Hepatoduodenal Ligament Research Articles

Safety assessment of dextrin hydrogel adhesion barrier (AdSpray®) for elective laparoscopic cholecystectomy

ObjectiveAdhesion barriers have not traditionally been used during laparoscopic cholecystectomy (lap-chole), and so there are no data confirming the safety of the dextrin hydrogel adhesion barrier (AdSpray®) for the use during lap-chole. The aim of this prospective study is to investigate the safety of AdSpray® for elective lap-chole. MethodsBetween July 2019 and March 2021, we conducted a prospective study at Saiseikai Kumamoto Hospital to assess the safety of applying AdSpray® around the hepatoduodenal ligament, liver surface, and port area after extraction of the gallbladder during elective lap-chole. We assessed patient morbidity, mortality, and laboratory data on postoperative day 1 and at the outpatient follow-up visit. ResultsA total of 100 patients (43 men, 57 women) received AdSpray® application during elective lap-chole at our institution. The mean patient age was 56.5 ± 14.8 y, and the mean body mass index was 25.1 ± 4.8 kg/m2. Preoperative gallbladder drainage was performed in 3 (3.0%) patients as conservative treatment for acute cholecystitis. The mean operative time was 91.7 ± 35.1 min, and the median blood loss was 5 mL (range, 5–120 mL). Intraoperative gallbladder perforation was observed in 4.0% of patients (n = 4). There was no intraoperative bile duct injury. One (1.0%) patient had a postoperative subhepatic fluid collection without bacterial infection. The mean white blood cell count and C-reactive protein level was significantly elevated on postoperative day 1 but returned to preoperative levels by the time of the follow-up visit. All patients were successfully discharged after surgery, and the median postoperative hospital stay was 2 d (range, 2–9 d). ConclusionApplying AdSpray® during elective lap-chole is safe, with an acceptable rate of postoperative complications.

IGG4-related Sclerosing Cholangitis Mimicking Cholangiocarcinoma: A Case Report

Introduction: IgG4-related sclerosing cholangitis may have variable clinical presentations and may sometimes mimic cholangiocarcinoma. We present a case of a 42-year-old male with IgG4-related sclerosing cholangitis who was initially diagnosed as cholangiocarcinoma. Case report: A 42-year-old gentleman presented with history of progressive jaundice for one month associated with generalized weakness and loss of appetite. His total and direct bilirubin were 5.7 and 4.8 mg/dl, respectively, with an ALP of 1570 U/L. CECT revealed an ill-defined soft tissue enhancing component infiltrating the lumen of the common hepatic duct, distal cystic duct, and proximal common bile duct. In addition, the MRCP of the patient showed an ill-defined lesion around the gall-bladder neck that was effacing a part of the distal cystic duct and a long segment of common hepatic duct suspicious of cholangiocarcinoma. With a provisional diagnosis of cholangiocarcinoma, the patient was subjected to diagnostic laparoscopy, which revealed scirrhous tissue encasing the proper hepatic artery and portal vein and prominent lymph nodes around the hepatoduodenal ligament. There were no ascites or evidence of peritoneal metastasis. Biopsy of the lesion revealed inflammatory cells comprising of lymphocytes, plasma cells, and eosinophils; there were no atypical or malignant cells. IgG-4 marker was positive and immuno-reactive in 5-6% of plasma cells. The patient’s symptoms were completely relieved after three months of steroid therapy. Conclusion: IgG4 -related sclerosing cholangitis can mimic cholangiocarcinoma. Although the disease is rare and its diagnosis remains challenging, knowledge of the disease is valuable when considering the differential diagnosis of obstructive jaundice.

Laparoscopic Liver Resection with Hilar Lymphadenectomy for the Patients with Intrahepatic Cholangiocarcinoma

Introduction: Hepatectomy concomitant with lymph node dissection of the hepatoduodenal ligament (HDL) for the patients with intrahepatic cholangiocarcinoma not requiring extrahepatic bile duct resection is rarely performed under laparoscopic approach. In our institute, we utilized a laparoscopic approach for two cases.

