Segmental Hepatectomy Research Articles

HPB SO22 - Clinical outcomes following radical cholecystectomies, a single centre experience in review

Abstract Background Gallbladder carcinoma (GBC) is a rare disease with dismal prognosis. The majority of cases are identified at an advanced state that preclude curative approaches which would usually necessitate removal of the gallbladder with en-block wedge hepatectomy of segment 4b/5 as well as periportal lymphadenectomy. The purpose of this study was to analyze our outcomes for patients undergoing a radical cholecystectomy for suspected GBC. Method A retrospective analysis of patients who underwent radical cholecystecomies at Queen’s Medical Centre, Nottingham, UK between 1st January 2014 and October 2023 was performed. Patients with concomitant primaries, incidental GBC or completion liver resection following index cholecystectomy were excluded. Results 41 patients were eligible for analysis, those were comprised of 13 males and 28 females with a median age of 67 (IQR 57-72) years. The incidence of malignancy on histology was 31.7% (GBC n=11, metastatic renal carcinoma n=1, metastatic melanoma n=1). Cystic margin assessment by frozen section was performed in 41% of cases. In cases with confirmed gallbladder cancer, the median tumour size was 30mm, positive periportal lymph nodes were identified in two patients while R0 resection was achieved in all cases. The median length of stay following surgery was 5 days (IQR 5-7) while Clavien Dindo complication grade ≥ III were experienced in 12% ( return to theatre for leak from repaired cholecysto-duodenal fistula n=1, IR drainage of post operative collection n=3, ITU stay for cardiac arrhythmia n=1). The pathologies encountered in benign cases (n=28) were compatible with chronic cholecystitis (53.5%, n=15), concurrent chronic cholecystitis and adenomyomatosis (21.4%, n=6), xanthogranulomatous cholecystitis (10.7%, n=3), adenomyomatosis (7.1%, n=2), follicular cholecystitis (3.5%, n=1), benign GB polyps (3.5%, n=1). Conclusion Radical cholecystectomy remains the standard of care for suspected GBC however sufficient preoperative counselling is prudent given likelihood of benign disease on histology.

Caudate lobe and posterosuperior segment hepatectomy using the robotic approach. Outcome analysis of liver resection in difficult locations

BackgroundCaudate and posterosuperior hepatectomy are technically challenging resections, especially in a minimally invasive approach. We aimed to analyze the outcomes of isolated caudate resection (ICR), en-bloc caudate resection with right/left hepatic lobectomy (ECR), and posterosuperior segment resection (PSR) using our institutional database. MethodsFollowing IRB approval, we prospectively followed 500 consecutive patients between 2013 and 2023 who underwent robotic hepatectomy. Posterosuperior segments include segment 4 ​A, 7, and 8. The data are presented as median (mean ​± ​standard deviation). ResultsOf the 500 patients included in this study, 19 (4 ​%) underwent ICR, 65 (13 ​%) underwent ECR, and 131 (26 ​%) patients underwent PSR. ECR was associated with significantly longer operative time, increased EBL, and longer LOS when compared with those of ICR and PSR. The patients who underwent ICR had the shortest operation duration, lowest EBL, and shortest LOS compared to ECR and PSR. ConclusionsRobotic resection of liver tumors located in difficult segments is safe and feasible with excellent clinical and oncological outcomes. With appropriate expertise, a minimally invasive approach to those operations should not be avoided.

