Laparoscopic segment 4b+5 liver resection for stage T3 gallbladder cancer.

BACKGROUND: There is still controversy over whether to perform laparoscopic surgery for T3 stage gallbladder cancer. In addition, the necessity of segment 4b+5 liver resection for stage T3 gallbladder has not been reported. This article aims to explore the safety, effectiveness, and short-term prognosis of laparoscopic segment 4b+5 liver resection for T3 stage gallbladder cancer. METHODS: This is a retrospective multicenter propensity score-matched study. Disease-free survival, perioperative complications, and intraoperative safety were analyzed to evaluate safety and effectiveness. RESULTS: There was no significant difference in the incidence of intraoperative bleeding, number of lymph nodes obtained, postoperative complications, or disease-free survival (DFS) between the open group (OG) and laparoscopic group (LG) (P > 0.05). The DFS time of the S4b+5 resection group (S4b5) was longer than that of the wedge group (P = 0.016). Cox regression showed that positive margins (HR, 5.32; 95% CI 1.03-27.63; P = 0.047), lymph node metastasis (HR, 2.70; 95% CI 1.31-5.53; P = 0.007), and liver S4b+5 resection (HR, 0.30; 95% CI 0.14-0.66; P = 0.003) were independent risk factors for DFS. The operative time of indocyanine green (ICG) fluorescence-guided liver S4b5 segment resection was shorter than that of traditional laparoscopic S4b+5 resection guided by hepatic veins (P ≤ 0.001). CONCLUSION: Laparoscopic liver S4b+5 resection for T3 stage gallbladder cancer is safe and feasible and can prolong DFS. ICG fluorescence-guided negative staining may reduce the difficulty of the operation.

A new strategy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy for complex hemihepatolithiasis: A propensity score matching study.

BACKGROUND: There have been no studies on laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotripsy for the treatment of complex hemihepatolithiasis. This study aimed to investigate the safety and efficacy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy to treat complex hemihepatolithiasis. METHODS: The clinical data for patients who underwent laparoscopic anatomical hemihepatectomy for complex intrahepatic bile duct stones with or without common bile duct stones from January 2016 to June 2020 were prospectively collected. Patients were divided into 2 groups according to surgical approach: laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein (middle hepatic vein group) or laparoscopic anatomical hemihepatectomy not guided by the middle hepatic vein (nonmiddle hepatic vein group). The safety and short-term and long-term efficacy outcomes of the 2 groups were compared with 1:1 propensity score matching. RESULTS: With only a slightly longer operative time (P = .006), the initial and final stone residual rates in the middle hepatic vein group (n = 70) were significantly lower than those in the nonmiddle hepatic vein group (n = 70) (P = .002, P = .009). The bile leakage rate and stone recurrence rate were also significantly lower (P = .001, P = .001). CONCLUSION: Laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein is safe and effective for treating intrahepatic bile duct stones and can decrease the stone residual rate, reduce the bile leakage rate and stone recurrence rate, and accelerate early recovery. However, owing to the complicated technical requirements for surgeons and anesthesiologists, use of the procedure is limited to large and experienced medical centers.

The effectiveness, risks and improvement of laparoscopic pancreaticoduodenectomy during the learning curve: a propensity score-matched analysis.

BACKGROUND: Propensity score-matched analyses comparing the safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) to open pancreaticoduodenectomy (OPD) that consider the effect of the learning curve for LPD are lacking. We use Propensity score-matched to compare the safety and efficacy of LPD during the learning curve to OPD. METHODS: The medical records of 296 consecutive patients who had undergone LPD or OPD between September 2016 and August 2019 at Fujian Provincial Hospital were retrospectively reviewed. Patients treated with LPD were matched 1:1 to those treated with OPD. Calculation of propensity scores considered age, gender, body mass index (BMI), tumor location, pathology, incidence of obstructive jaundice, incidence of biliary drainage, pancreatic texture, pancreatic duct diameter, previous abdominal surgery, comorbidities, and case distribution of the surgical team. RESULTS: After propensity score matching, 196 patients were divided into two groups: 98 patients in the LPD group and 98 patients in the OPD group. LPD performed during the learning curve was associated with a longer median operative time (OT) (432 vs. 328 min, P<0.001), a higher incidence of major surgery-associated complications (32.7% vs. 14.3%, P=0.002), a higher incidence of clinically relevant pancreatic fistula (27.6% vs. 13.3%, P=0.013), and prolonged LOS (21.06 d vs. 16.94 d, P=0.033), but lower median intraoperative blood loss (200 vs. 300 mL, P<0.001) compared to OPD. Mean OT and LOS were significantly shorter in the late phase of the learning curve for LPD (P<0.001), and were similar to that for OPD. Age >60 years and a non-dilated MPD were significant predictors of clinically relevant pancreatic fistula, major surgery-associated complications, prolonged LOS and postoperative mortality at 90 days (all P<0.05). CONCLUSIONS: OT, incidence of major surgery-associated complications, and LOS were significantly increased in patients that underwent LPD, but were significantly improved during the learning curve. Elderly patients and patients with a non-dialated MPD should not be treated with LPD performed by inexperienced surgeons.

Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: A propensity, long-term follow-up analysis at a single center.

