Application value of digital single-operator peroral cholangioscopy on the preoperative evalua-tion of extrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective:To investigate the application value of digital single-operator peroral cholangioscopy on the preoperative evaluation of extrahepatic cholangiocarcinoma.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 172 patients with extrahepatic cholangiocarcinoma who were admitted to the First Affiliated Hospital of Army Medical University from December 1, 2017 to April 1, 2022 were collected. There were 91 males and 81 females, aged 65(range, 45?68)years. Of 172 patients, 36 cases undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the experimental group, and 136 cases not undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the control group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) surgical conditions. Propensity score matching was done by the 1:1 nearest neighbor matching method and caliper setting as 0.02. Measurement data with normal distribution were expressed as Mean± SD, and t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M( Q1,Q3), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. The rank sum test was used for comparison of ordinal data. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of 172 patients, 60 cases were successfully matched, including 30 cases in the experiment group and 30 cases in the control group, respectively. Before propensity score matching, cases with or without preoperative bile drainage were 27, 9 in the experiment group, versus 62, 74 in the control group, showing a significant difference between the two groups ( χ2=9.86, P<0.05). The above indicators were 23, 7 in the experiment group, and 23, 7 in the control group after propensity score matching, showing no significant difference between the two groups ( χ2=0.00, P>0.05). The elimination of preoperative bile drainage confounding bias ensured comparability between the two groups. (2) Surgical conditions. After propensity score matching, there were 10 cases and 0 case without surgery in the two groups. Cases undergoing radical operation including R 0, R 1, R 2 resection were 16, 0, 4 in the experiment group, versus 18, 6, 6 in the control group, showing a significant difference between the two groups ( χ2=6.85, P<0.05). Conclusions:Preoperative digital single-operator peroral cholangioscopy exami-nation can improve the R 0 resection rate of extrahepatic cholangiocarcinoma.

Predictive value of preoperative abdominal adipose tissue measurement for early recurrence after resection of hepatocellular carcinoma / 中华消化外科杂志

Objective:To investigate the predictive value of preoperative abdominal adipose tissue measurement for early recurrence after resection of hepatocellular carcinoma (HCC).Methods:The retrospective case-control study was conducted. The clinicopathological data of 238 patients with HCC who underwent surgical resection from January 2018 to January 2020 in 2 medical centers in China were collected, including 46 cases in the First Affiliated Hospital of Chongqing Medical University and 192 cases in the First Affiliated Hospital of Army Medical University. There were 207 males and 31 females, aged 51(48,65)years. All patients underwent abdominal computed tomography (CT) and/or magnetic resonance imaging (MRI) before surgery. Observation indicators: (1) measure-ment of abdominal adipose tissue; (2) follow-up; (3) analysis of influencing factors for early recurrence after resection of HCC; (4) prediction of early recurrence after resection of HCC. Follow-up was conducted by outpatient examinations and telephone interview to detect the postoperative survival of patients up to February 2022. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was performed by the t test. Measurement data with skewed distribution was represented by M(range) or M( Q1, Q3), and comparison between groups was performed by the Mann-Whitney U test. Count data were expressed as absolute numbers or percen-tages, and the chi-square test was used for comparison between groups. Univariate analysis was conducted using the corresponding statistical methods based on data type. Multivariate analysis was performed using the Logistic regression model advance method. The receiver operating characteristic curve was drawn, and the area under curve was used to evaluate the efficacy. Results:(1) Measure-ment of abdominal adipose tissue. Of the 238 patients, the total abdominal adipose tissue, visceral adipose tissue, subcutaneous adipose tissue, total adipose tissue index, visceral adipose tissue index, subcutaneous adipose tissue index were 292(198,355)cm 2, 153(99,194)cm 2, 128(95,154)cm 2, 106(76,130)cm 2/m 2, (57±27)cm 2/m 2, 46(34,58)cm 2/m 2 for 139 patients with early postoperative recur-rence, versus 174(114,251)cm 2, 78(50,110)cm 2, 88(55,127)cm 2, 64(42,91)cm 2/m 2, (30±16)cm 2/m 2, 31(19,46) cm 2/m 2 for 99 patients without early recurrence, respectively, showing significant diffe-rences between them ( Z=?7.39, ?7.87, ?5.03, ?7.25, t=?9.46, Z=?5.00, P<0.05). (2) Follow-up. All the 238 patients were followed up according to the plan. The survival time of 238 patients was 26(8,44)months. The survival time was 11(5,18)months for patients with postoperative early recur-rence, versus 36(32,43)months for patients without early recurrence, respectively. (3) Analysis of influencing factors for early recurrence after resection of HCC. Results of univariate analysis showed that body mass index, total adipose tissue, visceral adipose tissue, subcutaneous adipose tissue, total adipose tissue index, visceral adipose tissue index and subcutaneous adipose tissue index were related factors for early recurrence after resection of HCC ( t=?5.88, Z=?7.39, ?7.87, ?5.03, ?7.25, t=?9.46, Z=?5.00, P<0.05). Results of multivariate analysis showed that visceral adipose tissue index was an independent influencing factor for early recurrence after resection of HCC ( odds ratio=1.06, 95% confidence interval as 1.04?1.08, P<0.05). (4) Prediction of early recurrence after resection of HCC. According to the results of multivariate analysis, the receiver operating characteris-tic curve showed that the area under curve of visceral adipose tissue index was 0.80 (95% confidence interval as 0.75?0.86, P<0.05), with the sensitivity and specificity as 75.5% and 71.7%. Conclusions:Visceral adipose tissue index is an independent influencing factor for early recurrence after resection of HCC. The risk of early recurrence increases with the increase of visceral adipose tissue index.

