Chinese expert consensus on CT-guided thermal ablation treatment of primary liver cancer / 中华内科杂志

In order to standardize CT-guided local ablation as treatment of liver cancer in China, integrate advanced concepts of "precision medicine", adopt the image guided thermal ablation (IGTA) technique, and improve multidisciplinary approach in the treatment of liver cancer, experts from the Society of Tumor Ablation Therapy of the Chinese Anti-Cancer Association, the Ablation Expert Committee of the Chinese Society of Clinical Oncology (CSCO), and the Expert Group on Tumor Ablation Therapy of the Chinese Medical Doctors, discussed and developed a consensus on CT-guided percutaneous thermal ablation therapy for primary liver cancer, based on current treatment guidelines in ablation therapy. This was an attempt to standardize and develop clinical practice related to CT-guided thermal ablation treatment in patients with primary liver cancer.

Specimen extraction through natural orifices with Cai tubes in gastrointestinal surgery: a single-institute series of 234 cases / 中华胃肠外科杂志

Objective: To investigate the feasibility of Cai tube-assisted natural orifice specimen extraction surgery (NOSES) in gastrointestinal surgery. Methods: This was a descriptive case-series study. Inclusion criteria: (1) colorectal or gastric cancer diagnosed by preoperative pathological examination or redundant sigmoid or transverse colon detected by barium enema; (2) indications for laparoscopic surgery; (3) body mass index <30 kg/m2 (transanal surgery) and 35 kg/m2 (transvaginal surgery); (4) no vaginal stenosis or adhesions in female patients undergoing transvaginal specimen extraction; and (5) patients with redundant colon aged 18-70 years and a history of intractable constipation for more than 10 years. Exclusion criteria: (1) colorectal cancer with intestinal perforation or obstruction, or gastric cancer with gastric perforation, gastric hemorrhage, or pyloric obstruction; (2) simultaneous resection of lung, bone, or liver metastases ; (3) history of major abdominal surgery or intestinal adhesions; and (4) incomplete clinical data. From January 2014 to October 2022, 209 patients with gastrointestinal tumors and 25 with redundant colons who met the above criteria were treated by NOSES utilizing a Cai tube (China invention patent number:ZL201410168748.2) in the Department of Gastrointestinal Surgery, Zhongshan Hospital, Xiamen University. The procedures included eversion and pull-out NOSES radical resection in 14 patients with middle and low rectal cancer, NOSES radical left hemicolectomy in 171 patients with left-sided colorectal cancer, NOSES radical right hemicolectomy in 12 patients with right-sided colon cancer, NOSES systematic mesogastric resection in 12 patients with gastric cancer, and NOSES subtotal colectomy in 25 patients with redundant colons. All specimens were collected by using an in-house-made anal cannula (Cai tube) with no auxiliary incisions. The primary outcomes included 1-year recurrence-free survival (RFS) and postoperative complications. Results: Among 234 patients, 116 were male and 118 were female. The mean age was (56.6±10.9) years. NOSES was successfully completed in all patients without conversion to open surgery or procedure-related death. The negative rate of circumferential resection margin was 98.8% (169/171) with both two positive cases having left-sided colorectal cancer. Postoperative complications occurred in 37 patients (15.8%), including 11 cases (4.7%) of anastomotic leakage, 3 cases(1.3%) of anastomotic bleeding, 2 cases (0.9%) of intraperitoneal bleeding, 4 cases (1.7%) of abdominal infection, and 8 cases (3.4%) of pulmonary infection. Reoperations were required in 7 patients (3.0%), all of whom consented to creation of an ileostomy after anastomotic leakage. The total readmission rate within 30 days after surgery was 0.9% (2/234). After a follow-up of (18.3±3.6) months, the 1-year RFS was 94.7%. Five of 209 patients (2.4%) with gastrointestinal tumors had local recurrence, all of which was anastomotic recurrence. Sixteen patients (7.7%) developed distant metastases, including liver metastases(n=8), lung metastases(n=6), and bone metastases (n=2). Conclusion: NOSES assisted by Cai tube is feasible and safe in radical resection of gastrointestinal tumors and subtotal colectomy for redundant colon.

Current status and future perspectives on the methods of prognosis evaluation for intrahepatic cholangiocarcinoma / 中华外科杂志

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary malignant tumor in the liver after hepatocellular carcinoma. Its incidence and mortality rates have increased worldwide in recent years. Surgical resection is the best treatment modality for ICC;however,the overall prognosis remains poor. Accurate evaluation of post operative prognosis allows personalized treatment and improved long-term outcomes of ICC. The American Joint Commission on Cancer TNM staging manual is the basis for the standardized diagnosis and treatment of ICC;however,the contents of stage T and stage N need to be improved. The nomogram model or scoring system established in the analysis of commonly used clinicopathological parameters can provide individualized prognostic evaluation and improve prediction accuracy;however,more studies are needed to validate the results before clinical use. Meanwhile,imaging features exhibit great potential to establish the post operative prognosis evaluation system for ICC. Molecular-based classification provides an accurate guarantee for prognostic assessment as well as selection of populations that are sensitive to targeted therapy or immunotherapy. Therefore,the establishment of a prognosis evaluation system,based on clinical and pathological characteristics and centered on the combination of multidisciplinary and multi-omics,will be conducive to improving the long-term outcomes of ICC after surgical resection in the context of big medical data.

