Open and/or laparoscopic one-stage resections of primary colorectal cancer and synchronous liver metastases: An observational study

One-stage resections of primary colorectal cancer and liver metastases have been reported to be feasible and safe. Minimally invasive approaches have become more common for both colorectal and hepatic surgeries. This study aimed to investigate outcomes of these combined surgical procedures among different approaches.We retrospectively analyzed patients diagnosed as having primary colorectal cancer with synchronous liver metastases and who underwent 1-stage primary resection and hepatectomy with curative intent in our hospital. According to the surgical approach for the primary tumor and hepatic lesions, namely open laparotomy (Op) or laparoscopic approach (Lap), patients were classified into Op-Op, Lap-Op (laparoscopic colorectal resection plus open hepatectomy), and Lap-Lap groups, respectively. Clinicopathological factors were reviewed, and short- and long-term outcomes were compared among the groups.The Op-Op, Lap-Op, and Lap-Lap groups comprised 36, 18, and 17 patients, respectively. The superior/posterior hepatic segments were more frequently resected via an open approach. There was no laparoscopic major hepatectomy. The median volume of intraoperative blood loss was smaller in the Lap-Lap and Lap-Op groups (290 and 270 mL) than in the Op-Op group (575 mL, P = .008). The hospital stay after surgery was shorter in the Lap-Lap and Lap-Op groups (median: 17 days and 15 days, vs 19 days for the Op-Op group, P = .033). The postoperative complication rates and survivals were similar among the groups.Application of laparoscopy to 1-stage resections of primary colorectal cancer and liver metastases may offer advantages of enhanced recovery from surgical treatment, given appropriate patient selection.     

Pure Laparoscopic Versus Open Liver Resection for Primary Liver Carcinoma in Elderly Patients: A Single-Center,Case-Matched Study

Pure laparoscopic liver resection (PLLR) has been reported to be as safe and effective as open liver resection (OLR) for liver lesions, and it is associated with less intraoperative blood loss, shorter hospital stay, and lower complication rate. However, studies comparing PLLR with OLR in elderly patients were limited. The aim of this study was to analyze the short-term outcome of PLLR versus OLR for primary liver carcinoma (PLC) in elderly patients.Between January 2008 and October 2014, 30 consecutive elderly patients (≥70 years) who underwent PLLR for PLC were included into analysis. Sixty patients who received OLR for PLC during the same study period were also included as a case-matched control group. Patients were well matched in terms of age, sex, comorbid illness, Child Pugh class, American Society of Anesthesiologists grade, tumor size, tumor location, and extent of hepatectomy.No significant differences were observed with regard to patient preoperative baseline status, median tumor size (Group PLLR 4.0 cm vs Group OLR 5.0 cm, P = 0.125), tumor location, extent of hepatectomy, and operation time (Group PLLR 133 minutes vs Group OLR 170 minutes, P = 0.073). Compared with OLR, the PLLR group displayed a significantly less frequent Pringle maneuver application (10.0% vs 70.0%, P < 0.001), less blood loss (100 vs 300 mL; P < 0.001), shorter hospital stay (5 vs 10 days; P < 0.001), and lower total hospitalization cost ($9147.50 vs $10,867.10, P = 0.008). The postoperative complication rates were similar between groups (Group PLLR 10.0% vs Group OLR 16.7%; P = 0.532). There was no hospital mortality in both groups.PLLR for PLC is as safe and feasible as OLR, but with less blood loss, shorter hospital stay, and lower hospitalization cost for selected elderly patients.     

Hepatic Resection for Hepatocellular Carcinoma in Patients With Portal Hypertension: A Long-Term Benefit Compared With Transarterial Chemoembolization and Thermal Ablation

