Ultrasound-Guided Continuous Thoracic Paravertebral Block Improves Patient's Quality of Recovery After Open Hepatectomy: A Randomized, Double-Blind, Placebo-Controlled Trial / 中国医学科学杂志(英文版)

Background Ultrasound-guided continuous thoracic paravertebral block can provide pain-relieving and opioid-sparing effects in patients receiving open hepatectomy. We hypothesize that these effects may improve the quality of recovery (QoR) after open hepatectomy. Methods Seventy-six patients undergoing open hepatectomy were randomized to receive a continuous thoracic paravertebral block with ropivacaine (CTPVB group) or normal saline (control group). All patients received patient-controlled intravenous analgesia with morphine postoperatively for 48 hours. The primary outcome was the global Chinese 15-item Quality of Recovery score on postoperative day 7, which was statistically analyzed using Student's t-test. Results Thirty-six patients in the CTPVB group and 37 in the control group completed the study. Compared to the control group, the CTPVB group had significantly increased global Chinese 15-item Quality of Recovery scores (133.14 ± 12.97 vs. 122.62 ± 14.89, P = 0.002) on postoperative day 7. Postoperative pain scores and cumulative morphine consumption were significantly lower for up to 8 and 48 hours (P < 0.05; P = 0.002), respectively, in the CTPVB group. Conclusion Perioperative CTPVB markably promotes patient's QoR after open hepatectomy with a profound analgesic effect in the early postoperative period.

Surgical Treatment Strategies of Intravenous Leiomyomatosis withRight Cardiac Cavities Extension / 中国医学科学院学报

Objective To investigate the diagnosis and surgical treatment strategies of intravenous leiomyomatosis(IVL)extending through inferior vena cava into the right cardiac cavities. Methods Thirty patients of IVL extending through inferior vena cava into the right cardiac cavities were treated in Peking Union Medical College Hospital from November 2002 to January 2015.The following variables were studied: age,cardiopulmonary bypass time,deep hypothermic circulatory arrest time,origins of IVL,blood loss,duration of post-operative hospital stay,hospitalization expenses,edema of lower extremity,blood transfusion,postoperative complication,residual IVL,and re-grow or recurrence. Results Thirteen of 30 patients reported double lower limb edema. The cardiopulmonary bypass was applied in 27 cases,and the average duration of cardiopulmonary bypass was(106.9±53.7)min. Then,21 patients were treated with the deep hypothermic circulatory arrest,and the mean time was(28.2±11.6) min. The tumors originated from the genital veins in 9 cases,the iliac vein in 13 cases,and both veins in 8 cases. The average intra-operative blood loss volume was (2060.5±2012.3)ml,and 21 patients received blood transfusion. The average hospitalization time was(18.9±8.3)days and the average hospitalization expenses was (80 840.4±28 264.2)RMB yuan. While 14 patients had postoperative complications,there was no serious postoperative complication or death.All patients have shown a favorable outcome.Conclusions Tumor embolus extending through inferior vena cava into the right cardiac cavities should be suspected in patients with multiple hysteromyoma. Successful therapy for IVL with right cardiac cavities extension is dependent on reasonable surgical treatment strategies. Surgical removal of the ovaries is vital to avoid IVL re-grow or recurrence.

