RESUMO
BACKGROUND: We aimed to identify the prognostic factors for late intrahepatic recurrence (IHR), defined as recurrence more than two years after curative treatment of newly diagnosed hepatocellular carcinoma (HCC). METHODS: This retrospective cohort study included patients with newly diagnosed, previously untreated, very early, or early HCC treated with initial curative treatment and followed up without recurrence for more than two years, excluding early IHR defined as recurrence within two years in single center. Late IHR-free survival (IHRFS) was defined as the time interval from initial curative treatment to the first IHR or death without IHR, whichever occurred first. RESULTS: Among all the enrolled 2,304 patients, 1,427 (61.9%) underwent curative intent hepatectomy and the remaining 877 (38.1%) underwent local ablative therapy (LAT). During the follow-up after curative treatment (median, 82.6 months; range, 24.1 to 195.7), late IHR was detected in 816 (35.4%) patients. In the multivariable analysis, age, male sex, cirrhotic liver at diagnosis, type of initial treatment, and modified albumin-bilirubin (mALBI) grade were significant prognostic baseline factors. Furthermore, mALBI grade at three (2a vs. 1, P = 0.02, hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.04-1.70; 2b/3 vs. 1, P = 0.03; HR, 1.42; 95% CI, 1.03-1.94) and six months (2b/3 vs. 1; P = 0.006; HR, 1.61; 95% CI, 1.13-2.30) after initial curative treatment was also a significant prognostic factor for late IHR. CONCLUSION: After curative treatment for newly diagnosed early HCC, the mALBI grade at three and six months after initial curative treatment, as well as at baseline, was one of the most crucial prognostic factors for late IHR.
Assuntos
Bilirrubina , Carcinoma Hepatocelular , Neoplasias Hepáticas , Recidiva Local de Neoplasia , Modelos de Riscos Proporcionais , Albumina Sérica , Humanos , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Bilirrubina/sangue , Recidiva Local de Neoplasia/patologia , Idoso , Albumina Sérica/análise , Albumina Sérica/metabolismo , Prognóstico , Fatores de Risco , Hepatectomia , Adulto , Intervalo Livre de DoençaRESUMO
OBJECTIVE: To evaluate the safety and advisability of repeated liver resection (RLR) for recurrent intrahepatic cholangiocarcinoma (ICC). MATERIAL AND METHODS: The results of RLR for ICC recurrence (n=10) were retrospectively analyzed between 1999 and 2023. The control group consisted of patients undergoing primary liver resection for ICC (n=195). RESULTS: Surgery time (p=0.001) and blood loss (p=0.038) were lower in the RLR group. There were no blood transfusions (0 vs. 31.8%, p=0.034) and 90-day mortality (0 vs. 3.2%, p=1.0) in the same group. The risk of complications (30.0% vs.45.6%, p=0.517) and adverse events grade ≥ III (20.0% vs. 17.9%, p=1.0) was similar in both groups. Multifocal intrahepatic nodes were more common in the RLR group (60% vs. 37.9%, p=0.193), while there were no negative factors such as lymph nodes involvement (0 vs. 34.4%, p=0.032) and invasion of surrounding structures (0 vs. 38.5%, p=0.015). Dimensions of the largest node were smaller in repeated resection (2 vs. 8 cm, p<0.0001). Incidence of R0 resections (80.0% vs. 82.1%, p=1.0) was comparable. Long-term results were similar: five-year overall survival 17.2% and 34.7% (p=0.912), three-year disease-free survival 20.0% and 26.5% (p=0.421). CONCLUSION: Similar results of repeated and primary liver resections confirm advisability of RLR for intrahepatic recurrence of ICC.