Successful subtotal gastrectomy and hepatectomy for HER2-positive gastric cancer with liver metastasis after trastuzumab-based chemotherapy: a case report

BackgroundConversion surgery (CS) after chemotherapy is weakly recommended as a promising tool for improving prognoses in patients with unresectable gastric cancer. Moreover, several investigators have demonstrated the clinical efficacy of subtotal gastrectomy (sTG) with a small remnant stomach for the nutritional status and surgical outcome compared with total gastrectomy. Here, we report a patient with liver metastasis from human epidermal growth factor receptor 2 (HER2)-positive gastric cancer who underwent sTG and hepatectomy after trastuzumab-based chemotherapy.Case presentationAn 84-year-old male patient was diagnosed with HER2-positive gastric cancer with a single liver metastasis. He was treated with eight courses of trastuzumab in combination with S-1 and oxaliplatin as first-line chemotherapy. The primary tumor and liver metastasis shrank significantly. The metastatic liver lesion’s reduction rate was 65%. According to the Response Evaluation Criteria in Solid Tumors, the patient had a partial response. Therefore, he underwent an sTG with D2 lymphadenectomy and partial hepatectomy of segment 2. Histopathological examination revealed a grade 3 histological response without lymph node metastases from the primary tumor. No viable cancer cells were observed in the resected liver specimens. The patient received adjuvant chemotherapy with S-1. The postoperative quality of life (QOL) evaluated using the Postgastrectomy Syndrome Assessment Scale-45 was maintained, and the patient was still alive 8 months after the CS without recurrence.ConclusionsAn sTG with a small remnant stomach might be clinically useful for preventing a decline in QOL and improving prognoses in patients with stage IV gastric cancer after chemotherapy.

Feasibility and safety of ultrasound-guided percutaneous transhepatic measurement of portal venous pressure.

The measurement of portal venous pressure (PVP) has been extensively studied, primarily through indirect methods. However, the potential of ultrasound-guided percutaneous transhepatic PVP measurement as a direct method has been largely unexplored. This study aimed to investigate the accuracy, safety, and feasibility of this approach. In vitro, the experiment aimed to select a needle that could accurately transmit pressure, had a small inner diameter and was suitable for liver puncture, and performed on 20 healthy New Zealand white rabbits. An ultrasound-guided percutaneous transhepatic portal vein puncture was undertaken to measure PVP. Additionally, free hepatic venous pressure (FHVP) and wedged hepatic venous pressure (WHVP) were measured under digital subtraction angiography (DSA). The correlation between the two methods was assessed. Enroll study participants from October 18, 2023 to November 11, 2023 with written informed consent. Five patients were measured the PVP under ultrasound guidance before surgery to determine the feasibility of this measurement method. There was no significant difference in the results obtained using 9 different types of needles (P > 0.05). This demonstrated a great repeatability (P < 0.05). The 22G chiba needle with small inner diameter, allowing for accurate pressure transmission and suitable for liver puncture, was utilized for percutaneous transhepatic PVP measurement. There were positive correlations between PVP and HVPG (r = 0.881), PVP and WHVP (r = 0.709), HVPG and WHVP (r = 0.729), IVCP and FHVP (r = 0.572). The PVP was accurately and safely measured in 5 patients with segmental hepatectomy. No complications could be identified during postoperative ultrasound. Percutaneous transhepatic portal venous puncture under ultrasound guidance is accurate, safe and feasible to measure portal venous pressure. This study has been registered in the Chinese Clinical Trial Registry with registration number ChiCTR2300076751.

Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

Feasibility of novel intraoperative navigation for anatomical liver resection using real-time virtual sonography combined with indocyanine green fluorescent imaging technology.