Hemangioma hepático gigante único: serie de casos con seguimiento de pacientes tratados quirúrgicamente / Single giant liver hemangioma: case series with follow-up of patients treated surgically

El tratamiento del hemangioma hepático gigante (HHG), sigue siendo motivo de controversia. El objetivo de este estudio fue reportar los resultados de pacientes con HHG resecados quirúrgicamente en términos de morbilidad postoperatoria (MPO). Serie de casos con seguimiento. Se incluyeron pacientes con HHG, sometidos a cirugía de forma consecutiva, en Clínica RedSalud Mayor, entre 2011 y 2020. La variable resultado fue MPO. Otras variables de interés fueron: tiempo quirúrgico, estancia hospitalaria y mortalidad. Las pacientes fueron seguidas de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión. Se intervinieron 5 pacientes, con una mediana de edad de 38 años. La medianas del tiempo quirúrgico y estancia hospitalaria; fueron 75 min y 4 días respectivamente. La MPO fue 20 % (1 caso de seroma). Con una mediana de seguimiento de 41 meses, los pacientes se encuentran asintomáticos y no se ha verificado morbilidad alejada. La resección quirúrgica de un HHG se puede realizar con escasa morbilidad, tanto en términos numéricos como de gravedad de la complicación observada.

SUMMARY: Treatment of giant hepatic hemangioma (GHH) remains controversial. The aim of this study was to report the outcomes of surgically resected GHH patients in terms of postoperative morbidity (POM). Case series with follow-up. Patients with GHH who underwent surgery consecutively at the RedSalud Mayor Clinic between 2011 and 2020 were included. The outcome variable was POM. Other variables of interest were surgical time, hospital stay and mortality. The patients were followed up clinically. Descriptive statistics were used, with measures of central tendency and dispersion. Five patients underwent surgery, with a median age of 38 years. The median surgical time and hospital stay; were 75 min and 4 days respectively. The MPO was 20 % (1 case of seroma). With a median follow-up of 41 months, the patients are asymptomatic, and no distant morbidity has been verified. Surgical resection of GHH can be performed with low morbidity, both in terms of numbers and the severity of the complication observed.

Angiomiolipoma hepático epitelioide: reporte de un caso / Hepatic epithelioid angiomyolipoma: Case Report

Angiomyolipomas (AML) are mesenchymal tumors belonging to the group of perivascular epithelioid cell tumors, which, rarely, can display a malignant behavior. They are composed of adipose tissue, vessels, and muscle tissue in different proportions, and constitute a differential diagnosis for other focal liver lesions. We report a 34-year-old woman in whom a focal hepatic lesion was discovered incidentally. The pathology report of an ultrasound guided biopsy informed an epithelioid angiomyolipoma, a rare variant of these lesions. During ten years of imaging follow, the size and features of the lesion has not changed. The patient rejected a surgical excision.

Lobectomia total como tratamento de hemangiossarcoma hepático em um cão - relato de caso / Total lobectomy as treatment of hepatic hemangiosarcoma in a dog - case report / Lobectomía total como tratamiento de hemangiosarcoma hepático en un perro - reporte de caso

O hemangiossarcoma é uma neoplasia mesenquimal maligna agressiva com elevada taxa de morbidade e de mortalidade em cães e gatos; que se desenvolve mais frequentemente em baço, fígado, coração, ossos além de poder manifestar metástases regionais. O presente relato tem por objetivo descrever um caso de um canino diagnosticado com hemangiossarcoma hepático em lobo caudado submetido a uma lobectomia total. A técnica cirúrgica consistiu na utilização da sutura de guilhotina modificada na base do lobo acometido utilizando fio de polidioxanona e, com o auxílio de um bisturi elétrico unipolar, e respeitando o distanciamento de 0,5 cm da sutura, foi realizada a lobectomia. Após a remoção do lobo, foi fixada uma esponja hemostática de colágeno na região da incisão como forma de auxílio no controle hemorrágico. Foi indicado também a realização de tratamento quimioterápico adjuvante, entretanto o tutor do animal optou pela não realização da mesma. Ainda assim, o paciente do presente relato obteve uma boa resposta ao procedimento, e o tutor ficou muito satisfeito, relatando que houve uma grande melhora na qualidade de vida do animal e que ele não sentia mais dor, voltando a ter o seu comportamento habitual.(AU)

Hemangiosarcoma is an aggressive malignant mesenchymal neoplasm with a high rate of morbidity and mortality in dogs and cats; which develops more frequently in the spleen, liver, heart, bones, in addition to being able to manifest regional metastases. The present report aims to describe a case of a canine diagnosed with hepatic hemangiosarcoma in the caudate lobe submitted to a total lobectomy. The surgical technique consisted of using a modified guillotine suture at the base of the affected lobe using polydioxanone thread and, with the aid of a unipolar electric scalpel, and respecting the distance of 0.5 cm from the suture, lobectomy was performed. After removing the lobe, a hemostatic collagen sponge was fixed in the region of the incision as an aid in hemorrhagic control. Adjuvant chemotherapy treatment was also indicated, however the animal's tutor chose not to perform it. Even so, the patient in the present report had a good response to the procedure, and the tutor was very satisfied, reporting that there was a great improvement in the animal's quality of life and that he no longer felt pain, returning to his usual behavior.(AU)

