Precise Hepatectomy Research Articles

Safety and efficacy of precision hepatectomy in the treatment of primary liver cancer

BackgroundThe aim of this study was to investigate the safety and efficacy of precision hepatectomy in the treatment of primary liver cancer.MethodsAn randomized controlled trial of 98 patients with primary liver cancer admitted to our hospital from February 2020 to February 2021 were analyzed for the study, and they were divided into 49 cases each in the control group (conventional hepatectomy) and the study group (precision hepatectomy) according to the different surgical methods. The surgical condition, complications and follow-up results of the two groups were counted, and the liver function and immune function of the two groups were observed before and 1 week after surgery.ResultsThe operation time, intraoperative bleeding, hospitalization time and anal venting time in the study group were less than those in the control group (P < 0.05). One week after surgery, AST, TBiL, ALT and ALB levels decreased, with in the study group significantly higher than those in the control group (P < 0.05); CD4+, CD3 + and CD4+/CD8 + levels were significantly higher in the study group (P < 0.05). The incidence of complications in the study group was significantly lower than that in the control group (P < 0.05). After 2 years of follow-up, the recurrence rate and mortality rate of the study group were lower than those of the control group (P < 0.05); the difference was not statistically significant when comparing the metastasis rate between the two groups (P > 0.05).ConclusionPrecision hepatectomy can effectively treat primary liver cancer with high safety and could be promoted in clinical practice.

Fluorescence-Guided Robotic Segment 8 Superior Liver Resection. Technical Approach to Sectoral Inflow Occlusion.

In the past decade, precision hepatectomy which requires the understanding of segmental and subsegmental liver anatomy has gained popularity due to its parenchymal-sparing benefits. The importance of this concept has led liver surgeons to a consensus conference and its guideline in regards to precision anatomy in minimally invasive liver resection, held in Tokyo in 2020. A precise control of the sectoral hepatic artery and portal vein allows for a bloodless liver resection, without the use of Pringle maneuver. In the literature, technical description of the right anterior portal pedicle dissection during minimally invasive robotic liver surgery is limited. In this study, we therefore demonstrate such a technique using fluorescence guidance during robotic segment 8 superior liver resection.

Recent Advances in Interventional Fluorescence Imaging: Toward the Precise Visualization of Transarterial Mini-Invasive Delivery Systems

ConspectusInterventional fluorescence imaging has gradually developed into a promising imaging strategy for the diagnosis of diseases in clinic. This strategy could benefit interventional targeted treatment because of the clear display of microstructures at the margins and boundaries. There are some stranded crucial issues in clinical application: (i) fast clearance of fluorescence probes; (ii) light instability and photobleaching; and (iii) residual and microsatellite lesions. The development of superstable homogeneous intermixed formulation technology (SHIFT) can solve the aforementioned clinical problems for precision hepatectomy. Interventional fluorescence imaging based on SHIFT-prepared product has some advantages such as (i) strong stability, (ii) greatly extending imageable time window, and (iii) precisely visualizing microsatellite lesions. In this Account, we overview our current progress in interventional fluorescence imaging based on SHIFT method for surgical resection following long-lasting embolization conversion. To greatly realize interventional fluorescence imaging, we summarize clinical and preclinical application of interventional fluorescence imaging in a transarterial delivery system. Indeed, compared with conventional fluorescence imaging, interventional fluorescence imaging possesses non-negligible strengths on improved intensity in target location and step-down systemic toxicity. Unfortunately, a challenging issue is that immobile fluorescence performance is difficult to maintain after long-time embolization, resulting in a failed hepatectomy. On this basis, associated with our previous research, SHIFT was proposed and developed. Thus, we detailedly introduce and account the development and preponderance of SHIFT on interventional fluorescence imaging. Predictably, after lengthy embolization, its lightful fluorescence was still observable in tumor targets of a clinical trial. To regulate the fluorescence rendering of microsatellite lesion, SHIFT combining with pure nanoprobes (nanoICG) occurs, namely SHIFT nanoICG, and we dwell on its performance in transarterial invasive surgical navigation and its clinical application under interventional fluorescence imaging compared with conventional indocyanine green (ICG) formulations. Amazingly, the SHIFT nanoICG brings us an extraordinary imaging consequence for deep-seated tumor tissues and imperceptible microsatellite lesions. Finally, we offer perspectives on the future tendency of interventional imaging-guided SHIFT products in clinical translation such as chemoembolization, radioembolization, and immunotherapy. Actually, these directions have been underway for some time, and even relative products are already applied for clinical trials, exhibiting effective therapeutic outcomes. Our green high-performance SHIFT products are concentrated on meeting clinical needs and solving clinical problems, breaking through the cure limitations of patients with advanced diseases. Thus, the discovery offers insight into the development and superiority of SHIFT products under interventional fluorescence imaging and simultaneously provides a new view on the development of clinically pragmatic products.

