Hepatic perivascular epithelioid cell tumors:The importance of preoperative diagnosis

Accurate preoperative diagnosis is highly important for the treatment of perivascular epithelioid cell tumors(PEComas)because PEComas are mainly benign tumors and may not require surgical intervention.By analyzing the causes,properties and clinical manifestations of PEComas,we summarize the challenges and solutions in the diagnosis of PEComas.

Visualizing traumatic brain injury:ocular clues for diagnosis and assessment

Traumatic brain injury (TBI) is defined as damage to the brain resulting from an external sudden physical force or shock to the head.It is considered a silent public health epidemic causing significant death and disability globally.There were 64,000 TBI related deaths reported in the USA in 2020,with about US$76 billion in direct and indirect medical costs annually.

Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People's Liberation Army

The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army(PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia(MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level Ⅱ facilities. In level Ⅲ facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.

Diagnosis and surgical treatment of primary hepatic lymphoma

AIM: To assess the benefi ts and limits of surgery for primary hepatic lymphoma (PHL), and probability of survival after postoperative chemotherapy. METHODS: A retrospective analysis was undertaken to determine the results of surgical treatment of PHL over the past 8 years. Only nine patients underwent such treatment. The detailed data of diagnosis, treatment, and prognosis were carefully studied. RESULTS: All patients were mistaken as having α-fetoprotein-negative hepatic cancer before pathological diagnosis. The mean delay time between initial symptoms and final diagnosis was 26.8 d (range:14-47 d). Hepatitis B virus infection was noted in 33.3% of these patients. Most of the lesions were found to be restricted to a solitary hepatic mass. The surgical procedure performed was left hepatectomy in five cases, including left lateral segmentectomy in three. Right hepatectomy was performed in three cases and combined procedures in one. One patient died on the eighth day after surgery,secondary to hepatic insufficiency. The cumulative 6-mo, 1-year, and 2-year survival rates after hepatic surgery were, respectively, 85.7%,71.4%, and 47.6%. One patient survived for>5 years after surgery without any signs of recurrence until latest follow-up, who received routine postoperative chemotherapy every month for 2 years and then regular follow-up. By univariate analysis, postoperative chemotherapy was a significant prognostic factor that influenced survival (P=0.006). CONCLUSION: PHL is a rare entity that is often misdiagnosed, and has a potential association with chronic hepatitis B infection. The prognosis is variable, with good response to early surgery combined with postoperative chemotherapy in strictly selected patients.

Hepatic epithelioid hemangioendothelioma:Update on diagnosis and therapy

With an estimated incidence of only 1-2 cases in every 1 million people,hepatic epithelioid hemangioendothelioma(HEHE)is a rare vascular endothelial cell tumor occurring in the liver and consisting of epithelioid and histiocyte-like vascular endothelial cells in mucus or a fibrotic matrix.HEHE is characterized as a low-to-moderate grade malignant tumor and is classified into three types:solitary,multiple,and diffuse.Both the etiology and characteristic clinical manifestations of HEHE are unclear.However,HEHE has a characteristic appearance on imaging including ultrasound,magnetic resonance imaging,and positron emission tomography/computerized tomography.Still,its diagnosis depends mainly on pathological findings,with immunohistochemical detection of endothelial markers cluster of differentiation 31(CD31),CD34,CD10,vimentin,and factor VIII antigen as the basis of diagnosis.Hepatectomy and/or liver transplantation are the first choice for treatment,but various chemotherapeutic drugs are reportedly effective,providing a promising treatment option.In this review,we summarize the literature related to the diagnosis and treatment of HEHE,which provides future perspectives for the clinical management of HEHE.

