A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma.

BACKGROUND: The aim of this study was to compare the perioperative and long-term oncologic outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for single hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score. PATIENTS AND METHODS: Between January 2005 and February 2013, 292 patients underwent surgical resection for HCC. Of these, 202 patients who underwent surgical resection for initial treatment for a single mass were enrolled. These patients were divided into two groups according to the method of operation: the Lap group (patients who underwent LLR) and the Open group (patients who underwent OLR). To correct different demographic and clinical factors in the two groups, propensity score matching was used at a 1:1 ratio, and, finally, 102 patients were enrolled in this study, 51 patients in each group. Preoperative characteristics, perioperative results, and long-term results were retrospectively analyzed based on the prospectively recorded database. RESULTS: Preoperative baseline variables were well balanced in both groups. There were no differences of extent of surgery and rate of anatomical resection between the two groups. With the exception of a shorter postoperative hospital stay in the Lap group than that of the Open group (8.2 days versus 12.3 days; P=.004), there were no significant differences in perioperative, pathological, and long-term outcomes. The 5-year overall survival rates were 80.1% in the Lap group and 85.7% in the Open group, respectively (P=.173). The 5-year disease-free survival rates were 67.8% in the Lap group and 54.8% in the Open group, respectively (P=.519). CONCLUSIONS: LLR for HCC is safe, and long-term oncologic outcomes in selected patients were comparable to those who underwent OLR.

Benefit of systematic segmentectomy of the hepatocellular carcinoma: revisiting the dye injection method for various portal vein branches.

BACKGROUND: Systematic segmentectomy is useful in treating small hepatocellular carcinoma in the cirrhotic liver. However, accomplishment of an exact systematic segmentectomy still remains a challenging procedure because of the variable anatomy of portal branches. We evaluated the usefulness of the dye injection method for systematic segmentectomy, which focuses on the various patterns of portal vein (PV) branches feeding the tumor. METHODS: From January 2001 to May 2011, systematic segmentectomy by the dye injection method was performed in 70 patients. We evaluated the efficiency of systematic segmentectomy by ultrasonogram-guided dye injection into the portal branches that feed the tumor-bearing segments. The type of tumor-feeding PV branch, perioperative outcome, and survival rates were analyzed retrospectively. RESULTS: There were variations in the PV branches that fed the masses in 70 patients in whom the dye injection method for anatomical segmentectomy was tried. Forty masses (54.8%) were fed by a single main PV branch (type 1), 17 masses (23.3%) by a couple of PV branches (type 2), and 11 masses (15.1%) were supplied partially by single PV branch (type 3). In 5 patients (7.1%), masses were supplied by several small distributed PVs (type 4). For types 1 and 2, the tumor-bearing segments were resected anatomically with the help of staining; type 3 was partially stained and as the opposite side was not discrete, it was demarcated through counterstaining; and in type 4, dye injection could not be performed. Anatomical systematic segmentectomy was obtained in types 1 to 3; however, nonanatomical resection was inevitable for type 4. The 3- and 5-year overall survival rates were 80.5% and 67.2%, respectively, and the 3- and 5-year disease-free survival rates were 61.5% and 42.5%, respectively. The anatomical segmentectomy group showed better overall and disease-free survival than the nonanatomical group, even though it is not significant statistically. CONCLUSION: Systematic segmentectomy by the dye injection method overcomes the variation in PV tributaries in the segments and can be done according to the natural branching pattern of PVs.

Living-donor liver transplant with an interposition graft of the inferior vena cava for hepatocellular carcinoma: beyond the Milan criteria and within the UCSF criteria.

Living-donor liver transplant for a big hepatocellular carcinoma located in the caudate lobe is challenging owing to dissemination of cancer cells during recipient hepatectomy. We report a case of living-donor liver transplant using the right side of the liver of a living donor combined with inferior vena cava interposition graft after en bloc resection of the liver and retrohepatic inferior vena cava for hepatocellular carcinoma in the caudate lobe. A 50-year-old man with chronic hepatitis B cirrhosis developed hepatocellular carcinoma in the caudate lobe and segment 5. The diameters of the masses were 4.5 cm and 2.5 cm. His model for end-stage liver disease score was 17, and he had a moderate amount of ascites. For the recipient hepatectomy, en bloc resection of the entire liver, including retrohepatic inferior vena cava and reconstruction of inferior vena cava with Dacron graft, were performed. We then performed a transplant of the right lobe taken from the living donor. This technique can be a new alternative curative treatment option for hepatocellular carcinoma located on the hepatocaval confluence or close to the inferior vena cava. We should evaluate the long-term safety for cancer recurrence and infection of an artificial vascular graft in the milieu of immunosuppression after liver transplant.

