Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM:To assess clinical outcomes of laparoscopic hepatectomy(LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.METHODS:This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery.Of the 80 patients who underwent LH,22 had prior abdominal surgeries,including hepatectomy(n = 12),pancreatectomy(n = 3),cholecystectomy and common bile duct excision(n = 1),splenectomy(n = 1),total gastrectomy(n = 1),colectomy with the involvement of transverse colon(n = 3),and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen(n = 1).Clinical indicators including operating time,blood loss,hospital stay,and morbidity were compared among the groups.RESULTS:Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver.However,there were no conversions to laparotomy in this group.In the 58 patients without a history of upper abdominal surgery,the median operative time was 301 min and blood loss was 150 m L.In patients with upper abdominal surgical history or repeat hepatectomy,the operative times were 351 and 301 min,and blood loss was 100 and 50 m L,respectively.The median postoperative stay was 17,13 and 12 d for patients with no history of upper abdominal surgery,patients with a history,and patients with repeat hepatectomy,respectively.There were five cases with complications in the group with no surgical history,compared to only one case in the group with a prior history.There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history,or with repeat hepatectomy.CONCLUSION:LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.     

Portal hypertension predicts short-term and long-term outcomes after hepatectomy in hepatocellular carcinoma patients

Background and aims: The impact of portal hypertension (PH) on postoperative short-term outcomes and long-term survival in hepatocellular carcinoma (HCC) patients has lately been discussed controversially. This study aimed to explore the influence of PH on postoperative outcomes in HCC patients undergoing surgical resection.

Methods: Patients undergoing hepatectomy for HCC from 2010 to 2014 were enrolled. The impact of PH on postoperative complications, posthepatectomy liver failure (PHLF) and overall survival (OS) was evaluated.

Results: A total of 355 HCC patients were enrolled; 129 (36.3%) experienced postoperative complications and 21 (5.9%) developed PHLF. PH was identified as an independent predictor of PHLF. Patients with PH experienced a higher incidence of complications and PHLF than patients without PH. On the Cox proportional hazards regression model, PH was verified as a risk factor of OS for BCLC stage 0/A and B patients. Patients without PH had significantly better long-term survival compared to patients with PH both in the total cohort and in cirrhosis subgroup.

Conclusion: Liver resection in HCC patients with PH showed a significantly increased postoperative complications and PHLF, and revealed a decreasing long-term survival than non-PH patients. Besides, tumor burden also played an important role in determining the OS. However, due to the improvement in surgical technique and perioperative management, surgery was feasible in carefully selected HCC patients with PH.     

Outcome of hepatectomy in super-elderly patients with hepatocellular carcinoma

Aim: The aim of this study was to investigate the characteristics of super‐elderly hepatocellular carcinoma (HCC) patients aged 80 years or more who underwent hepatectomy and to clarify whether elderly patients with HCC benefit from hepatectomy. Methods: Between March 1992 and December 2008, 278 patients who underwent curative hepatectomy for HCC were investigated. Super‐elderly patients were defined as those aged 80 years or more. Clinicopathological data and outcomes after hepatectomy were compared between super‐elderly and non‐super‐elderly groups. Results: Preoperative parameters, such as biochemical examinations, and liver function tests in the non‐super‐elderly group were comparable with those of the super‐elderly group (n = 11). Exceptionally, albumin level in the super‐elderly group was lower than that in the non‐super‐elderly group (P = 0.03). Surgical data and the prevalence of postoperative complications did not differ significantly between the two groups. No mortality was observed in the super‐elderly and non‐super‐elderly group. Conclusions: Hepatectomy for HCC was a feasible option even in super elderly patients aged 80 years or older with accurate selection.     

Impact of clinically significant portal hypertension on outcomes after partial hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

Background

Whether clinically significant portal hypertension (CSPH) is a contraindication of partial hepatectomy for patients with hepatocellular carcinoma (HCC) remains controversial. The aim was to assess the impact of CSPH on surgical morbidity, mortality and long-term survival of HCC patients who underwent partial hepatectomy.

