Surgical chest complications after liver transplantation

Liver transplantation is a major abdominal operation and the intimate anatomic relation of the liver with the right hemidiaphragm predisposes the patient to various manifestations in the chest cavity.Furthermore,chronic liver disease affects pulmonary function before and after liver transplantation resulting in a considerable percentage of patients presenting with morbidity related to chest complications.This review aims to identify the potential chest complications of surgical interest during or after liver transplantation.Complications of surgical interest are defined as those conditions that necessitate an invasive procedure(such as thoracocentesis or a chest tube placement)in the chest or a surgical intervention performed by a thoracic surgeon.These complications will be classified as perioperative and postoperative;the latter will be categorized as early and late.Although thoracocentesis or a chest tube placement is usually sufficient when invasive measures are deemed necessary,in some patients,thoracic surgical interventions are warranted.A high index of suspicion is needed to recognize and treat these conditions promptly.A close collaboration between abdominal surgeons,intensive care unit physicians and thoracic surgeons is of paramount importance.

Progress in research of liver surgery in China

INTRODUCTIONLiver surgery,was started in the late 1950s in Chinaand has developed rapidly in the past 40 years.The study on the diagnosis and treatment of primaryliver cancer in China underwent four stages:①Inthe 1950s,the anatomical study of the liver lay asolid foundation for liver resection.①In

Treatment efficacy of radiof requency ablation of 338 patients with hepatic malignant tumor and the relevant complications

AIM: To investigate the treatment efficacy of radiofrequency ablation (RFA) of hepatic malignant tumor and the relevant complications.METHODS: A total of 338 patients with 763 hepatic tumors underwent ultrasound-guided RFA (565 procedures).There were 204 cases of hepatic cellular carcinoma (HCC)with 430 tumors, the mean largest diameter was 4.0 cm.Of them, 48 patients (23.5％) were in stages Ⅰ-Ⅱ (UICC Systems) and 156 (76.5％) in stages Ⅲ-Ⅳ There were 134 cases of metastatic liver carcinoma (MLC), with 333metastases in the liver, the mean diameter was 4.1 cm,the liver metastases of 96 patients (71.6％) came from gastrointestinal tract. Ninety-three percent of the 338patients were treated using the relatively standard protocol. Crucial attention must be paid to monitor the abnormal changes in ultrasound images as well as the vital signs of the patients to find the possible hemorrhage and peripheral structures injury in time. The tumors were considered as ablated completely, if no viability was found on enhanced CT within 24 h or at 1 mo after RFA. These patients were followed up for 3-57 mo.RESULTS: The ablation success rate was 93.3％ (401/430tumors) for HCC and was 96.7％ (322/333 tumors) for MLC. The local recurrence rate for HCC and MLC was 7.9％ (34/430 tumors) and 10.5％ (35/333 tumors),respectively. A total of 137 patients (40.5％) underwent 2-11times of repeated ablations because of tumor recurrence or metastasis. The 1st, 2nd, and 3rd year survival rate was84.6％, 66.6％, and 63.1％, respectively;the survival rate from 48 patients of Ⅰ-Ⅱ stage HCC was 93.7％, 80.4％,and 80.4％, respectively. The major complication rate in this study was 2.5％ (14 of 565 procedures), which consisted of 5 hemorrhages, 1 colon perforation, 5 injuries of adjacent structures, 2 bile leakages, and 1 skin burn.CONCLUSION: RFA, as a minimally invasive local treatment,has become an effective and relatively safe alternative for the patients of hepatic malignant tumor, even of advanced liver tumor, tumor recurrence, and liver metastases. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.

Metabolic syndrome and non-alcoholic fatty liver disease in liver surgery: The new scourges?

The aim of this topic highlight is to review relevant evidence regarding the influence of the metabolic syndrome(MS) and its associated liver manifestation, non-alcoholic fatty liver disease(NAFLD), on the development of liver cancer as well as their impact on the results of major liver surgery. MS and NAFLD, whose incidences are significantly increasing in Western countries, are leading to a changing profile of the patients undergoing liver surgery. A MEDLINE search was performed for relevant articles using the key words "metabolic syndrome", "liver resection", "liver transplantation", "non alcoholic fatty liver disease", "non-alcoholic steatohepatitis" and "liver cancer". On one hand, the MS favors the development of primary liver malignancies(hepatocellular carcinoma and cholangiocarcinoma)either through NAFLD liver parenchymal alterations(steatosis, steatohepatitis, fibrosis) or in the absence of significant underlying liver parenchyma changes. Also, the existence of NAFLD may have a specific impact on colorectal liver metastases recurrence. On the other hand, the postoperative period following partial liver resection and liver transplantation is at increased risk of both postoperative complications and mortality. These deleterious effects seem to be related to the existence of liver specific complications but also higher cardio-vascular sensitivity in a setting of MS/NAFLD. Finally, the long-term prognosis after curative surgery joins that of patients operated on with other types of underlying liver diseases. An increased rate of patients with MS/NAFLD referred to hepatobiliary units has to be expected. The higher operative risk observed in this subset of patients will require specific improvements in their perioperative management.