El hemangiosarcoma es una neoplasia mesenquimatosa maligna agresiva con una alta tasa de morbilidad y mortalidad en perros y gatos; la cual se desarrolla con mayor frecuencia en bazo, hígado, corazón, huesos, además de poder manifestar metástasis regionales. El presente reporte tiene como objetivo describir un caso de un canino con diagnóstico de hemangiosarcoma hepático en el lóbulo caudado sometido a una lobectomía total. La técnica quirúrgica consistió en utilizar una sutura de guillotina modificada en la base del lóbulo afectado con hilo de polidioxanona y, con la ayuda de un bisturí eléctrico unipolar, y respetando la distancia de 0,5 cm de la sutura, se realizó la lobectomía. Después de retirar el lóbulo, se fijó una esponja hemostática de colágeno en la región de la incisión como ayuda para el control hemorrágico. También se indicó tratamiento de quimioterapia adyuvante, sin embargo el tutor del animal optó por no realizarlo. Aun así, el paciente del presente reporte tuvo una buena respuesta al procedimiento, y el tutor quedó muy satisfecho, informando que hubo una gran mejoría en la calidad de vida del animal y que ya no sintió dolor, volviendo a su comportamiento habitual.(AU)

Aplicación de modelos 3D en cirugía hepática / Implementation of three-dimensional printed models in hepatic surgery

RESUMEN La impresión de modelos tridimensionales (M3D) implica obtener una estructura sólida y formada a partir de un modelo digital. Para la reconstrucción 3D se utilizó tomografía computarizada contrastada, realizándose impresión de modelos sobre la base de las principales estructuras anatómicas hepáticas. Se utilizaron M3D en dos pacientes con indicación quirúrgica, una mujer con trombocitopenia familiar y metástasis hepática de adenocarcinoma rectal, sin respuesta a quimioterapia, y un hombre con hepatopatía infecciosa crónica y diagnóstico de carcinoma hepatocelular. La aplicación de M3D resultó de gran utilidad, pues permitió un mejor entendimiento de la relación espacial de las estructuras anatómicas en ambos casos. En nuestra experiencia, la aplicación de M3D fue muy útil para planificar la cirugía y dar una aproximación más certera de los reparos anatómicos. El modelo se obtuvo en 7 días y costó 380 dólares, un valor elevado para nuestro medio.

ABSTRACT Three-dimensional (3D) printing is the construction of a solid structure from a digital model. 3D reconstruction was performed using contrast-enhanced computed tomography scan, and 3D-printed models were built based on the main anatomic structures of the liver. 3D-printed models were used in two patients with indication of surgery; one woman with inherited thrombocytopenia and liver metastases from colorectal adenocarcinoma with no response to chemotherapy, and one man with chronic liver infection and hepatocellular carcinoma. The implementation of 3D printing technology was very useful, as it facilitated the understanding of the spatial relationships among the anatomical structures in both cases. In our experience, the use of 3D-printed models was very useful for preoperative planning and for understanding the anatomic landmarks. The model was built in 7 days, with a cost of 380 dollars which is elevated in our environment.

Trasplante hepático en hemangioendotelioma epiteloide hepático con metástasis pulmonares: reporte de un caso / Liver transplantation in hepatic epitheloid hemangioendothelioma and lung metastases: a case report

El hemangioendotelioma epiteloide hepático (HEHE) es un tumor vascular raro de menor malignidad que el hemangiosarcoma. En los poco frecuentes casos unilobulares, puede indicarse hepatectomía parcial con riesgo de recurrencia agresiva; en enfermedad hepática extensa, incluso con compromiso extrahepático, el trasplante hepático ha resultado efectivo. Las metástasis son más frecuentes en pulmón,peritoneo, ganglios linfáticos, bazo y sistema nervioso. Se presenta el caso de un adolescente asintomático con HEHE con metástasis pulmonares y compromiso ganglionar abdominal que recibió trasplante hepático con evolución favorable.

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor of less malignancy than hemangiosarcoma. In the rare unilobar cases, partial hepatectomy may be indicated with risk of aggressive recurrence; in extensive liver disease, even with extrahepatic involvement, liver transplantation has been performed successfully. Metastases are more common in the lung, peritoneum, lymph nodes, spleen, and nervous system. We present the case of an asymptomatic adolescent with HEHE with lung metastases and abdominal lymph node involvement who received a liver transplant with a favorable outcome.

Nuevos avances en cirugía hepática: evaluación y planificación preoperatoria (Parte 1) / New advances in liver surgery: evaluation and preoperative planning

Resumen Los avances en la cirugía hepática de los últimos años han permitido resecciones hepáticas más extensa y complejas para el tratamiento de diferentes patologías del hígado sin un aumento excesivo de la morbimortalidad perioperatoria. El desarrollo de diferentes técnicas, tecnologías y herramientas para la evaluación preoperatoria han mejorado la planificación quirúrgica con el uso por ejemplo de las tecnologías audiovisuales e impresión de modelos en 3 dimensiones (3D) de alta fidelidad. Otros avances, han permitido realizar una mejor evaluación funcional del parénquima hepático y una caracterización más precisa de las lesiones con el uso por ejemplo de verde de indocianina, cintigrafía hepática y resonancia magnética con contraste hepatoespecífico. Este artículo describe algunos de los nuevos avances en la evaluación y planificación preoperatoria en cirugía hepática.

