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With the application of FOLFOX regimen (oxaliplatin, fluorouracil, and leucovorin) in hepatic arterial perfusion (HAIC), chemotherapy has shown a higher value in the comprehensive treatment of hepatocellular carcinoma. Especially in the era of integration of targeted therapy and immunotherapy, the FOLFOX-HAIC, combined with immunotherapy and targeted therapy, further improves antitumor effect. The FOLFOX systemic chemotherapy combined with immunotherapy and targeted therapy scheme explored by the authors has achieved similar effects to triple therapy. Advanced hepatocellular carcinoma exhibits systemic disease characteristics, and systemic chemotherapy combined with targeted and immunotherapy has achieved higher disease control rates in the initial exploration. The mechanism may be that systemic chemotherapy changes the overall immune micro-environment of tumors, transforming the immune microenvironment from immunosuppressive to immune supportive, thereby better enhancing the efficacy of immunotherapy. The optimal regimen of systemic chemotherapy in comprehensive treatment may be obtained from the phase 3 study and basic studies in the future, which will be more efficient, safe and economical in the treatment of advanced hepatocellular carcinoma.
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Objective:To investigate the efficacy of mFOLFOX7 regimen systemic chemo-therapy combined with camrelizumab and apatinib for hepatocellular carcinoma (HCC) with Vp4 portal vain tumor thrombus (PVTT).Methods:The single-arm, open, exploratory clinical study was conducted. The clinicopathological data of 15 HCC patients with Vp4 PVTT who were admitted to the Sun Yat-sen Memorial Hospital of Sun Yat-sen University from April 2021 to October 2023 were collected. There were 14 males and 1 female, aged 48(range, 33-67)years. All patients underwent treatment with mFOLFOX7 regimen combined with camrelizumab and apatinib. Observa-tion indicators: (1) clinical efficacy; (2) survival of patients. Measurement data with skewed distribution were represented as M(rang), and count data were described as absolute numbers or percentages. Results:(1) Clinical efficacy. All 15 patients underwent treatment with mFOLFOX7 regimen combined with camrelizumab and apatinib. According to the response evaluation criteria in solid tumors version 1.1, the ratio of objective response, ratio of complete response, ratio of partial response, ratio of disease control, median progression free survival time and median total survival time of the 15 patients were 10/15, 1/15, 9/15, 15/15, not reached and not reached. The median progression free survival time and median total survival time were both >9 months. According to the modified response evaluation criteria in solid tumors, the ratio of objective response, ratio of complete response, ratio of partial response, ratio of disease control, median progression free survival time and median total survival time of the 15 patients were 12/15, 6/15, 6/15, 15/15, not reached and not reached. The median progression free survival time and median total survival time were both >9 months. Of the 15 patients, 7 cases were successfully treated with conversion therapy with the surgical conversion rate as 7/15, and all of them achieved R 0 resection. The other 6 cases were failed in conversion therapy, and there were 2 cases still undergoing conversion therapy. Of the 7 patients with successful conver-sion therapy, 5 cases achieved complete pathological remission, 1 case achieved major pathological remission with 90% of tumor tissue necrosis, and 1 case achieved complete remission through imaging examination, but new liver lesions appeared in multiple locations during further observation which were surgically removed. Results of histopathology examination on the patient confirmed multiple liver metastases. The proportion of treatment-associated adverse reactions in 15 patients was 13/15, with 7/15 having ≥grade 3 adverse reactions, including diarrhea (3/15), neutropenia (2/15), thrombo-cytopenia (2/15), and elevated aspartate aminotransferase (2/15). One patient may experience ≥1 adverse reaction. All patients were improved after symptomatic treatment. (2) Survival of patients. All 15 patients were followed up for 13.0(range, 2.0-31.0)months. During the follow-up period, 3 patients died. One case died of upper gastrointestinal bleeding after achieving partial remission, with a survival time of 7.5 months. One case died of multiple liver metastases of tumor, with tumors accounting for over 70% volume of liver and a survival time of 9.5 months. One case with multiple liver tumors and bilateral lung metastasis died due to disease progression after achieving partial remission, with a survival time of 13.5 months. The postoperative follow-up time for 7 patients undergoing surgical treatment was 14.0(range, 2.0-25.0)months. Of the 7 patients, 1 case experien-ced tumor recurrence 20.0 months after surgery, and 6 cases had no recurrence at last time of the follow-up (3 cases completed treatment and entered follow-up observation). The longest survival time was 31.0 months. Conclusion:The mFOLFOX7 regimen systemic chemotherapy combined with camrelizumab and apatinib for HCC with Vp4 PVTT is safe and feasible.
