National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26,2023,at the Pakistan Kidney and Liver Institute&Research Centre(PKLI&RC)after initial consultations with the experts.The Pakistan Society for the Study of Liver Diseases(PSSLD)and PKLI&RC jointly organised this meeting.This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma(hCCA).The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients.This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation.The diagnostic and staging workup includes high-quality computed tomography,magnetic resonance imaging,and magnetic resonance cholangiopancreato-graphy.Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis.However,histopathologic confirmation is not always required before resection.Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging.The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification.Selected patients with unresectable hCCA can be considered for liver transplantation.Adjuvant chemotherapy should be offered to patients with a high risk of recurrence.The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions.Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage.Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Parathyroid carcinoma located in the thyroid gland:A case report

BACKGROUND Parathyroid carcinoma(PC)is a difficult-to-diagnose rare disease with low incidence.Relatively accurate preoperative diagnosis is very important in choosing surgical methods and patient prognosis.CASE SUMMARY This study reported the clinical diagnosis and treatment of a rare patient with PC located in the thyroid gland and provided a case reference for the diagnosis and treatment of PC.A case of a 64-year-old male patient who presented to our hospital with systemic muscle and joint pain and palpitations is outlined.Subsequently,the patient was admitted to the Department of Nephrology for the treatment of“multiple myeloma nephropathy pending investigation”.The patient was diagnosed with“primary hyperparathyroidism and hypercalcemic crisis”using thyroid color ultrasound.CONCLUSION The intraoperative frozen section report considered the parathyroid tumor.Surgical tumor resection was promptly performed,and the diagnosis of PC was confirmed.

A rare presentation of unicentric Castleman's disease in the thigh:A case report and review of literature

BACKGROUND Castleman's disease(CD)is a rare lymphoproliferative,emulating both benign and malignant diseases.The diagnosis of CD is formulated upon the combination of clinical and laboratory criteria and ultimately confirmed by histopathological assessment.Due to its rarity,CD presents a challenge in treatment selection,with available options encompassing surgery,chemotherapy,and autologous stem cell transplantation.However,studies suggest that surgical resection of the lesion is the most effective treatment modality,especially for unicentric CD(UCD).CASE SUMMARY Here,we describe the case of a 25-year-old woman who presented with painless left thigh swelling for 10 wk.She had been following a low-fat diet to lose weight and had normal laboratory results.Magnetic resonance imaging revealed a wellcircumscribed,demarcated cystic lesion located in the left inguinal region with eccentrically positioned signal void vascular structures,measuring 4.3 cm×3 cm×3.2 cm,likely of lymphoid origin.The patient underwent surgical resection,and the final histopathology showed a vascular proliferation and hyalinization of the vessel walls,along with atretic germinal centers traversed by penetrating vessels,consistent with CD.The patient was discharged home one day after the procedure in good condition,with a follow-up appointment scheduled in our outpatient clinic.CONCLUSION Although surgical resection is the mainstay for UCD,a multidisciplinary approach is needed due the lack of specific diagnostic features and treatments.

Efficacy and safety of B-ultrasound-guided radiofrequency ablation in the treatment of primary liver cancer: Systematic review and metaanalysis

