Radiofrequency ablation versus transarterial chemoembolization for unresectable solitary hepatocellular carcinomas sized 5-8 cm.

OBJECTIVES: This retrospective review was conducted to compare the efficacy of radiofrequency ablation (RFA) with that of transarterial chemoembolization (TACE) in treating large (5-8 cm) unresectable solitary hepatocellular carcinomas (HCCs). METHODS: Patients with large unresectable solitary HCCs primarily treated by RFA or TACE were reviewed. The primary endpoint was overall survival. Secondary endpoints were tumour response, time to disease progression, and treatment-related morbidity and mortality. RESULTS: There were 15 patients in the RFA group. Of these, 12 achieved complete ablation, one had ablation site recurrence, and five developed complications. Median disease-free survival in this group was 13.0 months (range: 2.8-38.0 months). The TACE group included 26 patients, of whom four obtained a partial response, none achieved a complete response, and five developed complications. The median time to disease progression in this group was 8.0 months (range: 1.0-68.0 months). There were no hospital deaths in this series. Median survival was 39.8 months in the RFA group and 19.8 months in the TACE group (P = 0.257). Rates of 1-, 2- and 5-year survival were 93.3%, 86.2% and 20.9%, respectively, in the RFA group and 73.1%, 40.6% and 18.3%, respectively, in the TACE group. CONCLUSIONS: Both RFA and TACE are feasible treatments for large unresectable solitary HCCs. Both modes show comparable rates of complications and longterm survival, but RFA achieves better initial tumour control and results in better short-term survival.

Improved anterior hepatic transection for isolated hepatocellular carcinoma in the caudate.

BACKGROUND: One of the best treatments for isolated hepatocellular carcinoma in the caudate lobe is major hepatectomy with caudate lobectomy, but it is not suitable for patients with poor liver function reserve. Isolated caudate lobectomy, which is a very difficult operation, is thus an alternative option. METHODS: Here we report an isolated caudate lobectomy with an anterior approach in the treatment of a large hepatocellular carcinoma with underlying cirrhosis, with focus on the technical aspects. RESULTS: In the operation, both the left and right lobes of the liver were mobilized. Hepatotomy was done along the round ligament where parenchymal transection was minimal. After exposure of the left and middle hepatic veins and the hilar plate, the caudate lobe and the tumor were resected en bloc with a 5-mm margin. CONCLUSION: Isolated caudate lobectomy can be performed safely with this anterior approach on patients with poor liver function reserve.

Surgical management of recurrent pyogenic cholangitis: 10 years of experience in a tertiary referral centre in Hong Kong.

BACKGROUND: Recurrent pyogenic cholangitis (RPC) is common in Asia. Its management differs from centre to centre. METHODS: A retrospective review of 80 patients undergoing surgery for RPC was performed. Immediate and longterm outcomes were analysed. RESULTS: All patients underwent hepaticocutaneousjejunostomy (HCJ) for biliary drainage and stone removal. Additional hepatectomy was performed in 38 patients with intrahepatic ductal stricture or liver segmental atrophy. Twenty-three patients had residual stones and 25 had recurrent stones. All patients with residual stones underwent repeated choledochoscopy (median: four sessions) for stone removal and obtained confirmation of ductal clearance. Four patients developed cholangiocarcinoma, of which two died. The complication rate was 17.5%. Most of the complications were wound infections. No mortality related to surgery occurred. Multivariate analysis found that gender, disease extent (unilobar versus bilobar) and surgery type (HCJ alone versus HCJ with hepatectomy) were not associated with increased risk for residual or recurrent stones. A raised preoperative bilirubin level was the only risk factor identified as associated with an increased risk for recurrent stones (P < 0.001); it was not associated with an increased risk for residual stones. CONCLUSIONS: Recurrent pyogenic cholangitis is a distinct disease, the management of which requires a high level of surgical expertise. Hepaticojejunostomy is recommended as the primary drainage procedure, but hepatectomy should be reserved for complicated RPC.

Long-term survival analysis of pure laparoscopic versus open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a single-center experience.

