Laparoscopic liver resection for hepatocellular carcinoma with cirrhosis in a single institution

Background

In a statement by the second International Consensus Conference for Laparoscopic Liver Resection (LLR), minor LLR was confirmed to be a standard surgical practice, as it has become adopted by an increasing proportion of surgeons. However, it is unclear whether this applies to the more complex group of patients suffering from cirrhosis. Therefore, the aim of this retrospective study was to compare the feasibility and safety of LLR for hepatocellular carcinoma (HCC) between non-liver cirrhosis (NLC) patients and liver cirrhosis (LC) patients at a single high-volume laparoscopy center.

Methods

From the beginning of 2000 to the end of 2013, open liver resection (OLR) was performed in 99 HCC patients, and LLR was in 118. The HCC patients who underwent LLR were divided into NLC-LLR (n=60) and LC-LLR (n=58) groups, and we compare the short-term outcomes between them.

Results

There was no significant difference in the incidence of blood loss and transfusion requirements between the NLC-LLR group and the LC-LLR group, although wedge resection was mainly performed in the LC-LLR group. There was no significant difference in the complication rate between the two groups, and the remarkable finding was that there was a significantly lower incidence of postoperative ascites in the LC-LLR group than in the NLC-LLR group.

Conclusions

According to our experience, it appears that LLR for selected HCC patients with cirrhosis is a feasible and promising procedure that is associated with less blood loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted.     

Intrinsic activity and comparative molecular dynamics of buspirone analogues at the 5-HT(1A) receptors

In CNS, the 5-hydroxytryptamine(1A) (5-HT(1A)) receptors exist in two different populations with different behavioural and physiological effects: (1) somatodendritic autoreceptors located pre-synaptically of 5-HT containing neurons and (2) receptors located post-synaptic to 5-HT containing neurons. Clinical studies have shown that 5-HT(1A) partial agonists have anxiolytic properties, while antagonists of pre-synaptical autoreceptors shorten the onset time of selective serotonin reuptake inhibitors (SSRIs). In the present study, the pre- and post-synaptic activity of structural analogues of buspirone was evaluated in animal models. A three dimensional model of the 5-HT(1A) receptor was used to study their interaction modes and helical displacements upon receptor binding. The predicted receptor-ligand interactions indicated similarities in the receptor binding modes for all buspirone analogues, and no clear relationship between receptor contact residues and activity at pre- and post-synaptic receptors. Comparative molecular dynamics (MD) simulations for 650ps indicated that pre-synaptic antagonistic behaviour is connected to large displacements of transmembrane helix (TMH) 7 upon binding, while pre-synaptic agonistic behaviour is connected to large displacements of TMH2 and small displacements of TMH7. Post-synaptic partial agonist behaviour is connected to large displacements of TMH4 and TMH5 upon binding, while post-synaptic antagonists only slightly displace these helices.     

Laparoscopic right hepatectomy for hepatocellular carcinoma in cirrhotic patient

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer. Liver resection or liver transplantation is the therapeutic gold standards in patient with HCC related with or without underline liver disease. We present a video case of a 68-year-old woman admitted to our surgical and liver transplantation unit for HCC on liver segment VII. Patient has HCV cirrhosis. Patient underwent to previous right portal vein embolization. Model of end staged liver disease was 7. Body mass index (BMI) was 26.3 and ASA score was 2. Alpha-fetoprotein was 768. According with our multidisciplinary group, we suggest a laparoscopic right hepatectomy for the patient. Operation time was 343 min and blood loss estimation was 200 CC. No transfusion was required. Post-operative course was uneventful, grade 0 of Clavien-Dindo Classification. Patient was discharged in day 7. Pathology report describes a 17 mm × 15 mm HCC grade 4, pT2N0. Laparoscopic liver resection (LLR) for HCC should be performed by dedicated surgical teams in hepatobiliary and laparoscopic surgery. The use of LLR in cirrhotic patients is in many centers proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.     