The optimal treatment for hepatocellular carcinoma (HCC) in cirrhotic patients with portal hypertension (PHT) is still controversial. The objective of this study is to compare HCC patients with PHT treated with hepatic resection to those treated with transarterial chemoembolization (TACE) or thermal ablation.A series of 167 cirrhotic patients with HCC undergoing hepatic resection or TACE/ablation from 2001 to 2008 were retrospectively analyzed. Cirrhotic patients with HCC were divided into 3 groups: hepatic resection in HCC patients with PHT (PHT-R group, n = 58), without PHT (NPHT-R group, n = 67), and TACE or thermal ablation in HCC patients with PHT (PHT-O group, n = 42). The short-term and long-term outcomes of liver function, operative mortality and morbidity, and survival rate were compared.Baseline characteristics were similar among the 3 groups, except for patients in the PHT-R group had larger spleen (16.0 vs 11.4 cm, P = 0.001) and smaller tumor size (4.8 vs 7.1 cm, P = 0.001) in comparison with those in the NPHT-R group. The PHT-R group had better liver function compared with those in the PHT-O group (patients had Child–Turcotte–Pugh class B liver function: 5.2% vs 31%, P = 0.001). There was no significant difference of operative mortality and morbidity in all groups. The 1-, 3-, 5-year survival rates were 80.4%, 55.6%, and 28.1% in the PHT-R group; 79.1%, 64.2%, and 39.8% in the NPHT-R group (vs PHT-R, P = 0.313); and 60.7%, 24.4%, and 7.3% in the PHT-O group (vs PHT-R, P < 0.001).Hepatic resection shows better long-term results for cirrhotic HCC patients with PHT than TACE and thermal ablation.     

Immediate Postoperative Low Platelet Counts After Living Donor Liver Transplantation Predict Early Allograft Dysfunction

To investigate whether the platelets can improve liver function by mediating liver regeneration. Using a retrospective cohort with 234 consecutive adult-to-adult living donor liver transplantation recipients, we have discussed the relationship between immediate postoperative platelet count and outcome. Patients have been stratified into Low Platelet Group (106 patients) with platelet ≤68 × 10⁹/L and High Platelet Group (128 patients) with platelet >68 × 10⁹/L.Low Platelet Group has a higher rate of preoperative thrombocytopenia (90.6% vs. 32.8%, P < 0.001), higher model for end-stage liver disease score (15 vs. 11, P < 0.001), cirrhosis (86.8% vs. 76.6%, P = 0.046), hepatorenal syndrome (18.2% vs. 4.0%, P = 0.005) and fulminant hepatic failure (26.4% vs. 7.8%, P < 0.001). The packed red blood cells transfusion (7.5 vs. 5, P = 0.023) and plasma transfusion (1275 mL vs. 800 mL, P = 0.001) are more in patients with low platelet count. Low Platelet Group has a higher early allograft dysfunction (EAD) (22.6% vs. 7.0%, P = 0.001) and severe complications (22.6% vs. 10.9%, P = 0.016). The 90-day mortality between the 2 groups is similar. The multivariate analysis has found that postoperative platelet ≤68 × 10⁹/L is an independent risk factor for EAD.Platelet maybe influences the functional status of the liver by promoting graft regeneration after liver transplantation.     

Selective Inflow Occlusion Technique Versus Intermittent Pringle Maneuver in Hepatectomy for Large Hepatocellular Carcinoma: A Retrospective Study

Selective inflow occlusion (SIO) maneuver preserved inflow of nontumorous liver and was supposed to protect liver function. This study aims to evaluate whether SIO maneuver is superior to Pringle maneuver in patients undergoing partial hepatectomy with large hepatocellular carcinomas (HCCs).Between January 2008 and May 2012, 656 patients underwent large HCC resections and were divided into 2 groups: intermittent Pringle maneuver (IP) group (n = 336) and SIO group (n = 320). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.In comparison to the IP maneuver, the SIO maneuver significantly decreased intraoperative blood loss (473 vs 691 mL, P = 0.001) and transfusion rates (11.3% vs 28.6%, P = 0.006). The rate of major complication between the 2 groups was comparable (22.6% vs 18.8%, P = 0.541). Patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL in SIO group resulted in lower major complication rates.The SIO maneuver is a safe and effective technique for large HCC resections. In patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL, the SIO technique is preferentially recommended.     