Safety of hepatectomy accompanying combined resection of other organs

Background/Aims: The present study analyzed postoperative outcomes for patients who underwent hepatectomy accompanied by resection of other organs, to clarify operative safety. Methodology: We examined perioperative parameters in 95 patients who underwent hepatectomy and other organ resections (colorectal resection, n=46; gastrectomy or duodenectomy, n=13; splenectomy, n=17; resection of diaphragm, n=9; pulmonary resection, n=4; others, n=6). Results: Prevalence of chronic liver dysfunction (100%) or hepatocellular carcinoma (HCC) (100%) was significantly higher in patients who underwent splenectomy than in other groups (17% and 21%, respectively; p<0.01). Extent of hepatectomy, operating time and blood loss did not differ significantly between groups. Frequency of blood transfusion use was highest in patients who underwent splenectomy (p<0.01). Postoperative complications tended to be more frequent among patients who underwent splenectomy, but this difference was not significant. Wound infection tended to be more frequent among patients who underwent colorectal resection, but not significantly (p=0.11). Hepatectomy-associated complications in patients who underwent splenectomy most often appeared in the form of uncontrolled ascites (p<0.01), with hospital deaths rarely observed and hospital stay not significantly different between groups. Conclusions: Good postoperative outcomes in multi-organ resections with hepatectomy were observed by careful perioperative management based on adequate indications for hepatectomy.     

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma ≤4 cm

AIM: To determine which treatment modality -hepatectomy or percutaneous ablation - is more beneficial for patients with small hepatocellular carcinoma (HCC) (≤ 4 cm) in terms of long-term outcomes.METHODS: A retrospective analysis of 149 patients with HCC ≤4 cm was conducted. Eighty-five patients underwent partial hepatectomy (anatomic in 47 and nonanatomic in 38) and 64 underwent percutaneous ablation (percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6). The median follow-up period was 69 mo.RESULTS: Hepatectomy was associated with larger tumor size (P＜0.001), whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy (P＜ 0.0001). Survival was better following hepatectomy (median survival time:122 mo) than following percutaneous ablation (median survival time: 66 mo; P=0.0123). When tumor size was divided into ≤ 2 cm vs ＞ 2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors ＞2 cm (P= 0.0001). The Cox proportional hazards regression model revealed that hepatectomy (P= 0.006) and tumors ≤ 2 cm (P= 0.017) were independently associated with better survival.CONCLUSION: Hepatectomy provides both better local control and better long-term survival for patients with HCC ≤4 cm compared with percutaneous ablation. Of the patients with HCC ≤ 4 cm, those with tumors ＞ 2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.     

Repeat hepatectomy is the most useful treatment for recurrent hepatocellular carcinoma

Hepatic resection has been regarded as a curative treatment for primary hepatocellular carcinoma (HCC), but a high incidence of postoperative recurrence is general. Thus it is important to predict the patterns of recurrence and select the appropriate treatment for recurrence for a better long‐term prognosis of patients with HCC. Clinicopathological studies on 80 patients with intrahepatic recurrence after curative hepatectomy suggested that nodular‐type recurrence with up to three nodules is mainly due to metachronous multicentric hepatocarcinogenesis rather than intrahepatic metastases. We reviewed 300 patients with recurrent HCC, and repeat hepatectomy was done in 78 cases (26.0%). The 3‐ and 5‐year survival rates after repeat hepatectomy were 82.8% and 47.5%, respectively, showing better prognosis than those for other treatments. Repeat hepatectomy is the preferred treatment offering a hope of long‐term survival for patients with recurrent HCC as long as liver function is sufficient; thus early detection of recurrence should be ensured.     

Surgical treatment of recurrent hepatocellular carcinoma based on the mode of recurrence: repeat hepatic resection or ablation are good choices for patients with recurrent multicentric cancer

Hepatocellular carcinomas (HCC) often recur after curvative resection. Recurrence in the remnant liver originates from intrahepatic metastasis (IM) from the primary resected tumor, and/or from multicentric (MC) occurrence. In order to achieve better survival after intrahepatic recurrence in HCC patients, we have surgically treated patients according to the recurrence pattern. In this study, we investigated the advantage of repeat surgery for MC recurrent HCC. The subjects were 176 patients who had undergone primary macroscopically complete tumor removal for HCC at our department from 1984 to 1999. Differential diagnosis of IM and MC recurrence was done by pathological analysis. Twenty‐nine of the 149 patients with recurrence (19.5%) underwent a total of 31 second and third operations. Of the 29 patients, 18 had MC (14 received repeat hepatectomy and 4, microwave tissue coagulation [MTC]), 7 had IM (4 had repeat hepatectomy and 3, MTC), and, in 4 patients, pathological investigation failed to determine the mode of recurrence. The 1‐, 3‐, and 5‐year survival rates for MC patients after the repeat operations were 100%, 69.7%, and 58.1%, respectively, and the 1‐, 3‐, and 5‐year survival rates for the IM patients were 57.1%, 14.3%, and 14.3%, respectively. Survival after the repeat operation was significantly better in the MC group than in the IM group (P = 0.0016). Moreover, there was no significant difference between survival in the MC group after a repeat operation and survival in control patients after an initial hepatectomy (P = 0.9282). These results indicated that patients with resectable or ablative recurrent MC HCC have almost the same survival benefit after repeat operations as patients who undergo initial curative resection of HCC.     

