Robotic versus laparoscopic left lateral sectionectomy of liver.

BACKGROUND: A few studies have reported only short-term outcomes of various robotic and laparoscopic liver resection types; however, published data in left lateral sectionectomy (LLS) have been limited. The aim of this study was to compare the long- and short-term outcomes of robotic and laparoscopic LLS. METHODS: We retrospectively compared demographic and perioperative data as well as postoperative outcomes of robotic (n = 12) and laparoscopic (n = 31) LLS performed between May 2007 and July 2013. Resection indications included malignant tumors (n = 31) and benign lesions (n = 12) including intrahepatic duct (IHD) stones (n = 9). RESULTS: There were no significant differences in perioperative outcomes of estimated blood loss, major complications, or lengths of stay, but operating time was longer in robotic than in laparoscopic LLS (391 vs. 196 min, respectively) and the operation time for IHD stones did not differ between groups (435 vs. 405 min, respectively; p = 0.190). Disease-free (p = 0.463) and overall (p = 0.484) survival of patients with malignancy did not differ between groups. The 2- and 5-year disease-free survival rates were 63.2 and 36.5 %, respectively. However, robotic LLS costs were significantly higher than laparoscopic LLS costs ($8183 vs. $5190, respectively; p = 0.009). CONCLUSIONS: Robotic LLS was comparable to laparoscopic LLS in surgical outcomes and oncologic integrity during the learning curve. Although robotic LLS was more expensive and time intensive, it might be a good option for difficult indications such as IHD stones.

Predictors of mortality in cirrhotic patients undergoing extrahepatic surgery: comparison of Child-Turcotte-Pugh and model for end-stage liver disease-based indices.

BACKGROUND: Underlying liver cirrhosis is associated with high morbidity and mortality after surgery. Previous studies have reported conflicting results about the value of Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores as predictors of post-operative mortality. This study was designed to compare the capacities of CTP, MELD and MELD-based indices in predicting mortality for patients with liver cirrhosis who underwent elective extrahepatic surgery. METHODS: The medical records of 79 patients with liver cirrhosis who underwent elective extrahepatic surgery under general anaesthesia from December 2000 to December 2009 were reviewed retrospectively. RESULTS: The median follow-up period was 21 months, and the mortality rate was 24.1% (n = 19). Among the 19 mortalities, nine (11.4%) occurred while the patient was hospitalized after surgery. Intraoperative transfusion amount (≥700 mL; odds ratio 6.294, P = 0.004) and the integrated MELD score (≥34; odds ratio 6.654, P = 0.007) were significantly correlated with post-operative mortality. CTP score (hazard ratio 1.575, P = 0.012) was significantly correlated with overall mortality. CONCLUSIONS: Integrated MELD may be a more accurate predictor of operative mortality in cirrhotic patients undergoing extrahepatic surgery than CTP and other MELD-Na based indices. However, overall mortality may be reflected more accurately by CTP score. Further large-scale study will be needed to validate this result.

[Assessment of the definition of early extrahepatic bile duct cancer through the prognosis analysis who had received curative resection].

