Hepatic Lobectomy Research Articles

Health System Structure: An Opportunity to Address Structural Racism and Discrimination

INTRODUCTION: Health systems are often organized in a “hub-and-spoke” fashion to centralize complex surgical care to one high-volume hospital. We examined the role of hub-and-spoke systems as a key factor in structural racism and discrimination. METHODS: Adult surgical patients who underwent 1 of 10 general surgery operations in 13 geographically diverse states (2016 to 2018) were identified using the Healthcare Cost and Utilization Project’s State Inpatient Databases. System status was assigned using the American Hospital Association survey. Hub designation was assigned in two ways: the hospital performing the greatest number of complex operations or the hospital performing the greatest number of each specific operation. Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of receiving treatment at hubs by race and ethnicity. RESULTS: We identified 128,248 patients across 133 hospitals included in 44 systems. Most patients were White (70%), 13.5% were Black and 11.8% Hispanic. A smaller proportion of Black and Hispanic patients underwent operation at hubs compared with White patients (Black: 60.9%; Hispanic: 53.5%; White: 64.4%; p < 0.001). After adjustment for potential confounders, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (Table). CONCLUSION: When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the established potential advantages of high-volume care, especially for complex operation, this finding highlights an important gap in the pursuit of health equity. Table. - Risk-Adjusted Odds Ratios of Treatment at Hub Hospitals (Reference = White Patients) Variable All operations Common operation Complex operation Number of observations (n) 128,248 118,764 9,484 Black patients odds ratio 0.88* 0.88* 0.85* Black patients confidence interval [0.85, 0.92] [0.85, 0.92] [0.72, 1.00] Hispanic patients odds ratio 0.79* 0.79* 0.91 Hispanic patients confidence interval [0.76, 0.82] [0.75, 0.82] 0.76, 1.10] *Significance to the level of p <0.05. Results are displayed for the second definition of hub. Similar results were noted for the alternative definition. Model covariates include age, gender, income quartile, insurance type, state, admission status, and operation type. Common operations include cholecystectomy, inguinal hernia repair, mastectomy, colon resection, and small bowel resection. Complex operations include total gastrectomy, Whipple, hepatic lobectomy, esophagectomy, and rectal resection.

Laparoscopic versus open surgery for hepatic caudate lobectomy: a retrospective study.

This study was designed to investigate the feasibility and safety of laparoscopic hepatic caudate lobectomy (LHCL) for treating liver tumor by comparing with the open hepatic caudate lobectomy (OHCL). In the LHCL group, we included 24 patients with liver tumor received LHCL in Qilu Hospital of the Shandong University from January 2014 to January 2019. Meanwhile, 24 matched liver tumor patients underwent OHCL in our hospital served as control. Then we compared the patient characteristics, intraoperative parameters, and postoperative outcomes between LHCL group and OHCL group. There were no significant differences in gender, age, degree of cirrhosis, tumor size, preoperative liver function, Child-Pugh grading, proportion of liver cirrhosis, and tumor size between LHCL group and OHCL group (P > 0.05). No death was reported in both groups. The length of incision in LHCL group was significantly lower than that in OHCL group (4.22 ± 1.14cm vs. 22.46 ± 4.40cm, P < 0.001). The intraoperative blood loss in LHCL group was significantly lower than that of OHCL group (116.82 ± 71.61ml vs. 371.74 ± 579.35ml, P = 0.047). The total operation time, Pringle maneuver occlusion time, and blocking rate in LHCL group showed no statistical difference compared with those of the OHCL group (P > 0.05). The VAS scores at postoperative 24 and 48h showed no statistical differences between LHCL group and OHCL group (P > 0.05). Compared with the OHCL group, significant decrease was noticed in the proportion of patients with severe pain 48h after surgery (0 vs. 4.25 ± 0.46, P < 0.001) and dezocine consumption (90.45 ± 45.77mg vs. 131.6 ± 81.30mg, P = 0.0448) in the LHCL group. LHCL is effective and feasible for treating liver tumor, which is featured by reducing intraoperative blood loss and serious pain.

Establishment and assessment of postoperative cognitive impairment in intermittent hypoxia rats.