Enhanced Recovery Program Versus Traditional Care in Laparoscopic Hepatectomy

Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost associated with open liver resection. However, the benefit of ERAS in patients undergoing laparoscopic liver resection is still unclear, and clinical studies on this topic are limited.The ERAS program for laparoscopic liver resection was used in a group of 80 patients (ERAS group). The results were compared with those in a control group of 107 patients. All patients underwent laparoscopic liver resection. The primary endpoints were the postoperative hospital stay, defined as the number of days from surgery to discharge, and the hospitalization expense. The secondary endpoints were resumption of oral intake, readmissions, and complications.The median postoperative hospital stay was 6.2 ± 2.6 days in the ERAS group, which was significantly shorter than that in the control group (9.9 ± 5.9 d; P < 0.001). The hospitalization cost was $6871 ± 2571 in the ERAS group and $7948 ± 3630 in the control group (P = 0.020). The morbidity rate was 22.5% (18 of 80 patients) in the ERAS group and 43.9% (47 of 107 patients) in the control group (P = 0.002). There were no significant differences the in rate of readmission between the 2 groups.Enhanced recovery after surgery for laparoscopic liver resection is safe and effective. Patients in the ERPS group had a shorter hospital stay, fewer complications, and lower hospital costs.     

Liver retraction using n-butyl-2-cyanoacrylate glue during laparoscopic cholecystectomy

There might be a thick “protrusion” in the visceral surface of hepatic quadrate lobe during the laparoscopic cholecystectomy (LC), which affects the surgical fields and consequently triggers high risks of biliary tract injury. Although n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery for liver retraction, there is still no consensus on its safety and feasibility in LC. In this study, we investigated the safety, feasibility, and effectiveness of liver retraction using NBCA glue for these patients which have the thick “protrusion” on the square leaf surface of the liver during LC.Fifty-seven patients presenting thick “protrusion” hepatic quadrate lobe were included in our retrospective study. We performed LC in the presence of NBCA glue (n = 30, NBCA group) and absence of NBCA glue (n = 27, non-NBCA group), respectively. NBCA was used to fix the thick “protrusion” of the liver leaves to the hepatic viscera surface, which contributed to the revelation of the gallbladder triangle. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the 2 groups.Both the groups’ patients accomplished the operation in the laparoscopy. There was no mortality and no additional incision during operation. No severe complications including bile duct injury were available after surgery and no postoperative NBCA-related complications occurred after 9- to 30 months’ follow-up. The time of operation in NBCA group showed significant decrease compared with that of non-NBCA group (48.33 ± 16.15 vs 65.00 ± 22.15 minutes, P < .01). There were no significant differences in blood loss, postoperative hospital stays, and the preoperative and postoperative liver function between the two groups (P > .05). Besides, no significant differences were noticed in major clinical characteristics between the 2 groups (P > .05).Liver retraction using NBCA during LC for thick “protrusion” hepatic quadrate lobe patients is safe, effective, and feasible.     

Endoscopic Versus Open Resection for Small Gastric Gastrointestinal Stromal Tumors: Safety and Outcomes

Endoscopic resection has been performed to treat small gastric neoplasms. However, this technique for small gastric gastrointestinal stromal tumors (GISTs) remains controversial. This study aims to compare the safety and surgical outcomes of endoscopic versus open resection of small gastric GISTs.The medical records of 54 consecutive gastric GISTs patients with tumor size of ≤2 cm, who were surgically treated with endoscopic resection (endoscopic group) or open surgery (laparotomy group) in a single institution from March 2010 to June 2014, were retrospectively analyzed. The clinical and tumor characteristics, surgical safety, and tumor-related outcomes were evaluated.Of 54 patients, 32 and 22 patients underwent endoscopic resection and laparotomy, respectively. Patients who underwent endoscopic resection yielded a significantly shorter hospital stay compared with patients who underwent laparotomy (P < 0.001). Compared with patients in the endoscopic group, patients in the laparotomy group had more intraoperative blood loss (P < 0.001), had longer nasogastric tube retention (P < 0.001), and required longer operative time (P < 0.001). More laparotomy patients required postoperative analgesic drugs than those in the endoscopic group (n = 9 vs 4; P = 0.016). Gastric perforation occurred in 1 case during operation in the endoscopic group. Patients who underwent these 2 procedures did not differ with respect to tumor size (P = 0.168), perioperative transfusion (P = 1.000), reoperation (P = 1.000), early satiety (P = 0.560), and postoperative bleeding (P = 1.000). With a median follow-up time of 34.5 months, 1 high-risk patient in each group experienced tumor recurrence/metastasis postoperatively.The endoscopic procedure allows safe resection with good surgical outcomes for small gastric GISTs compared with laparotomy. Moreover, larger randomized controlled trials are warranted to confirm endoscopic application for small gastric GISTs.     