Advances in liver surgery in recent years have made it possible to achieve more extensive and complex liver resections for the treatment of different liver diseases without an excessive increase in perioperative morbidity and mortality. The development of different techniques, technologies and tools for preoperative evaluation have improved surgical planning with the use, for example, of audiovisual technologies and printing of high-fidelity 3-dimensional (3D) models. Other advances have allowed a better functional evaluation of the liver parenchyma and a more precise characterization of the lesions with the use, for example of indocyanine green or liver scintigraphy and magnetic resonance with hepatospecific contrast. This article describes some of the new advances in preoperative evaluation and planning in liver surgery.

Hepatectomía derecha totalmente laparoscópica para trasplante hepático con donante vivo adulto-adulto: técnica quirúrgica y experiencia inicial en Chile / Pure laparoscopic right hepatectomy for adult-to-adult living donor liver transplantation: surgical technique and initial experience in Chile

Resumen El trasplante hepático con donante vivo (THDV) es un procedimiento complejo y desafiante para el cirujano, ya que exige garantizar tanto la máxima seguridad para el donante, así como también, la mejor calidad del injerto para el receptor. Debido a lo anterior, la implementación de la cirugía mini-invasiva ha sido lenta en esta área. Sin embargo, en los últimos 10 años, gracias a los avances que ha experimentado la cirugía hepática laparoscópica, ha aumentado el interés de algunos grupos altamente especializados por incorporar la cirugía mini-invasiva a la cirugía del donante, principalmente en trasplante hepático donante vivo adulto-pediátrico (THDVA-P). Los favorables resultados obtenidos en esta área incluso han llevado a los expertos en el tema, a categorizar el abordaje laparoscópico para la cirugía del donante como el procedimiento estándar en THDVA-P. Contrario a lo anterior, la implementación de la laparoscopía para trasplante hepático donante vivo adulto-adulto (THDVA-A), es más compleja y requiere en su mayoría, una hepatectomía de lóbulo derecho o izquierdo para cumplir con las necesidades volumétricas del receptor. Esta cirugía es de mayor dificultad y riesgo para el donante, por lo que su indicación por vía mini-invasiva está limitada a centros de alto volumen y preparación, tanto en laparoscopía, como en trasplante hepático. En este trabajo, se busca dar a conocer la técnica quirúrgica y nuestra experiencia inicial con la primera hepatectomía derecha totalmente laparoscópica (HDTL) para THDVA-A realizada en Chile.

Living donor liver transplantation is a complex and challenging procedure. The surgeon needs to guarantee maximum safety for the donor, as well as the best quality of the graft for the recipient. For this reason, the implementation of mini-invasive surgery has been slow in this area. However, in the last 10 years, due to the advances in laparoscopic liver surgery, the interest of some highly specialized groups has increased in incorporating mini-invasive surgery into donor surgery, mainly in pediatric living donor liver transplantation. The favorable results obtained in this field, have even led to turn this procedure, into the technique of choice for pediatric living donor liver transplantation. Nevertheless, this procedure is even more challenging for adult-to-adult living donor transplantation. To meet the volumetric criteria of an adult, a complete hepatectomy of right or left lobe is mostly required. This surgery is of greater complexity and risk for the donor, so its indication by minimally invasive approach is limited to high-volume centers with preparation, both in laparoscopy and liver transplants. In this report we seek to present our surgical technique and initial experience with the first pure laparoscopic right hepatectomy for adult-to-adult living donor liver transplantation carried out in Chile.

Clinical application of bipolar tweezers-clamp for hepatic parenchymal transection / 中华外科杂志

Objective: To investigate the clinical value of the bipolar tweezers-clamp for the hepatic parenchymal transection in the resection of hepatocellular carcinoma. Methods: From January 2020 to January 2021,63 patients with the hepatocellular carcinoma for hepatectomy at Department of Hepatopancreatobiliary Surgery,Yuebei People's Hospital Affiliated to Shantou University Medical College were analyzed retrospectively.According to the different instruments used in the hepatic parenchymal transection,the patients were divided into bipolar tweezers-clamp group and ultrasonic scalpel group.There were 32 patients in bipolar tweezers-clamp group,with age of (55.5±10.5)years(range:37 to 78 years),including 22 males and 10 females,tumor size was (6.0±3.4)cm(range:2.4 to 13.4 cm). There were 6 patients with portal vein tumor thrombus and 5 patients with portal hypertension. There were 31 patients in ultrasonic scalpel group,with aged(57.8±10.1)years(range:37 to 79 years),including 27males and 4 females,tumor size was(7.9±5.1)cm(range: 2.4 to 21.3 cm),3 patients with portal vein tumor thrombus and 2 patients with portal hypertension. The preoperative baseline data,operation time,blood loss,postoperative liver function and the complications were compared between two groups using t test,χ2 test and Fisher exact probabilityrespectively. Results: The operation was successfully completed in both groups.Compared with the ultrasonic scalpel group,the operation time was significantly shorter((219.3±76.4)minutes vs.(294.0±100.8)minutes,t=-3.322,P=0.002),the blood loss was less((250(475)ml vs. 500(1 050)ml,t=-2.307,P=0.026),the concentrate red blood cells transfusion volume was less(0.92(0.88)U vs. 2.32(4.00)U,Z=-1.987,P=0.047) in the bipolar tweezers-clamp group.The postoperative serum ALB level was higher in the bipolar tweezers-clamp group than that in the ultrasonic scalpel group((33.5±6.1)g/L vs. (29.5±4.2)g/L,t=3.226,P=0.020) on postoperative day 1;((35.7±4.5)g/L vs.(30.1±3.2)g/L,t=5.575,P<0.01) on postoperative day 3;((33.2±3.7)g/L vs. (31.0±4.4)g/L,t=3.020,P=0.004) on postoperative day 7. There was no significant difference in serum ALT,TBIL and PT level between the two groups(all P>0.05).No postoperative bile leakage occurred in both groups.The postoperative complications occurred in 8 cases(25.0%)in the bipolar tweezers-clamp group,including liver failure in one,and in 11 cases(35.5%)in the ultrasonic scalpel group,including liver failure in two(P>0.05). Conclusion: The bipolar tweezers-clamp is a safe and reliable method for the hepatic parenchymal transaction,which is quick and less bleeding during the hepatic resection.