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic disease characterized by repeated episodes of apnea or hypopnea, accompanied by intermittent awakening and sleep disturbances. The incidence of OSAHS is increasing and has become a serious disease. In recent years, more and more evidence shows that OSAHS is closely related to postoperative neurocognitive disorders, and the preparation of models of postoperative cognitive impairment in intermittent hypoxia animals is an important way to study its pathogenesis and intervention targets. This study aims to explore the establishment and evaluation of the animal model of postoperative cognitive impairment in intermittent hypoxia rats. A total of 108 male SD rats were randomly divided into 8 groups: a control group (C group, n=27), a surgery group (S group, n=27), an intermittent hypoxia 7 d group (H1 group, n=9), an intermittent hypoxia 14 d group (H2 group, n=9), an intermittent hypoxia 21 d group (H3 group, n=9), an intermittent hypoxia 7 d operation group (O1 group, n=9), an intermittent hypoxia 14 d operation group (O2 group, n=9), and an intermittent hypoxia 21 d operation group (O3 group, n=9). The rats in the H1, H2 and H3 group treated with intermittent hypoxia for 7, 14, and 21 d, respectively. The rats in the O1, O2 and O3 groups received left lateral hepatic lobectomy after 7, 14, and 21 d intermittent hypoxia, respectively. The rats in each group were subjected to open field test, new object recognition test, and Barnes Maze test. The expression of IL-1β mRNA in hippocampus of rats was detected at the 1st day after the surgery. Compared with the C, S, and H2 groups, the discrimination index in novel object recognition test 6 h and 1 d after the surgery of the O2 group was significantly lower (P<0.05), the latency and errors in Barnes maze at the 1st day and 2nd day after the surgery were increased significantly (P<0.05) and the expression of IL-1β mRNA in hippocampus was significantly increased at the 1st day after the operation (P<0.05). However, there was no difference in the preference index in NORT 6 h and 1 d after the surgery, the latency and errors in Barnes maze and the expression of IL-1β mRNA in hippocampus between the O1 group and the H1 group, the H3 group and the O3 group (all P>0.05). The rate with intermittent hypoxia 14 d pretreatment with anesthesia and laparotomy could be established the animal model of postoperative cognitive impairment.

A Trapped Colon

A Trapped Colon

Right hepatic trisectionectomy combined total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma: A surgical case report (with video).

BackgroundExtended resection such as right trisegmentectomy combined with total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma (CCA) is still challenging for all Hepato-pancreato-biliary surgeons.PresentationA 45-year-old female with advanced hilar CCA involved the right intrahepatic bile ducts in continuity with the left medial sectional bile duct without PV invasion had undergone right trisegmentectomy combined with total caudate lobectomy with non-touch technique. Dissection of the hepatic peduncle by Lorta-Jacob Procedure, ligation, and resection of the right hepatic artery (RHA) and the right portal vein (PV), before that determine whether portal bifurcation's tumor infiltration or not. Mobilization of the right liver lobe, ligate all the short hepatic veins from the caudal to cranial direction, as well as the right hepatic vein (RHV) and the middle hepatic vein (MHV). Complete caudate lobectomy with right–left approach. Determine hepatic parenchyma cut, left cholangiostomy to the division of the subsegments 2,3, stitch formation of the subsegments 2,3 bile duct. Determine negative upper section of the biliary tract. The operative time was 432 min, and the blood loss was 750 ml. Postoperative recovery was uneventful without any major complications but developed intra-abdominal abscess that required percutaneous drainage.DiscussionExtended resection procedures such as extend right/left trisectionectomy, hepato-pancreaticoduodenectomy (HPD) and/or combined vascular resection are only curative treatment for advanced hilar CCA. There hadn't been any reported cases describing step-by-step right trisegmentectomy combined with total caudate lobectomy with non-touch technique with clear illustrations and videos yet.ConclusionCareful preparation with preoperative biliary drainage as well as precise evaluation of the functional capacity of the future liver remnant, as well as meticulous experience of surgeons in hepatic anatomy and non-touch resection technique are key points for success in extended resection for advanced hilar CCA.

Prevention of dexmedetomidine on postoperative delirium and early postoperative cognitive dysfunction in elderly patients undergoing hepatic lobectomy.