Analysis of patients with acute liver failure after liver surgery: Single center experience

Liver transplantation is the lifesaving treatment option for rare acute liver failure that develops due to iatrogenic bile duct injuries or after major hepatectomy. The aim of the study is to analyze patients with acute liver failure due to iatrogenic bile duct injury or major hepatectomy on the waiting list for emergency liver transplantation. Between the years 2011-2020, 9 patients (5 female/4 male; median age: 30 years old, (range:4-63 years)) with acute liver failure related to bile duct injury or major hepatectomy for whom urgent liver transplantation was planned were included in this study. Eight patients were accepted for urgent liver transplantation. Acute liver failure developed in 6 patients due to hepatoduodenal ligament injury during cholecystectomy, and in 3 patients due to major hepatectomy. The patients were listed for urgent transplantation within the mean of 1.5 days (range:0-3 days) after acute liver failure. Two patients had living donor and 1 patient had cadaveric liver transplantation. Acute hepatic failure, especially after iatrogenic bile duct injuries associated with vascular injuries, seems to be more fatal than post hepatectomy liver failure. In these cases of acute liver failure, which is a difficult situation to decide, emergency liver transplantation should be kept in mind as the treatment option.

Ultrasound manifestations of acute viral hepatitis a in children

26 children with HAV (12 boys and 14 girls) - mean age 13.2 ± 3.3 years and 21 children (8 boys and 13 girls) - mean age 14.3 ± 2.6 years were examined. In all cases, clinical laboratory examination, determined the level of ALT, AST, alkaline phosphatase. Ultrasound was performed on ultrasound systems Aplio 500 and MyLab Twice. Clinical manifestations of HAV consisted of anorexia (70%), nausea and vomiting (66%), fever (80%), jaundice (85%), dark urine (85%), upper abdominal pain (20%). The following echographic changes were determined: hepatomegaly and reduction of decreased echogenicity by 88.5%,reduced gallbladder 92%, thickening of the gallbladder wall 85%, double contour of the gallbladder wall 46%, increase in lymph node size: in the hepatoduodenal ligament 46% and mesenteric 73%, splenomegaly in 100% Ultrasound examination of the abdominal should be performed in all patients with clinical suspicion of acute viral hepatitis A and jaundice. Abdominal ultrasound examination is an important additional tool for monitoring the dynamics of HAV.

Intrahepatic Pancreatic Pseudocysts: A Review of Recent Literature and Case Report

Intrahepatic pancreatic pseudocysts (IHPP) are a rare clinical entity which results from migration of amylase rich proteolytic pancreatic fluid along hepatogastric or hepatoduodenal ligaments into the hepatic parenchyma. There are no current management guidelines, and definitive management depends on varying features within each individual case. We report a rare case presenting with features of acute gastric outlet obstruction on a background of chronic pancreatitis. The rapid formation of this IHPP does not appear to have been previously reported in the literature.

A case of pancreaticoduodenectomy and partial hepatic resection as repeat cytoreductive surgery for recurrent pseudomyxoma peritonei