Assuntos
Neoplasias dos Ductos Biliares , Colangiocarcinoma , Hepatectomia , Recidiva Local de Neoplasia , Humanos , Colangiocarcinoma/cirurgia , Masculino , Feminino , Hepatectomia/métodos , Hepatectomia/efeitos adversos , Pessoa de Meia-Idade , Neoplasias dos Ductos Biliares/cirurgia , Neoplasias dos Ductos Biliares/patologia , Recidiva Local de Neoplasia/epidemiologia , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Reoperação/métodos , Idoso , Federação Russa/epidemiologia , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Duração da Cirurgia , Avaliação de Processos e Resultados em Cuidados de SaúdeRESUMO
BACKGROUND: One of the main limitations to achieving a complete tumor resection in patients with technically resectable liver tumors is the presence of a small future liver remnant (FLR). Portal vein embolization (PVE) allows hypertrophy of the non-embolized lobe, reducing the risk of postoperative liver failure. AIM: To describe the experience of portal embolization prior to hepatectomy and its effectiveness in converting advanced unresectable liver tumors into resectable tumors. METHODS: Non-concurrent cohort study. All patients who underwent PVE before hepatectomy between 2016 and 2020 in our center were included. Demographic and diagnostic variables, pre and post-PVE volumes, perioperative variables, and global and disease-free survival were analyzed. RESULTS: Nineteen patients were included. Median age 66 (54-72) years and 57.9% (n= 11) were women. Bilateral metastases were present in 78.9% (n= 15). Sixteen patients (84.2%) received neoadjuvant chemotherapy. One patient (5.3%) had a complication after PVE. The median time between embolization and volumetry was 5.3 weeks (4.7-7.1). Median FLR before and after PVE were 19.8% (16.2-27.7) and 30% (25.2-40.5), respectively. The median percentage of hypertrophy was 48% (40.4-76.5). Fifteen patients (78.9%) underwent hepatectomy. Significant complications occurred in 26.6% (n= 4); among them, three patients (20%) presented postoperative liver failure. CONCLUSIONS: PVE is safe and effective in promoting FLR hypertrophy in the presence of chemotherapy, allowing patients with advanced liver tumors to undergo surgery with curative intent.
Assuntos
Embolização Terapêutica , Hepatectomia , Neoplasias Hepáticas , Veia Porta , Humanos , Hepatectomia/métodos , Feminino , Embolização Terapêutica/métodos , Pessoa de Meia-Idade , Masculino , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/terapia , Idoso , Chile , Resultado do Tratamento , Estudos Retrospectivos , Intervalo Livre de Doença , Cuidados Pré-Operatórios/métodosRESUMO
Platelets play a crucial role in tissue regeneration, and their involvement in liver regeneration is well-established. However, the specific contribution of platelet-derived Transforming Growth Factor Beta 1 (TGFß1) to liver regeneration remains unexplored. This study investigated the role of platelet-derived TGFß1 in initiating liver regeneration following 2/3 liver resection. Using platelet-specific TGFß1 knockout (Plt.TGFß1 KO) mice and wild-type littermates (Plt.TGFß1 WT) as controls, the study assessed circulating levels and hepatic gene expression of TGFß1, Platelet Factor 4 (PF4), and Thrombopoietin (TPO) at early time points post-hepatectomy (post-PHx). Hepatocyte proliferation was quantified through Ki67 staining and PCNA expression in total liver lysates at various intervals, and phosphohistone-H3 (PHH3) staining was employed to mark mitotic cells. Circulating levels of hepatic mitogens, Hepatocyte Growth Factor (HGF), and Interleukin-6 (IL6) were also assessed. Results revealed that platelet-TGFß1 deficiency significantly reduced total plasma TGFß1 levels at 5 h post-PHx in Plt.TGFß1 KO mice compared to controls. While circulating PF4 levels, liver platelet recruitment and activation appeared normal at early time points, Plt.TGFß1 KO mice showed more stable circulating platelet numbers with higher numbers at 48 h post-PHx. Notably, hepatocyte proliferation was significantly reduced in Plt.TGFß1 KO mice. The results show that a lack of TGFß1 in platelets leads to an unbalanced expression of IL6 in the liver and to strongly increased HGF levels 48 h after liver resection, and yet liver regeneration remains reduced. The study identifies platelet-TGFß1 as a regulator of hepatocyte proliferation and platelet homeostasis in the early stages of liver regeneration.
