Combined Hepatic Resection Research Articles

Additional Intrapancreatic Bile Duct Resection and Additional Pancreaticoduodenecotmy for Positive Distal Ductal Margin of Hilar Cholangiocarcinoma

Introduction: The feasibility and effectiveness of intrapancreatic bile duct resection (IPBR) and additional pancreaticoduodenectomy (aPD) for initial cancer positive distal duct margin (DM) in perihilar cholangiocarcinoma cases remain to be elucidated. The aim of this study was to clarify the feasibility and efficacy of both operative procedures. Method: All patients who underwent major hepatectomy and extrahepatic bile duct resection for perihilar cholangiocarcinoma between 2000 and 2020 were analyzed. IPBR for cancer positive DMs were indicated for cases with cancer-negative proximal margin and no extra-bile duct invasion. Results: A total 364 patients were enrolled. Additional resection was performed in 69 of 89 cancer positive DMs, resulting in 53 negative DMs (77%). Procedures of additional resection were 59 IPBR and 10 aPD. A multivariate analysis demonstrated that high preoperative serum carbohydrate antigen 19-9 level, combined hepatic artery resection, nodal involvement, distant metastasis, severe perineural invasion and R 1 resection were independent worse prognostic factors. DM was not prognostic factors independently. Only three cases developed initial recurrence at intrapancreatic bile duct in all positive DM cases (one in invasive cancer positive DM case, 1 year after resection and two with cancer-in-situ (CIS) positive DM cases, 4 and 6 year after resection). Overall survival of patients with cancer positive initial DM and cancer negative or CIS final DM treated by IPBR (n=56) were statistically compared with that of the patients treated by aPD (P=0.24). Conclusions: IPBR was feasible and effective procedure for the selected patients of cancer positive DMs of wide spread perihilar cholangiocarcinoma.

A validation study of combined resection and ablation therapy for multiple hepatocellular carcinoma

To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report. A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed. There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761). The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

The safety and efficacy of combined hepatic artery resection in treatment of hilar cholangiocarcinoma: a meta-analysis

Objective: To evaluate the safety and effectiveness of combined hepatic artery resection for the treatment of hilar cholangiocarcinoma. Methods: We searched Pubmed, The Cochrane Library, Embase, Web of Science, China Knowledge Network, Wanfang Data Resource System, Vip-Chinese Sci-tech Journal System Database, and China Biomedical Literature Database, and collected the randomized controlled studies or retrospective studies on the safety and efficacy of combined hepatic artery resection and non-hepatic artery resection in the treatment of hilar cholangiocarcinoma. The search period is from January 1, 2006 to December 31, 2019. Review Manager 5.3 software was used to analyze the extracted data indicators. Results: A total of 14 articles were collected, and a total of 2 374 patients with hilar cholangiocarcinoma were included in the study. Meta-analysis results showed that the perioperative mortality in the hepatic artery resection (HAR) group was higher than that of the control group (OR=1.70, 95%CI=0.02-2.90, P=0.05), and the total postoperative morbidity rate was higher than that of the control group (OR=1.28, 95%CI= 0.93-1.76, P=0.13), both of which were not statistically significant compared with the control group. Subgroup analysis showed that the incidence of liver failure (OR=1.15, 95%CI= 0.73-1.82, P=0.54), biliary fistula (OR=1.20, 95%CI= 0.78-1.84, P=0.40), and abdominal infection in the two groups (OR=0.98, 95%CI= 0.53-1.83, P=0.95) was without significant difference. The R0 resection rate of the HAR group was higher than that of the control group, and the difference was not statistically significant (OR=1.08, 95%CI=0.66-1.75, P=0.77). The rates of lymph node metastasis in the HAR group were higher than that in the control group (OR= 2.48, 95%CI= 1.05-5.84, P=0.04). One-year(OR=0.48, 95%CI= 0.32-0.72, P=0.000 5), 3-year (OR= 0.51, 95%CI=0.36-0.72, P=0.000 1), and 5-year (OR=0.50, 95%CI=0.35-0.70, P<0.000 1) survival rates of HAR group were lower than those of the control group. The survival rates of patients in HAR group treated with combined chemotherapy drugs after operation were significantly improved (OR= 7.33, P=0.02). Conclusions: The safety of combined HAR treatment for hilar cholangiocarcinoma is acceptable, but poor postoperative survival may be related to the high lymph node metastasis rate. Therefore, it is still necessary to be cautious in carrying out this operation. Combined with adjuvant chemotherapy after surgery may improve survival.