INTRODUCTION: Laparoscopic liver resection has been reported as a safe and effective approach to the management of liver cancer. However, studies of long-term outcomes regarding tumor recurrence and patient survival in comparison with the conventional open approach are limited. The aim of this study was to analyze the survival outcome of laparoscopic liver resection versus open liver resection. PATIENTS AND METHODS: Between October 2002 and September 2009, 32 patients underwent pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Case-matched control patients (n = 64) who received open liver resection for HCC were included for comparison. Patients were matched in terms of cancer stage, tumor size, location of tumor, and magnitude of resection. Immediate operation outcomes, operation morbidity, disease-free survival, and overall survival were compared between groups. RESULTS: With the laparoscopic group compared with the open resection group, operation time was 232.5 minutes versus 204.5 minutes (P = 0.938), blood loss was 150 mL versus 300 mL (P = 0.001), hospital stay was 4 days versus 7 days (P < 0.0001), postoperative complication was 2 (6.3%) versus 12 (18.8%) (P = 0.184), disease-free survival was 78.5 months versus 29 months (P = 0.086), and overall survival was 92 months versus 71 months (P = 0.142). The disease-free survival for stage II HCC was 22.1 months versus 12.4 months (P = 0.075). CONCLUSIONS: Laparoscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.

Outcome of laparoscopic versus open hepatectomy for colorectal liver metastases.

BACKGROUND: Liver resection provides one of the best oncological outcomes for liver metastases in patients with colorectal cancer. However, long-term results concerning laparoscopic resection versus open hepatectomy for stage IV colon cancer are still limited. The aim of this study is to compare the survival outcome of laparoscopic liver resection with open liver resection for colorectal metastases. METHOD: Between October 2002 and September 2011, a total of 1697 patients underwent liver resection for liver tumour and 60 patients underwent pure laparoscopic liver resection. Twenty patients had laparoscopic resection for colorectal liver metastases. Case-matched control patients who received open liver resection were included for comparison. The immediate operative outcomes and survival outcomes including operation morbidity were compared. RESULTS: Twenty patients underwent laparoscopic resection of liver metastases. Forty patients who had open hepatectomy for colorectal metastases were selected as case control. Comparing the laparoscopic group with the open resection group, the median operating time was 180 min versus 210 min P = 0.059, the median blood loss was 200 versus 310 mL (P = 0.043). Hospital stay was 4.5 versus 7 days (P = 0.021), disease-free survival was 9.8 versus 10.9 months (P = 0.299), and the median survival was 69.4 versus 42.1 months (P = 0.235). CONCLUSIONS: Laparoscopic liver resection is a safe and effective treatment for liver metastases in patients with colorectal cancer. It is associated with less blood loss and shorter hospital stay when compared with open surgery. Long-term survival is comparable to the conventional open approach.

Impact of antiviral therapy on the survival of patients after major hepatectomy for hepatitis B virus-related hepatocellular carcinoma.

OBJECTIVES: To assess whether commencement of antiviral therapy after hepatectomy improves the prognosis of hepatocellular carcinoma (HCC) in preoperatively antiviral-naive patients with chronic hepatitis B virus (HBV) infection. DESIGN: Retrospective analysis of a prospectively collected database. SETTING: University teaching hospital. MAIN OUTCOME MEASURES: Disease-free and overall survival rates. RESULTS: One hundred thirty-six patients received major hepatectomy for HBV-related HCC from September 1, 2003, through December 31, 2007. Among them, 42 patients received antiviral therapy (treatment group) after hepatectomy, whereas 94 did not (control group). Patient demographics, preoperative liver function, tumor characteristics, and liver function at the time of tumor recurrence were comparable between the 2 groups. Disease-free and overall survival rates were significantly prolonged in the treatment group. The 1-, 3-, and 5-year overall survival rates in the treatment group were 88.1%, 79.1%, and 71.2%, respectively; in the control group, 76.5%, 47.5%, and 43.5%, respectively (P = .005). The 1-, 3-, and 5-year disease-free survival rates in the treatment group were 66.5%, 51.4%, and 51.4%, respectively; in the control group, 48.9%, 33.8%, and 33.8%, respectively (P = .05). Subgroup analysis stratified against tumor stage and major vascular invasion showed that posthepatectomy antiviral treatment conferred a significant survival benefit in stages I and II tumors or HCCs without major venous invasion. CONCLUSIONS: Antiviral therapy improves the prognosis of HBV-related HCC. It should be considered after hepatectomy for HBV-related HCC, especially in early-stage tumors.

Continuous improvement of survival outcomes of resection of hepatocellular carcinoma: a 20-year experience.

