year disease-free survival rate 22.58%(14/62),and 5-year disease-free surial rate was 0(0/62);there was statistically significant difference in postoperative disease-free survival rate be-tween 2 groups (P<0.05). CONCLUSIONS:The application of α-interferon after radical hepatic resection can significantly inhibit the recurrence of postoperative tumor,improve the long-term survival rate,and is worthy of clinical research.

Hepatectomy: a critical analysis on expansion of the indications / Hepatectomia: uma analise critica da ampliacao das indicacoes

Background: Hepatic resection has evolved to become safer, thereby making it possible to expand the indications. Aim : To assess the results from a group of patients presenting these expanded indications. Method: Were prospectively studied all the hepatectomy procedures performed for hepatic tumor resection. Patients with benign and malignant primary and secondary tumors were included. Were included variables such as age, gender, preoperative diagnosis, preoperative treatment, type of operation performed, need for transfusion, final anatomopathological examination and postoperative evolution. The patients were divided into two groups: group A, with a traditional indication for hepatectomy; and group B, with an expanded indication (tumors in both hepatic lobes, extensive resection encompassing five or more segments, cirrhotic livers and postoperative chemotherapy using hepatotoxic drugs). Results: Were operated 38 patients, and 40 hepatectomies were performed: 28 patients in group A and 10 in group B. The mean age was 57.7 years, and 25 patients were women. Three in group B were operated as two separate procedures. Groups A and B received means of 1.46 and 5.5 packed red blood cell units per operation, respectively. There were three cases with complications in group A (10.7%) and six in group B (60%). The mortality rate in group A was 3.5% (one patient) and in groups B, 40% (four patients). The imaging examinations were sensitive for the presence of tumors but not for defining the type of tumor. The blood and derivative transfusion rates, morbidity and mortality were greater in the group with expanded indications and more extensive surgery. Conclusion: The indications for liver biopsy and portal vein embolization or ligature can be expanded, with special need of cooperation of the anesthesiology department and the use of hepatic resection devices to diminish blood transfusion. .

Racional: As ressecções hepáticas evoluíram, tornando-se mais seguras, permitindo ampliação das indicações. Objetivo : Avaliar os resultados com ampliação da indicação. Método : Estudo prospectivo de todas as hepatectomias realizadas para ressecção de tumores hepáticos. Foram incluídos pacientes com tumores primários e secundários, benignos e malignos e anotados idade, gênero, diagnóstico pré-operatório, tratamento realizado no pré-operatório, tipo de operação realizada, necessidade de transfusão, exame anatomopatológico final e evolução pós-operatória. Os pacientes foram divididos em dois grupos: grupo A, aqueles com indicação tradicional de hepatectomia e grupo B, com indicação ampliada (tumor nos dois lobos hepáticos, ressecções extensas de cinco ou mais segmentos, fígados cirróticos e pós-quimioterapia com drogas hepatotóxicas). Resultados: Foram operados 38 pacientes e realizadas 40 operações, 28 no grupo A e 10 no B. A média de idade foi 57,7 anos, sendo 25 mulheres. Três do grupo B foram operados em dois tempos. Os grupos A e B receberam em média 1,46 e 5,5 concentrados de hemácias por operação, respectivamente. Os pacientes do grupo A tiveram três complicações (10,7%) e os do B seis (60%). A mortalidade no grupo A foi de 3,5% (n=1) e no grupo B ocorreram quatro óbitos (40%). Os exames de imagem foram sensíveis para presença de tumor, mas não para definir o tipo. As transfusões, a morbidade e a mortalidade foram maiores no grupo com ampliação das indicações e operações mais extensas. Conclusão: Deve-se indicar a biópsia hepática com maior frequência no pré-operatório, ...

Prognosis after resection of early hepatocellular carcinoma in HBV-related cirrhotic patients / 中华肝胆外科杂志

Objective To identify clinicopathologic factors which predict survival following hepatectomy in HBV-related cirrhotic patients with early hepatocellular carcinoma (HCC).Methods A database was used to identify patients with histologically confirmed early HCC (≤5 cm,no nodal involvement,metastases,or major vascular invasion) who underwent surgical resection (excluding ablation or transplantation).Among 20 700 patients with HCC who were diagnosed at the Eastern Hepatobiliary Surgery Hospital from April 2005 to November 2010,537 (2.6％) patients with early HCC were studied retrospectively.Prognostic factors were evaluated using the Kaplan-Meier curves,Cox proportional hazards models and the receiver operating characteristic (ROC) curves.Results The study included 537 patients.The median tumor size was 2.9 cm,and 33％ of patients had tumors ≤2 cm.Most HCC lesions were solitary (63％) and had no evidence of vascular invasion (64％).Following surgery,the overall median and 5-year survival were 45 months and 33％ respectively.After adjusting for demographic factors and histological grade,tumor size ＞2 cm (hazard ratio [HR]:1.56),multifocal tumors (HR:1.34),and vascular invasion (HR:2.03) remained independent predictors of poor survival (all P ＜ 0.05).Based on these findings,a prognostic scoring system was developed that allotted 1 point each for these factors.Patients with early HCC could be stratified into 4 distinct prognostic groups (median and 5-year survival,respectively):0 points (97 months,96％),1 point (85 months,76％),2 points (76 months,54％),3 points (56 months,39％) (P ＜0.01).Conclusions The present study emphasized the importance of pathologic staging even in patients with small HCC.Anatomical resection of HCC should be the preferred surgical procedure in cirrhotic patients.

