Laparoscopic hepatectomy for liver neoplasms in 15 cases

Objective： The aim of our study was to retrospectively analyze 15 patients＇ clinical materials with laparoscopic resection of liver neoplasms. Methods： From December 2007, a total of 15 patients with liver neoplasms were performed with laparoscopic hepatectomy, and their clinical materials, perioperative dates, postoperative complications, postoperative recovery and short-term curative effects were analyzed and summarized respectively. Results： Laparoscopic hepatectomy （LH） were performed in 15 patients, including 1 case underwent laparoscopic hepatic left Iobectomy, 1 case of left lateral hepatectomy, 13 cases of partial liver resection. Fourteen cases of total laparoscopic liver resections for liver neoplasms, 1 case of hand-assisted laparoscopic liver resection of the tumor, there was no conversion to open approach. Of the 15 patients with liver neoplasms, 13 cases of hepatic neoplasms with the maximum diameter was 8 cm× 8 cm × 9 cm, 9 cases of the borderline micro hepatocellular carcinoma （MHCC） with the diameter not more than 2 cm, 3 cases of hepatic benign tumor. The mean operation time was （120 ± 30） min, and the intraoperative average hemorrhage was 100 mL, beginning to eat and get out of bed following 1-2 days of operation. The average postoperative hospitalization was 8 days, WBC, ALl＇, AST, albumin, bilirubin returned to normal after one week of operation. There were no postoperative complications such as hemorrhage, bile leakage or air embolism etc. Twelve patients with HCC were confirmed by postoperative pathology, 1 case of liver smooth muscle lipoma, 2 case of hepatic hemangioma. By one year of followed-up in 12 cases of HCC, the longest survival was 38 months, and no recurrence or death, 1 year survival rate was 100%. Conclusion： Among the choice of cases, the advantages of LH for liver neoplasms compared with open surgery were less trauma, faster recovery and less blood loss. it is safe and effective for choosing a reasonable surgical indication, especially for peripheral micro hepatocellular carcinoma.

Value and prognostic factors of repeat hepatectomy for recurrent colorectal liver metastasis

Background:More than 50%of patients with colorectal cancer develop liver metastases.Hepatectomy is the preferred treatment for resectable liver metastases.This review provides a perspective on the utility and relevant prognostic factors of repeat hepatectomy in recurrent colorectal liver metastasis(CRLM).Data sources:The keywords“recurrent colorectal liver metastases”,“recurrent hepatic metastases from colorectal cancer”,“liver metastases of colorectal cancer”,“repeat hepatectomy”,“repeat hepatic resec-tion”,“second hepatic resection”,and“prognostic factors”were used to retrieve articles published in the PubMed database up to August 2020.Additional articles were identified by a manual search of references from key articles.Results:Despite improvements in surgical methods and perioperative chemotherapy,recurrence remains common in 37%-68%of patients.Standards or guidelines for the treatment of recurrent liver metastases are lacking.Repeat hepatectomy appears to be the best option for patients with resectable metastases.The commonly reported prognostic factors after repeat hepatectomy were R0 resection,carcinoembryonic antigen level,the presence of extrahepatic disease,a short disease-free interval between initial and repeat hepatectomy,the number(>1)and size(≥5 cm)of hepatic lesions,requiring blood transfusion,and no adjuvant chemotherapy after initial hepatectomy.The median overall survival after repeat hepatectomy ranged from 19.3 to 62 months,and the 5-year overall survival ranged from 21%to 73%.Chemotherapy can act as a test for the biological behavior of tumors with the goal of avoiding unnecessary surgery,and a multimodal approach involving aggressive chemotherapy and repeat hepatectomy might be the treatment of choice for patients with early recurrent CRLM.Conclusions:Repeat hepatectomy is a relatively safe and effective treatment for resectable recurrent CRLM.The presence or absence of prognostic factors might facilitate patient selection to improve short-and long-term outcomes.