Hepatectomy for huge hepatocellular carcinoma in 634 cases

AIM: To clarify the safety and feasibility of hepatectomy for huge hepatocellular carcinoma (HCC). METHODS: A total of 4765 patients with HCC operated at Tongji Hospital were retrospectively studied, of them, 780 patients had huge HCC (10 cm or more in diameter). Hepatectomy was carried out on 634 patients (81.2%). The majority of the liver resection were major resections, and combined resection of the adjacent organs or structures was common (17.2%). The liver resection was combined with portal vein thrombectomy in 139 patients (21.9%). RESULTS: Postoperative complications were common (26.8%) and required another laparotomy to prevent the complications in 5 patients (0.8%). The 30-d mortality was 2.2%. The main causes of postoperative deaths were liver failure (n = 9), postoperative bleeding (n = 4) and septic complication (n = 1). The 3-, 5- and 10-year survival rates after liver resection were 35.1%, 18.2% and 3.5%, respectively. CONCLUSION: Hepatectomy for huge HCC is safe and effective. It should be used to treat patients with low surgical risks and resectable tumours.     

Repeat hepatic resection in patients with colorectal liver metastases

AIM:To investigate the survival outcomes of secondaryhepatectomy for recurrent colorectal liver metastases(CRLM).METHODS:From October 1994 to December 2009,patients with CRLM who underwent surgical treatment with curative intent were investigated.Patients were divided into two groups:patients who underwent primary hepatectomy(Group 1)and those who underwent secondary hepatectomy for recurrent CRLM(Group 2).RESULTS:Survival and prognostic factors were analyzed.A total of 461 patients were included:406patients in Group 1 and 55 patients in Group 2.After a median 39-mo(range,3-195 mo)follow-up,there was a significant difference between Groups 1 and 2in terms of disease-free survival(P=0.029)although there was no significant difference in overall survival(P=0.206).Secondary hepatectomy was less effective in patients with multiple recurrent CRLM than primary hepatectomy for initial CRLM(P=0.008).Multiple CRLM and radiofrequency ablation therapy were poor prognostic factors of secondary hepatectomy in multivariate Cox regression analysis(P=0.006,P=0.004,respectively).CONCLUSION:Secondary hepatectomy for single recurrent CRLM is as effective as primary surgical treatment for single recurrent CRLM.However,secondary hepatectomy for multiple recurrent CRLM is less effective than that for single recurrent CRLM.     

Safety of synchronous hepatectomy and splenectomy for patients with hepatocellular carcinoma and hypersplenism

Background/Aims: To assess the surgical safety of synchronous hepatic resection and splenectomy for patients with hepatocellular carcinoma (HCC) and hypersplenism. Methodology: Patients with HCC and hypersplenism who underwent surgical treatment were included in this study. According to the difference of operations, patients were divided into two groups (group A, patients who underwent hepatic resection; group B, patients who underwent synchronous hepatic resection and hypersplenism). Pre- and intra-operative parameters were statistically analyzed. Postoperative outcomes including white blood cell and platelet count changes, surgical complications and long-term survival rates were compared. Results: The pre- and intra-operative parameters of two groups were comparable except for preoperative white blood cell and platelet counts. The incidences of postoperative surgical complication were 53.33% for group A and 35.48% for group B (p=0.161). The 1- and 3-year survival rates of the two groups were 83%, 42% and 82%, 54%, respectively (p=0.313). Conclusions: Synchronous hepatic resection and splenectomy could increase the postoperative WBC and platelet level for patients with hepatocellular carcinoma and hypersplenism without increasing surgical risks.     

