ObjectiveTo find out the risk factors affecting the prognoses and microvascular invasion (MVI) of patients with China Liver Cancer Staging-stageⅠ a (CNLC Ⅰ a) hepatocellular carcinoma (HCC). MethodsBased on the established inclusion and exclusion criteria, the clinicopathologic information and follow-up data of patients with CNLC Ⅰ a HCC were retrospectively collected, who underwent radical resection in the West China Hospital of Sichuan University from Jan. 2012 to Dec. 2016. The Cox proportional hazards regression was utilized to analyze the risk factors affecting the prognosis of patients with CNLC Ⅰ a HCC, and the non-conditional logistic regression was utilized to analyze the preoperative clinical indicators associating with MVI. ResultsA total of 300 patients with CNLC Ⅰ a HCC were included in this study, among which 51 (17.0%) cases accompanied with MVI. The follow-up period ranged from 2 to 104 months (median 39 months), with a recurrence time ranging from 2 to 104 months (median 52 months), and an overall survival time ranging from 3 to 104 months (median 98 months). During the follow-up period, postoperative recurrence occurred in 145 (48.3%) cases. The Cox proportional hazards regression analysis revealed that: tumor diameter >3 cm, presences of MVI and satellite nodules increased the risk of shortened recurrence time for the patients with CNLC Ⅰ a HCC (P<0.05); Factors including gamma-glutamyltranspeptidase level >60 U/L, tumor low differentiation, presences of MVI and satellite nodules were associated with shortened overall survival time for the patients with CNLC Ⅰ a HCC (P<0.05). The preoperative alpha-fetoprotein level ≥400 μg/L and tumor diameter >3 cm increased the risk of presence of MVI for the patients with CNLC Ⅰ a HCC [χ2=3.059, OR(95%CI)=2.357(1.047, 5.306), P=0.038; χ2=3.002, OR(95%CI)=2.301(1.026, 5.162), P=0.043]. ConclusionThe results of this study suggest that adopting corresponding strategies to address the risk factors affecting prognosis of patients with CNLC Ⅰ a HCC and the risk factors associated with MVI can have a significant clinical impact on improving surgical treatment outcomes for these patients.
ObjectiveTo summarize short-term and long-term effects of ex vivo liver resection followed by autotransplantation (Abbreviation: autotransplantation) in treatment of advanced hepatic alveolar echinococcosis (HAE).MethodThe clinical data and follow-up data of 17 patients with advanced HAE who underwent autotransplantation from November 2016 to July 2019 in the Ganzi Tibetan Autonomous Prefecture People’s Hospital were retrospectively analyzed.ResultsThe autotransplantations were performed successfully in the 17 patients with advanced HAE. Ten patients underwent the inferior vena cava (IVC) reconstruction with autologous saphenous veins, 5 patients underwent the artificial revascularization, 1 patient underwent the direct anastomosis of the original IVC, and 1 patient didn’t reconstructed (the retroperitoneal collateral circulation was abundant). The mean liver graft mass was 681.3 g (365–1 350 g) and operation time was 11.5 h (9–16 h). The median anhepatic period was 312 min (175–450 min), blood loss was 2 000 mL(950–4 500 mL), red blood cell suspension transfusion was 6.4 U (1–20 U), and fresh frozen plasma was 1.1 L (0.8–2.0 L). The postoperative hospital stay was 5 to 45 d with an average of 25.6 d. There were 4 patients with the postoperative hepatic enveloping effusion, 1 patient with bile leakage, and 1 patient with bile duct stenosis. All of them were treated and cured, and no death occurred. The follow-up time of 17 patients was 3 to 35 months with an average of 9.5 months, no recurrence of HAE and distant metastasis were observed.ConclusionsIn highlands, autotransplantation in treatment of advanced HAE patients with different IVC reconstruction is satisfactory, but it has a higher risk and is difficult. Choice of intraoperative reconstruction materials, judgment of posterior peritoneal collateral circulation, presence or absence of tension in end-to-end anastomosis of the IVC require precise consideration. At the same time, anticoagulation therapy and complications management are difficult, and it is only suitable for plateau medical center with rich experience.