BackgroundFor recurrent pseudomyxoma peritonei (PMP), repeat cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can provide survival benefits if patients are carefully selected. We describe a case of pancreaticoduodenectomy and partial liver resection (HPD) as the repeat CRS for a recurrent tumor that infiltrated the pancreatic head around the hepatic hilum. This is the first report of HPD for recurrent PMP.Case presentationThe patient was a 58-year-old male without comorbidities. In 2001, he was diagnosed with PMP at the time of laparoscopic cholecystectomy. In 2004, CRS, including total peritoneal resection, pyloric gastrectomy, splenectomy, and right hemicolectomy with HIPEC was performed (peritoneal cancer index (PCI) = 28). In 2008, the first repeat CRS with HIPEC was performed (PCI = 14). In 2016, fourth repeat CRS, including partial hepatectomy with HIPEC for recurrence of the round ligament of the liver, was performed. In 2017, a tumor of 5 cm in size was observed from the hepatic hilum to the pancreatic head, which infiltrated the main pancreatic duct. Other tumors 2 cm in size were observed (PCI = 7). We performed the fifth repeat CRS, including HPD. The adhesions of the small intestine from around the liver to the lower abdomen were detached for the reconstruction of pancreatojejunostomy and cholangiojejunostomy. The uncinate approach was applied for the pancreatic head resection because it was difficult to identify the cranial part of the pancreas due to adhesions in the hepatoduodenal ligament and the omental bursa. We approached to the origin of the extrahepatic Glissonean pedicle by resecting a part of the liver around the hepatic hilum using transhepatic hilar approach. A complete cytoreduction was achieved. The postoperative pathological diagnosis was a recurrence of PMP, which is equivalent to peritoneal mucinous carcinomatosis. He was discharged on the 22nd postoperative day without major postoperative complications. The patient survived without recurrence four years after HPD.ConclusionsEven for recurrence around the hepatic hilum and the pancreatic head, repeat CRS can be safely performed by applying the techniques of hepatobiliary pancreatic surgery.

Multidisciplinary surgical approach for renal cell carcinoma with inferior vena cava tumor thrombus.

The optimal surgical management of renal cell carcinoma with tumor thrombus within the inferior vena cava (IVC) remains to be clarified. Sixteen consecutive cases were reviewed. Incision, the IVC clamping position, and the venous drainage procedure were modified according to the tumor thrombus extension level: level I or II (below the hepatic vein, n = 8), level III (above the hepatic vein but below the right atrium, n = 5), and level IV (extending into the right atrium, n = 3). For level I or II, resection could be simply achieved by clamping the IVC below the hepatic vein, without hemodynamic collapse. For level III, clamping the IVC above the hepatic vein and the hepatoduodenal ligament was required. Venous drainage from the lower body (cannulation to distal IVC) and portal system (cannulation to ileocolic vein) were applied. When opening the IVC, the significant backflow was controlled using cardiopulmonary bypass with drop-in suckers. For level IV, median sternotomy, exposure of the right atrium, and cardiopulmonary bypass were mandatory. With the combination of these approaches, the perioperative mortality rate was 0% and the 5-year overall survival rate was 52%. A multidisciplinary surgical approach is essential, especially for level III and IV cases.

A RARE CASE OF MUCINOUS CYSTADENOCARCINOMA OF LIVER PRESENTING AS HYDATID CYST

Hepatobiliary cystadenocarcinoma is a very rare cystic tumor that arises in the liver or, less frequently, in the extrahepatic biliary system mostly seen in elderly patients. It has been shown to arise in congenital liver cysts, bile ducts, biliary cystadenoma, in the context of bro- polycystic disease and in the hepatoduodenal ligament. In the present case report, we describe a case of rare entity of hepatobiliary cystadenocarcinoma presented in a 36 year old male patient presented to opd with complaints of pain abdomen in right side of upper abdomen since 2 months. Main concern of this case report is preoperative imaging is imprecise and frequently misdiagnosed as benign cystic lesions and delays in treatment.

Ultrasound Еxamination of the Еxtrahepatic Bile Ducts in Children (Literature Review with our own Clinical Observations)

To study the normal sonographic anatomy of extrahepatic bile ducts, a polypositional ultrasound examination of 120 children aged 0 to 17 years was conducted. The technique of hepatoduodenal ligament ultrasound examination is described. The main sonographic visual indicators for studying the anatomical and topographic structure of extrahepatic bile ducts in children are denoted. The normative parameters of the common bile and common hepatic ducts in children of different age groups are presented.

