ObjectiveTo investigate strategies and efficacy of surgical treatment of advanced hepatic alveolar echinococcosis. MethodsThirty-six patients with advanced hepatic alveolar echinococcosis who underwent surgical treatment in our hospital from August 2014 to March 2016 were selected, who were divided into three groups:radical hepatectomy group (15 cases), quasi-radical hepatectomy group (17 cases), and palliative surgery group (4 cases). The operative time, intraoperative blood loss, postoperative complications, and metastasis were analyzed among these three groups. ResultsThe operative time, intraoperative blood loss, and rate of postoperative complications had no significant differences between the radical hepatectomy group and the quasi-radical hepatectomy group. No patient had postoperative recurrence in the radical hepatectomy group. The hepatic portal residual lesion was enlarged for 1 case and the intrahepatic and extrahepatic lesions were stable for the other patients in the quasi-radical hepatectomy group. In the palliative surgery group,the retroperitoneal lesions enlargement was seen in 2 cases and the lesions around the abcess grew progressively in 1 case. ConclusionIndividualized treatment accompanied with multiple-disciplinary treatment and damage-control surgery concept could benefit optimally to patients with advanced hepatic alveolar echinococcosis.
ObjectiveTo explore the efficiency of two-stage hepatectomy applicated in complex alveolar echinococcosis. MethodThe clinical data of one case who suffered from complicated alveolar echinococcosis with multiple lesions and then treated with two-stage hepatectomy were analyzed retrospectively. ResultsPreoperative enhanced CT revealed that the hydatid lesion with irregular shape, measuring 14.1 cm×9.2 cm, invaded several segments including left medial lobe and right anterior lobe of liver and the right branch of portal vein and medium hepatic vein were entirely surrounded by it. After preoperative examination surgical exploration was performed, two larger lesions measuring 6 cm×5 cm×4 cm and 5 cm×4 cm×4 cm respectively were found in caudate lobe of liver, three smaller lesions were found in the right and left lobe of liver, among which two measured 2 cm×2 cm×1 cm in the right lobe and one measured 3 cm×2 cm×1 cm in the left lobe. Mesohepatectomy was performed in the first stage, the lesion in left medial lobe and right anterior lobe of liver and the right anterior branch of portal vein were resected during the procedure. The patient recovered well after the operation without complications such as bile leakage or hemorrhage observed. The second stage surgery was performed at three months after operation, the computed tomograph before the surgery revealed that the remained lesions in the right lobe of liver did not proceed obviously and the left lateral external lobe of liver regenerated significantly. In the second stage, the right anterior lobe and part of the right posterior lobe of liver were resected. The patient was discharged on 7 days after operation, and there was no complication and relapse during the 7 months of follow-up period. ConclusionTwo-stage hepatectomy applicated in treating complicated alveolar echinococcosis with multiple lesions is safe and feasible, offering a choice with smaller trauma, lower expense and less complications for patients compared with liver transplantation.
Objective To evaluate effects of three-dimensional (3D) visualized reconstruction technology on short-term benefits of different extent of resection in treating hepatic alveolar echinococcosis (HAE) as well as some disadvantages. Methods One hundred and fifty-two patients with HAE from January 2014 to December 2016 in the Department Liver Surgery, West China Hospital of Sichuan University were collected, there were 80 patients with ≥4 segments and 72 patients with ≤3 segments of liver resection among these patients, which were designed to 3D reconstruction group and non-3D reconstruction group according to the preference of patients. The imaging data, intraoperative and postoperative indicators were recorded and compared. Results The 3D visualized reconstructions were performed in the 79 patients with HAE, the average time of 3D visualized reconstruction was 19 min, of which 13 cases took more than 30 min and the longest reached 150 min. The preoperative predicted liver resection volume of the 79 patients underwent the 3D visualized reconstruction was (583.6±374.7) mL, the volume of intraoperative actual liver resection was (573.8±406.3) mL, the comparison of preoperative and intraoperative data indicated that both agreed reasonably well (P=0.640). Forty-one cases and 38 cases in the 80 patients with ≥4 segments and 72 patients with ≤3 segments of liverresection respectively were selected for the 3D visualized reconstruction. For the patients with ≥4 segments of liver resection, the operative time was shorter (P=0.021) and the blood loss was less (P=0.047) in the 3D reconstruction group as compared with the non-3D reconstruction group, the status of intraoperative blood transfusion had no significant difference between the 3D reconstruction group and the non-3D reconstruction group (P=0.766). For the patients with ≤3 segments of liver resection, the operative time, the blood loss, and the status of intraoperative blood transfusion had no significant differences between the 3D reconstruction group and the non-3D reconstruction group (P>0.05). For the patients with ≥4 segments or ≤3 segments of liver resection, the laboratory examination results within postoperative 3 d, complications within postoperative 90 d, and the postoperative hospitalization time had no significant differences between the 3D reconstruction group and the non-3D reconstruction group (P>0.05). Conclusion 3D visualized reconstruction technology contributes to patients with HAE ≥4 segments of liver resection, it could reduce intraoperative blood loss and shorten operation time, but it displays no remarkable benefits for ≤3 segments of liver resection.
