Results of hepatic resection for sarcoma metastatic to liver

OBJECTIVE: To evaluate the outcome of patients with liver metastases from sarcoma who underwent hepatic resection at a single institution and were followed up prospectively. SUMMARY BACKGROUND DATA: The value of hepatic resection for metastatic sarcoma is unknown. METHODS: There were 331 patients with liver metastases from sarcoma who were admitted to Memorial Hospital from 1982 to 2000, and 56 of them underwent resection of all gross hepatic disease. Patient, tumor, and treatment variables were analyzed to assess outcome. RESULTS: Of the 56 patients who underwent complete resection, 34 (61%) had gastrointestinal stromal tumors or gastrointestinal leiomyosarcomas. Half of the patients required an hepatic lobectomy or extended lobectomy. There were no perioperative deaths in the completely resected group, although 3 of the 75 patients who underwent exploration (4%) died. The postoperative 1-, 3-, and 5-year actuarial survival rates were 88%, 50%, and 30%, respectively, with a median of 39 months. In contrast, the 5-year survival rate of patients who did not undergo complete resection was 4%. On multivariate analysis, a time interval from the primary tumor to the development of liver metastasis greater than 2 years was a significant predictor of survival after hepatectomy. CONCLUSIONS: Complete resection of liver metastases from sarcoma in selected patients is associated with prolonged survival. Hepatectomy should be considered when complete gross resection is possible, especially when the time to the development of liver metastasis exceeds 2 years.     

Combined resection with radiofrequency ablation for bilobar hepatocellular carcinoma: a single-center experience

Background

Bilobar hepatocellular carcinoma (HCC) is not rare and curative resection often cannot be achieved. However, the long-term results of nonsurgical treatments remain unsatisfactory. This study investigates the safety, efficacy, and long-term outcome of hepatic resection (HR) and resection combined with radiofrequency ablation (RFA) in treating patients with bilobar HCC.

Materials and methods

A retrospective study of 364 patients with bilobar HCC was carried out. Among them, 89 received HR, 114 received resection combined with RFA, and 161 received transarterial chemoembolization (TACE). The clinicopathologic parameters, surgical results, long-term outcomes, and prognostic factors were analyzed.

Results

The median follow-up time was 28 mo (range, 3–84 mo). The 1-, 3-, 5-y overall survival rates were better after HR and resection combined with RFA than those of patients after TACE, that is, 78.9%, 49.4%, and 34.4%; 70.7%, 40.7%, and 22.3%; and 47.2%, 17.4%, and 8.6%, respectively (P < 0.001). Overall survival and recurrence-free survival rates were comparable between the two surgical groups. Child–Pugh stage, liver cirrhosis, and tumor number were identified as significant prognostic factors for overall survival by using the multivariate Cox model.

Conclusions

HR combined with RFA provided a chance for cure to patients with bilobar HCC who were traditionally deemed unresectable and yielded better long-term outcomes than TACE in a subset of patients. With preserved liver function, patients can receive aggressive treatment and survival could be prolonged.     

Pulmonary resection for metastatic sarcoma

Surgical resection plays an important role in the treatment of sarcoma that is metastatic to the lung. Multiple bilateral metastases are not contraindications to surgery. The rapidity of growth and the response to chemotherapy can be accurately determined by the tumor doubling time. Preoperative chemotherapy provides an in vivo measurement of tumor sensitivity, and the response to chemotherapy correlates with prognosis. Since residual microscopic pulmonary disease appears to be responsible for most failures after thoracotomy, attention should be directed toward delivering more effective adjuvant therapy to the lungs.     

Lung resection for metastatic sarcoma

Our experience with lung resection in fifty patients with metastatic sarcoma is presented. Seventeen patients underwent lung resection for solitary lung metastasis and thirty-three had multiple metastases.The overall estimated median survival of the patients was 22.2 months. Shorter tumor doubling time was found to indicate poor prognosis. The tumor-free interval, length of the waiting period, and the number of metastatic lesions removed did not influence the postoperative survival rate.Surgical therapy of solitary as well as multiple metastatic sarcoma of the lung appears to produce acceptable therapeutic results.     