ObjectiveTo explore the effect of hepatic outflow reconstruction with allograft vascular in ex-vivo liver resection and autologous liver transplantation.MethodThe clinical data of a patient with end-stage hepatic alveolar echinococcosis admitted to the Organ Transplantation Center of Sichuan Provincial People’s Hospital in August 2019 who underwent the ex-vivo liver resection and autologous liver transplantation combined with hepatic vein reconstruction with allograft vascular were analyzed retrospectively.ResultsThe patient, a 44-year-old female, was admitted to Sichuan Provincial People’s Hospital for “pain in the right abdomen accompanied by skin and sclera yellow staining for 6+ months and aggravated for 20+ d”. When the patient was admitted, the general condition was poor, such as hyperbilirubin and hypoproteinemia. The body mass was 45 kg and the standard liver volume was 852 mL. The hydatid lesions corroded the first and second hilum of the liver, the right hepatic vein and the posterior inferior vena cava. It was difficult to reconstruct the outflow tract of the hepatic vein in vivo, and it was extremely difficult to completely remove the hydatid lesions in vivo. After admission, the patient was generally in a good condition after the PTCD treatment, then after discussion and rigorous evaluation, the ex-vivo hepatectomy combined with autologous liver transplantation was required. The operative time was 15 h and the intraoperative blood loss was approximately 2 000 mL. After the operation, the routine treatment was performed, the antiviral treatment was continued, the international standardized ratio value was monitored at 1.5–2.5, and the anti-immune rejection drugs were not needed. The patient was transferred to the general ward on the 4th day after the operation, and there were no bile leakage, bleeding, infection and other complications. the result of postoperative pathological diagnosis was the alveolar echinococcosis. The re-examination of enhanced CT on 1 week after the operation suggested that the hepatic outflow tract of allograft vascular reconstruction was unobstructed, no stenosis and no thrombosis occurred. The patient was following-up at present.ConclusionsIn treatment of end-stage hepatic alveolar echinococcosis by autologous liver transplantation, reconstruction of hepatic outflow should be individualized. Allograft venous vessels could be used as ideal materials due to their advantages of matched tube diameter and length, no anti-rejection, and low risk of infection.
ObjectiveTo summarize the key operative points and efficacy of ex-vivo ex-vivo liver resection and autologous liver transplantation (ELRA) using various vascular materials for hepatic vein reconstruction in the treatment of end-stage hepatic alveolar echinococcosis (HAE). MethodThe clinicopathologic data of a patient with end-stage HAE who underwent ELRA combined with complex hepatic vein reconstruction were retrospectively analyzed. ResultsThe patient was a 60-year-old male who was admitted to the Sichuan Provincial People’s Hospital due to giant alveolar hydatid in the liver, with a body weight of 60 kg and a standard liver volume of 1 024.5 mL. The imaging showed that the hydatid invaded the first and second hepatic portals, middle hepatic vein, left hepatic vein, and retrohepatic inferior vena cava. The three-dimensional reconstruction of CT showed that the residual liver volume was 1 270.6 mL. The patient received supportive treatment after admission and underwent ELRA following strict evaluation. Intraoperatively, it was found that the multiple hepatic veins and retrohepatic inferior vena cava were widely invaded. The liver was split in vivo and the mass was excised ex vivo by “in vivo first” principle. The hepatic vein was repaired and reconstructed into a wide mouth outflow tract using allogeneic veins, autologous inferior mesenteric vein, and hepatic round ligaments, then performed the autotransplantation by wide mouth outflow-artificial inferior vena cava anastomosis (end to side). The operative time was 16 h, and the intraoperative blood loss was approximately 2 000 mL. FK506 was orally administered after operation, and low-molecular-weight heparin sodium was administered 24 h later for anticoagulation. The patient was returned to the general ward on the 6th day after the operation, and the enhanced CT scan showed that the hepatic outflow tract was unobstructed, without stenosis and thrombosis, and the patient was discharged on day 18 after the operation. The patient was pathologically diagnosed with alveolar echinococcosis. ConclusionsFrom the results of this case, combination of multiple vascular materials to reconstruct the hepatic outflow tract is an optional procedure for ELRA in treatment of end-stage HAE. Strict preoperative evaluation, skillful vascular anastomosis technique, and postoperative anticoagulation are important measures to maintain patency of postoperative reconstruction vessel.
