Added value of indocyanine green fluorescence imaging in liver surgery

Recently, indocyanine green (ICG) fluorescence imaging has been widely used as a substitute for cholangiography in hepatobiliary surgery, to detect hepatic tumors, for accurate anatomical hepatectomy, and to increase the safety and accuracy of minimally invasive (laparoscopic and robotic) hepatectomy. The clinical relevance of this method has been increasing gradually, as new procedures develop in this field. Various important roles and the latest added value of ICG fluorescence imaging in liver surgery are discussed in this report.     

Acetylsalicylic acid for metal stent in malignant distal common bile duct obstruction: A randomized controlled trial

BackgroundEndoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction. Self-expandable metal stents have clinical advantages including an increased duration of patency that may be prolonged by acetylsalicylic acid (ASA) use. The aim of this study was to investigate whether ASA had a positive effect on the patency of self-expandable metal stents compared with placebo.MethodsThis prospective, multicenter, double-blinded, and randomized placebo-controlled trial was conducted from October 2017 to May 2020 in Korea. Patients who underwent palliative endoscopic biliary drainage with self-expandable metal stents for malignant distal bile duct obstruction were enrolled, and allocated to ASA treatment or placebo. The study outcomes were the rate of stent dysfunction at 6 months, duration of stent patency, risk factors for stent dysfunction, and any adverse events.ResultsInterim analysis included 24 and 28 patients in the ASA and placebo groups, respectively. There was no significant difference between the ASA and placebo groups in stent dysfunction (25.0% vs. 20.7%, P = 0.761) or the duration of stent patency (150.97 ± 10.55 vs. 158.07 ± 8.70 days, P = 0.497). Six patients experienced suspected ASA-related adverse events, and there was one lethal case.ConclusionsASA did not prolong stent patency. This study was terminated early because of the possibility of serious adverse events related to ASA treatment of these patients receiving palliative care.     

Robotic surgery and liver transplantation: A single-center experience of 501 robotic donor hepatectomies

BackgroundOver the past two decades robotic surgery has been introduced to many areas including liver surgery. Laparoscopic liver surgery is an alternative minimally invasive approach. However, moving on to the complexity of living donor hepatectomies, the advantages of robotic versus laparoscopic approach have convinced us to establish the robotic platform as a standard for living donor hepatectomy.MethodsFrom November 2018 to January 2022, 501 fully robotic donor hepatectomies, including 177 left lateral donor lobes, 112 full left lobes and 212 full right lobes were performed. Grafts were donated to 296 adult recipients and 205 pediatric recipients. Donor age, sex, body weight, body mass index (BMI), graft weight, graft to body weight ratio (GBWR), operative time, blood loss, first warm ischemic time, pain score, length of intensive care unit (ICU) stay and hospital stay, and complications were retrospectively analyzed based on a prospectively kept database. Recipients were evaluated for graft and patient survival, age, sex, BMI, body weight, model of end-stage liver disease score, blood loss, transfusions, operative time, cold ischemic time, length of hospital stay and complications.ResultsThere was no donor mortality. Two cases needed to be converted to open surgery. The median blood loss was 60 mL (range 20-800), median donor operative time was 6.77 h (range 2.93-11.53), median length of hospital stay was 4 days (range 2-22). Complication rate in donors classified following Clavien-Dindo was 6.4% (n = 32) with one grade III complication. Three-year actual recipient overall survival was 91.4%; 87.5% for adult recipients and 97.1% for pediatric recipients. Three-year actual graft overall survival was 90.6%; 87.5% for adult recipients and 95.1% for pediatric recipients. In-hospital mortality was 6%, 9.1% (27/296) for adult recipients and 1.4% (3/205) for pediatric recipients. The recipients’ morbidity was 19.8% (n = 99). Twenty-eight recipients (5.6%) had biliary and 22 (4.4%) vascular complications. Six (12.0%) recipients needed to be re-transplanted.ConclusionsWith growing experience it is nowadays possible to perform any donor hepatectomy by robotic approach regardless of anatomical variations and graft size. Donor morbidity and quality for life results are encouraging and should motivate other transplant centers with interest in minimally invasive donor surgery to adopt this robotic technique.     

Verteporfin synergizes the efficacy of anti-PD-1 in cholangiocarcinoma

BackgroundCholangiocarcinoma (CCA) is one of the primary hepatobiliary malignant neoplasms with only 10% of 5-year survival rate. Promising immunotherapy with the blockade of immune checkpoints has no clear benefit in CCA. The inhibition of YAP1 signaling by verteporfin has shown encouraging results by inhibiting cell proliferation and inducing apoptosis. This study aimed to evaluate the potential benefit of the combination of verteporfin and anti-programmed cell death 1 (PD-1) in CCA mouse model.MethodsWe assessed the cytotoxicity of verteporfin in human CCA cell lines in vitro, including both intrahepatic CCA and extrahepatic CCA cells. We examined the in vitro effect of verteporfin on cell proliferation, apoptosis, and stemness. We evaluated the in vivo efficacy of verteporfin, anti-PD-1, and a combination of both in subcutaneous CCA mouse model.ResultsOur study showed that verteporfin reduced tumor cell growth and enhanced apoptosis of human CCA tumor cells in vitro in a dose-dependent fashion. Nevertheless, verteporfin impaired stemness evidenced by reduced spheroid formation and colony formation, decreased numbers of cells with aldehyde dehydrogenase activity and positive cancer stem cell markers (all P < 0.05). The combination of verteporfin and anti-PD-1 reduced tumor burden in CCA subcutaneous SB1 tumor model compared to either agent alone.ConclusionsVerteporfin exhibits antitumor effects in both intrahepatic and extrahepatic CCA cell lines and the combination with anti-PD-1 inhibited tumor growth.     