Application of augmented reality and mixed reality navigation technology in laparoscopic limited right hepatectomy / 中华外科杂志

Objective: To investigate the application effect of augmented reality and mixed reality navigation technology in three-dimensional(3D) laparoscopic narrow right hepatectomy(LRH). Methods: A retrospective analysis was performed on the clinical data of 5 patients with hepatic malignancy admitted to the First Department of Hepatobiliary Surgery,Zhujiang Hospital,Southern Medical University from September 2020 to June 2021,all of whom were males,aged from 42 to 74 years.Preoperative evaluation was performed using the self-developed 3D abdominal medical image visualization system; if all the 5 patients were to receive right hemihepatectomy,the remnant liver volume would be insufficient,so LRH were planned.During the operation,the independently developed 3D laparoscopic augmented reality and mixed reality surgical navigation system was used to perform real-time multi-modal image fusion and interaction between the preoperative 3D model and 3D laparoscopic scene.Meanwhile,intraoperative ultrasound assisted indocyanine green fluorescence was used to determine the surgical path.In this way,the LRH under the guidance of augmented reality and mixed reality navigation was completed.The predicted liver resection volume was evaluated before surgery,actual resected liver volume,surgical indicators and postoperative complications were analyzed. Results: All the 5 patients completed LRH under the guidance of augmented reality and mixed reality navigation technology,with no conversion to laparotomy.The median operative time was 300 minutes(range:270 to 360 minutes),no intraoperative blood transfusion was performed,and the median postoperative hospital stay was 8 days(range:7 to 9 days).There were no perioperative deaths,or postoperative complications such as liver failure,bleeding,or biliary fistula. Conclusion: For patients who need to undergo LRH,the use of augmented and mixed reality navigation technology can safely and effectively guide the implementation of surgery,retain more functional liver volume,improve surgical safety,and reduce postoperative complications.

Ten-year retrospect of ALPPS in the treatment of hepatocellular carcinoma:an eternal concept with cautious technologic choice / 中华外科杂志

Clinical practice using associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) or its modified procedures in treatment of primary hepatocellular carcinoma(HCC) with insufficient future liver remnant(FLR) in the past 10 years has failed to meet our expectations both in achieving decreased perioperative complications and mortality.The efficacy of ALPPS in improving long-term survival outcome of HCC still remains poor.Due to the trauma of two surgery within a short period,and patients with inadequate FLR are all diagnosed at advanced disease stages,ALPPS can only achieve surgical rather than biological tumor-curability.Previous studies have demonstrated comparable 5-year survival rates between early and advanced stages of HCC who underwent regional treatments.Therefore,tumor biological conversion is the key strategy prior to liver remnant volume conversion in improving treatment outcomes for HCC patients with insufficient FLR.Target therapy,immunotherapy together with locally treatment were expected to improve the conversion efficacy.Looking back at the development of ALPPS for the last decade,the rapid proliferation of FLR should be passed on,while the technology costs high risks and result in poor long-term outcome must be cautiously selected.

Practice of laparoscopic hepatectomy in primary care facilities in China: surgical planning, surgical techniques and postoperative management / 南方医科大学学报

With the development and application of laparoscopic hepatectomy in major medical centers, domestic and foreign guidelines have summarized the indications, surgical techniques and operational procedures of the surgery. But in primary care facilities, where the surgical equipment are available, laparoscopic hepatectomy is performed only in a small number of cases and the progress of its application remains slow. The reasons possibly lie in the failure of a full understanding of the surgery, the lack of anatomical knowledge of laparoscopic hepatectomy, the lack of close multidisciplinary cooperation in the perioperative period and insufficient training of laparoscopic technology. In this review, we elaborate on three aspects of laparoscopic hepatectomy: preoperative planning, surgical techniques and postoperative management. Before the operation, the surgeons should fully understand the anatomical structure of the liver and select appropriate cases considering both the difficulty of operation and the surgical experience of the surgeons. During the operation, the position of the patient and the layout of the stamping card should be appropriate, and the central venous pressure needs to be well controlled in close cooperation with the anesthesiologist. The surgeons should be proficient at the techniques of liver suspension and pulling and at the use of ultrasonic knife, and select correct techniques for management of bleeding and the control of blood flow in and out of the liver. The patient should receive postoperative management with standard enhanced recovery after surgery (ERAS) protocols. These experiences may help to improve the practice of laparoscopic hepatectomy in local hospitals or primary care facilities.