Microwave ablation combined with hepatectomy for treatment of neuroendocrine tumor liver metastases

BACKGROUND Hepatectomy is the first choice for treating neuroendocrine tumor liver metastases.However,most patients with neuroendocrine tumor liver metastases are not suitable for hepatectomy.Ablation combined with hepatectomy can be an alternative to liver resection.AIM To explore the clinical effect of microwave ablation combined with hepatectomy for the treatment of neuroendocrine tumor liver metastases.METHODS In this study,the data of patients who underwent microwave ablation combined with hepatectomy for the treatment of neuroendocrine tumor liver metastases from June 2015 to January 2018 were reviewed.Before the operation,the patients did not receive any treatment for liver neuroendocrine tumors.After a multidisciplinary expert group discussion,all patients were deemed unsuitable for liver resection.All patients were diagnosed with neuroendocrine tumors by pathology.The overall survival time and progression-free survival time were followed by telephone calls and outpatient visits after surgery.RESULTS Eleven patients with neuroendocrine tumor liver metastases were treated by microwave ablation combined with hepatectomy between June 2015 and January 2018.The median number of liver metastatic nodules was 4(range,2 to 43).The median number of lesions resected was 1(range,1 to 18),and the median number of lesions ablated was 3(range,1 to 38).The mean operation time was 405.6(±39.4)min.The median intraoperative blood loss was 600 mL(range,50 to 3000).Ten patients had a fever after surgery.The median duration of fever was 3 d(range,0 to 21).Elevated bilirubin levels occurred in all patients after surgery.The median bilirubin on the first day after surgery was 28.5(range,10.7 to 98.9)μmol/L.One patient developed respiratory failure,renal insufficiency,and pneumonia after the operation.No patient died postoperatively during hospitalization.The mean overall survival time after surgery was 34.1(±3.7)mo,and the median progression-free survival time was 8(range,2 to 51)mo.One year after surgery,ten patients survived and five patients survived without progression.Three year after surgery,eight patients survived and two patients survived without progression.CONCLUSION Microwave ablation combined with hepatectomy not only makes the patients obtain a survival rate similar to that of patients undergoing hepatectomy,but also has a low incidence of postoperative complications.

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma≤4 cm

AIM： To determine which treatment modality - hepatectomy or percutaneous ablation - is more beneficial for patients with small hepatocellular carcinoma （HCC） （≤4 cm） in terms of long-term outcomes. METHODS： A retrospective analysis of 149 patients with HCC ≤ 4 cm was conducted. Eighty-five patients underwent partial hepatectomy （anatomic in 47 and nonanatomic in 38） and 64 underwent percutaneous ablation （percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6）. The median follow-up period was 69 mo. RESULTS： Hepatectomy was associated with larger tumor size （P〈0.001）, whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy （P〈0.0001）. Survival was better following hepatectomy （median survival time： 122 mo） than following percutaneous ablation （median survival time： 66 mo; P= 0.0123）. When tumor size was divided into ≤ 2 cm vs 〉 2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors 〉2 cm （P= 0.0001）. The Cox proportional hazards regression model revealed that hepatoctomy （P= 0.006） and tumors ≤ 2 cm （P=0.017） were independently associated with better survival. CONCLUSION： Hepatectomy provides both better local control and better long-term survival for patients with HCC ≤4 cm compared with percutaneous ablation. Of the patients with HCC ≤4 cm, those with tumors 〉 2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.

Outcomes of patients with post-hepatectomy hypophosphatemia:A narrative review

Phosphate is an essential electrolyte for proper mineralisation of bone,buffering of urine,and diverse cellular actions.Hypophosphatemia(HP)is a clinical spectrum which range from asymptomatic to severe complications such as neuromuscular and pulmonary complications,or even death.Post-hepatectomy HP(PHH)has been reported to be 55.5%-100%.Post-hepatectomy,there is rapid uptake of phosphate and increased mitotic counts to aid in regeneration of residual liver.Concurrently,PHH may be due to increased urinary phosphorous from activation of matrix extracellular phosphoglycoprotein in the injured liver,which decreases phosphate influx into hepatocytes to sustain adenosine triphosphate synthesis.A literature review was performed on Pub Med till January 2022.We included 8 studies which reported on impact of PHH on post-operative outcomes.In patients with diseased liver,PHH was reported to have either beneficial or deleterious effects on post-hepatectomy liver failure(PHLF),morbidity and/or mortality in various cohorts.In living donor hepatectomy,PHLF was higher in PHH.Benefits of correction of PHH with reduced postoperative complications have been shown.Correction of PHH should be done based on extent of PHH.Existing studies were however heterogenous;further studies should be conducted to assess PHH on post-operative outcomes with standardized phosphate replacement regimes.

