Location and extent of cavernous transformation of the portal vein dictates different visceral side revascularization in Meso-Rex bypass.

BACKGROUND: As an emerging standard of care for portal vein cavernous transformation (PVCT), Meso-Rex bypass (MRB) has been complicated and variated. The study aim was to propose a new classification of PVCT to guide MRB operations. METHODS: Demographic data, the extent of extrahepatic PVCT, surgical methods for visceral side revascularization, intraoperative blood loss, operating time, changes in visceral venous pressure before and after MRB, postoperative complications and the condition of bypass vessels after MRB were extracted retrospectively from the medical records of 19 patients. RESULTS: The median age of the patients (13 males and 6 females) was 32.5 years, while two patients were underage. Causes of PVCT can be summarized as follows: thrombophilia such as dysfunction of antithrombin III or proteins C; secondary to abdominal surgeries; secondary to abdominal infection or traumatic intestinal obstruction, and unknown causes. Intraoperatively, the median operation time was 9.5 h (7-13 h), and the intraoperative blood loss was 300 mL (100-1,600 mL). Ten cases used autologous blood vessels while 10 used allogeneic blood vessels. The vascular anastomosis was divided into the following types according to the site and approach: Type (T) 1-PV pedicel type, T2-confluence type, T3-major visceral vascular type; and T4-collateral visceral vascular type. Furthermore, the visceral venous pressure before and after MRB dropped significantly from 36 cmH2O (28-44) to 24.5 cmH2O (15-31) (P < 0.01). Postoperatively, one patient had delayed wound healing, two developed biochemical pancreatic fistulae, one experienced lymphatic leakage, the former caused by heat damage of the pancreatic tissues, the latter by cutting lymphatic vessels in the mesentery or removing the local lymph nodes during the process of separating the superior mesenteric vein, and one was re-operated on for an intervening intestinal fistulae. Postoperative enhanced CT scans revealed a significant improvement in abdominal varix in the patients with patent bypass, and at the 1-year postoperative follow-up, enhanced CT scans of six patients showed that the long axis of the spleen was reduced by ≥ 2 cm. CONCLUSIONS: MRB can effectively reduce visceral venous pressure in patients with PVCT. It is feasible to determine the PVCT type according to the extent of involvement and to choose individualized visceral side revascularization performances.

Modified Meso-Rex bypass with umbilical vein recanalization and intra-operative stenting.

PURPOSE: The aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intra-operative stenting to treat portal vein cavernous transformation. METHODS: In total, 13 portal vein cavernous transformation patients underwent Meso-Rex bypass surgery, consisting of bypass grafts between the superior mesenteric vein (SMV) and the recess of Rex as well as through the ligamentum teres hepatis without stent implantation (Group A, n = 9) and umbilical vein recanalization with intra-operative stent implantation (Group B, n = 4). RESULTS: In Group A, the bypass diameter was 0-6 mm (median 3 mm) and blood flow velocity 25-115 cm/s (median 72 cm/s) 1 month after Meso-Rex bypass surgery, with open bypass times of 0-67 months (median 6 months); 6 patients in this group developed postoperative Meso-Rex bypass occlusions. A patient in Group A treated with ligamentum teres hepatis recanalization needed a thrombectomy and stent implantation during a second surgery 2 days after the Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group B, the average modified Meso-Rex bypass diameter was 5.5-6.5 mm (median 6 mm), and the bypass vessels remained open in all patients, with blood flow rates of 45-100 cm/s (median 76.5 cm/s) 1 month after the modified Meso-Rex bypass, up to the endpoint (15-33 months, median 24 months). The rate of bypass occlusions in Group A and Group B were 22.2% and 0%, 30.0% and 0%, and 55.6% and 0% at 1 month, 3 months, and 1 year, respectively, after bypass surgery. CONCLUSIONS: Our novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.

The Use of Three-Dimensional Printing Model in the Training of Choledochoscopy Techniques.