To analyze the feasibility and clinical effect of novel intraoperative navigation of real-time virtual sonography (RVS) combined with indocyanine green (ICG) fluorescent imaging technology in anatomical liver resection (ALR) for hepatocellular carcinoma. The clinical data of 41 patients who underwent ALR using RVS intraoperative navigation combined with ICG fluorescent imaging technology in the Department of Hepatobiliary Surgery of Peking University International Hospital from January 2020 to May 2022 were retrospectively analyzed. RVS was applied to guide the surgical plane through fusing real-time intraoperative ultrasound images with corresponding preoperative CT or MRI images. Operation methods, operation time, intraoperative blood loss, operative margin, hospital stay and postoperative complications were analyzed. The 1-year overall survival rate and tumor-free survival rate of patients were followed up by outpatient review or telephone calls. ALR surgery was performed on each of 41 patients. There were no deaths during perioperative period and postoperative complications occurred in 7 cases (17.1%). The postoperative pathological examinations demonstrated all cases of hepatocellular carcinoma and negative operative margins. The 41 patients were followed up for 12 to 20 months, with a median follow-up time of 14 months. The overall survival rate 1 year after surgery was 100.0% (41/41), 3 patients (7.3%) experienced tumor recurrence, and the tumor-free survival rate of 1 year after surgery was 92.7% (38/41). In conclusion, novel intraoperative navigation of RVS combined with ICG fluorescent imaging technology is safe and feasible in anatomical segmental hepatectomy of hepatocellular carcinoma.

Laparoscopic Surgery of an Isolated Splenic Hydatid Cyst in a 43- Year- Old Man: A Case Report

Introduction: Hydatid disease is a type of parasitic disease mainly affect the lungs and the liver and splenic hydatid cyst is a rare disease. We hereby present a rare case of splenic hydatid disease. Case report: A 43-years-old man with a history of left upper quadrant pain (LUQ) pain, anorexia, weakness, and weight loss was admitted to the surgery department in Iran. The imaging studies showed a cystic mass in the gastro-splenic ligament extending up to below the left diaphragm with adhesion to the spleen capsule and the fundus of the stomach caused focal elevation of this part of the diaphragm. A laparoscopic surgery was performed and splenic hydatid cyst with adhesion to the stomach and the left lobe of the liver and with penetration into the left hemi thorax was observed. Splenectomy, hepatectomy of the left segment of the liver, repair of diaphragmatic defect and stomach release was done. Conclusion: Splenic hydatid cyst surgery can be difficult and requires appropriate diagnostic evaluations and examination for adhesions and invasion to other organs.

Comments on Experience With Establishing a Robotic Donor Hepatectomy Program for Pediatric Liver Transplantation.

Comments on Experience With Establishing a Robotic Donor Hepatectomy Program for Pediatric Liver Transplantation.

Intrahepatic Glissonean Approach for Robotic Anatomical Liver Resection of Segment 7 Using the Saline-Linked Monopolar Cautery Scissors (SLiC-Scissors) Method: A Technical Case Report With Videos.

Anatomical hepatectomy of segment 7 (S7) is technically difficult due to its difficult accessibility. Here, we present our experience of robotic anatomical S7 subsectionectomy of the liver employing the saline-linked cauteryscissors (SLiC-Scissors) technique. After the right lobe was fully mobilized, dissection of the Glissonean pedicle and hepatic venous branch of S7, as well as the liver parenchymal transection, were safely performed using the SLiC-Scissors method. Despite its technological complexity, the intrahepatic Glissonean approach for robotic anatomical S7 subsectionectomy of the liver employing the SLiC scissors method is safe and efficient.

Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report

BackgroundMetastatic lung tumor with a tumor thrombus in the peripheral pulmonary vein is very rare. We present a case of a metastatic lung tumor from hepatocellular carcinoma (HCC) with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy.Case presentationA 77-year-old man underwent laparoscopic lateral segment hepatectomy for HCC eight years ago. Protein induced by vitamin K absence or antagonist-II remained elevated from two years ago. Contrast-enhanced chest computed-tomography (CT) showed a 27 mm nodule in the right apical segment (S1). He was pathologically diagnosed with a metastatic lung tumor from HCC via transbronchoscopic biopsy. We planned to perform right S1 segmentectomy. Before surgery, contrast-enhanced CT in the pulmonary vessels phase for three-dimensional reconstruction showed that the tumor extended into the adjusting peripheral pulmonary vein, and we diagnosed tumor thrombus invasion in V1a. The surgery was conducted under 3-port video-assisted thoracic surgery. First, V1 was ligated and cut. A1 and B1 were cut. The intersegmental plane was cut with mechanical staplers. Pathological examination revealed moderately-differentiated metastatic HCC with tumor thrombus invasions in many pulmonary veins, including V1a. No additional postoperative treatments were performed.ConclusionsAs malignant tumors tend to develop a tumor thrombus in the primary tumor, it might be necessary to perform contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus before the operation for metastatic lung tumors.