Efficacy evaluation and prognostic risk factors analysis of precise hepatectomy in the treatment of intermediate and advanced hepatocellular carcinoma.

To investigate the efficacy of precise hepatectomy in the treatment of patients with intermediate and advanced hepatocellular carcinoma and analyze the risk factors affecting prognosis. Totally 104 patients with intermediate and advanced hepatocellular carcinoma from January 2018 to January 2019 were enrolled in this retrospective analysis. Of these, four patients lost to follow-up. Logistic regression was conducted to explore the odds ratio (OR) and 95% confidence interval (CI). Compared with the control group, the precise hepatectomy decreased intraoperative blood loss (331.2928.91 to 203.29 ± 29.34 ml), operation time (198.29 ± 19.38 to 150.28 ± 18.27 min), perioperative blood transfusion volume (376.22 ± 25.93 to 228.29 ± 22.19 ml) (all P < 0.001). Logistic regression analysis of study group showed that hepatitis B infection (OR = 1.746; 95% CI, 1.068-2.976), P = 0.021, Child-Pugh classification (OR = 2.319; 95% CI, 1.428-3.213), P < 0.001, Eastern Cooperative Oncology Group (ECOG) score (OR = 2.287; 95% CI, 1.098-3.876; P = 0.013) and Barcelona-Clinic Liver Cancer (BCLC) staging (OR = 2.029; 95% CI, 1.086-3.671; P = 0.022) were independent risk factors for prognosis of the precise hepatectomy. Hepatitis B virus infection, Child-Pugh grade, ECOG score and BCLC staging grade were the independent risk factors affecting the prognosis of precise hepatectomy.

Increased Expression of NXPH4 Correlates with Immune Cell Infiltration and Unfavorable Prognosis in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is one of the leading malignant carcinomas. Despite the advancement in the treatment for HCC, such as precise hepatectomy, radiotherapy, transarterial therapies, chemotherapy, targeted treatments, and immunotherapy, the 5-year overall survival rate of HCC is extremely low. Hence, novel biomarkers are urgently needed for advancing the therapy and prognosis of HCC. Neurexophilin 4 (NXPH4) is a neuropeptide-like glycoprotein. The study is designed to investigate the function of NXPH4 in HCC through a comprehensive bioinformatics analysis. NXPH4 expression status and prognostic values were analyzed via multiple datasets, such as TCGA, GEO, and ICGC. The association between NXPH4 and immune cell infiltration was estimated by TIMER, TISIDB, and CIBERSORT. In vitro, we explored the biological function of NXPH4 in JHH7 and SNU182 cells through knocking down the expression of NXPH4 via siRNA. In general, NXPH4 was predominantly upregulated in HCC tumors, and increased NXPH4 expression predicted unfavorable prognosis. The gene enrichment analysis displayed that NXPH4 was related with metabolic pathways. NXPH4 expression was correlated with immune cell infiltration. NXPH4 knockdown significantly suppressed proliferation, migration, and invasion of JHH7 and SNU182 cells. This study suggested that the upregulation of NXPH4 is associated with adverse prognosis and immune cell infiltration in HCC. NXPH4 could be a novel biomarker of unfavorable prognosis and an underlying target for immunotherapy in HCC.