Efficiency and safety of radiofrequency-assisted hepatectomy for hepatocellular carcinoma with cirrhosis:A single-center retrospective cohort study

AIM: To assess the efficiency and safety of radiofrequencyassisted hepatectomy in patients with hepatocellular carcinoma(HCC) and cirrhosis.METHODS: From January 2010 to December 2013, 179 patients with HCC and cirrhosis were recruited for this retrospective study. Of these, 100 patients who received radiofrequency-assisted hepatectomy(RF+ group) were compared to 79 patients who had hepatectomy without ablation(RF- group). The primary endpoint was intraoperative blood loss. The secondary endpoints included liver function, postoperative complications, mortality, and duration of hospital stay.RESULTS: The characteristics of the two groups were closely matched. The Pringle maneuver was not used in the RF+ group. There was significantly less median intraoperative blood loss in the RF+ group(300 vs 400 m L, P = 0.01). On postoperative days(POD) 1 and 5, median alanine aminotransferase was significantly higher in the RF+ group than in the RF- group(POD 1: 348.5 vs 245.5, P = 0.01; POD 5: 112 vs 82.5, P = 0.00), but there was no significant difference between the two groups on POD 3(260 vs 220, P = 0.24). The median AST was significantly higher in the RF+ group on POD 1(446 vs 268, P = 0.00), but there was no significant difference between the two groups on POD 3 and 5(POD 3: 129.5 vs 125, P = 0.65; POD 5: 52.5vs 50, P = 0.10). Overall, the rate of postoperative complications was roughly the same in these two groups(28.0% vs 17.7%, P = 0.11) except that post hepatectomy liver failure was far more common in the RF+ group than in the RF- group(6% vs 0%, P = 0.04).CONCLUSION: Radiofrequency-assisted hepatectomy can reduce intraoperative blood loss during liver resection effectively. However, this method should be used with caution in patients with concomitant cirrhosis because it may cause severe liver damage and liver failure.     

Comparison of pre- and postoperative pulmonary function in obese and non-obese female patients undergoing coronary artery bypass graft surgery

OBJECTIVE AND BACKGROUND: Various studies have suggested that body size and in-hospital mortality are related. However, only a few analysed the effects of obesity on pulmonary complications following coronary artery bypass graft surgery (CABG). The purpose of the present study was to assess early changes in lung volumes, respiratory complications and arterial blood gas tension following CABG in obese women. METHODS: Pulmonary function tests (PFTs), treadmill exercise capacity tests (TM), arterial blood gases and pulmonary complications were studied in 124 obese (mean age 57.2+/-5.8 years) and 108 non-obese (mean age 58.6+/-5.9 years) female patients undergoing elective CABG. PFT, TM tests, arterial blood gas analyses and CXR were performed in the preoperative and postoperative periods and pulmonary complications were recorded. Breathing and coughing exercises, early ambulation and pulmonary clearing techniques were used by physical therapists to prevent pulmonary complications after CABG surgery. RESULTS: Postoperative PFT and TM tests deteriorated significantly in both groups (P<0.0001). The deterioration in the obese group was highly significant. The postoperative deterioration of blood gas measurements in obese patients was also statistically significant compared to non-obese patients. Early pulmonary complications developed in 21 (16.94%) of the obese patients and in 10 (9.25%) of non-obese patients. Duration of mechanical ventilation, intensive care unit and hospital stays were longer compared to the non-obese patients (P=0.008, P<0.0001, P=0.0386, respectively). CONCLUSION: Obesity has a detrimental effect on pulmonary function, exercise capacity, blood gas measurements and complications rates in postoperative period following CABG surgery.     

Results of repeated hepatectomy for recurrent hepatocellular carcinoma

BACKGROUND/AIMS: The long-term outcome of patients undergoing repeated hepatectomy for secondary hepatocellular carcinoma (HCC) were investigated to assess the selection criteria for, and efficacy of, repeated hepatectomy. METHODOLOGY: 21 patients with secondary HCC who had undergone repeated hepatectomy (R group) were analyzed. Clinical characteristics, histopathologic findings and postoperative clinical course were compared for patients with primary and secondary HCCs in the R group. The risk factors for post repeated hepatectomy survival and disease-free survival were estimated for the R group. RESULTS: There were no significant differences in patient characteristics or histologic features of primary and secondary HCCs in the R group. A significant difference in cumulative postoperative disease-free survival was not seen for primary and secondary HCCs, average duration was 39.4 and 21.3 months. Liver cirrhosis and narrow hepatectomy (subsegmentectomy, limited resection and enucleation) were found to be significant risk factors of survival after secondary hepatectomy. The 5-year post-recurrence survival rate of nine patients in the R group who had two risk factors was 14.8%. CONCLUSIONS: In cirrhotic patients with secondary HCC, inadequate narrow repeated hepatic resection should not receive repeated hepatectomy.     

