Precise Liver Research Articles

Clinical value of precision liver surgery concept in the treatment of primary liver cancer

Objective To investigate the clinical value of precision liver surgery concept in the treatment of primary liver cancer.Methods The clinical data of 141 patients with primary liver cancer who were admitted to the No.81 Hospital of PLA from January 2009 to October 2011 were retrospectively analyzed.The three-dimensional reconstruction,preoperative evaluation and virtual surgery were done based on the data of imaging examination.Hepatic functional reserve evaluation was done based on the condition of patients.The blood flow was occluded in selected patients according to the results of ultrasonography,and the tumor was anatomically resected.Patients were followed up via phone call or out-patient examination till January 2014.The survival rate was calculated by Kaplan-Meier method.Results Three-dimensional reconstruction was done in 77 patients preoperatively.Thirty-nine patients received ICG R15 test to detect the liver functional reserve and 95 received intraoperative color Doppler uhrasonography.The operation was successfully done on 141 patients.Four patients underwent total inflow occlusion,48 underwent partial inflow occlusion in the hepatic pedicle by Pringle maneuver.Eighty-nine patients did not receive inflow occlusion.The proportion of patients who received anatomical hepatectomy was 85.11％ (120/141).The operation time,volume of intraoperative blood loss,number of patients who received blood transfusion,volume of peritoneal drainage at postoperative day 0 were (188 ± 56) minutes,(230 ± 100) mL,12 and (147 ± 58)mL,respectively.The peak levels of postoperative alanine transaminase,aspartate transaminasc and total bilirubin were (219 ± 121) U/L,(214 ± 104) U/L and (32 ± 14) μmol/L,respectively.Eight patients were complicated with thoracic effusion,subphrenic infection,peritoneal effusion and bile leakage,and 5 patients were complicated with pulmonary infection and incisional infection,with the complication rate of 9.22％ (13/141) after the operation.All the patients were cured after symptomatic treatment,without occurrence of hepatic failure or perioperative death.The duration of postoperative hospital stay was (11.0 ± 2.6) days.There were 130 patients with hepatocellular carcinoma and 11 patients with cholangiocarcinoma.The mean diameter of tumors resected was (5.8 ± 1.7) cm,and the resection margin of 1 patient was positive.One hundred and thirty eight patients were followed up for (40 ± 10) months,and the 1-,2-,3-year survival rates were 91.5％,75.9％and 65.2％,and the survival time was (43 ± 5) months.Conclusion Precision liver surgery has advantages of few postoperative complications and better short-and long-term efficacy. Key words: Liver neoplasms; Precision liver surgery

Precision liver surgery

Continnous theoretical and technological progress in the face of increasing expectations for quality of health care and progress in medical technology has transformed the surgical paradigm.Based on the historical trends and technique advances,a novel paradigm of Precision Surgery has been proposed,which is featuring certainty-based practice to ensure the best results for each patient with multi-objective optimization of therapeutic effectiveness,surgical safety and minimal invasiveness.The main characteristics of precision surgery may be summarized as determinacy,predictability,controllability,integration,standardization and individualization.The strategy of precision hepatic surgery is to seek a balance of maximizing the removal of the target lesions,while maximizing the functional remnant liver and minimizing surgical invasiveness.The concept of precision surgery should be considered for wider application in liver surgery and other fields as a step toward the ultimate goal of perfect surgery. Key words: Precision liver surgery; Certainty; Multi-objective optimization

Practice and experiences in precision hepatectomy

With the wide application of liver transplantation techniques,rapid development of digital imaging medicine and continuous update of surgical implements,the theory of precision hepatectomy still keeps optimizing.Precision hepatectomy is not a surgical implement or surgical technique,but a concept of liver surgery emphasizing less bleeding,minimal invasion,fast recovery and long-term curative effect,which is updating and improving with the development of modern science.Much less intraoperative bleeding,shorter operation time,better postoperative recovery and long-term survival should be the chief pursuit and principle of precision hepatectomy. Key words: Precision liver surgery; Hepatectomy; Surgical concept