Comparison of Ultrasound Guided Transversus Abdominis Plane Block versus Intraperitoneal and Perioportal Bupivacaine Infiltration in Post Operative Analgesia after Laparoscopic Cholecystectomy

Abstract Background Laparoscopic cholecystectomy is one of the commonest elective laparoscopic surgeries done in our setup. We found that post-surgery most of the patients complain of incisional pain at port sites and right shoulder tip pain. Objectives The aim of this study has been to test the efficacy of TAP block versus intraperitoneal and periportal infilteration with local anesthetic agent specially to provide postoperative analgesia after laparoscopic cholecystectomy. Patients and Methods All patients were informed with the procedure US guided TAP block and were trained to use the visual analogue scale (VAS). The study was conducted on 50 randomly chosen patients aged 20 to 60 years, American Society of Anesthesiologists (ASA) class I or II scheduled for elective laparoscopic cholecystectomy in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 25 patients each: TAP block Group: received general anaesthesia and 20 ml of 0.25% bupivacaine on each side by midaxillary approach under ultrasound guidance. Intraperitoneal and periportal infiltration Group: received general anaesthesia and 20 ml of 0.25% bupivacaine was injected under the direct vision into the hepato-diaphragmatic space, near and above the hepato-duodenal ligament and above the gall bladder before removal of the probes, also 20ml of 0.25% bupivacaine was injected at the port sites at the end of operation. Results The Patients receiving TAP block had significantly lower pain scores at rest for 6 hrs and upon coughing for 6 hrs also after operation and decrease total need of analgesic in first 24 h post operative compared with patients who received Intraperitoneal and periportal infiltration. Conclusion Bilateral TAP block was effective in reducing postoperative pain scores at rest and upon coughing for 6-12 hours and lower total 24-h postoperative opioid and analgesic consumption after laparoscopic cholecystectomy under general anesthesia, compared to intraperitoneal and periportal infiltration. This technique can be a promising mode of postoperative analgesia where epidural catheter insertion is contraindicated.

Safety in Electrosurgery as an Essential Skill in the Training of Surgeons

The analysis of 19 videotapes of laparoscopic cholecystectomy performed by accredited on the virtual simulator "LapSim" during the passage of the station "Planned Surgery" within the framework of primary specialized accreditation in the specialty "Surgery" was carried out. The mistakes made by those accredited in the application of high-energy methods at the stage of isolation of the elements of the hepatoduodenal ligament have been studied. Mistakes when using high-energy methods were made by 14 out of 19 accredited. The importance of training surgeons in the basics of electrosurgical safety is emphasized.

Peritoneal Metastases: Their Associated Imaging Features

Peritoneal Metastases (PM) detection remains a challenge even with modern imaging. Knowing imaging features of abnormal findings frequently associated with PM is of interest to improve PM detection. Although ascites is a common imaging finding of PM, the presence of ascites alone, even in patients with known cancer, is not enough to diagnose PM. The peritoneum should be read as an own organ with careful analysis of the ligament (e.g. falciform and hepatoduodenal ligament), the mesos and the omenta. Indirect manifestations of visceral peritoneal involvement is a segment of small bowel fixed to the parietal peritoneum, the appearance of blockage of free circulation of ascites, plurisegmental bowel obstruction and clumped bowel that is a strong predictor of diffuse involvement of the visceral peritoneum by a high grade tumor. Ovarian and umbilical metastases are frequently associated with PM in particular in digestive cancers. Moreover, ovarian metastases has been shown to be less responsive to chemotherapy than other metastases and should not be chosen as a target lesion for RECIST assessment. The presence of cardiophrenic angle lymph nodes also increases the possibility of metastatic spread in peritoneum. Finally, the most common PM mimickers include colonic diverticulum, mesenteric lymph nodes, splenosis implants, fat necrosis and postoperative changes after cytoreductive surgery and HIPEC.