Liver transplantation as an alternative for the treatment of intrahepatic cholangiocarcinoma: Past, present, and future directions

Intrahepatic cholangiocarcinoma(iCCA)is a rare biliary tract cancer with high mortality rate.Complete resection of the iCCA lesion is the first choice of treatment,with good prognosis after margin-negative resection.Unfortunately,only 12%-40% of patients are eligible for resection at presentation due to cirrhosis,portal hypertension,or large tumor size.Liver transplantation(LT)offers margin-negative iCCA extirpation for patients with unresectable tumors.Initially,iCCA was a contraindication for LT until size-based selection criteria were introduced to identify patients with satisfied post-LT outcomes.Recent studies have shown that tumor biology-based selection can yield high post-LT survival in patients with locally advanced iCCA.Another selection criterion is the tumor response to neoadjuvant therapy.Patients with response to neoadjuvant therapy have better outcomes after LT compared with those without tumor response to neoadjuvant therapy.Another index that helps predict the treatment outcome is the biomarker.Improved survival outcomes have also opened the door for living donor LT for iCCA.Patients undergoing LT for iCCA now have statistically similar survival rates as patients undergoing resection.The combination of surgery and locoregional and systemic therapies improves the prognosis of iCCA patients.

Surgical Resection of Right or Total Caudate Lobe of the Liver Including the Paracaval Portion

Objective To explore the method for and experience of the right or total caudate lobectomies including the paracaval portion. Methods The right posterior approach was employed for right caudate lobectomy and the left lateral approach for total caudate lobectomy. Prior to liver parenchymal transection, dissection was made to separate the caudate lobe and the tumor from the retrohepatic inferior vena cava (IVC). The transection was carried out by forceps and finger fracture with or without some kind of hepatic vascular occlusion. Results A total of 7 right and 6 total caudate lobectomies were performed, all including resection of the paracaval portion. There were no operative deaths or severe complications. The mean intraoperative blood loss was 896 ml (range: 250–2 000 ml). Among the 13 hepatectomies, 10 were done under portal triad clamping with a mean clamp time of 25 min (range: 10–83 min). There was a mean postoperative hospital stay of 12 days (range: 9–22 days). Conclusion Athough deeply located and in close proximity to the trunk of the main hepatic veins and the portal pedicle, the caudate lobe including paracaval portion can be safely resected either alone or combined with liver resection. Key words hepatectomy - liver neoplasms - inferior vena cava-surgery

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.

Clinical application of hepatic venous occlusion for hepatectomy

Background Most liver resections require clamping of the hepatic pedicle （Pringle maneuver） to avoid excessive blood loss. But Pringle maneuver can not control backflow bleeding of hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from the injuries of the hepatic veins. Although total hepatic vascular exclusion can prevent bleeding of the hepatic veins effectively, it also may result in systemic hemodynamic disturbance because of the inferior vena cava being clamped. Hepatic venous occlusion, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. Methods A total of 71 cases of liver tumors underwent resection with occlusion of more than one of the main hepatic veins. All tumors involved the second porta hepatis and at least one main hepatic vein. Ligation or occlusion with serreflnes, tourniquets and auricular clamps were used in hepatic venous occlusion. Results Of the 71 patients, ligation of the hepatic veins was used in 28 cases, occlusion with a tourniquet in 26, and occlusion with a serrefine in 17. Right hepatic veins were occluded in 38 cases, both right and middle hepatic veins in 2, the common trunk of the left and middle hepatic veins in 24, branches of the left and middle hepatic veins in 2, and all three hepatic veins in 5. Thirty-five cases underwent hemihepatic vascular occlusion, 4 alternate hemihepatic vascular occlusion, 23 portal triad clamping plus selective hepatic vein occlusion, and 9 portal triad clamping plus total hepatic vein occlusion. The third porta hepatis was isolated in 26 cases. The amount of intraoperative blood loss averaged （540±2.83） （range 100 to 1000） ml in the group of total hemihepatic vascular occlusion and in the group of alternate hemihepatic vascular occlusion, （620±317） （range 200-6000） ml in the group of portal triad clamping plus selective or total hepatic vein occlusion. All tumors were completely removed. Conclusions Hepatic venous occlusion applied in hepatectomy can prevent bleeding and air embolism, and is safe and effective with stable hemodynamics.