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common operative neurocognitive disorders, which places a heavy burden on patients, families and society. Therefore, it is very important to search for preventive drugs. Previous studies have demonstrated that perioperative use of dexmedetomidine resulted in a decrease the incidence of POD and POCD. But the specific effect of dexmedetomidine on elderly patients undergoing hepatic lobectomy and its potential mechanism are not clear. This study aims to evaluate the efficacy of intraoperative use of dexmedetomidine on preventing POD and POCD in elderly patients undergoing hepatic lobectomy and the influence on the balance between proinflammation and anti-inflammation. This trial was designed as a single-center, prospective, randomized, controlled study. One hundred and twenty hospitalized patients from January 2019 to December 2020, aged 60-80 years old with American Society of Anesthesiologists (ASA) II-III and scheduled for hepatic lobectomy, were randomly allocated into 3 groups (n=40) using a random number table: A C group, a Dex1 group, and a Dex2 group. After anesthesia induction, saline in the C group, dexmedetomidine [0.3 μg/(kg·h)] in the Dex1 group, and dexmedetomidine [0.6 μg/(kg·h)] in the Dex2 group were infused until the end of operation. The incidences of hypotension and bradycardia were compared among the 3 groups. Confusion Assessment Method (CAM) for assessing POD and Mini Mental State Examination (MMSE) for evaluating POCD were recorded and venous blood samples were obtained for the determination of neuron specific enolase (NSE), TNF-α, IL-1β, and IL-10 at the different time below: the time before anesthesia (T0), and the first day (T1), the third day (T2), the fifth day (T3), and the seventh day (T4) after operation. Compared with the C group, the incidences of bradycardia in the Dex1 group or the Dex2 group increased (both P<0.05) and there was no difference in hypotension in the Dex1 group or the Dex2 group (both P>0.05). The incidences of POD in the C group, the Dex1 group, and the Dex2 group were 22.5%, 5.0%, and 7.5%, respectively. The incidences of POD in the Dex1 group or the Dex2 group declined significantly as compared to the C group (both P<0.05). However, there is no difference in the incidence of POD between the Dex1 group and the Dex2 group (P>0.05). The incidences of POCD in the C group, the Dex1 group, and the Dex2 group were 30.0%, 12.5%, and 10.0%, respectively. The incidences of POCD in the Dex1 group and the Dex2 group declined significantly as compared to the C group (both P<0.05). And no obvious difference was seen in the incidence of POCD in the Dex1 group and the Dex2 group (P>0.05). Compared with the C group, the level of TNF-α and IL-1β decreased and the level of IL-10 increased at each time points (from T1 to T4) in the Dex1 group and the Dex2 group (all P<0.05). Compared with the Dex1 group, the level of IL-1β at T2 and IL-10 from T1 to T3 elevated in the Dex2 group (all P<0.05). Compared with the T0, the concentrations of NSE in C group at each time points (from T1 to T4) and in the Dex1 group and the Dex2 group from T1 to T3 increased (all P<0.05). Compared with the C group, the level of NSE decreased from T1 to T4 in the Dex1 group and the Dex2 group (all P<0.05). Intraoperative dexmedetomidine infusion can reduce the incidence of POCD and POD in elderly patients undergoing hepatic lobectomy, and the protective mechanism appears to involve the down-regulation of TNF-α and IL-1β and upregulation of IL-10 expression, which lead to rebalance between proinflammation and anti-inflammation.

A216 WHEN CANCER CASTS THE FIRST STONE: A CASE REPORT OF GALLBLADDER CANCER PRESENTING AS GALLSTONE ILEUS

BackgroundGallstone ileus is a rare cause of mechanical bowel obstruction. It occurs when a biliary stone passes through a cholecystoenteric fistula and becomes impacted in the bowel lumen, most commonly at the terminal ileum or ileocecal valve.Gallbladder cancer is rare and often has a poor prognosis. Many patients present with advanced-stage disease and only 10% of patients are candidates for surgical resection. Early research has shown there is an increased incidence of gallbladder cancer among patients with gallstone ileus. To date, this relationship remains poorly understood.AimsTo present a case of an elderly female whose gallbladder cancer presented after causing a cholecystoenteric fistula and gallstone ileus.MethodsA retrospective review of a single patient case.ResultsOur patient was a 78-year-old female with a background history of hypertension, iron-deficiency anemia, osteoporosis, and treated bilateral breast cancer. She initially presented with acute cholecystitis, complicated by a concurrent pulmonary embolism. Given her need for systemic anticoagulation, she was treated non-operatively with antibiotics and an outpatient cholecystectomy was planned.She returned to hospital eight months later reporting two days of nausea and vomiting. A repeat CT scan showed a cholecystoduodenal fistula with a 3.5cm x 2.6cm gallstone impacted 20cm from the ileocecal valve. A laparoscopic-assisted enterolithotomy was performed and her postoperative course was uneventful.One month later, a CT scan was organized by her family physician to follow-up on incidental liver lesions. While the liver lesions were deemed benign, there was new lobulated soft tissue within the gallbladder, measuring 4.8cm x 4.7cm x 6.2cm, suspicious for a primary gallbladder malignancy. A follow-up MRI confirmed an intraluminal mass with direct invasion into hepatic segment III as well as marked segment III intrahepatic biliary dilatation. Endoscopy to the duodenum and cholecystoduodenal fistula was performed with a biopsy confirming gallbladder adenocarcinoma.She underwent an open radical cholecystectomy, left hepatic lobectomy, antrectomy, resection of 1st portion of duodenum, and reconstruction with a Roux-en-Y gastrojejunostomy. Final pathology and staging confirmed a pT3pN0M0 adenocarcinoma of the gallbladder with a fistula tract within the cancer extending to the duodenum. She was then referred to a cancer center to complete a six-month course of adjuvant chemotherapy with capecitabine.ConclusionsGallstone ileus is a cause of mechanical bowel obstruction and rarely, it can be the first presentation of gallbladder cancer. Gallbladder cancer has a poor prognosis with many patients presenting with late-stage disease. As a result, we recommend the consideration of post-enterolithotomy imaging in select patients to evaluate for evidence of malignancy.Funding AgenciesNone