An imported case of cystic echinococcosis in the liver.

A 25-year-old Uzbek male presented with right upper abdominal pain for 20 days. On radiologic studies, a huge cystic mass was noticed in the right liver which was suspected as parasitic. The patient received right hepatic segmentectomy (segment 7), and the surgically resected mass was confirmed as cystic echinococcosis (CE), measuring 10.5 cm in its diameter. The inner surface of the cyst was bile-stained. The patient was discharged on the 8th hospital day, and was rechecked 6 months after the surgical intervention without any evidence of recurrence. The present report describes findings of an imported case of CE which represented ultrasound images of the 'ball of wool'.

Inflammatory pseudotumors mimicking intrahepatic cholangiocarcinoma of the liver; IgG4-positivity and its clinical significance.

BACKGROUND: Inflammatory pseudotumor (IPT) of the liver is a benign condition with a good prognosis. However, it is difficult to distinguish clinical and radiological findings of IPT from those of malignancies. The aims of this study are to determine the clinical, radiological, and pathological characteristics, particularly relating to the role of the autoimmune mechanism in the development of inflammatory pseudotumours (IPTs) of the liver, and to suggest appropriate diagnostic and therapeutic strategy. STUDY DESIGN: The clinical, diagnostic, and pathological characteristics including IgG4 immunohistochemical stain and follow-up data of 22 IPT patients were retrospectively analyzed. RESULTS: The patients were 16 men and 6 women with a mean age of 59 years. Fifteen patients (68.2%) had associated biliary diseases. Of the 16 patients treated conservatively, the masses completely resolved in 10 patients, and reduced in size in 5 patients within the first 6 months. The remaining 6 patients were treated by surgical resection. IgG4 staining of 17 tissue samples from 22 patients were negative, most of the infiltrate being of fibrohistiocytic type, whereas 4 of 5 lymphoplasmacytic cells of dominant tumors show positive staining of IgG4. Although IgG4-related sclerosing cholangitis was mostly of lymphoplasmacytic type, other histological and clinical characteristics were similar in both types of IPTs. CONCLUSIONS: IPTs of the liver can be diagnosed based on radiological and pathological findings by needle biopsy. Although the lymphoplasmacytic type of IPTs seems to correspond to IgG4-related disease, as assessed by IgG4 immunohistochemical stain, its clinical significance is unknown. Although most IPTs can be resolved with conservative therapy, surgical resection should be considered in cases of uncertain biopsy result, presumed malignant lesion, combination with other pathology, or lack of response to conservative management.

Determination of malignant and invasive predictors in branch duct type intraductal papillary mucinous neoplasms of the pancreas: a suggested scoring formula.

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 ± 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

The impact of old age on surgical outcomes after pancreaticoduodenectomy for distal bile duct cancer.

BACKGROUNDS/AIMS: To compare surgical results and survival of two groups of patients, age ≥70 vs. age <70, who underwent pancreaticoduodenectomy and to identify the safety of this procedure for elderly patients for the treatment of distal common bile duct (CBD) cancer. METHODS: Between January 2003 and December 2009, 55 patients who underwent pancreaticoduodenectomy for the treatment of distal CBD cancer at Keimyung University Dong San Medical Center were enrolled in our study. RESULTS: Of 55 patients, 28 were male and 27 female. Nineteen were over 70 years old (older group) and 36 were below 70 years (younger group). The mean ages of the two groups of patients were 73.5 years and 60.5 years respectively. Although patients of the older group had significantly more comorbid diseases, perioperative results including operation time, amount of intraoperative bleeding, duration of postoperative hospital stay and postoperative complications were not significantly different. A higher level (more than 5 mg/dl) of preoperative initial bilirubin showed significant correlations with operative morbidity by univariate analysis, and age was not an independent risk factor of operative morbidity. Overall 5 year survival of older and younger groups were 45.9% and 39.5% respectively (p=0.671) and disease-free 5-year survival were 31.7% and 31.1%, respectively (p=0.942). CONCLUSIONS: Surgical outcomes of elderly patients were similar to those of younger patients, despite a higher incidence of comorbid disease. This results shows that pancreaticoduodenectomy can be applied safely to elderly patients.