Construction of painless ward in the era of precision liver surgery

The progress of liver surgery is characterized by precision,minimal invasion and effectiveness in the 21 st century.Establishment of painless liver surgery ward and implementation of pain management in the perioperative period are not only the central content of enhanced recovery after surgery,but also one of the core connotation in precision liver surgery research.Conducting training programs for medical staffs,emphasizing health education of pain,selecting the reasonable pain assessment strategy,combination of preemptive analgesia and multimodal analgesia in the perioperative period and paying attention to individualized analgesia are important contents of construction of painless liver surgery ward.To carry out multicentre clinical study energetically,explore clinical pathway for the construction of painless ward and perioperative analgesic model are the development orientation for the construction of painless liver surgery ward. Key words: Precision liver surgery; Painless ward

Precise liver resection in liver cancer

Precise liver resection in liver cancer

Effects of concept and techniques of precision liver surgery on the perioperative safety of patients undergoing major hepatectomy

Objective To evaluate the effects of concept and techniques of precision hepatic surgery on the perioperative safety of patients who received major hepatectomy.Methods The clinical data of 1250 patients with hepatic diseases who received major hepatectomy at the Chinese PLA General Hospital from January 1986 to January 2012 were retrospectively analyzed.All the patients were divided into 2 groups,459 patients who were admitted from January 1986 to December 2006 were in the traditional surgery group,and 791 patients who were admitted from January 2007 to January 2012 were in the precision surgery group.The perioperative conditions of the patients in the 2 groups were compared,and the risk factors of morbidity and mortality were analyzed.The patients were followed up via out-patient examination,mail or telephone till December 2012.The measurement data,non-normal data and count data were analyzed using independent sample t test,non-parametric MannWhitney U test and chi-square test,respectively.The univariate and multivariate analysis were done using the chisquare test and bivariate Logistic regression analysis,respectively.The survival rates were calculated by using the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The ratios of anatomical hepatectomy and unanatomical hepatectomy were 62.31％ (286/459) and 37.69％ (173/459) in the traditional surgery group,and 85.59％ (677/791) and 14.41％ (114/791) in the precision surgery group,with significant difference between the 2 groups (x2 =88.98,88.98,P ＜ 0.05).The ratios of right hemihepatectomy,left hemihepatectomy and extended left hemihepatectomy were 18.52％ (85/459),29.85％ (137/459) and 3.05％ (14/459)in the traditional surgery group,which were significantly lower than 28.45 ％ (225/791),37.67 ％ (298/791) and 6.32％ (50/791) in the precision surgery group (x2=15.35,7.84,6.40,P ＜ 0.05).The ratios of hepatic inflow occlusion with Pringle maneuver and selective inflow occlusion were 66.01％ (303/459) and 12.42％ (57/459)in the traditional surgery group,27.18％ (215/791) and 31.73％ (251/791) in the precision surgery group,with significant difference between the 2 groups (x2=180.49,58.35,P ＜ 0.05).The operation time,median volume of intraoperative blood loss,ratio of intraoperative blood transfusion,duration of postoperative hospital stay,morbidity and mortality were (291 ± 124)minutes,750 ml,62.75％ (288/459),(18± 14)days,26.36％ (121/459)and 3.49％ (16/459) in the traditional surgery group,and (337 ± 142) minutes,550 ml,35.40％ (280/791),(14±9) days,20.73％ (164/791) and 1.52％ (12/791) in the precision surgery group,with significant difference between the 2 groups (t =-5.74,Z =-2.01,x2 =87.62,t =5.90,x2 =5.23,5.14,P ＜ 0.05).The results of univariate analysis showed that age ＞ 60 years,hepatic cirrhosis,hepatic inflow occlusion,operation time ＞360 minutes,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,vessel reconstruction,preoperative total bilirubin ＞ 17.1 μmol/L,preoperative albumin ＜35 g/L were correlated with the morbidity (x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P ＜ 0.05) ; hepatic cirrhosis,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 × 109/L were correlated with the mortality (x2=4.21,22.31,12.68,32.25,P ＜ 0.05).The results of multivariate analysis showed that volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,hepatic inflow occlusion and preoperative albumin ＜ 35 g/L were the independent risk factors of morbidity (odds ratio =2.642,2.515,1.637,1.796,P ＜ 0.05) ; volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 x 109/L were the independent risk factors of mortality (odds ratio =1.325,1.682,3.742,P ＜ 0.05).A total of 345 patients in the traditional surgery group and 651 patients in the precision surgery group were followed up for 11-96 months.The 1-,3-,5-year survival rates of patients with primary liver cancer in the traditional surgery group were 83.5％,51.6％,42.0％,and the 1-,3-year survival rates of patients with primary liver cancer of the precision surgery group were 85.4％ and 63.8％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.96,P ＜ 0.05).The 1-,3-,5-year survival rates of patients with hilar cholangiocarcinoma of the traditional surgery group were 63.1％,31.4％ and 26.7％,and the 1-,3-year survival rates of patients with hilar cholangiocarcinoma of the precision surgery group were 71.3％ and 48.1％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.95,P ＜ 0.05).Conclusion Application of the concept and techniques of precision hepatic surgery significantly decreases the perioperative morbidity and mortality,increase the safety and improves the long-term efficacy of treatment. Key words: Liver diseases; precision liver surgery; Hepatectomy; Complication; Mortality

