Single-Port Laparoscopic Surgery Is Feasible and Safe for Hepatic Left Lateral Sectionectomy for Benign Liver Lesions.

BACKGROUND AND OBJECTIVES: The feasibility and safety of single-port laparoscopic surgery for left lateral liver lobectomy are largely unknown. This study is aimed at comparing the effectiveness and safety between single-port laparoscopic (SPL) and conventional multiport laparoscopic (CL) surgeries for hepatic left lateral sectionectomy. METHODS: A total of 65 patients receiving laparoscopic hepatic left lateral sectionectomy between January 2008 and July 2015 were included and divided into the SPL group (n = 40) and the CL group (n = 25). RESULTS: There was no significant difference in the operative time, estimated intraoperative blood loss, length of hospital stay, and incidences of postoperative complications (biliary leakage, hemorrhage, and contusion at incision) between groups (all P > 0.05). However, the SPL group had a significantly lower VAS pain score (at 24 h but not 7 days postoperation) and higher cosmetic satisfaction scores (at both 2 months and 6 months postoperation) than the CL group (all P < 0.01). Moreover, multivariate linear regression analysis further confirmed the superior pain score and cosmetic outcome in the SPL group. CONCLUSIONS: Single-port laparoscopic hepatic left lateral sectionectomy is a safe and feasible treatment for patients with lesions in the left hepatic lobe. Patients with benign lesions in the left hepatic lobe are more suitable to receive single-port laparoscopic hepatic left lateral sectionectomy than those with malignancies.

Correlation Between Postoperative Early Recurrence of Hepatocellular Carcinoma and Mesenchymal Circulating Tumor Cells in Peripheral Blood.

BACKGROUND: Circulating tumor cells (CTCs) have been actively studied for their functions in hepatocellular carcinoma (HCC) recurrence. However, the relationship between circulating tumor cells subtypes and hepatocellular carcinoma recurrence is still unclear. METHODS: CTCs were collected from the peripheral blood of 62 postoperative HCC patients. The CTCs were isolated with a filtration-based method. Multiplex fluorescence in situ hybridization was used to characterize the CTCs based on mRNA expression levels of epithelial and mesenchymal markers. RESULTS: Of the 62 HCC patients, 26 were diagnosed with early recurrence (ER) and 36 did not experience recurrence. Comparison between the recurrence group and the non-recurrence group showed the total number of CTCs, mesenchymal CTCs, and mixed CTCs in the recurrence group was significantly higher than in the non-recurrence group. Receiver operator characteristic (ROC) curve analysis was performed to define the positive cutoff values as follows: total number of CTCs ≥ 4, mesenchymal CTCs ≥ 1, and mixed CTCs ≥ 3. Analysis showed that portal vein tumor thrombus (hazard ratio [HR] = 2.905, P = 0.023) and mesenchymal CTC positivity (HR = 3.453, P = 0.007) were independent risk factors for ER. The correlation between the presence of mesenchymal CTCs and time to recurrence was further examined, and the results showed significantly shortened postoperative disease-free survival in patients positive for mesenchymal CTCs (P < 0.001). CONCLUSIONS: HCC patients with positive peripheral mesenchymal CTCs have a more serious risk of ER, which could be a potential biomarker in HCC prognosis monitoring.

Novel D-galactosamine-induced cynomolgus monkey model of acute liver failure.