Resultados del tratamiento del hepatoblastoma en los Andes Ecuatorianos / Results of the treatment of hepatoblastoma in the Ecuadorian Andes

RESUMEN: El hepatoblastoma (HB), es una neoplasia maligna, que se origina en el hígado. La supervivencia (SV) depende de la extensión de avance de la enfermedad. El objetivo de este estudio fue determinar diferencias en la SV actuarial global (SVAG) y libre de enfermedad (SVLE) en pacientes con HB, según la extensión de su enfermedad. Serie de casos con seguimiento. Se incluyeron pacientes de entre 4 y 160 meses de edad tratados en un centro oncológico de Los Andes ecuatorianos (2000-2019). Las variables resultado fueron: lóbulo afectado, metástasis pulmonar, infiltración vascular, estadio PRETEXT, riesgo, histología, niveles de alfafetoproteína (AFP), remisión completa (RC), SVAG y SVLE. Se utilizó estadística descriptiva y analítica (Chi2, exacto de Fisher y corrección por continuidad). Se realizaron análisis de SV con curvas de Kaplan Meier y log-rank. Fueron estudiados 28 pacientes (53,6 % hombres), con una mediana de edad de 40 meses. Se verificaron metástasis pulmonares e infiltración vascular en el 25,0 % y 35,7 % de los casos respectivamente. La histología, estadio clínico y riesgo alto fueron mayoritariamente tipo epitelial (42,8 %), PRETEXT II (50,0 %) y riesgo alto (67,8 %) respectivamente. La media de AFP al diagnóstico fue 1055712ng/ml y 9 pacientes alcanzaron RC. La SVAG y SVLE general a 19 años fue 33,1 % y 26,0 % respectivamente. Según su extensión, la SVAG y la SVLE para los pacientes de riesgo estándar y alto fueron 50,0 % y 25,4 % (p=0,148); y 50,0 % y 14,7 % (p=0,037) respectivamente. La SVAG y SVLE verificadas son menores a las reportadas en otros estudios. La SVLE según su extensión, presentó diferencia significativa, sin embargo, este resultado debe ser tomado con cautela debido al número pequeño de pacientes.

SUMMARY: Hepatoblastoma (HB), is a malignant neoplasm, which originates in the liver. Survival (SV) depends on the extent of disease progression. The objective of this study was to determine differences in overall SV (OS) and disease-free (DFS) in patients with HB, according to the extent of their disease. Case series with follow-up. Patients between 4 and 160 months of age treated at an oncology center in the Ecuadorian Andes (2000-2019) were included. The result variables were affected lobe, lung metastasis, vascular infiltration, PRETEXT stage, risk, histology, alpha-fetoprotein levels (AFP), complete remission (RC), OS and DFS. Descriptive and analytical statistics (Chi2, Fisher's exact and continuity correction) were used. SV analyzes were performed with Kaplan Meier and log-rank curves. In this analysis 28 patients (53.6 % men), with a median age of 40 months, were studied. Lung metastases and vascular infiltration were verified in 25.0 % and 35.7 % of the cases, respectively. Histology, clinical stage, and high risk were mainly epithelial type (42.8 %), PRETEXT II (50.0 %), and high risk (67.8 %), respectively. The mean AFP at diagnosis was 1055712 ng / ml and 9 patients achieved CR. OS and DFS at 19 years were 33.1 % and 26.0 % respectively. According to their extension, the OS and DFS for standard and high risk patients were 50.0 % and 25.4 % (p = 0.148); and 50.0 % and 14.7 % (p = 0.037) respectively. The verified OS and DFS are lower than those reported in other studies. DFS according to its extension, presented a significant difference, however, this result should be considered with caution due to the small number of patients.

Simultaneous resection for colon cancer and synchronous liver metastases: case series with follow-up / Resección simultánea por cáncer de colon y metástasis hepáticas sincrónicas: serie de casos con seguimiento

SUMMARY: Treatment of colonic cancer (CC) and synchronic liver metastasis (SLM) is still controversial in relation to how to act. The aim of this study was to analyze initial single center experience in simultaneous surgical approach of patients with CC and SLM, in terms of overall survival (OS) and disease-free survival (DFS). Retrospective case series of patients with CC and SLM undergoing simultaneous surgery, consecutively, at Clínica RedSalud Mayor Temuco, between 2007 and 2021. Outcome variables were OS and DFS. Other variables of interest were postoperative morbidity (POM), surgical time, hospital stay and mortality. Descriptive statistics was used (measures of central tendency and dispersion), and survival analysis was estimated applying Kaplan Meier curves. Sixteen patients (10 female and 6 male) were operated, with a median age of 61 years. The most frequent localization was cecum and right colon (37.5 %). In all patients some type of liver resection was added (parenchymal-sparing hepatectomy or anatomical resection). Median surgical time and hospital stay were 150 min and 5 days respectively. POM was 31.2 % (5 cases), mainly Clavien & Dindo I and II (12.5 % of patients required a re-intervention). With a median follow-up of 52 months 1, 3 and 5-year OS were 100 %, 62.5 %, and 50.0 % respectively. On the other hand, DFS rates of 1, 3 and 5-year were 75.0 %, 43.8 %, and 25.0 % respectively. The series had no mortality. OS, DFS, POM and mortality, were like other series. Simultaneous resection of CC and SLM is an aggressive approach, but not compromise oncological outcomes.

