Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy:Optimal treatment of benign and malignant disease of the left pancreas

Background:Laparoscopic distal pancreatectomy(LDP)has become the preferred approach for surgical management of left sided pancreas pathology.Our institution previously published its experience with distal pancreatectomies using a clockwise technique with good outcomes.We now reexamine our outcomes across a longer time interval.Methods:From August 2008 to November 2020,364 patients underwent LDP by hepatobiliary surgeons(HA and JS).All procedures were performed using the same clockwise approach,which includes the stepwise slow compression technique.Retrospective descriptive analysis of patient demographic,clinical,operative,and pathologic data was conducted.Results:Of the 364 patients who underwent LDP using this technique,clinically significant postoperative pancreatic fistula(POPF)was noted in 26(7.1%)patients,while major morbidity and mortality were reported in 9.9%and 0.3%,respectively.Hand-assisted method was required for 18(4.9%)patients and unplanned conversion in 20(5.5%)patients.In a subset analysis of patients with pancreatic adenocarcinoma(n¼90),POPF was noted in 13(14.4%),with minor complications occurring in 34.4%and major morbidity in 14.4%.Conclusion:LDP with a clockwise approach for dissection,combined with the stepwise slow compression technique results in excellent outcomes,with even lower POPF rates than originally reported.Subset analysis of patients with pancreatic adenocarcinoma shows acceptable perioperative outcomes with this technique.

Therapeutic advances: Single incision laparoscopic hepatopancreatobiliary surgery

Single-port laparoscopic surgery(SPLS) is proposed to be a step towards minimizing the invasiveness of surgery, and has since gained popularity in several surgical sub-specialties including hepatopancreatobiliary surgery. SPLS has since been applied to cholecystectomy, liver resection as well as pancreatectomy for a multitude of pathologies. Benefits of SPLS over conventional multi-incision laparoscopic surgery include improved cosmesis and potentially post-operative pain at specific time periods and extra-umbilical sites. However, it is also associated with longer operating time, increased rate of complications, and increased rate of port-site hernia. There is no significant difference between length of hospital stay. SPLS has a significant learning curve that affects operating time, rate of conversion and rate of complications. In this article, we review the literature on SPLS in hepatobiliary surgery- cholecystectomy, hepatectomy and pancreatectomy, and offer tips on overcoming potential technical obstacles and minimizing the complications when performing SPLS- surgeon position, position of port and instruments, instrument crossing position, standard hand grip vs reverse hand grip, snooker cue guide position, prevention of incisional hernia. SPLS is a promising direction in laparoscopic surgery, and we recommend step-wise progression of applications of SPLS to various hepatopancreatobiliary surgeries to ensure safe adoption of the surgical technique.

Advancements and challenges in treating advanced gastric cancer in the West

Gastric cancer is a leading cause of cancer incidence and death worldwide.Patients with advanced gastric cancer benefit from a multi-modality treatment regimen.Sound oncologic resection with negative margins and complete lymphadenectomy plays a crucial role in long-term survival for patients with resectable disease.The utilization of minimally invasive techniques for gastric cancer has been slowly increasing and is proving to be both technically and oncologically safe.Perioperative chemotherapy is the current standard of care for advanced gastric cancer.A variety of chemotherapy regimens have been used with the combination of docetaxel,oxaliplatin,5-fluorouracil,and leucovorin being the current recommendation given its superior ability to induce a complete pathologic response and prolong survival.The use of radiation has been more controversial with its optimal place in the treatment sequence being unclear.There are current ongoing studies assessing the impact of radiation as an adjunct or in place of chemotherapy.Targeted treatments(e.g.,trastuzumab for human epidermal growth factor receptor 2 positive tumors and pembrolizumab for programmed death-ligand 1 positive tumors)are showing promise and are part of a continued emphasis on individualized care.Intraperitoneal chemotherapy may also play a role in preventing peritoneal recurrences for patients with high risk lesions.The treatment of patients with advanced gastric cancer in the West continues to advance and improve with a better understanding of optimal treatment sequences and the utilization of personalized treatment regimens.