Laparoscopic liver resection and the learning curve: a 14-year,single-center experience

Background

Laparoscopic liver resection has not been widely used because of intraoperative bleeding. This problem should be solved with instruments and techniques that require a short learning curve.

Materials and methods

The aim of this work was to present the technique used in our center to perform laparoscopic liver resection using the ‘curettage and aspiration’ technique with laparoscopic Peng’s multifunctional operational dissectors and regional occlusion of inflow and outflow. We retrospectively analyzed patients who underwent a laparoscopic liver resection from August 1998 to August 2012, and collected the conversion rate, operating time, blood loss, hospitalization, bile leakage rate, bleeding rate, and other complications on a yearly basis and in total. We used SPSS software to analyze whether there was a significant difference, and summarized the learning curve of laparoscopic liver resection with various procedures.

Results

We performed 365 cases of laparoscopic liver resection, including left hemihepatectomy, left lateral lobectomy, segmental hepatectomy, non-anatomic liver resection, right hemihepatectomy, and caudate lobectomy. The diseases included liver cancer, hepatolithiasis, liver hemangioma, focal nodular hyperplasia, liver abscess, and metastatic hepatic carcinoma. In total, 63 cases (17.20 %) were converted to open surgery because of severe adhesions, bleeding, or anatomical limitation. Mean blood loss was 370.6 ± 404.0 ml; mean operating time was 150.8 ± 73.0 min; and mean postoperation hospitalization was 9.2 ± 5.3 days. There were four cases (1.32 %) with the complication of bile leakage and two cases of hemorrhage (0.66 %). No intraoperative or postoperative deaths occurred. After finishing 15–30, 43, 35, and 28 cases of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy, respectively, the average operating time, blood loss, and hospitalization were almost the same as the overall mean results.

Conclusion

The technique used in our center is a safe, fast, and effective approach to laparoscopic liver resection. Our 14 years of experience demonstrates that this technique can prevent postoperative bleeding and bile leakage. A surgeon can master the skill of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy after ～15–30, 43, 35, and 28 case procedures, respectively.     

Prognostic factors after liver resection for hepatocellular carcinoma: a single-center experience from China

BackgroundThis study aimed to clarify the risk factors for survival and recurrence of hepatocellular carcinoma (HCC) in a cohort of Chinese HCC patients after hepatectomy and to compare 6 developed staging systems.MethodsA retrospective analysis was performed on 165 consecutive patients. The Kaplan–Meier method was used to calculate survival. Postoperative prognostic factors were evaluated using univariate and multivariate analyses. The overall predictive power of each staging system was evaluated by the area under the receiver operating characteristic curve.ResultsThe overall survival rates of 1, 3, and 5 years were 81.2%, 58.6%, and 56.7%, respectively, and the corresponding disease-free survival rates were 52.9%, 23.3%, and 15.5%, respectively. α-fetoprotein level and blood transfusion were correlated significantly with patients' overall survival, and portal vein thrombosis and tumor size (>5 cm) were correlated significantly with poor disease-free survival.ConclusionsThe French staging system is better for predicting the prognosis of HCC patients receiving surgical treatment.     