Assuntos
Plaquetas , Hepatectomia , Regeneração Hepática , Camundongos Knockout , Trombopoetina , Fator de Crescimento Transformador beta1 , Animais , Regeneração Hepática/fisiologia , Fator de Crescimento Transformador beta1/metabolismo , Fator de Crescimento Transformador beta1/genética , Camundongos , Plaquetas/metabolismo , Trombopoetina/metabolismo , Interleucina-6/metabolismo , Interleucina-6/genética , Proliferação de Células , Fator de Crescimento de Hepatócito/metabolismo , Fator de Crescimento de Hepatócito/genética , Fígado/metabolismo , Hepatócitos/metabolismo , Masculino , Fator Plaquetário 4/metabolismo , Fator Plaquetário 4/genética , Camundongos Endogâmicos C57BLRESUMO
Sarcomas are challenging and conventionally referred to sarcoma specialist centres. In select cases with required surgical expertise, collaboration with a quaternary sarcoma centre rather than an upfront transfer of care may reduce logistic challenges without compromising patient care.We present a case series of three rare tumours of hepatobiliary origin-two cases of undifferentiated embryonal liver sarcoma in adults and one case of follicular dendritic sarcoma of the cystic lymph node.All three patients underwent surgery in a non-sarcoma specialist centre by hepatobiliary specialist surgeons with concurrent remote referrals to a sarcoma specialist quaternary centre. Both centres belong to the same cluster. R0 resection and no significant postoperative morbidity were achieved. All three patients currently remain disease-free.The unique and integrated healthcare systems within Singapore render cross-institution management possible. This case series suggests that an established setup for cross-centre collaboration facilitates wholistic patient care with good outcomes.
Assuntos
Hospitais de Ensino , Neoplasias Hepáticas , Sarcoma , Humanos , Sarcoma/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/patologia , Masculino , Feminino , Adulto , Singapura , Pessoa de Meia-Idade , Hepatectomia/métodosRESUMO
BACKGROUND: This study aims to investigate preoperative prognostic factors available for intrahepatic cholangiocarcinoma (ICC) patients and propose a new preoperative prognostic scoring system for ICC that combines CA19-9 and neutrophil/lymphocyte ratio (NLR). METHODS: In this retrospective analysis, 1728 patients diagnosed with ICC and undergoing curative liver resections were studied. This study employed univariate and multivariate Cox regression to find factors affecting recurrence and overall survival (OS), and furthermore assessed how preoperative models influenced tumor traits and postoperative recurrence. RESULTS: The results of the multivariate Cox regression analysis indicated that two preoperative variables, NLR and Ca19-9, were independent risk factors affecting postoperative recurrence and OS in ICC patients. Based on this data, assigning a score of 0 (NLR ≤ 2.4 and Ca19-9 ≤ 37U/ml) or 1 (NLR > 2.4 and Ca19-9 > 37U/ml) to these two factors, a preoperative prognostic score was derived. According to the scoring model, patients were divided into three groups: 0 points (low-risk group), 1 point (intermediate-risk group), and 2 points (high-risk group). The 5-year recurrence and OS rates for the three groups were 56.6%, 68.2%, 77.8%, and 56.8%, 40.6%, 27.6%, respectively, with all P values < 0.001. Furthermore, high-risk group patients were more prone to early recurrence (early recurrence rates for high-, intermediate-, and low-risk groups were 56.8%, 51.5%, and 37.1%, respectively, P < 0.001) and extrahepatic metastasis (extrahepatic metastasis rates for high-, intermediate-, and low-risk groups were 31.7%, 26.4%, and 15.4%, respectively, P < 0.001). In terms of tumor characteristics, high-risk group patients had larger tumor diameters and were more likely to experience microvascular invasion, lymph node metastasis, and perineural invasion. CONCLUSIONS: The predictive capacity of postoperative recurrence and OS rates in ICC patients is effectively captured by the preoperative scoring system incorporating NLR and CA19-9 levels.