A Case of Intraductal Oncocytic Papillary Neoplasms of the Bile Duct (IOPN) Metachronously Arising in the Liver

62-year-old woman presented with left hypochondriac pain and a giant cystic lesion in the left lobe of the liver was pointed out by CT examination. The tumor appeared a multilocular cystic lesion connecting to the left hepatic duct and included a solid component with internal septum, which were enhanced by contrast CT. Preoperative diagnosis was a intraductal papillary neoplasm of the bile duct or intrahepatic cholangiocarcinoma, and a left hepatic lobectomy was performed. Macroscopically, it was a multilocular cystic lesion, 17 cm in size, containing abundant mucin and papillary nodule. Microscopically, papillary growth of the cuboidal neoplastic cells comprising with eosinophilic cytoplasm and enlarged nuclei in the dilated bile ducts was observed. The tumor was diagnosed as a intraductal oncocytic papillary neoplasm of the bile duct (IOPN). Four years after the left hepatectomy, a tumor, 2 cm in size, was found in the caudate lobe and the partial caudate lobectomy was performed. Pathologically, the secondary lesion revealed the similar morphology as the primary tumor. By genomic analysis, identical mutation in CTNNB1 was detected in both tumors. That is, the metachronous tumor arising in caudate lobe was originated from primary cancer clone, and considered as a postoperative recurrence in the remnant intrahepatic bile duct. This is a rare case of IOPN metachronously arisen in the liver. The repeated surgical attempts were possibly contributed to prolonged survival.

Anatomical, Histological, and Ultrasonographical Studies on the Liver of Red Fox (Vulpes vulpes) with its Arterial Blood Distribution and Biliary Ducts

The study aimed to investigate the anatomical and histological characteristics of the Egyptian red fox. We performed liver ultrasonography on eight animals while used two livers for morphological study. To illustrate the hepatic artery branches, two specimens were injected with colored red latex neoprene through the abdominal aorta. The other two specimens were injected with a mixture of lead oxide and colored green latex neoprene through the major duodenal papilla to demonstrate the radiological images of the biliary duct pattern. The last two specimens were used for histological study. The fox's liver had six lobes; left lateral, left medial, quadrate, right medial, right lateral, and caudate lobes. The gall bladder was pear-shaped and was embedded in a fossa between the right medial and the quadrate lobes. The left hepatic duct formed the common bile duct, and the cystic duct union then passed about 0.5-1cm to join with the right hepatic duct. The branches of the proper hepatic artery supply the liver lobes. Histologically, liver parenchyma consisted of lobules; each lobule had a central vein and hepatic cords with hepatic sinusoids in between. Histochemically, hepatocytes were stained with Periodic Acid Schiff and Bests carmine stains. Gall bladder lined by simple columnar cells rests on fibrous propria-submucosa rich in blood capillaries. This study has practical importance in surgical treatment, as in partial hepatic lobectomy and hepatic artery or lobar arteries ligation in case of tumors.

Role of Different Doses of Ketamine in Postoperative Neurocognitive Function in Aged Mice Undergoing Partial Hepatectomy by Regulating the Bmal1/NMDA/NF-Κb Axis