Surgical Treatment of Giant Liver Hemangioma Larger Than 10?cm: A Single Center's Experience With 86 Patients

The ideal surgical treatment of giant liver hemangioma is still controversial. This study aims to compare the outcomes of enucleation with those of resection for liver hemangioma larger than 10 cm in different locations of the liver and establish the preoperative predictors of increased intraoperative blood loss.Eighty-six patients underwent enucleation or liver resection for liver hemangioma larger than 10 cm was retrospectively reviewed. Patient demographic, tumor characteristics, surgical indications, the outcomes of both surgical treatment, and the clinicopathological parameters influencing intraoperative blood loss were analyzed.Forty-six patients received enucleation and 40 patients received liver resection. Mean tumor size was 14.1 cm with a range of 10–35 cm. Blood loss, blood product usage, operative time, hepatic vascular occlusion time and frequency, complications and postsurgical hospital stay were similar between liver resections and enucleation for right-liver and left-liver hemangiomas. There was no surgery-related mortality in either group. Bleeding was more related to adjacency of major vascular structures than the size of hemangioma. Adjacency to major vascular structures and right or bilateral liver hemangiomas were independently associated with blood loss >550 mL (P = 0.000 and 0.042, respectively).Both enucleation and liver resection are safe and effective surgical treatments for liver hemangiomas larger than 10 cm. The risk of intraoperative blood loss is related to adjacency to major vascular structures and the location of hemangioma.     

The clinical profiles,management, and prognostic factors of biliary mixed neuroendocrine nonneuroendocrine neoplasms: A systematic review of the literature

Background:Mixed neuroendocrine nonneuroendocrine neoplasms (MiNENs) originating from the biliary system (gallbladder, biliary tract, or ampulla of Vater) are extremely rare and have not been discussed in detail or systematically. We aimed to present the demographics, clinicopathological characteristics, management, and prognostic factors of biliary MiNENs.Methods:A systematic search of electronic biomedical databases (Web of Science, PUBMED, and Embase) was performed to identify eligible studies. Survival was analyzed with the Kaplan–Meier method. Log-rank tests were used to evaluate the differences between groups, and the effects of various clinical and histopathological features on prognosis were analyzed by univariate and multivariate Cox regression.Results:Fifty-three publications (patients, n = 67) were included. The median overall survival time was 21.0 months. Fifty-one patients (76.1%) underwent radical surgery and median survival for 41 months (P < .001). Twenty-two patients who received adjuvant radiochemotherapy treatment after radical surgery had a median survival for 43 months (P = .076). Radical resection (P < .001), Ki-67 index (P = .011), tumor stage (P < .001), neuroendocrine (NEC) grade (P = .011), and non-NEC grade (P = .017) were independent statistically significant prognostic factors according to univariate analysis; radical resection (P = .010) and small morphological subtype (P = .036) were independent statistically significant prognostic factors associated with higher overall survival according to multivariate analysis, and radical resection (P = .005) and age < 65 years (P = .026) were associated with higher recurrence free survival time.Conclusion:Radical resection is essential for long-term survival. Aggressive multimodality therapy with adjuvant radiochemotherapy and biotherapy may improve survival of biliary MiNENs. Further randomized controlled trials are needed to determine the standard treatment.     

Reduced Red Blood Cell Count Predicts Poor Survival After Surgery in Patients With Primary Liver Cancer