Objective To explore the effect of “in situ first” ex vivo liver resection and autologous liver transplantation (ELRA) for end stage hepatic alveolar echinococcosis (HAE). Methods The clinicopathologic data of 85 end stage HAE cases were initially scheduled underwent ELRA from June 2019 to May 2022 in the Sichuan Provincial People’s Hospital were collected retrospectively. The included cases were operated under “in situ first” ERLA principle. The analyzed data included the final surgical style, operative time, time of anhepatic phase and intraoperative blood transfusion volume for ELRA cases. Results All the included 85 cases underwent radical HAE lesions resection and without perioperative death occurred. According to the principle of “in situ first”, 57 cases underwent HAE lesions resection combined vascular reconstruction without ex vivo liver resection (in situ resection group); 1 case underwent auxiliary partial autologous liver transplantation, and 27 cases underwent ERLA procedures (ELRA group). In the in situ resection group, the operative time was 210–750 min, （380±134）min, and the intraoperative blood transfusion was 0–3 250 mL with a median of 0 mL. In the ELRA group, the operative time was 450–1 445 min, (852±203) min, and the intraoperative blood transfusion was 0–6 800 mL with a median of 1 960 mL. The operative time and the amount of blood transfusion in the ELRA group were longer or more than those in the in situ resection group. The time of anhepatic phase for the ELRA group was 60–480 min, (231±83) min. On the 5th day after operation, except that the total bilirubin and direct bilirubin in the ELRA group were higher than those in the in situ resection group, the other indexes of liver function were similar between the two groups. The postoperative stay in ICU and the total postoperative hospital stay in the ELRA group were longer than those in the in situ resection group. Conclusions The advantage of “in situ first” ERLA principle for end stage HAE patients include resecting the HAE lesions radically without ex vivo liver resection and alleviating the hepatic ischemia and reperfusion injury. For the inevasible ELRA cases, “in situ first” principle could shorten the anhepatic phase and reduce intraoperative blood loss, and turn some cases to auxiliary partial autologous liver transplantation, which will reduce the risk of postoperative hepatic failure.
Hepatic alveolar echinococcosis (HAE) is a severe zoonotic disease caused by Echinococcus multilocularis, primarily affecting the liver. Due to its insidious nature, the patients are often diagnosed at advanced stage, posing significant treatment challenges. We comprehensively examines the progress in surgical techniques for HAE management, focusing on various strategies across different disease stages. For the patients with early-stage HAE, ablation therapy has emerged as an effective treatment option. In the moderate to advanced cases, numerous surgical techniques and innovative approaches have been introduced, including laparoscopic surgery and liver transplantation, with particular emphasis on ex vivo liver resection and autotransplantation. These advancements offer more effective treatment options for the patients with advanced HAE. However, significant challenges persist, notably the preservation of adequate liver function while achieving complete lesion removal. Future research should prioritize the exploration and optimization of existing surgical methods, especially for advanced HAE cases. This includes refining surgical techniques through precise preoperative evaluation and staging, as well as developing novel surgical approaches to enhance safety and efficacy. Furthermore, multicenter and long-term follow-up prospective studies are crucial for validating the effectiveness of new surgical techniques and strategies. Through these concerted efforts, it is anticipated that the survival rates and quality of life for HAE patients will significantly be improved, marking a new era in the management of this complex disease.