上海某区儿童血清轮状病毒LLR型疫苗株的免疫水平

[目的]了解2012年上海部分0～5周岁儿童的血清轮状病毒LLR型中和抗体水平及不同年龄段儿童轮状病毒感染的情况,为疫苗的研究提供科学数据。[方法]在2012年6—8月上海市静安区儿保门诊部就诊的儿童中,筛选无发热、无轮状病毒感染疑似症状的健康儿童血清标本210份,采用微量中和试验方法检测儿童血清对轮状病毒LLR型疫苗株的中和抗体水平,并对检测结果进行统计学分析。[结果]210份0～5周岁儿童血清中,轮状病毒LLR型中和抗体阳性率为27.1%,中和抗体几何平均滴度（GMT）为1∶35.36;0～6个月婴儿血清中和抗体阳性率为16.0%,GMT为1∶28.72;7～11个月儿童血清中和抗体阳性率为2.5%,GMT为1∶25.88。1～2周岁儿童的中和抗体阳性率为20.0%,GMT为1∶30.78,2～3周岁儿童的中和抗体阳性率为20.0%,GMT为1∶32.99,该两年龄组（段）间差异无统计学意义。3～4周岁儿童的中和抗体阳性率为56.67%,GMT为1∶54.84,4～5周岁儿童的中和抗体阳性率为63.33%,GMT为1∶44.55,此两年龄组（段）儿童的阳性率和GMT均显著高于3周岁以下各年龄组,此两组间阳性率差异无统计学意义。[结论]0～3周岁儿童中和抗体水平较低,特别是7～11个月年龄组为最低,提示可能为轮状病毒感染的高危儿童群体。     

The electrically evoked long latency reflex of the biceps brachii muscle: The impact of train stimuli, preceding stimuli, and voluntary muscle contraction

Long latency reflex (LLR) responses were examined over the biceps brachii (BB) at different contraction levels after electrical single or train stimuli over the ipsilateral superficial radial nerve with an inter-stimulus interval of 3ms. Two constant motor waves were present, LLR2 with a peak latency value of 53±4ms and LLR3 with 85±10ms. LLR responses showed a significant increase (twofold) in amplitudes after train stimuli compared to up to a fourfold increase after train stimuli were combined with a weight load of 1.5kg. When LLR were investigated after subsequent (1/s) stimuli by selective averaging, a significant increase in LLR2 amplitude values was seen after the third compared with the first stimulus for trains of 3 stimuli. In the present study, 3 factors exerted an influence on LLR, namely temporal summation of synaptic potentials (by train stimuli), facilitation (with higher stimulus repetition rates), and volition (resulting in muscle contraction). The augmentation behaviour of LLR may be useful for the investigation of central nervous system diseases such as e.g. movement disorders.     

Learning curve in laparoscopic liver surgery: a fellow’s perspective

The learning curve for laparoscopic liver surgery is infrequently addressed in current literature. In this paper, we explored the challenges faced in embarking on laparoscopic liver surgery in a unit that did predominantly open liver surgery. In setting up our laparoscopic liver surgery program, we adopted skills and practices learnt during fellowships at various high volume centers in North America and Australia, with modifications to suit our local patients’ disease patterns. We started with simple minor resections in anterolateral segments to build confidence, which allowed us to train the surgical and nursing team before progressing to more difficult resections. Inter institutional collaboration and exchange of skills also enabled the synergistic development of techniques for safe progression to more complex surgeries. Multimedia resources and international guidelines for laparoscopic liver surgery are increasingly accessible, which further guide the practice of this emerging field, as evidence continues to validate the laparoscopic approach in well selected cases.     

Laparoscopic resection for hepatocellular carcinoma: comparison between Middle Eastern and Western experience

Background

Laparoscopic liver resection (LLR) is growing in popularity, but the short- and long-term outcome of patients undergoing LLR for hepatocellular carcinoma (HCC) has not yet been established.

Methods

A literature search was performed using PubMed, Scopus, and Web of Science (WoS) from cited English and Chinese publications. Clinical and survival parameters were extracted. The search was last conducted in October 2013. After application of selective criteria, 24 remaining original studies with more than 15 patients were analyzed.

