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

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.

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.

Diagnosis and Treatment of Liver Cystadenocarcinoma:Report of 18 Cases

Objective： To discuss the diagnosis and treatment of liver cystadenocarcinoma. Methods： The clinical, imaging, and pathological data of 18 patients with liver cystadenocarcinoma between January 2000 and December 2004 in our hospital were retrospectively analyzed. Results： The liver cystadeno- carcinoma was seen in males and females （m/f： 9/9）; mean age was 51 years. Ultrasonography revealed cystic parenchymatous mass echoes of fluid predominance with uneven margins. Nonenhanced CT revealed intrahepatic low-density space occupying shadows with nodular protrusions on the margins in all cases. Enhancement CT revealed that part of the nodular protrusions and tissues around the lesions were enhanced and the delayed phase disappeared. 66.67% （12/18） of the lesions were more than 10 cm in diameter. The diagnosis of liver cystadenocarcinoma was confirmed by postoperative pathology in all cases. Of these patients, 12 lesions were in the left lobe, 3 in the right lobe, 1 in the mid lobe, 1 in the right and left lobe, and 1 in the caudate lobe. Of tile 18 patients, 6 had completely resect the cystadenocarcinoma, 2 were surgically explored, one received TAE＋fine needle aspiration cytology＋injection of chemotherapy drugs, and 9 underwent radical hepatectomy＋choledochostomy or T-tube drainage, in which, one patient underwent choledochostomy＋left hepatectomy＋radical gastrectomy for cancer＋lymphadenectomy; one patient underwent resection of the cystadenocarcinoma, who had relapse 20 months after the initial procedure. The patient received repeat reseet for the recurrent cystadenoeareinoma＋eholangio-jejunostomy. Six months later she had another relapse and received repeat reseet （only PMCT） for the recurrent cystadenoearcinoma. The patient died from eholangiopleural fistula after third time operation （PMCT） was attempted perioperatively. Seven patients died of metastatic disease after operation. The remaining 10 patients were alive without cancer recurrence or metastasis （mean follow-up 20 months）. Conclusion： Liver eystadenocarcinoma is rarely seen and grows slowly. It shows some typical clinical and imaging features. The crux for diagnosing and treating liver cystadenoeareinoma is how familiar the surgeon is with the pathology and clinical features of the condition. Prolonged survival can be achieved by radical resection of the tumor.

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.

Prevention of metastasis to liver by using 5-FU intraperitoneal chemotherapy in nude mice inoculated with human colonic cancer cells

AIMS Using a new approach of regional adjuvant chemotherapy to prevent cancer cells hepatic metasta- sis after radical surgery of large bowel cancer. METHODS A model of liver with metastasis of hu- man colonic cancer (HCC) cells in nude mice was used to observe the effect in prevention of metastasis of HCC cells inoculated via spleen applied with early postoper- ative intraperitoneal (IP) chemotherapy using large dose of 5-FU. RESULTS The incidence of metastasis to liver was decreased by 40%,the mean number of metastatic liv- er nodules in each animal was reduced by 50.89% and the mean survival times of each animal was prolonged by 48.21% by using 5-FU 40 mg/NS 40 ml/kg IP for two consecutive days as compared with the controls. CONCLUSIONS IP is a new and more effective re- gional adjuvant chemotheraputic approach in the pre- vention of liver metastasis HCC cells after radical surgery of large bowel cancer.

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。

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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Liver-first approach of colorectal cancer with synchronous hepatic metastases: A reverse strategy

Recently, there has been a change in the strategy of how synchronous colorectal hepatic metastases are attributed to the development of more valuable protocols of chemotherapy and radiotherapy for neoadjuvant treatment of colorectal neoplasms and their hepatic metastases. There is a consensus that patients with synchronous colorectal hepatic metastases have lower survival than those with metachronous colorectal hepatic metastases. Currently, controversy remains concerning the best approach is sequence in a patient with colorectal cancer and synchronous hepatic metastases resection. To obtain a better patient selection, the authors have suggested the initial realization of systemic chemotherapy in the circumstance of patients with colorectal tumor stage Ⅳ, since these patients have a systemic disease. The rationale behind this liver-first strategy is initially the control of synchronous hepatic metastases of colorectal carcinoma, which can optimize a potentially curative hepatic resection and longstanding survival. The liver-first strategy procedure is indicated for patients with colorectal hepatic metastases who require downstaging therapy to make a curative liver resection possible. Thus, the liver-first strategy is considered an option in cases of rectal carcinoma in the early stage and with limited or advanced synchronous colorectal hepatic metastases or in case of patients with asymptomatic colorectal carcinoma, but with extensive liver metastases. Patients undergoing systemic chemotherapy and with progression of neoplastic disease should not undergo hepatic resection, because it does not change the prognosis and may even make it worse. To date, there have been no randomized controlled trials on surgical approach of colorectal synchronous hepatic metastases, despite the relatively high number of available manuscripts on this subject. All of these published studies are observational, usually retrospective, and often non-comparative. The patient selection criteria for the liver-first strategy should be individualized, and the approach of these patients should be performed by a multidisciplinary team so its benefits will be fully realized.