ObjectiveTo investigate the risk factors affecting severe postoperative complications (Clavien-Dindo classification Ⅲa or higher) in patients with end-stage hepatic alveolar echinococcosis (HAE) underwent ex vivo liver resection and autotransplantation (ELRA), and to develop a nomogram prediction model. MethodsThe clinical data of end-stage HAE patients who underwent ELRA at the West China Hospital of Sichuan University from January 2014 to June 2024 were retrospectively analyzed. The logistic regression was used to analyze the risk factors affecting severe postoperative complications. A nomogram prediction model was established basing on LASSO regression and its efficiency was evaluated using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. Simultaneously, a generalized linear model regression was used to explore the preoperative risk factors affecting the total surgery time. Test level was α=0.05. ResultsA total of 132 end-stage HAE patients who underwent ELRA were included. The severe postoperative complications occurred in 47 (35.6%) patients. The multivariate logistic analysis results showed that the patients with invasion of the main trunk of the portal vein or the first branch of the contralateral portal vein (type P2) had a higher risk of severe postoperative complications compared to those with invasion of the first branch of the ipsilateral portal vein (type P1) [odds ratio (OR) and 95% confidence interval (CI)=8.24 (1.53, 44.34), P=0.014], the patients with albumin bilirubin index (ALBI) grade 1 had a lower risk of severe postoperative complications compared to those with grade 2 or higher [OR(95%CI)=0.26(0.08, 0.83), P=0.023]. Additionally, an increased total surgery time or the autologous blood reinfusion was associated with an increased risk of severe postoperative complications [OR(95%CI)=1.01(1.00, 1.01), P=0.009; OR(95%CI)=1.00(1.00, 1.00), P=0.043]. The nomogram prediction model constructed with two risk factors, ALBI grade and total surgery time, selected by LASSO regression, showed a good discrimination for the occurrence of severe complications after ELRA [area under the ROC curve (95%CI) of 0.717 (0.625, 0.808)]. The generalized linear regression model analysis identified the invasion of the portal vein to extent type P2 and more distant contralateral second portal vein branch invasion (type P3), as well as the presence of distant metastasis, as risk factors affecting total surgery time [β (95%CI) for type P2/type P1=110.26 (52.94, 167.58), P<0.001; β (95%CI) for type P3/type P1=109.25 (50.99, 167.52), P<0.001; β (95%CI) for distant metastasis present/absent=61.22 (4.86, 117.58), P=0.035]. ConclusionsFrom the analysis results of this study, for the end-stage HAE patients with portal vein invasion degree type P2, ALBI grade 2 or above, longer total surgery time, and more autologous blood transfusion need to be closely monitored. Preoperative strict evaluation of the first hepatic portal invasion and distant metastasis is necessary to reduce the risk of severe complications after ELRA. The nomogram prediction model constructed based on ABLI grade and total surgery time in this study demonstrates a good predictive performance for severe postoperative complications, which can provide a reference for clinical intervention decision-making.
Objective To explore the effect of ex-vivo liver resection and autologous liver transplantation (ERAT) combined with complicated hepatic venous reconstruction for end stage hepatic alveolar echinococcosis (AE). Method Theclinical data of one case with hepatic AE who treated in Organ Transplantation Center of Sichuan Provincial People’s Hospital in December 2017 was analyzed retrospectively. Results Pre-operative examination and intraoperative exploration revealed the hepatic vein (HV) and retrohepatic inferior vena cava (RHIVC) were invaded widely. We successfully initiated operation through vivo and ex-vivo hepatic AE resection, portal vein reconstruction, right/short/right inferior HV reconstruction into a wide mouth outflow with the assist of autogenous saphenous vein, and then piggyback autologous liver transplantation by wide mouth outflow-artificial inferior vena cava anastomosis (side to side). The operative time was 16 hours, and blood loss was 1 000 mL approximately. The patient was admitted routine treatment after hepatectomy. The inject low-molecular-weight heparin sodium was admitted for anticoagulant therapy 24 hours after operation. This patient recovered smoothly without bile leakage, bleeding, infection and liver failure, and so on. The patient was discharged uneventfully 14 days after operation, and there was no special situation during the6 months follow-up period. Conclusions ERAT is an ideal surgical method for end stage hepatic AE. Hepatic parenchymal transection and individual duct reconstruction, especially hepatic outflow reconstruction, are the key steps for ERAT.