腹腔镜解剖性肝切除治疗位于中央部位肝癌单中心经验

目的探讨腹腔镜解剖性肝切除治疗中央部位肝细胞癌的安全性和可行性。方法2015年1月至2019年12月,12例肿瘤位于肝中央部位的肝细胞癌患者在佛山市第一人民医院肝脏外科实施了腹腔镜肝切除;其中男9例、女3例,平均年龄(55.5±6.8)岁,平均肿瘤直径(3.7±2.5)cm,术前肝脏储备功能ICG-R15(3.9±2.82)%,肝功能Child-Pugh分级A级。实施肝Ⅳ~Ⅷ段切除5例、肝Ⅴ~Ⅷ段切除6例、肝Ⅳ段切除1例。统计分析手术时间、手术切缘、术中出血量、术后并发症及住院时间等。结果12例患者均在腹腔镜下完成手术,无中转开腹,平均手术时间(398.8±115.4)min,平均术中出血量(420.8±279.2)ml,有1例输血,术后平均住院时间(9.1±2.2)d,无围手术期死亡病例,术后并发症包括肝断面出血1例、胆漏1例、膈下包裹性积液1例,平均手术切缘(1.2±0.6)cm。结论对位于肝中央部位的肝细胞癌,行解剖性肝Ⅳ~Ⅷ段切除、肝Ⅴ~Ⅷ段切除以及肝Ⅳ段切除是安全、可行的。采取肝内Glissonian鞘外的方法预先控制肝蒂有利于掌握断肝平面,术前精准的评估,术中有效的控制出血以及娴熟的腔镜外科技术能有效帮助术者安全实施手术。     

Adverse events after radiofrequency ablation of unresectable liver tumors: a single-center experience

Background

Radiofrequency ablation (RFA) is a relatively new modality to treat liver tumors that is being incorporated into practice despite the fact that its risk profile has not been well described.

Methods

A retrospective cohort study, using structured chart review, on patients with liver tumor(s) was conducted from August 1998 to November 2006. Univariate and multivariate exploratory analyses were used to evaluate factors associated with adverse events.

Results

RFA procedures were performed on 196 patients (58% primary tumors, 24% colorectal metastases, and 18% other metastases). Twenty-three patients (12%) experienced serious adverse events. Multivariate analysis showed advanced age (≥55 y), underlying liver disease, large tumor size (>4 cm), and concomitant procedure were associated with an increased risk of adverse events (P = .01, P < .01, P = .01, and P = .01, respectively). There were no in-hospital deaths.

Conclusions

RFA was associated with acceptable morbidity and mortality. Factors associated with adverse events should be considered when counseling patients regarding RFA procedures.     

Pulmonary resection for metastatic osteogenic sarcoma.

A retrospective analysis of thirty patients who underwent pulmonary resection for metastatic osteosarcoma over a twenty-eight-year period revealed that most were young males with previous amputations for primary lesions of the lower extremity. In each, one to four thoracotomies had been performed, for a total of fifty-two chest operations with resection of 124 pulmonary metastatic lesions. At last follow-up, eleven of the thirty patients were alive and free of disease. At five years 28 per cent had survived: three of them were alive at more than nine years, and one was alive at nearly twenty years. Adverse survival factors identified were short tumor-free interval and multicentricity of pulmonary metastases. Long-term survival was associated with a tumor-free interval of more than two years and one to four thoracotomies at which few foci were present. As a group, patients selected for lung resection had significantly longer suvival than did patients whose pulmonary metastasis was untreated.     

Endoscopic resection of gastrointestinal lipomas: a single-center experience

Background

Gastrointestinal (GI) lipomas are benign, slow-growing subepithelial tumors. Most lipomas are detected incidentally at endoscopy, but they can cause GI bleeding, abdominal pain, intestinal obstruction, and intussusception, particularly if they are larger than 2 cm in diameter. The aim of this study was to investigate the efficacy, safety, and long-term prognosis of endoscopic treatment of GI lipomas.

Methods

A total of 28 GI lipomas treated endoscopically from January 2005 to June 2012 were retrospectively reviewed. Endoscopic treatment was performed by four methods: the unroofing technique, endoscopic mucosal resection (EMR), EMR after precutting (EMR-P), and endoscopic submucosal dissection (ESD).