Examining Perioperative Risk Associated with Simultaneous Resection of Primary Neuroendocrine Tumors and Synchronous Hepatic Metastases.

Surgical debulking of primary neuroendocrine tumors (NETs) and hepatic resection of metastatic NET disease may each independently improve overall survival. However, evidence for combined primary site debulking and metastasectomy on survival and impact on short-term perioperative outcomes is limited. The 2014-2016 ACS-NSQIP targeted hepatectomy database was queried for all patients undergoing liver resection for metastatic NET. Secondary procedure codes were evaluated for major concurrent operations. Multivariable analysis was performed to determine risk factors for 30-day morbidity and mortality. A total of 472 patients were identified, of whom 153 (32.4%) underwent ≥1 additional concurrent major operation. The most common concurrent procedures were small bowel resection (14.6%), partial colectomy (8.9%), and radical lymphadenectomy (7.4%). Among all patients, overall 30-day mortality and morbidity were 1.5% and 25.6%, respectively. Modifiable and treatment-related factors associated with increased major postoperative morbidity risk included >10% weight loss within six months of surgery (p = 0.05), increasing number of hepatic lesions treated (p = 0.05), and biliary reconstruction (p = 0.001). No major concurrent procedure was associated with increased 30-day morbidity (all p > 0.05). Approximately one-third of patients with stage IV NET underwent combined hepatic and multi-organ resection. Although modifiable and treatment-related factors predictive of perioperative morbidity were identified, performance of concurrent major procedures did not increase perioperative morbidity. These results support consideration of multi-organ resection in carefully selected patients with metastatic NET.

MRI-guided percutaneous thermoablation in combination with hepatic resection as parenchyma-sparing approach in patients with primary and secondary hepatic malignancies: single center long-term experience

BackgroundCombination therapy using hepatic resection (HR) and intra-operative thermal ablation is a treatment approach for patients with technically unresectable liver malignancies. The aim of this study was to investigate safety, survival and local recurrence rates for patients with technically unresectable liver tumors undergoing HR and separate percutaneous MR-guided thermoablation procedure as an alternative approach.MethodsData from all patients with primary or secondary hepatic malignancies treated at a single institution between 2004 and 2018 with combined HR and MR-guided percutaneous thermoablation was collected and retrospectively analyzed. Complications, procedure related information and patient characteristics were collected from institutional records. Overall survival and disease-free survival were estimated using the Kaplan-Meier method.ResultsA total of 31 patients (age: 62.8 ± 9.1 years; 10 female) with hepatocellular carcinoma (HCC; n = 7) or hepatic metastases (n = 24) were treated for 98 hepatic tumors. Fifty-six tumors (mean diameter 28.7 ± 23.0 mm) were resected. Forty-two tumors (15.1 ± 7.6 mm) were treated with MR-guided percutaneous ablation with a technical success rate of 100%. Local recurrence at the ablation site occurred in 7 cases (22.6%); none of these was an isolated local recurrence. Six of 17 patients (35.3%) treated for colorectal liver metastases developed local recurrence. Five patients developed recurrence at the resection site (16.1%). Non-local hepatic recurrence was observed in 18 cases (58.1%) and extrahepatic recurrence in 11 cases (35.5%) during follow-up (43.1 ± 26.4 months). Ten patients (32.3%) developed complications after HR requiring pharmacological or interventional treatment. No complication requiring therapy was observed after ablation. Median survival time was 44.0 ± 7.5 months with 1-,3-, 5-year overall survival rates of 93.5, 68.7 and 31.9%, respectively. The 1-, 3- and 5-year disease-free survival rates were 38.7, 19.4 and 9.7%, respectively.ConclusionThe combination of HR and MR-guided thermoablation is a safe and effective approach in the treatment of technically unresectable hepatic tumors and can achieve long-term survival.