Negative impact of low body mass index on surgical outcomes after hepatectomy for hepatocellular carcinoma

Background

Studies have previously indicated that surgical outcomes are poorer for obese patients. To date, few reports concerning the effect of obesity on patient outcomes following a hepatectomy for hepatocellular carcinoma (HCC) have been published. The present study, therefore, sought to determine the impact of patients’ body mass index (BMI, kg/m²) on short- and long-term surgical outcomes and to identify potential prognostic factors for HCC following a hepatectomy.

Methods

Patient data was retrospectively collected from 181 consecutive patients between September 2002 and August 2007 who had undergone hepatectomy for HCC with curative intent. Patients were assigned to three groups according to their BMI (low <18.5, standard 18.5–25, and high >25), and the clinical and pathological data, surgical outcome, and long-term survival were analyzed and compared between the three groups.

Results

The overall survival rate of the low BMI group was notably below that of the standard group. Surgical outcomes were not significantly different between the three groups. Multivariate analysis revealed that a low BMI (<18.5) is a predictor of unfavorable prognosis.

Conclusions

The present study suggests that a low BMI is a significant prognostic factor for low overall survival when performing a hepatectomy for HCC.     

Survival after repeat hepatectomy for recurrent colorectal liver metastasis: A review and meta-analysis of prognostic factors

BackgroundFrequent recurrent hepatic metastasis after hepatic metastasectomy is a major obstacle in the treatment of colorectal liver metastasis (CRLM). We performed the present systematic review to evaluate the short- and long-term outcomes after repeat hepatectomy for recurrent CRLM and determine factors associated with survival in these patients.Data sourcesAn electronic search of PubMed database was undertaken to identify all relevant peer-reviewed papers published in English between January 2000 and July 2018. Hazard ratios (HR) with 95% confidence interval (95% CI) were calculated for prognostic factors of overall survival (OS).ResultsThe search yielded 34 studies comprising 3039 patients, with a median overall morbidity of 23% (range 8%–71%), mortality of 0 (range 0–6%), and 5-year OS of 42% (range 17%–73%). Pooled analysis showed that primary T3/T4 stage tumor (HR = 1.94; 95% CI: 1.04–3.63), multiple tumors (HR = 1.49; 95% CI: 1.10–2.01), largest liver lesion ≥5 cm (HR = 1.89; 95% CI: 1.11–3.23) and positive surgical margin (HR = 1.80; 95% CI: 1.09–2.97) at initial hepatectomy, and high serum level of carcinoembryonic antigen (HR = 1.87; 95% CI: 1.27–2.74), disease-free interval ≤12 months (HR = 1.34; 95% CI: 1.10–1.62), multiple tumors (HR = 1.64; 95% CI: 1.32–2.02), largest liver lesion ≥5 cm (HR = 1.85; 95% CI: 1.34–2.56), positive surgical margin (HR = 2.25; 95% CI: 1.39–3.65), presence of bilobar disease (HR = 1.62; 95% CI: 1.19–2.20), and extrahepatic metastases (HR = 1.60; 95% CI: 1.23–2.09) at repeat hepatectomy were significantly associated with poor OS.ConclusionsRepeat hepatectomy is a safe and effective therapy for recurrent CRLM. Long-term outcome is predicted mainly by factors related to repeat hepatectomy.     

Repeat hepatectomy for recurrent hepatic metastases from colorectal cancer.