AIM: To establish a simplified, reproducible D-galactosamine-induced cynomolgus monkey model of acute liver failure having an appropriate treatment window. METHODS: Sixteen cynomolgus monkeys were randomly divided into four groups (A, B, C and D) after intracranial pressure (ICP) sensor implantation. D-galactosamine at 0.3, 0.25, 0.20 + 0.05 (24 h interval), and 0.20 g/kg body weight, respectively, was injected via the small saphenous vein. Vital signs, ICP, biochemical indices, and inflammatory factors were recorded at 0, 12, 24, 36, 48, 72, 96, and 120 h after D-galactosamine administration. Progression of clinical manifestations, survival times, and results of H&E staining, TUNEL, and Masson staining were recorded. RESULTS: Cynomolgus monkeys developed different degrees of debilitation, loss of appetite, and jaundice after D-galactosamine administration. Survival times of groups A, B, and C were 56 ± 8.7 h, 95 ± 5.5 h, and 99 ± 2.2 h, respectively, and in group D all monkeys survived the 144-h observation period except for one, which died at 136 h. Blood levels of ALT, AST, CK, LDH, TBiL, Cr, BUN, and ammonia, prothrombin time, ICP, endotoxin, and inflammatory markers [(tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, and IL-6)] significantly increased compared with baseline values in different groups (P < 0.05). Pathological results showed obvious liver cell necrosis that was positively correlated with the dose of D-galactosamine. CONCLUSION: We successfully established a simplified, reproducible D-galactosamine-induced cynomolgus monkey model of acute liver failure, and the single or divided dosage of 0.25 g/kg is optimal for creating this model.

Artificial liver support in pigs with acetaminophen-induced acute liver failure.

AIM: To establish a reversible porcine model of acute liver failure (ALF) and treat it with an artificial liver system. METHODS: Sixteen pigs weighing 30-35 kg were chosen and administered with acetaminophen (APAP) to induce ALF. ALF pigs were then randomly assigned to either an experimental group (n = 11), in which a treatment procedure was performed, or a control group (n = 5). Treatment was started 20 h after APAP administration and continued for 8 h. Clinical manifestations of all animals, including liver and kidney functions, serum biochemical parameters and survival times were analyzed. RESULTS: Twenty hours after APAP administration, the levels of serum aspartate aminotransferase, total bilirubin, creatinine and ammonia were significantly increased, while albumin levels were decreased (P < 0.05). Prothrombin time was found to be extended with progression of ALF. After continuous treatment for 8 h (at 28 h), aspartate aminotransferase, total bilirubin, creatinine, and ammonia showed a decrease in comparison with the control group (P < 0.05). A cross-section of livers revealed signs of vacuolar degeneration, nuclear fragmentation and dissolution. Concerning survival, porcine models in the treatment group survived for longer times with artificial liver system treatment (P < 0.05). CONCLUSION: This model is reproducible and allows for quantitative evaluation of new liver systems, such as a bioartificial liver. The artificial liver system (ZHJ-3) is safe and effective for the APAP-induced porcine ALF model.

Tripartite comparison of single-incision and conventional laparoscopy in cholecystectomy: A multicenter trial.

AIM: To compare the characteristics of two single-incision methods, and conventional laparoscopy in cholecystectomy, and demonstrate the safety and feasibility. METHODS: Three hundred patients with gallstones or gallbladder polyps were admitted to two clinical centers from January 2013 to January 2014 and were randomized into three groups of 100: single-incision three-device group, X-Cone group, and conventional group. The operative time, intraoperative blood loss, complications, postoperative pain, cosmetic score, length of hospitalization, and hospital costs were compared, with a follow-up duration of 1 mo. RESULTS: A total of 142 males (47%) and 158 females (53%) were enrolled in this study. The population characteristics of these three groups is no significant differences exist in terms of age, sex, body mass index and American Society of Anesthesiology (P > 0.05). In results, there were no significant differences in blood loss, length of hospitalization, postoperative complications.The operative time in X-Cone group was significantly longer than other groups.There were significant differences in postoperative pain scores and cosmetic scores at diffent times after surgery (P < 0.05). CONCLUSION: This study shows that this two single-incision methods are safe and feasible. Both methods are superior to the conventional procedure in cosmetic and pain scores.

Transumbilical single-incision endoscopic splenectomy: report of ten cases.