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

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

A pure nanoICG-based homogeneous lipiodol formulation: toward precise surgical navigation of primary liver cancer after long-term transcatheter arterial embolization

To surmount the critical issues of indocyanine green (ICG), and thus achieving a precise surgical navigation of primary liver cancer after long-term transcatheter arterial embolization. In this study, a facile and green pure-nanomedicine formulation technology is developed to construct carrier-free indocyanine green nanoparticles (nanoICG), and which subsequently dispersed into lipiodol via a super-stable homogeneous lipiodol formulation technology (SHIFT nanoICG) for transcatheter arterial embolization combined near-infrared fluorescence-guided precise hepatectomy. SHIFT nanoICG integrates excellent anti-photobleaching capacity, great optical imaging property, and specific tumoral deposition to recognize tumor regions, featuring entire-process enduring fluorescent-guided precise hepatectomy, especially in resection of the indiscoverable satellite lesions (0.6mm × 0.4mm) in rabbit bearing VX2 orthotopic hepatocellular carcinoma models. Such a simple and effective strategy provides a promising avenue to address the clinical issue of clinical hepatectomy and has excellent potential for a translational pipeline.

Short-term efficacy of precise hepatectomy and traditional hepatectomy for primary liver cancer: a systematic review and meta-analysis.

As the base of hepatitis B patients has been increasing annually, it has developed into a high incidence source of primary liver cancer worldwide. The fatality rate of liver cancer is still relatively high. Among the many treatment methods, liver resection is the first-line treatment of primary liver cancer. Although precision hepatectomy has achieved rapid development in recent years, the understanding of its efficacy is still not completely clear. This study aimed to analyze and compare the safety and effectiveness of precision hepatectomy and traditional hepatectomy in the treatment of primary liver cancer. We performed a literature search of the CNKI, Wanfang, Weipu.com, PubMed, Cochrane Library, Web of Science databases for studies on precision liver resection (precision group) and traditional liver resection (traditional group) for the treatment of primary liver cancer. Data including the operation time, intraoperative blood loss, hospital stay, postoperative complications, liver function, and survival rate were analyzed using RevMan 5.3 software to compare the differences in the effects of the two surgical procedures. Ten articles were included in the study, involving a total of 1,969 patients, including 1,045 cases in the precision group and 924 cases in the traditional group. Meta-analysis results showed that compared with the traditional group, the precision group had a longer operation time [mean difference (MD) =8.01, P=0.004], and total bilirubin (TBiL; MD =-2.78, P=0.055) was similar. Meanwhile, the precision group exhibited advantages in terms of intraoperative blood loss (MD =-149.37, P=0.000), hospital stay (MD =-5.59, P=0.000), postoperative liver function indexes [aspartate aminotransferase (AST; MD =-11.61, P=0.000) and alanine aminotransferase (ALT; MD =-18.53, P=0.000)], postoperative complication rate [relative risk (RR) =0.51, P=0.000], and 1-year survival rate (RR =1.11, P=0.000). The application of precision surgery in the treatment of primary liver cancer can be a safe and effective method. It can minimize intraoperative blood loss, mitigate surgical risk, reduce postoperative complications, improve patient prognosis and quality of life, and provide better short-term curative effect and patient benefits.

Exploring the effect of microecological agents on postoperative immune function in patients undergoing liver cancer surgery: a systematic review and meta-analysis.

Precision hepatectomy for primary liver cancer has been widely used in clinical practice. As an effective nutritional supplement to prevent endotoxemia and hepatic impairment, microecological agents have been used together with traditional enteral nutritional support substances in several clinical studies. Chinese and English databases were searched using the terms "hepatocellular carcinoma", "hepatectomy", "microecological agents", and "microecological regulators". The search terms were "hepatocellular carcinoma", "liver resection", "microecological agents", and "microecological regulators". Meta-analysis was performed using Rev Man 5.3 and Stata 13 software provided by the Cochrane system. Eleven randomized controlled trials (RCTs) were included in this study. Of these, all 11 described the correct method of random assignment; 8 described in detail the concealment of the assignment scheme; and 9 used blinding methods in the research. Microecological agents significantly reduced total bilirubin (TBIL) levels [mean difference (MD)=-0.10, 95% confidence interval (CI): (-0.14, -0.06), P<0.00001] of patients after hepatectomy. The alanine transaminase (ALT) levels [MD =-3.65, 95% CI: (-14.65, 7.34), P=0.52], aspartate aminotransferase (AST) levels [MD =-0.64, 95% CI: (-6.87, 5.58), P=0.84], prothrombin level [MD=1, 95% CI: (-2.57, 4.57), P=0.58], and C-reactive protein (CRP) level [MD =-0.28, 95% CI: (-3.01, 2.45), P=0.84] among the included articles were statistically significant. However, probiotics could significantly reduce the risk of postoperative infection in patients with liver cancer (MD =0.23, 95% CI: (0.07, 0.79), P=0.02 <0.05), and did not significantly increase the risk of complications in patients with liver cancer [odds ratio (OR) =0.82, 95% CI: (0.38, 1.77), P=0.61]. This study used meta-analysis to confirm that microecological agents can significantly improve the immune function of patients with hepatocellular carcinoma, and have alleviating effects on endotoxemia and hyperbilirubinemia.