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.

Total laparoscopic liver resection in 78 patients

AIM： To summarize the clinical experience of laparoscopic hepatectomy at a single center. METHODS： Between November 2003 and March 2009, 78 patients with hepatocellular carcinoma （n = 39）, metastatic liver carcinoma （n = 10）, and benign liver neoplasms （n = 29） underwent laparoscopic hepatectomy in our unit. A retrospective analysis was done on the clinical outcomes of the 78 patients. RESULTS： The lesions were located in segments Ⅰ （n = 3）, Ⅱ （n = 16）, Ⅲ （n = 24）, Ⅳ （n = 11）, Ⅴ （n = ii）, Ⅵ （n = 9）, and Ⅷ （n = 4）. The lesion sizes ranged from 0.8 to 15 cm. The number of lesions was three （n = 4）, two （n = 8） and one （n = 66） in the study cohort. The surgical procedures included left hemi-hepatectomy （n = 7）, left lateral lobectomy （n = 14）, segmentectomy （n = 11）, local resection （n = 39）, and resection of metastatic liver lesions during laparoscopic surgery for rectal cancer （n = 7）. Laparoscopic liver resection was successful in all patients, with no conversion to open procedures. Only four patients received blood transfusion （400-800 mL）. There were no perioperative complications, such as bleeding and biliary leakage. The liver function of all patients recovered within 1 wk, and no liver failure occurred. CONCLUSION： Laparoscopic hepatectomy is a safe and feasible operation with minimal surgical trauma. It should be performed by a surgeon with sufficient experience in open hepatic resection and who is proficient in laparoscopy.

Spontaneous rupture of a mucinous cystic neoplasm of the liver resulting in a huge biloma in a pregnant woman:A case report

BACKGROUND Mucinous cystic neoplasm of the liver(MCN-L)and intraductal papillary neoplasm of the bile duct(IPN-B)are two different types of mucin-producing bile duct tumour that may complicate the course of pregnancy.To the best of our knowledge,we describe herein the first case of MCN-L with spontaneous rupture during pregnancy necessitating complex surgical treatment.CASE SUMMARY A 24-year-old woman was initially admitted to another hospital in October 2018 with signs of jaundice(serum bilirubin level 12 mg/dL)and upper abdominal pain radiating to the left shoulder.Initial magnetic resonance imaging(MRI)of the abdominal cavity revealed a multilocular cystic tumour of the liver hilum(37 mm×40 mm in diameter)located between segments 3 and 4 of the left liver lobe.Six weeks later(December 2018),the patient was found to be 12 wk pregnant and was referred to our institution for further diagnostics and treatment.At admission,a soft,palpable,and tender mass in the left upper abdomen was found.It was determined via MRI(with no intravenous contrast in view of the first-trimester pregnancy)to be a large collection of fluid(19 cm×17 cm×10 cm)located close to the liver hilum and below the left liver lobe.The patient did not undergo any diagnostic or therapeutic procedures nor did they have any abdominal trauma in the preceding weeks.The fluid collection proved to be of biliary origin following percutaneous drainage.Therefore,we concluded this was a spontaneous rupture of an MCN-L with the formation of a biloma.The MRI study also revealed the previously found cystic tumour of the liver hilum communicating with the left hepatic duct,which,together with left hepatic duct dilatation,suggested the diagnosis of IPN-B.The follow-up MRI with intravenous gadolinium contrast performed in the second trimester of pregnancy(week 14)showed,in turn,some features of MCN-L,including enhancement of the internal septations within the cystic liver mass.A precise preoperative differential diagnosis between IPN-B and MCN-L was therefore not possible.The patient was submitted to surgery in the second trimester of pregnancy(week 18).Surgery included a cholecystectomy,left hepatectomy,and concomitant resection of the extrahepatic bile ducts followed by anastomosis of the right hepatic duct with the Roux limb of the jejunum.The post-operative period was uneventful and the patient was discharged 8 days after surgery.The histopathological examination of the resected specimen revealed a final diagnosis of MCN-L with low-grade dysplasia and epithelium surrounded by ovarian-type stromal tissue.The patient delivered a healthy baby girl and both remain well at present,after 2 years of follow-up since surgery.CONCLUSION The differential diagnosis and management of MCN-L and IPN-B may be very challenging,particularly in the setting of pregnancy.When indications for surgery are obvious,the final diagnosis is based on histopathological examination,with ovarian-type stroma being pathognomonic for MCN-L.We believe that the growth of this subepithelial stroma secondary to the high levels of sex hormones produced during pregnancy might have been the main causative factor leading to the tumour rupture with the formation of a biloma in our patient.