Tu1060 Precise Liver Resection by Intraoperative Intervention Intravascular Segmental Vessel Balloon Catheter Occlusion

Tu1060 Precise Liver Resection by Intraoperative Intervention Intravascular Segmental Vessel Balloon Catheter Occlusion

Computer-assisted surgical planning system in liver resection for hepatocellular carcinoma

Objective To evaluate the role of computer-assisted surgical planning system in liver resection for patients with hepatocellular carcinoma (HCC).Methods Between January 2010 and January 2012,21 patients with HCC who underwent liver resection were included in this study.Computer assisted operative planning was performed before surgery.Results Computer-assisted surgical planning was performed successfully in all the 21 patients.The three dimensional anatomic evaluation was precise and quantitative.The predicted liver resection volume showed a significant correlation with the actual volume,with a mean difference of 3.5％.The types of liver resection included anatomic liver resection (15 patients) and local resection (6 patients).There was a 0％ mortality and a 14.3％ morbidity (3/21).Conclusions The computer-assisted surgical planning system reliably analyzed the 3D vascular structures and predicted accurately liver resection volumes.It can help to promote precise and safe liver resection. Key words: Hepatectomy; Computer-aided design; Three-dimensional reconstruction; Liver neoplasms; Liver volume

Precise liver resection by intraoperative interventional intravascular segmental vessel balloon catheter occlusion

Objective To evaluate the feasibility of precise hepatic segmentectomy or subsegmentectomy using intraoperative image-guided interventional intravascular segmental vessel balloon catheter occlusion of the segmental hepatic artery and portal vein.Methods 6 patients with liver resection carried out from 2011.3-2011.8 were retrospectively analyzed.Results The mean operating time was (270.83±21.31) min,the median of blood loss was 800 ml,the median of intraoperative transfusion volume was 450 ml.The tumors were mainly located in segments Ⅴ,Ⅵ,Ⅶ,Ⅷ.The mean diameter of tumor was (5.67±1.03) cm.Postoperative liver function in the first postoperative day showed the mean alanine aminotranferase (ALT) was (570.00±157.76) U/L,the mean aspirate aminotrarsferase (AST) was (410.00 ±189.94) U/L,and the mean total bilirubin (TBIL) was (10.83± 1.60) mmol/L.Liver function recovered to normal within 7 days.There was intestinal leakage and wound dehiscence in one patient,pleural and effusion in two patients.Conclusion Imageguided interventional intravascular segmental vessel balloon catheter occlusion was a safe and efficacious maneuver.This technique allowed hepatic segmentectomy or subsegmentectomy to be carried out,decreased intraoperative bleeding,and protected the function of the liver remnant. Key words: Hepatic segmentectomy; Balloon catheter occlusion; Intraoperative intervention