Application value of three-dimensional reconstruction in preoperative evaluation of precise hepatectomy for complex primary liver cancer

Objective: To explore the application value of three-dimensional reconstruction of liver based on computer software in preoperative evaluation of precise hepatectomy for complex primary liver cancer. Methods: The clinical data of patients in Peking University People's Hospital Hepatobiliary surgery with complicated primary liver cancer from September 17, 2019 to December 20, 2020 were analyzed retrospectively. Preoperative enhanced CT/MR data of patients were collected, and 3D reconstruction of liver was performed in IQQA􀳏-3D Liver system. The liver volume of patients was calculated, the size and location of tumor were described, and the relationship between tumor and intrahepatic bile duct, portal vein, hepatic artery and inferior vena cava was described. Preoperative decision-making and treatment plan were made to compare the compliance of the actual operation plan with the planned operation plan under the guidance of three-dimensional reconstruction. Results: Among all 10 patients, there were 6 males and 4 females, aged 36 to 75 years. There were 6 cases of Child-Pugh grade A and 4 cases of B liver function. There were 5 cases of portal vein variation and 5 cases of hepatic artery variation. The range and M(Q1,Q3)of actual liver volume measured by 3D reconstruction in 10 patients was 895- 2 477 cm3 and [1 444(1 001, 1 854)] cm3;the nodule volume was 7-1 808 [133(50, 566)] cm3;the nodule volume in the liver was 0.8%-73.0% [11.0(3.3,32.7)]% and the number of suspected lesions was 1-7. In the end, 6 patients received surgical treatment;3 received chemotherapy, and 1 received conservative treatment. The preoperative three-dimensional reconstruction of liver anatomy and tumor location of the patients receiving surgical treatment were basically consistent with the intraoperative situation. There was no case of liver failure or death during perioperative period. Conclusion: In the preoperative evaluation of precise hepatectomy for complex primary liver cancer, 3D reconstruction can improve the rationality of treatment and the surgeon's understanding of the anatomical characteristics of the liver, so as to select the best treatment for patients, which has great application value.

计算机辅助手术系统在精准肝切除手术中的指导意义

计算机辅助手术系统在精准肝切除手术中的指导意义

Precise hepatectomy in the intelligent digital era.

In the past 20 years, the concept of surgery has undergone profound changes. Surgical practice has shifted from emphasizing the complete elimination of lesions to achieving optimal rehabilitation in patients. Collaborative optimization of surgery consists of three core elements, removal of lesions, organ protection and injury close monitoring, and controlled surgical intervention. As a result, the traditional surgical paradigm has quietly transformed into a modern precision surgical paradigm. In this review, we summarized the latest breakthroughs and applications of precision medicine in liver surgery. In addition, we also outlined the progresses that have been made in precision liver surgery, the opportunities and challenges that may encountered in the future.

Application of stroke volume variation-guided liquid therapy in laparoscopic precision hepatectomy