The effects of different concentrations of sevoflurane combined with propofol on recovery quality in pa-tients undergoing partial hepatic resection / 临床麻醉学杂志

Objective To observe effects of different concentrations of sevoflurane combined with propofol on recovery quality in patients undergoing partial hepatic resection.Methods Seventy-eight patients,aged 20-70 years old,selected for partial hepatic resection were randomly divided into three groups,26 patients in each group:total intravenous propofol anesthesia group (group T), propofol combined with 0.5 MAC sevoflurane anesthesia group (group S1),propofol combined with 1.0 MAC sevoflurane anesthesia group (group S2).Spontaneous respiration recovery time,recovery time,extubation time and modified Aldrete score of 9 time were recorded after operation.Modified OAA/S scores as well as modified Aldrete score at extubation immediate time (T1 )and 5 min (T2 ), 1 5 min(T3 ),30 min(T4 )after extubation were also recorded.Results Total amount of propofol in groups S1,S2 significantly less than group T and total amount of propofol in group S2 significantly less than group S1(P <0.05).The recovery time,extubation time,modified Aldrete score of 9 time in groups S1 and S2 were significantly shorter than group T (P <0.05).Modified OAA/S scores at T1 ,T2 and the modified Aldrete scores at T1 in both groups S1 and S2 were significantly higher than group T,while group S2 was significantly higher than group S1 (P <0.05).Conclusion Compared with total intravenous propofol anesthesia,both propofol combined with 0.5 MAC sevoflurane and propofol combined with 1.0 MAC sevoflurane anesthesia improves the recovery quality in patients un-dergoing partial hepatic resection,and the recovery time was decreased in propofol combined with 1.0 MAC sevoflurane anesthesia.

Resección de metástasis hepáticas en cáncer de colon: nuevas perspectivas / Resection of liver metástasis in colon cancer: new perspectives

Liver metastasis of colon cancer is a very common clinical entity. Resective surgery can be used to improve the overall survival and disease-free. The problem is that major resections are associated with hepatic failure caused by an inadequate residual volume. Chemotherapy with diagrams as FOLFOX, FOLFIRI associated with antibodies such as bevacizumab, cetuximab or panitumumable added an important role in the conversion of unresectable to resectable tumors. Another widely used technique is portal vein ligation in a first surgical procedure, that generates left hepatic growth, to perform the resection in a second surgical procedure. The liver hypertrophy is achieved in a period of 2 months. The latest new technical procedure is the association of the ligation portal to the liver partition of the hepatic parenchyma without resection, which allows a segmental hypertrophy of the liver remnant between 7 to 10 days. This technique is called ALPPS. Radiofrecuency also has a role in the treatment of liver metastases. However,it is secondary.

La metástasis hepáticas del cáncer de colon es una entidad clínica muy frecuente. La cirugía resectiva permite mejorar la sobrevida global y libre de enfermedad. El problema es que grandes resecciones se asocian a insuficiencia hepática por un inadecuado volumen residual. La quimioterapia con esquemas como FOLFOX, FOLFIRI asociada a anticuerpos como bevacizumab, cetuximab o panitumumable agregan un rol importante en la conversión de tumores irresecables a resecables. Otra técnica utilizada es la ligadura portal en un primer tiempo, que genera crecimiento hepático izquierdo, para realizar la resección en un segundo tiempo quirúrgico. La hipertrofia hepática se logra en un período de 2 meses. La última novedad técnica es la asociación de la ligadura portal a la transección del parénquima hepático sin resección, lo que permite una hipertrofia segmentaria del hígado remanente entre 7 a 10 días. Esta técnica se denomina ALPPS. La radiofrecuencia también tiene un rol en el tratamiento de las metástasis hepáticas, aunque este es secundario.

Histopathologic factors affecting tumor recurrence after hepatic resection in colorectal liver metastases

PURPOSE: Hepatic resection is a standard method of treatment for colorectal liver metastases (CRLM). However, the pathologic factors of metastatic lesions that affect tumor recurrence are less well defined in CRLM. The aim of this study was to evaluate the risk factors for recurrence of CRLM, focusing on histopathologic factors of metastatic lesions of the liver. METHODS: From January 2003 to December 2008, 117 patients underwent curative hepatic resection for CRLM were reviewed. Tumor size and number, differentiation, tumor budding, angio-invasion, dedifferentiation and tumor infiltrating inflammation of metastatic lesions were investigated. RESULTS: The mean number of hepatic tumors was 2 (range, 1-8). The mean size of the largest tumor was 2.9 cm (range, 0.3-18.5 cm) in diameter. The moderate differentiation of the hepatic tumor was the most common in 86.3% of the patients. Tumor budding, angio-invasion, and dedifferentiation were observed in 81%, 34%, and 12.8% of patients. Inflammation infiltrating tumor was detected in 6.8% of patients. Recurrence after hepatic resection appeared in 69 out of 117 cases (58.9%). Recurrence-free survival at 1, 2 and 5 years were 62.4%, 43.6%, and 34.3%. The multivariate analysis showed the number of metastases > or =3 (P = 0.007), the tumor infiltrating inflammation (P = 0.047), and presence of dedifferentiation (P = 0.020) to be independent risk factors for tumor recurrence. CONCLUSION: Histopathological factors, i.e., dedifferentiation and tumor infiltrating inflammation of the metastatic lesion, could be one of the risk factors of aggressive behavior as well as the number of metastases even after curative resection for CRLM.