Assuntos
Neoplasias dos Ductos Biliares , Antígeno CA-19-9 , Colangiocarcinoma , Hepatectomia , Linfócitos , Recidiva Local de Neoplasia , Neutrófilos , Humanos , Colangiocarcinoma/cirurgia , Colangiocarcinoma/sangue , Colangiocarcinoma/patologia , Colangiocarcinoma/mortalidade , Masculino , Feminino , Neutrófilos/patologia , Pessoa de Meia-Idade , Prognóstico , Neoplasias dos Ductos Biliares/cirurgia , Neoplasias dos Ductos Biliares/patologia , Neoplasias dos Ductos Biliares/sangue , Neoplasias dos Ductos Biliares/mortalidade , Estudos Retrospectivos , Linfócitos/patologia , Antígeno CA-19-9/sangue , Idoso , Recidiva Local de Neoplasia/sangue , Recidiva Local de Neoplasia/patologia , Adulto , Período Pré-Operatório , Contagem de Linfócitos , Fatores de RiscoRESUMO
BACKGROUND: Evaluation of the influence of the age of the patients upon the outcomes of liver resection (LR) for hepatocellular carcinoma (HCC). METHODS: HCC patients who underwent LR between 2010 and 2020 were analyzed. They were divided into 3 groups depending on the patient's age. Group I (patients less than 60 years), Group II (patients between 60 and 69 years), and Group III (patients equal to or more than 70 years). RESULTS: 364 patients were included. A significantly higher serum bilirubin and alpha feto-protein were noted in Group I and serum creatinine was noted in Group III. The study groups did not show any significant differences regarding HCC site, number, macrovascular invasion, the extent of LR, Pringle maneuver, and perioperative blood transfusions. Longer operation time was found in Groups II and III, while more blood loss was noted in Group (I) Group I patients had longer hospital stays. Higher postoperative morbidities were noted in both Group I and Group (II) Higher incidence of post-hepatectomy liver dysfunction was noted in Group I. More early mortalities were found in Group I, related to liver failure. We did not experience early mortality in Group (III) Late Mortalities occurred in 117 patients (32.1%). HCC recurrence occurred in 165 patients (45.3%). Regarding the overall- and tumor-free survival, we did not experience any significant differences among the 3 groups (Log Rank: p = 0.371 and 0.464 respectively). CONCLUSIONS: Curative LR can be safely performed in selected elderly patients with HCC. An advanced patient's age should not be considered as a contraindication for curative LR.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/mortalidade , Hepatectomia/métodos , Idoso , Masculino , Feminino , Pessoa de Meia-Idade , Fatores Etários , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso de 80 Anos ou mais , Adulto , Duração da Cirurgia , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: The prognostic implications of the RAS status in colorectal cancer liver metastasis (CRLM) remain unclear. This study investigated the prognostic significance of RAS status after curative hepatectomy, focusing on surgical controllability. METHODS: This retrospective study included liver-only CRLM patients who underwent the first hepatectomy between 2015 and 2022 at the National Cancer Center Hospital. Recurrence-free survival (RFS), surgically controllable period (SCP), and overall survival (OS) were compared between RAS wild-type (RAS-wt) and mutant (RAS-mt) patients. Multivariate analyses were conducted to identify independent prognostic factors for each outcome and independent risk factors for less than 1 year SCP. RESULTS: A total of 150 patients were evaluated, comprising 63 patients with RAS-mt status. There was no significant difference in RFS between RAS-mt and RAS-wt (7.00 vs. 8.03 months, p = 0.48). RAS-mt patients exhibited worse SCP (11.80 vs.21.13 months, p < 0.001) and OS (44.03 vs. 70.03 months, p < 0.001) compared to RAS-wt. Multivariate analysis identified RAS-mt as an independent prognostic factor for both OS (hazard ratio [HR]: 3.37, p < 0.001) and SCP (HR: 2.20, p < 0.001), and as an independent risk factor for less than 1 year of SCP (odds ratio, 2.31; p = 0.03). CONCLUSIONS: CRLM with RAS mutations should be considered for strict surgical indications with preoperative chemotherapy and thorough examination, considering the possibility of short SCP.
Assuntos
Neoplasias Colorretais , Hepatectomia , Neoplasias Hepáticas , Mutação , Humanos , Estudos Retrospectivos , Masculino , Neoplasias Colorretais/patologia , Neoplasias Colorretais/genética , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/mortalidade , Feminino , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/mortalidade , Pessoa de Meia-Idade , Hepatectomia/métodos , Prognóstico , Taxa de Sobrevida , Idoso , Seguimentos , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Adulto , Biomarcadores Tumorais/genéticaRESUMO
BACKGROUND: We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. METHODS: The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. RESULTS: The median operative time and estimated blood loss were 395 min and 50 mL, respectively. The median length of postoperative hospital stay was 9 days. Pneumothorax was the only severe postoperative complication. CONCLUSIONS: Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.