Resection of the Caudate Lobe Tumor of Liver

Objective To analyze the operative technique and results of the resection for caudate lobe carcinoma of the liver. Methods The liver was fully freed of the ligments, short hepatic veins were divided and sutured, and the tumor was then freed from the inferior vena cava(IVC) . The caudate lobe was resected alone or in combination with other segment.Results 28 patients underwent resection of caudate lobe tumor. The number of the short hepatic veins transected and tied was 2-5 ( mean 3) . An intermittent Pringle' s manoeuver was used in 26 patients with a median occlusion time of 21.7 ( range 10-32) min. The median blood loss was 574 (range 100? 300) ml. No major complications such as massive bleeding and biliary fistula occurred. Intraop-erative total vascular occlusion was perfored on only 5 cases. All patients were discharged from the hospital. Outpatient periodic TAE plus chemotherapy was performed. Postoperative recurrence and metastasis was found in 13 cases,with 5 deaths.Conclusion The use of third porta hepatis dissection for resection of the caudate lobe tumor can reduce the risk of massive bleeding during the operation and can raise the rate of resection of caudate lobe tumor.

Resection of Huge Liver Cancer Involving the Second Porta Hepatis: A Report of 55 Cases

Objective To investigate the possibility and surgical procedures for huge liver cancer involving the second porta hepatis.Methods 55 cases of huge liver cancer, with the diameter of 8-28 cm(mean 12.7 cm) were studied. Right subcostal or “rooftop” incision was made, the liver ligments were divided, good exposure of the tumor and access to retrohepatic inferior vena cava were achieved.Hepatectomies were completed under intermittent interruption of first porta hepatis. Occluding tape around vena cava was applied before liver resection if necessary.Results All tumors were successfully resected without death during operation.The longest survival time was now 4 years in one case. The 1-4 year postoperative survival rates were 63%,50%,50% and 30% respectively.Conclusion Young patients with solitary large liver tumor, which grows slowly over a long period on basis of non-cirrhotic or mild cirrhotic liver, should undergo an exploration in an attempt of resection irrespective of the image contraindication, provided that there is no extra-hepatic metastasis.

Perioperative liver and spleen elastography in patients without chronic liver disease

AIM To investigate changes in hepatic and splenic stiffness in patients without chronic liver disease during liver resection for hepatic tumors.METHODS Patients scheduled for liver resection for hepatic tumors were considered for enrollment. Tissue stiffness measurements on liver and spleen were conducted before and two days after liver resection using point shear-wave elastography. Histological analysis of the resected liver specimen was conducted in all patients and patients with marked liver fibrosis were excluded from further study analysis. Patients were divided into groups depending on size of resection and whether they had received preoperative chemotherapy or not. The relation between tissue stiffness and postoperative biochemistry was investigated. RESULTS Results are presented as median(interquartile range). 35 patients were included. The liver stiffness increased in patients undergoing a major resection from 1.41(1.24-1.63) m/s to 2.20(1.72-2.44) m/s(P = 0.001). No change in liver stiffness in patients undergoing a minor resection was found [1.31(1.15-1.52) m/s vs 1.37(1.12-1.77) m/s, P = 0.438]. A major resection resulted in a 16%(7%-33%) increase in spleen stiffness, more(P = 0.047) than after a minor resection [2(-1-13) %]. Patients who underwent preoperative chemotherapy(n = 20) did not differ from others in preoperative right liver lobe [1.31(1.16-1.50) vs 1.38(1.12-1.56) m/s, P = 0.569] or spleen [2.79(2.33-3.11) vs 2.71(2.37-2.86) m/s, P = 0.515] stiffness. Remnant liver stiffness on the second postoperative day did not show strong correlations with maximum postoperative increase in bilirubin(R^2 = 0.154, Pearson's r = 0.392, P = 0.032) and international normalized ratio(R^2 = 0.285, Pearson's r = 0.534, P = 0.003). CONCLUSION Liver and spleen stiffness increase after a major liver resection for hepatic tumors in patients without chronic liver disease.