Update on surgical treatment of pancreatic neuroendocrine neoplasms

Pancreatic neuroendocrine neoplasms(PNENs) are rare and account for only 2%-4% of all pancreatic neoplasms. All PNENs are potential(neurendocrine tumors PNETs) or overt(neuroendocrine carcinomas PNECs) malignant,but a subset of PNETs is low-risk. Even in case of low-risk PNETs surgical resection is frequently required to treat hormone-related symptoms and to obtain an appropriate pathological diagnosis. Low-risk PNETs in the body and the tail are ideal for minimallyinvasive approaches which should be tailored to the individual patient. Generally,surgeons must aim for parenchyma sparing in these cases. In high-risk and malignant PNENs,indications for tumor resection are much wider than for pancreatic adenocarcinoma,in many cases due to the relatively benign tumor biology. Thus,patients with locally advanced and metastatic PNETs may benefit from extensive resection. In experienced hands,even multi-organ resections are accomplished with acceptable perioperative morbidity and mortality rates and are associated with excellent long term survival. However,poorly differentiated neoplasms with high proliferation rates are associated with a dismal prognosis and may frequently only be treated with chemotherapy. The evidence on surgical treatment of PNENs stems from reviews of mostly singlecenter series and some analyses of nation-wide tumor registries. No randomized trial has been performed to compare surgical and non-surgical therapies in potentially resectable PNEN. Though such a trial would principally be desirable,ethical considerations and the heterogeneity of PNENs preclude realization of such a study. In the current review,we summarize recent advances in the surgical treatment of PNENs.

Establishment of an Assessment System for the Prediction of Severe Post-operative Complications after Hepatectomy Based on Preoperative Parameters

Objective At present,there is no appropriate system to evaluate the severe complications of liver surgery through the preoperative factors.This study aimed to design and verify a risk assessment system for the prediction of severe post-operative complications after a hepatectomy based on the preoperative parameters.Methods A retrospective analysis was performed on 1732 patients who had undergone liver surgery.The severity of the complications was graded by Accordion Severity Grading of post-operative complications.The variables were screened by multivariate analysis,and graded scores were assigned to the selected variables.A logistic regression equation was used to form the liver operation risk formula(LORF)for the prediction of severe post-operative complications.The LORF was verified by the receiver operating characteristic(ROC)curve.Results The multivariate correlation analysis revealed the independent influencing factors of the severe post-operative complications of liver surgery were Child-Pugh grade(OR=4.127;P<0.001),medical diseases requiring drug treatment(OR=3.092;P<0.001),the number of liver segments to be removed(OR=2.209;P=0.006),organ invasion(OR=4.538;P=0.024),and pathological type(OR=4.023;P=0.002).The binomial logistic regression model was established to obtain the calculation formula(LORF)of the severe complication risk.The area under the ROC curve(AUC)of the LORF was 0.815.The cut-off value of the expected probability of severe complications was 0.3225(32.25%).Furthermore,in the validation data set,the corresponding AUC of the LORF was 0.829.Conclusion As a novel and simplified assessment system,the LORF could effectively predict the severe post-operative complications of liver surgery through the preoperative factors,and therefore it could be used to evaluate the risk of severe liver surgical complications before surgery.