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Due to the inherent disease characteristics and surgical difficulties, the develop-ment of minimally invasive surgery in biliary tract cancer has encountered more difficulties and controversies. As one of the representative fields of modern precise surgery and an important part of multidisciplinary therapy, the value and application of minimally invasive surgery in the treatment of biliary tract cancer need to be further elaborated and standardized. Minimally invasive surgical techniques should be explored and studied under reasonable norms and supervision. More higher level evidence-based evidences should be obtained under the premise of ensuring the ethical prin-ciple of maximum benefit to patients, and ultimately promote the overall progress in the field.
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Comprehensive treatment of biliary tract cancer has evolved rapidly, thereby improving disease control and long-term survival. The authors focus on the update of this emerging field and its impacts on surgical treatment to explore the development of surgery in the treatment of biliary tract cancer in the future. With the goal of medium- and long-term benefits, a comprehensive treat-ment based on multidisciplinary team and surgery-centered approach is recommended throughout treatment of biliary tract cancer. In the era of multidesciplinary team, surgical treatment of biliary tract cancer will develop toward precision, limited surgical scope, and minimally invasive technique.
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Anatomic resection aims to improve the surgical efficacy of hepatocellular carcinoma by systematic resection of portal territory. However, due to its deviation of traditional theory and practice, the oncology effect is questionable. Anatomic resection based on portal territory(PT-AR) is planned by the analysis of real portal vein territory, and performed complete resection of tumor-bearing portal territory by fluorescent guidance, while exposing typical inter-territory hepatic vein, so as to ensure the complete function of future liver remnant. PT-AR is based on the core theory of classical anatomic resection, which will correct the deviation of traditional theory and practice from the technical level, so as to lead a better surgical oncology outcomes for hepatocellular carcinoma.
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Objective:To investigate the clinical efficacy of laparoscopic anatomical right posterior sector combined with anterior-dorsal segment resection for hepatocellular carcinoma.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 15 patients with hepatocellular carcinoma who underwent laparoscopic anatomical right posterior sector combined with anterior-dorsal segment resection in the Sun Yat-sen Memorial Hospital of Sun Yat-sen University from September 2020 to August 2021 were collected. There were 9 males and 6 females, aged 66(range, 35?77)years. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted using outpatient examination and telephone interview to detect tumor recurrence and survival of patients in the postoperative 90 days. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:(1) Surgical situations. All the 15 patients underwent laparoscopic anatomical right posterior sector combined with anterior-dorsal segment resection successfully, without blood transfusion and conversion to laparotomy during the operation. The operation time, volume of intraoperative blood loss and occlusion time of first porta hepatis of the 15 patients were (155±17)minutes, (254±66)mL and (51±7)minutes, respectively. (2) Postoperative situations. The duration of postoperative hospital stay of the 15 patients was (7.4±2.1)days. Results of postoperative histopathological examination showed hepatocellular carcinoma and R 0 margins in all the 15 patients with a minimum distance from margin to tumor of (1.5±0.8)cm. There was none of the 15 patients transferred to intensive care unit, perioperative death or rehospitalization within 30 days after surgery. Of the 15 patients, 2 cases had postoperative complications, including 1 case with biliary fistula (grade Ⅰ of Clavien-Dindo classification) and 1 case with ascites (grade Ⅱ of Clavien-Dindo classification). Patients with complications were improved after washing and drainage, abdominal puncture and drainage. (3) Follow-up. All the 15 patients were followed up for the postoperative 90 days and none of them had tumor recurrence or death within postoperative 90 days. Conclusion:The laparoscopic anatomical right posterior sector and anterior-dorsal segment resec-tion for hepatocellular carcinoma is safe and feasible.
