Modified hepatic left lateral lobe inversion in laparoscopic proximal gastrectomy: An analysis of 13 cases

BACKGROUND In laparoscopic proximal gastrectomy(LPG),the prolapse of the hepatic left lateral lobe near the lesser curvature and esophageal hiatus can obstruct the field of vision and operation.Therefore,it is necessary to retract or obstruct the hepatic left lateral lobe to ensure a clear field of vision.AIM To investigate the safety and clinical efficacy of the modified hepatic left lateral lobe inversion technique for LPG.METHODS A retrospective analysis was conducted on the clinical data of 13 consecutive patients with early-stage upper gastric adenocarcinoma or adenocarcinoma of the esophagogastric junction treated with LPG from January to December 2023 at the Department of Gastrointestinal Surgery,Second Affiliated Hospital of Fujian Medical University.The modified hepatic left lateral lobe inversion technique was used to expose the surgical field in all patients,and short-term outcomes were observed.RESULTS In all 13 patients,the modified hepatic left lateral lobe inversion technique was successful during surgery without the need for re-retraction or alteration of the liver traction method.There were no instances of esophageal hiatus occlusion,eliminating the need for forceps to assist in exposure.There was no occurrence of intraoperative hepatic hemorrhage,hepatic vein injury,or hepatic congestion.No postoperative digestive complications of Clavien-Dindo grade≥II occurred wi-thin 30 days after surgery,except for a single case of pulmonary infection.Some patients experienced increases in alanine aminotransferase and aspartate aminotransferase levels on the first day after surgery,which significantly decreased by the third day and returned to normal by the seventh day after surgery.CONCLUSION The modified hepatic left lateral lobe inversion technique has demonstrated satisfactory results,offering ad-vantages in terms of facilitating surgical procedures,reducing surgical trauma,and protecting the liver.

Single hepatocellular carcinoma ≤ 3 cm in left lateral segment:Liver resection or radiofrequency ablation?

AIM: To evaluate the long-term results of radiofrequency ablation (RFA) compared to left lateral sectionectomy (LLS) in patients with Child-Pugh class A disease for the treatment of single and small hepatocellular carcinoma (HCC) in the left lateral segments.

Left lateral decubitus sleeping position is associated with improved gastroesophageal reflux disease symptoms: A systematic review and meta-analysis

BACKGROUND A limited number of studies have demonstrated that sleeping in the left lateral decubitus(LLD)decreases nocturnal reflux in patients with gastroesophageal reflux disease(GERD)compared to right lateral decubitus(RLD)and supine.AIM This systematic review summarizes the association between sleeping in the LLD position and nocturnal reflux in patients with GERD.METHODS Studies published up to July 17,2023,in MEDLINE,EMBASE,and CENTRAL were searched.Eligible studies were randomized and nonrandomized studies assessing the effect of sleeping in LLD compared to RLD and supine in reducing nocturnal reflux in GERD patients.Outcomes include the acid exposure time(AET)(%time in pH<4),acid clearance time(ACT)(in sec/episode),number of reflux episodes,and improvement in N-GSSIQ scores.RESULTS Two nonrandomized studies showed decreased AET and ACT in LLD sleep position in comparison to RLD(mean difference[MD]-2.03[95%CI:-3.62 to-0.45];-81.84[95%CI:-127.48 to-36.20],respectively)and supine position(MD-2.71[95%CI:-4.34 to-1.09];-74.47[95%CI:-116.26 to-32.69],respectively).There was no difference in AET and ACT between RLD sleep position and supine.Furthermore,one randomized controlled trial investigating the use of electronic sleep positional therapy,which increased the duration of LLD sleep and decreased the duration of RLD sleep compared to sham,showed nocturnal symptoms improvement(improved N-GSSIQ score,increased reflux-free nights,and resolution of nocturnal reflux symptoms).CONCLUSION Current evidence suggests that sleeping on the left side could reduce nocturnal reflux and improve GERD-related quality of life,therefore warranting interventions that promote LLD sleep position.

Alternatives to left lateral segment for pediatric liver transplantation, or required surgeon toolkit?

We read with great interest the systematic review on modified grafts for pediatric liver transplantation by Gavriilidis et al.(1)recently published in Hepatobiliary Surgery and Nutrition.The authors aimed to review existing literature related to liver transplantation(LT)in small pediatric recipients using modified left lateral segment(LLS)grafts-reduced/hyper-reduced LLS or monosegments-and how comparable these techniques are to the standard practice using LLS.We congratulate the authors on their publication and would like to highlight some important findings of this study.Gavriilidis et al.’s(1)systematic review included a final cohort of 330 small pediatric recipients of modified LLS over two decades.The discrepancy between years evaluated and number of reported cases included in the systematic review is striking,and somehow not surprising.In the Unites States alone,the pre-transplant mortality amongst candidates younger than 1 year is reported to be 21.7 deaths per 100 patient-years(2).

