A novel approach with holmium laser ablation for endoscopic management of intrahepatic biliary stricture.

BACKGROUND: Hepatolithiasis, featuring high incidence, severe symptoms, and common recurrence, poses a heavy disease burden. Endoscopic management provides an opportunity to cure hepatolithiasis, but fails to properly resolve biliary stricture without additional interventional techniques. An innovative approach towards endoscopic management of biliary stricture is required. METHODS: Holmium laser ablation was applied to biliary strictures via endoscopic access. Patients' demographic, operative, and follow-up data after receiving holmium laser ablation were retrospectively collected for analysis. RESULTS: A total of 15 patients (4 males and 11 females) underwent stricture ablation by holmium laser via cholangioscopy. All the patients successfully received holmium laser ablation, indicating a technical success rate of 100%. No postoperative mortality or no major perioperative complication was observed. During the follow-up period, the recurrence-free rate was 73% at 2 years and 67% at 5 years. CONCLUSIONS: We successfully developed a novel technique of biliary stricture removal by cholangioscopic holmium laser ablation with satisfying clinical outcomes.

Body Mass Index Is Associated with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Prior work suggested that patients with inflammatory bowel diseases (IBD) have lower body mass index (BMI) than controls and patients with lower BMI have more serious complications. GOAL: The study was aimed to find relationship between BMI in patients with and without IBD, investigate effects of medicine therapy and disease stages on patients' BMI. METHODS: Potentially eligible studies were identified through searching PubMed, Cochrane and Embase databases. Outcome measurements of mean BMI and the number of patients from each study were pooled by a random-effect model. Publication bias test, sensitivity analysis and subgroup analysis were conducted. RESULTS: A total of 24 studies containing 1442 patients and 2059 controls were included. Main results were as follows: (1) BMI in Crohn's disease (CD) patients was lower than that in health controls (-1.88, 95% CI -2.77 to -1.00, P< 0.001); (2) Medical therapy significantly improved BMI of CD patients (with therapy: -1.58, -3.33 to 0.16; without: -2.09, 95% CI -3.21 to -0.98) while on the contrary not significantly improving BMI of UC patients (with therapy: -0.24, 95% CI -3.68 to 3.20; without: -1.34, 95% CI -2.87 to 0.20, P = 0.57); (3) Both CD and UC patients in active phase showed significantly greater BMI difference compared with controls than those in remission (CD patients: remission: -2.25, 95% CI -3.38 to -1.11; active phase: -4.25, 95% CI -5.58 to -2.92, P = 0.03; UC patients: remission: 0.4, 95% CI -2.05 to 2.84; active phase: -5.38, -6.78 to -3.97, P = 0.001). CONCLUSIONS: BMI is lower in CD patients; medical therapy couldn't improve BMI of IBD patients; the state of disease affects BMI of CD patients and UC patients.

Autologous bone marrow transplantation in decompensated liver: Systematic review and meta-analysis.

AIM: To evaluate the efficacy of autologous bone marrow mononuclear cell transplantation in decompensated liver disease. METHODS: Medline, EMBASE, PubMed, Science Direct, and the Cochrane Library were searched for relevant studies. Retrospective case-control studies were included along with randomized clinical trials. Meta-analysis was performed in line with recommendations from the Cochrane Collaboration software review manager. Heterogeneity was assessed using a random-effects model. RESULTS: Four randomized controlled trials and four retrospective studies were included. Cell transplantation increased serum albumin level by 1.96 g/L (95%CI: 0.74-3.17; P = 0.002], 2.55 g/L (95%CI: 0.32-4.79; P = 0.03), and 3.65 g/L (95%CI: 0.76-6.54; P = 0.01) after 1, 3, and 6 mo, respectively. Patients who had undergone cell transplantation also had a lower level of total bilirubin [mean difference (MD): -1.37 mg/dL; 95%CI: -2.68-(-0.06); P = 0.04] after 6 mo. This decreased after 1 year when compared to standard treatment (MD: -1.26; 95%CI: -2.48-(-0.03); P = 0.04]. A temporary decrease in alanine transaminase and aspartate transaminase were significant in the cell transplantation group. However, after 6 mo treatment, patients who had undergone cell transplantation had a slightly longer prothrombin time (MD: 5.66 s, 95%CI: 0.04-11.28; P = 0.05). Changes in the model for end-stage liver disease score and Child-Pugh score were not statistically significant. CONCLUSION: Autologous bone marrow transplantation showed some benefits in patients with decompensated liver disease. However, further studies are still needed to verify its role in clinical treatment for end-stage liver disease.