Surgical treatment and prognostic analysis of hepatolithiasis-associated intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective To analyze the surgical treatment and prognostic factors of patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma (HICC).Methods The retrospective case-control study was conducted.The clinicopathological data of 109 patients with HICC who were admitted to the First Affiliated Hospital of Army Medical University between January 2011 and December 2015 were collected,including 40 males and 69 females,aged from 29 to 81 years,with an average age of 55 years.The patients underwent imaging and laboratory examinations before operation,and then the operation plan was worked out according to the results of examination and intraoperative conditions,including radical operation,palliative surgery and simple biopsy.Observation indicators:(1) surgical situations;(2) follow-up;(3) analysis of risk factors affecting postoperative survival of HICC patients.The follow-up using telephone interview and outpatient examination was performed to detect patients' survival up to January 2018.The normality test was done by ShapiroWilk.Measurement data with normal distribution were represented as Mean±SD and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were described as M (range) and comparison between groups was analyzed using the Wilcoxon rank sum test.Categorical variables were analyzed using the chi-square test.The survival curve and cumulative survival rate were respectively drawn and calculated using the Kaplan-Meier method.The univariate analysis was done using the Log-rank test.The indexes with P＜ 0.05 were incorporated into COX regression model for multivariate analysis in the forward wald.Results (1) Surgical situations:109 patients with HICC underwent surgery.Distribution of hepatolithiasis and HICC in the 109 patients:the stones of 58,26 and 25 patients were located in the left liver,right liver and bilateral sides,respectively.The tumors of 65,31 and 13 patients were located in the left liver,right liver and bilateral sides,respectively.Operation methods:radical operation was performed in 51 cases (combined choledochojejunostomy in 38 cases,regional lymph node dissection in 33 cases,vascular reconstruction in 3 cases and pancreaticoduodenectomy in 2 cases),including 33 with hemihepatectomy and 18 with non-hemihepatectomy.Palliative surgery was performed in 46 cases (local resection of tumors in 13 cases,choledochojejunostomy in 19 cases,gastrointestinal anastomosis in 9 cases,jejunostomy in 13 cases,simple biliary drainage in 5 cases,other operations in 12 cases,some patients combined with a variety of surgical methods),and simple biopsy was performed in 12 cases.Invasion and metastasis in the 109 patients:intrahepatic metastasis occurred in 22 cases,vascular invasion in 52 cases,lymph node metastasis in 55 cases,extrahepatic invasion and metastasis in 58 cases (64 cases were complicated with multiple invasion and metastasis).The operation time and volume of intraoperative blood loss of 109 patients were respectively (359± 170)minutes and (556±382)mL,and 53 patients received intraoperative blood transfusion.Postoperative complications occurred in 35 patients,including pulmonary infection,pleural and peritoneal effusion,abdominal hemorrhage,abdominal infection,bile leakage and organ failure.Twenty-nine of the 35 patients were improved or recovered after treatment,and 6 died (3 died of severe pulmonary infection,1 died of liver failure,1 died of septic shock and 1 died of gastrointestinal hemorrhage).Histopathological characteristics of tumors in the 109 patients:mass type,peritubular infiltration type and intratubular growth type were detected respectively in 50,49 and 10 cases;according to the degree of tumor differentiation,high-differentiated,moderate-differentiated and low-differentiated tumors were detected in 22,50 and 37 cases,respectively.(2) Follow-up:107 patients were followed up for 1-84 months,with a median followup time of 51 months.The median survival time was 25.0 months (range,17.9-32.1 months).The 1-,3-and 5-year overall survival rates were 78.7％,39.4％ and 9.8％,respectively.The 1-,3-and 5-year survival rates were 86.3％,61.8％,20.6％ in patients with radical surgery and 88.4％,19.1％,0 in patients with palliative surgery and 34.6％,0,0 in patients with simple biopsy,respectively,showing a statistically significant difference (x2 =43.237,P＜0.05).(3) Analysis of risk factors affecting postoperative survival of HICC patients:① the results of univariate analysis showed that course of stone,cirrhosis,operation method,tumor diameter,tumor gross classification,degree of tumor differentiation,intrahepatic metastasis,vascular invasion,lymph node metastasis,extrahepatic invasion and metastasis,percentage of neutrophils,total bilirubin (TBiL),direct bilirubin (DBiL),albumin (Alb) and CA19-9 were the related factors affecting the prognosis of HICC patients after surgical treatment (x2 =5.764,8.768,43.273,4.086,11.995,21.910,15.436,6.469,17.181,35.307,24.676,10.691,11.367,5.808,3.907,P＜0.05).② The results of multivariate analysis showed that simple biopsy as operation method,course of stone ≥ 60 months,cirrhosis,low-differentiated tumor,vascular invasion,extrahepatic invasion and metastasis and Alb ＜ 35 g/L were independent factors affecting the prognosis of HICC patients after surgical treatment (hazard ratio =3.317,1.809,1.917,1.882,1.761,2.283,0.502,95％ confidence interval:1.263-8.712,1.132-2.892,1.061-3.463,1.291-2.744,1.087-2.852,1.220-4.271,0.304-0.827,P＜0.05).Conclusions Some patients with chronic hepatolithiasis can progress to HICC,and surgical resection is the first choice.However,due to the high malignancy,there is usually a combination of invasion and mnetastasis,resulting in poor prognosis.The simple biopsy as operation method,course of stone ≥ 60 months,cirrhosis,low-differentiated tumor,perihepatic vascular invasion,extrahepatic invasion and metastasis,Alb ＜ 35 g/L are independent risk factors affecting the prognosis of HICC patients after surgical treatment.