BACKGROUND/AIMS: The definition of early extrahepatic bile duct cancer might be different from that of other gastrointestinal cancer because of the differences of histologic features including the lack of muscularis mucosa and submucosal layer in bile duct. The purpose of this study was to evaluate the concept of early extrahepatic bile duct cancer in Korea. METHODS: We evaluated seventynine cases of extrahepatic bile duct cancer who had received curative resection in Severence Hospital, Yonsei University from March 1986 to October 2005. We retrosptectively reviewed the medical records and analyzed variable prognostic factors to define early extrahepatic bile duct cancer. RESULTS: Invasion limited to the mucosa was noted in 5 cases (6.3%), fibromuscular layer in 12 cases (15.2%), adventitia of fibromuscular layer and serosa in 26 cases (32.9%), and invasion of adjacent organs in 36 cases (45.6%). Disease free 5-year survival according to the depth of invasion were 80.7% in tumor confined within mucosa, 80.0% within fibromuscular layer, 57.2% within adventitia of fibromuscular layer and serosa, and 51.5% in tumor with invasion of adjacent organ. There was no significant difference in the survival rate between patients with tumor confined to mucosa and patients with tumor invasion limited to the fibromuscular layer. However, the survival rate of patients with tumor limited to the mucosa or fibromuscular layer was significantly higher than that of patients with tumor invaded beyond fibromusular layer. In early cancer, there were more papillary polypoid type in gross finding and papillary adenocarcinoma in pathologic finding when compared to advanced cancer. CONCLUSIONS: Early extrahepatic bile duct cancer can be defined as the tumor invasion limited to the mucosa and fibromuscular layer.

Quantitative assessment of hTERT mRNA expression in dysplastic nodules of HBV-related hepatocarcinogenesis.

BACKGROUND: Telomerase reverse transcriptase (hTERT) is the rate-limiting determinant of telomerase, which is critical for carcinogenesis. Dysplastic nodules (DNs) appear to be preneoplastic lesions of hepatocellular carcinomas (HCCs). In this study, in order to characterize DNs, hTERT mRNA, hTERT gene dosage, and mRNA for c-myc, a transcriptional activator of hTERT were studied in human multi-step hepatocarcinogenesis. METHODS: Fifty four hepatic nodules including 5 large regenerative nodules, 14 low-grade DNs, 7 high-grade DNs, 11 DNs with HCC foci and 17 HCCs, 23 livers with chronic hepatitis/cirrhosis, and 6 normal livers were examined. Transcript levels were measured by real-time quantitative RT-PCR and gene dosages by real-time PCR and Southern blotting. RESULTS: The hTERT mRNA levels increased with the progression of hepatocarcinogenesis, and a significant induction in the transition between low- and high-grade DNs was seen. Most high-grade DNs strongly expressed hTERT mRNA at levels similar to those of HCCs. Twenty-one percent of low-grade DNs had high levels of hTERT mRNA, up to those of high-grade DNs and there was no difference in the pathological features between low-grade DNs with and without increased hTERT mRNA levels. No correlation was found between hTERT mRNA levels, hTERT gene dosage, and c-myc mRNA levels. CONCLUSIONS: These results suggest that the induction of hTERT mRNA is an important early event and that its measurement by real-time quantitative RT-PCR is a useful tool to detect premalignant/malignant tendencies in hepatic nodules. However, hTERT gene dosage and c-myc expression are not the main mechanisms regulating hTERT expression in hepatocarcinogenesis.

Percutaneous cholecystostomy using a central venous catheter is effective for treating high-risk patients with acute cholecystitis.

Percutaneous cholecystostomy (PC) using a pigtail catheter is performed on high-risk patients with acute cholecystitis as their general condition does not usually allow them to undergo a "definite" cholecystectomy. However, this method of PC is time-consuming and expensive and requires an interventional radiologist and specially designed radiologic equipment. To determine whether another PC approach was viable, we retrospectively compared patients who underwent PC using a central venous catheter (group A, n = 15) with those who underwent standard pigtail catheter PC (group B, n = 29). The waiting time prior to undergoing the PC was 1.8 days in group A and 3.5 days in group B (P < 0.05). The cost per patient was 293,364 won (254.44 dollars) for group A, and 438,719 won (380.50 dollars) for group B (P < 0.05). There were 4 complications in group A and 5 in group B. Following PC, 7 patients in group A and 15 patients in group B underwent delayed definite cholecystectomy, and there were no differences between these groups in terms of complications, mortality, and the delayed definite cholecystectomy surgical method. We conclude that in combination with careful patient selection, PC using a central venous catheter in high-risk patients with acute cholecystitis is a viable alternative to pigtail catheter PC.