Laparoscopic resection of schwannoma in the hepatoduodenal ligament: a case report

BackgroundThe occurrence of schwannomas in the hepatoduodenal ligament is rare, and its preoperative accurate diagnosis is difficult. Only few cases have been treated with laparoscopic surgery.Case presentationA 54-year-old man visited our hospital following abnormal abdominal computed tomography findings. He had no complaints, and his laboratory investigations were normal. Abdominal contrast-enhanced computed tomography revealed a tumor with enhancement at the margin of the hepatoduodenal ligament. The abdominal magnetic resonance imaging findings of the tumor showed hypointensity on the T1-weighted images and mixed hypointensity and hyperintensity on the T2-weighted fat-suppression images. Positron emission tomography showed localized accumulation of fludeoxyglucose only in the hepatoduodenal ligament tumor. The patient underwent laparoscopic tumor resection for accurate diagnosis. Histopathologically, the tumor was mainly composed of spindle cells, which were strongly positive for S-100 protein on immunohistochemical staining. The patient was discharged without any postoperative complications on day 5.ConclusionsComplete tumor resection is essential for schwannomas to avoid recurrence. Laparoscopic surgery is useful for schwannomas occurring in the hepatoduodenal ligament and can be performed safely by devising an appropriate surgical method.

Technique and short-term outcomes of surgical treatment in patients with renal cell carcinoma and tumor venous thrombosis: experience of the Urology Clinic, N.N. Blokhin National Medical Research Center of Oncology

Objective: to describe the technique of nephrectomy and thrombectomy used in patients with renal cell carcinoma (RCC) and tumor venous thrombosis of various levels, and to identify risk factors of in-hospital death among operated patients.Materials and methods. This study included 768 patients with RCC and tumor venous thrombosis who have undergone surgical treatment. Median age was 58 years (range: 16-82 years); the male to female ratio was 2.3:1. The symptoms of venous tumor thrombosis were identified in 199 patients (25.9 %). In the majority of patients (n = 509; 66.3 %), the tumor thrombus originated from the right renal vein. The cranial border of the tumor thrombus was located in the perirenal inferior vena cava (IVC) in 219 patients (28.5 %), subhepatic IVC in 201 patients (26.2 %), intrahepatic IVC in 171 patients (22.3 %), and above the diaphragm in 177 patients (23.0 %). We used an individual approach to choose an optimal method of vascular control and to identify indications for circulatory support. Two-thirds of patients (n = 512; 66.7 %) underwent temporary block of the second renal vein; 268 patients (34.9 %) - temporary block of the hepatoduodenal ligament and right heart; 11 patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 190 ± 63.6 min; median blood loss was 3,000 ± 71.6 mL (≥50 % of circulating blood in 35.1 % of patients). Intraoperative complications were registered in 23 patients (3.0 %); eight patients (1.0 %) died during surgery with 4 of them died due to pulmonary embolism (0.5 %), 3 died due to hemorrhagic shock (0.4 %), and 1 died due to myocardial infarction (0.1 %). One hundred and ninety individuals (25.0 %) developed postoperative complications with Clavien-Dindo grade III-V complications observed in 115 cases (15.1 %). Forty-one patients (5.3 %) died in the early postoperative period. The causes of death included multiple organ dysfunction (n = 21; 2.8 %), pulmonary embolism (n = 7; 0.9 %), sepsis (n = 6; 0.8 %), stroke (n = 4; 0.5 %), myocardial infarction (n = 2; 0.2 %), and RCC progression (n = 1; 0.1 %). We have identified several independent risk factors for in-hospital mortality, including ascites (hazard ratio (HR) 8.3; 95 % confidence interval (CI) 3.2-21.4; p < 0.0001), preoperative pulmonary embolism (HR 3.5; 95 % CI 1.3-9.4; p = 0.013), supradiaphragmatic thrombi (HR 1.5; 95 % CI 1.1-2.0; p = 0.003). The in-hospital mortality rate was 3.5 % (20/575) among patients with no risk factors, 9.8 % (16/163) among those with 1 risk factor, 40.0 % (10/25) among those with 2 risk factors, and 60.0 % (3/5) among those with 3 risk factors (area under the curve (AUC) 0.705; p <0.0001 for all).Conclusion. The incidence of severe complications and postoperative mortality rate in RCC patients with tumor venous thrombosis who have undergone nephrectomy and thrombectomy were 15.1 and 6.4 %, respectively. Risk factors for perioperative mortality included ascites, preoperative pulmonary embolism, and supradiaphragmatic thrombosis.