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Gallbladder cancer is a biliary malignant disease with difficulty in early diagnosis,high malignancy and poor prognosis.Radical resection is the most effective approach to improve the prognosis of patients.With the update of minimally invasive devices and the accumulation of surgeon experience,laparoscopic surgery has achieved satisfactory results in the treatment of malignant tumors of the digestive tract,but there is still controversy in its application in gallbladder cancer treatment,mainly due to lack of reliable evidence for improved survival outcomes.The current studies indicated that laparoscopic surgery could benefit some patients with early gallbladder cancer in perioperative period and survival.For advanced gallbladder cancer,although there is still no consensus on the resection extent,laparoscopic staging can prevent patients from unnecessary expanded resection.The minimally invasive process of radical cholecystectomy needs to be promoted through a high-quality diagnosis and treatment process.Only in this way can there be practical clinical evidence to guide the best clinical practice.
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Gallbladder cancer is a biliary malignant disease with difficulty in early diagnosis, high malignancy and poor prognosis. Radical resection is the most effective approach to improve the prognosis of patients. With the update of minimally invasive devices and the accumulation of surgeon experience, laparoscopic surgery has achieved satisfactory results in the treatment of malignant tumors of the digestive tract, but there is still controversy in its application in gallbladder cancer treatment, mainly due to lack of reliable evidence for improved survival outcomes. The current studies indicated that laparoscopic surgery could benefit some patients with early gallbladder cancer in perioperative period and survival. For advanced gallbladder cancer, although there is still no consensus on the resection extent, laparoscopic staging can prevent patients from unnecessary expanded resection. The minimally invasive process of radical cholecystectomy needs to be promoted through a high-quality diagnosis and treatment process. Only in this way can there be practical clinical evidence to guide the best clinical practice.
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Laparoscopic hepatectomy has brought new techniques and concepts to the liver surgery.Compared with the traditional laparotomic resection, the approaches of laparoscopic hepatectomy are quite different and have advantages.In this article, the characteristics, selection and application of various laparoscopic hepatectomy approaches are summarized and described.Different surgical strategies lead to different approaches, and the choice of each approach is not fixed and independent.The safety and effectiveness of laparoscopic hepatectomy can be guaranteed to the greatest extent by reasonable selection and combination of various approaches.
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Objectives@#To propose a novel clinical classification system of gallbladder cancer, and to investigate the differences of clinicopathological characteristics and prognosis based on patients who underwent radical resection with different types of gallbladder cancer.@*Methods@#The clinical data of 1 059 patients with gallbladder cancer underwent radical resection in 12 institutions in China from January 2013 to December 2017 were retrospectively collected and analyzed.There were 389 males and 670 females, aged (62.0±10.5)years(range:22-88 years).According to the location of tumor and the mode of invasion,the tumors were divided into peritoneal type, hepatic type, hepatic hilum type and mixed type, the surgical procedures were divided into regional radical resection and extended radical resection.The correlation between different types and T stage, N stage, vascular invasion, neural invasion, median survival time and surgical procedures were analyzed.Rates were compared by χ2 test, survival analysis was carried by Kaplan-Meier and Log-rank test.@*Results@#Regional radical resection was performed in 940 cases,including 81 cases in T1 stage,859 cases in T2-T4 stage,119 cases underwent extended radical resection;R0 resection was achieved in 990 cases(93.5%).The overall median survival time was 28 months.There were 81 patients in Tis-T1 stage and 978 patients in T2-T4 stage.The classification of gallbladder cancer in patients with T2-T4 stage: 345 cases(35.3%)of peritoneal type, 331 cases(33.8%) of hepatic type, 122 cases(12.5%) of hepatic hilum type and 180 cases(18.4%) of mixed type.T stage(χ2=288.60,P<0.01),N stage(χ2=68.10, P<0.01), vascular invasion(χ2=128.70, P<0.01)and neural invasion(χ2=54.30, P<0.01)were significantly correlated with the classification.The median survival time of peritoneal type,hepatic type,hepatic hilum type and mixed type was 48 months,21 months,16 months and 11 months,respectively(χ2=80.60,P<0.01).There was no significant difference in median survival time between regional radical resection and extended radical resection in the peritoneal type,hepatic type,hepatic hilum type and mixed type(all P>0.05).@*Conclusion@#With application of new clinical classification, different types of gallbladder cancer are proved to be correlated with TNM stage, malignant biological behavior and prognosis, which will facilitate us in preoperative evaluation,surgical planning and prognosis evaluation.