Postoperative complications after robotic resection of colorectal cancer:An analysis based on 5-year experience at a large-scale center

BACKGROUND As a common gastrointestinal malignancy,colorectal cancer(CRC)poses a serious health threat globally.Robotic surgery is one of the future trends in surgical treatment of CRC.Robotic surgery has several technical advantages over laparoscopic surgery,including 3D visualization,elimination of the fulcrum effect,and better ergonomic positioning,which together lead to better surgical outcomes and faster recovery.However,analysis of independent factors of postoperative complications after robotic surgery is still insufficient.AIM To analyze the incidence and risk factors for postoperative complications after robotic surgery in patients with CRC.METHODS In total,1040 patients who had undergone robotic surgical resection for CRC between May 2015 and May 2020 were analyzed retrospectively.Postoperative complications were categorized according to the Clavien-Dindo(C-D)classification,and possible risk factors were evaluated.RESULTS Among 1040 patients who had undergone robotic surgery for CRC,the overall,severe,local,and systemic complication rates were 12.2%,2.4%,8.8%,and 3.5%,respectively.Multivariate analysis revealed that multiple organ resection(P<0.001)and level III American Society of Anesthesiologists(ASA)score(P=0.006)were independent risk factors for overall complications.Multivariate analysis identified multiple organ resection(P<0.001)and comorbidities(P=0.029)as independent risk factors for severe complications(C-D grade III or higher).Regarding local complications,multiple organ resection(P=0.002)and multiple bowel resection(P=0.027)were independent risk factors.Multiple organ resection(P<0.001)and level III ASA score(P=0.007)were independent risk factors for systemic complications.Additionally,sigmoid colectomy had a lower incidence of overall complications(6.4%;P=0.006)and local complications(4.7%;P=0.028)than other types of colorectal surgery.CONCLUSION Multiple organ resection,level III ASA score,comorbidities,and multiple bowel resection were risk factors for postoperative complications,with multiple organ resection being the most likely.

Individualized risk estimation for postoperative pulmonary complications after hepatectomy based on perioperative variables

BACKGROUND At present,there is no perfect system to evaluate pulmonary complications of liver surgery using perioperative variables.AIM To design and verify a risk assessment system for predicting postoperative pulmonary complications(PPCs)after hepatectomy based on perioperative variables.METHODS A retrospective analysis was performed on 1633 patients who underwent liver surgery.The variables were screened using univariate and multivariate analyses,and graded scores were assigned to the selected variables.Logistic regression was used to develop the liver operation pulmonary complication scoring system(LOPCSS)for the prediction of PPCs.The LOPCSS was verified using the receiver operating characteristic curve.RESULTS According to the multivariate correlation analysis,the independent factors which influenced PPCs of liver surgery were age[≥65 years old/<65 years old,odds ratio(OR)=1.926,P=0.011],medical diseases requiring drug treatment(yes/no,OR=3.523,P<0.001),number of liver segments to be removed(≥3/≤2,OR=1.683,P=0.002),operation duration(≥180 min/<180 min,OR=1.896,P=0.004),and blood transfusion(yes/no,OR=1.836,P=0.003).The area under the curve(AUC)of the LOPCSS was 0.742.The cut-off value of the expected score for complications was 5.The incidence of complications in the group with≤4 points was significantly lower than that in the group with≥6 points(2.95%vs 33.40%,P<0.001).Furthermore,in the validation dataset,the corresponding AUC of LOPCSS was 0.767.CONCLUSION As a novel and simplified assessment system,the LOPCSS can effectively predict PPCs of liver surgery through perioperative variables.

Enhanced recovery after surgery in laparoscopic major liver resection: A propensity score matching analysis

Objective:Even though enhanced recovery after surgery(ERAS)has been applied to liver resection worldwide,there is a lack of evidence covering its feasibility in laparoscopic major hepatectomy.This study aimed to preliminarily evaluate the superiority of ERAS in major liver resection.Methods:The data were collected from patients who underwent laparoscopic major hepatectomy from July 2014 to November 2020 in Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.The baseline characteristics,pathological features,surgical outcomes,medical costs,and postoperative pain scores were compared before and after propensity score matching(PSM).The patients were divided into the ERAS group and the routine group based on the treatment protocols.Results:Eighty-one patients who underwent laparoscopic major hepatectomy were retrospectively enrolled in the study.Before PSM,there were differences in pathology(p¼0.037)and surgical extent(p¼0.011)between the ERAS group(n¼42)and routine group(n¼39).After PSM,26 patients from each group were matched.For surgical outcomes,patients in the ERAS group had a significantly lower postoperative complication incidence than patients in the routine group(28.6%vs.53.8%,RR:0.531[0.303,0.929],p¼0.021)before PSM.However,after PSM,superiority was not observed in the ERAS group(30.8%vs.53.8%,RR:0.571[0.290,1.13],p¼0.092).The duration of abdominal tube retention(before PSM:5.0 d vs.10.0 d,p<0.001;after PSM:6.0 d vs.9.0 d,p¼0.001),the duration of urinary tube retention(before PSM:1.0 d vs.2.0 d,p<0.001;after PSM:1.0 d vs.2.0 d,p¼0.002),and hospital stay(before PSM:6.0 d vs.11.0 d,p<0.001;after PSM:7.0 d vs.11.5 d,p<0.001)was significantly shorter in the ERAS group than in the routine group.A significant benefit on postoperative day 3(2 vs.3,p¼0.038)was observed with respect to the alleviation of pain after PSM.Conclusions:Our preliminary study revealed the superiority of ERAS in the setting of major liver resection,although further investigations in a large number of patients from multiple institutions are needed to evaluate the feasibility of ERAS.