Comparison of Hepatic Resection Combined with Intraoperative Radiofrequency Ablation, or Hepatic Resection Alone, for Hepatocellular Carcinoma Patients with Multifocal Tumors Meeting the University of California San Francisco (UCSF) Criteria: A Propensity Score-Matched Analysis

Whether hepatic resection (HR) combined with radiofrequency ablation (RFA) or HR alone is the treatment of choice for early or moderately advanced multifocal hepatocellular carcinomas (HCCs) is a matter of debate. This study compared the short- and long-term outcomes of patients with multifocal tumors meeting the University of California San Francisco (UCSF) criteria after HR plus intraoperative RFA or HR alone. A total of 261 consecutive patients with multifocal HCCs meeting the UCSF criteria from January 2010 to January 2018, who underwent combined treatment (n = 51) or HR (n = 210), were included. Propensity score matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup analysis, along with univariate and multivariate analyses, were performed. The 1-, 3-, and 5-year OS rates after combined treatment or HR alone were 86.3%, 66.6%, and 34.2%, and 92.8%, 67.1%, and 37%, respectively (p = 0.423); combined treatment provided similar RFS rates as HR at 1, 3, and 5years (78.4%, 35.8% and 20.9% vs. 82.6%, 50.4% and 24.5%, respectively; p = 0.076). The propensity matching model showed similar results. Subgroup analysis showed that HR was associated with better RFS than HR plus RFA for patients with two tumors or major tumors ≤ 3cm. Multivariate analysis revealed that portal hypertension and three tumors are independent risk factors. For multifocal HCC patients meeting the UCSF criteria, combined treatment may offer similar OS and RFS as HR; however, HR may be more suitable than combined treatment for patients with two tumors or major tumors ≤ 3cm.

Combined liver resection and transarterial chemoembolization versus liver resection alone for the management of solitary large exophytic hepatocellular carcinoma with extrahepatic arterial supply: is two always better than one?

Purpose Does the control of extrahepatic arterial feeders with preoperative transarterial chemoembolization (TACE) in large exophytic hepatocellular carcinoma improve surgical and oncological outcomes compared with surgery alone? Patients and methods A total of 545 patients were assessed for eligibility, and 108 patients fulfilled the inclusion criteria and were assigned to either upfront surgery (group I) or surgery after TACE (group II). Results Patients in both groups had no significant difference with respect to age (P=0.573), sex (P=0.464), α-fetoprotein (P=0.313), American Society of Anesthesiologists score (P=0.820), and Child–Pugh score (P=0.577). The mean tumor size was comparable (9.8±2.2 cm in group I vs. 10.3±2.3 cm in group II, P=0.265). In group I, four patients underwent major hepatectomy, whereas 48 patients underwent minor hepatectomy. In group II, 54 patients underwent 121 TACE sessions with a mean of number of 2±0.8 session (range: 1–4 sessions). The mean interval between first TACE and surgery was 45±10.7 days (range: 12–72 days). Surgery after TACE had significantly higher rate of perihepatic adhesions (P=0.006), longer operative time (P Conclusion In patients with solitary large exophytic hepatocellular carcinoma, combined hepatic resection plus TACE is associated with increased perihepatic adhesions, increased operative time, blood loss, and postoperative hospital stay compared with liver resection alone. Preoperative TACE has no additional oncological benefit, with no reduction in recurrence rate or improvement in disease-free survival.