Tools for the diagnosis of hepatitis C virus infection and hepatic fibrosis staging

Hepatitis C virus(HCV)infection represents a major public health issue.Hepatitis C can be cured bytherapy,but many infected individuals are unaware of their status.Effective HCV screening,fast diagnosis and characterization,and hepatic fibrosis staging are highly relevant for controlling transmission,treating infected patients and,consequently,avoiding end-stage liver disease.Exposure to HCV can be determined with high sensitivity and specificity with currently available third generation serology assays.Additionally,the use of point-of-care tests can increase HCV screening opportunities.However,active HCV infection must be confirmed by direct diagnosis methods.Additionally,HCV genotyping is required prior to starting any treatment.Increasingly,high-volume clinical laboratories use different types of automated platforms,which have simplified sample processing,reduced hands-on-time,minimized contamination risks and human error and ensured full traceability of results.Significant advances have also been made in the field of fibrosis stage assessment with the development of non-invasive methods,such as imaging techniques and serum-based tests.However,no single test is currently available that is able to completely replace liver biopsy.This review focuses on approved commercial tools used to diagnose HCV infection and the recommended hepatic fibrosis staging tests.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries(BDIs)are difficult to avoid absolutely when the biliary tract has a malformation,such as accessory hepatic duct.Here,we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

Hepatic epithelioid hemangioendothelioma: Dilemma and challenges in the preoperative diagnosis

Hepatic epithelioid hemangioendothelioma(HEHE) is a rare category of vascular tumor with uncertain malignant potential. It commonly presents nonspecific and variable clinical manifestations, ranging from asymptomatic to hepatic failure. In addition, laboratory measurements and imaging features also lack specificity in the diagnosis of HEHE. The aim of the present study is to highlight the dilemma and challenges in the preoperative diagnosis of HEHE, and to enhance awareness of the range of hepatobiliary surgery available in patients with multiple hepatic nodular lesions on imaging. In these patients, HEHE should at least be considered in the differential diagnosis.

Diagnosis and surgical treatment of hepatic hilar cholangiocarcinoma

BACKGROUND: Hepatic hilar cholangiocarcinoma can be diagnosed early with the progress in diagnostic imaging, and thus the rate of resection of the tumor has increased markedly. To assess the effectiveness of resection, we reviewed 185 cases of hepatic hilar cholangiocarcinoma diagnosed and treated at our hospital. METHODS: The clinical data of 185 patients with hepatic hilar cholangiocarcinoma who had been treated surgically from 1972 to 2006 were retrospectively analyzed. RESULTS: The records of the 185 patients were divided into first stage (1972-1986) or second stage (1987-2006) according to the incidence of the tumor and its resection rate. Primary symptoms included upper abdominal discomfort or pain, anorexia, tiredness, weight loss and progressive jaundice. Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) were first line methods for atraumatic diagnosis. If the patients displayed intrahepatic bile duct dilatation or were diagnosed as suffering from extrahepatic obstructive jaundice, percutaneous transhepatic cholangiography (PTC), MRCP or endoscopic retrograde cholangiopancreatography (ERCP) should be used. In this series, 87 patients underwent resection of the tumor (47.0%). Of the 87 patients, 43 received radical resection and 44 palliative resection. Fifteen patients underwent resection in the first stage and 72 in the second stage. A total of 74 patients were followed up after the resection. The median survival time of the radical resection group was 37 months and that of the palliative resection group was 17 months (P<0.001). The other 62 patients receiving no resection died within 1.5 years. CONCLUSIONS: Once patients are diagnosed with hepatic hilar cholangiocarcinoma, they should undergo exploratory laparotomy. Resection is the most effective method for the treatment of hepatic hilar cholangiocarcinoma.

Isolated segmental,sectoral and right hepatic bile duct injuries

The treatment of isolated segmental, sectoral and right hepatic bile duct injuries is controversial. Nineteen patients were treated over a 26-year period. Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery; 3 over a T-tube, 1 with a Roux-en-Y. These patients had an uneventful recovery. The second group consisted of 5 patients in whom the duct was ligated; 4 developed infection, 3 of which required drainage and biliary repair. Two patients had good long-term outcomes; the third developed a late anastomotic stricture requiring further surgery. The fourth patient developed a small bile leak and pain which resolved spontaneously. The fifth patient developed complications from which he died. The third group was comprised of 4 patients referred with biliary peritonitis; all underwent drainage and lavage, and developed biliary fistulae, 3 of which resolved spontaneously, 1 required Roux-en-γ repair, with favorable outcomes. The fourth group consisted of 6 patients with biliary fistulae. Two patients, both with an 8-wk history of a fistula, underwent Roux-en-γ repair. Two others also underwent a Roux-en-γ repair, as their fistulae showed no signs of closure. The remaining 2 patients had spontaneous closure of their biliary fistulae. A primary repair is a reasonable alternative to ligature of injured duct. Patients with ligated ducts may develop complications. Infected ducts require further surgery. Patients with biliary peritonitis must be treated with drainage and lavage. There is a 50% chance that a biliary fistula will close spontaneously. In cases where the biliary fistula does not close within 6 to 8 wk, a Roux-en-γ anastomosis should be considered.