[Risk factors for early recurrence after surgical resection for hepatocellular carcinoma].

BACKGROUND/AIMS: Early recurrence (ER) after liver resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). This study aimed to identify the factors associated with ER after curative hepatic resection for HCC. METHODS: From the July 2000 to July 2006, 144 patients underwent hepatic resection for HCC at a single institution. After excluding those with ruptured HCC, combined or mixed HCC, and who died during admission, 116 patients were analyzed. Patients with ER (defined as within 1 year) were compared with those who remained free of disease for more than 1 year. Various clinical characteristics including tumor and operative factors were evaluated to determine the factors predicting postoperative ER using univariate and multivariate analyses. RESULTS: ER occurred in 51 patients (44%). In the univariate analysis, tumor size (P=0.001), microvascular invasion (P=0.003), portal vein invasion (P=0.001), TNM stage (P=0.010), serum levels of alpha-fetoprotein (AFP) (P=0.002) and aspartate aminotransferase (AST) (P=0.011), and operative time (P=0.033) were significantly associated with ER. AFP and AST were the independent predictors of ER in the multivariate analysis (P<0.05). CONCLUSIONS: Preoperative serum AFP and AST levels were the independent risk factors for ER after surgical resection for HCC. Close postoperative surveillance is recommended for early detection of recurrence and additional treatments in patients with these factors.

Optimal cycle of intermittent portal triad clamping during liver resection in the murine liver.

We designed this experimental study to determine the optimal cycle for intermittent inflow occlusion during liver resection. A cycle of intermittent clamping (IC) for 15 minutes of ischemia followed by reperfusion for 5 minutes during liver resection is currently the most popular protocol used by experienced liver centers. As each period of reperfusion is associated with bleeding, longer periods of clamping would be advantageous. However, the longest safe duration of successive ischemia is unknown. Three groups of mice were subjected to a total liver ischemic period for 90 minutes; 2 groups underwent IC for 15 or 30 minutes, respectively, followed by 5 minutes of reperfusion, while the control group was subjected to continuous inflow occlusion only. The degree of tissue injury was assessed using biochemical and histological markers, as well as animal survival. While serious injury was observed in the continuous clamping group, both IC groups were associated with minimal injury, including lesser degrees of apoptosis and necrosis. All animals survived in the IC groups, while all animals died following 90 minutes of continuous inflow occlusion. In conclusion, intermittent portal pedicle clamping with 15- or 30-minute cycles is highly protective. A period of 30 minutes clamping should be preferred, since this would decrease the amount of blood loss associated with each cycle. This data should be confirmed in humans, and may represent a change in the current practice of hepatic surgery.

Tip for microlaparoscopic cholecystectomy: easy removal of the gallbladder after laparoscopic cholecystectomy using the three-port technique.

The standard laparoscopic cholecystectomy usually requires four trocars: two 10-mm and two 5-mm trocars. With the development of mini-instruments, laparoscopic surgeons have developed the two- or three-port techniques. The selection of the number and size of trocars depends on the surgeon's experience and preferences. Removal of the gallbladder is critical in the mini-instrument technique. To remove the gallbladder through the umbilical port, a 5-mm telescope should be inserted through one of the 5-mm ports, or one of the 5-mm trocars should be replaced with an 11-mm trocar by extending the incision. A simple and easy technique was applied to retrieve the gallbladder without changing the telescope or extending the skin incision for the trocar port to 11 mm. When the gallbladder is detached from the liver, the surgeon grasps the neck of the gallbladder via the 5-mm trocar and positions the gallbladder in the 11-mm trocar. While the surgeon keeps the gallbladder in the 11-mm trocar with the grasper held tangentially, the assistant removes the telescope and inserts a straight-toothed grasper to capture the gallbladder neck blindly. Subsequently, the removal of the gallbladder together with the trocar follows the usual technique. We have applied this technique to all our patients with limited or no inflammation of the gallbladder.