OBJECTIVE: To investigate the trend of the posthepatectomy survival outcomes of hepatocellular carcinoma (HCC) patients by analysis of a prospective cohort of 1198 patients over a 20-year period. BACKGROUND: The hospital mortality rate of hepatectomy for HCC has improved but the long-term survival rate remains unsatisfactory. We reported an improvement of survival results 10 years ago. It was not known whether there has been further improvement of results in recent years. METHODS: The patients were categorized into two 10-year periods: period 1, before 1999 (group 1, n = 390) and period 2, after 1999 (group 2, n = 808). Patients in group 2 were managed according to a modified protocol and technique established in previous years. RESULTS: The patients in group 2 were older and had a higher incidence of comorbid illness and cirrhosis. They had a lower hospital mortality rate (3.1% vs 6.2%, P = 0.012) and longer 5-year overall survival (54.8% vs 42.1%, P < 0.001) and disease-free survival rates (34.8% vs 24%, P = 0.0024). An improvement in the overall survival rate was observed in patients with cirrhosis, those undergoing major hepatectomy, and those with tumors of tumor-node-metastasis stages II, IIIA, and IVA. A significant increase in the survival rates was also seen in patients whose tumors were considered transplantable by the Milan criteria (72.5% vs 62.7%, P = 0.0237). Multivariate analysis showed a significantly more favorable patient survival for hepatectomy in period 2. CONCLUSIONS: A continuous improvement of survival outcomes after hepatectomy for HCC was achieved in the past 20 years even in patients with advanced diseases. Hepatectomy remains the treatment of choice for resectable HCC in a predominantly hepatitis B virus-based Asian population.

Outcome of severely injured trauma patients at a designated trauma centre in the Hong Kong Special Administrative Region.

BACKGROUND: The Hong Kong Special Administrative Region (HKSAR) of the People's Republic of China (PRC) has seen significant changes in its trauma service over the last ten years including the implementation of a regional trauma system. The author's institution is one of the five trauma centres designated in 2003. This article reports our initial clinical experience. METHODS: A prospective single-centre trauma registry from January 2004 to December 2008 was reviewed. The primary clinical outcome measure was hospital mortality. The Trauma and Injury Severity Score (TRISS) methodology was used for bench-marking with the North America Major Trauma Outcome Study (MTOS) database. RESULTS: There were 1451 patients. The majority (83.9%) suffered from blunt injury. The overall mortality rate was 7.8%. Severe injury, defined as the Injury Severity Score > 15, occurred in 22.5% of patients, and was associated with a mortality rate of 31.6%. A trend of progressive improvement was noted. The M-statistic was 0.99, indicating comparable case-mix with the MTOS. The Z- and W-statistics of each individual year revealed fewer, but not significantly so, number of survivors than expected. CONCLUSIONS: Trauma centre designation was feasible in the HKSAR and was associated with a gradual improvement in patient care. Trauma system implementation may be considered in regions equipped with the necessary socio-economic and organizational set-up.

Results of percutaneous transhepatic cholecystostomy for high surgical risk patients with acute cholecystitis.

AIM: To assess the efficacy and safety of percutaneous transhepatic cholecystostomy (PTC) in treatment for acute cholecystitis in high surgical risk patients. PATIENTS AND METHODS: A retrospective review was carried out from January 1999 to June 2007 on 23 patients, 11 males and 12 females, who underwent PTC for the management of acute cholecystitis at the Department of Surgery, Queen Mary Hospital, Hong Kong, China. The mean age of the patients was 83. They all had either clinical or radiological evidence of acute cholecystitis and had significant pre-morbid diseases. The median follow-up period on them was 35 months. RESULTS: All the PTCs performed were technically successful. One patient died from procedure-related haemoperitoneum, while 87% (n = 20) of all the patients had clinical resolution of sepsis by 20 h after PTC. Eight patients underwent elective cholecystectomy afterwards (62.5% with the laparoscopic approach). Eight patients had dislodgement of the PTC catheter and one of them developed recurrent acute cholecystitis 3 months after PTC. That patient was treated conservatively. Four patients died from their pre-morbid conditions during the follow-up period. CONCLUSION: PTC was a safe and effective alternative for treating acute cholecystitis in this group of patients. Thirteen of them without elective cholecystectomy performed did not have recurrent acute cholecystitis after a single session of PTC. It may be considered as a definitive treatment for this group of patients.

Diffuse large B-cell lymphoma associated with chronic inflammation as an incidental finding and new clinical scenarios.