Computed tomography and magnetic resonance imaging features of the myomatous hepatic angiomyolipoma / 中华消化外科杂志

Objective To investigate the computed tomography (CT) and magnetic resonance imaging (MRI) features of the myomatous hepatic angiomyolipoma (MHAML).Methods The retrospective cross-setional study was conducted.The clinicopathological data of 22 patients with MHAML who were admitted to the Southwest Hospital of the Third Military Medical University between January 2010 and June 2016 were collected.Patients underwent plain and enhanced scans of CT and MRI,and then received pathological examination after surgical resection or liver puncture and immunohistochemical staining.Observation indicators:(1) findings of CT and MRI,2 radiologists independently read films;(2) diagnostic consistency of 2 radiologists;(3) results of pathological examination.The Kappa test was used for evaluating the consistency,κ ≥0.75 as a good consistency,0.40＜κ＜0.75 as a normal consistency and κ ≤0.40 as a poor consistency.Results (1) Findings of CT and MRI:of 22 patients,16 received CT scans and 6 received CT and MRI scans.Tumors of 22 patients were single lesion,showing similar-circular type.Tumors located in the right liver lobe,left liver lobe and caudate lobe were respectively detected in 14,7 and 1 patients.① Plain and enhanced scans of CT:tumors of 22 patients showed low density.Twenty patients had clear boundary of tumor and 2 had an unclear boundary.Tumors of 22 patients demonstrated obvious enhancement in arterial phase by enhanced scans of CT,including fast-in and slow-out enhancement in 10 patients and fast-in and fast-out enhancement in 12 patients.The draining veins inside tumors were detected in 12 patients in early arterial phase by enhanced scans of CT.The dilated blood vessels inside tumors were found in 12 patients.The ring enhancement of tumor margin was detected in 16 patients,with formation of small blood vessels involving tumor blood supply.② MRI scan:tumors of 6 patients presented as low signal on T1WI and high signal on T2WI.Of 6 patients,5 had clear boundary of tumor and 1 had an unclear boundary.Tumors of 6 patients demonstrated obvious enhancement in arterial phase by enhanced scans of MRI,with a fast-in and fast-out enhancement.The draining veins inside tumors were detected in 3 patients in early arterial phase by enhanced scans of MRI.The dilated blood vessels inside tumors were found in 1 patient.The persistent ring enhancement of tumor margin was detected in 5 patients,with formation of small blood vessels.All the lesions of 6 patients using GD-EOB-DTPA MR contrast-enhanced scan demonstrated restricted diffusion with a high b value (b=800 s/mm2),an average apparent diffusion coefficient of 1.549× 10-3 mm2/s (1.209× 10-3-1.796× 10-3 mm2/s) and low a signal in liver phase.(2) Diagnostic consistency of 2 radiologists:there were good diagnostic consistencies of 2 radiologists in tumor location,density,T1WI,T2WI,bleeding,enhancement method and dilated blood vessels (κ=1.00,1.00,1.00,1.00,0.82,0.82,P＜0.05).There were normal diagnostic consistencies of 2 radiologists in tumor fat,calcification,component of cystolization,boundary,draining veins and enhancement of tumor margin (κ =0.46,0.45,0.64,0.54,P＜0.05).(3) Results of pathological examination:results of pathological examination of tumors from surgical resection of 17 patients and liver puncture of 5 patients showed that smooth muscle cells were the major components,and thick-walled vessels were found in the tumor of 12 patients.Results of immunohistochemical staining showed that anti melanoma specific monoclonal antibody (HMB-45) was positive.Conclusion The persistent enhancement of tumor margin,draining veins in early arterial phase by enhanced scans and dilated blood vessels might play roles in diagnosis of MHAML.

Optimization of immunosuppressive therapy after liver transplantation / 中华消化外科杂志

The toxic effects of immunosuppressants are often dangerous factors which influence long-term survival of recipients.Individualized immunosuppressive therapy has been a hotspot and difficulty for comprehensive treatment of liver transplantation.Immunosuppressive therapy has been gradually developed to pursue long-term survival for receipients and graft,minimized side effects of immunosuppressants,optimized quality of life of patients,and reduce the economic burden of patients.Through consideration of patient's pathophysiological state,understanding the characteristics and side effects of various immunosuppressive,appropriate choose of the immune inhibitor,correct evaluation of immune state of recipients and graft,minimization of drug doses,individualized dosing regimen could be successfully carried out.

Treatment of hepatic cancer recurrence and metastasis after liver transplantation / 中华消化外科杂志