Hepatic epithelioid hemangioendothelioma:Clinical characteristics,diagnosis,treatment,and prognosis

BACKGROUND Hepatic epithelioid hemangioendothelioma(HEHE)is a rare hepatic vascular tumor with unpredictable malignant potential.The etiology,characteristics,diagnosis,treatment,and prognosis of HEHE are not well-understood,and largescale retrospective studies are required to understand better this disease.AIM To determine the characteristics of HEHE and identify its optimal treatments and prognostic factors.METHODS The clinical data of two patients diagnosed with HEHE at the Fourth Hospital of Hebei Medical University and 258 previously reported cases retrieved from the China National Knowledge Infrastructure and PubMed databases between 1996 and 2021 were combined and summarized.All cases were pathologically identified as HEHE.Information such as clinical features,laboratory examination findings,imaging findings,pathological characteristics,treatment,and survival periods was reviewed.Kaplan-Meir curves were used for survival analysis.Prognostic factors were identified by Cox regression analysis.RESULTS HEHE primarily affected middle-aged women.The typical manifestations included epigastric pain,hepatosplenomegaly,inappetence,distension,weight loss,and fatigue.Tumor markers were expressed normally.The incidence of extrahepatic metastasis was 34.5% at the time of diagnosis.The most common sites of extrahepatic involvement were the lungs(22.3%),lymph nodes(5.6%),peritoneum(3.6%),bones(6.6%),and spleen(5.1%).Furthermore,“capsular retraction”,“target sign”,and“lollipop sign”were the characteristic features of HEHE on imaging.The immunohistochemical profile for HEHE(expression of vascular markers,such as factor VIII-related antigen,CD31,and CD34;expression levels of D2-40)can facilitate and ensure an accurate diagnosis.The management options for patients with HEHE include liver resection(29.7%),liver transplantation(16.1%),palliative treatments(12.7%),transhepatic arterial chemotherapy and embolization(TACE,10.2%),chemotherapy(11.0%),antiangiogenic therapy(15.3%),and other treatments(5.1%);the mean survival time was 158.6,147.3,4.2,90.8,71.4,83.1,and 55.0 mo,respectively.The survival time of patients who underwent surgical treatment was longer than that of patients who did not.TACE and antiangiogenic therapy tended to prolong survival compared with other nonsurgical treatments.The 1-,5-,and 10-year survival rates were 82%,71%,and 64%,respectively.Multivariate analysis showed that liver function(P=0.045),intrahepatic metastasis(P=0.029),and treatment(P=0.045)were independent prognostic factors.The presence of extrahepatic metastases was not an independent risk factor for poor prognosis(P=0.558).CONCLUSION The clinical course of HEHE is rare and variable,and patients with intrahepatic metastases and liver dysfunction may have a poorer prognosis than those without.Surgical intervention,whether liver resection or transplantation,might be warranted regardless of extrahepatic metastasis.For patients without the option for surgery,clinicians should consider the use of TACE with antiangiogenic drugs in the treatment of HEHE.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery:An algorithmic approach

AIM:To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. METHODS:During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. RESULTS:Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). CONCLUSION:Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Diagnosis and Treatment of 42 Cases of Multiple Injuries with Pancreatic Injury