AIM: To investigate the feasibility and clinical application of transumbilical single-incision endoscopic splenectomy using conventional laparoscopic instruments. METHODS: Between 2010 and 2012, transumbilical single-incision endoscopic splenectomy was performed in 10 patients in our department, of whom 4 had refractory idiopathic thrombocytopenic purpura, 4 had enlarged splenic cyst and 2 had splenic hematoma. A 2.5-cm curved incision was made at the lower umbilicus edge, and a 10 mm laparoscope was inserted into the middle of the incision. A 5-mm harmonic scalpel was placed on the right side, and a 5-mm auxiliary instrument on the left side of the laparoscope. Splenic ligaments were incised with a harmonic scalpel, and the splenic pedicle was cut with an Endo-gastrointestinal anastomosis. The spleen was dissected and placed in a large retrieval bag, blended, and then removed. RESULTS: All transumbilical single-incision endoscopic splenectomies were performed successfully with mean operative time of 80 ± 5 min and mean blood loss of 150 ± 20 mL. Conversion to laparotomy or multi-port laparoscopic surgery was not required in all cases. All patients were discharged on postoperative days 4-6. During the postoperative hospitalization period, no painkillers were required. No intra-abdominal complications such as infection, ascites, gastric leakage, pancreatic leakage, or wound infection occurred in any case during the 6-mo follow-up. CONCLUSION: Transumbilical single-incision endoscopic splenectomy using conventional laparoscopic instruments is technically feasible and safe in selected patients.

Learning curve of transumbilical suture-suspension single-incision laparoscopic cholecystectomy.

AIM: To investigate the learning curve of transumbilical suture-suspension single-incision laparoscopic cholecystectomy (SILC). METHODS: The clinical data of 180 consecutive transumbilical suture-suspension SILCs performed by a team in our department during the period from August 2009 to March 2011 were retrospectively analyzed. Patients were divided into nine groups according to operation dates, and each group included 20 patients operated on consecutively in each time period. The surgical outcome was assessed by comparing operation time, blood loss during operation, and complications between groups in order to evaluate the improvement in technique. RESULTS: A total of 180 SILCs were successfully performed by five doctors. The average operation time was 53.58 ± 30.08 min (range: 20.00-160.00 min) and average blood loss was 12.70 ± 11.60 mL (range: 0.00-100.00 mL). None of the patients were converted to laparotomy or multi-port laparoscopic cholecystectomy. There were no major complications such as hemorrhage or biliary system injury during surgery. Eight postoperative complications occurred mainly in the first three groups (n = 6), and included ecchymosis around the umbilical incision (n = 7) which resolved without special treatment, and one case of delayed bile leakage in group 8, which was treated by ultrasound-guided puncture and drainage. There were no differences in intraoperative blood loss, postoperative complications and length of postoperative hospital stay among the groups. Bonferroni's test showed that the operation time in group 1 was significantly longer than that in the other groups (F = 7.257, P = 0.000). The majority of patients in each group were discharged within 2 d, with an average postoperative hospital stay of 1.9 ± 1.2 d. CONCLUSION: Following scientific principles and standard procedures, a team experienced in multi-port laparoscopic cholecystectomy can master the technique of SILC after 20 cases.

Laparoendoscopic single-site cholecystectomy vs three-port laparoscopic cholecystectomy: a large-scale retrospective study.