Hypoxia-inducible factor 1α expression and its clinical significance in pancreatic cancer: a meta-analysis.

BACKGROUND AND AIMS: Pancreatic cancer is characterized by inadequate vascularization and considerable tumor hypoxia is prevalent. However, whether hypoxia-inducible factor 1α (HIF-1α) is significantly correlated with clinical prognosis in pancreatic cancer remains unclear. We aimed to determine the value of HIF-1α as a predictor of survival in pancreatic cancer through a meta-analysis of available cohort studies. METHODS: We performed a literature search of the MEDLINE, Embase, and Cochrane Library databases to identify cohort studies on the prognostic value of HIF-1α in pancreatic cancer. We conducted a meta-analysis to examine the clinical status and overall survival of patients with high HIF-1α expression compared to those with low expression. RESULTS: We analyzed eight studies involving 557 patients. HIF-1α was associated with higher rate of lymph node metastasis (odd ratio [OR] = 3.16; 95% confidence interval [CI] = 1.95-5.11; p < 0.05) and advanced tumor stage (OR = 3.66; 95% CI = 2.01-6.69; p < 0.05), while no significant difference was detected for tumor diameter (OR = 1.58; 95% CI = 0.46-5.47; p > 0.05). Notably, HIF-1α overexpression was significantly correlated with poor overall survival (hazard ratio [HR] = 1.88; 95% CI = 1.39-2.56; p < 0.05). CONCLUSIONS: We believe that HIF-1α overexpression is significantly associated with poor prognosis in pancreatic cancer, and may serve as an important parameter for evaluating the biological behavior and prognosis of pancreatic cancer.

Laparoscopic hepatectomy is associated with considerably less morbidity and a long-term survival similar to that of the open procedure in patients with hepatic colorectal metastases.

BACKGROUND: Laparoscopic hepatectomy (LH) provides significant promising results when compared with open hepatectomy (OH). However, the oncologic outcome of LH for hepatic colorectal metastases (HCRM) remains controversial. The purpose of this study was to review the results of LH retrospectively and to compare them with those obtained using the conventional OH procedure for HCRM patients. MATERIALS AND METHODS: Demographic details of 24 patients with pathologic determination of HCRM who underwent LH were reviewed retrospectively and weighed against the 25 HCRM patients chosen from the prospective OH database. Postsurgical benefits and 3-year outcomes of these 2 groups were compared. RESULTS: The LH had a significantly less estimated blood loss (210 vs. 380 mL; P<0.01), less analgesic requirements (20.8% vs. 50.2%; P<0.001), shorter hospital stay (7.4 vs. 11.4 d; P<0.0001), and less postoperative complication rates (25% vs. 48%; P=0.02) compared with the OH approach. The operative time, positive surgical margin, and postoperative liver function changes were similar in the 2 groups. There were no significant differences between the 2 groups in tumor recurrence and the 3-year overall survival rate (24% vs. 30%; P=0.83), respectively. CONCLUSIONS: LH is a practicable replacement for OH with probable advantages within the short-term outcomes for elected HCRM patients. Nevertheless, it remains an approach in advancement; in addition, randomized controlled trails and prolonged follow-up are necessary to verify its oncologic benefits and long-term survival.

Portal vein arterialization as a bridge procedure against acute liver failure after extended hepatectomy for hilar cholangiocarcinoma.

BACKGROUND: Acute liver failure (ALF) is a severe and highly fatal complication arising after extended hepatobiliary surgery. The aim of this study was to investigate the primary management experience of portal vein arterialization (PVA) as a bridge procedure to reduce the risk of ALF for hilar cholangiocarcinoma (HCCA) after extended hepatectomy. METHOD: Between January 2010 and January 2012, 4 patients with HCCA with possible involvement of the right and/or left hepatic artery underwent resectional surgery with reconstruction of the right or left artery blood flow by arterializations of portal vein. RESULTS: The arteries used for this surgical procedure included gastroduodenal artery (n = 2), common hepatic artery (n = 1), and right gastroepiploic artery (n = 1). PVA was verified as a key point during the course of the disorder between surgery and postoperative recovery. During follow-up, 1 patient suffered secondary portal hypertension and was subsequently cured by interventional artery coil embolization. CONCLUSION: PVA can be indicated where there is arterial involvement in HCCA patients who have undergone extended hepatectomy or trisectionectomy.

Laparoscopic hepatectomy for hepatic colorectal metastases -- a retrospective comparative cohort analysis and literature review.