In order to summarize the clinical diagnosis and treatment methods for 42 cases of multiple injuries with pancreatic injury, a retrospective analysis on 42 cases of multiple injuries with pancreatic injury from January 1990 to January 2006 was carried out in our hospital. Most cases were associated with hemopneumothorax and rib fractures （52.3%）, shock （50%）, multiple fractures （47.6%）, and severe brain injury （26.1%）. In 42 cases, one case died of severe hemorrhagic shock, and the remaining 41 cases （97.6%） were cured （including 40 cases receiving surgical operation and one case receiving the conservative treatment）. Postoperative complications occurred in 16 cases （21 cases/times）： pancreatic fistula （5 cases/times） and incisional wound infection （5 cases/times）, intra-abdominal infection （3 cases/times）, stress ulcer （3 cases/times）, pleural effusion （3 cases/times）, pulmonary infection （one case） and wound dehiscence （1 case）. The principle therapy of multiple injuries with pancreatic injury is to rescue life, followed by active treatment to prevent injuries which giving rise to the abnormal respiratory and circulatory functions, management of cerebral hernia and other injuries which endangers life at last, and the pancreatic injury to increase the survival rate and survival quality.

Doppler Ultrasound of Hepatic Vessels in the Diagnosis of Cirrhosis of the Liver in Togo

The aim of this work is to evaluate the role of Ultrasound-Doppler in the hemodynamic study of hepatic vessels during the liver cirrhosis in Togo. Method: This was an analytic cross-sectional study that measured the velocimetric parameters of hepatic vessels in cirrhotic patients and in non-cirrhotic patients. Results: The velocimetric parameters of the hepatic artery, the portal vein, and the hepatic veins were measured in 50 cirrhotic patients and 50 non-cirrhotic The caliber of the portal vein was significantly increased in cirrhotic patients compared to non-cirrhotic patients with 13.11 ± 2.16 mm versus 11.45 ± 1.02 (p Conclusion: The hemodynamic study of the hepatic vessels can and must rightly be a diagnostic argument for liver cirrhosis.

Visual electrophysiological examination in diagnosis of hepatic encephalopathy

Clinical observation of the neuropsychiatric condition, psychometric tests, and EEG recordings has been used to diagnose hepatic encephalopathy. However, no standardization for the diagnosis of minimal hepatic encephalopathy (MHE) has been achieved. According to the study in normal subjects, visual electrophysiology testing is a method of simple, objective record for the medical examination, which includes visual evoked potentials (VEP), electroretinograms (ERG), etc. 23 hepatic encephalopathy patients prospectively underwent visual electrophysiology testing and laboratory serum analysis, and it was found that 22 visual electrophysiology abnormalities which showed that the amplitudes were decreased and the implicit times were prolonged compared with the normal. The relationship between biochemical parameters and visual electrophysiology parameters showed that visual recording was related to the damage of the liver. On the basis of this preliminary study, we could conclude that this method can be as a way to predict for hepatic encephalopathy and it appears to be a method in the recognition of the MHE.

Evaluation of hepatic fibrosis parameter model and elastic modulus of liver and spleen for the diagnosis of hepatic fibrosis in chronic hepatitis b

Objective Toinvestigate the diagnostic value of hepatic fibrosis parameter model and elastic modulus of liver and spleen in hepatic fibrosis of chronic hepatitis b.Methods 77 patients with hepatic fibrosis of chronic hepatitis in the infection clinic were recruited from July 2016 to December 2018.According to the classification of hepatic fibrosis,23 patients were classified as S1,20 as S2,18 as S3 and 16 as S4.The serum indexes of liver function in all patients were tested,FIB-4,APRI and GPR model indexes were calculated.SWE values of liver and spleen were evaluated,and the correlation between FIB-4,APRI,GPR and SWE was analyzed.Results The SWE values of liver and spleen in the study group were significantly higher than those in the normal group(P<0.01),and the differences in serum GGT,PLT,AST and portal vein velocity between the two groups were statistically significant(P<0.01).GGT and PLT were correlated with SWE values of liver and spleen,which were statistically significant(P<0.01).The model indexes of fib-4,APRI and GPR in the study group were all higher than those in the normal group,with statistically significant differences(P<0.01).Pearson correlation analysis showed that liver SWE value and spleen SWE value were positively correlated with fib-4,APRI and GPR,and the differences were significant(P<0.01),with a higher correlation with GPR.Conclusion GGT,PLT and GPR are positively correlated with SWE of liver and spleen,and combined detection can improve the early diagnosis accuracy of liver fibrosis.