AIM: To perform a large-scale retrospective comparison of laparoendoscopic single-site cholecystectomy (LESSC) and three-port laparoscopic cholecystectomy (TPLC) in a single institution. METHODS: Data were collected from 366 patients undergoing LESSC between January 2005 and July 2008 and were compared with the data from 355 patients undergoing TPLC between August 2008 and November 2011 in our department. Patients with body mass index greater than 35 kg/m(2), a history of major upper abdominal surgery, signs of acute cholecystitis, such as fever, right upper quadrant tenderness with or without Murphy's sign, elevated white blood cell count, imaging findings suggestive of pericholecystic fluid, gallbladder wall thickening > 4 mm, and gallstones > 3 cm, were excluded to avoid bias. RESULTS: Altogether, 298 LESSC and 315 TPLC patients met the inclusion criteria. The groups were well matched with regard to demographic data. There were no significant differences in terms of postoperative complications (contusion: 19 vs 25 and hematoma at incision: 11 vs 19), hospital stay (mean ± SD, 1.4 ± 0.2 d vs 1.4 ± 0.7 d) and visual analogue pain score (mean ± SD, 8 h after surgery: 2.3 ± 1.4 vs 2.3 ± 1.3 and at day 1: 1.2 ± 0.4 vs 1.3 ± 1.2) between the LESSC and TPLC patients. Four patients required the addition of extra ports and 2 patients were converted to open surgery in the LESSC group, which was not significantly different when compared with TPLC patients converted to laparotomy (2 vs 2). LESSC resulted in a longer operating time (mean ± SD, 54.8 ± 11.0 min vs 33.5 ± 9.0 min), a higher incidence of intraoperative gallbladder perforation (56 vs 6) and higher operating cost (mean ± SD, 1933.7 ± 64.4 USD vs 1874.7 ± 46.2 USD) than TPLC. No significant differences in operating time (mean ± SD, 34.3 ± 6.0 min vs 32.7 ± 8.7 min) and total cost (mean ± SD, 1881.3 ± 32.8 USD vs 1876.2 ± 33.4 USD) were found when the last 100 cases in the two groups were compared. A correlation was observed between reduced operating time of LESSC and increased experience (Spearman rank correlation coefficient, -0.28). More patients in the LESSC group expressed satisfaction with the cosmetic result (98% vs 85%). CONCLUSION: LESSC is a safe and feasible procedure in selected patients with benign gallbladder diseases, with the significant advantage of cosmesis.

[Comparison of operative techniques in single-incision laparoscopic cholecystectomy: suture-suspension versus three-device method].

OBJECTIVE: To compare the operative techniques of single-incision laparoscopic cholecystectomy (SILC) via suture-suspension versus three-device method. METHODS: Retrospective analysis was performed for a total of 300 patients undergoing umbilical single-incision laparoscopic cholecystectomy from June 2008 to November 2011 at our hospital. The procedures were of suture-suspension (n = 200) and three-device (n = 100). Operative duration, estimated intra-operative blood loss, exposure extent of Calot's triangle, postoperative pain score, hospital stay and complications were compared respectively between two groups. Both groups were matched for age, gender, body mass index (BMI), diagnoses and American Society of Anesthesiology (ASA) class. RESULTS: All procedures were completed by the same surgeon. Comparison between two groups showed insignificant differences in blood loss (mean: (15.6 ± 9.5) vs (16.8 ± 7.4) ml; t = 1.266, P = 0.207), postoperative complications (number of case, incision contusion:4 vs 2, P = 1.000;incision hemorrhage:2 vs 2, P = 0.603) and hospitalization duration (mean: (1.6 ± 0.5) vs (1.6 ± 0.5) d; t = 0.653, P = 0.514), but significant differences in operative duration (mean:(40.5 ± 16.0) vs (51.5 ± 18.0) min; t = 5.381, P = 0.000), postoperative pain (mean: 2.0 ± 1.7 vs 3.7 ± 1.6; t = 8.324, P = 0.000) and exposure of Calot's triangle (number of case, 197 vs 68; χ(2) = 60.178, P = 0.000). Thus the suture-suspension method was superior to the three-device counterpart. CONCLUSION: The suture-suspension method of SILC is safe, economic and easy-to-handle in clinical practice.

Single-incision vs three-port laparoscopic cholecystectomy: prospective randomized study.