Effects of α-adrenoreceptor antagonists on apoptosis and proliferation of pancreatic cancer cells in vitro

AIM: To discuss the expression of α-adrenoreceptors in pancreatic cancer cell lines PC-2 and PC-3 and the effects of α1- and α2-adrenoreceptor antagonists, yohimbine and urapidil hydrochloride, on the cell lines in vitro. METHODS: We cultured the human ductal pancreatic adenocarcinoma cell lines PC-2 and PC-3 and analyzed the mRNA expression of α1- and α2-adrenergic receptors by reverse transcription polymerase chain reaction (RT-PCR). The effects of yohimbine and urapidil hydrochloride on cell proliferation were assessed by 3-(4,5-dimethylthiasol-2-yl)- 2,4,-diphenyltetrazolium bromide (MTT) assay. Apoptosis was detected using the terminal deoxyribonucleotidyl transferase (TdT)-mediated biotin-16-dUTP nick-end labeling (TUNEL) assay and flow cytometry (FCM). RESULTS: PC-2 expressed mRNA in α1- and α2- adrenoreceptors. MTT assays showed that urapidil hydrochloride had no effect on PC-3 cell lines. However, exposure to urapidil hydrochloride increased DNA synthesis in PC-2 cell lines as compared to the control group. PC-2 cell lines were sensitive to both drugs. The proliferation of the 2 cell lines was inhibited by yohimbine. Cell proliferation was inhibited by yohimbine via apoptosis induction. CONCLUSION: The expression of α1- and α2- adrenoreceptors is different in PC-2 and PC-3 cell lines, which might be indicative of their different functions. The α2-adrenoceptor antagonist, yohimbine, can inhibit theproliferation of both cell lines and induce their apoptosis, suggesting that yohimbine can be used as an anticancer drug for apoptosis of PC-2 and PC-3 cells.

Comparison of open and closed hyperthermic intraperitoneal chemotherapy: Results from the United States hyperthermic intraperitoneal chemotherapy collaborative

BACKGROUND Cytoreductive surgery(CRS)with hyperthermic intraperitoneal chemotherapy(HIPEC)for peritoneal carcinomatosis can be performed in two ways:Open or closed abdominal technique.AIM To evaluate the impact of HIPEC method on post-operative and long-term survival outcomes.METHODS Patients undergoing CRS with HIPEC from 2000-2017 were identified in the United States HIPEC collaborative database.Post-operative,recurrence,and overall survival outcomes were compared between those who received open vs closed HIPEC.RESULTS Of the 1812 patients undergoing curative-intent CRS and HIPEC,372(21%)patients underwent open HIPEC and 1440(79%)underwent closed HIPEC.There was no difference in re-operation or severe complications between the two groups.Closed HIPEC had higher rates of 90-d readmission while open HIPEC had a higher rate of 90-d mortalities.On multi-variable analysis,closed HIPEC technique was not a significant predictor for overall survival(hazards ratio:0.75,95%confidence interval:0.51-1.10,P=0.14)or recurrence-free survival(hazards ratio:1.39,95%confidence interval:1.00-1.93,P=0.05)in the entire cohort.These findings remained consistent in the appendiceal and the colorectal subgroups.CONCLUSION In this multi-institutional analysis,the HIPEC method was not independently associated with relevant post-operative or long-term outcomes.HIPEC technique may be left to the discretion of the operating surgeon.

Long noncoding RNA LINC01124 activates hepatocellular carcinoma cell proliferation, migration, and invasion by absorbing microRNA-1247-5p and overexpressing FOXO3

Long intergenic non-protein coding RNA 1124(LINC01124)has been identified as an important regulator of non-small-cell lung cancer.However,the expression and detailed role of LINC01124 in hepatocellular carcinoma(HCC)remain unestablished to date.Therefore,this study aimed to elucidate the role of LINC01124 in the aggressiveness of HCC cells and identify the underlying regulatory mechanism.Quantitative reverse transcriptase-polymerase chain reaction was performed to measure the expression of LINC01124 in HCC.Cell Counting Kit-8 assay,Transwell cell migration and invasion assays,and a xenograft tumor model were used to investigate the function of LINC01124 in HCC cells,and bioinformatics analysis,RNA immunoprecipitation,luciferase reporter assay,and rescue experiments were used to elucidate the underlying mechanisms.Herein,LINC01124 overexpression was confirmed in HCC tissues as well as cell lines.Further,the downregulation of LINC01124 decreased HCC cell proliferation,migration,and invasion in vitro,whereas the upregulation of LINC01124 triggered the opposite results.Additionally,LINC01124 ablation impaired tumor growth in vivo.Mechanistic analyses revealed that LINC01124 functions as a competing endogenous RNA to sponge microRNA-1247-5p(miR-1247-5p)in HCC cells.Moreover,forkhead box O3(FOXO3)was identified as a direct target of miR-1247-5p.FOXO3 was positively regulated by LINC01124 in HCC cells through the sequestration of miR-1247-5p.Finally,rescue assays revealed that the inhibition of miR-1247-5p or overexpression of FOXO3 reversed the effects of LINC01124 silencing on the HCC cell malignant phenotype.In summary,LINC01124 plays a tumor-promoting role in HCC by regulating the miR-1247-5p-FOXO3 axis.The LINC01124-miR-1247-5p-FOXO3 pathway may provide a foundation for the identification of alternative therapies for HCC.