DAMAGE TO THE BILE DUCTS AFTER LAPAROSCOPIC CHOLECYSTECTOMY. REVIEW.

This article provides a review of the literature on bile duct injuries after laparoscopic cholecystectomy. Laparascopy is considered the gold standard in the treatment of gallstone disease. This technique has a number of positive advantages: minimally invasiveness, quick rehabilitation, a shorter hospital stay, a good cosmetic effect, and a low lethal outcome. Along with these advantages, the number of complications also increased: damage to the bile ducts, hepatic vessels, bile leakage, formation of strictures, defects in drainage of the biliary tract and improper treatment of the cystic duct, insufficient drainage of the abdominal cavity. Today, many aspects of surgical treatment and prevention of bile duct injuries remain controversial and are still considered relevant. The main reasons for this complication are: lack of experience of the surgeon, inattention, ignorance of the main options and possible anomalies of important anatomical structures in the area of the hepatic hilum and hepato-duodenal ligament, technical errors.

Comparisons of survival outcomes of T2 intracholecystic papillary neoplasm of the gallbladder according to the surgical extent: Simple cholecystectomy vs. extended cholecystectomy

Extended cholecystectomy (EC) has been considered as the standard surgery of T2 gallbladder (GB) cancer. However, little is known an appropriate surgical strategy for intracholecystic papillary neoplasm (ICPN) of the GB, especially for the invasive ICPN. This study conducted to investigate clinicopathologic characteristics of T2 ICPN and compare the survival outcomes according to the surgical extent. This was a retrospective cohort study. Between 2003 and 2018, patients who underwent curative-intent simple cholecystectomy (SC) or EC were included. EC was defined as liver wedge resection with at least 2-cm margin from the GB and lymphadenectomy around hepatoduodenal ligament. Preoperative patients' demographics and pathologic data were investigated. Of total 96 patients with T2 ICPN, 29 (30.2%) and 67 (69.8%) patients underwent SC and EC, respectively. Age at surgery was older in SC than EC group (73.0 vs. 65.4 years, p = 0.002). Overall, EC group showed better survival outcome than SC group (5-year overall survival [5YSR], 83.3% vs. 49.8%, p = 0.001). However, statistical significance was not shown in patients with age ≥ 75 years (5YSR, EC 67.7% vs. SC 35.6%, p = 0.606). In a multivariate analysis, older age (≥ 75 years, HR 3.03; p = 0.009), higher preoperative CA 19-9 level (≥ 37 IU/mL; p = 0.001), histologic differentiation (moderate, HR 2.47; p = 0037), and surgical extent (SC, HR 2.58; p = 0.022) were independent risk factors for worse survival outcome in T2 ICPN. Systemic recurrence was more frequently in SC group (31.0% vs. 7.5%; p = 0.003). Similar to the T2 GB cancer, EC should be the standard surgical extent of T2 ICPN.

Caudate lobe abscess: Challenging site with less invasive option of treatment: A case series

The rarity of caudate lobe abscess has made it difficult to outline a treatment algorithm for this pathology due to its anatomically challenging site. Caudate lobe abscesses also poses a risk of rupture, making its management more complicated. However, advances in imaging have made it possible for early detection and paradigm shift in its management from open surgery to non-operative intervention. All patients with isolated caudate lobe abscess were selected retrospectively and diagnosis was confirmed by imaging. Patient in this case series underwent either percutaneous or endoscopic drainage and empirical antibiotic therapy alone. There are 5 patients in this case series, 3 of them underwent percutaneous drainage, 1 of them treated with antibiotic alone and another underwent endoscopic ultrasound (EUS)-guided drainage. All patients showed complete resolution of caudate lobe abscess without procedural complications. The caudate lobe, which lies posterior to the hepatoduodenal ligament and anterior to the inferior vena cava exposes the patient to possible life-threatening complications when subjected to drainage via a percutaneous approach. EUS allows not only identification of intervening vessels which is the major reason for technical difficulty in percutaneous drainage, but excellent visualization of abscess cavities and the surrounding landmarks. In conclusion, non-surgical approach is our treatment of choice in management of caudate lobe liver abscess.