To observe the safety and impact on the short-term prognosis for patients of stroke volume variation (SVV) goal-directed fluid therapy (GDFT) in laparoscopic precision hepatectomy. Methods: A total of 120 patients (18-65 years old) undergoing laparoscopic precision hepatectomy were randomly divided into the fluid therapy group (group S) guided by SVV and the fluid therapy group (group C) guided by central venous pressure group (CVP), with 60 cases in each group. Mean arterial pressure (MAP) and heart rate (HR) were recorded at the following time: at home calm (T0), the operation started (T1), began to cut the liver (T2), the hepatectomy was acheived (T3), and in the end (T4). The lactic acid was measured at T0 to T4 and 1 day after surgery (T5). The amount of blood loss, urine output and fluid supplement, the incidence of intraoperative hypotension, and the use of neophryn were recorded. The recovery of liver function, Hb, and so on were also recorded. Results: Compared with the group C, the number of hypotension cases, the amount of blood loss and the amount of neophryn in the group S were decreased during the operation (P<0.05), while the lactic acid values in the group S were not significantly increased than those in the group C at T3 and T4 (P<0.05) and the elevation of AST, ALT, DBIL and TBIL in the group S was significantly decreased than those in the group C at 1 and 2 d after the operation (P<0.05). Hb and Hct in the group S were higher than those in the group C at 1 d after the surgery (P<0.05). Compared with the group C, the postoperative exhaust time and hospitalization time were shortened in the group S (P<0.05), and the infection rate and ICU admission rate were decreased in the group S (P<0.05). Conclusion: SVV-guided GDFT in laparoscopic precise hepatectomy is safe and effective. It reduces intraoperative blood loss and benefits the short-term prognosis of patients after operations. High SVV value (13%-17%) is adopted at the liver resection stage, and SVV value with 8%-12% at the end of trans-section may be used as one of intraoperative liquid therapy in laparoscopic precise hepatectomy.

Clinical applicaton of three-dimensional visualization technology in hepatectomy of complex hepatocellular carcinoma

Objective To study the clinical application of three-dimensional (3D) visualization technology in liver resection of complicated liver cancer. Methods A retrospective analysis of 28 patients with complicated liver cancer treated from June 2017 to June 2018 in the Department of Hepatobiliary Surgery, the Affiliated Tumor Hospital of Guangxi Medical University. There were 26 males and 2 females, aged (46±10) years old. A treatment plan on how to perform liver resection for these patients was developed under the guidance of 3D visualization technology. The actual surgical procedures, operation time, intraoperative blood loss, and postoperative complications were documented. The virtual resected liver volume was compared with the actual resected liver volume. The virtual surgical resection margin was also compared with the actual surgical resection margin. Results All the 28 patients with complicated liver cancer completed the 3D visualization analysis with the location, shape and quantity of tumor being clearly shown. Of the 27 patients who underwent liver resection, 13 underwent anatomical hepatectomy, and 14 underwent non-anatomical hepatectomy. The operation time ranged from 145 to 350 min (median 240 min). The intraoperative blood loss ranged from 100 to 1 500 ml (median 300 ml). The incisional wound healed slowly in 4 patients, pleural effusion developed in 8 patients, and ascites in 2 patients. There were no significant differences in the virtual resected liver volume compared with the actual resected liver volume (P>0.05). There was an excellent positive correlation between the patient's virtual resected liver volume and the actual resected liver volume (r=0.986, P 0.05). There was an excellent positive correlation between virtual surgical resection margin and the actual surgical resection margin (r=0.983, P<0.05). Conclusion Three-dimensional visualization technology accurately assessed the liver status, optimized surgical procedures, and played an important role in liver resection of complex liver cancer. Key words: Imaging, three-dimensional; Complex hepatocellular carcinoma; Precise hepatectomy; Preoperative planning

Application value of three-dimensional reconstruction technique in laparoscopic hepatectomy