Currently, the optimal therapy of primary liver cancer (PLC) remains to be hepatic resection. For better management of the patients, we evaluated the prognostic predicting value of red blood cell (RBC) count, a routine laboratory parameter, on the long-term survival of patients who underwent surgical treatment.Clinical and laboratory data of 758 patients, who underwent surgical hepatic resection, were retrospectively studied by χ² tests and logistic regression. All patients were enrolled at Henan Cancer Hospital, Zhengzhou, China, from February 2009 to July 2013, and none of them received any other treatments before surgery. Kaplan–Meier survival analysis and Cox proportional hazard models were used to examine the influence of RBC counts on patients’ survival.The Cox univariate and multivariate analyses showed that preoperative RBC count was an independent risk factor of poor prognosis after surgical treatment. The Kaplan–Meier curves showed that the overall survival (OS) of patients without reduced preoperative RBC counts was significantly better than those patients with reduced preoperative RBC counts (P < 0.001). Concordantly, compared with the patients with either reduced preoperative and/or postoperative RBC counts, patients without reduced RBC counts preferred to be low Child–Pugh grades (P = 0.0065), which implies a better hepatic function. In addition, low RBC count was found to be significantly associated with patients of female (P = 0.003), younger age (P =  < 0.001), and with higher AST/ALT ratio (P = 0.005).This study revealed that patients with preoperative RBC counts lower than normal had worse OS rates than those without reduced preoperative RBC counts, perhaps due to the significant correlation of reduced preoperative RBC count to patients’ worse Child–Pugh grade that reflect the loss of liver functions.     

Robot-assisted versus laparoscopic minor hepatectomy: A systematic review and meta-analysis

Background:Robot-assisted and laparoscopic surgery are the most minimally invasive surgical approaches for the removal of liver lesions. Minor hepatectomy is a common surgical procedure. In this study, we evaluated the advantages and disadvantages of robot-assisted vs laparoscopic minor hepatectomy (LMH).Methods:A systematic literature search was performed in PubMed, Embase, and the Cochrane Library to identify comparative studies on robot-assisted vs. laparoscopicminor hepatectomy up to February, 2020. The odds ratios (OR) and mean differences with 95% confidence intervals were calculated using the fixed-effects model or random-effects model.Results:A total of 12 studies involving 751 patients were included in the meta-analysis. Among them, 297 patients were in the robot-assisted minor hepatectomy (RMH) group and 454 patients were in the LMH group. There were no significant differences in intraoperative blood loss (P = .43), transfusion rates (P = .14), length of hospital stay (P > .64), conversion rate (P = .62), R0 resection rate (P = .56), complications (P = .92), or mortaliy (P = .37) between the 2 groups. However, the RMH group was associated with a longer operative time (P = .0003), and higher cost (P < .00001) compared to the LMH group. No significant differences in overall survival or disease free survival between the 2 groups were observed. In the subgroup analysis of left lateral sectionectomies, RMH was still associated with a longer operative time, but no other differences in clinical outcomes were observed.Conclusions:Although RMH is associated with longer operation times and higher costs, it exhibits the same safety and effectiveness as LMH. Prospective randomized controlled clinical trials should now be considered to obtain better evidence for clinical consensus.     

Radiofrequency Ablation Versus Surgical Resection for Small Unifocal Hepatocellular Carcinomas

We aimed to compare the effectiveness and safety of hepatic resection and radiofrequency ablation (RFA) for small hepatocellular carcinomas (HCCs) less than 5 cm in diameter.A total of 289 patients were diagnosed with a small HCC (a single tumor no larger than 5 cm). Among these patients, 133 underwent hepatic resection, and 156 received RFA. Demographic data, intraoperative data, post-operative recovery data, and the baseline characteristics of the 2 groups of patients were compared. The incidence of post-operative complications; 1-, 3-, and 5-year survival rates; and tumor recurrence were determined.No statistically significant differences in the baseline characteristics were noted between the 2 groups. By contrast, operation time (P = 0.003), intraoperative blood loss (P = 0.000), and the length of post-operative hospital stay (P = 0.000) were significantly lower in the RFA group compared with the surgical resection group. The 2 groups displayed similar post-operative complication rates (12% or 16/133 in the liver resection group vs. 8.3% or 13/156 in the RFA group, P = 0.395). The 1-, 3-, and 5-year overall survival rates of the patients in the liver resection group were 88.7%, 78.2%, and 66.2%, respectively, whereas the rates in the RFA group were 90.4%, 76.3%, and 66.0%, respectively (P = 0.722). The 1-, 3-, and 5-year tumor-free survival rates of patients in the resection group were 87.2%, 69.9%, and 58.6%, respectively, whereas the rates in the RFA group were 85.9%, 66.0%, and 54.5%, respectively (P = 0.327). In addition, among HCC patients receiving RFA, patients with tumors no greater than 3 cm in diameter exhibited no significant differences regarding overall survival and tumor-free survival rates compared with patients with tumors 3 to 5 cm in diameter (all P > 0.05).RFA is an effective and safe treatment option for small HCCs and may be a preferred choice for HCC patients with small lesions.     