Background: The current study set out to probe the function of different doses of ketamine in postoperative neurocognitive disorder (PND) in aged mice undergoing partial hepatectomy (PH) with the involvement of the brain and muscle aryl hydrocarbon receptor nuclear translocator-like protein 1 (Bmal1)/n-methyl-D-aspartate (NMDA)/nuclear factor-kappa B (NF-κB) axis. Methods: First, aged mice were intraperitoneally injected with different doses of ketamine prior to surgery, followed by hepatic lobectomy. Afterward, mice cognitive function was assessed. In addition, Bmal1 mRNA expression patterns were quantified, while NMDA 2B receptor, NF-κB p65, synapsin 1, and postsynaptic density 95 (PSD95) levels were determined; the release of inflammatory factors was detected, and ionized calcium-binding adapter molecule-1 expression was measured to quantify microglia activation. In addition, Bmal1-knockout (Bmal1-KO) mice were intraperitoneally injected with a subanesthetic dose of ketamine to verify the mechanism of Bmal1 in regulating the NMDA 2B subunit (NR2B)/NF-κB axis to affect PH in aged patients. Results: After PH, hippocampal-dependent memory was impaired, and synapsin 1 and PSD95 levels were downregulated. On the other hand, PH diminished Bmal1 expression but elevated NR2B and NF-κB p65 levels and anesthetic doses of ketamine further regulated the Bmal1/NMDA/NF-κB axis. In Bmal1-KO mice, the NMDA/NF-κB axis was activated, the release of inflammatory cytokines was promoted, and hippocampus-dependent memory was impaired, which were reversed by a subanesthetic dose of ketamine. Conclusion: Altogether, findings obtained in our study indicated that a subanesthetic dose of ketamine activated Bmal1, downregulated the NMDA/NF-κB axis, and reduced inflammation and microglia activation to alleviate PND in aged mice undergoing PH.

Outcomes of Central Hepatectomy for Pediatric Liver Tumors

Central hepatectomy (CH) is an uncommon surgical technique that is an option for resection of centrally located tumors, with the advantage of sparing normal hepatic parenchyma. Few studies have described outcomes in children undergoing CH. An IRB-approved, retrospective chart review of patients who underwent CH at Children's Hospital Los Angeles between 2005 and 2016 was performed. Data included patient demographics, peri-operative factors, and post-operative outcomes. The IRB approved waiver of consent. Eight patients (4F:4M) with median age of 1.9 Y underwent CH: 7 patients for HB and 1 patient for focal nodular hyperplasia. Two of the seven HB patients had metastatic disease at diagnosis. Six of the seven HB patients received a median of 4 rounds (3-7 rounds) of pre-operative chemotherapy. The median operative time was 197.5 Min (143-394 Min) with median blood loss of 175 mL (100-1200 mL). Complications included a bile fluid collection requiring aspiration. Seven patients had negative margins on pathology. One patient with a positive margin successfully completed therapy, without recurrent disease. All patients survived to follow-up, with a median follow-up duration of 1.1 Y (0.1-12.1 Y). Two patients developed recurrent disease requiring formal hepatic lobectomy and orthotopic liver transplantation. These patients had negative pathologic margins, with tumor within 1 mm of resection margins. CH is an effective alternative to extended hepatectomy for patients with centrally located liver tumors and is associated with good clinical and pathologic outcomes.

Polycystic liver disease with lethal abdominal wall rupture: a case report

BackgroundPolycystic liver disease is a clinical feature of autosomal dominant polycystic kidney disease, and it can sometimes cause health damage more serious than polycystic kidney. Dialysis therapy can be used for renal failure, but liver transplantation is the only method available for liver failure. Thus, giant and multiple hepatic cysts may affect mortality. However, liver transplantation is not indicated in many cases because of the preserved liver function.Case presentationA 54-year-old Japanese woman with polycystic liver disease was transferred back to our hospital for abdominal pain caused by liver cyst infection with abdominal wall herniation. She had been diagnosed with polycystic liver disease associated with sporadic autosomal dominant polycystic kidney disease 25 years earlier. Although she had several surgical interventions to reduce her liver volume, including right hepatic lobectomy and fenestration for liver cysts in another hospital, she needed further repair of the recurrent incisional herniation with patch graft surgery using fascia lata to cover the herniation site. However, new herniation sites reemerged in the fragile abdominal wall area around the patch, and therefore, she reduced the recurrent abdominal wall herniation by herself. Recurrent intestinal obstructions were luckily released by fasting with decompression treatment via nasogastric tube insertion, but multiple skin ulcers around the enlarged hernia sac gradually developed, and ascites was extremely difficult to control with any medication. At final admission, her abdominal wall was even more prominent, causing shortness of breath, and it spontaneously ruptured many times, which was accompanied by discharge of around 5 liters of ascites each time. She died from sepsis caused by drug-resistant Enterococcus.ConclusionsWe report a case of autosomal dominant polycystic kidney disease with ruptured abdominal wall resulting from a hepatic cyst enlargement despite multiple laparotomy operations. Throughout the entire disease course, her liver volume increased rapidly, and her quality of life was severely impaired, but she could not undergo liver transplantation after readmission to our hospital. We will discuss the therapeutic strategy for this patient, including the timing and indication for liver transplantation.