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 approach feasibility, safety, and the application range of pure laparoscopic resection （PLR）, hand-assisted laparoscopic resection （HALR）, and robotic liver resection （RLR） in the minimally invasive liver resection （MILR）. Methods?The clinical data of 128 patients underwent MILR in the Surgical Department of the Shanghai Ruijin Hospital from September 2004 to January 2012 were analyzed retrospectively. According to the different methods, the patients were divided into PLR group, HALR group, and RLR group. The intraoperative findings and postoperative recovery of patients in three groups were compared.?Results?There were 82 cases in PLR group, 3 cases of which were transferred to open surgery；the mean operating time was （145.4±54.4） minutes （range：40-290 minutes）；the mean blood loss was （249.3±255.7） ml （range：30-1 500 ml）；abdominal infection was found in 3 cases and biliary fistula in 5 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （7.1±3.8） days （range：2-34 days）. There were 35 cases in HALR group, 3 cases of which were transferred to open surgery；the mean operating time was （182.7±59.2） minutes （range：60-300 minutes）；the mean blood loss was （754.3±785.2） ml （range：50-3 000 ml）；abdominal infection was found in 1 case, biliary fistula in 2 cases, and operative incision infection in 2 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （15.4±3.7） days （range：12-30 days）. There were 11 cases in RLR group, 2 cases of which were transferred to open surgery； the mean operating time was （129.5±33.5） minutes （range：120-200 minutes）； the mean blood loss was （424.5±657.5） ml （range：50-5 000 ml）； abdominal infection was found in 1 case and biliary fistula in 1 case after operation, but all recovered after conservative treatment； the mean length of hospital stay was （6.4±1.6） days （range：5-9 days）. The operating time （P=0.001） and length of hospital stay （P=0.000） of the RLR group were shortest and the blood loss （P=0.000） of the PLR group was least among three groups. Conclusions?Minimally invasive resection is a safe and feasible. Different surgical procedures should be chosen according to different cases. The robotic liver resection provides new development for treatment of liver tumor.
Evidence from numerous animal models and clinical studies in recent years has demonstrated that macrophages play an important role in the regulation of liver fibrosis regression. The safety and efficacy of utilizing autologous macrophages for the treatment of liver fibrosis have been demonstrated in patients and shows promising application prospects, but the therapeutic effects need to be improved. Cirrhotic liver undergoes a process of marked extracellular matrix degradation after partial hepatectomy surgery, and single-cell sequencing identified multiple restorative macrophage subsets that express different matrix metalloproteinases (MMPs) at high levels. Future efforts to further characterize this population of macrophages and improve their enrichment in the liver may allow macrophage therapy to be a highly effective strategy to reverse liver fibrosis.
ObjectivesTo evaluate the learning curve of radical hepatectomy combined with vascular and/or bile duct reconstruction (RHVBR) in the treatment of hepatic alveolar echinococcosis (HAE), and to explore the feasibility and safety of RHVBR. MethodsThe clinical data of 203 patients who received RHVBR treatment for HAE complicated with vascular invasion in West China Hospital from 2010 to 2018 were analyzed retrospectively. Cumulative sum (CUSUM) and risk-adjusted cumulative sum (RA-CUSUM) were used to analyze the learning curve of RHVBR, determine the learning stage, and compare the differences of intraoperative and postoperative outcome indexes in different learning stages. ResultsThe average operative time was (537.9±207.6) minutes, with blood loss amounted to 617.3 (138.9, 1 094.2) mL. Postoperative complications occurred in 65 cases, and the incidence of complications was 32.0%. Among them, 29 cases (14.3%) had serious complications. Three cases (1.5%) died within 90 days after operation. The results of RA-CUSUM analysis showed that 54 cases of surgery were the cut-off point of learning curve for serious postoperative complications. According to the results of CUSUM analysis, the whole queue was divided into the first stage (n=53) and the second stage (n=150) based on the completion of 53 operations. Compared with the first stage, the operative time and total postoperative hospital stay in the second stage was shortened, the incidence of serious complications was reduced, and the number of resected liver segments was increased. The differences were statistically significant (P<0.05). ConclusionIt is feasible and safe to treat HAE with RHVBR, and the incidence of serious complications is obviously reduced after 54 cases of operation.