BACKGROUND Primary liver cancer is one of the most lethal malignancies in the world.Tradi-tional treatment methods have limitations in terms of efficacy and safety.Ra-diofrequency ablation(RFA)guided by B-ultrasound,as a minimally invasive treatment,has attracted increasing attention in the treatment of primary liver cancer in recent years.AIM To study the efficacy and safety of RFA were compared with those of traditional surgery(TS)for treating small liver cancer.METHODS At least 2 people were required to search domestic and foreign public databases,including foreign databases such as EMBASE,PubMed and the Cochrane Library,and Chinese databases such as the China National Knowledge Infrastructure database,China Biomedical Literature database,Wanfang database and VIP database.Controlled trials of RFA vs conventional surgery for small liver cancer were retrieved from January 2008 to January 2023.They were screened and eva-luated according to the quality evaluation criteria in the Cochrane Handbook of Systematic Reviews.The meta-analysis was performed using RevMan 5.3 soft-ware.RESULTS A total of 10 studies were included in this study,including 1503 patients in the RFA group and 1657 patients in the surgery group.The results of the meta-ana-lysis showed that there was no significant difference in 1-year overall survival between the two groups(P>0.05),while the 3-year and 5-year overall survival rates and 1-year,3-year and 5-year tumor-free survival rates in the surgery group were greater than those in the RFA group(P<0.05).In terms of complications,the incidence of complications in the RFA group was lower than that in the surgery group(P<0.05).CONCLUSION In terms of long-term survival,TS is better than RFA for small liver cancer patients.However,RFA has fewer complications and is safer.

Evaluation of oxaliplatin and tigio combination therapy in locally advanced gastric cancer

BACKGROUND Locally advanced gastric cancer(LAGC)is a common malignant tumor.In recent years,neoadjuvant chemotherapy has gradually become popular for the treatment of LAGC.AIM To investigate the efficacy of oxaliplatin combined with a tigio neoadjuvant chemotherapy regimen vs a conventional chemotherapy regimen for LAGC.METHODS Ninety patients with LAGC were selected and randomly divided into control and study groups with 45 patients in each group,according to the numerical table method.The control group was treated with conventional chemotherapy,and the study group was treated with oxaliplatin combined with tigio-neoadjuvant che-motherapy.The primary outcome measures were the clinical objective response rate(ORR)and surgical resection rate(SRR),whereas the secondary outcome measures were safety and Karnofsky Performance Status score.RESULTS The ORR in the study group was 80.00%,which was significantly higher than that of the control group(57.78%).In the study group,SRR was 75.56%,which was significantly higher than that of the control group(57.78%).There were 15.56%adverse reactions in the study group and 35.56%in the control group.These differences were statistically significant between the two groups.CONCLUSION The combination of oxaliplatin and tigio before surgery as neoadjuvant chemotherapy for patients with LAGC can effectively improve the ORR and SRR and is safe.

Nursing of a patient with multiple primary cancers: A case report and review of literature

BACKGROUND Although the occurrence of multiple primary cancers(MPC)is not exceedingly common,it is not rare in clinical practice.In recent years,there has been a notable increase in its incidence.The frequent confusion between MPC and tumor metastasis or recurrence often leads to delays in diagnosis and treatment.This study aimed to enhance understanding of MPC,improve diagnostic accuracy,guide precise clinical treatment,and implement a case management nursing model(CMNM)to facilitate quick patient recovery.CASE SUMMARY A 61-year-old female patient presented with persistent upper abdominal pain lasting over 2 months.Gastroscopy revealed the presence of both gastric and duodenal cancers.Following a thorough evaluation,the patient underwent pancreaticoduodenectomy,cholecystectomy,and total gastrectomy.Post-surgery,an individualized case management nursing approach was applied,leading to a successful recovery.Three months after the surgery,follow-up examinations showed no signs of recurrence.CONCLUSION The CMNM effectively promoted rapid patient recovery,enhanced the quality of orthopedic nursing services,and accelerated postoperative recovery,ultimately leading to increased patient satisfaction with nursing care.

Outcomes of liver resection in hepatitis C virus-related intrahepatic cholangiocarcinoma:A systematic review and meta-analysis