Assuntos
Hepatectomia , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos , Hepatectomia/métodos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fígado/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Neoplasias Hepáticas/cirurgia , Tempo de Internação , Adulto , Resultado do Tratamento , Instrumentos CirúrgicosRESUMO
Objective The influence of macrovascular invasion on the therapeutic efficacy of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) in hepatocellular carcinoma (HCC) patients has not been previously reported. This study primarily examines the therapeutic effect of ALPPS in treating HCC with macrovascular invasion. Methods 89 patients who underwent ALPPS at the First Affiliated Hospital of Guangxi Medical University from December 2016 to December 2021 were included. Patients were categorized into three groups based on macrovascular invasion status: pure HCC, HCC with portal vein tumor thrombus (PVTT), and HCC with hepatic vein tumor thrombus (HVTT). Outcome measures such as postoperative complications, liver hyperplasia rates, and survival times were compared across the groups. Results The study comprised 44 patients without macrovascular invasion and 45 cases with it, including 37 PVTT and 8 HVTT cases. Patients with PVTT or HVTT had a higher rate of complications and liver failure after the first ALPPS stage compared to those without macrovascular invasion (P = 0.018, P = 0.036). This trend was also observed in the stratified analysis of severe complications. However, no significant differences were found in these outcomes after the second ALPPS stage among the groups. The volume and rate of future liver remnant proliferation between the two stages of ALPPS were not statistically different among the groups, with median overall survival times of 42, 39, and 33 months, and progression-free survival times of 30, 24, and 14 months, respectively (P = 0.412 and P = 0.281). Conclusion ALPPS for HCC with macrovascular invasion was considered safe, feasible, and effective, as it achieved therapeutic effects comparable to those in cases without macrovascular invasion.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Invasividade Neoplásica , Veia Porta , Humanos , Hepatectomia/métodos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/mortalidade , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/mortalidade , Masculino , Veia Porta/cirurgia , Veia Porta/patologia , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Ligadura/métodos , Taxa de Sobrevida , Seguimentos , Prognóstico , Complicações Pós-Operatórias/etiologia , Idoso , AdultoRESUMO
RATIONALE: Neuroendocrine carcinoma originating from extrahepatic bile duct is very rare, and only a few cases have been reported. Because of its scarcity of incidence, not much is known about the disease but for its aggressiveness and poor prognosis. PATIENT CONCERNS: In this report, we present 2 cases of large cell neuroendocrine carcinoma (LCNEC) originating from extrahepatic bile duct. Case 1: a 60-year-old woman presented with jaundice but no abdominal pain. Case 2: a 67-year-old man also presented with jaundice, along with abdominal discomfort and appetite loss. DIAGNOSES: Case 1: LCNEC with a focal adenocarcinoma component (pT2aN1M0, pStage IIIB). Case 2: LCNEC with a focal adenocarcinoma component (pT1N1M0, pStage IIB). INTERVENTIONS: Case 1: the patient underwent left hepatectomy and caudatectomy with hepaticojejunostomy, followed by 6 cycles of adjuvant chemotherapy (etoposide and cisplatin). Case 2: the patient underwent laparoscopic pylorus-preserving pancreatoduodenectomy, followed by 6 cycles of adjuvant chemotherapy (etoposide and cisplatin). OUTCOMES: Case 1: liver metastasis was detected 6 months postoperatively, and despite multiple chemotherapy regimens, the patient died 24 months post-surgery. Case 2: liver metastasis was detected 23 months postoperatively. The patient is still alive 36 months post-surgery after receiving multiple chemotherapy regimens and radiotherapy. LESSONS: Given the rarity of LCNEC, it is essential to continue collecting and reporting additional case studies to build a more comprehensive understanding of the disease. Although the prognosis for LCNEC is generally poor, the use of a multidisciplinary approach and further research will be critical in developing more effective treatment strategies in the future.