Laparoscopic liver resection for benign and malignant liver tumors

BACKGROUND:Laparoscopic liver resection is one of the most complex procedures in hepatobiliary surgery.In the last two decades,laparoscopic liver surgery has emerged as an option at major academic institutions.The purpose of this study is to describe the initial experience of minimally invasive liver resections at a non-academic institution. METHODS:We retrospectively reviewed medical records of patients undergoing laparoscopic liver resections between June 2006 and December 2009 at our center.Indications, technical aspects,and outcomes of these patients are described. RESULTS:Laparoscopic liver resection was attempted in 28 patients.Of these,27 patients underwent laparoscopic liver resection(22 total laparoscopic and 5 hand assisted)and one needed conversion to open surgery.Twenty patients had a benign lesion and 8 had malignant lesions.Three patients had multiple lesions in different segments requiring separate resections.The lesions were located in segments Ⅱ-Ⅲ(n=18), Ⅳ(n=3),Ⅴ-Ⅵ(n=9),and VII(n=1).Tumor size ranged from 1.5 cm to 8.5 cm.The surgical procedures included left lateral sectionectomy(n=17),left hepatectomy(n=2),sectionectomy (n=8),and local resections(n=4).Median operative time was 110 minutes(range 55-210 minutes),and the median length of hospital stay was 2.5 days(range 1-7 days).There was no perioperative mortality.One patient developed hernia at the site of tumor extraction requiring repair at 3 months. CONCLUSIONS:Laparoscopic liver resections can be safely performed in selected patients with benign and malignant liver tumors.With increasing experience,laparoscopic liver resections are likely to become a favorable alternative to open resection.

Clinicopathologic risk factors and prognostic evaluation in hepatocellular carcinoma recurrence after surgery

AIM To analyze the clinicopathologic risk factors in hepatocellular carcinoma recurrence after surgery. METHODS Significance test (χ 2 and Student t test) of the single and multiple factors, and Wilcoxon Cox tropic examination were used, a retrospective clinicopathologic analysis was made in 156 cases of hepatocellular carcinoma after hepatectomy. RESULTS Of the 156 cases, 68 4%, 57 3%, 46 7%, 31 5% and 28 6% had 1, 2, 3, 4 and 5 postoperative tumor free years respectively with a total recurrence rate of 53 2% (83/156). In the 83 recurrent cases, 65 were of intrahepatic sabclinical type, with a re resection rate of 78 3% (65/83). The relevant factors involved in recurrence were: males, tumor number and size, capsule infiltration, portal veins involvement, etc. Those factors obviously influenced the prognosis of the patients with postoperative hepatocellular carcinoma ( P <0 05). 63 1% tumor nodes (41/65) of recurrent liver cancinomas were located at the ipsilateral segment of the primary ones. CONCLUSION Males, tumor number and size, capsule infiltration and portal veins involvement are the factors for postoperative hepatocellular carcinoma recurrence after surgery. The recurrence is mainly unicentral. Right front lobe is the liver segment with a high recurrence rate.

Current surgical management of pancreatic endocrine tumor liver metastases

BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved. DATA SOURCES: A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery. RESULTS: The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation. CONCLUSION: It seems that the current management of PETs can achieve important improvements, even in advanced cases.

Resection of a rapid-growing 40-cm giant liver hemangioma

Hemangiomas are the most frequent benign tumors of the liver. Most hemangiomas are asymptomatic and therefore largely diagnosed only in routine screening tests. Usually they are small and require no specific treatment. In some situations they can reach great dimensions, causing some discomfort to the patient. Resection of liver hemangioma is indicated in cases of great dimension tumors causing symptoms such as pain, nausea or bloating caused by compression of adjacent organs. We report a case of a rare giant hemangioma with rapid growth in short time:a 50 year old female reported to our institution with a 40 cm giant liver hemangioma and then underwent a left hepatectomy.

Liver resection for cancer

HISTORY OF HEPATIC RESECTIONThe earliest hepatic surgery was almost exclusively performed for trauma with records from as for tumor were those of Langenbuch in 1888 [3] , Tiffany in 1890 [4],and Lucke in 1891[5].By1899,76 cases of liver resection had been reported with a mortality rate of 14.9% [6], a remarkably low figure for operations of this magnitude,all performed at the end of the 19th century.

