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Objective To study the clinical application of three-dimensional (3D) visualization technology in liver resection of complicated liver cancer.Methods A retrospective analysis of 28 patients with complicated liver cancer treated from June 2017 to June 2018 in the Department of Hepatobiliary Surgery,the Affiliated Tumor Hospital of Guangxi Medical University.There were 26 males and 2 females,aged (46± 10) years old.A treatment plan on how to perform liver resection for these patients was developed under the guidance of 3D visualization technology.The actual surgical procedures,operation time,intraoperative blood loss,and postoperative complications were documented.The virtual resected liver volume was compared with the actual resected liver volume.The virtual surgical resection margin was also compared with the actual surgical resection margin.Results All the 28 patients with complicated liver cancer completed the 3D visualization analysis with the location,shape and quantity of tumor being clearly shown.Of the 27patients who underwent liver resection,13 underwent anatomical hepatectomy,and 14 underwent nonanatomical hepatectomy.The operation time ranged from 145 to 350 min (median 240 min).The intraoperative blood loss ranged from 100 to 1 500 ml (median 300 ml).The incisional wound healed slowly in 4 patients,pleural effusion developed in 8 patients,and ascites in 2 patients.There were no significant differences in the virtual resected liver volume compared with the actual resected liver volume (P ＞ 0.05).There was an excellent positive correlation between the patient's virtual resected liver volume and the actual resected liver volume (r =0.986,P ＜ 0.05).There was no significant difference between the virtual surgical resection margin and the actual surgical resection margin (P ＞ 0.05).There was an excellent positive correlation between virtual surgical resection margin and the actual surgical resection margin (r =0.983,P ＜ 0.05).Conclusion Three-dimensional visualization technology accurately assessed the liver status,optimized surgical procedures,and played an important role in liver resection of complex liver cancer.
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Objective@#To study the clinical application of three-dimensional (3D) visualization technology in liver resection of complicated liver cancer.@*Methods@#A retrospective analysis of 28 patients with complicated liver cancer treated from June 2017 to June 2018 in the Department of Hepatobiliary Surgery, the Affiliated Tumor Hospital of Guangxi Medical University. There were 26 males and 2 females, aged (46±10) years old. A treatment plan on how to perform liver resection for these patients was developed under the guidance of 3D visualization technology. The actual surgical procedures, operation time, intraoperative blood loss, and postoperative complications were documented. The virtual resected liver volume was compared with the actual resected liver volume. The virtual surgical resection margin was also compared with the actual surgical resection margin.@*Results@#All the 28 patients with complicated liver cancer completed the 3D visualization analysis with the location, shape and quantity of tumor being clearly shown. Of the 27 patients who underwent liver resection, 13 underwent anatomical hepatectomy, and 14 underwent non-anatomical hepatectomy. The operation time ranged from 145 to 350 min (median 240 min). The intraoperative blood loss ranged from 100 to 1 500 ml (median 300 ml). The incisional wound healed slowly in 4 patients, pleural effusion developed in 8 patients, and ascites in 2 patients. There were no significant differences in the virtual resected liver volume compared with the actual resected liver volume (P>0.05). There was an excellent positive correlation between the patient's virtual resected liver volume and the actual resected liver volume (r=0.986, P<0.05). There was no significant difference between the virtual surgical resection margin and the actual surgical resection margin (P>0.05). There was an excellent positive correlation between virtual surgical resection margin and the actual surgical resection margin (r=0.983, P<0.05).@*Conclusion@#Three-dimensional visualization technology accurately assessed the liver status, optimized surgical procedures, and played an important role in liver resection of complex liver cancer.