Assessment of a novel biliary-specific near-infrared fluorescent dye (BL-760) for intraoperative detection of bile ducts and biliary leaks during hepatectomy in a preclinical swine model.

Postoperative bile leakage is a common complication of hepatobiliary surgery and frequently requires procedural intervention. Bile-label 760 (BL-760), a novel near-infrared dye, has emerged as a promising tool for identifying biliary structures and leakage, owing to its rapid excretion and strong bile specificity. This study aimed to assess the intraoperative detection of biliary leakage using intravenously administered BL-760 compared with intravenous (IV) and intraductal (ID) indocyanine green (ICG). Laparotomy and segmental hepatectomy with vascular control were performed on two 25-30 kg pigs. ID ICG, IV ICG, and IV BL-760 were administered separately, followed by an examination of the liver parenchyma, cut liver edge, and extrahepatic bile ducts for areas of leakage. The duration of intra- and extrahepatic fluorescence detection was assessed, and the target-to-background (TBR) of the bile ducts to the liver parenchyma was quantitatively measured. In Animal 1, after intraoperative BL-760 injection, three areas of leaking bile were identified within 5 min on the cut liver edge with a TBR of 2.5-3.8 that was not apparent to the naked eye. In contrast, after IV ICG administration, the background parenchymal signal and bleeding obscured the areas of bile leakage. A second dose of BL-760 demonstrated the utility of repeated injections, confirming two of the three previously visualized areas of bile leakage and revealing one previously unseen leak. In Animal 2, neither ID ICG nor IV BL-760 injections showed obvious areas of bile leakage. However, fluorescence signals were observed within the superficial intrahepatic bile ducts after both injections. BL-760 enables the rapid intraoperative visualization of small biliary structures and leaks, with the benefits of fast excretion, repeatable intravenous administration, and high-fluorescence TBR in the liver parenchyma. Potential applications include the identification of bile flow in the portal plate, biliary leak or duct injury, and postoperative monitoring of drain output. A thorough assessment of the intraoperative biliary anatomy could limit the need for postoperative drain placement, a possible contributor to severe complications and postoperative bile leak.

A novel method of ultrasound-guided positive staining using indocyanine green fluorescence in laparoscopic anatomical liver resection of segments VII and VIII.

Recently, in many Asian centers, laparoscopic anatomical liver resection (LALR) using the indocyanine green (ICG) fluorescence imaging technique has been increasingly applied in resecting hepatocellular carcinoma, even in colorectal liver metastases. However, LALR techniques have not been fully standardized, especially in right superior segments. Due to the anatomical position, prevailing positive staining using a PTCD (percutaneous transhepatic cholangial drainage) needle was superior to negative staining in right superior segments hepatectomy, while it was difficult to manipulate. Herein, we design a novel method of ICG-positive staining for LALR of right superior segments. Between April 2021 and October 2022, we retrospectively studied patients in our institute who underwent LALR of right superior segments using a novel method of ICG-positive staining, which comprised a customized puncture needle and an adaptor. Compared to the PTCD needle, the customized needle was not limited by the abdominal wall and could be punctured from the liver dorsal surface, which was more flexible to manipulate. The adapter was attached to the guide hole of the laparoscopic ultrasound (LUS) probe to ensure the precise puncture path of the needle. Guided by preoperative three-dimensional (3D) simulation and intraoperative laparoscopic ultrasound imaging, we punctured the transhepatic needle into the target portal vein through the adaptor and then slowly injected 5-10ml of 0.025 mg/ml ICG solution into the vessel. LALR can be guided by the demarcation line under fluorescence imaging after injection. Demographic, procedural and postoperative data were collected and analyzed. In this study, 21 patients underwent LALR of the right superior segments with ICG fluorescence-positive staining, and the procedures had a success rate of 71.4%. The average staining time was 13.0 ± 6.4min, the operative time was 230.4 ± 71.7min, R0 resection was 100%, the postoperative hospital stay was 7.1 ± 2.4 days, and no severe puncture complications occurred. The novel customized puncture needle approach seems to be feasible and safe for ICG-positive staining in LALR of right superior segments, with a high success rate and a short staining time.