BACKGROUND: Laparoscopic hepatectomy (LH) for management of hepatic colorectal metastases (HCRM) is commonly being performed; however, there are limited reports comparing LH outcomes with those of open hepatectomy (OH) procedure. The aim of the present study was to compare perioperative outcomes between the LH and OH procedures performed at a single medical center. METHODS: From Jan 2008 to May 2012, 30 patients with pathologically confirmed HCRM underwent LH, and 140 patients underwent OH at our hospital. Patients' demographics, perioperative outcomes were retrospectively analyzed. RESULTS: 2 patients (6.7%) in the LH group underwent laparotomies for intraoperative hemorrhage. The LH group had an increased surgical duration (235 min vs. 365 min, (P<0.001), shorter hospital stay (7.5 days vs. 11.5 days, P<0.001), and fewer complications (26.2% vs. 55%, P<0.001) than the OH group. However, in a matched cohort comparison of 30 LH cases and 30 OH cases, no significant variations were observed in the following parameters: surgical duration (235 min vs. 255 min, P = 0.23), positive margin rates (6.7% vs. 0.0%, P = 0.27), or postoperative hematological changes. LH patients had less estimated blood loss (215 ml vs. 385 ml, P<0.001), less morbidity (26.2% vs. 50%, P = 0.02), shorter hospital stay (7.5 days vs. 11.5 days, P<0.001), and lower analgesic requests than with those in the OH group. CONCLUSIONS: LH for metastatic colorectal cancer is a safe and feasible treatment, even in patients who underwent prior laparotomy surgeries and provides significantly less morbidity and shorter hospital stay than OH, without compromising curability or increasing morbidity.

Laparoscopy versus open distal gastrectomy for advanced gastric cancer: a systematic review and meta-analysis.

BACKGROUND: Laparoscopy-assisted distal gastrectomy (LADG) is one of the most accepted laparoscopic procedures in the field of gastric surgery. However, currently this procedure for the advanced gastric cancer (AGC) has still not reached the area of the popularization. The aim of this study was to compare laparoscopy with open distal gastrectomy in AGC patients using the meta-analytical techniques. METHODS: The Medline Ovid, PubMed, Cochrane Library, and the Controlled Trials Registry were electronically searched. Randomized controlled trails and retrospective case-control studies, which were published between 2001 and 2011 on the management of AGC were collected on the basis of the predetermined eligibility criteria to establish a literature database. Meta-analysis was performed using RevMan 5.0 software (Cochrane Library). RESULTS: There were no randomized controlled trails available online; 7 case-control studies involving 1271 patients, of which 626 (49.2%) were laparoscopic and 645 (50.3%) were open procedures, were included in final pooled analysis. Meta-analysis results showed that LADG patients had a longer operative time [mean difference (MD), 37.2; 95% confidence interval (CI), 19.92 to 54.72, P < 0.0001] but a less estimated blood loss (MD, 122.94; 95% CI, -171.13 to -74.75; P < 0.0001), a few analgesic requirement (MD, 1.62; 95% CI, -2.51 to -0.73; P = 0.004), and a shorter hospital stay (MD, 3; 95% CI, -3.14 to -2.26; P < 0.00001) compared with patients undergoing open distal gastrectomy. There were no significant differences between the 2 groups in number of lymph node dissections (MD, -0.73; 95% CI, -3.04 to 1.57; P = 0.53), postoperative mortality [odds ratio (OR), 0.80; 95% CI, 0.14 to 4.73; P = 0.81], overall complications (OR, 1.24; 95% CI, 0.53 to 2.91; P = 0.62), and a 3-year overall survival rate (OR, 1.21; 95% CI, 0.92 to 1.60; P = 0.18). CONCLUSIONS: The oncologic outcomes of LADG for AGC patients were comparable with open approach. Although open distal gastrectomy may be associated with shorter operative time, patients undergoing laparoscopic approach may be benefitted from a shorter hospital stay and a faster resumption without translation into an increase in both postoperative morbidity and mortality. Nevertheless, further prospective, controlled studies, and extended follow-up are needed for a more comprehensive comparison between the 2 procedures.

Laparoscopic and open splenectomy for splenomegaly secondary to liver cirrhosis: an evaluation of immunity.