AIM: To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) with three-port laparoscopic cholecystectomy (TPLC). METHODS: Between 2009 and 2011, one hundred and two patients with symptomatic benign gallbladder diseases were randomized to SILC (n = 49) or TPLC (n = 53). The primary end point was post operative pain score (at 6 h and 7 d). Secondary end points were blood loss, operation duration, overall complications, postoperative analgesic requirements, length of hospital stay, cosmetic result and total cost. Surgical techniques were standardized and all operations were performed by one experienced surgeon, who had performed more than 500 laparoscopic cholecystectomies. RESULTS: One patient in the SILC group required conversion to two-port LC. There were no open conversions or major complications in either treatment groups. There were no differences in terms of estimated blood loss (mean ± SD, 14 ± 6.0 mL vs 15 ± 4.0 mL), operation duration (mean ± SD, 41.8 ± 17.0 min vs 38.5 ± 22.0 min), port-site complications (contusion at incision: 5 cases vs 4 cases and hematoma at incision: 2 cases vs 1 case), total cost (mean ± SD, 12 075 ± 1047 RMB vs 11 982 ± 1153 RMB) and hospital stay (mean ± SD, 1.0 ± 0.5 d vs 1.0 ± 0.2 d) , respectively. TPLC had a significantly worse visual analogue pain score at 8 h after surgery (mean ± SD, 3.5 ± 1.6 vs 2.0 ± 1.5), however, the scores were similar on day 7 (mean ± SD, 2.5 ± 1.4 vs 2.0 ± 1.3). Cosmetic satisfaction, as determined by a survey at 2 mo follow-up favored SILC (mean ± SD, 8 ± 0.4 vs 6 ± 0.2). CONCLUSION: SILC is a safe and feasible approach in selected patients. The main advantages are a better cosmetic result and less pain.

Single-incision laparoscopic hepatectomy: a case report.

AIMS: Single-incision laparoscopic procedures are reported to be accessible comprehensively for abdominal surgeries. Herein, we report 1 case of partial hepatectomy in which the single-incision laparoscopic surgery (SILS) technique or the laparoendoscopic single-site surgery was conducted. CASE: One 53-year-old woman diagnosed with hepatic multicystis (the largest one had a diameter of 5 cm) underwent single-incision laparoscopic partial hepatectomy on January 1, 2010. RESULTS: The entire procedure was completed in 105 minutes without any complications. The patient went out of bed for mobilization 8 hours after surgery and was discharged on the fifth postoperative day. CONCLUSION: Single-incision laparoscopic procedures are available for many abdominal surgeries, whereas trials reported to perform partial hepatectomy using SILS are fewer. Therefore, our success in the case of partial hepatectomy by SILS provides another optional approach to liver surgeries.

[Percutaneous transhepatic biliary radiofrequency and endoprothesis: a new therapy for malignant biliary obstruction].

OBJECTIVE: To explore a new approach to the management of malignant biliary obstruction using percutaneous transhepatic biliary radiofrequency and endoprothesis. METHODS: Percutaneous transhepatic biliary radiofrequency and endoprothesis were performed in 2 cases of malignant biliary obstruction, including 1 of hilar cholangiocarcinoma and 1 of pancreatic head carcinoma. The tumor was ablated with radiofrequency followed by placement of matched metal stents into the biliary duct. RESULTS: The surgical procedures were carried out smoothly in the 2 cases. The symptoms of the patients were obviously improved after the operation with a significant decrease in the serum levels of total bilirubin, and CA-199 level decreased to the normal level in 1 case. CONCLUSIONS: This new approach is safe for management of malignant biliary obstruction. Compared with the more conventional interventional therapy, radiofrequency can reduce the intraoperative bleeding and arrest the local tumor growth to promote the patency of the stent as well as the postoperative survival of the patients.

[Effect of recipient derived bone marrow stromal cells on immunological rejection in mouse allogeneic skin transplantation].