Alternatives to left lateral sector in paediatric liver transplantation-a systematic review on monosegmental and reduced grafts

Background: Paediatric liver transplantation (pLT) is the treatment of choice for many liver conditions. However, it still poses relevant challenges, mainly related to the size of the recipients. Unlike in adults, excessive graft volume might represent an issue when the estimated graft-recipient-weight-ratio (GRWR) is significantly disproportionate. In this situation, the traditional left lateral sector (LLS) grafts are too big and other alternatives are required, such as monosegmental or reduced (including hyper-reduced) grafts (RLLS/HRLLS). Results with conventional LLS-pLT are excellent and replicating them with monosegmental or RLLS is challenging given (I) the technical complexity and (II) the need to overcome the large-for-size scenario. This article is to review the existing experience with monosegmental, RLLS/HRLLS grafts and appraise its results. Methods: Systematic search of the electronic databases, conducted from their inception until May 2020. Results: After scrutiny of the available literature, 16 studies were included reporting 330 patients transplanted with monosegmental and RLLS/HRLLS grafts. There were 10 re-grafts (6 of them <90 days);90% of grafts were LDLT. Overall, median recipient’s age and weight were 7 months (range, 5 days-22 months) and 5.8 kg (range, 2.6-8 kg) respectively. Median graft weight was 209 grams (range, 124-264 grams) and median GRWR was 3.5% (range, 2.7-5.6%). Hepatic artery and portal vein thrombosis overall incidence were 1.5% and 4.2%;120 out of the 330 pLT were monosegmental (37%) producing a smaller graft (median of 164 grams) and accordingly a lower GRWR (median 3.2%) compared to reduced LLS. With a median follow-up of 39 months (range, 6-87 months), the overall graft and patient survival were 84% (285/340) and 89% (295/330). Discussion: Monosegmental and RLLS/HRLLS grafts provide access to liver transplantation for very small recipients with excellent results comparable to the standard LLS.

Cholangiojejunostomy for multiple biliary ducts in living donor liver transplantation: A case report

BACKGROUND Laparoscopic living donor hepatectomy(LLDH)has been successfully carried out in several transplant centers.Biliary reconstruction is key in living donor liver transplantation(LDLT).Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage.Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points,biliary variability and limitations associated with LLDH,multiple biliary tracts are often encountered during surgery,which inhibits biliary reconstruction.A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT.This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARY A 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation.Due to the scarcity of deceased donors,she was put on the waiting list for LDLT.Her father was a suitable donor;however,after a rigorous evaluation,preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract.Therefore,a laparoscopic left lateral section was performed on the donor,which met the estimated graft-to-recipient weight ratio.Under intraoperative indocyanine green cholangiography,4 biliary tracts were confirmed in the graft.It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm.A reliable cholangiojejunostomy was,therefore,utilized:Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures.At the last follow-up(1 year after surgery),the patient was complication-free.CONCLUSION Intrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.

CENOZOIC DISPLACEMENT HISTORY OF THE ALTYN TAGH FAULT:GEOLOGICAL EVIDENCE FROM FIELD OBSERVATIONS IN SOUERKULI AND MANGAR REGIONS, NW CHINA

The ENE\|striking Altyn Tagh Fault (ATF) has been well known as a large, active left\|lateral strike\|slip fault that bounds the thrusting systems in NE Tibet.This fault has been the focal point in the debate between the discrete extrusion vs. distributed crustal shortening models. Although its active left\|lateralstrike\|slip features have been largely investigated and well documented by both satellite imagery and air\|photo interpretations and field observations, little study has been done upon its Cenozoic displacement history. Questions about the age of initiation and total offset accumulated on the fault remain controversial. A key area to resolve such question is located along the central segment of the fault in the Souerkuli and Mangar regions, where Neogene sedimentary basins well develop and are mostly distributed in three zones, namely from east to west: the Gobiling, Yitunbulak and Yusuale Tagh (Fig.1). Our field investigations were conducted along the ATF cutting the Yitunbulak and Gebiling Neogene sedimentary basins. Two stratigraphic unconformities observed within this Neogene conglomeratic series allow a separation of three major stratigraphic sequences and record the initiation and major deformational episodes of ATF during Cenozoic. An early stratigraphic unconformity occurred between a yellow depositional series below and early Pliocene red\|colored conglomeratic mudstones above. A later stratigraphic unconformities occurred between early and late Pliocene sedimentary series. The lower series below the early stratigraphic unconformities is mainly composed of a conglomeratic rocks containing cobbles and pebbles of basement rock units (mostly mylonitic granites, limestones and quartzes); this series has been poorly mapped and dated; its age could be assigned to late Oligocene to early Miocene; this series tilts to NW with an angle of about 30° and is overlain in angular unconformity by early Pliocene pebble\|sized conglomerates. A weathering zone on top of the lower conglomeratic series is clearly seen, that represents a long period of uplift and erosion. This lacuna occurred between early Miocene and early Pliocene in the west Qaidam basin, which has been documented only locally. Early Pliocene deposits correspond to alluvial to lacustrine facies rocks deposited in strike\|slip basin probably originated at releasing bend of the strike\|slip ATF; late Pliocene deposits is composed by fluviatile conglomerates and fanglomerates lying in unconformity on the upper Pliocene rocks. Early Quaternary deposits are absent along the ATF and have been well documented in the Qaidam basin. Late Quaternary fanglomerates infills active fault valleys.

Large-for-size syndrome prophylaxis in infant liver recipients with low body mass

Transplantation of the left lateral section(LLS)of the liver is now an established practice for treating advanced diffuse and unresectable focal liver diseases in children,with variants of the LLS primarily used in infants.However,the surgical challenge of matching the size of an adult donor's graft to the volume of a child's abdomen remains significant.This review explores historical developments,various approaches to measuring the required functional liver mass,and techniques to prevent complications associated with large-for-size grafts in infants.