Development and prospect of telemedicine

With the continuous improvement and development of modern network information technology and the continuous improvement of people’s demands for health care,the traditional health care model has evolved,giving birth to a new telemedicine health care model.Telemedicine refers to the comprehensive application of information technology for medical information transmission and long-distance communication between different places.It integrates medicine,computer technology,and communication technology for remote monitoring,diagnosis,consultation,case discussion,teaching,and surgery as well as a series of medical activities.With the continuous development of communication technology,telemedicine is also constantly changing.As a relatively novel technology,telemedicine is sought after by major hospitals.With the advancement of internet technology,digitization and informatization have been gradually applied in telemedicine,but due to various factors,telemedicine still has great limitations.This paper summarized the development status of telemedicine;discussed in detail the development of telemedicine at home and abroad;reviewed the application of telemedicine as well as the feasibility and limitations of its promotion and development;and put forward an outlook for the future development of telemedicine.

Appropriate treatment strategies improve survival of hepatocellular carcinoma patients with portal vein tumor thrombus

AIM:To evaluate the survival benefits of different treatment strategies for hepatocellular carcinoma(HCC)patients with portal vein tumor thrombus(PVTT)and to determine the prognosis factors.METHODS:Between 2007 and 2009,338 HCC patients treated for PVTT were retrospectively studied.The patients were divided into 4 groups that underwent different treatments:the conservative treatment group(n=75),the transarterial chemoembolization(TACE)group(n=86),the hepatic resection group(n=90),and the hepatic resection associated with postoperative TACE group(n=87).Survival rates were determined using the Kaplan-Meier method and differences between the groups were identified through log-rankanalysis.Cox’s proportional hazard model was used to identify the risk factors for survival.RESULTS:The mean survival periods for patients in the conservative treatment,TACE,hepatic resection and hepatic resection associated with postoperative TACE groups were 3.8,7,8.2 and 15.1 mo,respectively.Significant differences were observed in the survival rates.For the surgical resection associated with postoperative TACE group,the survival rates after 1,2 and3 years were 49%,37%and 19%,respectively.These results were significantly higher than those of the other groups(P<0.05).Meanwhile,the 1,2 and 3 year survival rates for the surgical resection group were 28%,20%and 15%,whereas those for the TACE group were17.5%,0%and 0%,respectively.These values significantly increased after hepatic resection compared with those after TACE(P<0.05).CONCLUSION:Surgical resection is the most effective therapeutic strategy for HCC patients with PVTT and results in high hepatic functional reserve.For patients who can tolerate the procedure,postoperative TACE is necessary to prevent recurrence and prolong the survival period.

Chimeric antigen receptor-engineered T-cell therapy for liver cancer

Background: Chimeric antigen receptor-engineered T-cell(CAR-T) therapy is a newly developed immunotherapy used in the treatment of cancers. Because CAR-T therapy has shown great success in treating CD19-positive hematological malignancies, its application has been explored in the treatment of solid tumors, such as liver cancer. In this review, we discuss the immune characteristics of liver cancer, the obstacles encountered during the application of CAR-T therapy, and preclinical and clinical progress in the use of CAR-T therapy in patients with liver cancer.Data sources: The data on CAR-T therapy related to liver cancers were collected by searching Pub Med and the Web of Science databases prior to December 2017 with the keywords "chimeric antigen receptor","CAR-T", "liver cancer", "hepatocellular carcinoma", and "solid tumor". Additional articles were identified by manual search of references found in the primary articles. The data for clinical trials were collected by searching Clinical Trials.gov.Results: The liver has a tolerogenic nature in the intrahepatic milieu and its tumor microenvironment significantly affects tumor progression. The obstacles that reduce the efficacy of CAR-T therapy in solid tumors include a lack of specific tumor antigens, limited trafficking and penetration of CAR-T cells to tumor sites, and an immunosuppressive tumor microenvironment. To overcome these obstacles, several strategies have emerged. In addition, several strategies have been developed to manage the side effects of CAR-T, including enhancing the selectivity of CARs and controlling CAR-T activity. To date, no clinical trials of CAR-T therapy against HCC have been completed. However, preclinical studies in vitro and in vivo have shown potent antitumor efficacy. Glypican-3, mucin-1, epithelial cell adhesion molecule, carcinoembryonic antigen, and other targets are currently being studied.Conclusions: The application of CAR-T therapy for liver cancer is just beginning to be explored and more research is needed. However, we are optimistic that CAR-T therapy will offer a new approach for the treatment of liver cancers in the future.