Comparative analysis of vascular bulldog clamps used in laparoscopic liver resection

To compare the clinical effect of Bulldog clamps with traditional Pringle for vascular occlusion during laparoscopic hepatectomy.One hundred ten patients were retrospectively investigated in this research from December 2014 to January 2019 in the second hospital of Anhui Medical University, who underwent laparoscopic liver resection using Bulldog (modified group, n = 54) and cotton tourniquet (traditional group, n = 56) for blocking the liver inflow-blood. Intraoperative blood loss, duration of the operation time, clamping time, postoperative outcomes were analyzed.All the operations were accomplished successfully without conversion to laparotomy, perioperative period clinical date was calculated. Intraoperative operative time, blood loss and resection sections had no statistical significance, but the clamping time (36.2 ± 5.6 vs 277.3 ± 88.4 s, P < .001) was significantly shorter in the bulldog group. Albumin, alanine aminotransferase, aspartate aminotransferase and serum total bilirubin had no statistical differences in postoperative day (POD) 1and 3, but POD 5 alanine aminotransferase (71.0 ± 46.8vs 105.8 ± 61.7IU/L P = .018) and aspartate aminotransferase (72.8 ± 39.7 vs 100.2 ± 16.7 IU/L P = .028). The postoperative hospital stays (7.02 ± 1.56 vs 8.50 ± 2.35 days P = .026) in bulldog group were lower than cotton group and differences had statistical significance. The C-reactive protein levels were significantly higher in the traditional group than in the modified group on POD 3 (46.3 ± 19.2 vs 57.7 ± 23.9 mg/L P = .019), and POD5 (13.3 ± 4.2 vs 17.5 ± 7.3 mg/L P = .001). There were 8 postoperative complications occurred in cotton group, while there was 5 in Bulldog group, all patients with complications were discharged after adequate drainage and symptomatic treatment.Bulldog is an effectively performed approach for vascular occlusion during laparoscopic hepatectomy than traditional Pringle maneuver.     

Long-term outcome after sequential resections of liver and lung metastases from colorectal carcinoma

Background:

Surgical resection of colorectal liver metastases (CLM) is an established form of treatment. Limited data exists on the value of sequential hepatic and pulmonary metastasectomy. We analysed patients who underwent sequential liver and lung resections for CLM.

Methods:

A total of 910 patients who underwent liver resection for CLM between January 2000 and December 2007, were analysed to identify patients with resectable pulmonary metastases (n= 43; 4.7%). Patient demographics, overall survival and survival difference between synchronous and metachronous pulmonary metastasectomy groups were compared. In addition, outcomes in the ‘liver and lung resection’ group were compared with a matched group of ‘liver resection only’ patients (matched for age, primary disease stage, interval to liver resection and liver disease stage).

Results:

Forty-three patients (median age 62, range 43–83 years, 22 males) underwent sequential liver and lung resection. A total of 36 patients underwent major hepatic resections, 18 patients had bilobar disease and the median number of liver lesions resected was 3 (range 1–5 lesions). Ten patients had synchronous liver and lung metastases. The median interval between liver and lung metastasectomy was 25 months (range 2–88 months). A total of two patients underwent major lobectomies, three patients had bilateral disease and the median number of lung lesions resected was one (range 1–3). The 1-, 3- and 5-year overall survival rates after first metastasectomy were 100%, 87.1% and 53.9%, respectively, with a median survival of 42 months.

Patients:

Undergoing metachronous pulmonary metastasectomy had better 1-, 3- and 5-year survival rates than those with synchronous disease (100%, 88.9% and 60.9% vs. 100%, 75% and 0%, respectively; P= 0.02, log rank test). There was no significant survival difference between the ‘liver and lung resection’ and the ‘liver resection only’ groups.