Deep vein thrombosis after open hepatectomy or other major upper abdominal surgery in Taiwan: A prospective and cross-sectional study relevant to the issue of pharmacological thromboprophylaxis

Venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important complication in patients who underwent open hepatic surgery as well as other major upper abdominal surgery. This study aims to investigate the occurrence of postoperative DVT without pharmacological thromboprophylaxis in such cohorts in Taiwan. This is a prospective, cross-sectional cohort study conducted from March 2010 to December 2011. Patients who underwent major upper abdominal surgery, including open hepatectomy, were enrolled. Color duplex compression ultrasonography (CUS) was used to detect DVT. Symptomatic PE was excluded if there were no suggestive respiratory symptoms or sudden death. Relevant clinicopathological and surgical information of each patient was collected and analyzed. 195 patients (118 male and 77 female) were enrolled, with a median age of 63.6 years. The majority (169/195, 88.7%) were treated for active malignancy. Totally 147 patients received open hepatectomy. Only one asymptomatic and distal postoperative DVT event was identified by CUS, which occurred on a 73-year-old female patient who received a left lateral segmental hepatectomy for removing the advanced hepatocellular carcinoma (pathologic stage, T3aN0M0). No cases of symptomatic PE or sudden death were observed. No correlation between DVT and precipitating factor was demonstrated in our cohort. Without pharmacological thromboprophylaxis, a low rate of postoperative DVT among patients undergoing open hepatectomy (0.7%, 1/147) or major upper abdominal surgery (0.5%, 1/195) in Taiwan was reported. A distinctively regional role of pharmacological thromboprophylaxis for hepatic surgery was also suggested by our data.

Overview of recurrent pyogenic cholangitis

BackgroundThe clinical illness known as recurrent pyogenic cholangitis (RPC) is characterized by recurrent suppurative cholangitis caused by hepatolithiasis and extrahepatic stones in the biliary channels. The actual pathophysiology of RPC is still unknown, but certain enteric bacterial species colonizing the biliary tract in conjunction with potential dietary variables have been suggested as potential causes. RPC is frequently referred to as having hepatobiliary surgery, especially segmental hepatectomy, as the only effective treatment. Objectivesto determine the prevalence of recurrent pyogenic cholangitis, explain the typical symptoms a patient with the condition would exhibit, and describe the diagnosis and treatment of RPC. Methodsthe PubMed database and EBSCO Information Services were utilized to choose the articles. In our review, all pertinent articles related to both our topic and other articles were used. Other articles that have nothing to do with this subject were not included. The group members looked through a certain format in which the data had been extracted. Conclusion Recurrent pyogenic cholangitis is a complicated illness, and it is becoming more common in Western nations. Radiologists need to understand how to diagnose this condition and how to use imaging as a benchmark for subsequent treatment. Before the surgical intervention, the intrahepatic distribution of the patient's condition must be determined, and the combined efforts of gastroenterologists, radiologists, and surgeons are necessary for the effective treatment of recurrent pyogenic cholangitis.

Diagnosis and treatment of liver metastases of parathyroid carcinoma.