Vascular endothelial growth factor attenuates hepatic sinusoidal capillarization in thioacetamide-induced cirrhotic rats

AIM: To investigate the effect of vascular endothelial growth factor (VEGF) transfection on hepatic sinusoidal capillarization. METHODS: Enhanced green fluorescent protein (EGFP)/ VEGF transfection was confirmed by immunofluorescence microscopy and immunohistoche-mistry both in primary hepatocytes and in normal liver. Cirrhotic rats were generated by thioacetamide (TAA) administration and then divided into a treatment group, which received injections of 400 μg of plasmid DNA encoding an EGFP- VEGF fusion protein, and a blank group, which received an equal amount of normal saline through the portal vein. The portal vein pressure was measured in the normal and cirrhotic state, in treated and blank groups. The average number of fenestrae per hepatic sinusoid was determined using transmission electron microscopy (TEM), while the relative abundance of VEGF transcripts was examined by Gene array. RESULTS: Green fluorescent protein was observed in the cytoplasms of liver cells under immunofluorescence microscopy 24 h after transfection with EGFP/VEGF plasmid in vitro. Staining with polyclonal antibodies against VEGF illustrated that hepatocytes expressedimmunodetectable VEGF both in vitro and in vitro. There were significant differences in the number of fenestrae and portal vein pressures between normal and cirrhotic rats (7.40 ± 1.71 vs 2.30 ± 1.16 and 9.32 ± 0.85 cmH2O vs 17.92 ± 0.90 cmH2O, P < 0.01), between cirrhotic and treated rats (2.30 ± 1.16 cmH2O vs 4.60 ± 1.65 and 17.92 ± 0.90 cmH2O vs 15.52 ± 0.93 cmH2O, P < 0.05) and between the treatment group and the blank group (4.60 ± 1.65 cmH2O vs 2.10 ± 1.10 cmH2O and 15.52 ± 0.93 cmH2O vs 17.26 ± 1.80 cmH2O, P < 0.05). Gene- array analysis revealed that the relative abundance of transcripts of VEGF family members decreased in the cirrhotic state and increased after transfection. CONCLUSION: Injection of a plasmid encoding VEGF through the portal vein is an effective method to induce the formation of fenestrae and decrease portal vein pressure in cirrhotic rats. Therefore, it may be a good choice for treating hepatic cirrhosis and portal hypertension.

Optimizing outcomes for patients with gastric cancer peritoneal carcinomatosis

Peritoneal carcinomatosis (PC) from gastric cancer has traditionally been considered a terminal progression of the disease and is associated with poor survival out-comes. Positive peritoneal cytology similarly worsens the survival of patients with gastric cancer and treatment options for these patients have been limited. Recent ad-vances in multimodality treatment regimens have led to innovative ways to care for and treat patients with this disease burden. One of these advances has been to use neoadjuvant therapy to try and convert patients with positivecytologyorlow-volume PC to negative cytolo-gy with no evidence of active peritoneal disease.These strategies include the use of neoadjuvant systemic chemotherapy alone,using neoadjuvant laparoscopic heated intraper itoneal chemotherapy(NLHIPEC)after systemic chemotherapy,or using neoadjuvant intra-peritoneal and systemic chemother apy(NIPS)in a bi-dir ectional manner. For patients with higher volume PC,cytoreductive surgery (CRS) and hyperthermic intrape-ritoneal chemotherapy(HIPEC)have been mainstays of treatment. When used together, CRS and HIPEC can improve overall outcomes in properly selected patients,but overall survival outcomes remain unacceptably low.The extent of peritoneal disease, commonly measured by the peritoneal carcinomatosis index (PCI), and the com-pleteness of cytor eduction,has been shown to greatly impact outcomes in patients undergoing CRS and HIPEC.The uses of NLHIPEC and NLHIPEC plus NIPS have both been shown to decrease the PCI and thus increase the opportunity for complete cytoreduction. Newer therapies like pressurized intraperitoneal aerosol chemother apy and immunotherapy, such as catumaxomab, along with improved systemic chemotherapeutic regimens, are being explored with great interest.There is exciting progress being made in the management of PC from gastric can-cer and its’ treatment is no longer futile.