BACKGROUND Cholangiocarcinoma is the second most common primary liver malignancy.Its incidence and mortality rates have been increasing in recent years.Hepatitis C virus(HCV)infection is a risk factor for development of cirrhosis and cholan-giocarcinoma.Currently,surgical resection remains the only curative treatment option for cholangiocarcinoma.We aim to study the impact of HCV infection on outcomes of liver resection(LR)in intrahepatic cholangiocarcinoma(ICC).AIM To study the outcomes of curative resection of ICC in patients with HCV(i.e.,HCV+)compared to patients without HCV(i.e.,HCV-).METHODS We conducted a systematic review and meta-analysis of randomized controlled trials(RCTs)and observational studies to assess the outcomes of LR in ICC in HCV+patients compared to HCV-patients in tertiary care hospitals.PubMed,EMBASE,The Cochrane Library and Scopus were systematically searched from inception till August 2023.Included studies were RCTs and non-RCTs on patients≥18 years old with a diagnosis of ICC who underwent LR,and compared outcomes between patients with HCV+vs HCV-.The primary outcomes were overall survival(OS)and recurrence-free survival.Secondary outcomes include perioperative mortality,operation duration,blood loss,intrahepatic and extrahepatic recurrence.RESULTS Seven articles,published between 2004 and 2021,fulfilled the selection criteria.All of the studies were retrospective studies.Age,incidence of male patients,albumin,bilirubin,platelets,tumor size,incidence of multiple tumors,vascular invasion,bile duct invasion,lymph node metastases,and stage 4 disease were comparable between HCV+and HCV-group.Alanine transaminase[MD 22.20,95%confidence interval(CI):13.75,30.65,P<0.00001]and aspartate transaminase levels(MD 27.27,95%CI:20.20,34.34,P<0.00001)were significantly higher in HCV+group compared to HCV-group.Incidence of cirrhosis was significantly higher in HCV+group[odds ratio(OR)5.78,95%CI:1.38,24.14,P=0.02]compared to HCV-group.Incidence of poorly differentiated disease was significantly higher in HCV+group(OR 2.55,95%CI:1.34,4.82,P=0.004)compared to HCV-group.Incidence of simultaneous hepatocellular carcinoma lesions was significantly higher in HCV+group(OR 8.31,95%CI:2.36,29.26,P=0.001)compared to HCV-group.OS was significantly worse in the HCV+group(hazard ratio 2.05,95%CI:1.46,2.88,P<0.0001)compared to HCV-group.CONCLUSION This meta-analysis demonstrated significantly worse OS in HCV+patients with ICC who underwent curative resection compared to HCV-patients.

Colorectal cancer with liver metastases:Neoadjuvant chemotherapy,surgical resection first or palliation alone?

Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for &#x0003e; 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.

Surgical treatment for liver cancer

Primary liver cancer is amongst the commonest tumors worldwide,particularly in parts of the developing world,and is increasing in incidence. Over the past three decades,surgical hepatic resection has evolved from a high risk,resource intensive procedure with limited application,to a safe and commonly performed operation with a range of indications. This article reviews the approach to surgical resection for malignancies such as hepatocellular cancer,metastatic liver de-posits and neuroendocrine tumors. Survival data after resection is also reviewed,as well as indications for curative resection.

Surgical outcome of pancreatic cancer using radical antegrade modular pancreatosplenectomy procedure

AIM:To evaluate the surgical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic cancer. METHODS:Twenty-four patients underwent RAMPS with curative intent between January 2005 and June 2009 at the National Cancer Center, South Korea. Clinicopathologic data, including age, sex, operative findings, pathologic results, adjuvant therapy, postop-erative clinical course and follow-up data were retro-spectively collected and analyzed for this study. RESULTS:Twenty-one patients (87.5%) underwent distal pancreatectomy and 3 patients (12.5%) underwent total pancreatectomy using RAMPS. Nine patients (37.5%) underwent combined vessel resection, including 8 superior mesenteric-portal vein resections and 1 celiac axis resection. Two patients (8.3%) underwent combined resection of other organs, including the colon, stomach or duodenum. Negative tangential margins were achieved in 22 patients (91.7%). The mean tumor diameter for all patients was 4.09 ± 2.15 cm. The 2 patients with positive margins had a mean diameter of 7.25 cm. The mean number of retrieved lymph nodes was 20.92 ± 11.24 and the node positivity rate was 70.8%. The median survival of the 24 patients was 18.23 ± 6.02 mo. Patients with negative margins had a median survival of 21.80 ± 5.30 mo and those with positive margins had a median survival of 6.47 mo (P = 0.021). Nine patients (37.5%) had postoperative complications, but there were no postoperative mortalities. Pancreatic fistula occurred in 4 patients (16.7%):2 patients had a grade A fistula and 2 had a grade B fistula. On univariate analysis, histologic grade, positive tangential margin, pancreatic fistula and adjuvant therapy were significant prognostic factors for survival. CONCLUSION:RAMPS is a feasible procedure for achieving negative tangential margins in patients with carcinoma of the body and tail of the pancreas.