Ablation of segmental glissonian pedicle by ultrasound-guided radiofrequency in precision liver resection in a porcine model

To demonstrate the ablation of segmental glissonian pedicle by ultrasound-guided radiofrequency in precision liver resection in porcine model. The study was carried out on 6 Bama miniature pigs. Coagulative desiccation of the vessels feeding the segment to be resected was induced by introduction of a "cooled-tip" radiofrequency electrode under intraoperative ultrasound guidance at the level of the vessels. Then, an area of marked discoloration on the surface of the liver became obvious. Liver parenchymal transection followed without any form of hepatic inflow occlusion. Three segments (segment 3, 5, and 6) were resected on each pig. The criteria studied the local and general tolerance, the change of blood flow parameters of each segmental arterial and portal branches, and the microscopic appearance of the segmental arterial, portal and biliary tract branches. Using t test as the statistical methods. Postoperative mortality and morbidity were 0 and all serum parameters had normalized by 14 days. Demarcation area was obtained in 15 segments. The flow rate of the resected segmental portal branches was 0 cm/s after radiofrequency and the value of the arterial branches was (28 ± 18) cm/s which was significantly lower than pre-radiofrequency, which were (10.2 ± 3.0) cm/s and (60 ± 17) cm/s (t = 14.439, 5.502; P = 0.000). There was no significant difference in the flow rate of the remnant segmental arterial and portal branches among pre-radiofrequency, post-radiofrequency and 14 days after operation. On microscopic observation, the mean ablated length of segmental portal, arterial and biliary tract branches were (1.6 ± 0.4) cm, (1.2 ± 0.4) cm, and (1.7 ± 0.3) cm respectively. The ablation of the segmental glissonian pedicle by ultrasound-guided radiofrequency is quick, safe and effective. The probe needs to be away from vessels feeding segments 1.5 cm at least to avoid thermal injuries.

Navigated laparoscopy – liver shift and deformation due to pneumoperitoneum in an animal model

Background: Precise laparoscopic liver resection requires accurate planning and visualization of important anatomy such as vessels and tumors. Combining laparoscopic ultrasound with navigation technology could provide this. Preoperative images are valuable for planning and overview of the procedure, while intraoperative images provide an updated view of the surgical field. Purpose: To validate the accuracy of navigation technology based on preoperative images, we need to understand how much the liver shifts and deforms due to heartbeat, breathing, surgical manipulation and pneumoperitoneum. In this study, we evaluated liver tumor shift and deformation due to pneumoperitoneum in an animal model. Methods: Tumor models were injected into the liver of the animal, and 3D CT images were acquired before and after insufflation. Tumor shifts and deformation were determined. Results: The results showed significant tumor position shift due to pneumoperitoneum, with a maximum of 28 mm in cranio-caudal direction. No significant tumor deformation was detected. Small standard deviations suggest rigid body transformation of the liver as a whole, but this needs further investigation. Conclusion: The findings indicate a need for anatomic shift correction of preoperative images before they are used in combination with LUS guidance during a laparoscopic liver resection procedure.