Current status of surgical management of patients with gastroenteropancreatic neuroendocrine neoplasms

Neuroendocrine neoplasms(NENs)of the gastroenteropancreatic system are rare and heterogeneous tumours,yet with increasing prevalence.The most frequent primary sites are the small intestine,rectum,pancreas,and stomach.For a localized disease,surgical resection with local lymph nodes is usually curative with good overall and disease free survival.More complex situation is the treatment of locally advanced lesions,liver metastases,and,surprisingly,small asymptomatic tumours of the rectum and pancreas.In this review,we focus on the current role of surgical management of gastroenteropancreatic NENs.We present surgical approach for the most frequent primary sites.We highlight the role of endoscopic surgery and the watch-and-wait strategy for selected cases.As liver metastases pose an important clinical challenge,we present current indications and contraindications for liver resection and a role of liver transplantation for metastatic NENs.

Role of surgical treatments in high-grade or advanced gastroenteropancreatic neuroendocrine neoplasms

Over the last 40 years,the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms(GEP-NENs)have continued to increase.Compared to other epithelial neoplasms in the same organ,GEP-NENs exhibit indolent biological behavior,resulting in more chances to undergo surgery.However,the role of surgery in high-grade or advanced GEP-NENs is still controversial.Surgery is associated with survival improvement of well-differentiated highgrade GEP-NENs,whereas poorly differentiated GEP-NENs that may benefit from resection require careful selection based on Ki67 and other tissue biomarkers.Additionally,surgery also plays an important role in locally advanced and metastatic disease.For locally advanced GEP-NENs,isolated major vascular involvement is no longer an absolute contraindication.In the setting of metastatic GEP-NENs,radical intended surgery is recommended for patients with low-grade and resectable metastases.For unresectable metastatic disease,a variety of surgical approaches,including cytoreduction of liver metastasis,liver transplantation,and surgery after neoadjuvant treatment,show survival benefits.Primary tumor resection in GEP-NENs with unresectable metastatic disease is associated with symptom control,prolonged survival,and improved sensitivity toward systemic therapies.Although there is no established neoadjuvant or adjuvant strategy,increasing attention has been given to this emerging research area.Some studies have reported that neoadjuvant therapy effectively reduces tumor burden,improves the effectiveness of subsequent surgery,and decreases surgical complications.

手术室整体干预模式对肝癌介入手术患者负性情绪、并发症、生活质量及护理满意度的影响

目的探讨手术室整体干预模式对肝癌介入手术患者的负性情绪、并发症发生情况、生活质量及护理满意度的影响。方法依据干预模式的不同将120例接受介入手术的肝癌患者分为对照组(n=56)和观察组(n=64)。对照组患者围手术期给予手术室常规干预模式,观察组患者围手术期给予手术室整体干预模式。比较两组患者的负性情绪[焦虑自评量表(SAS)和抑郁自评量表(SDS)]、生活质量[欧洲癌症研究与治疗组织生命质量测定量表(EORTC QLQ-C30)]、并发症发生情况及护理满意度[纽卡斯尔护理满意度量表(NSNS)]。结果术后,两组患者的SAS、SDS评分均明显低于本组术前,观察组患者的SAS、SDS评分均明显低于对照组,差异均有统计学意义(P﹤0.01);观察组患者术后并发症总发生率为17.19%,低于对照组患者的35.71%,差异有统计学意义(P﹤0.05);术后,两组患者的EORTC QLQ-C30评分均明显高于本组术前,观察组患者的EORTC QOL-C30评分明显高于对照组,差异均有统计学意义(P﹤0.01)。出院时,观察组患者的护理满意度为98.44%,高于对照组患者的85.71%,差异有统计学意义(P﹤0.05)。结论手术室整体干预模式能明显减轻肝癌介入手术患者的焦虑、抑郁情绪,降低术后并发症发生率,提高患者的生活质量及护理满意度。