Parameter optimization for non-contrast-enhanced selective magnetic resonance portography imaging / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate subtraction images acquired with 3D true steady-state free-precession(SSFP)sequence combined with time-spatial labeling inversion pulse(T-SLIP)for selective and non-contrast-enhanced(non-CE)visualization of the portal venous system,and explore the optimization of this protocol.</p><p><b>METHODS</b>Totally 13 healthy volunteers were recruited.Respiratory-triggered 3D true SSFP sequences on a 1.5T MRI system combined with T-SLIP placed on the spleen and mesenteric area were performed.The portographic images were generated from the subtraction between the pulse on and off images.According to the difference in inversion time(TI)of T-SLIP,four image groups group A(TI of 1300 ms),group B(TI of 1100 ms),group C(TI of 900 ms)and group D(TI of 700 ms),were assigned and compared to detect the optimal TI for portography.For quantitative analysis,the signal intensity(SI)of left and right liver lobe,the large vessels as main,right and left portal vein(MPV,RPV and LPV,respectively)and small vessels as branches of segments four(P4),six(P6)and eight(P8)were measured.The relative SI of MPV,RPV and LPV,as well as P4,P6 and P8 were also compared.For qualitative evaluation,the quality score of visualization was also evaluated using a 4-point scale.One-Way ANOVA and LSD test were used for comparison of quantitative data,and Friedman signed rank test was used for comparison of qualitative scores.</p><p><b>RESULTS</b>In 52 sequences of 13 volunteers,the selective visualization of the portal vein was all successfully conducted.Quantitative evaluation showed significant increased SI at the left lobe between C and D groups and A and B groups(comparison of group C to group A and BP=0.004,0.011;comparison of group D to group A and BP=0.001,0.004),while relative SI of LPV of groups C and D were lower than groups A and B(comparison of group C to group A and BP=0.015,0.015;comparison of group D to group A and BP=0.000,0.000).The relative SI of MPV in group D were decreased than groups A(P=0.000),B(P=0.000),and C(P=0.019).There was no significant difference in relative SI of small vessels among four groups(P>0.05).The image score of portal vessels in four groups also showed no differences(P>0.05).</p><p><b>CONCLUSIONS</b>3D true SSFP scan with T-SLIP enabled selective non-CE visualization of the portal vein with digital subtraction method.A fixed TI of both 1300 and 1100 ms can be preferable.</p>

Early recurrence after the resection of hepatocellular carcinoma / 中国医学科学院学报

<p><b>OBJECTIVE</b>To observe the precise time of the recurrence after resection of hepatocellular carcinoma (HCC) and to further explore the risk factors associated with postoperative recurrence.</p><p><b>METHODS</b>Totally 94 patients who had undergone resection of HCC were divided into three groups based on the time of recurrence, which was indicated by the digital subtraction angiography (DSA) examination: recurrence between 1 to 6 months, recurrence between 7 to 12 months, and tumor-free after 12 months. Patients with intra-hepatic recurrence were treated with transcatheter arterial chemoembolization and confirmed by CT scans after embolization, contrast-enhanced ultrasound, or magnetic resonance imaging.</p><p><b>RESULTS</b>The recurrence rates of 6 months and 1 year were 30.9% and 36.2%, respectively. No statistically significant difference between 6-month and 1-year recurrence rates was observed. Nine (26.5%) patients with recurrence and five (8.3%) patients free of tumor had previously presented as multifocal HCC, which showed a statistical significance (P = 0.032). The diagnostic accuracy of DSA was 87.2%, which was eventually confirmed by the other investigations.</p><p><b>CONCLUSIONS</b>Most recurrences occure within the first six months postoperatively and multifocal carcinogenesis is one of the risk factors associated with early recurrence after liver resection for advanced HCC. DSA is an important surveillance for early detection of intra-hepatic recurrence after surgery; meanwhile, it also provides information for early management to control the disease progression and for future active therapies.</p>

Preoperative evaluation of liver function using 99mTc-diethyl iminodiacetic acid based on single photon emission computed tomography / 中国医学科学院学报

<p><b>OBJECTIVE</b>To establish a three-dimentional liver function evaluation system using 99mTc-diethyl iminodiacetic acid (99mTc-EHIDA) scintigraphy based on single photon emission computed tomography (SPECT).</p><p><b>METHODS</b>Totally 16 patients with liver lesions were divided into cirrhosis group and non-cirrhosis group. SPECT was performed 2 days before operation and 5 days after operation. Serum liver functions were examined on the same day of scintigraphy. SPECT images of areas of interest of heart and liver were aquired. Time of the peak of EHIDA density in liver (Tpeak), five-minutes heart liver index (HLI5), blood clearance index (HH15), receptor index (LHL15), and the predictive values were calculated.</p><p><b>RESULTS</b>Tpeak was not significantly different between two groups, while HLI5, HH15, and LHL15 were significantly different (P = 0.033, P = 0.001, and P = 0.005). HLI, and LHL15 were significantly correlated with preoperative total protein and prealbumin levels (P = 0.003, P = 0.015, P = 0.022, P = 0.038) and post-operative prealbumin (P = 0.037, P = 0.042). The predictive values of HLI5 and LHL15 correlated well with postoperative HLI5 and LHL15 (r = 0.675, P = 0.016; r = 0.629, P = 0.028).</p><p><b>CONCLUSION</b>The three-dimentional liver function evaluation system using 99mTc-EHIDA based on liver SPECT may facilitate the further studies of risks of liver surgery.</p>