Objective To evaluate the application value of three-dimensional (3D) reconstruction technique in laparoscopic hepatectomy. Methods The retrospective cohort study was conducted. The clinicopathological data of 189 patients with liver cancer who were admitted to the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine from January 2014 to December 2018 were collected. There were 142 males and 47 females, aged from 27 to 86 years, with an average age of 60 years. According to the difficulty score of surgery, 50 of 189 patients underwent laparoscopic complex hepatectomy, including 23 with preoperative 3D reconstruction in the complex reconstruction group and 27 with no preoperative 3D reconstruction in the complex control group; other 139 patients underwent laparoscopic non-complex hepatectomy, including 25 with preoperative 3D reconstruction in the non-complex reconstruction group and 114 with no preoperative 3D reconstruction in the non-complex control group. Observation indicators: (1) vascular assessment of patients who received 3D reconstruction; (2) surgical and postoperative situations; (3) typical case analysis. Measurement data with normal distribution were presented as Mean±SD, and comparison between groups was done using the t test. Measurement data with skewed distribution were presented as M (range), and comparison between groups was done using the Mann-Whitney U test. Count data were represented as absolute number or percentage, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results (1) Vascular assessment of patients who received 3D reconstruction: 48 of 189 patients were performed preoperative 3D reconstruction. Vascular assessment of 48 patients showed 41 of hepatic arterial Michels Ⅰ type, 4 of Michels Ⅱ type, 1, 1, and 1 of Michels Ⅲ, Ⅳ, Ⅷ type, respectively. There were 35 belonging to hepatic venous Ⅰ type and 12 belonging to hepatic venous Ⅱ type and 1 with unclear distribution of hepatic vein. There were 5 and 3 belonging to portal venous Ⅰ type and Ⅱ type, 38 with normal distribution of portal vein, and 2 with unclear distribution of portal vein, respectively. (2) Surgical and postoperative situations: 50 of 189 patients underwent laparoscopic complex hepatectomy, and 139 underwent laparoscopic non-complex hepatectomy. The operation time and volume of intraoperative blood loss were (234±64)minutes and 200 mL (range, 100-408 mL) in the complex reconstruction group, and (289±80)minutes and 500 mL (range, 400-800 mL) in the complex control group, respectively, showing statistically significant differences between the two groups (t=-2.474, Z=-2.981, P 0.05). The operation time, volume of intraoperative blood loss, cases of postoperative complications and duration of postoperative hospital stay were 160.0 minutes (range, 117.5-221.0 minutes), 100 mL (range, 75-200 mL), 8, 5 days (range, 4-8 days) in the non-complex reconstruction group, 157.5 min (range, 100.0-222.5 minutes), 100 mL (range, 50-200 mL), 43, 6 days (range, 4-7 days) in the non-complex control group, showing no significant difference between the two groups (Z=-0.525, -0.797, χ2=0.289, Z=-0.011, P>0.05). (3) Typical case analysis: one 48-year-old male patient with primary liver cancer developed a personalized hepatectomy plan through simulation function of vascular drainage area in 3D reconstruction. One 49-year-old female patient achieved indirect intraoperative navigation through emulation function of 3D reconstruction. Conclusions The 3D reconstruction of liver in preoperative assessment is beneficial to choice of surgical options and personalized surgical plan in the precise hepatectomy. Especially in the laparoscopic complex hepatectomy, preoperative 3D reconstruction can shorten operation time, and reduce volume of intraoperative blood loss. Key words: Liver neoplasms; Liver cancer; Three-dimensional reconstruction; Surgery planning; Liver resection; Laparoscopy

Progress in precise treatment of liver surgery

After more than a hundred years of development, hepatic surgery has gradually developed from a traditional rough model to a precise model in the 21st century. The era of precision liver surgery, and even precision medicine has come. Under the guidance of precise concept, the therapeutic effect of all liver diseases, especially liver malignant tumors, has been significantly improved, and the quality of life of patients has been significantly improved. Precise hepatectomy, precise radiofrequency ablation and precise transcatheter arterial chemoembolization are the three magic weapons of precise treatment in liver surgery. The precise concept will be the future development direction of medicine. This article reviews the research progress of precise treatment in liver surgery in order to further promote the concept of precise treatment in liver surgery. Key words: Hepatectomy; Liver diseases; Precise radiofrequency ablation; Precisetreatment

The role and significance of digital reconstruction technique in liver segments based on portal vein structure