Assuntos
Neoplasias dos Ductos Biliares , Carcinoma Neuroendócrino , Humanos , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/tratamento farmacológico , Carcinoma Neuroendócrino/terapia , Feminino , Quimioterapia Adjuvante/métodos , Pessoa de Meia-Idade , Idoso , Masculino , Neoplasias dos Ductos Biliares/cirurgia , Neoplasias dos Ductos Biliares/patologia , Carcinoma de Células Grandes/cirurgia , Carcinoma de Células Grandes/patologia , Carcinoma de Células Grandes/tratamento farmacológico , Carcinoma de Células Grandes/terapia , Evolução Fatal , Hepatectomia/métodos , Pancreaticoduodenectomia/métodos , Ductos Biliares Extra-Hepáticos/patologia , Ductos Biliares Extra-Hepáticos/cirurgia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêuticoRESUMO
Pure laparoscopic donor hepatectomy (PLDH) has become a standard practice for living donor liver transplantation in expert centers. Accurate understanding of biliary structures is crucial during PLDH to minimize the risk of complications. This study aims to develop a deep learning-based segmentation model for real-time identification of biliary structures, assisting surgeons in determining the optimal transection site during PLDH. A single-institution retrospective feasibility analysis was conducted on 30 intraoperative videos of PLDH. All videos were selected for their use of the indocyanine green near-infrared fluorescence technique to identify biliary structure. From the analysis, 10 representative frames were extracted from each video specifically during the bile duct division phase, resulting in 300 frames. These frames underwent pixel-wise annotation to identify biliary structures and the transection site. A segmentation task was then performed using a DeepLabV3+ algorithm, equipped with a ResNet50 encoder, focusing on the bile duct (BD) and anterior wall (AW) for transection. The model's performance was evaluated using the dice similarity coefficient (DSC). The model predicted biliary structures with a mean DSC of 0.728 ± 0.01 for BD and 0.429 ± 0.06 for AW. Inference was performed at a speed of 15.3 frames per second, demonstrating the feasibility of real-time recognition of anatomical structures during surgery. The deep learning-based semantic segmentation model exhibited promising performance in identifying biliary structures during PLDH. Future studies should focus on validating the clinical utility and generalizability of the model and comparing its efficacy with current gold standard practices to better evaluate its potential clinical applications.
Assuntos
Aprendizado Profundo , Hepatectomia , Laparoscopia , Transplante de Fígado , Doadores Vivos , Humanos , Hepatectomia/métodos , Laparoscopia/métodos , Transplante de Fígado/métodos , Estudos Retrospectivos , Ductos Biliares/cirurgia , Masculino , Feminino , Adulto , Estudos de Viabilidade , Sistema Biliar/diagnóstico por imagem , AlgoritmosRESUMO
INTRODUCTION: Robotic-assisted surgery has become increasingly popular because of its potential benefits. Anatomical liver resection (ALR) is a valuable strategy in hepatocellular carcinoma (HCC) management. ALR with indocyanine green (ICG) fluorescence navigation was reported as an effective solution for segment identification. We reported a simple and convenient "preoperative positive staining technique" for laparoscopic ALR to overcome some limitations. To our knowledge, this is the first report of robotic-assisted surgery in which ALR was performed using this technique. MATERIALS AND SURGICAL TECHNIQUE: A 69-year-old man presented with a 12-mm HCC in segment 8. Preoperative three-dimensional simulation images showed that the fourth-order branch of the portal vein was a tumor-bearing portal pedicle. After anesthesia induction, 1 mL of 0.025 mg/mL ICG was injected percutaneously into this branch under B-mode ultrasound guidance before pneumoperitoneum. A robotic laparoscope was inserted. The preoperative positive staining area was clearly stained on the liver surface with the Firefly mode on the da Vinci Xi system. Based on the demarcation line, the liver parenchymal resection was started. The ICG fluorescence staining area was checked frequently on the resected side of the liver transection plane. Subsequently, the fourth-order portal branch was identified with the ICG fluorescence technique and ligated. Finally, the specimen was resected. The operation took 352 min, with 10 mL of blood loss, and was completed without any operative problems. DISCUSSION: Although many cases are required, the proposed preoperative positive staining technique appears useful for accurate and precise surgery given the increasing application of robotic-assisted hepatectomy.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Verde de Indocianina , Neoplasias Hepáticas , Procedimentos Cirúrgicos Robóticos , Humanos , Idoso , Masculino , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Procedimentos Cirúrgicos Robóticos/métodos , Hepatectomia/métodos , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Ultrassonografia de Intervenção , Corantes , Laparoscopia/métodos , Cuidados Pré-Operatórios/métodosRESUMO