Objective To summarize the strategies of treatment and investigate the risk factors affecting the survival of patients with hepatic cancer recurrence and metastasis after liver transplantation.Methods The clinical data of 99 patients with hepatic cancer recurrence and metastasis after liver transplantation who were admitted to the Southwest Hospital of Third Military Medical University from January 1999 to September 2011 were retrospectively analyzed.Of the 99 patients,7 patients who did not meet the criteria were excluded from the study,and 92 patients were enrolled in the study.All patients were divided into single therapy group (18 patients) and combined therapy group (74 patients).The study was reviewed by the ethics committee,and all the patients signed the informed consent form.The survival time of the 2 groups was compared,and the risk factors affecting the survival time was analyzed.All data were analyzed using the t test,chi-square test or by calculating the Fisher exact probability.The survival curve was drawn using the Kaplan-Meier method,and the survival time was compared by the Log-rank test.Factors influencing the prognosis were analyzed using the multivariate linear regression analysis.Results The survival time of patients in the single therapy group and the combined therapy group after hepatic cancer recurrence and metastasis were (5.5 ± 1.1) months and (8.5 ± 1.6) months,respectively,with a significant difference between the 2 groups (Log-rank value =7.489,P ＜ 0.05).The survival time were (7.9 ± 1.5) months for patients in TNM Ⅱ and Ⅲ A,and (7.0 ± 1.3) months for patients in TNM Ⅲ B and ⅣA,with significant difference between the 2 groups (Log-rank value =2.567,P ＜0.05).The survival time of patients with moderately or well differentiated tumors after tumor recurrence and metastasis was (8.1 ± 1.5) months,which was significantly longer than (7.2 ± 1.4)months of patients with poorly differentiated tumor (Log-rank value =2.749,P ＜ 0.05).TNM stage,tumor differentiation,Milan criteria,great vessel invasion were independent factors affecting the survival of patients with hepatic cancer recurrence and metastasis (t =2.610,3.132,4.378,2.258,P ＜ 0.05).Conclusions Combined therapy can significantly prolong the survival time of patients with hepatic cancer recurrence and metastasis.Earlier hepatic cancer recurrence and metastasis after liver transplantation result in a shorter survival time.TNM stage,tumor differentiation,great vessel invasion and Milan criteria are risk factors affecting the survival of patients with hepatic cancer recurrence and metastasis after liver transplantation.

Ex-vivo liver resection combined partial liver autotransplantation for hepatocellular carcinoma located at critical site / 中华消化外科杂志

Ex-vivo liver resection is developed based on liver transplantation and technique of cold preservation of organs.It overcomes the shortcomings of time limit of warm ischemia and high technique demand of hepatectomy of tumors located at critical sites.A 58-year-old woman with hepatocellular carcinoma located close to the middle hepatic vein combined with invasion of right hepatic vein was admitted to Southwest Hospital.Because of the critical tumor site,conventional liver resection Wag assessed as impossible.Ex-vivo liver resection was performed,and a vessel patch from an organ wag harvested to repair the defect of the right hepatic vein,and then the liver remnant was subsequently autotransplanted.After operation,the patient recovered smoothly without venous outflow complication.Bile leakage wag observed on postoperative day 23,and the maximnm volume of intraperitoneal drainage wag 200 ml per 24 hours.Endoscopic nasobiliary drainage Was performed and the volume of intraperitoneal drainage gradually decreased to none.Liver function of the patient was back to normal and with no tumor recurrence at the end of 6 months of follow up.Ex-vivoliver resection is beneficial to patients with centrally located hepatocellular carcinoma with the involvement of hepatic vein and inferior vena cava.

Total pancreatectomy combined with cold perfusion of liver via portal vein / 中华消化外科杂志

Cold perfusion of liver can significantly alleviate the ischemia-reperfusion injury caused by hepatic blood flow occlusion. We have modified the technique of cold perfusion of liver and applied it to total pancreatectomy for patients with pancreatic head carcinoma complicated with metastasis to the body and tail of pancreas and with portal invasion. After skeletonization of the hepatoduodenal ligament, the amputation of the portal vein and blockage of the superior mesentoric vein were performed before portal perfusion. Meanwhile, pancreatic head resection, duodenectomy, subtotal gastrectomy and partial resection of the superior mesenteric vein and portal vein were carried out. Superior mesenteric vein and portal vein bypass grafting was achieved with artificial vessels. The digestive tract was reconstructed after it was freed of the spleen and resection of the body and tail of pancreas to the left side of superior mesenteric vein, greater omentum and intestine from the end of the colon to splenic flexure of colon. The patient was followed up for 3 months, and the general condition was good, although diarrhea frequently occurred. No tumor metastasis occurred.