AIM: To evaluate the application value of a three-dimensional (3D) printing model in the training of choledochoscopy techniques. MATERIALS AND METHODS: Imaging data from two patients with biliary dilatation were used to produce two 3D reconstruction models which were subsequently constructed into 3D printing models (No. 1 and No. 2). Four hepatobiliary surgeons evaluated the anatomical accuracy and academic teaching value of the printed models. Twenty resident trainees with no prior experience in any kind of endoscopic techniques were randomly and symmetrically divided into two groups. The training group (A) used the 3D model No. 1 in the learning of biliary tract anatomy and practice techniques of choledochoscopy. The control group (B) got the virtual 3D image of the same model on computer for learning. After 4 weeks, the model No. 2 was used to reassess the trainees' subjective and objective progress in anatomy familiarity and choledochoscopy manipulations. RESULTS: All consulted surgeons agreed that the 3D models realistically reproduced the anatomy of the biliary system. All trainees in group A agreed or strongly agreed that the 3D models provided good anatomical realism, enhanced their experience in the training of choledochoscopy techniques, and aided in their learning of biliary anatomy. With the practice went on, they increased the accuracy and showed a reduction in operation time on the model No. 1. During final examination with model No. 2, the rate of correct anatomical structure identification in training group was significantly higher than group B (p < 0.05). CONCLUSION: The 3D printed biliary tract model is an excellent teaching tool in the training of choledochoscopy techniques. The 3D model is anatomically realistic and can improve the trainee's anatomical knowledge and endoscopic skills.

Choledochoscopic Examination of a 3-Dimensional Printing Model Using Augmented Reality Techniques: A Preliminary Proof of Concept Study.

BACKGROUND: We applied augmented reality (AR) techniques to flexible choledochoscopy examinations. METHODS: Enhanced computed tomography data of a patient with intrahepatic and extrahepatic biliary duct dilatation were collected to generate a hollow, 3-dimensional (3D) model of the biliary tree by 3D printing. The 3D printed model was placed in an opaque box. An electromagnetic (EM) sensor was internally installed in the choledochoscope instrument channel for tracking its movements through the passages of the 3D printed model, and an AR navigation platform was built using image overlay display. The porta hepatis was used as the reference marker with rigid image registration. The trajectories of the choledochoscope and the EM sensor were observed and recorded using the operator interface of the choledochoscope. RESULTS: Training choledochoscopy was performed on the 3D printed model. The choledochoscope was guided into the left and right hepatic ducts, the right anterior hepatic duct, the bile ducts of segment 8, the hepatic duct in subsegment 8, the right posterior hepatic duct, and the left and the right bile ducts of the caudate lobe. Although stability in tracking was less than ideal, the virtual choledochoscope images and EM sensor tracking were effective for navigation. CONCLUSIONS: AR techniques can be used to assist navigation in choledochoscopy examinations in bile duct models. Further research is needed to determine its benefits in clinical settings.

The comparison of surgical patients with primary hepatic squamous cell carcinoma or adenosquamous carcinoma and surgical patients with hepatocellular carcinoma.

BACKGROUND: There are still several controversies and ambiguities in the aspects of primary hepatic squamous cell carcinoma and primary hepatic adenosquamous carcinoma. To further clarify the specific features of these two infrequent diseases and provide beneficial propose for clinical decision, we did this retrospective study. METHODS: We reviewed the clinical features and outcomes of three primary hepatic squamous cell carcinoma (SCC) patients and six primary hepatic adenosquamous carcinoma (ASC) patients from January 1998 to December 2011 in Eastern Hepatobiliary Surgery Hospital in China. Meanwhile, 40 hepatocellular carcinoma (HCC) patients and 26 metastatic hepatic SCC or ASC patients who were hospitalized in the same period were also reviewed to make a comparison. In order to find out the definite survival information of SCC and ASC patients, 30 previous studies containing 37 primary hepatic SCC (16) and ASC (21) patients were reviewed, and their information of survival was analyzed together with the included patients in our hospital. RESULTS: Serum tumor markers showed significant differences between primary hepatic SCC/ASC and HCC patients, especially for serum alpha fetal protein (AFP) level and carbohydrate antigen 19-9 (CA 19-9). On the pathologic performance, primary SCC/ASC tumor was rarely accompanied with tumor capsule. They presented peripheral hepatic lymph node metastasis more likely and showed low proportion of microvascular invasion. The median survival time of primary hepatic SCC/ASC patients after liver resection (LR) was 15 months. And the 1-, 3-, 5-year survival rates after LR were 60%, 24%, and 12%, respectively. Significant difference was not discovered when SCC and ASC patients were compared with HCC patients (P = 0.294). The median survival time after LR for primary SCC and ASC patients was respectively 23 months and 13 months. CONCLUSIONS: The comprehensive application of some clinical characteristics, histopathologic features, and imaging findings may be useful for us in making definite diagnoses for primary hepatic SCC and ASC patients preoperatively. And the treatment of liver resection was effective for those patients who met the selection criteria for liver resection.