Clinical application of combined hepatic artery resection and reconstruction in surgical treatment for hilar cholangiocarcinoma

Objective: To clarify whether the surgical treatment for hilar cholangiocarcinoma combined with artery reconstruction is optimistic to the patients with hilar cholangiocarcinoma with hepatic artery invasion. Methods: There were 384 patients who received treatment in the First Affiliated Hospital to Army Medical University from January 2008 to January 2016 analyzed retrospectively. There were 27 patients underwent palliative operation, 245 patients underwent radical operation, radical resection account for 63.8%. Patients were divided into four groups according to different operation method: routine radical resection group(n=174), portal vein reconstruction group (n=47), hepatic artery reconstruction group (n=24), palliative group(n=27). General information of patients who underwent radical operation treatment was analyzed by chi-square test and analysis of variance. The period of operation time, blood loss, the length of hospital stay and hospitalization expenses of the radical operation patients were analyzed by one-way ANOVA. Comparison among groups was analyzed by LSD-t test. Results: The follow-up ended up in June first, 2016. Each of patients followed for 6 to 60 months, the median follow-up period was 24 months. 1-, 3-, and 5-year survival rates were 81.3%, 44.9% and 13.5% of routine radical operation group, and were 83.0%, 44.7% and 15.1% of portal vein reconstruction group, and were 70.8%, 27.7% and 6.9% of hepatic artery reconstruction group, respectively. And 1-, 3-, and 5-year survival rates of hepatic artery reconstruction group was lower than routine radical group and portal vein reconstruction group significantly (P<0.05). However, the rate of postoperative complications of the hepatic artery reconstruction group and the routine radical operation group and the portal vein reconstruction group were 62.5%(15/24), 55.3%(96/174) and 51.5%(24/47), respectively. There was no significant difference among them (P>0.05). The data shows that the ratio of lymphatic metastasis in hepatic artery reconstruction group (70.8%) is much higher than them in routine radical operation group (20.1%) and portal vein reconstruction group (19.1%) significantly (P<0.05). The presented data also indicate that hepatic artery resection prolongs survival time comparing with patients undergoing palliative therapy for hilar cholangiocarcinoma. Cox regression analysis indicate that hepatic artery resection and reconstruction is a protective factor compare with palliative therapy (RR=0.38, 95%CI: 0.22-0.67). The significant reason for shorter survival time is a positive correlation between hepatic artery invasion and lymph node metastasis. Conclusion: Hepatic artery resection and reconstruction has beneficial impact on oncologic long-term outcome in patients with advanced stage hilar cholangiocarcinoma.

Combined resection and radiofrequency ablation versus transarterial embolization for intermediate-stage hepatocellular carcinoma: A propensity score matching study.

This study aimed to compare the outcomes of combined hepatic resection (HR) plus intraoperative radiofrequency ablation (RFA) and transarterial embolization (TAE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score. A total of 179 patients with multifocal HCC treated with HR plus RFA (n=26) or TAE(n=153) were retrospectively studied. All patients were classified as BCLC stage B and Child-Pugh class A. Analyses were performed over all participants as well as for propensity score-matched (1:3) patients to adjust for baseline differences. Cumulative overall survival (OS) and time to progression (TTP) were compared between the two groups using the Kaplan-Meier method, and independent predictors were identified by multivariate Cox regression analysis. Patients treated with HR plus RFA had better OS and longer TTP than those with TAE (p=0.011 and p<0.001, respectively). Multivariate Cox regression analysis showed that combined therapy (hazard ratio 0.31; 95% confidence interval (CI), 0.12-0.78; p=0.013), BCLC substage B2 (hazard ratio 1.82; 95% CI, 1.13-2.92; p=0.013) and alpha-fetoprotein≥400ng/ml (hazard ratio 1.85; 95% CI, 1.12-3.05; p=0.016) were independent factors associated with OS. After propensity score matching, combined therapy was the significant factor associated with OS and TTP by univariate and multivariate analyses. Combined HR plus RFA may provide survival advantage compared to TAE in patients with BCLC stage B HCC.