Modern concept and clinical practice of precise liver surgery

The principles of “precise liver surgery”include to absolutely clearing target lesions,ensuring structural integrity of residual liver,maximizing the volume of remnant liver,controlling bleed as well as minimizing hepatic parenchymal damage and surgical invasiveness.This theory serves the whole procedure of liver surgery for the optimal recovery of patients.The major strategies consist of accurate preoperative evaluation:rigorous surgical planning,refined surgical operation and meticulous perioperative care.The construction of “recise liver surgery” system requires the combination of modern technology and traditional surgery,and the breakthrough in the core theory and key techniques of liver surgery. Key words: Precise surgery; Surgical planning; Surgical procedures, operative

Automatic liver segmentation in MRI images using an iterative watershed algorithm and artificial neural network

Precise liver segmentation in abdominal MRI images is one of the most important steps for the computer-aided diagnosis of liver pathology. The first and essential step for diagnosis is automatic liver segmentation, and this process remains challenging. Extensive research has examined liver segmentation; however, it is challenging to distinguish which algorithm produces more precise segmentation results that are applicable to various medical imaging techniques. In this paper, we present a new automatic system for liver segmentation in abdominal MRI images. The system includes several successive steps. Preprocessing is applied to enhance the image (edge-preserved noise reduction) by using mathematical morphology. The proposed algorithm for liver region extraction is a combined algorithm that utilizes MLP neural networks and watershed algorithm. The traditional watershed transformation generally results in oversegmentation when directly applied to medical image segmentation. Therefore, we use trained neural networks to extract features of the liver region. The extracted features are used to monitor the quality of the segmentation using the watershed transform and adjust the required parameters automatically. The process of adjusting parameters is performed sequentially in several iterations. The proposed algorithm extracts liver region in one slice of the MRI images and the boundary tracking algorithm is suggested to extract the liver region in other slices, which is left as our future work. This system was applied to a series of test images to extract the liver region. Experimental results showed positive results for the proposed algorithm.

Intraoperative nursing cooperation for robotic-assisted laparoscopic precise liver resection

Objective To investigate intraoperative nursing cooperation for robotic-assisted laparoscopic precise liver resection. Methods Between April and July 2009, 13 consecutive patients underwent roboticassisted laparoscopic anatomic hepatectomy for benign and malignant hepatic diseases. The clinical data of preoperative preparation, intraoperative cooperation and management of emergency were analyzed retrospectively and summarized gradually. Results All 13 robotic-assisted laparoscopic precise liver resections were performed successfully in the manner of pure laparoscopic resection. The nursing protocol was formulated to improve the preoperative preparation, intraoperative cooperation, management of emergency and postoperative summary. The nursing outcome was satisfactory due to effective nursing strategy. Conclusions Robotic surgery has been expanded into multi-disciplinary field, therefore preparation, communication, discreet placement and protection are important guarantees in its development. Key words: Robot; Intraoperative care; Precise liver resection

The safety and efficiency of precise liver resection for patients with primary liver cancer

Objective To evaluate the the safety and efficiency of precise liver resection for patients with primary liver cancer. Methods 86 patients with primary liver cancer were randomized to receive conventional routine hepatectomy (n=44) or the precise liver resection (n=42). Outcomes were compared between the precise hepatectomy group and the routine group, including, the blood loss, operation time, morbidity and mortality. Results There were significant differences in morbidity rates (7.1% vs. 20.5%; P<0.001), the blood loss [(320±315) ml vs. (613±526) ml;P<0.001) , postoperative alanine aminotransferase (ALT) value (in postoperation 7 d, 82.7 U/L vs.321.7 U/L; P<0.001) and length of hospital stay (12.3 d vs. 18.6 d; P<0.001) between precise hepatectomy and routine groups. The 1 year tumor recurrence rate and 1 year survival rate were 26.2%(11/42) and 78.6% (33/42) in precise liver resection group, 38.6% (17/44) and 65.9%(29/44) in routine liver resection group,with significant difference (P=0.010;P=0.018). Conclusion Precise liver resection is safe and effective in the treatment of liver tumor without much injury to patients. Key words: Liver neoplasm; Precise liver resection; Prognosis