Objective: To study the segment of liver according to the large amount of three-dimensional(3D) reconstructive images of normal human livers and the vascular system, and to recognize the basic functional liver unit based on the anatomic features of the intrahepatic portal veins. Methods: The enhanced CT primitive DICOM files of 1 260 normal human livers from different age groups who treated from October 2013 to February 2017 provided by 16 hospitals were analyzed using the computer-aided surgery system.The 3D liver and liver vascular system were reconstructed, and the digital liver 3D model was established.The vascular morphology, anatomical features, and anatomical distributions of intrahepatic portal veins were statistically analyzed. Results: The digital liver model obtained from the 3D reconstruction of CAS displayed clear intrahepatic portal vein vessels of level four.Perform a digital liver segments study based on the analysis of level four vascular distribution areas.As the less anatomical variation of left hepatic portal vein, the liver was classified into four types of liver segmentation mainly based on right hepatic portal vein.Type A was similar to Couinaud or Cho's segmentation, containing 8 segments(537 cases, 42.62%). Type B contained 9 segments as there are three ramifications of right-anterior portal vein(464 cases, 36.82%). The main difference for Type C was the variation of right-posterior portal vein which was sector shape(102 cases, 8.10%). Type D contained the cases with special portal vein variations, which needs three-dimensional simulation to design individualized liver resection plan(157 cases, 12.46%). These results showed that there was no significant difference in liver segmental typing between genders(χ(2)=2.179, P=0.536) and did not reveal any significant difference in liver segmental typing among the different age groups(χ(2)=0.357, P=0.949). Conclusions: The 3D digital liver model can demonstrate the true 3D anatomical structures, and its spatial vascular variations.The observation of anatomic features, distribution areas of intrahepatic portal veins and individualized liver segmentation achieved via digital medical 3D visualization technology is of great value for understand the complexity of liver anatomy and to guide the precise hepatectomy.

A prospective study of early enteral nutrition and combined enteral nutrition and parenteral nutrition in patients with hepatocellular carcinoma after precise hepatectomy

Objective To compare the clinical value of early enteral nutrition (EEN) and combined enteral nutrition (EN) and parenteral nutrition (PN) in patients with hepatocellular carcinoma (HCC) after precise hepatectomy. Methods The prospective study was conducted. The clinical data of 60 HCC patients who underwent precise hepatectomy in the Affiliated Drum Tower Hospital of Nanjing University Medical School between January 2013 and December 2014 were collected. All patients were allocated into the EN group and combined EN+ PN group by random number table method. Patients in the EN group and combined EN+ PN group respectively received EEN and early combined EN+ PN at 24 hours postoperatively for 7 days, total nutrient intakes between groups were consistent, with an average daily intake of nitrogen-feeding of 0.2 g/(kg·d) and an average daily intake of nonprotein calories of 25 kcal/(kg·d). Observation indicators: (1) comparison of nutritional indexes between groups; (2) comparison of liver function between groups; (3) comparison of postoperative conditions between groups. Measurement data with normal distribution were represented as ±s. Comparisons at the same time between groups were respectively analyzed using the group-design t test. Comparisons of count data were analyzed using the chi-square test. Ordinal data were analyzed by the nonparametric test. Comparison of repeated measurement data were done using the repeated measures ANOVA. Results Sixty patients were screened for eligibility, and 30 in each group. (1) Comparison of nutritional indexes between groups: levels of albumin (Alb), globulin, prealbumin and hemoglobin (Hb) and lymph nodes count in the EN group were respectively (41±4)g/L, (28±4)g/L, (188±37)mg/L, (139±17)g/L, (1.6±0.6)×109/L before operation and (32±4)g/L, (23±5)g/L, (114±41)mg/L, (121±19)g/L, (1.1±0.7)×109/L at 1 day postoperatively and (34±5)g/L, (26±4)g/L, (169±41)mg/L, (113±16)g/L, (1.9±1.1)×109/L at 8 days postoperatively, with statistically significant differences in above indexes (F=2.23, 4.45, 8.96, 5.21, 2.18, P 0.05). Levels of Alb, globulin, prealbumin and Hb and lymph nodes count in the combined EN+ PN group were respectively (42±4)g/L, (28±6)g/L, (188±29)g/L, (142±16)g/L, (1.6±0.6)×109/L before operation and (31±5)g/L, (20±5)g/L, (96±31)g/L, (124±16)g/L, (0.9±0.4)×109/L at 1 day postoperatively and (34±4)g/L, (24±4)g/L, (143±18)g/L, (115±18)g/L, (1.4±0.7)×109/L at 8 days postoperatively, with statistically significant differences in above indexes (F=3.21, 7.35, 4.36, 7.78, 3.19, P 0.05) and in changing trends of Alb, globulin, prealbumin, Hb and lymph nodes count (F=8.54, 3.83, 7.21, 6.33, 3.91, P>0.05). Levels of prealbumin at 8 days postoperatively were statistically different between groups (t=3.00, P 0.05) and in levels of TBil and DBil (t=0.08, 0.23, P>0.05). Levels of ALT, AST, ALP, GGT, TBil, DBil and CRP in the combined EN+ PN group were respectively (41±38) U/L, (43±25)U/L, (100±89)U/L, (106±46)U/L, (17.9±9.8)μmol/L, (6.2±3.6)μmol/L, (3.7±2.3)mg/L before operation and (462±409)U/L, (494±162)U/L, (73±53)U/L, (75±57)U/L, (28.1±18.8)μmol/L, (9.1±6.1)μmol/L, (40.7±26.2)mg/L at 1 day postoperatively and (90±47)U/L, (42±16)U/L, (95±40)U/L, (110±66)U/L, (22.5±14.5)μmol/L, (8.2±8.1)μmol/L, (26.9±24.6)mg/L at 8 days postoperatively, with statistically significant differences in above indexes among pre-operation, 1 and 8 days postoperatively (F=5.96, 3.73, 6.94, 3.88, 7.97, 4.14, 5.25, P 0.05) and in levels of TBil, DBil and CRP (t=0.09, 0.37, 0.58, P>0.05). There was no statistically significant difference in changing trends of ALT, AST, ALP, GGT, TBil, DBil and CRP of 2 groups (F=7.18, 2.23, 3.94, 5.88, 4.72, 2.17, 6.53, P>0.05) and in above indexes among pre-operation, 1 and at 8 days postoperatively (t=0.27, 0.42, 0.91, 0.12, 0.96, 0.24, 0.59, 0.32, 0.49, 1.27, 0.88, 0.07, 1.07, 1.45, 0.23, 1.11, 0.88, 0.32, 0.35, 0.93, 0.21, P>0.05). (3) Comparison of postoperative conditions between groups: times of initial defecation were respectively (3.2±1.0)days and (4.2±1.2)days in the EN group and combined EN+ PN group, showing a statistically significant difference (t=3.21, P<0.05). Conclusion EEN and combined EN+ PN are safe and feasible in HCC patients after precise hepatectomy, and also can improve liver function recovery, but EEN has advantages of promoting protein synthesis and gastrointestinal function recovery. Key words: Hepatic neoplasms; Precise hepatectomy; Nutritional support therapy; Enteral nutrition; Parenteral nutrition