PURPOSE: Hepatocellular carcinoma (HCC) patients beyond the Milan criteria (MC) who undergo liver resection have high recurrence rates and poor prognosis, and sometimes experience very early recurrence (VER) within six months after surgery. This study aimed to identify predictive factors, including the newly proposed C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index, for VER after surgery for HCC beyond MC. METHODS: We included patients who underwent initial liver resection for HCC beyond MC between 2000 and 2021. We defined VER as recurrence within six months after surgery and compared the clinicopathological factors and long-term prognosis between the VER and non-VER groups. Multivariate analysis identified risk factors for VER and evaluated the potential for prognostic stratification using these factors. RESULTS: The overall survival (OS) and post-recurrence survival were significantly worse in the VER group compared to patients with recurrence in 7-12 months, over 12 months, and without recurrence (median survival time (MST) 1.16 vs. 5.14, 7.26, and undefined; and MST 0.81 vs. 4.34, and 5.48, respectively, P < 0.01). Alpha-fetoprotein (AFP) ≥ 200, non-simple nodule (SN) type on preoperative imaging, and CALLY index < 2.8 were independent prognostic factors (P < 0.01 for all). An increased risk factor count was correlated with poorer VER and OS rates, allowing for effective stratification. CONCLUSION: VER after hepatic resection for HCC beyond MC was associated with a significantly poorer prognosis. AFP, non-SN type on imaging, and CALLY index are valuable preoperative indicators. Patients with multiple risk factors have a worse prognosis and may be candidates for multimodal treatment.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Recidiva Local de Neoplasia , Humanos , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Feminino , Recidiva Local de Neoplasia/patologia , Pessoa de Meia-Idade , Idoso , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Proteína C-Reativa/análise , Valor Preditivo dos Testes , Taxa de Sobrevida , AdultoRESUMO
Nucleostemin (NS) plays a role in liver regeneration, and aging reduces its expression in the baseline and regenerating livers following 70% partial hepatectomy (PHx). Here we interrogate the mechanism controlling NS expression during liver regeneration and aging. The NS promoter was analyzed by TRANSFAC. Functional studies were performed using cell-based luciferase assay, endogenous NS expression in Hep3B cells, mouse livers with a gain-of-function mutation of C/EBPα (S193D), and mouse livers with C/EBPα knockdown. We found a CAAT box with four C/EBPα binding sites (-1216 to -735) and a GC box with consensus binding sites for c-Myc, E2F1, and p300-associated protein complex (-633 to -1). Age-related changes in NS expression correlated positively with the expression of c-Myc, E2F1, and p300, and negatively with that of C/EBPα and C/EBPß. PHx upregulated NS expression at 1d, coinciding with an increase in E2F1 and a decrease in C/EBPα. C/EBPα bound to the consensus sequences found in the NS promoter in vitro and in vivo, inhibited its transactivational activity in a binding site-dependent manner, and decreased the expression of endogenous NS in Hep3B cells. In vivo activation of C/EBPα by the S193D mutation resulted in a 4th-day post-PHx reduction of NS, a feature shared by 16-m/o livers. Finally, C/EBPα knockdown increased its expression in aged (24-m/o) livers under both baseline and regeneration conditions. This study reports the C/EBPα suppression of NS expression in aged livers, providing a new perspective on the mechanistic orchestration of tissue homeostasis in aging.
Assuntos
Envelhecimento , Proteínas de Ligação ao GTP , Regeneração Hepática , Proteínas Nucleares , Regiões Promotoras Genéticas , Proteínas Proto-Oncogênicas c-myc , Animais , Regeneração Hepática/genética , Regeneração Hepática/fisiologia , Camundongos , Envelhecimento/metabolismo , Envelhecimento/fisiologia , Envelhecimento/genética , Humanos , Proteínas Nucleares/metabolismo , Proteínas Nucleares/genética , Proteínas de Ligação ao GTP/metabolismo , Proteínas de Ligação ao GTP/genética , Proteínas Proto-Oncogênicas c-myc/metabolismo , Proteínas Proto-Oncogênicas c-myc/genética , Proteína beta Intensificadora de Ligação a CCAAT/metabolismo , Proteína beta Intensificadora de Ligação a CCAAT/genética , Fator de Transcrição E2F1/metabolismo , Fator de Transcrição E2F1/genética , Hepatectomia , Sítios de Ligação , Fígado/metabolismo , Proteína p300 Associada a E1A/metabolismo , Regulação da Expressão Gênica , Transcrição Gênica , Proteína alfa Estimuladora de Ligação a CCAAT/metabolismo , Proteína alfa Estimuladora de Ligação a CCAAT/genética , Masculino , Proteínas de Transporte/metabolismo , Proteínas de Transporte/genética , Camundongos Endogâmicos C57BL , Linhagem Celular Tumoral , Proteínas de Ligação a RNARESUMO
BACKGROUND: Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. METHODS: A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. RESULTS: A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). CONCLUSIONS: Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance. TRIAL REGISTRATION: The study was registered in the Clinical Trials Registry at www. CLINICALTRIALS: gov/ , NCT number: NCT06301932.