Expert consensus on management of metabolic disease in Chinese liver transplant recipients

Metabolic disease,including diabetes mellitus,hypertension,dyslipidemia,obesity,and hyperuricemia,is a common complication after liver transplantation and a risk factor for cardiovascular disease and death.The development of metabolic disease is closely related to the side effects of immunosuppressants.Therefore,optimization of the immunosuppressive regimen is very important for the prevention and treatment of metabolic disease.The Chinese Society of Organ Transplantation has developed an expert consensus on the management of metabolic diseases in Chinese liver transplant recipients based on recent studies.Emphasis is placed on the risk factors of metabolic diseases,the effect of immunosuppressants on metabolic disease,and the prevention and treatment of metabolic diseases.

COVID-19 or treatment associated immunosuppression may trigger hepatitis B virus reactivation: A case report

BACKGROUND Since the initial recognition of coronavirus disease 2019(COVID-19)in Wuhan,this infectious disease has spread to most areas of the world.The pathogenesis of COVID-19 is yet unclear.Hepatitis B virus(HBV)reactivation occurring in COVID-19 patients has not yet been reported.CASE SUMMARY A 45-year-old hepatitis B man with long-term use of adefovir dipivoxil and entecavir for antiviral therapy had HBV reactivation after being treated with methylprednisolone for COVID-19 for 6 d.CONCLUSION COVID-19 or treatment associated immunosuppression may trigger HBV reactivation.

Effect of glial cells on remyelination after spinal cord injury

Remyelination plays a key role in functional recovery of axons after spinal cord injury.Glial cells are the most abundant cells in the central nervous system.When spinal cord injury occurs,many glial cells at the lesion site are immediately activated,and different cells differentially affect inflammatory reactions after injury.In this review,we aim to discuss the core role of oligodendrocyte precursor cells and crosstalk with the rest of glia and their subcategories in the remyelination process.Activated astrocytes influence proliferation,differentiation,and maturation of oligodendrocyte precursor cells,while activated microglia alter remyelination by regulating the inflammatory reaction after spinal cord injury.Understanding the interaction between oligodendrocyte precursor cells and the rest of glia is necessary when designing a therapeutic plan of remyelination after spinal cord injury.

Restrictive versus liberal fluid therapy for major abdominal surgery: is the evidence strong?

We have read with great interest the original study by Myles et al. (1), in which the authors claimed a restrictive fluid regimen during and up to 24 hours after major abdominal surgery was associated with higher rate of acute kidney injury. This international, randomized, assessor-blinded trail compared the following outcomes between restrictive and liberal intravenous-fluid regimen: disability-free survival at 1 year, acute kidney injury at 30 days, renal-replacement therapy at 90 days, septic complications, surgical-site infection, and death. The perioperative fluid management is of great clinical significance, the results demonstrated by Myles et al. provide high-level evidence with dedicate design and adequate case volume, serving as potential reference to guidelines of surgical patient care. Shortly after its online publication, the article has drawn tremendous attention and caused extensive discussion among surgeons world-wide.

Comparative long-term outcomes for pancreatic volume change, nutritional status, and incidence of new-onset diabetes between pancreatogastrostomy and pancreatojejunostomy after pancreaticoduodenectomy