Clinical usefulness of ^(18) F-FDG PET/CT in the restaging of esophageal cancer after surgical resection and radiotherapy

AIM： To evaluate the clinical usefulness of lSF-fluorodeoxyglucose positron emission and computed tomography QSF-FDG PET/CT） in restaging of esophageal cancer after surgical resection and radiotherapy. METHODS： Between January 2007 and Aug 2008, twenty histopathologically diagnosed esophageal cancer patients underwent 25 PET/CT scans （three patients had two scans and one patient had three scans） for restaging after surgical resection and radiotherapy. The standard reference for tumor recurrence was histopathologic confirmation or clinical follow-up for at least ten months after ^18F-FDG PET/CT examinations. RESULTS： Tumor recurrence was confirmed histopathologically in seven of the 20 patients （35%） and by clinical and radiological follow-up in 13 （65%）. ^18F-FDG PET/CT was positive in 14 patients （68.4%） and negative in six （31.6%）. ^18F-FDG PET/CT was true positive in 11 patients, false positive in three and true negative in six. Overall, the accuracy of ^18F-FDG PET/CT was 85%, negative predictive value （NPV） was 100%, and positive predictive value （PPV） was 78.6%.The three false positive PET/CT findings comprised chronic inflammation of mediastinal lymph nodes （n = 2） and anastomosis inflammation （n = 1）. PET/ CT demonstrated distant metastasis in 10 patients. ^18F-FDG PET/CT imaging-guided salvage treatment in nine patients was performed. Treatment regimens were changed in 12 （60%） patients after introducing ^18F-FDG PET/CT into their conventional post-treatment follow-up program. CONCLUSION： Whole body ^18F-FDG PET/CT is effective in detecting relapse of esophageal cancer after surgical resection and radiotherapy. It could also have important clinical impact on the management of esophageal cancer, influencing both clinical restaging and salvage treatment of patients.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND： Hepatocellular carcinoma （HCC） is a com- plex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple con- founding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortal- ity globally with a rising trend of incidence in some of the de- veloped countries, which indicates the need for better surgical and nonsurgical management strategies.

Evaluation of intraoperative radiotherapy for gastric carcinoma with D2 and D3 surgical resection

AIM： TO study the proper sites and doses of intraoperative radiotherapy （IORT） for gastric carcinoma and the effects of this treatment. METHODS： A total of 106 patients with stage Ⅰ -Ⅳ gastric carcinoma who received D2 or D3 radical operation combined with IORT were analyzed. Sixty-seven patients with gastric cancer of the antrum and body underwent distal gastrectomy. The sites of irradiation were at the celiac artery and hepatoduodenal ligment area. Another 39 patients with carcinoma of the cardia and upper part of the gastric body and whole stomach underwent proximal gastrectomy or total gastrectomy. The sites of irradiation for this group were the upper margin of the pancreas and the regional para-aorta. The therapeutic effects （including survival and complications） of these 106 cases received operation combined with IORT （IORT group） were compared with 441 cases treated during the same time period by a radical operation alone （operation group）. RESULTS： The radiation dose below 30 Gy was safe. The therapeutic method of the operation combined with IORT did not prolong the survival of patients with stage Ⅰ and Ⅳ gastric cancer, but the 5-year survival rates of patients with stage Ⅱ and Ⅲ gastric cancers were significantly improved. The 5-year survival rates of the stages Ⅲ cancer patients receiving D2 resection combined with IORT were markedly improved, while for those receiving D3 radical resection, only the postoperative 3- or 4-year survival rates were improved （P 〈 0.005-0.001）. The 5-year survival rate for those patients was raised only by 4.7% （P 〉 0.05）. CONCLUSION： The 5-year survival rates of patients with stages Ⅱ and Ⅲ gastric carcinoma who received D2 lymphadenectomy combined with IORT were improved, and there was no influence on the postoperative complications and mortality.