达芬奇机器人辅助腹腔镜胰腺癌手术患者术后意外低体温影响因素分析

目的探讨行达芬奇机器人辅助腹腔镜胰腺癌根治手术的患者发生术后意外低体温(UPH)的危险因素,构建风险预测模型并评价其预测效能。方法选取2020年12月至2021年12月在海军军医大学(第二军医大学)第一附属医院接受达芬奇机器人辅助腹腔镜胰腺癌根治手术的患者作为研究对象,根据UPH的发生情况将患者分为UPH组和非UPH组。比较两组患者的一般资料(年龄、性别、美国麻醉医师学会分级、BMI、术前血红蛋白、术前白蛋白、基础体温)、手术资料(手术方式、神经阻滞类型、麻醉时间、手术时间、人工气腹建立时间、术后体温、术后并发症、院内转归)、围手术期液体管理资料(晶体液、胶体液、红细胞悬液、新鲜冰冻血浆、失血量、尿量)。采用logistic回归方法构建UPH预测模型,绘制ROC曲线和决策曲线评价模型预测UPH的效能,并建立列线图模型。结果共纳入患者246例,其中117例(47.6%)发生UPH。两组患者的BMI(P=0.047)、术前血浆白蛋白水平(P=0.038)、术后肺部并发症(PPC,P=0.039)、非肺部术后感染(NPPI,P=0.018)、总住院时间(P=0.001)、手术方式(P=0.042)、手术时间(P=0.038)、术中人工气腹建立时间(P=0.004)、神经阻滞类型(P=0.004)、术后体温(P<0.001)比较差异均有统计学意义。logistic回归分析结果显示达芬奇机器人辅助术式(OR=9.369,95%CI 2.528~34.717,P=0.001)、BMI(OR=0.787,95%CI 0.687~0.902,P=0.001)、手术时间(OR=0.040,95%CI 0.009~0.183,P<0.001)、人工气腹建立时间(OR=15.608,95%CI 3.814~63.870,P<0.001)、输液速率(OR=0.808,95%CI 0.706~0.924,P=0.002)、输液总量(OR=3.431,95%CI 1.480~7.956,P=0.004)及神经阻滞类型(OR=0.240,95%CI 0.131~0.443,P<0.001)与UPH的发生具有独立相关性。ROC曲线的AUC值为0.739,预测发生UPH的灵敏度为0.778,特异度为0.628。决策曲线分析结果表明预测模型具有较好的临床净收益。结论BMI低、输液速率慢、输液总量大、椎旁神经阻滞、胰十二指肠切除术、手术时间长、人工气腹建立时间长是达芬奇机器人辅助腹腔镜胰腺癌根治手术患者发生UPH的危险因素,根据上述因素构建的风险预测模型效果较好。

Comprehensive review of hepatocellular carcinoma with portal vein tumor thrombus:State of art and future perspectives

Background:Despite advances in the diagnosis of patients with hepatocellular carcinoma(HCC),70%-80%of patients are diagnosed with advanced stage disease.Portal vein tumor thrombus(PVTT)is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.Data sources:A systematic search of MEDLINE(PubMed),Embase,Cochrane Library and Database for Systematic Reviews(CDSR),Google Scholar,and National Institute for Health and Clinical Excellence(NICE)databases until December 2022 was conducted using free text and MeSH terms:hepatocellular carcinoma,portal vein tumor thrombus,portal vein thrombosis,vascular invasion,liver and/or hepatic resection,liver transplantation,and systematic review.Results:Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy.Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus,accurate identification of the subgroups of patients who may benefit from resection,as well as meticulous surgical technique.This review addressed five specific areas:(a)formation of PVTT;(b)classifications of PVTT;(c)controversies related to clinical guidelines;(d)surgical treatments versus non-surgical approaches;and(e)characterization of surgical techniques correlated with classifications of PVTT.Conclusions:Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.