Application of technetium galactosyl human serum albumin diethylenetriamine pentaacetic acid injection on liver imaging in mouse models with different hepatic injuries / 中国医学科学院学报

<p><b>OBJECTIVE</b>To identify the uptake and biological distribution of technetium galactosyl human serum albumin diethylenetriamine pentaacetic acid injection (99mTc-GSA) in three mouse models with different degrees of hepatic injuries.</p><p><b>METHODS</b>Three mouse models including hepatic fibrosis, hepatic cholestasis, and liver cancer were established. Hepatic fibrosis model was established by intraperitoneal injection of carbon tetrachloride, 0.4 ml 10%, every 48 hours for 48 days. Hepatic cholestasis model was set up by ligature of the common bile duct for 72 hours, and liver cancer model by implantation of H22 tumor cells underneath liver capsule for 10 days. On measurement, each mouse in different models and normal controls was injected with 0.1 ml (0.37 MBq)99mTc-GSA (2 microg) into vena caudalis, and 5 minutes later sacrificed by decapitation. Important organs and tissues including liver, heart, lungs, kidney, spleen, stomach, blood, bones, muscles, and intestines were taken and their different radio countings were measured. The hepatic injuries were evaluated with serum and pathological examinations.</p><p><b>RESULTS</b>99mTc-GSA was concentrated in the liver in all three models and the control mice ( >40% ID x g(-1)). Compared with the control mice (90.05 +/- 10.55)% ID x g(-1), the density of 99mTc-GSA was significantly lower in the models with hepatic injuries (P < 0.001). The liver function test indicated that the injury in hepatic fibrosis model was less serious than those in the other two models. However, the concentration of 99mTc-GSA in hepatic fibrosis model [(72.20 +/- 2.13)% ID x g(-1)] was significantly higher than those in the models with cholestasis [(56.72 +/- 5.92)% ID x g(-1)] and liver cancer [(42.80 +/- 6.05)% ID x g(-1)] (P < 0.001).</p><p><b>CONCLUSIONS</b>99mTc-GSA may well concentrate in liver and its concentration degree is adversely correlated with hepatic injuries. Therefore 99mTc-GSA may be clinically used as liver imaging agent. When combined with three-dimensional scanning technique, it may facilitate constructing a new three-dimensional imaging method to demonstrate the function of designed liver segments.</p>

Clinical experiences of surgical manipulations for hepatic masses in difficult sites / 中国医学科学院学报

<p><b>OBJECTIVE</b>To summarize the surgical experiences, risks, complications, and managements for hepatic masses in difficult sites.</p><p><b>METHODS</b>Totally 47 patients were divided into three groups based on the liver tumor sites: primary porta hepatis group, secondary porta hepatis group, and caudate lobe group. All patients underwent different portion of hepatectomy.</p><p><b>RESULTS</b>The surgery duration was (289.6 +/- 62.2) ml-nutes, intra-operative blood loss was (602.3 +/- 256.4) ml, and intra-operative blood transfusion was (524.0 +/- 325.9) ml. Incidence of surgical complications in each group was 61.5%, 26.9%, and 25%, respectively. Serious complications observed were biliary leakage (27.7%), bleeding (6.4%), and post-operative liver failure (2.1%). Three perioperative deaths were reported: two patients died of bleeding, and one patient died from liver failure.</p><p><b>CONCLUSIONS</b>Dissection of the liver and exposure of major blood vessels and biliary ducts are of critical importance in the surgeries for hepatic masses in difficult sites, and post-operative complications may be remarkably reduced through delicate manipulations of the small intra-hepatic vessels and biliary ducts during resection. A thorough pre-operative evaluation plays a key role in predicting the feasibility and risks of the surgery. Damage to the major blood vessels adjacent to the tumor, in addition to bleeding, may result in in-flow or outflow obstruction and cause necrosis of the corresponding hepatic lobe. Compared with damage to the primary portal area, vascular damage to the secondary porta is generally associated with higher fatality.</p>