Radiofrequency ablation vs surgical resection in elderly patients with hepatocellular carcinoma in Milan criteria

BACKGROUND Surgical resection and radiofrequency ablation(RFA)represent two possible strategy in treatment of hepatocellular carcinoma(HCC)in Milan criteria.AIM To evaluate short-and long-term outcome in elderly patients(>70 years)with HCC in Milan criteria,which underwent liver resection(LR)or RFA.METHODS The study included 594 patients with HCC in Milan criteria(429 in LR group and 165 in RFA group)managed in 10 European centers.Statistical analysis was performed using the Kaplan-Meier method before and after propensity score matching(PSM)and Cox regression.RESULTS After PSM,we compared 136 patients in the LR group with 136 patients in the RFA group.Overall survival at 1,3,and 5 years was 91%,80%,and 76%in the LR group and 97%,67%,and 41%in the RFA group respectively(P=0.001).Diseasefree survival at 1,3,and 5 years was 84%,60%and 44%for the LR group,and 63%,36%,and 25%for the RFA group(P=0.001).Postoperative Clavien-Dindo IIIIV complications were lower in the RFA group(1%vs 11%,P=0.001)in association with a shorter length of stay(2 d vs 7 d,P=0.001).In multivariate analysis,Model for End-stage Liver Disease(MELD)score(>10)[odds ratio(OR)=1.89],increased value of international normalized ratio(>1.3)(OR=1.60),treatment with radiofrequency(OR=1.46),and multiple nodules(OR=1.19)were independent predictors of a poor overall survival while a high MELD score(>10)(OR=1.51)and radiofrequency(OR=1.37)were independent factors associated with a higher recurrence rate.CONCLUSION Despite a longer length of stay and a higher rate of severe postoperative complications,surgery provided better results in long-term oncological outcomes as compared to ablation in elderly patients(>70 years)with HCC in Milan criteria.

Efficacy of surgical resection in management of isolated extrahepatic metastases of hepatocellular carcinoma

AIM:To clarify the benefit of surgical excision for patients with extrahepatic metastases of hepatocellular carcinoma(HCC). METHODS:We retrospectively reviewed the medical records of 140 patients with pathologically proven extrahepatic metastases of HCC and evaluated the outcomes of those who had undergone surgical resection(SR)for extrahepatic metastatic lesions.Prognoses made on the basis of extrahepatic metastatic sites were also examined. RESULTS:The survival rates of patients who underwent SR of extrahepatic metastases were significantly better than those of patients who did not receive SR. For the SR group,1-and 3-year survival rates were 24%and 7%,respectively,while for the non-resection group,the survival rates were 8%and 0%,respec- tively(P<0.0001).Survival rates related to metastatic sites were also significantly superior after SR of extrahepatic metastases:median survivals were 32 mo with lung metastasis,10 mo with bone metastasis,6.1 mo with brain metastasis. CONCLUSION:SR can provide survival benefits forpatients with 1 or 2 isolated extrahepatic metastases and who concurrently exhibit good hepatic functional reserve and general performance status as well as successful treatment of intrahepatic HCC.