OBJECTIVE: We sought to investigate the perioperative inflammatory response and immunological function of patients with portal hypertension-induced splenomegaly who underwent laparoscopic (LS) or open splenectomy (OS). METHODS: This prospective study investigated a total of 34 patients with splenomegaly due to portal hypertension who underwent either LS (n = 18) or OS (n = 16) between May 2009 and September 2010. Peripheral venous blood samples were taken from these patients prior to surgery and on postoperative days (POD) 1, 3, and 7. The perioperative clinical outcomes and immunological function results were analyzed and compared within each surgical group. RESULTS: The demographics of the two groups did not differ. The patients in the LS group experienced longer operating time, less intraoperative blood loss, earlier resumption of diet, and shorter postoperative hospital stay. Both the open and laparoscopic groups exhibited statistically significant differences in interleukin -6 and C-reactive protein levels, and total lymphocyte, CD4 T, and natural killer cell numbers on POD 1 and 3 compared with pre splenectomy. The immune responses in the LS group were significantly lower than those in the OS group. The LS group exhibited better preserved cellular immune response and faster recovery than the OS group on POD 7. CONCLUSIONS: An examination of the inflammatory reaction and cellular immune response after LS and OS demonstrated that there are significant differences in the immune responses observed in the two groups. Further human studies are required to determine the permanent effects of LS on immune function.

Long-term postoperative outcomes of hypersplenism: laparoscopic versus open splenectomy secondary to liver cirrhosis.

BACKGROUND: Hypersplenism is a common clinical manifestation in patients with liver cirrhosis. For treatment, surgeons can choose between two options: open splenectomy (OS) or laparoscopic splenectomy (LS). Although splenectomy has wide exposure and acceptance as a remedy for the patients with hypersplenism secondary to liver cirrhosis, the data are sparse with regard to its long-term outcomes, including hematologic response and liver function after the surgery. This study aimed to determine the long-term effect of OS versus LS for cirrhotic patients with hypersplenism. METHODS: Between September 2003 and June 2011, the study enrolled 63 consecutive patients with hypersplenism secondary to liver cirrhosis who were treated with LS (n = 34) or OS (n = 29). The hematologic parameters and liver function in both groups were evaluated before and after splenectomy, and a comparative study of the long-term follow-up period was conducted. RESULTS: Postoperatively, 100% of the patients in both groups had a complete response in terms of platelet and leukocyte counts. No changes in liver function were noted. The LS group benefited from less intraoperative blood loss and a shorter postoperative hospital stay than the OS group experienced. The mean follow-up period was 25 months. To date, no death has been reported in either group. All the patients showed complete or partial hematologic response to splenectomy and exhibited improvement in liver function. None of the parameters differed significantly between the two groups. Portal or splenic vein thromboses were detected in three patients (2 in OS and 1 in LS), whereas esophageal variceal bleeding occurred for one patient in the LS group and one patient in the OS group. CONCLUSION: This study investigated patients with hypersplenism secondary to liver cirrhosis. The findings showed that LS can be considered a well-disposed surgical procedure with good surgical outcomes compared with OS.

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy.

BACKGROUND: Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy. METHODS: From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients' demographics, perioperative data, clinical outcome, and hematological changes were analyzed. RESULTS: Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period. CONCLUSIONS: Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.

Synchronous intraoperative radiofrequency ablation for multiple liver metastasis and resection of giant solid pseudopapillary tumors of the pancreas / 中华医学杂志(英文版)

The solid pseudopapillary tumors of the pancreas (SPTP) are rare tumors, which are commonly found in adolescent women. Radical surgical resection of the primary tumor or metastases is the standard treatment for SPTP and could achieve long-term survival. We reported a case of a 20-year-old female with multiple liver metastases of SPTP, and performed surgical resection for primary tumor 14 cm in diameter and 2 major liver metastases (both 5 cm in diameter), radiofrequency ablation (RFA) for small lesions and one major liver metastase 6 cm in diameter successfully. No evidence of recurrence in situ or in the liver was found by computed tomography (CT) scan 3 months after the operation. RFA is a safe and effective treatment for unresectable multiple liver metastases of SPTP.

Laparoscopic splenectomy for immune thrombocytopenia (ITP) patients with platelet counts lower than 1 × 109/L.

