Combined hepatic segment color rendering technique improves the outcome of anatomical hepatectomy in patients with hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the third most common cause for cancer-related death worldwide,especially in China[1].Hepatectomy is considered one of the most potentially curative therapies for HCC[2].As HCC is capable of vascular invasion and metastasis via the portal venous system,anatomical resection is often performed to reduce tumor recurrence.This process involves resecting the tumor-bearing portal branches and the corresponding hepatic parenchyma[3].Certain comparative studies have demonstrated better overall survival and disease-free survival with the use of anatomical resection when compared with nonanatomical resection[4–6].

Risk scoring system and predictor for clinically relevant pancreatic fistula after pancreaticoduodenectomy

AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula(POPF) was defined and classified by the international study group of pancreatic fistula(ISGPF).We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups(low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day(POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic(ROC) curves.RESULTS: Grade A POPF occurred in 106(11.5%)patients, grade B occurred in 57(6.2%) patients,and grade C occurred in 32(3.5%) patients. A predictive scoring system for CR-POPF(0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio(OR) = 3.86;95% confidence interval(CI): 1.92-7.75, P = 0.00],soft gland texture(OR = 4.50; 95%CI, 2.53-7.98, P =0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL(OR = 3.45; 95%CI,1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct(OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value(Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinicalPOPF(the sensitivity and specificity were 75% and85%, respectively). In the high risk group, the best cutoff was a drain amylase level of 1600(the sensitivity and specificity were 77 and 63%, respectively).CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.

Comprehensive application of modern technologies in precise liver resection

BACKGROUND: Liver surgery has gone through the phases of wedge liver resection, regular resection of hepatic lobes, irregular and local resection, extracorporeal hepatectomy, hemi-extracorporeal hepatectomy and Da Vinci surgical system-assisted hepatectomy. Taking advantage of modern technologies, liver surgery is stepping into an age of precise liver resection. This review aimed to analyze the comprehensive application of modern technologies in precise liver resection. DATA SOURCE: PubMed search was carried out for English-language articles relevant to precise liver resection, liver anatomy, hepatic blood inflow blockage, parenchyma transection, and down-staging treatment. RESULTS: The 3D image system can imitate the liver operation procedures, conduct risk assessment, help to identify the operation feasibility and confirm the operation scheme. In addition, some techniques including puncture and injection of methylene blue into the target Glisson sheath help to precisely determine the resection. Alternative methods such as Pringle maneuver are helpful for hepatic blood inflow blockage in precise liver resection. Moreover, the use of exquisite equipment for liver parenchyma transection, such as cavitron ultrasonic surgical aspirator, ultrasonic scalpel, Ligasure and Tissue Link is also helpful to reduce hemorrhage in liver resection, or even operate exsanguinous liver resection without blocking hepatic blood flow. Furthermore, various down-staging therapies including transcatheter arterial chemoembolization and radio-frequency ablation were appropriate for unresectable cancer, which reverse the advanced tumor back to early phase by local or systemic treatment so that hepatectomy or liver transplantation is possible.CONCLUSIONS: Modern technologies mentioned in this paper are the key tool for achieving precise liver resection and can effectively lead to maximum preservation of anatomical structural integrity and functions of the remnant liver. In addition, large randomized trials are needed to evaluate the usefulness of these technologies in patients with hepatocellular carcinoma who have undergone precise liver resection.

Usefulness of three-dimensional visualization technology in minimally invasive treatment for infected necrotizing pancreatitis

AIM To explore the value of three-dimensional(3 D) visualization technology in the minimally invasive treatment for infected necrotizing pancreatitis(INP). METHODS Clinical data of 18 patients with INP, who were admitted to the PLA General Hospital in 2017, were retrospectively analyzed. Two-dimensional images of computed tomography were converted into 3 D images based on 3 D visualization technology. The size, number, shape and position of lesions and their relationship with major abdominal vasculature were well displayed. Also, percutaneous catheter drainage(PCD) number and puncture paths were designed through virtual surgery(percutaneous nephroscopic necrosectomy) based on the principle of maximum removal of infected necrosis conveniently.RESULTS Abdominal 3 D visualization images of all the patients were well reconstructed, and the optimal PCD puncture paths were well designed. Infected necrosis was conveniently removed in abundance using a nephroscope during the following surgery, and the median operation time was 102(102 ± 20.7) min. Only 1 patient underwent endoscopic necrosectomy because of residual necrosis. CONCLUSION The 3 D visualization technology could optimize the PCD puncture paths, improving the drainage effect in patients with INP. Moreover, it significantly increased the efficiency of necrosectomy through the rigid nephroscope. As a result, it decreased operation times and improved the prognosis.

Post-pancreaticoduodenectomy hemorrhage:risk factors, managements and outcomes

BACKGROUND： Post-pancreaticoduodenectomy（PD） hemorrhage（PPH） is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.METHODS： A total of 840 patients with PD between 2000 and2010 were retrospectively analyzed. Among them, 73 patients had PPH： 19 patients had early PPH and 54 had late PPH.The assessment included the preoperative history of disease,pancreatic status and surgical techniques. Other postoperative complications were also evaluated.RESULTS： The incidence of PPH was 8.7%（73/840）. There were no independent risk factors for early PPH. Male gender（OR=4.40, P0.02）, diameter of pancreatic duct（OR=0.64,P0.01）, end-to-side invagination pancreaticojejunostomy（OR=5.65, P0.01）, pancreatic fistula（OR=2.33, P0.04）and intra-abdominal abscess（OR=12.19, P0.01） were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8%（15/54）. Initial endoscopy was operated in 12 patients（22.2%）, initial angiography in 19（35.2%）,and relaparotomy in 15（27.8%）. Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure,hemorrhagic shock, sepsis and uncontrolled rebleeding.CONCLUSIONS： Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH,surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.

Diagnosis and Treatment of Cholangiocarcinoma: A Consensus from Surgical Specialists of China

Cholangiocarcinoma refers to malignant tumors that develop in epithelial lining of biliary system, and it is divided into two categories according to tumor location, intrahepatic cholangiocarcinoma （ICC） and extrahepatic cholangiocarcinoma （ECC）. ICC occurs from the epithelial cells of the intrahepatic bile duct, its branches and interlobular biliary tree; and ECC is divided into hilar cholangiocarcinoma and distal cholangiocarcinoma by the circumscription at the confluence of cystic duct and the common hepatic duct.

Left hepatectomy with caudate lobe resection using the methylene blue staining technique for bismuth lllb hilar cholangiocarcinoma

Left hepatectomy with caudate lobe resection has been widely accepted as the standard treatment for bismuth IIIb hilar cholangiocarcinoma(1-6).However,there is no clear boundary between the right caudate lobe and the right posterior section.The methylene blue staining technique are commonly used to delineate the margin of the relevant hepatic segment for anatomic hepatectomy(7).Herein,we described this technique to demarcate the boundary between the caudate lobe and the right posterior lobe for an en bloc resection of the tumor and improve the R0 surgical margin.