Combined Hepatic and Inferior Vena Cava Resection for Colorectal Cancer

Hepatic metastases occur in up to half of all colorectal cancers, the third most common malignancy in the United States. Surgery provides the only chance for cure in this clinical situation and indications for resection are broadening. Colorectal metastases can invade the inferior vena cava, owing to its intimate association with the liver. While these lesions were historically classified as unresectable, surgical proficiency has progressed to the point that they can frequently be removed via a complex resection. Patient selection with the help of a multidisciplinary team and the careful use of pre-operative imaging studies is essential to maximize results. It is also critical that the operative surgeon is experienced with the complex anatomy, the resection techniques and the instruments available. While inferior vena cava invasion from colorectal cancer metastases is a poor prognostic factor, the evidence suggests that a combined hepatic and inferior vena cava resection can be performed with an acceptably low operative mortality and provides the best chance for long-term survival.

Combined hepatic resection with the inferior vena cava and diaphragm and reconstruction using an equine pericardial patch: Report of a case

We herein report a case of combined hepatic resection with inferior vena cava (IVC) and diaphragm resection, and reconstruction using an equine pericardial patch. A 54-year-old woman showed hepatic cancer recurrence on radiological imaging, with invasion to the caudate lobe of the liver, IVC, diaphragm, and adrenal gland. We resected 10 × 5 cm of the diaphragm. After dissecting the hepatic parenchyma, the caudate lobe was connected only to the IVC. Clamping of the IVC was performed between the IVC below the confluence of the hepatic vein and the suprarenal IVC. A 6 × 3-cm segment of the IVC was then resected. The IVC and diaphragm were reconstructed using an equine pericardial patch, as both defects were too large to repair without a patch. The equine pericardium represents a suitable graft material for repairing both the IVC and diaphragm. Further investigation is needed to determine the durability and anti-infection properties of equine pericardial grafts.

“Supraportal” Right Posterior Hepatic Artery: An Anatomic Trap in Hepatobiliary and Transplant Surgery

A supraportal right posterior hepatic artery (RPHA), which runs cranially to the right portal vein and goes to the liver, has never been described. The course of the RPHA to the right portal vein was evaluated, using (1) computed tomography (CT) arteriography and portography in 300 patients who underwent multidetector row CT (radiologic study) and (2) operative records in 203 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (surgical study). In the radiologic study, an infraportal type RPHA was observed in 239 (79.7%) patients, a supraportal type in 35 (11.7%), and a combined type in 26 (8.7%). In the surgical study, an infraportal type was observed in 179 (88.2%) patients, a supraportal type in 11 (5.4%), and a combined type in 13 (6.4%). In two patients with the combined type RPHA, the supraportal hepatic artery of the right posterior superior segment (A7) was injured during surgery. In another two patients with advanced carcinoma involving the supraportal PRHA, combined hepatic artery resection and reconstruction was necessary. Overall, in 4 (17.4%) of the 24 hepatectomized patients with supraportal or combined type RPHA, iatrogenic injury during surgery or cancer invasion of the hepatic artery occurred due to the course of the RPHA itself. In contrast, 179 hepatectomized patients with infraportal type RPHA did not have such course-dependent complications. The supraportal RPHA runs just beneath the right hepatic duct, which may function as an anatomic trap during hepatobiliary and transplant surgery.

Preoperative or postoperative therapy for resectable gallbladder cancer? A retrospective analysis of patients treated at a single institution.

309 Background: Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. Less than 30% present at an early stage where surgical resection is curative. We examine a cohort of patients with GBC toward determining if preoperative and postoperative treatment of locally advanced GBC demonstrate any differing results in complications or survival. Methods: A retrospective review of patients seen at FCCC with GBC from Jan 1991 to Nov 2008 was performed. Demographics, clinical stage, surgical procedure, AJCC 7th stage, details of neoadjuvant and adjuvant treatment and complications of surgery were analyzed. Results: Fifty-one patients with GBC were identified. Of these, 66% had their GBC found incidentally, 77% had stage 2 or greater cancers, and 35 patients needed liver resection with portal lymphadenectomy. 13 patients had an extrahepatic bile duct resection. 10 patients had extended resections including pancreatoduodenectomy (5) or colectomy (5), while 6 had cholecystectomy alone. 25% (n=13) of the population had preoperative chemoradiation only, 30 % (n=15) had postoperative chemoradiation only, while 15% (n=8) received maintenance chemotherapy only. 10% (n=5) had preoperative and postoperative therapy, while twenty percent of the group (n=10) had surgery only. 49% had recurrences (n=25), with 48% percent of these being local-regional. Median survival was 30 months for the whole group, with 54.6 month median survival for the 41 patients without extended resection. No significant difference in survival was seen comparing preoperative therapy versus postoperative treatment (p=0.13). Five-year survival is 47% for those with minor hepatic resection compared to 25% for those with combined hepatic and colon or pancreatic resection. Conclusions: We present a retrospective view of patients treated in our center, the majority of whom received either preoperative or postoperative adjuvant therapy, both of which had good median survival and acceptable morbidity and mortality. Given the poor survival and high recurrence rate for stage II and greater cancers, we suggest that preoperative or postoperative adjuvant therapy for these cases may be equally effective. No significant financial relationships to disclose.