Conclusion:

Sequential liver and lung resection for CLM is associated with good long-term survival in selected patients, except in those presenting with synchronous lung and liver metastases.     

Hepatic Resection as a Safe and Effective Treatment for Hepatocellular Carcinoma Involving a Single Large Tumor,Multiple Tumors,or Macrovascular Invasion

This systematic review examined whether the available evidence justifies using hepatic resection (HR) during later stages of hepatocellular carcinoma (HCC), which contravenes treatment guidelines but is current practice at many medical centers.Official guidelines and retrospective studies recommend different roles for HR for patients with large/multinodular HCC or with HCC involving macrovascular invasion (MVI).Several databases were systematically searched for studies examining the safety and efficacy of HR for treating HCC involving a single large tumor (>5 cm) or multiple tumors, or for treating HCC involving MVI.We identified 50 studies involving 14 808 patients that investigated the use of HR to treat large/multinodular HCC, and 24 studies with 4389 patients that investigated HR to treat HCC with MVI. Median in-hospital mortality for patients with either type of HCC was significantly lower in Asian studies (2.7%) than in non-Asian studies (7.3%, P < 0.001). Median overall survival (OS) was significantly higher for all Asian patients with large/multinodular HCC than for all non-Asian patients at both 1 year (81% vs 65%, P < 0.001) and 5 years (42% vs 32%, P < 0.001). Similar results were obtained for median disease-free survival at 1 year (61% vs 50%, P < 0.001) and 5 years (26% vs 24%, P < 0.001). However, median OS was similar for Asian and non-Asian patients with HCC involving MVI at 1 year (50% vs 52%, P = 0.45) and 5 years (18% vs 14%, P = 0.94). There was an upward trend in 5-year OS in patients with either type of HCC.HR is reasonably safe and effective at treating large/multinodular HCC and HCC with MVI. The available evidence argues for expanding the indications for HR in official treatment guidelines.     

Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay

BackgroundAfter liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time.MethodsSurgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed.ResultsOf 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection.ConclusionConditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.     

Mechanisms of splenic hypertrophy following hepatic resection

Background

Following hepatic resection, liver regeneration has been associated with concurrent splenic hypertrophy. The mechanisms of this phenomenon are unknown, may be multiple and include: splanchnic sequestration caused by a reduction in the hepatic mass; hepatic growth factors that may indirectly act on the spleen, and the redistribution of the total reticuloendothelial system.

Methods

Seventy-five patients (40 males; median age: 60 years) who underwent minor (16%) or major (84%) hepatectomy between September 2004 and October 2009 were included. Prospective measurements of liver and spleen volumes were obtained preoperatively and postoperatively 1 month after hepatectomy using computed tomography (CT). The future remnant liver volume (RLV) was calculated on preoperative CT and the extent of resection was expressed as the RLV divided by total liver volume (TLV). Liver and spleen hypertrophy were expressed according to the absolute gain or relative increase in the initial volumes (%).The presence of fibrosis >F1, associated extrahepatic resection (except minor resections), and previous hepatectomy (major or minor) within 3 months represented exclusion criteria.

Results

Mean ± standard deviation (SD) liver volume at 1 month was higher than RLV (1187 ± 286 cm³ versus 764 ± 421 cm³; P < 0.001). Mean ± SD splenic volume increased from 252 ± 100 cm³ preoperatively to 300 ± 111 cm³ at 1 month (P < 0.001). Liver and splenic hypertrophy were significant after major hepatectomies (+100% and +26%, respectively; P < 0.001), but not after minor hepatectomies. Liver hypertrophy was inversely correlated to RLV/TLV (r = −0.687, P < 0.001). Splenic hypertrophy was not correlated to RLV/TLV. Liver and splenic hypertrophy were linearly correlated (r = 0.495, P < 0.001). Neoadjuvant chemotherapy (n = 37), preoperative portal vein embolization (n = 10) and postoperative complications (overall: n = 25; major: n = 10; infectious: n = 6) had no impact on hepatic or splenic hypertrophy.

Conclusions

Splenic hypertrophy occurred after major hepatectomy, but was not correlated to the extent of resection, by contrast with liver hypertrophy. Nevertheless, there was a linear correlation between splenic and liver hypertrophy. This correlation suggests the hypothesis of a splenic action of hepatic growth factors or a redistribution of the total reticuloendothelial system rather than an effect of reduction of the portal bed or hepatic outflow.     