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Intrahepatic cholangiocarcinoma (ICC) is a primary malignant tumor derived from epithelial cell of the subbranches of the intrahepatic bile ducts,which has characteristics of atypical clinical symptom,high misdiagnosis rate and poor prognosis.Radical surgery in early stage is considered as the only effective measure to cure ICC.Nowadays,it has been a focus and still remains debatable that whether perihepatic lymph node dissection (LND) could improve the long-time survival for ICC patients in consideration of that ICC is easy to migrate via lymphatic system.Therefore,for standardization of surgical treatment of ICC and improvement of patients' survival,it is quite important to evaluate the necessity of LND in radical resection and benefits of LND in patients highly suspected lymph node metastasis or without lymph node metastasis preoperatively and intraoperatively.Based on the current situation of the global clinical research of LND in ICC,along with the clinical practice experience in authors' clinical center,this paper focused on the safety and effectiveness of LND aiming to provide some evidences for the indication of LND in ICC patients.
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The biliary tract cancer (BTC) is a kind of disease with poor prognosis.Due to the lack of typical clinical manifestations and the effective early diagnosis method,the disease is usually detected at an advanced stage and lost the opportunity of surgical therapy.While the traditional radiotherapy and chemotherapy are limited in the treatment of BTC.The immune system plays an important role in the pathogenesis of BTC.Therefore,the programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors may have great potential value in the treatment of BTC.Authors reviewed the latest literatures and tried to find the current situation and prospect of PD-1 / PD-L1 inhibitors in the treatment of BTC.
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Pancreaticoduodenectomy (PD) is a standard surgical method for periampullary cancer.The hemorrhage is a dangerous complication after PD,how to effectively prevent and treat hemorrhage is a difficult point of pancreatic surgery,and also a key for reducing postoperative mortality.Four famous experts and their teams in surgical fiell explored prevention and treatment of the hemorrhage after PD from different angles based on clinical experiences.Professor Shen Boyong has conducted a discussion on early and Date hemorrhage after PD combined with previous successful experiences and prospective research data.Professor Chen Yajin suggested preventing hemorrhage in the aspects of anatomical resection,anastomosis and reconstruction,peritoneal drainage-tube placement and postoperative management based on different causes of hemorrhage.Professor Peng Bing paid attention to hemorrhage after laparoscopic PD,and supposed that intraoperative careful hemostasis,precise anastomosis,reasonable peritoneal drainage-tube placement and optimal perioperative management can reduce incidences of postoperative pancreatic fistula,biliary fistula and intra-abdominal infection,thereby lowering the incidence of hemorrhage.Professor Tan Guang respectively proposed processing strategies of hemorrhagc for grading A (mild at early stage),B (severe at early stage and mild at late stage) and C (severe at late stage).
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Compared with the regeneration ability of normal liver,that of liver with cirrhosis is so weak that its reserve function is insufficient,resulting in a great increase of chance of liver failure after partial hepatectomy,and limiting the development of major hepatectomy.It has been demonstrated that the hepatocytes of cirrhosis still possess the suppressed ability of regeneration.The morphological structures as well as physiological functions of regenerated hepatocytes are not complete.The important mechanisms leading to the impairment of regeneration ability include pathophysiologic changes such as excessive deposition of extracellular matrix and the capillarization,the imbalance of energy metabolism of hepatocytes and disruptive secretion of sinus endothelial cells and so on.The clinical observation is that many factors can stimulate the regeneration of liver with cirrhosis,including radiofrequency ablation,partial hepatectomy,associated liver partition and portal vein ligation for staged hepatectomy,splenectomy,drugs,cell transplantation,tokines et al.It is of great significance to promote the regeneration ability of liver with cirrhosis associated with various approaches reasonably for enhancing the security of partial hepatectomy and treatment of end-stage liver diseases.
