The benefit of curative liver resection with a selective bile duct preserving approach for hepatocellular carcinoma with macroscopic bile duct tumor thrombus

BackgroundHepatocellular carcinoma (HCC) presenting with macroscopic bile duct tumor thrombus (BDTT) is an uncommon event. The role of a curative hepatic resection and associated long-term outcomes remain controversial. In addition the necessity for bile duct resection is still unclear. The aim of this study was to evaluate outcomes of hepatectomy with a selective bile duct preservation approach for HCC with BDTT in comparison to outcomes without BDTT.MethodsA total of 22 HCC with BDTT patients who had undergone curative hepatic resection with a selective bile duct preservation approach at our institute were retrospectively reviewed. These were compared to group of 145 HCC without BDTT patients. The impact of curative surgical resection and BDTT on clinical outcomes and survival after surgical resection were analyzed.ResultsAll HCC with BDTT cases underwent major hepatectomy vs. 32.4% in the comparative group. Bile duct preservation rate was 56.5%. The 1-, 3- and 5-year survival rates of HCC with BDTT patients in comparison to the HCC without BDTT group were 81.8%, 52.8% and 52.8% vs. 73.6%, 55.6% and 40.7% (P=0.804) respectively. Positive resection margin, tumor size ≥5 cm and AFP ≥200 IU/mL were significant risk factors regarding overall survival. However, it is unclear whether presence of a bile duct tumor thrombus has an adverse impact on either recurrence free survival or overall survival.ConclusionsBile duct obstruction from tumor thrombus did not necessarily indicate an advanced form of disease. Tumor size and AFP had greater impact on long-term outcomes than bile duct tumor thrombus. Major liver resection with a selective bile duct preserving approach in HCC with BDTT can achieve favorable outcomes comparable to those of HCC without BDTT in selected patients.     

Combination of etoricoxib and low-pressure pneumoperitoneum versus standard treatment for the management of pain after laparoscopic cholecystectomy: a randomized controlled trial

Background and objectives

Postoperative pain is one of the significant problems in laparoscopic surgery, especially during the first 6–12 h. This randomized controlled trial aimed to investigate the effect of combined preemptive etoricoxib 120 mg and low-pressure pneumoperitoneum for the management of pain after laparoscopic cholecystectomy (LC).

Patients and methods

One hundred and twenty patients aged 18–75 with American Society of Anesthesiologists class I–II who were candidates for elective LC were recruited into the study. The patients were randomly divided into two groups, by ‘block of four’ randomization. The treatment group received preemptive etoricoxib 120 mg and intraabdominal pressure of 7 mmHg, and the control group received placebo and intraabdominal pressure of 14 mmHg. The postoperative pain score at rest was recorded utilizing a numeric rating scale at 1, 2, 6, 10, 14, 18, 22, and 24 h. Pain on movement/ambulation (cough) was also recorded at 6, 10, 14, 18, 22, and 24 h.

Results

There were no significant differences in the baseline characteristics of the two groups. The pain scores of the treatment versus control group of abdominal pain and incisional pain were significant on movement. Abdominal pain scores of the treatment group were decreased 0.98 when compared with the control group (p = 0.017), and incisional pain scores were also decreased 0.99 (p = 0.001). The incidences of postoperative shoulder/back pain were statistically significant: 41.8 % vs. 66.7 % in the treatment and control group, respectively (p = 0.009). The postoperative hospital stay in the treatment group and control group was: 1 day = 96.4 and 75.0 %, >1 day = 3.6 and 25.0 %, respectively (p = 0.001).

Conclusions

A combination of preemptive etoricoxib and low-pressure pneumoperitoneum had significant effects in decreasing overall pain and the incidence of shoulder/back pain after LC and also shortened the hospital stay.

Clinical trials registration number

TCTR20140213001.

     

Effect of Recombinant Human Erythroferrone Protein on Hepcidin Gene (Hamp1) Expression in HepG2 and HuH7 Cells