Objective To detect and analize the expressions and it’s clinical significance of apoptosis factors in hepatic alveolar echinococcosis tissues by using antibody chip technology. Methods The liver tissue specimens (including the edge of lesions and normal liver tissues) of surgical resection of 6 patients with hepatic alveolar echinococcosis in Affiliated Hospital of Qinghai University were collected. The tissue protein was extracted and the level of apoptosis was detected by antibody chip technology. The data were analyzed by AAH-APO-G1 software. Results The expression levels of 5 kinds of apoptosis factors (Bad, Fas, IGFBP-3, P21 and XIAP) in the liver tissues of the marginal zone of hepatic alveolar echinococcosis were compared with that of the normal liver tissues, and the difference was statistically significant (P<0.05). The expression levels of Bad, Fas, IGFBP-3 and P21 were up-regulated, and the expression level of XIAP was down regulated. Conclusions Apoptosis-related factors play a role in the progression of the hepatic alveolar echinococcosis, there may be contact with the immune escape mechanisms, while promote apoptosis factor and inhibitory apoptosis factor that may exist the function imbalance, so more in-depth exploration the mechanism of apoptosis factors on hepatic alveolar echinococcosis in diagnosis and treatment have important significance.
ObjectiveTo explore value of partial liver preservation in situ for ex-vivo liver resection and auxiliatry autologous liver transplantation in end-stage hepatic alveolar echinococcosis.MethodsThe clinical data of one patient with end-stage hepatic alveolar echinococcosis treated with auxiliatry autologous liver transplantation combined partial liver preservation in situ were analyzed retrospectively. This patient was admitted on January 2019. During the auxiliatry autologous liver transplantation procedure, the S1, S4-S8 segments of the liver were resected for mass dissection, whereas the S2 and S3 segments of left liver were preserved in situ.ResultsThe preoperative evaluation and intraoperative exploration indicated that the mass located in the S4, S5, S8 segments, which was adjacent to the first hepatic portal and involved the anterior wall of posterior inferior vena cava, middle hepatic veins, the opening of right hepatic veins and the right wall of left hepatic veins. Based on the " in situ first” principle, the left lesion was slit using the anterior approach, the left hepatic vein was repaired and the S2 and S3 segments were preserved in situ. Then, the right lesion to involved hepatic vein was slit along the right interlobar fissure. The right hepatic artery, right portal vein and right bile duct were divided separately. The S1 and S4-S8 segments were removed completely. Next, the mass was resected, the out flow of the right liver was reconstructed using the allogeneic veins during the ex-vivo liver resection. Then, the auxiliatry autologous right liver transplantation was initiated by the wide-caliber hepatic vein-artificial inferior vena cava anastomosis. The surgical procedures lasted for 12 h, and the intraoperative bleeding was approximately 800 mL. The patient was routinely treated and smoothly recovered after the operation.ConclusionsProcedure of auxiliatry autologous liver transplantation preserved part functional liver in situ during ex-vivo resection, which could maintain stability of systemic and portal vein circulation, hold part liver function during operation, preserve functional liver furthest, and reduce risk of hepatic failure, is an effective attempt for end stage hepatic alveolar echinococcosis.
Objective To summarize the methods, safety, and efficacy of the ex vivo liver resection followed by autotransplantation in the treatment of advanced hepatic alveolar echinococcosis (HAE). Method A retrospective analysis of clinical data and follow-up data in 21 cases who received ex vivo liver resection followed by autotransplantation in the treatment of HAE from February 2014 to December 2016 in West China Hospital was performed. Results All the patients successfully underwent ex vivo liver resection followed by autotransplantation and no death happened during operation. The median weight of remnant liver was 701.4 g (360–1 300 g), the average operation time were 13.6 h (9.4–19.5 h), the anhepatic phase time were 180–455 min with median of 314 min. The average of intraoperative blood loss were 2 379 mL (1 200–6 000 mL). The average of patients entered red blood cell suspension were 10.6 u (0–39.5 u), the average of fresh frozen plasma were 1 377 mL (0–6 050 mL) , of which 7 patients received autologous blood transfusion, with average of 1 578 mL (500–3 700 mL). The average of postoperative hospital stay were 23.5 days (4–51 days). Postoperative complications occurred in 12 patients during hospitalization, and 4 cases of postoperative complications were in grade Clavien-Dindo Ⅲ or above, 2 cases of grade Ⅴ (died). During the follow-up period, 19 patients were followed for a median of 16.2 months (3–38 months), no HAE recurrence or metastasis was found, only 1 patient were lost follow-up after surgery for 12 months. Massive ascites and hyponatremia were found in 1 patient who was diagnosis as left hepatic vein stenosis at the end of the 3 months after operation. The patient was cured after interventional treatment of hepatic vein stent implantation and angioplasty. Conclusions The ex vivo liver resection followed by autotransplantation provides radical treatment for patients with advanced HAE, but the surgery is difficult and has high risk of postoperative complications. The detailed preoperative evaluation, intraoperative pipeline reconstruction reasonably, and fine postoperative management can improve the patient’s survival, and reduce the rate of complications.