IntroductionParathyroid carcinoma (PC) is a very rare endocrine malignancy occurring in less than 1% of all cases of primary hyperparathyroidism (pHPT). The liver is the second most common target organ for distant metastases of PC, but no guidelines are available for the diagnosis and treatment of liver metastases. In this study, we attempted to summarize the characteristics of the diagnosis and treatment of liver metastases based on our patients and other cases reported in the literature.Materials and methodsThe files of all patients diagnosed with PC with liver metastases summarized at our center between 2000 and 2022 were reviewed, and three datasets from Medline, Web of Science, and Embase were systematically searched to identify relevant articles.ResultsThree patients with liver metastases from our center and 11 patients from the literature were included in the study. All patients had pHPT with borderline remission of hypercalcemia after each operation. A total of 71.4% of the patients’ liver lesions were found by abdominal CT scans, while 35.7% were found by MRI, PET-CT, and fine-needle aspiration biopsy (FNAB), which were also helpful for diagnosis. Eight of nine patients (88.9%) who underwent surgery, radiofrequency ablation (RFA), or transcatheter arterial embolization (TAE) were alive, and only one postoperative patient died after a follow-up of 60 months.ConclusionsPC is a rare malignant tumor prone to recurrence and metastasis, and postoperative reviews should be carried out routinely. Abnormally elevated parathyroid hormone (PTH) and serum calcium can indicate recurrence or metastasis. Enhanced CT and MRI can provide valuable support for the diagnosis of liver metastases, but whether [18F]FDG-PET-CT, [18F]FCH-PET-CT, or [11C]choline-PET-CT can be used as a diagnostic basis requires further study. Resection of liver metastases, segmental hepatectomy, or RFA can significantly improve patients’ symptoms.

Standardized and Feasible Laparoscopic Approach for Tumors Located in the Caudate Lobe

Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure. Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy. In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis. Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach.

Application of 3D Simulation Software in Chemotherapy and Hepatoblastoma Surgery in Children.

PurposeThis study aims to explore the clinical value of a computer-assisted surgery system (Hisense CAS) in hepatoblastoma (HB) surgery in children after neoadjuvant chemotherapy.Patients and MethodsThe clinical medical records of children with HB treated after neoadjuvant chemotherapy at the Affiliated Hospital of Qingdao University from January 2016 to January 2019 were analyzed retrospectively.ResultsA total of 21 children were enrolled in this study, including 13 boys and 8 girls. All cases successfully underwent three-dimensional (3D) reconstruction of the liver and tumor using Hisense CAS, simulated hepatectomy, and hepatectomy according to the preoperative operation plan. There were twelve cases of right hemihepatectomy, four cases of right trefoil hepatectomy, one case of left lobe hepatectomy, and three cases of middle lobe hepatectomy, and one case of V and VI segment hepatectomy. All children recovered well after the operation. The follow-up ranged from 5 months to 3 years. One child died of systemic metastasis 8 months after the operation. One child received one course of chemotherapy after the operation. Due to the serious reaction to the chemotherapy, the family refused further treatment and follow-up. The remaining 19 children had no complications or recurrence.ConclusionHisense CAS can clearly and intuitively display the position and shape of the HB before and after chemotherapy and its relationship with the intrahepatic pipeline system and accurately evaluate the changes in tumor volume and the distance between important blood vessels, which is conducive to the operator selecting the best operation opportunity, timely formulating the best operation plan and implementing individualized and accurate liver tumor resection.

Successful conversion surgery for stage IV gastric cancer with liver metastases after second-line chemotherapy with ramucirumab and paclitaxel: a case report