BACKGROUND/AIMS: Resection of liver metastases from colorectal cancer is accepted as a safe, and curative treatment. Furthermore, repeat hepatectomy has been indicated for hepatic recurrence after initial hepatectomy to achieve long-term survival or cure. The present study is a retrospective review of our results using repeat hepatectomy for colorectal liver metastases to identify outcomes and prognostic factors associated with long-term survival. METHODOLOGY: Ninety-four patients underwent an initial hepatectomy for colorectal metastases between 1990 and 1995. Thirty patients had hepatic recurrence after the initial hepatectomy. Eleven patients underwent repeat hepatectomy for isolated hepatic recurrence. RESULTS: The operative mortality was 0%. The overall 5-year survival rate after detection of second liver metastases of 11 patients was 45.5%. The distribution of first liver metastases and disease-free interval between the first and second hepatectomy demonstrated significance in relation to survival after repeat hepatectomy (P = 0.0303 and 0.0338). CONCLUSIONS: Repeat hepatectomy for recurrent liver metastases from colorectal cancer was the most effective treatment to improve survival time for selected patients. In patients with isolated second liver metastasis, unilateral spread of first liver metastases, and a disease-free interval between the first and second hepatectomies of more than 12 months, long-term survival or cure can be expected after repeat hepatectomy.     

Efficacy of surgical microwave ablation for recurrent hepatocellular carcinoma after curative hepatectomy

BackgroundLittle evidence exists regarding postrecurrence survival after microwave ablation for recurrent hepatocellular carcinoma (HCC) after curative hepatectomy; we aimed to evaluate the feasibility of surgical microwave ablation.MethodsIn this retrospective review, we enrolled patients who underwent curative hepatectomy for primary HCC in our department and had intrahepatic recurrence. We analyzed overall survival according to treatment modality to clarify the prognostic factors for survival.ResultsOf 257 patients, 119 had intrahepatic recurrence. Three patients underwent repeat hepatectomy; 75 patients underwent surgical microwave ablation, and 34 patients underwent transcatheter arterial chemoembolization or hepatic arterial infusion chemotherapy. The median postrecurrence survival time and 5-year postrecurrence survival after surgical microwave ablation were 37.4 months and 55.4%, respectively. The major complication rate (Clavien–Dindo classification IIIa or above) after surgical microwave ablation was 5.3% with no mortality. Multivariate analysis showed that microvascular invasion at primary tumors, and recurrent tumors within 3 cm and 3 nodules were independent prognostic factors for overall survival after surgical microwave ablation for recurrent HCC.ConclusionOur results suggested that surgical microwave ablation is safe and feasible for recurrent intrahepatic HCC after curative hepatectomy. Close follow-up and further curative treatment could be important for improving postrecurrence survival.     

不同取标本途径在直肠癌微创手术中的疗效对比

目的对常规直肠癌经辅助切口取标本与经自然腔道取标本手术（NOSES）进行比较,探讨NOSES的近远期疗效。 方法回顾性分析2018年1月至2020年12月大连医科大学附属第二医院胃肠外科行直肠癌微创手术的217例患者的临床资料,根据标本取出方式不同分为NOSES组（研究组）和传统经腹部辅助切口组（对照组）。采用PSM平衡两组患者术前基本资料,研究组和对照组各纳入患者63例,比较两组患者的围手术期资料、术后病理资料及远期随访资料。 结果研究组患者腹壁切口更短（t=-19.791,P＜0.001）,术后离床时间更早（t=-5.978,P＜0.001）,胃肠道功能恢复更快（t=-7.656,P＜0.001）,疼痛评分更低（术后12 h：t=-4.372,P＜0.001;术后24 h：t=-5.835,P＜0.001）,两组对比差异均存在统计学意义。研究组患者切口并发症发生率明显低于对照组,差异存在统计学意义［（0）vs.（9.5%）,χ²=4.375;P=0.028］。采用Clavien-Dindo分级标准对术后并发症进行分类,研究组共8例术后并发症（12.7%）,其中CD Ⅰ级并发症3例（4.8%）,CD Ⅱ级并发症2例（3.2%）,CD Ⅲ级并发症3例（4.8%）;研究组术后并发症发生率较对照组低,但差异无统计学意义［（12.7%）vs.（22.2%）,χ²=1.983;P=0.159］。对比两组患者的术后病理资料及远期随访资料,在淋巴结检出总数（t=0.603,P=0.548）、近切缘（t=-0.110,P=0.912）及远切缘长度（t=-0.126,P=0.900）、总生存率（χ²=0.002,P=0.962）及无病生存率（χ²=0.625,P=0.429）上,差异均无统计学意义。 结论NOSES安全可行,具有术后疼痛轻、损伤小、胃肠道功能恢复较快等优点,具有与传统经辅助切口取标本手术相似的长期肿瘤学结果。     

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism:A casecontrol study

AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.