Clinical Outcomes and Complications of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms in the Elderly

The number of elderly people with superficial gastric neoplasms is increasing, but the clinical outcome of endoscopic submucosal dissection (ESD) for treating elderly people with superficial gastric neoplasms remains unclear. We aimed to compare the efficacy and safety of ESD for patients with early gastric cancer (EGC) and precancerous lesions in elderly (≥75 years of age) and nonelderly (<75 years of age) patients.From October 2005 to December 2014, 83 consecutive patients with EGC and precancerous lesions (86 lesions) who were treated using ESD in our hospital were retrospectively reviewed. There were 44 lesions in 42 elderly patients who were at least 75-years old. The following parameters were compared between the 2 groups: preexisting comorbidities, performance status (PS), lesion inclusion criteria, lesion characteristics, treatment outcomes, surgery time, duration of hospitalization, complications, and intraoperative hemodynamic changes.Elderly patients had significantly higher preexisting comorbidity rates (90.9% vs 59.5%, P = 0.001), expanded lesion criteria rates (43.2% vs 19.0%, P = 0.016), and lower best PS rates (38.6% vs 81.0%, P < 0.001) than nonelderly patients. Lesion characteristics were similar in the 2 groups. The elderly had higher intraoperative hypotension rates (47.7% vs 21.4%, P = 0.011) and oxygen desaturation rates (9.1% vs 0.0%, P = 0.045) than nonelderly patients. In addition, the elderly also had a longer surgery time (107.0 ± 51.4 vs 91.5 ± 66.2 minutes, P = 0.049) and duration of hospitalization (7.5 ± 3.8 vs 5.9 ± 2.0 days, P = 0.016) than nonelderly patients. There were no differences in the prevalence rates of en-bloc resection, complete resection, bleeding, perforation, pneumonia, or intraabdominal free air between the 2 groups.Although elderly patients who underwent ESD for superficial gastric neoplasms had an increasing risk of intraoperative hypotension and oxygen desaturation, all patients were treated appropriately without postoperative sequelae. ESD is a safe and feasible intervention for elderly patients who have more comorbidity, a worse PS and more expanded lesions.     

The Value of Palliative Gastrectomy for Gastric Cancer Patients With Intraoperatively Proven Peritoneal Seeding

The aim of this study was to evaluate the survival benefit of palliative gastrectomy for gastric cancer patients with peritoneal seeding proven intraoperatively and to identify positive predictive factors for improving survival.The value of palliative resection for gastric cancer patients with peritoneal metastasis is controversial.From 2006 to 2013, 267 gastric cancer patients with intraoperatively identified peritoneal dissemination were retrospectively analyzed. Patients were divided into resection group and nonresection group according to whether a palliative gastrectomy was performed. Clinicopathologic variables and survival were compared. Subgroup analyses stratified by clinicopathologic factors and multivariable analysis for overall survival were also performed.There were 114 patients in the resection group and 153 in nonresection group. The morbidities in the resection and nonresection groups were 14.91% and 5.88%, respectively (P = 0.014). There, however, was no difference in mortality between the 2 groups. The median survival time of patients in the resection group was longer than in nonresection group (14.00 versus 8.57 months, P = 0.000). The median survivals among the patients with different classifications of peritoneal metastasis were statistically significant (P = 0.000). Patients undergoing resection followed by chemotherapy had a significantly longer median survival, compared with that of patients who had chemotherapy alone, those who had resection alone, or those who had not received chemotherapy or resection (P = 0.000). Results of subgroup analyses showed that except for P3 patients and patients with multisite distant metastases, overall survival was significantly better in patients with palliative gastrectomy, compared with the nonresection group. In multivariate analysis, P3 disease (P = 0.000), absence of resection (P = 0.000), and lack of chemotherapy (P = 0.000) were identified as independently associated with poor survival.Palliative gastrectomy might be beneficial to the survival of gastric cancer patients with intraoperatively proven P1/P2 alone, rather than P3. Postoperative palliative chemotherapy could improve survival regardless of operation and should be recommended.