Assuntos
Analgesia Epidural , Analgésicos Opioides , Hepatectomia , Morfina , Dor Pós-Operatória , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Analgesia Epidural/métodos , Analgésicos Opioides/administração & dosagem , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Morfina/administração & dosagem , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Pontuação de Propensão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes. METHODS: All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann-Whitney test and the Kruskal-Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality. RESULTS: A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042). CONCLUSION: Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality.
Assuntos
Hepatectomia , Fígado , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Estudos Retrospectivos , Idoso , Fígado/cirurgia , Fígado/irrigação sanguínea , Fígado/diagnóstico por imagem , Artéria Celíaca/cirurgia , Artéria Celíaca/diagnóstico por imagem , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , AdultoRESUMO
Background and Objectives: Microvascular invasion (MVI) significantly impacts recurrence and survival rates after liver resection in hepatocellular carcinoma (HCC). Pre-operative prediction of MVI is crucial in determining the treatment strategy. This study aims to develop a nomogram model to predict the probability of MVI based on clinical features in HCC patients. Materials and Methods: A total of 489 patients with a pathological diagnosis of HCC were enrolled from our hospital. Those registered from 2012-2015 formed the derivation cohort, and those from 2016-2019 formed the validation cohort for pre-operative prediction of MVI. A nomogram model for prediction was created using a regression model, with risk factors derived from clinical and tumor-related features before surgery. Results: Using the nomogram model to predict the odds ratio of MVI before hepatectomy, the AFP, platelet count, GOT/GPT ratio, albumin-alkaline phosphatase ratio, ALBI score, and GNRI were identified as significant variables for predicting MVI. The Youden index scores for each risk variable were 0.287, 0.276, 0.196, 0.185, 0.115, and 0.112, respectively, for the AFP, platelet count, GOT/GPT ratio, AAR, ALBI, and GNRI. The maximum value of the total nomogram scores was 220. An increase in the number of nomogram points indicated a higher probability of MVI occurrence. The accuracy rates ranged from 55.9% to 64.4%, and precision rates ranged from 54.3% to 68.2%. Overall survival rates were 97.6%, 83.4%, and 73.9% for MVI(-) and 80.0%, 71.8%, and 41.2% for MVI(+) (p < 0.001). The prognostic effects of MVI(+) on tumor-free survival and overall survival were poor in both the derivation and validation cohorts. Conclusions: Our nomogram model, which integrates clinical factors, showed reliable calibration for predicting MVI and provides a useful tool enabling surgeons to estimate the probability of MVI before resection. Consequently, surgical strategies and post-operative care programs can be adapted to improve the prognosis of HCC patients where possible.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Nomogramas , Humanos , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Feminino , Hepatectomia/métodos , Pessoa de Meia-Idade , Idoso , Invasividade Neoplásica , Microvasos/patologia , Adulto , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND/AIM: Combined hepatocellular cholangiocarcinoma (cHCC-CCA) is a rare subtype of primary liver carcinoma, characterized by the unequivocal presence of both hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA). However, its clinicopathological characteristics have not yet been thoroughly elucidated. In particular, cholangiolocellular carcinoma (CLC) was classified as a subtype of cHCC-CCA according to the 2010 World Health Organization (WHO) classification. However, according to the 2019 WHO classification, tumors displaying histological features consistent with CLC but lacking evidence of hepatocellular differentiation should be regarded as a distinct subtype of iCCA. Nevertheless, there may be notable differences in prognosis between CLC and iCCA, indicating the necessity for refining the classification when devising clinical treatment strategies. This study aimed to determine the clinicopathological features and prognostic factors of cHCC-CCAs following radical resection. PATIENTS AND METHODS: Between January 2010 and September 2020, based on the 2010 WHO classification, we retrospectively studied the clinicopathological features and prognoses of patients with cHCC-CCAs in relation to the pathological dominant classification. The patients were classified according to the pathological dominant components of cHCC-CCA as HCC-dominant (HCC-D), iCCA-dominant (iCCA-D), or CLC-dominant (CLC-D). RESULTS: Data of 55 patients who underwent primary radical hepatectomy for cHCC-CCA were analyzed. The prevalences of each dominant classification were HCC-D, 21 (38.2%); iCCA-D, 11 (20.0%); and CLC-D, 23 (41.8%). Multivariate analysis showed that dominant classification was an independent risk factor for recurrence and cancer-specific survival (CSS). CONCLUSION: The dominant classification of cHCC-CCA has the potential to predict recurrence and CSS.