Laparoscopic major (&gt; 2 segments) hepatectomy in Greece

Despite gaining traction around the world, laparoscopic approach to major hepatectomy, defined as resection of at least two neighboring hepatic segments, has not been fully adopted in Greece. We sought to describe our growing experience. Data on six patients who underwent major hepatic resection in the last year in two major urban hospitals. The predominant indication for hepatectomy in these patients were metastatic disease to the liver. Three patients had colorectal metastases, one patient had metastatic melanoma, and two patients had benign pathology. There were two males and four females, with an average age of 59 (range: 52-71 years). Four patients had a solitary lesion and two had two lesions. Four patients had received pre-hepatectomy disease-specific chemotherapy or immunotherapy. The median size of the lesion was 5 cm (range: 3.5-12 cm). Two patients underwent a right hepatic lobectomy, one a left hepatic lobectomy together with a right colectomy, and three patients underwent right anterior sectorectomy. All operations were done purely laparoscopic except one, where a hand port was employed due to the size of the lesion. Median operative time was 190 minutes and median stay at the hospital was 2 nights. No patient required intensive care unit monitoring. There was no 30-day mortality. Major laparoscopic hepatic resection can be accomplished safely in well selected patients in the current Greek health system. Patients who have a laparoscopic hepatectomy benefit from a short hospital stay, without jeopardizing the safety of the operation.

Study of R2* value to evaluate regulation of liver regeneration by hepatic warm ischemia-reperfusion injury after partial hepatectomy in rabbits

Objective: To investigate the effect of R2* value on the evaluation of different degrees of hepatic warm ischemia-reperfusion injury (WIRI) and liver regeneration after partial hepatectomy in rabbits. Methods: Thirty healthy adult male New Zealand White rabbits were randomly divided into five groups. Hepatic caudal lobectomy was performed in both the control and the warm ischemia time-dependent variation group. After reperfusion, routine MRI and BOLD MRI scans were performed for each group at 6 h, 3 d, 7 d, 14 d and 30 d, respectively, and then R2* value and liver regeneration rate (LRR) were measured and calculated. After 30 days of scanning, the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH), malondialdehyde (MDA), superoxide dismutase (SOD), myeloperoxidase (MPO), tumor necrosis factor - α (TNF - α), interleukin-6 (IL-6) and proliferating cell nuclear antigen (PCNA) were detected in frozen rabbit liver tissues, and the pathological sections were collected. Repeated measures analysis of variance was used to evaluate the changes of R2* value, LRR and its influencing factors at different follow-up time and warm ischemia time in each group. Pearson's or Spearman's correlation analysis was used to evaluate the correlation of R2* value with LRR and various biochemical indexes. Results: The interaction between different follow-up time and warm ischemia time (F = 24.600, P < 0.001) and the single effect of the both on the R2* value had statistically significant difference (P < 0.05). The interaction of different follow-up time and different warm ischemia time had no effect on LRR, and the difference was not statistically significant (F = 0.925, P = 0.528), but the difference in the main effect of the both on LRR was statistically significant (P < 0.05). At the same follow-up time, except for the 40-min ischemia group, the R2* values ​​were significantly positively correlated with LRR (3, 7, 14, 30 days after operation, r = 0.510, 0.681, 0.612, 0.541 respectively, P < 0.05). At the same warm ischemia time, the R2* value were significantly negatively correlated with LRR (3, 7, 14, 30 and 40 days after operation, r = - 0.800, -0.852, -0.893, -0.648, -0.853, respectively, P < 0.05). There was no correlation between R2 * value and biochemical indexes at 30 days after operation (P > 0.05). Conclusion: The R2* value may be used for noninvasive and quantitative evaluation of microstructural changes of WIRI and affect liver regeneration after partial hepatectomy in rabbits. A certain degree of WIRI (≤30 min) after partial hepatectomy can promote liver regeneration in rabbits. Furthermore, as the warm ischemia time prolongs, the promoting effect becomes more pronounced, and if the warm ischemic time exceeds 30 minutes, the promoting effect is significantly reduced.