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia(IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.

Current technical aspects of oncological hepatic surgery

BACKGROUND： With the recent advances in oncological hepatic surgery, major liver resections became more widely utilized procedures. The era of modern hepatic surgery witnessed improvements in patients care in preoperative, intraoperative and postoperative aspects. This significantly improved surgical outcomes regarding morbidity and mortality. This review article focuses on the recent advances in oncological hepatic surgery.DATA SOURCES： This review includes only data from peer-reviewed articles and journals. Pub Med database was utilized as the primary source of the supporting literature to this review article on the latest advances in oncological hepatic surgery.Comprehensive and high sensitivity search strategies were performed to search related studies exhaustively up till June 2016. We critically and independently assessed over 50 recent publications written on this topic according to the selection criteria and quality assessment standard. We paid particular attention to the studies published in high impact journals that address the use of the surgical techniques mentioned in the articles in well-known institutions.RESULTS： Among all utilized approaches aiming at the preoperative assessment of the liver function, Child-TurcottePugh classification remains the most reliable tool correlating with survival outcome. Although the primary radiological tools including ultrasonography, computed tomography and magnetic resonance imaging remain on top of the menu of tests utilized in assessment of focal hepatic lesions, intraoperative ultrasonography projects to be a powerful additional tool in terms of sensitivity and specificity compared to the other conventional techniques in assessment of the liver inthe operative setting, a procedure that can change the surgical strategy in 27.2% of the cases and consequently improve the oncological surgical outcome. In addition to the conventional surgical techniques of liver resection and portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy “ALPPS” projects to be an alternative option in patients with marginally resectable tumors with an inadequate size of future liver remnant with an accepted surgical oncological outcome.CONCLUSIONS： Considering the clinicopathological nature of hepatic lesions, the comprehensive assessment and proper choice of the liver resection technique in highly selected patients is associated with improved surgical oncological outcome. Patients with underlying marginal future liver remnant volumes can now safely benefit from a wider range of surgical intervention, a breakthrough that significantly improved morbidity and mortality in this group of patients.

Review of the literature laparoscopic surgery for metastatic hepatic leiomyosarcoma associated with smooth muscle tumor of uncertain malignant potential: Case report

Metastatic hepatic leiomyosarcoma is a rare malignant smooth muscle tumor.We report a case of metastatic hepatic leiomyosarcoma associated with smooth muscle tumor of uncertain malignant potential(STUMP).A 68-year-old female presented with a liver mass(60 mm × 40 mm, Segment 4).She underwent left salpingooophorectomy for an ovary tumor with STUMP in a broad ligament 6 years ago.Though FDG-PET showed obvious metabolically active foci, abnormal metabolically active foci other than the lesion were not detected.A malignant liver tumor was strongly suspected and laparoscopic partial liver resection was performed with vessel-sealing devices using the crush clamping method and Pringle maneuver.Immunohistochemical findings revealed metastatic liver leiomyosarcoma associated with STUMP in a broad ligament.This case is an extremely rare case of malignant transformation from primary STUMP to metastatic hepatic leiomyosarcoma.It provides important evidence regarding the treatment for metastatic hepatic leiomyosarcoma associated with STUMP.

A STUDY OF INTRAOPERATIVE TREATMENT MODALITIES FOR NONRESECTABLE PRIMARY LIVER CANCER:A FOLLOW-UP OF 200 CASES

This paper reports the results of intraoperativetreatments with (different modality in 200 patients withnonresectable primary liver carcinoma (PLC) from April1964 to July 1993 in our hospital. PLC was verifiedhistologically in all cases. They were divided into 2 groupsaccording to the methods of treatment. In group 1, 115cases received anticancer agents by hepatic arteryinfusion (HAl). The 1- and 2-year survival rates were10.40/o and 1.7o/o, respectively and only one patientsurvived for 65 months. In group Ⅱ, 85 cases receivedmultimodality treatments (MMT) with variouscombination of hepatic artery chemoembolization(HACE), hepatic artery ligation (HAL), microwavecoagulation of tumor (MWC) and ethanol injection intotumor (EIT). The 1-, 2-, 3- and 5- survival rates were34.1o/o, 21.2o/o, 12-o/o and 6.7o/o, respectively. 5 casessurvived for 41 to 63 months. The tumor was resected atsecond stage in 6 cases after MMT. The results suggestthat MMT is an effective approacb to improve the long-term survival of patients with nonresectable PLC.