OBJECTIVE: To investigate the effect of recipient derived bone marrow stromal cells (BMSCs) on immunological rejection in mouse allogeneic skin transplantation. METHODS: The C57BL/6 to BALB/c allogeneic skin transplantation model was created. The bone marrow stromal cells (BMSCs) were isolated from BALB/c by gradient density centrifugation and adhesion separation. The BMSCs were injected back through tail vein. The mouse were divided into three groups as group A (BALB/c + BMSCs), group B (BALB/c with skin transplantation), and group C (BALB/c with skin transplantation + BMSCs). The pathologic examination of the graft was performed and the cytokines such as IL-2, IFN-gamma were detected at the different time. RESULTS: The attained BMSCs in the experiment had the characteristics of BMSCs. The acute immunological rejection reaction detected by immunohistochemistry staining was alleviated noticeably in group C than that in group B. The concentrations of cytokines IL-2, IFN-gamma in group B were lower than that in group C at 7 d (F = 248,954.6, P < 0.05; F = 148,311.7, P < 0.05) and 14 d (F = 117,372.3, P < 0.05; F = 126,743.3, P < 0.05) after skin transplantation. CONCLUSIONS: Recipient derived BMSCs transfusion can alleviate the acute immunological rejection after allogeneic skin transplantation. The possible mechanism maybe related to the inhibitory effect on the secretion of cytokines like IL-2, IFN-gamma.

[Multipotent adult progenitor cells from human bone marrow differentiate into hepatocyte-like cells induced by co-culture with human hepatocyte line].

OBJECTIVE: To investigate the possibility of multipotent adult progenitor cells from human bone marrow ZHJ-MAPC to differentiate into hepatocytes by co-culture with human hepatocyte line L02 in vitro. METHODS: (1) Multipotent adult progenitor cells from human bone marrow, screened in Zhujiang hospital, named ZHJ-MAPC, were divided into 2 parts. Some ZHJ-MAPCs undergo co-culture with human hepatocytes of the line L-02 in the manner without cell to cell contact. On the days 1, 3, 5, and 7 immunocytochemistry was used to detect the expression of albumin (ALP), alpha-fetoprotein (AFP), cytokeratin (CK)-18, and CK-19, characteristic of hepatocyte. Some ZHJ-MAPC were labeled with Certified Functional Safety Expert (CFSE), a fluorescent reagent, and were mixed with L02 cells so as to undergo co-culture in the manner with cell to cell contact. Then the mixed cells were seeded on specialized dish for detection by Laser Scanning Confocal Microscope (LSCM). 5 days later, the cells were double stained with SABC-Cy3. The expression of ALP, AFP, and CK-18 in the ZHJ-MAPC were observed under LSCM. Separately cultured L02 hepatocytes served as positive control s and separately cultured ZHJ-MAPC served as negative controls. RESULTS: (1) Results of co-culture without cell to cell contact. On the first day, the ZHJ-MAPC expressed high level of AFP and then the AFP expression tapered daily. The expression of ALP was very weak on day 1 and then increased and peaked on day 5. The expression of CK-18 began to appear on day 5 and peaked on day 7. The expression of CK-19 was always negative. (2) Results of co-culture with cell to cell contact. On day 5 there were three colors of fluorescence under LSCM. Yellow cells represented the ZHJ-MAPC differentiating into hepatocytes; the green cells were undifferentiating ZHJ-MAPC; and the red cells were L02 hepatocytes. The result showed that ALP and CK-18 were expressed in many ZHJ-MAPC; AFP appeared only in a few cells. CONCLUSION: ZHJ-MAPC can be induced to differentiate into mature hepatocyte-like cells by co-culture, either with or without cell to cell contact.

Dynamic changes of matrix metalloproteinases in rat liver during the development of diethylnitrosamine-induced hepatocarcinoma.

OBJECTIVE: To study the dynamic changes of matrix metalloproteinases (MMPs) in the liver of rat during experimental hepatocarcinogenesis. METHODS: Immunohistochemistry, gelatin zymography, and reverse transcriptase-PCR were used for detection of latent and active forms and mRNA of MMPs in each phases of carcinogenic stages. RESULTS: MMPs expression was detected in normal and cirrhotic liver, which was most obvious in the cancer cells after the development of hepatic carcinoma. Normal tissue showed only low levels of MMPs expression, which kept increasing in the course of hepatocarcinogenesis, as was also the case with the corresponding mRNA. CONCLUSION: Transcription and expression of MMPs keep increasing throughout the the process of hepatocarcinogenesis.