Therapeutical effect of combined hepatic resection and fenestration on patients with severe adult polycystic liver disease

To evaluate therapeutical effect of combined hepatic resection and fenestration on patients with severe adult polycystic liver disease (APLD). Preoperative clinical symptoms, postoperative complications and prognoses from 33 patients with severe adult polycystic liver disease (APLD) treated with combined hepatic resection and fenestration were recorded. According to the number and location of cysts before surgery and the remnant liver parenchyma after operation, all patients were classified into two types: class A and B. And patients in each type were further classified into three grades: Grade I, II and III. The frequency of postoperative complications of two types patients was compared. The mean follow-up time was 57 months. There were three patients with recurrence of symptoms at 81, 68 and 43 mouths after operation. Two patients died of renal failure due to polycystic kidney disease at 137 and 85 mouths after operation. And one patient with postoperative hepatic inadequacy received an orthotopic liver transplantation. The total number of patients with postoperative complications was 26 cases, including one patient with bleeding, two patients with bile leakage, fourteen patients with mild ascites, twelve patients with severe ascites and eighteen patients with pleural effusion, and the overall incidence was 78.8%. There were 22 patients with imaging data, including 6 patients within A type and sixteen patients within B type. The frequencies of postoperative complications were 4 and 31, respectively, and the difference was statistically significant (Chi-square test = 4.99, P less than 0.05). Combined hepatic resection and fenestration is a safe and acceptable procedure for the treatment of severe APLD.

Melatonin protects from hepatic reperfusion injury through inhibition of IKK and JNK pathways and modification of cell proliferation

Reactive oxygen species (ROS) are involved in pathophysiology of ischemia/reperfusion injury. Melatonin is a potent scavenger of ROS. Thus, this study was designed to elucidate its effects in a combined hepatic warm ischemia and resection model. The right lateral and caudate lobes (32% of liver volume) of Sprague-Dawley rats underwent warm ischemia for 30 min followed by reperfusion and subsequent resection of the nonischemic liver tissue. Some rats were gavaged with 50 mg/kg melatonin 2 hr before the onset of experiments. Controls received the same volume of microcrystalline cellulose. Survival, transaminases, histology, flow cytometry, inducible nitric oxide synthase (iNOS) expression, and activation of signal transduction pathways [c-Jun N-terminal kinase (JNK), cJUN, IkappaB kinase alpha (IKKalpha), proliferating cell nuclear antigen (PCNA), and Ki67] were assessed for hepatic injury, oxidative stress, and cell proliferation. Melatonin significantly improved animal survival and decreased transaminase levels, the indices for necrosis, liver damage, leukocyte infiltration, and iNOS expression. In parallel, the expression of IKKalpha, JNK1, and cJUN decreased by 35-50% after melatonin (P < 0.05). At the same time, melatonin reduced the expression of both PCNA and Ki67 in liver (P < 0.05). Melatonin is hepatoprotective most likely via mechanisms including inhibition of IKK and JNK pathways and regulation of cell proliferation.