Efficient Computer Aided Diagnosis System for Hepatic Tumors Using Computed Tomography Scans

One of the leading causes of mortality worldwide is liver cancer.The earlier the detection of hepatic tumors,the lower the mortality rate.This paper introduces a computer-aided diagnosis system to extract hepatic tumors from computed tomography scans and classify them into malignant or benign tumors.Segmenting hepatic tumors from computed tomography scans is considered a challenging task due to the fuzziness in the liver pixel range,intensity values overlap between the liver and neighboring organs,high noise from computed tomography scanner,and large variance in tumors shapes.The proposed method consists of three main stages;liver segmentation using Fast Generalized Fuzzy C-Means,tumor segmentation using dynamic thresholding,and the tumor’s classification into malignant/benign using support vector machines classifier.The performance of the proposed system was evaluated using three liver benchmark datasets,which are MICCAI-Sliver07,LiTS17,and 3Dircadb.The proposed computer adided diagnosis system achieved an average accuracy of 96.75%,sensetivity of 96.38%,specificity of 95.20%and Dice similarity coefficient of 95.13%.

Novel computerized psychometric tests as primary screening tools for the diagnosis of minimal hepatic encephalopathy

Minimal hepatic encephalopathy(MHE)is a critical neurocognitive complication of decompensated liver cirrhosis and portosystemic shunting,which results in a wide range of cognitive deficits including impairments in working attention,psychomotor speed,and executive function.Current guidelines have recommended paper-and-pencil psychometric tests for the diagnosis of MHE.Most high-risk cirrhotic patients are required to be examined;however,paperand-pencil psychometric tests are neither convenient nor rapid to perform in the clinic.Recently,novel computerized psychometric tests,including the inhibitory control test,EncephalApp Stroop App,and critical flicker frequency,have been proven to be rapid,effective,and convenient methods for screening MHE in clinical practice and for identifying high-risk cirrhotic patients for further validation using rigid neuropsychometric examinations.However,diagnostic accuracy of these tests is influenced by educational background,age,and cultural differences.This review summarizes clinical evidence of the application of novel computerized psychometric tests for screening MHE.

Early Diagnosis and Treatment of Traumatic Diaphragmatic Injuries

Introduction: Early diagnosis and treatment of injuries of the diaphragm are important both because of high incidence of concomitant injuries and since they may lead to life-threatening intestinal and gastric strangulation in the late term. Herein, cases with diaphragmatic injury that have been diagnosed and operated in the early period after injury or during surgery were presented. Methods: Data of 14 cases, which have been diagnosed with diaphragmatic injury after trauma or during surgical procedure that was performed because of concomitant abdominal or intra-thoracic injury between January 2008 and April 2013, were retrospectively reviewed. Results: Of the traumatic diaphragmatic injuries, 10 (71.4%) have occurred due to penetrating trauma, whereas 4 (28.5%) have occurred due to blunt trauma. Diagnosis was made using I.V. contrast-enhanced whole abdominal and thoracic tomography in all 3 pediatric cases (21.4%) and during surgery in the others (78.5%). Conclusion: All of the diaphragmatic injuries have been accompanied by intra-abdominal or intra-thoracic organ injury that requires surgery. In these cases, the diagnosis was made on suspicion of diaphragmatic injury in the course of surgical procedure performed for concomitant organ injury. Computed tomography was diagnostic for diaphragmatic injuries in the pediatric cases.

Diagnosis and treatment of trauma of hepatic portal bile duct

Objective To investigate the diagnosis and treatment of trauma of hepatic portal bile duct. Methods Eight cases of trauma of the hepatic portal bile duct were reviewed. All short-term splits were treated with repair plus drainage with supporting tube. In 7 cases, there were combined injuries of 2 or more than 2 organs. The combined injuries were respectively treated. Long-term complication of bile duct stenosis was managed with internal drainage. Results Five cases were found during operation. Of these 5 patients, 3 were with the traumatic split less than 50% diameter and 2 with that more than 50% diameter. After repair,1 of the former 3 died and 2 remained in good condition. However, 1 of the latter 2 died and 1 was reoperated on due to bile duct stricture after the repair. Other 3 cases were found due to postoperative bile leakage. They were treated with internal drainage and good results achieved. Conclusion It is difficult to make a definite diagnosis of traumatic injury of hepatic protal bile