Iron is essential for all living organisms. It is strictly controlled by iron transporters, transferrin receptors, ferroportin and hepcidin. Erythroferrone (ERFE) is an iron-regulatory hormone which is highly expressed in erythroblasts by erythropoietin (EPO) stimulation and osteoblasts independently of EPO by sequestering bone morphogenetic proteins and inhibiting hepatic hepcidin expression. Although the hepcidin suppressive function of ERFE is known, its receptors still require investigation. Here, we aim to identify ERFE receptors on the HepG2 and Huh7 cells responsible for ERFE. Recombinant ERFE (rERFE) was first produced in HEK293 cells transfected with pcDNA3.1 + ERFE, then purified and detected by Western blot. The liver cells were treated with an rERFE-rich medium of transfected HEK293 cells and a purified rERFE-supplemented medium at various time points, and hepcidin gene (Hamp1) expression was determined using qRT-PCR. The results show that 37-kD rERFE was expressed in HEK293 cells. Hamp1 was suppressed at 3 h and 6 h in Huh7 cells after rERFE treatments (p < 0.05), then restored to the original levels. Hamp1 was activated after treatment with purified rERFE for 24 h and 48 h. Together, these results reveal that ERFE suppressed Hamp1 expression in liver cells, possibly acting on membrane ERFE receptor, which in Huh7 cells was more sensitive to the ERFE concentrate.     

How to Reconstruct Middle Hepatic Vein Branches With Explanted Portal Vein and Inferior Mesenteric Vein Graft: A Case Report

Objective

The middle hepatic vein reconstruction is one of the crucial parts in adult living donor liver transplantation. Numerous techniques had been reported by using cadaveric iliac vessel or synthetic graft. The limitations of reported techniques are availability of the vessel and complication of synthetic graft. We report the technique of using explanted portal vein and inferior mesenteric vein graft in sequential fashion.

Digital quantitation of HCC-associated stem cell markers and protein quality control factors using tissue arrays of human liver sections

The most common type of liver cancer, hepatocellular carcinoma (HCC), affects over 500,000 people in the world. In the present study, liver tumor resections were used to prepare tissue arrays to examine the intensity of fluorescence of IHC stained stem cell markers in liver tissue from malignant HCC tumors and accompanying surrounding non-tumor liver. We hypothesized that a correlation exists between the fluorescence intensity of IHC stained HCC and surrounding non-tumor liver compared to liver tissue from a completely normal liver. 120 liver resection specimens (including four normal controls) were placed on a single slide to make a tissue array. They were examined by digitally quantifying the intensity of fluorescence using immuno-histochemically stained stem cell markers and protein quality control proteins. The stem cell markers were OCT3/4, Nanog, CD133, pEZH2, CD49F and SOX2. The protein quality control proteins were FAT10, UBA-6 and ubiquitin. The data collected was used to compare normal liver tissue with HCCs and parent liver tissue resected surgically using antibodies to stem cell markers and quality control protein markers. The measurements of the stem cell marker CD133 indicated an increase of fluorescence intensity for both the parent liver tissue and the HCC liver tissues. The other stem cell markers changed as follows: Nanog and OCT3/4 were decreased in both the HCCs and the parent livers; PEZH2 was reduced in the HCCs; SOX2 was increased in the parent livers compared to the controls; and CD49f was decreased in HCCs only. Protein quality control markers FAT10 and ubiquitin were downregulated in both the HCCs and the adjacent non-tumor tissue compared to the controls. UBA6 was increased in both the HCCs and the parent livers, and the levels were higher in the HCCs compared to the parent livers.     

Prognostic Factors and Survival of Patients with Carcinoma of the Ampulla of Vater after Pancreaticoduodenectomy

Background: Although carcinoma of the ampulla of Vater (CAV) is a rare tumor, accounting for just 0.2% of gastrointestinal cancers, the survival of CAV patients is unfavorable. The five-year rates have ranged from 36.8-75.2% in previous reports but there is a lack of data relating to Thai people. Also prognostic factors are controversial. Objectives: This study aimed to determine survival outcomes and to identify prognostic factors for a positive outcome for CAV patients after surgery. Methods: In this retrospective cohort study, data were collected from CAV patients who underwent surgery in Chiang Mai University Hospital from 2005 to 2012 for time to event analysis, the log rank test and univariate and multivariate Cox’s regression analysis. Results: There were 72 CAV patients recruited, 45.8% being male. The mean age was 65.1 ± 10.5 years and the median waiting time for surgery was 56.5 days (24.5-91.5). The 30 day mortality rate was 5.6%., while 5-yr survival was 33.3%. The average disease free survival was 14.6 months. Prognostic factors relating to recurrence were positive lymph nodes (50% VS 19.6% p = 0.015) and advanced stage (44.1% VS 18.4% p = 0.023). Multivariate analysis showed that the potential prognostic factors for CAV patients included recurrence, moderate and poor differentiation, comorbidities and a tumor size > 2.0 cm. Conclusions: The findings of the study indicate that the overall survival of CAV patients after surgery is quite fair, with a tendency for better outcome with early as compared to advanced lesions. The key prognostic factors were recurrence, moderate and poor differentiation, comorbidity and tumor size > 2.0 cm.