Perceived stress mediates the association between perceived control and emotional distress: The moderating role of psychological resources and sex differences.

Studies have confirmed that perceived control is strongly negatively correlated with emotional distress. However, few studies have explored whether perceived stress plays a potential mediating role in this relationship and whether the association between perceived stress and emotional distress is moderated by psychological resources, such as self-esteem and social support. Furthermore, it is unclear whether there are sex differences in the moderating effects of psychological resources on emotional distress. A total of 951 healthy adults (51.84% females) from different regions of mainland China participated in the study and completed questionnaires in early December 2022, when prevention and control policies concerning COVID-19 in China underwent rapid change. Perceived control negatively correlated with emotional distress, and perceived stress mediated the association between perceived control and emotional distress. In addition, both internal (i.e., self-esteem) and external psychological resources (i.e., social support) moderated the association between perceived stress and emotional distress, and the positive correlation between perceived stress and emotional distress was higher in individuals with low social support (and self-esteem) than in those with high social support (and self-esteem). We found sex differences in the moderating roles of psychological resources. Specifically, self-esteem had a moderating effect on both men and women, whereas social support had a moderating effect only on women. These findings improve understanding of the relationship between perceived control and emotional distress and suggest that intervention programs should be designed to target men and women differently.

Augmented Reality-Assisted Pancreaticoduodenectomy with Superior Mesenteric Vein Resection and Reconstruction.

INTRODUCTION: Pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV) reconstruction are often required to achieve complete (R0) resection for pancreatic head cancer (PHC) with tumor invasion of the SMV. Augmented reality (AR) technology can be used to assist in determining the extent of SMV involvement by superimposing virtual 3-dimensional (3D) images of the pancreas and regional vasculature on the surgical field. MATERIALS AND METHODS: Three patients with PHC and tumor invasion of the SMV underwent AR-assisted PD with SMV resection and reconstruction following preoperative computed tomography scanning. Preoperative imaging data were used to reconstruct 3D images of anatomical structures, including the tumor, portal vein (PV), SMV, and splenic vein (SV). Using AR software installed on a smart phone, the reconstructed 3D images were superimposed on the surgical field as viewed in a smart phone display to provide intermittent navigational assistance to the surgeon in identifying the boundaries of PHC tumor invasion for resection of the vessels involved. RESULT: All patients successfully completed the operation. Intraoperative AR applications displayed virtual images of the pancreas, SMV, bile duct, common hepatic artery (CHA), and superior mesenteric artery (SMA). Two patients required end-to-end anastomosis for reconstruction of the SMV. One patient required allogenic vascular bypass to reconstruct the SMV-PV juncture with concomitant reconstruction of the SV-SMV confluence by end-to-side anastomosis of the SV and bypass vessel. Postoperative pathology confirmed R0 resections for all patients. CONCLUSION: AR navigation technology based on preoperative CT image data can assist surgeons performing PD with SMV resection and reconstruction.

Expression of epithelial cell adhesion molecule associated with elevated ductular reactions in hepatocellar carcinoma.

AIM: To evaluate the prognostic significance of the epithelial cell adhesion molecule (EpCAM) expression in HCC, the relationship between EpCAM with ductular reactions and other clinical features. METHODS: From 2001 to 2003, 106 HCC patients who underwent curative resection in Eastern Hepatobiliary Hospital were enrolled. The expression of EpCAM in tumoral tissues and ductular reactions in paired non-tumoral tissues was assessed by immunohistochemistry. EpCAM was evaluated with prognosis, ductular reactions and other clinical variables. RESULTS: HCC expressing high level of EpCAM showed more aggressively than usual progressed HCC. High EpCAM expression was associated with poor overall survival and recurrence free survival. (P=0.0005, 0.0019, respectively). A close association was found between tumoral EpCAM expression and peritumoral ductular reactions. Patients with high level of ductular reactions tended to have higher EpCAM expression than those with low level (P=0.016). CONCLUSION: HCC stratification by EpCAM may reflect different prognosis. EpCAM expression correlated with ductular reactions may be a result of unregulated activation and differentiation blockage of progenitor cells.