Laparoscopic splenectomy (LS) has become the gold-standard surgical intervention for the treatment of immune thrombocytopenia (ITP) and the patients who experienced medical relapse to steroid. Fewer series are available regarding LS for patients with an extremely low platelet count. The aim of this study is to investigate the feasibility and safety of laparoscopic splenectomy in the treatment of patients with a preoperative platelet count of less than 1 × 109/L. From April 2006 to Jan 2011, 10 patients were managed by laparoscopic splenectomy for idiopathic thrombocytopenia with an extremely low preoperative platelet count. Preoperative, perioperative, and postoperative medical management has been reviewed. Before laparoscopic splenectomy, all of the 10 patients had a platelet count of less than 1 × 109/L but a normal level of coagulation function. Emergency laparoscopic splenectomy was performed. The mean operating time was 157 min; the mean intraoperative blood loss was 44 mL. During the operations, transfusion was provided in two patients. No intraoperative complications ensued. The patients were followed up for a mean of 28 months and showed good recovery without any postoperative complications. Laparoscopic splenectomy is a feasible technique in the treatment of ITP patients, characterized by severe mucocutaneous bleeding, extremely low platelet count, and normal prothrombin time (PT) and activated partial thromboplastin time (APTT).

Laparoscopic fenestration vs open fenestration in patients with congenital hepatic cysts: a meta-analysis.

AIM: To determine whether the outcomes of laparoscopic fenestration (LF) were superior to open fenestration (OF) for congenital liver cysts. METHODS: Comparative studies published between January 1991 and May 2010 on Medline (Ovid), Emsco, PubMed, Science Direct; Cochrane Reviews; CNKI; Chinese Biomedical Database, VIP and other electronic databases were searched. Randomized controlled trials (RCTs) and retrospective case-control studies on the management of congenital hepatic cysts were collected according to the pre-determined eligibility criteria to establish a literature database. Retrieval was ended in May 2010. Meta-analysis was performed using RevMan 5.0 software (Cochrane library). RESULTS: Nine retrospective case-control studies involving 657 patients, comparing LF with OF were included for the final pooled analysis. The meta-analysis results showed less operative time [mean difference (MD): -28.76, 95% CI: -31.03 to 26.49, P < 0.00001]; shorter hospital stay (MD: -3.35, 95% CI: -4.46 to -2.24, P < 0.00001); less intraoperative blood loss (MD: -40.18, 95% CI: -52.54 to -27.82, P < 0.00001); earlier return to regular diet (MD: -29.19, 95% CI: -30.65 to -27.72, P < 0.00001) and activities after operation (MD: -21.85, 95% CI: -31.18 to -12.51, P < 0.0001) in LF group; there was no significant difference between the two groups in postoperative complications (odds ratio: 0.99, 95% CI: 0.41 to 2.38, P = 0.98) and cysts recurrence rates. CONCLUSION: The short-term outcomes of LF for patients with congenital hepatic cysts were superior to open approach, but its long-term outcomes should be verified by further RCTs and extended follow-up.

Hemi-portocaval shunt: a simple salvage maneuver for small-for-size graft during living donor liver transplantation: a case report / 中华医学杂志(英文版)

Since the fast expansion of living donor liver transplantation (LDLT) over last few decades, small-for-size syndrome (SFSS) has emerged as a tough problem. Herein the first case of LDLT combined hemi-portocaval shunt in the mainland of China was reported. Portal venous over perfusion was well modulated and the recipient recovered uneventfully. LDLT combined hemi-portocaval shunt was a feasible procedure for preventing SFSS in LDLT.

Surgical Management for Giant liver Hemangiomas Greater Than 20 cm in Size

BACKGROUND/AIMS: The aim of this study was to investigate the primary management experience for giant liver hemangiomas greater than 20 cm in size. METHODS: Records of patients referred for evaluation of radiologically and/or histopathologically proven giant liver hemangiomas between January 2007 and March 2010 were retrospectively analyzed. The reasons for referral, results of imaging studies, preoperative and surgical treatments, and outcome were reviewed. RESULTS: A retrospective analysis was performed for 14 patients diagnosed with a giant hemangioma on the basis of an imaging study and/or a histopathological examination. All cases were diagnosed as giant liver hemangioma with at least one lesion greater than 20 cm in size. Abdominal discomfort was the main presenting complaint for the referral in 9 patients (64.2%). Abdominal ultrasound established the diagnosis in 12 patients (85.7%). Twelve patients underwent liver resection, 2 of whom underwent staged resection. Enucleation was performed in 2 patients. Selective transcatheter arterial embolization was implemented in 9 patients. Postoperative morbidity occurred in 3 patients (21.4%). No complications related to the hemangiomas occurred during follow up. CONCLUSIONS: Liver resection is indicated for giant liver hemangiomas with abdominal discomfort, especially for lesions greater than 20 cm in size. Staged operations are performed for patients with multiple lesions. Preoperative selective transcatheter arterial embolization alleviates progressive abdominal pain.