Intraoperative image-guided laparoscopic and robotic hepatectomies

Laparoscopic and robotic hepatectomies have proved to be safe and feasible with advantages of minimally invasive and enhanced recovery, despite the inherent defects of restricted endoscopic angle of vision and having no tactile sensing. In recent years, the development of intraoperative image-guided techniques, such as real-time intraoperative ultrasonography, intraoperative CT/MRI-guided navigation system, fusion ICG fluorescence imaging, and augmented reality, have greatly assisted surgeons with precise targeting of the tumors, preoperative surgical planning, along with supervision and in-time revision of the amputation plane of hepatic papernchyma. Therefore, it has enabled precise hepatectomy without damaging important vascular structures, reduced intraoperative blood loss, and increased the safety of surgical procedures. Besides, intraoperative image guide could compensate the defect of restricted vision in laparoscopic and robotic hepatectomies, pushing the limits of human vision field. This article will describes the application of image-guided techniques in laparoscopic and robotic hepatectomies. Key words: Image-guided surgery; Laparoscopic surgery; Robotic surgery; Hepatectomy

Surgical treatment of hepatocellular carcinoma in the precision medicine era

Precision medicine is currently being paid much attention and greatly promotes the diagnosis and treatment of various diseases, especially cancer. Surgery plays a pivotal role in the treatment of hepatocellular carcinoma (HCC) and precision hepatectomy stands as the most updated surgical idea. Application of the concept and techniques of precision medicine to further improve HCC surgery, consummate the skills and modalities of HCC surgical treatment, enrich the nature of precision hepatectomy, so as to make precise evaluation, early prediction, reduce postoperative recurrence and metastasis, find biomarkers of molecular targeted therapy and improve the prognosis is the prime task of HCC surgery. Key words: Liver neoplasms; Precision medicine; Surgical procedures, operative