BackgroundIn recent years, conversion surgery after chemotherapy has been considered a promising strategy for improving the prognosis of patients with stage IV gastric cancer. However, there are few reports on conversion gastrectomy after second-line chemotherapy. Here, we report a case of long-term survival of a patient with liver metastases from gastric cancer who underwent conversion surgery after second-line chemotherapy with ramucirumab and paclitaxel.Case presentationA 77-year-old man complaining of weight loss was diagnosed with human epidermal growth factor receptor 2-positive gastric cancer with multiple liver metastases. Although the patient initially received trastuzumab-based chemotherapy, it was discontinued, because he experienced trastuzumab-induced infusion reactions. Thereafter, he was treated with six courses of S-1 plus cisplatin and six courses of ramucirumab plus paclitaxel as the first- and second-line regimens, respectively. The primary tumor and liver metastases remarkably shrank, and the reduction rate of the measurable metastatic liver lesions was 81.1%. According to the Response Evaluation Criteria in Solid Tumors, the patient responded partially. Therefore, he underwent total gastrectomy with D2 lymphadenectomy and partial hepatectomy of segments 3 and 4. Pathological examination revealed tumor invasion into the muscularis propria, a grade 1a histological response, and no lymph node metastases. No viable cancer cells were identified in the specimens resected from liver segments 3 and 4. Accordingly, the patient was pathologically diagnosed with stage IB (ypT2N0M0). Postoperatively, the patient received adjuvant chemotherapy with S-1 for 6 months, and he survived without recurrence for 42 months after conversion surgery.ConclusionsConversion surgery might be clinically useful for improving survival in certain patients with gastric cancer, including those who previously received second-line chemotherapy.

Laparoscopic S7 hepatectomy for hepatic mucinous neoplasm: a case report and literature review

BackgroundMucinous cystic neoplasm of the Liver is rare tumors with malignant potential that occur in the biliary epithelium. Because of its rare presentation, it is often misdiagnosed before surgery.Case presentationA 63-year-old female patient presented with intermittent upper abdominal pain for three months. Laparoscopic hepatectomy of Segment 7 was conducted based on the preoperative diagnosis of space-occupying lesion in the right lobe of the liver. Postoperative pathology showed a low-grade mucinous cystic neoplasm in the right posterior lobe of the liver. The preoperative CA19-9 level was significantly increased while the postoperative CA19-9 returned to the normal range.ConclusionsThe diagnosis of mucinous cystic neoplasm of the liver is closely related to the thickening of the cystic wall or the increase of CA19-9, which has great significance and deserves clinical attention.

Surgery After Conversion Therapy With PD-1 Inhibitors Plus Tyrosine Kinase Inhibitors Are Effective and Safe for Advanced Hepatocellular Carcinoma: A Pilot Study of Ten Patients.

Background and AimsImmunotherapy with PD-1 inhibitors combined with tyrosine kinase inhibitors (TKIs) has been proven to be effective against advanced hepatocellular carcinoma (HCC). The aim of this study was to identify the feasibility and safety of subsequent salvage surgery after this combination therapy.Methods and PatientsA retrospective analysis was performed on patients with primary HCC with major vascular invasion between 2018 and 2019. All cases were treated with a combination of a PD-1 inhibitor and TKI agents and subsequent surgery.ResultsA total of 10 HCC cases with major vascular invasion met the successful conversion criteria after the combination therapy, and eight patients underwent subsequent salvage surgery after both radiology and 3D quantitative oncological assessment. Partial response (PR) was recorded in 7 of 10 patients and complete response (CR) in 3 of 10 patients before salvage surgery. Salvage surgery included right hepatectomy, left hepatectomy, and anatomic segmental hepatectomy. The mean intraoperative blood loss was 1,650 ml (50–3,000 ml). No complications beyond Clavien–Dindo level III or postoperative mortality were observed. The viable tumor cell rate of the PR cases (modified response evaluation criteria in solid tumors, mRECIST) varied from 1.5% to 100%, and only one patient had pathology-proven pathological complete response (pCR). The postoperative median follow-up time was 19.7 months (9.1–24.9 months). The 12-month recurrence-free survival rate of all cases who underwent salvage surgery was 75%.ConclusionSalvage surgery was effective and safe after conversion therapy with PD-1 inhibitors plus TKIs and may increase the long-term oncological benefit for patients with unresectable HCC.