Hisense计算机辅助手术系统在腹腔镜肝癌切除术围手术期的应用

目的:探讨Hisense计算机辅助手术系统(CAS)在腹腔镜肝癌切除术围手术期的临床应用。方法:收集2021年1月至2022年12月行腹腔镜肝切除术(LH)的肝癌患者的临床资料。将患者按手术难度分为低、中、高难度3个组,再根据术前是否使用CAS辅助系统分成CAS辅助亚组和对照组,比较不同组别患者的人口学及围手术期资料。结果:共收集317例患者临床资料,其中低难度组31例,中难度组132例,高难度组154例;CAS辅助亚组108例(34.1%),对照组209例(65.9%)。中难度组CAS辅助亚组的手术时间、引流管留置时间和术后住院时间均短于对照组(P<0.001),术后1月AFP低于对照组(P<0.001)。高难度组CAS辅助亚组的手术时间、引流管留置时间和术后住院时间均短于对照组,术中出血量少于对照组,术后1月AFP低于对照组(P均<0.001)。结论:中、高难度LH术前行CAS的患者围手术期结局更佳。Hisense CAS可有效协助普外科医生清晰确定肝肿瘤解剖部位,提供精准术前模拟和术中导航,为患者制定最佳手术方案。

快速康复外科-集束化护理干预策略对肝癌患者的影响分析

目的:探讨快速康复外科-集束化护理干预策略对肝癌患者的影响。方法:选取我院2021年6月至2022年10月期间收治的肝癌患者108例作为研究对象,均行肝癌切除术治疗,采用数字表法将患者分成对照组和研究组,每组各54例。对照组给予常规护理;研究组基于对照组加用快速康复外科-集束化护理干预策略。分析对比两组入院期间并发症发生率、康复状况、护理满意度,并于术前1 d、出院前1 d利用调查问卷方式,采用视觉模拟量表、匹兹堡睡眠质量量表进行疼痛度、睡眠质量评估。结果:研究组住院以及术后下床时间、并发症发生率少于对照组,护理满意度高于对照组(P<0.05);干预后两组疼痛、睡眠评分均少于对照组(P<0.05)。结论:快速康复外科-集束化护理干预策略应用于肝癌患者,可促进患者术后康复,降低并发症发生率,改善睡眠质量、护理满意度。

减重代谢手术在非酒精性脂肪性肝病患者中的应用

非酒精性脂肪性肝病(nonalcoholic fatty liver disease,NAFLD)是一种与代谢综合征密切相关的慢性肝脏疾病。迄今为止,NAFLD已成为全球最常见的慢性肝病,严重危害人类健康,造成巨大的社会负担。减重代谢手术可显著改善患者的肝脏脂肪变性和炎症,但国内外均没有正式批准用于治疗NAFLD。减重代谢手术治疗NAFLD的确切机制尚不明确,在改变生活方式和药物治疗效果不令人满意的情况下,手术是非常值得考虑的治疗方式。在我国,目前对减重代谢手术治疗NAFLD的相关报道较少,所以本文对其临床有效性、并发症和可能的作用机制等方面进行综述。

平乐疏肝活血汤防治PLIF术后早期胃肠道并发症临床观察

目的:观察平乐疏肝活血汤防治后路腰椎椎间融合术(posterior lumbar interbody fusion,PLIF)术后早期胃肠道并发症的临床疗效。方法:将60例接受PLIF手术后出现胃肠道并发症的患者按照随机数字表法分为治疗组与对照组,每组30例。治疗组给予术后常规腹部按摩、穴位贴敷护理,并给予平乐疏肝活血汤治疗,对照组给予术后常规腹部按摩、穴位贴敷护理,并给予枸橼酸莫沙必利片口服治疗。观察治疗后两组的临床疗效、治疗前后两组患者的腹胀评分、腹痛评分及便秘症状积分,比较两组患者术后首次肛门排气、首次排便时间、胃肠道激素及炎症因子水平的差异。结果:治疗组有效率为93.3%,对照组有效率为70.0%,治疗组有效率高于对照组,差异有统计学意义(P<0.05);治疗组治疗后腹胀评分、腹痛评分及便秘症状评分低于对照组,差异具有统计学意义(P<0.05);治疗组术后首次排气时间、首次排便时间短于对照组,差异具有统计学意义(P<0.05);治疗组治疗后促胃动素、生长抑素及胆囊收缩素水平高于对照组,差异具有统计学意义(P<0.05);治疗组治疗后白细胞计数、C反应蛋白及降钙素原水平低于对照组,差异具有统计学意义(P<0.05)。结论:平乐疏肝活血汤防治PLIF术后早期胃肠道并发症,能减轻腹痛、腹胀及便秘症状,促进术后排气、排便,提高促胃动素、生长抑素及胆囊收缩素水平,降低白细胞计数、C反应蛋白及降钙素原水平。

Laparoscopic liver resection:Experience based guidelines

Laparoscopic liver resection(LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant(both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments(1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers' practice. Continuous surgical training, as well as new technologies should augment the application of lap-aroscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Clinical research advances in primary liver cancer

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