Treatment of polycystic liver disease with resection-fenestration and a new classification

To evaluate outcomes in patients with autosomal dominant polycyst liver disease (APLD) treated by combined hepatic resection and fenestration. A new classification was recommended to presume postoperative complications and long outcome of patients. Twenty-one patients with APLD were treated by a combined hepatic resection and fenestration technique. All patients were reviewed retrospectively, and clinical symptoms, performance status and morbidity were recorded. A new classification of APLD is recommended here. All patients were discharged when free of symptoms. The mean follow-up time was 55.7 mo and three patients had a recurrence of symptoms at 81, 68 and 43 mo after operation, respectively. The overall morbidity rate was 76.2%. Two patients with Type B-II and Type B-I developed biliary leakage. Four patients had severe ascites, including three with Type B-III and one with Type B-II. Nine patients had pleural effusion, including one with Type A-I; one with Type B-I; five with Type B-II; one with Type A-III and one with Type B-III. Three patients with Type B had recurrence of symptoms, while none with Type A had severe complications. Combined hepatic resection and fenestration is an acceptable procedure for treatment of APLD. According to our classification, postoperative complications and long outcome can be predicted before surgery.

Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection

Radical surgical resection has been revealed to be the only hope of cure for the patient with hilar cholangiocarcinoma. Therefore, major efforts have been made to increase the resection rate by surgeons employing combined hepatic resection and vascular resection of the portal vein and the hepatic artery. Especially, the technical feasibility and surgical safety of hepatic resection with combined portal vein resection have recently been reported by several authors. On the other hand, there have been few reports of combined hepatic artery resection in hilar cholangiocarcinoma. There are fears that combined vascular resection with extended hepatectomy for hilar cholangiocarcinoma may lead to high surgical morbidity and mortality. Herein, we describe the results of aggressive surgical approaches in our series, and we also review the outcomes of hepatic resection with combined vascular resection in the previously reported literature.

Combined vascular resection in operative resection for hilar cholangiocarcinoma: Does it work or not?

It is still not clear how combined vascular resection affects the outcome of patients with hilar cholangiocarcinoma. Our aim was to evaluate implications of combined vascular resection in patients with hilar cholangiocarcinoma by analyzing the outcomes of all patients who underwent operative resection. A total of 161 of 228 consecutive patients with hilar cholangiocarcinoma underwent bile duct resection with various types of hepatectomy (88%) and pancreaticoduodenectomy (4%). Combined vascular resection was carried out in 43 patients. Thirty-four patients had portal vein resection alone, 7 patients had both portal vein and hepatic artery resection, and 2 patients had right hepatic artery resection only. The outcomes were compared between the 3 groups: the portal vein resection alone (34), hepatic artery resection (9), and non-vascular resection (118). Histologically-positive tumor invasion to the portal vein beyond the adventitia was present in 80% of 44 patients undergoing combined portal vein resection. Operative mortality occurred in 11 (7%) patients. The survival rates of the non-vascular resection group were better than that of the portal vein resection alone and the hepatic artery resection groups: 1, 3, and 5 years after curative resection, 72%, 52%, and 41% versus 47%, 31%, and 25% (P < .05), and 17%, 0%, and 0% (P < .0001), respectively. Multivariate analysis showed 4 independent prognostic factors of adverse effect on survival after operation; operative curability, lymph node metastases, portal vein resection, and hepatic artery resection. Although both portal vein and hepatic artery resection are independent poor prognostic factors after curative operative resection of locally advanced hilar cholangiocarcinoma, portal vein resection is acceptable from an operative risk perspective and might improve the prognosis in the selected patients, however, combined hepatic artery resection can not be justified.

Isolated total caval clamping with “preserved remnant liver perfusion” for combined hepatic and venacaval resection in tumors involving venacava

Isolated total caval clamping with “preserved remnant liver perfusion” for combined hepatic and venacaval resection in tumors involving venacava

Surgical therapy options in polycystic liver disease

Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease. Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50 years (range 33-72). All were symptomatic and their cysts had a median diameter of 11 cm (range 5-22). Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient's abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range 7-98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation. Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced stage PLD combined hepatic resection and cyst fenestration.