A case of resected hepatocellular carcinoma with gallbladder metastasis

BackgroundAdvanced hepatocellular carcinoma (HCC) can often spread as intrahepatic metastases. Extrahepatic metastasis (e.g., lung, lymph nodes, and bones) is rare, and gallbladder metastasis from HCC is extremely rare.Case presentationA 66-year-old woman who presented with right hypochondrial pain was referred to our hospital for further examination of a liver tumor. The blood chemistry data showed elevated levels of serum α-fetoprotein (AFP) (3730 ng/mL), protein induced by vitamin K absence or antagonist II (PIVKA-II) (130 mAU/mL), and carcinoembryonic antigen (CEA) (358.6 ng/mL). Hepatitis B surface antigen and hepatitis C virus antibody were negative. Dynamic computed tomography (CT) showed a tumor measuring 12 × 7 cm in the right lobe of the liver. This tumor was contrast-enhanced in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase. A well-enhanced tumor was found in the gallbladder. No regional lymph nodes were enlarged. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated that the liver tumor showed a pattern of early enhancement and washout. The gallbladder tumor was also detected as an enhanced mass. Endoscopic retrograde cholangiography (ERC) showed compression of the left hepatic duct due to the liver tumor. The patient was diagnosed with simultaneous HCC and gallbladder cancer. Right hepatic trisectionectomy and caudate lobectomy with extrahepatic bile duct resection were performed. Histopathological examination of the resected liver specimen showed a poorly differentiated HCC cell component with a trabecular and solid growth, and diffuse invasion of the portal vein. The same tumor cells were found in the gallbladder, but no continuity with the liver tumor was identified. Immunohistochemistry of the liver tumor and gallbladder was positive for AFP, Glypican 3, and CK7, and negative for CK19. The final pathological diagnosis was the gallbladder metastasis from HCC. A follow-up diagnostic image 33 months after surgery showed a mass in the upper lobe of the left lung. The patient underwent left upper lobectomy. Postoperative pathology revealed that the lung lesion was a metastasis of HCC. The patient was still alive with lung metastasis and was being treated with a molecular-targeting drug in good health 42 months after the initial surgery.ConclusionsThe standard treatment for advanced HCC with extrahepatic metastases is molecularly targeted drugs, but surgery is also an option if the lesion can be resected en bloc without remnants.

Clinical characteristics and surgical treatments of primary hepatic angiosarcoma

PurposePrimary hepatic angiosarcoma is a very rare and highly malignant tumor with poor prognosis. It is difficult to diagnose because of the lack of typical clinical features, and the treatment protocols for PHA are also not clear. Therefore, this study wants to find out the clinical characteristics and surgical treatments of primary hepatic angiosarcoma.MethodsAmong 8990 patients diagnosed with primary malignant tumor of the liver from January 2000 to December 2019 in our hospital, only four patients were diagnosed with primary hepatic angiosarcoma. The demographics, clinical manifestation, past history, serology test results, MRI features, pathology, treatment modality and prognosis of four patients were collected and analyzed.ResultsThree of four patients had no clinical symptoms, while one patient's symptom was abdominal pain. The levels of tumor markers of all four patients were within the normal reference range and serological tests were negative for hepatitis B and C virus. The MRI imaging findings of all four patients were mixed mass with highly disordered vascular characteristics. All four patients were misdiagnosed preoperatively. One patient who underwent hepatic lobectomy was still alive for about 18 months after surgery. One patient who underwent hepatic lobectomy has survived for only 6 months due to severe pneumonia. The other two patients who received transarterial chemoembolization survived 16 months and 11 months respectively.ConclusionThe clinical symptoms of primary hepatic angiosarcoma are not typical, and primary hepatic angiosarcoma is easily misdiagnosed. The typical imaging manifestations are structural disorder and heterogeneous tumor. Hepatic lobectomy and transarterial chemoembolization may be important surgical treatments to improve the prognosis of patients.

A225 INFERIOR VENA CAVA STENOSIS AFTER HEPATIC LOBECTOMY: A RARE CAUSE OF PORTAL HYPERTENSION AND REFRACTORY ASCITES

Abstract Background Inferior vena cava (IVC) stenosis is a rare occurrence in post-liver transplant patients, affecting less than 3% of recipients. IVC stenosis is rarely described in non-transplant patients or considered in the differential of portal hypertension and refractory ascites. Patients with IVC stenosis may experience lower extremity edema, dyspnea, ascites and other signs of portal hypertension. Aims We describe a case of portal hypertension and refractory ascites secondary to IVC stenosis following hepatic lobectomy. Methods Case report. Results We report a 61-year-old woman with a history of diabetes, obesity status post sleeve gastrectomy and solitary neuroendocrine tumor of the right hepatic lobe, adjacent to the porta hepatis with no evidence of metastasis. She underwent a laparoscopic right hepatectomy with wedge resection (&amp;lt;5 cm) in segment 4 to remove the neuroendocrine tumor in 2016. Surgery also included an intraoperative cholangiogram and placement of intra-ductal stent using endoscopic retrograde cholangiopancreatography (ERCP) technology as well as significant adhesiolysis along the IVC, right hepatic vein and biliary tract. In February 2020, the patient was referred to Hepatology for evaluation of new ascites. Imaging did not demonstrate evidence of tumor recurrence or features of cirrhosis but identified a new findings of portal hypertension and moderate ascites. Common causes of chronic liver disease were excluded and hepatic synthetic function was normal. Paracentesis revealed a high serum albumin ascites gradient (SAAG; 20 g/L) and a high ascitic fluid protein (34 g/L). Although these findings were suggestive of cardiac ascites, a 2D echocardiogram was normal. A trans-jugular liver biopsy was attempted in July 2020. The right atrial pressure was 8 mmHg and inferior vena cava (IVC) pressure was 22 mmHg at the level of the liver. Loss of pulsation suggested hemodynamically significant stenosis of the hepatic IVC. The wedged hepatic venous pressure was 3 mmHg and the calculated portal systemic gradient was 4 mmHg. A trans jugular biopsy failed due to unfavourable anatomy. These findings, taken in conjunction with previous results, suggested non-cirrhotic post-hepatic portal hypertension. Subsequent computed tomography imaging confirmed stenosis of the hepatic portion of the IVC and this was felt to be the ultimate cause of the portal hypertension. She has since been referred back to interventional radiology (IR) for consideration of balloon angioplasty dilation of the IVC stenosis as well as additional testing to determine if there is any underlying hepatic fibrosis related to congestive hepatopathy. Conclusions IVC stenosis post hepatic lobectomy is a rare phenomenon described in the literature but warrants high suspicion in cases of refractory ascites. Funding Agencies None