Surgical resection of a solitary para-aortic lymph node metastasis from hepatocellular carcinoma

Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver cirrhosis was admitted for the evaluation of a liver tumor. He had already undergone radiofrequency ablation, transcatheter arterial chemoembolization, and percutaneous ethanol injection therapy for HCC. Despite treatment, viable regions remained in segments 4 and 8. We performed a right paramedian sectionectomy with partial resection of the left paramedian section of the liver. Six months later, serum concentrations of alpha-fetoprotein (189 ng/mL) and PIVKA-2 (507 mAU/mL) increased. Enhanced com- puted tomography of the abdomen revealed a tumor (20 mm in diameter) on the right side of the abdominal aorta. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed an increased standard uptake value. There was no evidence of recurrence in other regions. Esophagogastroduodenoscopy and colonoscopy revealed no malignant tumor in the gastrointestinal tract. Para-aortic LN metastasis from HCC was thus diagnosed. We performed lymphadenectomy. Histopathological examination revealed that the tumor was largely necrotic, with poorly differentiated HCC on its surface, which confirmed the suspected diagnosis. After 6 mo tumor marker levels were normal, with no evidence of recurrence. Our experience suggests that a solitary para-aortic LN metastasis from HCC can be treated surgically.

Effectiveness of surgical resection for complicated liver cancer and its influencing factors: A retrospective study

BACKGROUND Surgical resection is the preferred method for patients with complex liver cancer.But the tumor is in a special position, the surgery is highly risky, postoperative complications can easily occur, and the prognosis is not ideal.AIM To investigate the effectiveness of surgical resection for complex liver cancer and its influencing factors.METHODS Fifty-seven patients who had complicated liver cancer and underwent surgical resection at our hospital from August 2015 to August 2016 were enrolled in this study. All patients were followed for three years, and their postoperative complications, survival, and factors that impacted their survival were analyzed.RESULTS The total incidence of postoperative complications was 45.61%, and the incidence of pleural effusion was the highest at 28.07%. There were no correlations between the 2-year and 3-year survival rates and sex, age, and Hbs Ag of the patients(P >0.05). In terms of pathological parameters, the 2-year and 3-year survival rates were significantly different according to the presence of a tumor capsule, degree of liver cirrhosis, satellite or focal lesions, hepatic vein thrombosis, portal vein tumor thrombus, and intraoperative blood loss(P < 0.05).CONCLUSIONThe effectiveness of surgical resection for complex hepatocellular carcinoma may be affected by factors such as the presence of a tumor capsule, cirrhosis degree,satellite or focal lesions, hepatic vein embolization, portal vein tumor thrombus,and intraoperative blood loss. Therefore, these factors should be controlled and prevented during surgery to help improve patient survival after surgery.

Impact of parenchyma-preserving surgical methods on treating patients with solid pseudopapillary neoplasms:A retrospective study with a large sample size

BACKGROUND Solid pseudopapillary neoplasm of the pancreas(SPN)is a rare neoplasm that mainly affects young women.AIM To evaluate the impact of parenchyma-preserving surgical methods(PPMs,including enucleation and central pancreatectomy)in the treatment of SPN patients.METHODS From 2013 to 2019,patients who underwent pancreatectomy for SPNs were retrospectively reviewed.The baseline characteristics,intraoperative index,pathological outcomes,short-term complications and long-term follow-up data were compared between the PPM group and the conventional method(CM)group.RESULTS In total,166 patients were included in this study.Of them,33 patients(19.9%)underwent PPM.Most of the tumors(104/166,62.7%)were found accidentally.Comparing the parameters between groups,the hospital stay d(12.35 vs 13.5 d,P=0.49),total expense(44213 vs 54084 yuan,P=0.21),operation duration(135 vs 120 min,P=0.71),and intraoperative bleeding volume(200 vs 100 mL,P=0.49)did not differ between groups.Regarding pathological outcomes,tumor size(45 vs 32 mm,P=0.07),Ki67 index(P=0.53),peripheral tissue invasion(11.3%vs 9.1%,P=0.43)and positive margin status(7.5%vs 6%,P=0.28)also did not differ between groups.Moreover,PPM did not increase the risk of severe postoperative pancreatic fistula(3.8%vs 3.0%,P=0.85)or tumor recurrence(3.0%vs 6.0%,P=0.39).However,the number of patients who had exocrine insufficiency during follow-up was significantly lower in the PPM group(21.8%vs 3%,P=0.024).CM was identified as an independent risk factor for pancreatic exocrine insufficiency(odds ratio=8.195,95%confident interval:1.067-62.93).CONCLUSION PPM for SPN appears to be feasible and safe for preserving the exocrine function of the pancreas.