Prediction of early recurrence of hepatocellular carcinoma after liver transplantation based on computed tomography radiomics nomogram

BackgroundEarly recurrence results in poor prognosis of patients with hepatocellular carcinoma (HCC) after liver transplantation (LT). This study aimed to explore the value of computed tomography (CT)-based radiomics nomogram in predicting early recurrence of patients with HCC after LT.MethodsA cohort of 151 patients with HCC who underwent LT between December 2013 and July 2019 were retrospectively enrolled. A total of 1218 features were extracted from enhanced CT images. The least absolute shrinkage and selection operator algorithm (LASSO) logistic regression was used for dimension reduction and radiomics signature building. The clinical model was constructed after the analysis of clinical factors, and the nomogram was constructed by introducing the radiomics signature into the clinical model. The predictive performance and clinical usefulness of the three models were evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA), respectively. Calibration curves were plotted to assess the calibration of the nomogram.ResultsThere were significant differences in radiomics signature among early recurrence patients and non-early recurrence patients in the training cohort (P < 0.001) and validation cohort (P < 0.001). The nomogram showed the best predictive performance, with the largest area under the ROC curve in the training (0.882) and validation (0.917) cohorts. Hosmer-Lemeshow testing confirmed that the nomogram showed good calibration in the training (P = 0.138) and validation (P = 0.396) cohorts. DCA showed if the threshold probability is within 0.06-1, the nomogram had better clinical usefulness than the clinical model.ConclusionsOur CT-based radiomics nomogram can preoperatively predict the risk of early recurrence in patients with HCC after LT.     

The critical role of therapeutic plasma exchange in ABO-incompatible liver transplantation

BackgroundThe shortage of donor liver restricts liver transplantation (LT). Nowadays, donor liver with ABO blood group incompatibility between donor and recipient has become an option to expand the source of donor liver. Although it is now possible to perform ABO-incompatible (ABO-I) LT, antibody-mediated rejection (AMR) has been recognized as the primary cause of desperate outcomes after ABO-I LT. Anti-A/B antibody is the trigger of immune response to ABO-I LT graft injury. Therapeutic plasma exchange (TPE) can quickly reduce the titer of plasma antibodies and effectively inhibit humoral immunity.Data sourcesWe searched PubMed and CNKI databases using search terms “therapeutic plasma exchange”, “ABO-incompatible liver transplantation”, “ABO-I LT”, “liver transplantation”, “LT”, “antibody-mediated rejection”, and “AMR”. Additional publications were identified by a manual search of references from key articles. The relevant publications published before September 30, 2020 were included in this review.ResultsDifferent centers have made different attempts on whether to use TPE, when to use TPE and how often to use TPE. However, the control standard of lectin revision level is always controversial, the target titer varies significantly from center to center, and the standard target titer has not yet been established. TPE has several schemes to reduce antibody titers, but there is a lack of clinical trials that provide standardized procedures.ConclusionsTPE is essential for ABO-I LT. Hence, further research and clinical trials should be conducted to determine the best regimen for TPE to remove ABO antibodies and prevent AMR.     

Ubiquitin specific peptidase 1 promotes hepatic fibrosis through positive regulation of CXCL1 by deubiquitinating SNAIL

BackgroundHepatic fibrosis is attributed to an imbalance of extracellular matrix production and lysis. Human hepatic stellate cells (HSCs) have been uncovered to converge through complex interactions with hepatocytes and immune cells, causing scarring in liver damage.AimsWe aimed to investigate the expression status of ubiquitin specific peptidase 1 (USP1) and its potential mechanisms on HSCs and hepatic fibrosis.MethodsHepatic fibrosis animal and cell models were generated using mice with carbon tetrachloride (CCl4) treatment and HSCs LX-2 with TGF-β1 treatment. Relationships among USP1, SNAIL, and CXCL1 were identified via dual-luciferase reporter gene assay, co-immunoprecipitation, and chromatin immunoprecipitation. With gain- and loss-of-experiments, CCK-8 and flow cytometry assays were employed for cell proliferation and apoptosis.ResultsUSP1 upregulated SNAIL expression through deubiquitination to increase CXCL1 expression. USP1 downregulation decreased expressions of fibrosis-related genes, suppressed proliferation, and promoted apoptosis in TGF-β1-induced LX-2 cells, which were reversed by SNAIL overexpression. The pro-fibrosis role caused by SNAIL upregulation was abolished by CXCL1 reduction. Promotive function of USP1/SNAIL/CXCL1 axis in hepatic fibrosis was further confirmed in vivo.ConclusionThese data supported siRNA-mediated silencing of USP1 improved hepatic fibrosis through inhibition of SNAIL and CXCL1, which yields a new therapeutic target for hepatic fibrosis treatment.     

肝血管放置化疗泵术后并发症的处理(附36例病例分析)

目的探讨肝血管置泵术后并发症的处理及预防方法：方法920例置药泵患肯，术后通过药泵治疗一年以上，有36例出现不同的并发症，对不同的并发症采用不同的治疗和预防方法。结果常见并发症32例(导管阻塞17例，移位8例，漏药7例)，罕见并发症4例：结论不论是术中置药泵，还是术后注射药泵，只要按照操作规程，熟练掌握穿刺手术，所有并发症均可避免：