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Precision medicine significantly promotes the diagnosis and treatment of various diseases,which also induces the revolution of evidence-based clinical practice guidelines,as well as multimodality therapy for hepatocellular carcinoma (HCC).In the application of the concept of precision medicine and evidence-based medicine,surgeons will concretize the precise surgery,establish an improved multimodality therapy for HCC,and ultimately achieve the goal of overall benefit.This is also a new task of surgeons in the precision medicine era.
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Objective To investigate the safety and feasibility of totally laparoscopic radical resection of gallbladder cancer.Methods The retrospective cross-sectional descriptive study was adopted.The clinical data of 30 patients who underwent laparoscopic radical resection of gallbladder cancer at the Sun Yat-sen Memorial Hospital of Sun Yat-sen University from January 2013 to August 2015 were collected.The patients received synchronous hepatic segmental or extrahepatic bile duct resection according to the conditions of patients,and choledochojejunostomy was applied to patients undergoing extrahepatic bile duct resection.The patients accepted postoperative adjuvant chemotherapy according to the results of postoperative pathological examination.Observation indicators included (1) operation situations,including surgical procedures,operation time,volume of intraoperative blood loss and number of lymph node dissected,(2) postoperative situations,including time for outoff-bed activity,time for diet intake,time of drainage tube removal,occurrence of complications and duration of hospital stay,(3) results of postoperative pathological examination,including tumor stage and surgical margin,(4) postoperative adjuvant treatment,(5) follow-up situation including the survival of patients,tumor recurrence and metastasis.The follow-up using outpatient examination and telephone interview was performed to detect the survival of patients and tumor recurrence and metastasis up to December 2015.Count data were represented as average (range).Results All the 30 patients underwent successful laparoscopic radical resection of gallbladder cancer combined with hepatic S4b and S5 resection + lymph node dissection at N1 region.Six patients with obstructive jaundice caused by tumor invaded to extrahepatic bile duct underwent combined laparoscopic extrahepatic bile duct resection + Roux-en-Y hepaticojejunostomy,without perioperative death.The average operation time,average volume of intraoperative blood loss and average number of intraoperative lymph node dissected were 238 minutes (range,178-430 minutes),250 mL (range,200-600 mL) and 7 (range,4-15),respectively.(2) The patients got out-off-bed activity and normal diet intake at postoperative day 2,with a average time of drainage tube removal of 3 days (range,0-25 days) and an average duration of hospital stay of 5 days (range,3-28 days).Two patients with complications were cured by symptomatic treatment.(3) Results of postoperative pathological examination showed that all the patients received R0 resection,and pathological stage showed that 12 patients were detected in Ⅰ B stage,10 in Ⅱ stage,7 in ⅢA stage and 1 in ⅢB stage.(4) One patient in Ⅲ B stage (pT3N1 M0 stage) received gemcitabine + cisplatin chemotherapy and other patients didn't receive the adjuvant treatment.(5) All the patients were followed up for a median time of 16 months (range,4-32 months),without tumor recurrence and metastasis at Trocar puncture site.There were 25 patients with tumor-free survival and 5 patiens died of tumor recurrence.Conclusion Laparoscopic radical resection of gallbladder cancer is technically safe and feasible,with a satisfactory short-term outcome.
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is used for patients with advanced hepatocellular carcinoma who cannot tolerate major hepatectomy due to an insufficient future liver remnant,but the morbidity and mortality rate in the perioperative period are still high.Available studies indicate that damage control surgery variations such as laparoscopic procedure and associating radiofrequency/microwave ablation/liver tourniquet and portal vein ligation could improve the morbidity and mortality associated with ALPPS,as could portal vein embolization.However,randomized controlled trials are needed to determine benefits in technical variations.