Proteins of allogeneic hepatocytes and pharmacological preparations for the correction of immunometabolic disorders in experimental liver pathology

Introduction: The relationship of numerous metabolic shifts, disorders of hepatocytes functional activity resulting from hypoxia and toxic liver damage with the function of the immune system has not been sufficiently studied so far, nor have the most effective methods of pharmacological correction been established.
 Materials and Methods: The studies were carried out on 603 mature male Wistar rats and 45 mice. Acute toxic liver damage (ATLD) was modeled by intramuscular introduction of carbon tetrachloride; acute liver ischemia (ALI) was caused by clamping the hepatoduodenal ligament for 20 minutes; chronic alcohol intoxication (CAI) was modeled by forced intragastric administration of 20% ethanol solution for 60 days. Isolation of xenogeneic (murine) and allogeneic (rat) hepatocytes from newborn mice and rats was carried out according to the method of Berry and Friend (1969); culture fluid of hepatocytes and its protein fractions were prepared according to our developed techniques. The obtained biological material was intraperitoneally introduced into the rats with ATLD, ALI, and CAI.
 Results and Discussion: In all the models of the liver damage, there developed morphological and biochemical signs of the liver damage, impaired congenital and adaptive immunity, oxidative stress, increased lipid peroxidation processes.
 Conclusion: The introduction of allogeneic hepatocytes, culture fluid obtained on their basis,and proteins isolated from it with MW less than 130 kDa to the recipients with toxic and ischemic liver damage more effectively corrects the pathologic changes in the liver in comparison with xenogeneic hepatocytes, their culture fluid and pharmacological preparations (combinations of Essentiale N and Hypoxenum or Heptral and Mexicor).

Extent of Lymph Node Dissection for Accurate Staging in Intrahepatic Cholangiocarcinoma

BackgroundAlthough lymph node metastasis is a known factor predictive of a poor prognosis after radical surgery for intrahepatic cholangiocarcinoma (ICC), few studies have investigated lymph node dissection (LND) areas for accurate staging. The aim of this study was to identify the optimal LND level for ICC considering lymphatic flow. MethodsClinical characteristics and pathologic nodal status (presence of metastasis) for 163 patients were reviewed according to tumor location. In the node-positive (N1) group, the distribution of metastatic nodes was described. The coverage of metastatic nodes according to dissection level was assessed, and the minimum dissection level for accurate ICC staging was estimated accordingly. For validation, the node-negative (N0) group was divided into two subgroups according to the estimated dissection level, and survival outcomes were compared. ResultsIn the N1 group, expanding dissection to stations no. 12 and 8 covered 82.0% (n = 50) of metastatic cases regardless of tumor location. In survival analysis of N0 group, patients who underwent LND covering stations no. 8+12 showed better disease-free survival (DFS) and overall survival (OS), although the differences were not statistically significant (DFS: covering no. 12+8 vs. not covering no. 12+8, 109.0 months [24.2–193.8] vs. 33.0 months [10.3–55.7], p = 0.078; OS: covering no. 12+8 vs. not covering no. 12+8, 180.0 months [21.6–338.4] vs. 73.0 months [42.8–103.2], p = 0.080). ConclusionLND including at least stations no. 12 (hepatoduodenal ligament) and 8 (common hepatic artery), regardless of tumor location, is recommended for accurate staging in ICC patients.