Progress on precise hepatectomy

The development of liver surgery can be divided into several stages, including wedge liver resection, regular segmental liver resection and anatomical liver resection. With the development of biomedical sciences and information technology, liver surgery has developed into precise hepatectomy. The goals of precise hepatectomy are minimal invasion, maximal liver protection and best rehabilitation, This is mainly achieved through accurate preoperative evaluation, precise surgical planning, sophisticated surgical procedure and postoperative management. Its application significantly improves prognosis and quality of life of patients. This paper summarizes the concept and surgical technique of precise liver resection. Key words: Liver neoplasms; Precise hepatectomy; Progress

Treatment of primary liver cancer by precise liver surgery: an analysis of 53 cases

Treatment of primary liver cancer by precise liver surgery: an analysis of 53 cases

Clinical application of precise liver resection techniques in patients with complicated liver space-occupying lesions

To evaluate the early results of precise liver resection. Between May 2006 and June 2009, 65 patients with complicated liver space-occupying lesions were included in the study. Fifty-one patients underwent curative liver resection. Liver resections performed included 16 trisectionectomies, 11 hemihepatectomy, 5 meso hepatectomies, 3 combined segmentectomies, 5 caudate lobectomies and 11 irregular local resections. Patients undergoing resection had no mortality with a major morbidity of 9.8%. Nineteen vascular repairs and reconstructions were patent at last follow-up. The postoperative 1-year survival rate was 100% in 10 patients with benign lesions and 92.7% in 41 patients with malignant tumors. The 1-year survival rate was zero in patients with malignant tumors, who underwent no liver resection. Precise liver resection, as an aggressive surgical approach, offers hope for these patients, who would otherwise have a dismal prognosis.

La chirurgie hépatique. Quels progrès ? Quel avenir ?

Progress in liver surgery has increased the safety of all types of anatomical liver resections and has, in association with chemotherapy and interventional radiology, extended the limits of resectability for many primary and secondary liver tumors. This progress has been achieved thanks to a better method of vascular clamping, vascular reconstruction and better techniques and instruments to achieve more precise liver transection of this extremely vascular organ with a good haemostasis on the cut surface. These technical advances have allowed the procurement of partial liver grafts from living donors for transplantation and have also extended the scope of laparoscopic access to practically all types of hepatic resections. Preoperative manipulation of the liver volume with hypertrophy of the future liver remnant has made complex and extended hepatectomies feasible. These major hepatic resections are often performed in the background of damaged liver parenchyma due to chronic liver disease, steatosis and chemotherapy-induced lesions. A better knowledge of the functional anatomy with a clearer understanding of the role of venous drainage in the recovery of liver function and the process of regeneration have been the major factors which have facilitated these extended resections. The future of hepatic surgery, which is constantly influenced by the continuous technical progress with computer-aided reconstruction of the tumor zones and vascular and biliary anatomy, is certainly going to see a robotic-assisted surgical approach. Indications will change. While major and complex resections will still be required for advanced tumors, very few benign lesions will be operated in the future. Huge changes will happen in the management of malignant lesions where surgery will become a part of a combined therapeutic strategy where oncologic and radiointerventional treatments will have a major role. Surgery could then be limited to the resection of residual nodules susceptible to harbour persistent viable tumor cells.

An Improved Level Set for Liver Segmentation and Perfusion Analysis in MRIs

Determining liver segmentation accurately from MRIs is the primary and crucial step for any automated liver perfusion analysis, which provides important information about the blood supply to the liver. Although implicit contour extraction methods, such as level set methods (LSMs) and active contours, are often used to segment livers, the results are not always satisfactory due to the presence of artifacts and low-gradient response on the liver boundary. In this paper, we propose a multiple-initialization, multiple-step LSM to overcome the leakage and over-segmentation problems. The multiple-initialization curves are first evolved separately using the fast marching methods and LSMs, which are then combined with a convex hull algorithm to obtain a rough liver contour. Finally, the contour is evolved again using global level set smoothing to determine a precise liver boundary. Experimental results on 12 abdominal MRI series showed that the proposed approach obtained better liver segmentation results, so that a refined liver perfusion curve without respiration affection can be obtained by using a modified chamfer matching algorithm and the perfusion curve is evaluated by radiologists.