Background:The difference in volume change in a pancreatic remnant according to the type of pancreaticoenterostomy after pancreaticoduodenectomy(PD)for long-term follow-up is unknown.Also,there are few studies that evaluate the difference in general nutritional status and pancreatic endocrine function,including new-onset diabetes mellitus(NODM)depending on the type of pancreaticoenterostomy.This study aimed to compare serial pancreatic volume changes in pancreatic remnants between pancreatogastrostomy(PG)and pancreatojejunostomy(PJ)after PD and to evaluate the difference in general nutritional status and incidence of NODM between PG and PJ.Methods:This study enrolled 115 patients who had survived for more than 3 years after PD.They were divided into the PG group and the PJ group.Their clinicopathologic factors were collected and analyzed.We calculated serial pancreas volume and pancreatic duct size precisely from preoperative stage to 5 years after surgery by image-processing software specifically designed for navigation and visualization of multimodality and multidimensional images.Consecutive changes of albumin and body mass index(BMI)as related to general nutritional status were compared between the PG and PJ groups.To evaluate the incidence and risk factors of NODM following PD,subgroup analysis was performed in 88 patients who did not have diabetes preoperatively.Results:Most patient demographics were not significantly different between the PG group(n=45)and PJ group(n=70).There was no significant difference in volume reduction between the groups from postoperative 1 month to 5 years(PG group?18.21±14.66 mL versus PJ group?14.43±13.05 mL,P=0.209).But there was a significant difference in increased pancreatic duct size between the groups from postoperative 1 month to 5 years(PG group 1.66±2.20 mm versus PJ group 0.54±1.54 mm,P=0.007).There was no significant difference in the increase of total serum albumin between the groups for 5 years after surgery(PG group 0.51±0.47 g/dL,14.3%versus PJ group 0.42±0.60 g/dL,11.3%,P=0.437).There was also no significant difference in BMI decrease between the groups(PG group?1.13±3.12,?4.9%versus PJ group?1.97±2.01,?8.7%,P=0.206).On the whole,NODM was diagnosed in 19 patients out of the 88 patients(21.6%)who did not have DM preoperatively.The incidence of NODM was not significantly different between the groups(PG group 21.6%versus PJ group 21.5%,P=0.995).In addition,pancreaticoenterostomy was not an independent risk factor for NODM by logistic regression analysis(odds ratio,0.997,95%CI:0.356–0.2.788,P=0.995).No other risk factors for NODM were found.Conclusions:PG and PJ following PD induced similar pancreatic volume reduction during long-term follow-up.There was no difference in general nutritional status or incidence of NODM between the groups after PD.

The evolution of anatomical hepatectomy:Past,present,and future

The liver contains a complex structure of blood vessels and bile ducts,and the vascular structure is highly variable.The anatomical segmentation of the liver is still controversial,and the Couinaud segmentation method based on the portal vein is more widely used in clinical practice.The treatment of liver tumors and other lesions is closely related to the liver anatomy.The mechanism of liver tumor invasion and metastasis is complex,and it is currently believed that tumor invasion mainly spreads along the portal vein.Anatomic liver resection is an important surgical method for liver diseases,especially liver tumors.This article reviews the vascular structure of the liver,the development of anatomical hepatectomy,blood flow control,surgical planning,intraoperative navigation,minimally invasive surgery,and precise hepatectomy.Anatomic liver resection is a part of precision liver surgery,which is becoming increasingly more precise in terms of surgical evaluation,surgical planning,and surgical operation.New technologies will facilitate precision surgery with less trauma and greater benefits for patients.With the development and advancement of technology,image-based surgical planning and intraoperative surgical navigation will become more widely used in precision liver surgery.

Advances in managing hepatocellular carcinoma

Multiple modalities for treatment of hepatocellular carcinoma are available, depending on tumor size and number. Surgical resection remains the gold standard, so long as the residual liver function reserve is sufficient. In patients with advanced cirrhosis, liver transplantation is the preferred option, as these patients may not have adequate hepatic reserve after resection. Salvage liver transplantation has also become an option for a select few patients who recur after surgical resection. Ablative techniques have been used for palliation as well as to either completely destroy the tumor, act as an adjunct to resection, or downstage the tumor to meet Milan criteria such that a patient may be a candidate for liver transplantation. Radiofrequency ablation, microwave ablation, chemoembolization, radioembolization, and irreversible electroporation have all been used in this capacity. Currently, sorafenib is the only US Food and Drug Administration-approved chemotherapeutic for hepatocellular carcinoma. The efficacy of sorafenib, in combination with other agents, transarterial chemoembolization, and surgical resection is currently being investigated. Sunitinib and brivanib, tyrosine kinase inhibitors, have failed as potential first- or second-line options for chemotherapy. Bevacizumab in combination with erlotinib is also currently being studied. Final analysis for ramucirumab and axitinib are pending. Tivantinib, a selective mesenchymai-epithelial transition factor （MET） inhibitor, is also undergoing clinical trials for efficacy in MET- high tumors. This review serves to emphasize the current and new technologies emerging in the treatment of hepatoeellular carcinoma.