Diffuse large B-cell lymphoma that develops in the setting of long-standing chronic inflammation is typically associated with Epstein-Barr virus, and usually presents as tumor mass involving body cavities, as in pyothorax-associated lymphoma. It is listed as a distinct entity in the latest World Health Organization lymphoma classification. We report four cases that were incidentally discovered on histologic examination, one each in a splenic false cyst, a long-standing hydrocele, an atrial myxoma, and metallic-implant wear debris. Microscopic foci of atypical (neoplastic) large lymphoid cells were found within the contents of the cysts or curettage material, or within the stroma of the atrial myxoma. Despite the diverse clinical scenarios, all cases showed a homogeneous phenotype: positivity for B-lineage markers (CD20+, CD79a+, PAX5+), non-germinal center immunophenotype (CD10-, BCL6-/+, MUM-1+), and positivity for Epstein-Barr virus with type III latency (LMP1+, EBNA2+). The last feature supports the hypothesis that the lymphoma has arisen in a setting of 'local immunodeficiency' as a result of long-standing chronic inflammation in an enclosed space, a characteristic pathogenetic mechanism of diffuse large B-cell lymphoma associated with chronic inflammation. These cases therefore expand the spectrum of this entity to include new clinical scenarios for the development of this lymphoma type.

An update on long-term outcome of curative hepatic resection for hepatocholangiocarcinoma.

BACKGROUND: Hepatocholangiocarcinoma (HCC-CC) is a rare primary liver cancer. Its long-term prognosis is still not well-defined. Results from the Eastern and Western literature have been conflicting and no conclusions can be drawn. The aim of the present study was to review the long-term outcome of curative hepatectomy for HCC-CC. PATIENTS AND METHODS: Prospectively collected data from December 1991 to 2006 recording patients with primary liver cancer receiving curative hepatectomy were reviewed. Twenty-five patients, 16 men and 9 women with a median age of 48 years, all ethnic Chinese, had HCC-CC. Their long-term outcome of resection was analyzed and compared to that of patients with cholangiocarcinoma (CC) or hepatocellular carcinoma (HCC). RESULTS: The HCC-CC patients had a median tumor size of 7.5 cm. Five of them developed postoperative complications. The median follow-up period was 25 months. All of the patients developed recurrence. The median overall survival was 25.2 months. The HCC-CC and CC groups had significantly worse overall survival than the HCC group (HCC versus HCC-CC, p = 0.012; HCC versus CC, p = 0.001) whereas between them there was no significant difference (p = 0.822). As for disease-free survival, there was no significant difference between the three groups; the median disease-free survival for HCC-CC patients was 13.5 months; that for CC patients, 16.1 months; and that for HCC patients, 19.0 months. All HCC-CC patients died within 120 months of primary surgery. CONCLUSIONS: Hepatocholangiocarcinoma entails poor long-term outcome after potentially curative hepatectomy. Other modalities of treatment should be explored in order to prolong survival of patients with this disease.

External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial.

OBJECTIVE: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy. External drainage of pancreatic duct with a stent has been shown to reduce pancreatic fistula rate of pancreaticojejunostomy in a few retrospective or prospective nonrandomized studies, but no randomized controlled trial has been reported thus far. This single-center prospective randomized trial compared the results of pancreaticoduodenectomy with external drainage stent versus no stent for pancreaticojejunal anastomosis. METHODS: A total of 120 patients undergoing pancreaticoduodenectomy with end-to-side pancreaticojejunal anastomosis were randomized to have either an external stent inserted across the anastomosis to drain the pancreatic duct (n = 60) or no stent (n = 60). Duct-to-mucosa anastomosis was performed in all cases. RESULTS: The 2 groups were comparable in demographic data, underlying pathologies, pancreatic consistency, and duct diameter. Stented group had a significantly lower pancreatic fistula rate compared with nonstented group (6.7% vs. 20%, P = 0.032). Radiologic or surgical intervention for pancreatic fistula was required in 1 patient in the stented group and 4 patients in the nonstented group. There were no significant differences in overall morbidity (31.7% vs. 38.3%, P = 0.444) and hospital mortality (1.7% vs. 5%, P = 0.309). Two patients in the nonstented group and none in the stented group died of pancreatic fistula. Hospital stay was significantly shorter in the stented group (mean 17 vs. 23 days, P = 0.039). On multivariate analysis, no stenting and pancreatic duct diameter <3 mm were significant risk factors of pancreatic fistula. CONCLUSION: External drainage of pancreatic duct with a stent reduced leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy.