RESUMEN: El tratamiento del cáncer de colon (CC) con metástasis hepática sincrónica (MHS), tiene un tratamiento controvertido aún. El objetivo de este estudio fue analizar la experiencia unicéntrica en el tratamiento de pacientes con CC y MHS simultáneo, en términos de supervivencia global (SG) y supervivencia libre de enfermedad (SLE). Serie de casos retrospectiva consecutiva, de pacientes con CC y MHS sometidos a cirugía simultánea, en Clínica RedSalud Mayor Temuco, entre 2007 y 2021. Las variables de resultado fueron SG y SLE. Otras variables de interés fueron la morbilidad postoperatoria (MPO), tiempo quirúrgico, estancia hospitalaria y mortalidad. Se utilizó estadística descriptiva (medidas de tendencia central y dispersión) y se estimó supervivencia aplicando curvas de Kaplan Meier. Se operaron 16 pacientes (10 mujeres y 6 hombres), con mediana de edad de 61 años. La localización más frecuente fue ciego-colon derecho (37,5 %). En todos los casos se practicó algún tipo de resección hepática (hepatectomía conservadora o resección anatómica). La mediana del tiempo quirúrgico y la estancia hospitalaria fueron de 150 min y 5 días respectivamente. La MPO fue del 31,2 % (5 casos), principalmente Clavien & Dindo I y II (hubo 12,5 % de reintervenciones). Con una mediana de seguimiento de 52 meses. La SG a 1, 3 y 5 años fue 100 %, 62,5 % y 50,0 %, respectivamente. Por otro lado, la SLE a 1, 3 y 5 años fue 75,0 %, 43,8 % y 25,0 %, respectivamente. La serie no tuvo mortalidad. La SG, SLE, MPO y la mortalidad fueron similares a otras series. La resección simultánea de CC y SLM es agresiva, pero no compromete los resultados oncológicos.

Hepatectomía en dos tiempos por metástasis hepáticas bilobares de origen colorrectal: reporte de un caso / Two-stage hepatectomy for bilobar colorectal liver metastases: case report / Hepatectomia em dois estágios para metástases hepáticas bilobares de origem colorretal: relato de um caso

La mitad de los pacientes con cáncer de origen colorrectal desarrollan metástasis hepáticas durante el curso de su enfermedad y de esas el 80% son irresecables. La resecabilidad se define no por la extensión de la hepatectomía, sino por la función del hígado remanente, por lo que para pacientes con ciertos factores favorables se pueden realizar técnicas de remodelación hepática para aumentar el volumen del hígado remanente para que este sea suficiente. La hepatectomía en dos tiempos se basa en procedimientos secuenciales que buscan tratar metástasis hepáticas colorrectales consideradas inicialmente irresecables, logrando la resección completa de las mismas dejando un remanente hepático funcionante suficiente, lo cual no sería posible en un solo acto quirúrgico. El objetivo de este trabajo es presentar el caso clínico de un paciente portador de metástasis hepáticas sincrónicas de origen colorrectal irresecables, que luego de una quimioterapia de conversión, con el fin de aumentar el futuro remanente hepático y evitar falla hepática postoperatoria y realizar una resección oncológica, fue sometido a una hepatectomía en dos tiempos, técnica utilizada con baja frecuencia en nuestro medio, destacando una evolución favorable, con marcadores tumorales en valores normales y sin evidencia imagenológica de recaída local ni sistémica.

Half of colorectal cancer patients develop liver metastases during the course of their disease, 80% of which are unresectable. Resectability is defined not by the extent of the hepatectomy, but by the function of the liver remnant. Therefore, for patients with certain factors, liver remodeling techniques can be performed to increase volume of the remaining liver so that it is sufficient. Two-stage hepatectomy is performed on colorectal liver metastases which are initially considered unresectable in one stage resection procedures, in which sequential procedures are performed in order to achieve complete resection and preserve a sufficient functioning liver remnant. The objective of this paper is to present the case of a patient with unresectable synchronous colorectal liver metastases, in which after conversion chemotherapy, in order to increase the future liver remnant, avoid postoperative liver failure and perform an oncological resection underwent a two-stage hepatectomy, a technique used with low frequency in our setting, highlighting a favorable evolution, with tumor markers in normal values and without imaging evidence of local or systemic relapse.