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Objective To assess the effects of limited hepatectomy on liver regeneration and function recovery of cirrhotic animal model.Methods Cirrhotic rat models were first prepared by intraperitoneal injection of CCL4.After that,the cirrhotic animal models underwent 20％ hepatectomy (n =30).The cirrhotic animals that underwent sham operation (n =30) and normal animals that underwent 20％ hepatectomy (n =30) were used as control groups.From the time when cirrhotic models were prepared to 3 months after 20％ hepatectomy,the hepatic function,coagulation function were tested regularly.Western blotting and real-time PCR were carried out to test the protein and gene expression of TGF-β,HGF and PCNA.Results Hepatic fibrosis and cirrhosis were observed during the preparation of cirrhotic rat models by intraperitoneal injection of CCL4.The hepatic function and coagulation function of cirrhotic models were partly recovered 3 month after 20％ hepatectomy.The gene and protein expression levels of TGF-β in the liver of animal model get higher during the preparation of cirrhotic rat models.However,the gene and protein expression levels of TGF-β get lower in cirrhotic model undergoing 20％ hepatectomy,when compared with that in cirrhotic animals (sham operation) and normal animals (20％ hepatectomy).Furthermore,the gene and protein expression levels of HGF and PCNA get higher in cirrhotic model undergoing 20％ hepatectomy,when compared with that in cirrhotic animals (sham operation) and normal animals (20％ hepatectomy).Conclusions Experimental limited hepatectomy facilitates the liver regeneration and function recovery of cirrhotic animal model,which may provide a novel method for the prevention and treatment of cirrhosis using limited hepatectomy technique.
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Objective To investigate the feasibility of spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy for the treatment of pancreatic cystic tumor of body and tail.Methods The clinical data of a female patient with pancreatic cystic tumor of body and tail who was admitted to the Sun Yat-Sen Memorial Hospital of the Sun Yat-Sen University in March 2013 were retrospectively analyzed.Spleen-and splenic vesselspreserving laparoscopic distal pancreatectomy was determined as the optimal therapeutic method according to the physical examination and the results of computered tomography scan.Laparoscopic or open operation combined with distal pancreatectomy and splenectomy would be carried out as a candidate choice once it is hard to separate the splenic artery and vein from distal pancreas or to control the serious vessels hemorrhage.The patient was followed up by outpatient examination every 1 to 3 months up to March 2015.Results Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy was finished successfully.The operation time and volume of intraoperative blood loss were 192 minutes and 50 mL,respectively.The patient took out-of-bed for activity at postoperative day 1 without complications.The multiple severe microcystic pancreatic adenoma was confirmed by postoperative pathological examination,with a maximum diameter of 3.5cm.The leakage tube was removed at postoperative day 5.The levels of serum amylase at postoperative day 1,3,5 were normal.The patient was discharged at postoperative day 8 and got regular follow-up without bleeding,pancreatic fistula,infection and a symptom of epigastric pain or discomfort.Conclusion Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy has advantages of less traumas,faster postoperative recovery and a preservation of normal splenic function,deserving clinical application.
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Various bile duct injuries caused bile leakage or biliary obstruction and severe secondary long-term complications which threaten patients' survival.At present, confirmative surgeries to reconstruct bile flow into gastrointestinal tract remains as a major resort to treat bile duct injury.Successful reconstruction mainly depends on experienced surgeons armed with precisely biliary surgical technology.Surgical repair should be based on cautious preoperative assessment and identification of bile duct injury.The basic principle of reconstruction includes that anastomosis is performed on the healthy bile duct with sufficient blood supply and without inflammation, ischemia and scar.The core of reconstruction includes the exposure of proximal and distal bile ducts and preparation of materials for repair and anastomosis.The definite goal of this surgery is to build up an unobstructed biliary drainage, tension-free mucosa with sufficient blood supply for mucosa anastomosis.