Results

Of 28 GI lipomas, 5 were located in the stomach, 2 in the duodenum, and 21 in the colon. Thirteen lipomas were <2 cm in diameter (small lipoma), and the other 15 were ≥2 cm (large lipoma). The unroofing technique was performed in 2 cases, EMR in 17 cases, EMR-P in 4 cases, and ESD in 5 cases. En bloc resection was performed with 21 lesions (75 %), and endoscopic complete resection was achieved with 26 lesions (93 %). Incomplete resection occurred in the 2 cases treated by the unroofing technique. On pathologic examination, complete resection was achieved with 21 lesions (75 %). Delayed bleeding was observed in one patient. There were no serious complications such as perforation or post-procedural stricture. During the mean follow-up period of 19 months (range 2–91 months), no recurrence was observed.

Conclusions

Endoscopic treatment appears to be a safe and effective treatment for GI lipomas, including large lipomas (≥2 cm in diameter).     

A single-center experience with liver transplantation for Wilson's disease

Abstract:  Wilson's disease is an inherited disorder of copper metabolism, presenting with prominent hepatic and neurologic manifestations. There is an established place for liver transplantation in the presence of liver disease, while the indication for neurologic manifestations is debated. Between 1993 and 2005, 11 patients were liver transplanted for Wilson's disease at our institution. We retrospectively reviewed the medical records of the patients. The pathology of the explanted livers was analyzed. The patients were divided into three groups based on the evolution of the disease. Postoperative data gathered included patient and graft outcome, complications, neurologic status, and copper metabolism. Six males and five females were transplanted at a mean age of 29.7 yr (range 15–48 yr). Three patients had a fulminant presentation, two patients had decompensation of established disease, and six patients had chronic disease. Neurologic features were prominent in five patients. The pathologic analysis of the explanted graft showed cirrhosis in all patients. The five patients with fulminant and acute on chronic presentations also showed necrosis in the explant. The mean postoperative follow-up was 56.8 months (range 10–129 months). Two patients were re-transplanted. One patient died because of severe sepsis. Two patients with severe neurologic dysfunction showed significant remission of symptoms. Liver transplantation is a safe and effective treatment for both acute and chronic presentations of Wilson's disease. Acute presentation correlates with the presence of necrosis in the explanted liver. In our series, there was a relevant improvement of the neurologic features after transplantation.     

Endoscopic resection of ampullary neoplasms: a single-center experience

Background

An ampullary tumor, whether malignant or not, must be completely resected. A benign adenoma has the potential for malignant transformation. Currently, endoscopic papillectomy with curative intent is increasingly performed for benign papillary tumors. This study aimed to evaluate the outcome of endoscopic papillectomy performed for ampullary tumors at a single center.

Methods

From July 2003 to June 2008, 22 patients with a diagnosis of ampullary tumors determined by endoscopic retrograde cholangiopancreatography (ERCP) were treated using endoscopic resection of the tumors. Endoscopic resection was performed in a radical fashion analogous to polypectomy for colon adenomas.

Results

The 22 patients (9 men and 13 women) had an average age of 58 ± 14 years (range, 19–85 years). The median follow-up period was 169 days (range, 14–903 days). The papillary lesions ranged in size from 8 to 33 mm. The rate of concordance between the endoscopic forceps biopsy and the resected specimen was 50% (9/18) according to the Vienna classification. Complete endoscopic resections were performed for 17 of 22 the cases (77.3%). The median length of hospital stay was 4 days (range, 2–11 days), and there were no readmissions for complications. Endoscopic complications occurred for 5 (22.7%) of the 22 patients: postpapillectomy pancreatitis for 4 patients, bleeding for 1 patient, and retroperitoneal perforation for 1 patient. However, no procedure-related deaths occurred. After the papillectomy, a pathologically incomplete resection was noted in 10 cases, including submucosal invasion of an adenocarcinoma with lateral clean resection margins.

Conclusions

The findings showed that an endoscopic papillectomy was safe and effective for benign-appearing adenomas with negative biopsy results for a malignancy. This procedure should be considered as the initial intervention in such cases. The decision whether to perform a pancreatoduodenectomy can be made after the pathology report of the resected specimen is obtained from the endoscopic papillectomy.     