Objective To explore feasibility and safety of ex vivo liver resection and autotransplantation in treating end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Methods The patient was diagnosed with the end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. The ultrasonography, computed tomography, and magnetic resonance imaging were used to access the characteristics of the lesions and the extent of involvement of the portal vein and its branches. The liver model was reconstructed using a three-dimensional imaging data analysis system (EDDA Technology, Inc. USA), the remnant liver volume and the extent of involvement of the first hepatic hilum were recorded. Then the multidisciplinary team repetitively discussed the risks and procedures involved in the surgery. Finally, the ex vivo liver resection and autotransplantation was proposed. Results The preoperative evaluation showed the patient had a large intrahepatic lesion which severely invaded the retrohepatic inferior vena cava, the right hepatic vein, and the middle hepatic vein and were completely occluded, the left hepatic vein was partially invaded, and the portal vein was spongiform. The remnant liver volume was 912 mL, the ratio of residual liver volume to standard liver volume was 0.81. The preoperative liver function Child-Pugh score was grade A. The ex vivo liver resection and autotransplantation was successfully managed according to the expected schedule. The autografts (made by patient’s great saphenous vein) were used to reconstruct the hepatic vein and portal vein, and the retrohepatic inferior vena cava was not reconstructed. The patient recovered well and was discharged on day 20 after the operation. Conclusions Ex vivo liver resection and autotransplantation could successfully be applied in treating patient with end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Adequate preoperative assessment and management of the first hepatic hilum are key to this operation.
ObjectiveTo investigate the predictive value of preoperative red blood cell distribution width to platelet count ratio (RPR) and platelet-albumin-bilirubin (PALBI) scoring for postoperative complications after radical resection of hepatic alveolar echinococcosis (HAE). MethodsAccording to the inclusion and exclusion criteria, the clinicopathologic data of patients diagnosed with HAE and underwent radical hepatectomy in the Affiliated Hospital of Qinghai University from January 2018 to October 2022 were retrospectively collected. The risk factors affecting postoperative complications after radical hepatectomy for HAE were analyzed by univariate and multivariate unconditional logistic regression analysis, which were used to construct the nomogram. The receiver operating characteristic curve was used to evaluate the value in predicting postoperative complications by nomogram model. The discrimination of the nomogram was evaluated using Bootstrap internal 1 000 resampling and evaluated using a consistency index. The predicted postoperative complications probability by nomogram and actual postoperative complications probability were calculated by Kaplan-Meier method, and the calibration curve was drawn. The calibration ability of the nomogram model was evaluated by Hosmer-Lemeshow goodness-of-fit test. The decision curve analysis was used to evaluate clinical benefit of the nomogram model. ResultsA total of 160 patients with HAE radical hepatectomy were included, of which 105 had no postoperative complications and 55 had postoperative complications. The multivariate unconditional logistic regression analysis showed that the operation time ≥207 min, intraoperative bleeding ≥650 mL, and albumin ＜38 g/L, RPR ≥0.054, and higher PALBI grading (3 levels) were the risk factors affecting postoperative complications after HAE radical hepatectomy (OR＞1, P<0.05). Based on the risk factors, the nomogram was constructed. The area under the receiver operating characteristic curve (95%CI) predicted by the nomogram for the postoperative complications was 0.873 (0.808, 0.937), with an optimal cutoff value of 0.499. The consistency index was 0.855 for discriminating postoperative complications after HAE radical hepatectomy. The calibration curve was tested by Hosmer-Limeshow and showed a good fit between the predicted curve by the nomogram and actual curve (χ2=3.193, P=0.367), indicating that the nomogram had a good calibration ability. The decision curve analysis showed that there was a good clinical applicability within the range of 11% to 93% of the threshold probability. ConclusionsThe preoperative RPR and PALBI scoring are risk factors affecting postoperative complications after radical hepatectomy for HAE. The nomogram constructed with risk factors including RPR and PALBI has a good predictive value for postoperative complications after radical hepatectomy for HAE.