Prospective randomized trial on low-pressure versus standard-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy.

Inpatient low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPLC) has been shown to have less postoperative pain (especially shoulder-tip pain). No report so far has documented the use of lower-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy (LC). A prospective randomized trial was conducted in Tung Wah Hospital, Day Surgery Centre from January 2004 to December 2004. A total of 40 patients were recruited and 20 of whom were allocated to each arm. Outcome measures included operation time, treatment-related morbidity, mortality, postoperative pain (eg, shoulder-tip pain), consumption of analgesics, and level of satisfaction. All patients in both groups could be discharged on the same day. Patients' demographics and operation time were comparable in both groups. There were no treatment-related morbidity and mortality, nor was there any significant difference in postoperative pain. Less shoulder-tip pain was observed in the LPLC group though without significant difference (5% vs. 20%; P=0.151). Three patients in the LPLC group needed higher insufflation pressure (12 mm Hg) because of inadequate exposure and adhesions, and the operations were successful in all of them. Otherwise, no conversion to open procedure was noted in both groups. The consumption of analgesics was minimal and a high level of satisfaction was achieved in both groups of patients. The present study demonstrated no difference in LPLC and standard-pressure pneumoperitoneum laparoscopic cholecystectomy in the outcomes of outpatient LC. Routine use of lower-pressure pneumoperitoneum in outpatient LC would not be recommended unless in selected straightforward cases.

Outpatient laparoscopic cholecystectomy in Hong Kong Chinese -- an outcome analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is now the procedure of choice for symptomatic gallbladder disease. Although many recent studies, mostly from abroad, report that it can be performed safely in the outpatient setting, the experience of outpatient LC in Hong Kong is still limited. This retrospective study evaluated the feasibility, safety and patient acceptance of outpatient LC in Hong Kong Chinese patients. PATIENTS AND METHODS: The data of 73 consecutive patients who had undergone outpatient LC between February 2000 and October 2002 in the Day Surgery Centre of Tung Wah Hospital were prospectively collected and reviewed. The selection criteria for patients undergoing outpatient LC included American Society of Anesthesiologists risk classification I or II, age less than 70 years, and the availability of a competent adult to accompany the patient home and look after them for 24 hours. No effort was made to exclude complicated cases. After assessment by the operating surgeon, patients were discharged from the Day Surgery Centre in the afternoon when their clinical condition satisfied pre-defined discharge criteria. All patients were followed up in the Day Surgery Centre in the first and fourth postoperative weeks. RESULTS: The same-day discharge rate was 88% and the conversion rate was 4%. Six patients (8.2%) with uneventful LC required hospitalization after the procedure. There was no major complication and no unplanned admission. Two patients had port site wound infection requiring hospital admission at the first follow-up. Patient satisfaction was high, pain acceptance was good, and analgesic consumption was minimal. Mild fat intolerance was common in patients postoperatively (> 50%), but this had almost all resolved by postoperative week four. All patients were able to resume their usual daily activities within 2 weeks after surgery. CONCLUSIONS: LC is a safe and feasible outpatient procedure in Hong Kong, with high levels of patient satisfaction. A prospective study with a larger patient population is warranted to verify whether it should be recommended as treatment for gallstone disease in selected patients in future.

Pancreaticoduodenectomy with en bloc portal vein resection for pancreatic carcinoma with suspected portal vein involvement.

Pancreaticoduodenectomy combined with portal vein resection is increasingly accepted as a viable treatment option for pancreatic carcinoma with suspected involvement of the portal vein.However, its clinical benefit remains controversial. This study evaluated the outcomes of pancreaticoduodenectomy with portal vein resection for pancreatic carcinoma in a group of Chinese patients operated on by a specialized team in a center with a low case volume of pancreatic cancer. The perioperative and long-term outcomes of 12 patients with portal vein resection for suspected involvement of the portal vein and 38 patients who underwent pancreaticoduodenectomy without portal vein resection during the same period were compared. In the former group, eight patients underwent segmental resection, and four patients underwent wedge resection of the portal vein. There were no significant differences in operative blood loss (median 0.8 vs. 0.8 liter, p = 0.313), hospital mortality (0% vs. 2.6%, p = 1.000), or operative morbidity (41.7% vs. 42.1%, p = 0.979) between the two groups. Patients who required portal vein resection had higher frequencies of microscopic lymphatic permeation (58.3% vs. 18.4%, p = 0.023) and vascular invasion (50.0% vs. 15.8%, p = 0.025). Long-term survival was comparable between patients with portal vein resection and those without it (median 19.5 vs. 20.7 months,p = 0.769). These findings suggest that pancreaticoduodenectomy combined with portal vein resection can be performed safely by a specialized team in a center with a low case volume of pancreatic carcinoma and that it may offer survival benefit in patients with suspected portal vein involvement.

Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database.

OBJECTIVE: To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases. METHODS: Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed. RESULTS: Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of > or = 3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless, group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3% versus 67.7%, P < 0.001), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity. CONCLUSIONS: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.

Value of live donor liver transplantation experience in major hepatectomy for hepatocellular carcinoma.

BACKGROUND: Live donor liver transplantation (LDLT) mandates conversance in liver anatomy and major hepatectomy. Hepatocellular carcinoma is most reliably treated by hepatectomy. HYPOTHESIS: The outcomes of major hepatectomy for hepatocellular carcinoma are influenced by the surgeon's LDLT experience. DESIGN: We collected prospective cohort study data on patient and disease characteristics. SETTING: Tertiary referral center. PATIENTS: A retrospective study was performed on 250 patients who underwent major hepatectomy for hepatocellular carcinoma from January 16, 1996, through December 28, 2001. MAIN OUTCOME MEASURES: Overall and disease-free survival and outcomes including blood loss, blood transfusion, and complications. RESULTS: The 3 liver transplantation surgeons (LTSs) performed 102 major hepatectomies; the 4 hepatobiliary and pancreatic surgeons (HBPSs), 148 major hepatectomies. Patients in both groups had similar baseline characteristics. The mean +/- SD blood loss in the LTS and HBPS groups was 1.36 +/- 1.37 and 2.21 +/- 2.40 L, respectively (P<.001). The mean +/- SD blood transfusion in the LTS and HBPS groups was 0.27 +/- 0.82 and 0.51 +/- 0.94 L, respectively (P =.001). Fewer patients in the LTS group required blood transfusion (17/102 [16.7%]; HBPS group, 57/148 [38.5%]; P<.001). We found no difference in overall and disease-free survival between the groups. The median overall survival was 55.8 months for the nontransfused group, and 34.3 months for the transfused group (P =.06). Median disease-free survival was 16.1 months for the nontransfused group compared with 12.4 months for the transfused group (P =.25). Cox regression multivariate analysis showed that transfusion, cirrhosis, and venous invasion worsened overall survival. Venous invasion, cirrhosis, and tumor size adversely affected disease-free survival. CONCLUSIONS: The LTS group lost less blood and required less blood transfusions than the HBPS group. Blood transfusion worsened overall survival. The significantly lower blood transfusion requirement of the LTS group contributes to a potential advantage in their overall survival.

Two hundred endoscopic extraperitoneal inguinal hernioplasties: cost containment by reusable instruments.

OBJECTIVE: To report our experience of 200 endoscopic totally extraperitoneal inguinal hernioplasties utilizing reusable instruments. METHODS: Between August 1999 and June 2000, 200 endoscopic totally extraperitoneal hernioplasties were performed on 163 patients. The mean age of the study population was 63 years with a male to female ratio of 157:6. Perioperative details and postoperative outcomes were prospectively evaluated and analyzed. RESULTS: A total of 196 (98%) endoscopic extraperitoneal inguinal hernioplasties were successfully performed. Conversion rates to transabdominal preperitoneal and open repairs were 1.5% (n = 3) and 0.5% (n = 1), respectively. There were no other intraoperative complications. Postoperative morbidity included retention of urine (n = 7), wound bruising (n = 2), atelectasis (n = 2) and gouty arthritis (n = 1). The mean visual analogue pain scores at rest were 2.3, 1.6 and 1.9 on postoperative days 0, 1 and 2, respectively. The mean length of hospital stay was 1.9 days. 113 patients (69%) returned to normal activities within one week. Of the 35 patients who experienced both open and laparoscopic repair, 80% expressed preference for endoscopic hernioplasty in the event of future recurrence. CONCLUSIONS: Endoscopic extraperitoneal inguinal hernioplasty can be safely performed utilizing reusable trocars. Substantial reduction of operative cost could be achieved by the elimination of disposable instruments. Deficiencies of the reusable metallic trocar, namely peri-cannula air-leak and sliding movements of the trocar, can be overcome by purse-string suture of the fascial opening.