Surgical resection versus liver transplantation for hepatocellular carcinoma within the Hangzhou criteria: a preoperative nomogram-guided treatment strategy

BACKGROUND: With the expansion of surgical criteria, the comparative efficacy between surgical resection (SR) and liver transplantation (LT) for hepatocellular carcinoma is inconclusive. This study aimed to develop a prognostic nomogram for predicting recurrence-free survival of hepatocellular carcinoma patients after resection and explored the possibility of using nomogram as treatment algorithm reference. METHODS: From 2003 to 2012, 310 hepatocellular carcinoma patients within Hangzhou criteria undergoing resection or liver transplantation were included. Total tumor volume, albumin level, HBV DNA copies and portal hypertension were included for constructing the nomogram. The resection patients were stratified into low- and high-risk groups by the median nomogram score of 116. Independent risk factors were identified and a visually orientated nomogram was constructed using a Cox proportional hazards model to predict the recurrence risk for SR patients. RESULTS: The low-risk SR group had better outcomes compared with the high-risk SR group (3-year recurrence-free survival rate, 71.1% vs 35.9%; 3-year overall survival rate, 89.8% vs 78.9%, both P<0.001). The high-risk SR group was associated with a worse recurrence-free survival rate but similar overall survival rate compared with the transplantation group (3-year recurrence-free survival rate, 35.9% vs 74.1%, P<0.001; 3-year overall survival rate, 78.9% vs 79.6%, P>0.05). CONCLUSIONS: This nomogram offers individualized recurrence risk evaluation for hepatocellular carcinoma patients within Hangzhou criteria receiving resection. Transplantation should be considered the first-line treatment for high risk patients.

The extent and value of lymphadenectomy in the surgical treatment of gastroesophageal junction carcinoma

Objective： We studied the extent and value of the lymphadenectomy in surgical treatment of carcinoma of gastroesophageal junction （GEJ）. Methods： 217 patients with GEJ who underwent surgical resection were retrospectively analyzed. The extent of lymphadenectomy was divided into 5 types （DO to D4） and the curability of operation was graded as A, B and C. Results： The patients had been treated as follows： 186 with proximal gastrectomy, 31 with total gastrectomy, 97 with a combined-visceral resection. The patients who underwent D1, D2 and D3 lymphadenectomy were respectively 158, 58 and 1. The patients who were performed with resection of grade A, B and C were 53, 107 and 57 respectively. All patients were performed with a lymphadenectomy and well registered. The lymph node metastasis occurred in 157 cases （72.4%）. The lymph node metastasis rate in the group 1, 2, 3, 4, 7, 9, 12 and 110 as well as in the pulmonary ligament group were higher than other groups. 2868 lymph nodes were removed, in which 655 （22.8%） demonstrated the existence of metastasis. The total lymph node metastatic degree in these groups was higher compared to the other groups. Conclusion： The survival rate in the D1 lymphadenectomy and D2 is similar for all patients, and there may be some differences in the 2nd and 3rd years for the DI lymphadenectomy and D2 in the stage-Ⅲb patients. The survival rate of D2 lymphadenectomy in stage Ⅲb is better than D1 and that of D2 lymphadenectomy is superior to D1 in stage-Ⅳ patients. The survival rate of grade A and B operation is much better than grade C, and the survival rate of grade A is also higher than B.