Metade dos pacientes com câncer colorretal desenvolve metástases hepáticas durante o curso da doença e, desses, 80% são irressecáveis. A ressecabilidade é definida não pela extensão da hepatectomia, mas pela função do fígado remanescente; portanto, para pacientes com certos fatores favoráveis, técnicas de remodelação hepática podem ser realizadas para aumentar o volume do fígado remanescente de forma que seja suficiente. A hepatectomia em dois estágios é baseada em procedimentos sequenciais que buscam tratar metástases hepáticas colorretais inicialmente consideradas irressecáveis, obtendo ressecção completa, deixando um remanescente hepático funcional suficiente, o que não seria possível em um único ato cirúrgico. O objetivo deste trabalho é apresentar o caso clínico de um paciente com metástases hepáticas sincrônicas irressecáveis ​​de origem colorretal, que após quimioterapia de conversão, com o objetivo de aumentar o futuro remanescente hepático e evitar insuficiência hepática pós-operatória e realizar uma ressecção oncológica, foi submetido a dois Hepatectomia em estágio, técnica utilizada com baixa frequência em nosso meio, evidenciando evolução favorável, com marcadores tumorais em valores normais e sem evidências de imagem de recidiva local ou sistêmica.

Protocolo de transplante hepático para metástase colorretal irressecável / Protocol for liver transplantation in unresectable colorectal metastasis

RESUMO - RACIONAL: O câncer colorretal é a terceira neoplasia mais frequente e metade dos pacientes desenvolvem metástase hepática. O melhor fator prognóstico na metástase hepática de câncer colorretal (MHCCR) é a possibilidade de ressecção com margens livres, porém a maioria permanece irressecável. O racional em realizar transplante hepático (TH) em pacientes portadores de MHCCR está na ampliação do número de pacientes ressecáveis através de uma hepatectomia total. OBJETIVO: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com MHCCR irressecável. MÉTODO: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela Universidade de Oslo. A elaboração foi dividida em 4 etapas. RESULTADO: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. CONCLUSÃO: Foi possível elaborar protocolo de transplante hepático para MHCCR irressecável a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

ABSTRACT - BACKGROUND: Colorectal cancer (CRC) is the third most common neoplasm, and half of the patients with CRC develop liver metastasis. The best prognostic factor for colorectal liver metastasis (CRLM) is the possibility of performing a resection with free margins; however, most of them remain unresectable. The justification for performing liver transplantation (LT) in patients with CRLM regards an increase in the number of resectable patients by performing total hepatectomy. AIM: The aim of this study was to provide a Brazilian protocol for LT in patients with unresectable CRLM. METHOD: The protocol was carried out by two Brazilian institutions, which perform a large volume of resections and LTs, based on the study carried out at the University of Oslo. The elaboration of the protocol was conducted in four stages. RESULT: A protocol proposal for this disease is presented, which needs to be validated for clinical use. CONCLUSION: The development of an LT protocol for unresectable CRLM aims to standardize the treatment and to enable a better evaluation of surgical results.

Ressecção laparoscópica de tumores benignos do fígado: posição atual / Laparoscopic liver resection for benign tumors: the current position

RESUMO - RACIONAL: As principais indicações das hepatectomias video-laparoscópicas (HVL), inicialmente, eram nas lesões hepáticas benignas. À medida que a HVL se tornou mais popular, as indicações de doenças malignas superaram as de doenças benignas. Este estudo teve como objetivo discutir as indicações e resultados da HVL para o tratamento de tumores hepáticos benignos. MÉTODOS: De 445 HVL realizadas em um único centro, 100 (22,4%) foram para tumores benignos. Os autores discutem as indicações para ressecção e apresentam seus resultados perioperatórios. RESULTADOS: No total, 100 pacientes com tumores benignos foram avaliados, a saber: 66 casos de adenomas hepatocelulares; 14 de neoplasia mucinosa biliar; 13 de hiperplasia nodular focal; 4 de angiomiolipomas; e 3 de hemangiomas. O tamanho médio das lesões foi de 7,6 cm (3,1 a 19,6 cm). A taxa de morbidade total foi de 19%, sendo 9% classificados como Clavien-Dindo 3 ou 4 e não foi observada mortalidade. CONCLUSÃO: A HVL para tumores hepáticos benignos é segura e apresenta excelentes resultados. No entanto, as indicações para cirurgia são cada vez mais restritas, não sendo recomendável indicar a ressecção somente por se tratar de procedimento minimamente invasivo.

ABSTRACT - BACKGROUND: The main indications of the use of laparoscopic liver surgery (LLS), in the early days, were benign liver lesions. As LLS became more popular, indications for malignant diseases outnumbered those for benign ones. This study aims to rule out the indications and results of LLS for the treatment of benign liver tumors. METHODS: Out of 445 LLS performed in a single center, 100 (22.4%) were for benign tumors. The authors discuss the indications for resection and present their perioperative results. RESULTS: In total, 100 patients with benign tumors were evaluated. Specifically, these were as follows: 66 cases of hepatocellular adenomas; 14 cases of biliary mucinous neoplasm; 13 cases of focal nodular hyperplasia; 4 cases of angiomyolipomas; and 3 cases of hemangiomas with a mean size of 7.6 cm (ranging from 3.1 to 19.6 cm). The total morbidity rate was 19%, with 9% classified as Clavien-Dindo grades 3 or 4. No mortality was observed. CONCLUSION: LLS for benign liver tumors is safe and presents excellent results. However, indications for resection are increasingly restricted and should not be performed just because it is a minimally invasive procedure.