Concurrent Chemoradiotherapy Shows Long-Term Survival after Conversion from Locally Advanced to Resectable Hepatocellular Carcinoma

PURPOSE: For locally unresectable hepatocellular carcinoma (HCC) patients, concurrent chemoradiotherapy (CCRT) has been applied as a loco-regional treatment. After shrinkage of tumors in selected patients, surgical resection is performed. The aim of this study was to evaluate prognostic factors and long-term survivors in such patients. MATERIALS AND METHODS: From January 2000 to January 2009, 264 patients with HCC were treated with CCRT (45 Gy with fractional dose of 1.8 Gy), and intra-arterial chemotherapy was administered during radiotherapy. Eighteen of these patients (6.8%) underwent hepatic resection after showing a response to CCRT. Cases were considered resectable when tumor-free margins and sufficient remnant volumes were obtained without extrahepatic metastasis. Prior to operation, there were six patients with complete remission, 11 with partial remission, and six with stable disease according to modified Response Evaluation Criteria in Solid Tumors. RESULTS: In pathologic review, four patients (22.2%) showed total necrosis and seven patients (38.9%) showed 70-99% necrosis. A high level of necrosis (> or =80%) was correlated with low risk for extrahepatic metastasis and long-term survival. In univariate analyses, vessel invasion and capsular infiltration were significantly correlated with disease free survival (DFS) (p=0.017 and 0.013, respectively), and vessel invasion was significantly correlated with overall survival (OS) (p=0.013). In multivariate analyses, capsule infiltration was a significant factor for DFS (p=0.016) and vessel invasion was significant for OS (p=0.015). CONCLUSION: CCRT showed favorable responses and locally advanced HCC converted into resectable tumor after CCRT in selected patients. Long-term survivors showed the pathological features of near total necrosis, as well as negative capsule and vessel invasion.

Influence of metabolic and other clinicopathologic factors on the prognosis of patients with hepatocellular carcinoma undergoing hepatic resection

BACKGROUNDS/AIMS: The prognosis of hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis is worse than in those without cirrhosis. In Korea, the hepatitis B virus prevalence rate is higher than in other countries. Therefore, we investigated patients' clinicopathologic and metabolic factors that affect the postoperative outcomes of hepatic resection for HCC in our hospital in Korea. METHODS: From August 2000 to December 2012, 171 HCC patients underwent hepatic resections at our institution. Two operative mortality cases and two short-term follow up cases were excluded. Data was collected from a retrospective chart review. There were 133 males (79.6%) and 34 females (20.3%), with a mean age of 58.2+/-10.2 years (range, 22-81 years), and the relationship between clinicopathologic and metabolic factors and the prognosis of patients with HCC undergoing hepatic resection were evaluated by univariate and multivariate analysis. RESULTS: Hypertension, major surgery, perioperative transfusion, resection with radiofrequency ablation (RFA) or cryoablation, and resection margin were risk factors for overall survival, and hypertension, albumin, resection with RFA or cryoablation, perioperative transfusion, and tumor size were risk factors for disease-free survival. CONCLUSIONS: We found that hypertension, perioperative transfusion, and resection with RFA or cryoablation were risk factors for both disease-free and overall survival after hepatic resection in HCC patients. Further study is required to clarify the influence of metabolic and other clinicopathologic factors on the prognosis of HCC.

Retrograde caudate lobectomy combined with right hemi-hepatectomy / 中华消化外科杂志

Retrograde caudate lobectomy is a proper technique to resect the tumor in caudate lobe when the tumor is too big or closely adherent to the inferior vena cava.A male patient aged 44 years was admitted to the Eastern Hepatobiliary Surgery Hospital in November 2007.The ligaments around the liver were firstly dissected to mobilize the whole liver,and the right hepatic pedicle was dissected and ligated,then the liver was splited anteriorly along the Cantlie's line.The tumor was opposed in the sight and then it was dissected from the liver parenchyma.The short hepatic veins were ligated and the tumor was detached from the inferior vena cava.The inflow blood was occluded for 19 minutes,and the total blood loss was 4500 ml.The technique of retrograde caudate lobectomy can improve the success rate and safety of caudate lobectomy when the tumor in the caudate lobe is too large or adherent to the inferior vena cava.

Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience

BACKGROUND/AIMS: Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection. METHODS: This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS. RESULTS: Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative alpha-fetoprotein (> 400 ng/mL), tumor size (> or = 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS. CONCLUSIONS: The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.