“Three-Grade Criteria” of Radical Resection for Primary Liver Cancer

OBJECTIVE The present study was designed to develop the “Three- Grade Criteria” for radical resection of primary liver cancer （PLC） and to evaluate its clinical significance. METHODS Criteria for radical resection of PLC were summed up to 3 grades based on criterion development. Grade Ⅰ： complete removal of all gross tumors with no residual tumor at the excision margin. Grade Ⅱ： on the basis of Grade Ⅰ, additional 4 requirements were added： （1） the tumor was not more than two in number; （2） no tumor thrombi in the main trunks or the primary branches of the portal vein, the common hepatic duct or its primary branches, the hepatic veins or the inferior vena cava; （3）no hilar lymph nodes metastases; （4）no extrahepatic metastases. Grade Ⅲ ： in addition to the above criteria, negative postoperative follow-up result including AFP dropping to a normal level （with positive AFP before surgery） within 2 months after operation, and no residual tumor upon diagnostic imaging.The clinical data from 354 patients with PLC who underwent hepatectomy were reviewed retrospectively. Based on the “Three-Grade Criteria” these patients were divided into 6 groups： Grade Ⅰ radical group, Grade Ⅰ palliative group, Grade Ⅱ radical group, Grade Ⅱ palliative group, Grade Ⅲ radical group, Grade Ⅲ palliative group. The survival rate of each group was calculated by the life-table method and the rates compared among the groups. RESULTS The survival rate of patients receiving radical treatment was better than those receiving palliative treatment （P〈0.01）. Survival improved as more criteria were applied. The 5-year survival rate of the patients in Grade Ⅰ, Ⅱ and Ⅲ who underwent radical resection was 43.2%, 51.2% and 64.4%, respectively （P〈0.01）. CONCLUSION The “Three-Grade Criteria” may be applied for judging the curability of resection therapy for PLC. The stricter the criterion used, the better the survival would be. Adopting high-grade criteria to select cases and guide operations and strengthening postoperative follow-up would improve the results of hepatectomy for PLC.

Methods of vascular control technique during liver resection:a comprehensive review

BACKGROUND: Significant hemorrhage together with blood transfusion increases postoperative morbidity and mortality of hepatic resection. Hepatic vascular occlusion is effective in minimizing bleeding during hepatic parenchymal transection. This article aimed to review the current role and status of various techniques of hepatic vascular occlusion during hepatic resection. DATA SOURCES: The relevant manuscripts were identified by searching MEDLINE, and PubMed for articles published between January 1980 and April 2010 using the keywords 'vascular control', 'vascular clamping', 'vascular exclusion' and 'hepatectomy'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: One randomized controlled trial (RCT) and 5 RCTs showed intermittent Pringle maneuver and ischemic preconditioning followed by continuous Pringle maneuver were superior to continuous Pringle maneuver alone, respectively. Two RCTs compared the outcomes of hepatectomy with and without intermittent Pringle maneuver. One showed Pringle maneuver to be beneficial, while the other failed to show any benefit. One RCT showed that ischemic preconditioning had significantly less blood loss than using intermittent Pringle maneuver. Four RCTs evaluated the use of hemihepatic vascular occlusion. One RCT showed it had significantly less blood loss than Pringle maneuver, while the other 3 showed no significant difference. Only 1 RCT showed it had significantly less liver ischemic injury. No RCT had been carried out to assess segmental vascular occlusion. Two RCTs compared the outcomes of total hepatic vascular exclusion (THVE) and Pringle maneuver. One RCT showed THVE resulted in similar blood loss, but a higher postoperative complication. The other RCT showed less blood loss using THVE but the postoperative complication rate was similar. Both studies showed similar degree of liver ischemic injury. Only one RCT showed that selective hepatic vascular exclusion (SHVE) had less blood loss and liver ischemic injury than Pringle maneuver. CONCLUSION: Due to the great variations in these studies, it is difficult to draw a definitive conclusion on the best technique of hepatic vascular control.

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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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.