Spontaneous intracapsular hemorrhage of a giant hepatic cavernous hemangioma: a rare case report and literature review

BackgroundHepatic cavernous hemangioma is the most common type of benign liver tumor. Although ruptures and hemorrhages of hepatic hemangioma are rare complications, they are associated with high mortality. Most practitioners only pay more attention to abdominal hemorrhages caused by the rupture of hepatic hemangiomas. However, spontaneous intracapsular hemorrhages can often be neglected and poorly understood.Case presentationA 65-year-old man was referred to our institution with right upper quadrant pain, which had occurred suddenly and without a history of recent trauma. The blood test results were normal. Magnetic resonance imaging (MRI) of the abdomen showed a cystic mass in the right liver lobe. Considering the possibility of hepatic cystadenoma with hemorrhage, the patient underwent a right hepatic lobectomy. The pathological findings unexpectedly revealed intratumoral hemorrhage of hepatic hemangioma. The patient recovered well and was discharged eight days after surgery.ConclusionsIntracapsular hemorrhage of hepatic cavernous hemangioma is challenging to diagnose and has a high potential risk of rupture. MRI is beneficial for diagnosing subacute internal hemorrhage cases, and it is recommended to undergo surgery for patients with a definitive diagnosis.

Anesthesia in hepatobiliary disorders

Multiple factors have led to an increased incidence of hepatobiliary disease across the continents, and with it we witness an increased number of patients, who report for surgery for a hepatobiliary disease, e.g. hepatic lobectomy, cholecystectomy, corrective surgery on bile ducts and even liver transplantation, or they report for surgery for an unrelated disease but with a concurrent hepatobiliary disease. These patients require special considerations during perioperative period. Please select the one best option in each of the following questions.&#x0D;

Laparoscopic left hemihepatectomy combined with right lateral hepatic lobectomy in pigs: surgical approach and comparative study of the inflammatory response versus open surgery.

This study describes a left hemihepatectomy combined with a right lateral hepatic lobectomy. It compares the inflammatory response associated with laparoscopic hepatectomy (LH group, n = 7) with conventional open hepatectomy (OH group, n = 7). Blood was collected before surgery as well as 1, 2, 3, 5, and 7 days after surgery to determine the white blood cell count and levels of serum cortisol (COR), interleukin-6 (IL-6), and C-reactive protein (CRP). The left hemi-hepatectomy combined with a right lateral hepatic lobectomy was completed in miniature pigs. The average operative time was 139.00 ± 9.07 min, which was longer than that in the OH group (121.67 ± 3.02 min). The length of surgical incision associated with the OH group was 17.93 ± 1.09 cm, significantly longer than that related to the LH group (5.10 ± 0.17 cm). The estimated mean blood loss in the LH group was 136.43 ± 63.24 mL, which was significantly lower than that in the OH group. No severe complications (e.g., massive bleeding, bile leakage, and air embolism) were reported. The CRP levels, COR, and IL-6, increased significantly in the OH group and then slowly returned to their preoperative levels. A postoperative laparoscopic exploration revealed that the incised portion of the liver adhered to the omentum, but no additional abnormalities were observed. These findings indicate that a 4-trocar method for laparoscopic left hemihepatectomy combined with a right lateral hepatic lobectomy is safe and feasible. The inflammatory response for those receiving LH are lower than that for those receiving OH. This porcine model can be used as a research analog for liver disease and regeneration.