A single-center experience of retransplantation for liver transplant recipients with a failing graft

With the accumulation of orthotopic liver transplantation (OLT) recipients, an increased number of patients with graft failure need retransplantation (re-OLT). This study was undertaken to examine our clinical experience of re-OLT for patients with poor graft function after primary transplantation at a single center. We analyzed retrospectively, the clinical data of 32 re-OLTs in 31 patients at our center from January 2004 to February 2007, including indications and causes of death, timing of retransplantation, and surgical techniques. The indications included bile leak (2 cases), biliary stricture (16 cases), recurrence of hepatocellular carcinoma (HCC) (5 cases), hepatic artery stenosis (4 cases), hepatic artery thrombosis (HAT) (2 cases), and hepatitis B recurrence (3 cases). The rate of re-OLT was 4.29%. All patients underwent modified piggyback liver transplantations with cadaveric allografts. No intraoperative mortality and acute rejection occurred. Overall, 17 of 31 patients (54.8%) died after re-OLT with survival times ranging from 2 weeks to 28 months. Another 14 patients were cured with survival times of 4 to 32 months. The perioperative mortality rate of patients who underwent re-OLT between 8 and 30 days after their initial transplantation was highest (66.7%). The most common cause of death after re-OLT was sepsis (47.1%), multiple-organ failure (17.6%), and recurrence of HCC (17.6%), whereas the majority of deaths posttransplantation were sepsis-related (54%) within 1 year. Re-OLT is the only therapeutic option for a failing liver graft. Proper indications and optimal operative time, advanced surgical procedures, reasonable individual immunosuppression regimens, and effective perioperative anti-infection treatments contribute to the improved survival of patients after re-OLT.     

Pediatric liver transplantation for inherited metabolic liver disease: a single-center experience

Objective

We performed single-center outcome comparison of pediatric recipients who underwent liver transplantation for either genetic or metabolic disease including the clinical impact of using heterozygote parents as living donors.

Materials and Methods

Pediatric liver transplant recipients from September 2007 to December 2010 were included. Patients were separated into 2 categories by etiology of liver disease: (1) genetic or metabolic liver disease (G/M) and (2) nongenetic or metabolic liver disease (non-G/M), which included all other remaining etiologies combined. Patient demographics, recipient and donor characteristics, graft type, operative data, recipient complications, allograft and patient survival were analyzed.

Results

Forty liver transplants were performed on 40 patients; 18 were transplanted for G/M; mean waiting time was 101 days for G/M group and 57 days for non-G/M group; 9 patients were listed as status 1, 5 were granted PELD/MELD exceptions; the overall mean PELD/MELD score was 21. Four G/M patients had hepatocellular carcinoma in the explant without microvascular invasion. Overall complications requiring either surgery or interventional radiology occurred in 14 patients—G/M (n = 5); CMV viremia was seen in 11 patients (G/M, n = 1); detectable EBV DNA was detectable in 8 patients (G/M, n = 4), acute cellular rejection was seen in 10 (G/M, n = 5), postransplant lymphoproliferative disease occurred in 2 G/M patients; and 1 G/M patient showed significantly improved posttransplant neurologic motor function. Children with G/M who received a living donor liver transplant from heterozygote parents did well without any signs of expressing underlying metabolic disease. Posttransplant graft and patient overall survival at 12 months for G/M and non-G/M was 100%, and at 36 months, 83% and 100%, respectively.

Conclusion

The majority of children transplanted for either genetic or metabolic disease were status 1 or awarded UNOS exception points. Cadaveric split livers and live donors including obligate heterozygotes resulted in excellent allograft and patient survival outcomes. In metabolic and genetic liver diseases, close follow-up and timely transplantation can preclude malignant spread and prevent disease progression and consequences, as well as reverse neurologic sequelae.