Results

In the Western experience, mean operative time was between 150 to 300 minutes, and mean blood loss ranged from 55 to 452 mL. Transfusion was required in all series, ranging from 2.8% to 50%. The conversion rate ranged from 5% to 19.4%. Three cases of death were reported. General morbidity rate ranged from 1.5% to 25%. Specific complications were divided into hemorrhage (2.4% to 25%), ascites (3.7% to 15.3%), and biliary collection (0.6% to 5%). Liver insufficiency was reported in two cases. Mean hospital stay ranged from 5.4 to 15 days. In all case-matched studies, LLR was statistically associated with a shorter hospital stay. The 5-year overall survival rate ranged from 55% to 70%. No trocar-site recurrence was observed. The recurrence rate ranged from 21.4% to 50%. Comparative studies did not demonstrate any significant difference in terms of recurrence between LLR and open liver resection (OLR). In the Middle Eastern experience, mean operative time ranged from 147 to 325 minutes, and mean blood loss ranged from 88 to 808 mL. Transfusion was required, ranging from 1.8% to 19.2%. The conversion rate ranged from 1.8% to 18.6%, and four series reported no conversion. There was no mortality. The main specific complication was ascites (1.7% to 26.6%). A biliary collection was reported in only two series (10.7% and 13.3%), and only one case of postoperative liver insufficiency was reported. Mean hospital stay ranged from 4 to 11.5 days. Statistically, three comparative studies reported a shorter postoperative hospital stay following LLR versus OLR. The 5-year overall survival rate ranged from 50% to 76.6%. Comparative studies did not demonstrate any significant difference in terms of overall survival and recurrence rate between LLR and OLR. No trocar-site recurrence was reported. The recurrence rate ranged from 26.9% to 45.5%, and two series reported no recurrence.

Conclusions

Laparoscopic surgery should be considered an acceptable alternative for the treatment of HCC.     

Laparoscopic liver resection for posterosuperior and anterolateral lesions—a comparison experience in an Asian centre

Background

Minimally invasive surgery has been one of the recent developments in liver surgery, laparoscopic liver resection (LLR) was initially performed for benign lesions at easily accessible locations. As the surgical techniques, technology and experience improved over the past decades, LLR surgery had evolved to tackle malignant lesions, major resections and even in difficult locations without compromising safety and principles of oncology. It was also shown to be beneficial in cirrhotic patients. We describe our initial experience with LLR in a population with significant proportion having cirrhosis, emphasising our approach for lesions in the posterosuperior (PS) segments of the liver (segments 1, 4a, 7, and 8).

Methods

A review of patients undergoing LLR in single institution from 2006 to 2015 was performed from a prospective surgical database. Clinicopathological, operative and perioperative parameters were analyzed to compare outcomes in patients who underwent LLR for PS vs. anterolateral lesions (AL).

Results

LLR was performed in consecutive 197 patients, with a mean age of 60 years. The indications for resection were hepatocellular carcinoma (HCC) (n=105; 53%), colorectal cancer liver metastasis (n=31; 16%), other malignancies (n=19; 10%) and benign lesions (n=42; 21%). A significant proportion had liver cirrhosis (25.9%). More females underwent surgery in the AL group and indications for surgery were similar between both groups. Major liver resection was performed more frequently for the PS group than for the AL group (P<0.001) and significantly more PS resections was performed in our latter experience (P=0.02). The mean operative time and the conversion rate were significantly greater in the PS group than in the AL group (P≤0.001 and 0.03, respectively). However, the estimated blood loss (EBL), rate of blood transfusion and mean postoperative stay were similar in the two groups (P=0.04, 0.88 and 0.92, respectively). The overall 90-day morbidity and mortality rate was 21.3% and 0.5% respectively, with no differences between the two groups. Surrogates of difficulty such as operative time, blood loss, conversion and outcomes e.g., morbidity and mortality, were similar in patients who underwent PS resections with or without cirrhosis.

Conclusions

LLR in selected patients is technically feasible and safe including cirrhotic patients with lesions in the PS segments.