BACKGROUND: This trial was performed to compare short- and long-term outcomes after laparoscopic left-sided hepatectomy and open left-sided hepatectomy. Left-sided hepatectomy is a novel, minimally invasive operative technique for primary left-sided hepatolithiasis, but it has not been accepted widely due to the limited information about short- and long-term outcomes, effectiveness, and safety compared with the open approach. METHODS: Patients who underwent left-sided hepatectomy between January 2007 and December 2016 were reviewed and grouped into the open left-sided hepatectomy and left-sided hepatectomy groups, according to propensity score matching in terms of age, sex, body mass index, liver function, location of stone, hepatitis serology, and comorbidity on a ratio of 1:1. RESULTS: No significant differences were observed in the demographic characteristics of the 200 patients included in the study. For the left-sided hepatectomy group (100 patients) when compared to the open left-sided hepatectomy group (100 patients, the duration of hospital stay was less (10.3 vs 14.7 days, P< .001), the incidence of postoperative biliary fistulas (5% vs 14%, P = .003) and overall morbidity were less (25% vs 45%, P = .003), out of bed return to activity was expedited (2.0 vs 2.7 days, P< .001), and the rate of stone recurrence in the long-term follow-up was les (5.1% vs 17%, P = .003). CONCLUSION: Left-sided hepatectomy was associated with significantly lesser rate of stone recurrence, a shorter hospital stay, decreased morbidity and clinical biliary fistula rate, and expedited postoperative recovery compared with open left-sided hepatectomy.

Adenomas of the common bile duct in familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) or Gardner's syndrome is often accompanied by adenomas of the stomach and duodenum. We experienced a case of adenomas of the common bile duct in a 40-year-old woman with FAP presenting with acute cholangitis. Only 8 cases of adenomas or adenocarcinoma of the common bile duct have been reported in the literature in patients with FAP or Gardner's syndrome. Those patients presented with acute cholangitis or pancreatitis. Local excision or Whipple procedure may be the reasonable surgical option.

Amplified in breast cancer 1 enhances human cholangiocarcinoma growth and chemoresistance by simultaneous activation of Akt and Nrf2 pathways.

UNLABELLED: Transcriptional coactivator amplified in breast cancer 1 (AIB1) plays important roles in the progression of several cancers such as prostate cancer, breast cancer, and hepatocellular carcinoma. However, its role in cholangiocarcinoma (CCA), a chemoresistant bile duct carcinoma with a poor prognosis, remains unclear. In this study we found that AIB1 protein was frequently overexpressed in human CCA specimens and CCA cell lines. Down-regulation of AIB1 induced the G2/M arrest and decreased the expression of mitosis-promoting factors including Cyclin A, Cyclin B, and Cdk1 through suppressing the Akt pathway, which resulted in inhibiting CCA cell proliferation. In addition, AIB1 enhanced the chemoresistance of CCA cells at least in part through up-regulating the expression of antiapoptotic protein Bcl-2. AIB1 regulated the expression of Bcl-2 in CCA cells through activating the Akt pathway as well as suppressing intracellular reactive oxygen species (ROS). AIB1 suppressed ROS by up-regulating antioxidants such as glutathione synthetase and glutathione peroxidase, which are targets of the NF-E2-related factor 2 (Nrf2), a critical transcription factor that regulates antioxidants, detoxification enzymes, and drug efflux proteins. AIB1 also increased the expression of another two Nrf2 targets, ABCC2 and ABCG2, to enhance drug efflux. AIB1 served as an essential coactivator for Nrf2 activation by physically interacting with Nrf2 to enhance its transcriptional activity. CONCLUSION: AIB1 plays an important role in proliferation and chemoresistance of CCA through simultaneous activation of Akt and Nrf2 pathways, suggesting that AIB1 is a potential molecular target for CCA treatment.

Inhibition of allogeneic T-cell response by Kupffer cells expressing indoleamine 2,3-dioxygenase.

AIM: To explore the possibility and mechanism of inhibiting allogeneic T-cell responses by Kupffer cells (KC) pretreated with interferon-gamma (IFN-gamma) in vitro. METHODS: The expressions of indoleamine 2,3-dioxygenase (IDO) mRNA and FasL mRNA in KC pretreated with IFN-gamma were studied with real-time polymerase chain reaction (PCR). The catabolism of tryptophan by IDO from KC was analyzed by high performance liquid chromatography. Allogeneic T-cell response was used to confirm the inhibition of KC in vitro. The proliferation of lymphocytes was detected using [(3)H] thymidine incorporation. Cell cycle and lymphocyte apoptosis were evaluated by flow cytometric assay. RESULTS: Real-time PCR revealed IDO mRNA and FasL mRNA expressions in KC pretreated with IFN-gamma, and IDO catabolic effect was confirmed by a decrease in tryptophan and increase in kynurenine concentration. KC expressing IDO and FasL in BABL/c mice acquired the ability to suppress the proliferation of T-cells from C57BL/6, which could be blocked by addition of 1-methyl-tryptophan and anti-FasL antibody. KC expressing IDO could induce allogeneic T-cell apoptosis. CONCLUSION: In addition to Fas/FasL pathway, IDO may be another mechanism for KC to induce immune tolerance.

Pedunculated hepatocellular carcinoma and splenic metastasis.

Only a few cases of pedunculated hepatocellular carcinoma (P-HCC) have been reported in the literature. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals. Metastasis to spleen is mostly via hematogenous metastasis, direct metastasis to spleen was very rare. We report a case of P-HCC presenting as a left upper abdominal lesions which involved the spleen that was actually a P-HCC with splenic metastasis. This case is unique as P-HCC directly involved the spleen which is not via hematogenous metastasis.