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Objective To investigate the application value of three-dimensional (3D) reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma.Methods The retrospective crosssectional study was conducted.The clinical data of 36 patients with hilar cholangiocarcinoma who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2014 and September 2017 was collected.Before operation,images of 3D virtual surgery planning were respectively reconstructed and determined using IQQA-Liver imaging analysis system,and then precise resection of tumor was performed based on results of virtual surgical planning and intraoperative conditions.Observation indicators:(1) virtual surgical planning;(2) surgical and postoperative situations;(3) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and tumor recurrence or metastasis up to November 2017.Measurement data with normal distribution were represented as (x)±s.Comparison between indicator of preoperative virtual surgical planning and surgical indicators was analyzed by the t test.The postoperative survival time was calculated by the Kaplan-Meier method.Results (1) Virtual surgical planning:36 patients accomplished 3D visualization reconstruction and virtual surgical planning.Three D visualization reconstruction clearly showed adjacent relationship between tumor size and surrounding vessels or bile duct space.Type Ⅱ,Ⅲ a,Ⅲb and Ⅳ of Bismuth-Corlette Classification were detected in 2,13,14 and 7 patients by 3D visualization system,respectively.The tumor volume,whole liver volume,predicted liver resection volume and remnant liver volume were respectively (76± 26) mL,(1 319± 306) mL,(588± 128) mL and (731± 269) mL.(2) Surgical and postoperative situations:of 36 patients,16,12,5 and 3 patients underwent left hemigepatectomy,right hemigepatectomy,extended left hemigepatectomy and extended right hemigepatectomy,respectively,and all of them were combined with caudate lobectomy of liver.Combined resection and reconstruction of hepatic artery,combined wedge resection and repair of the portal vein and combined end-to-end anastomosis after resection of the portal vein were detected in 1,2 and 1 patients,respectively.Operation time and volume of intraoperative blood loss of 36 patients were respectively (368± 134)minutes and (474±288)mL.Thirty-six patients with postoperative complications were cured by conservative treatment,including 3 with pulmonary infection,3 with intra-abdominal infection and 2 with intra-abdominal lymphatic fistula.Duration of hospital stay of 36 patients was (19±7) days.Type Ⅱ,Ⅲ a,Ⅲ b and Ⅳ of postoperative Bismuth-Corlette Classification were detected in 2,11,13 and 10 patients,respectively.Accuracy of tumor classification through 3D visualization reconstruction was 91.7％ (33/36).Actual liver resection volume of 36 patients was (551± 141)mL,and was not significantly different from predicted liver resection volume (t =1.148,P＞0.05).(3) Follow-up and survival:31 of 36 patients were followed up for 2-39 months after surgery,with a median time of 16 months.The postoperative median survival time was 13 months,and 9 patients had tumor recurrence or metastasis during the follow-up.Conclusion The 3D reconstruction virtual surgery planning can accurately complete the preoperative evaluation,meanwhile,it can also provide important reference for the surgical therapy of hilar cholangiocarcinoma.
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Objective To evaluate the value of precise hepatectomy in treatment of early-stage primary liver cancer after radical resection. Methods Between June 2012 and July 2014,174 patients undergoing radical resection of hepatocellular carcinoma were enrolled in this comparative study at Nan fang Hospital. 118 patients with liver resection under precise hepatectomy were assigned to precise resection group and 56 patients with liver resection under Pringle maneuver were assigned to occlusion group. The two groups were compared in terms of preoprational clinical pathological and laboratory data ,volume of intraoperative bleeding and blood transfusion , postoperative hepatic function recovery,hospitalization days,and postoperative tumor-free survival rate of 1,2 years. Results There was no significant difference between the two groups in the sex,age,liver disease,preo-pration albumin,ALT,AST,alcohol intake and liver cirrhosis(P>0.05). No differences between the two groups were found about the volume of intraoperative bleeding and blood transfusion as well as surgery cost (P > 0.05). The recovery of hepatic function was accelerated and the incidence of complications ,hospitalization days and peri-od of drainage were significantly reduced in the precise resection group compared with the occlusion group (P <0.05). The 1,2-years postoperative tumor-free survival rate was 79.7%(94/118),60.9%(46/118)in the precise group and 50.0%(28/56),46.4%(26/56) in the occlusion group ,with significant difference between them (χ2=4.741,8.722,P<0.05). Conclusions For early-stage liver cancer patients,the precise hepatectomy during radical resection results in quick recovery and fewer complications ,thus it should be the first choice of clinical operation.
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Objective To evaluate the value of precise hepatectomy in treatment of early-stage primary liver cancer after radical resection. Methods Between June 2012 and July 2014,174 patients undergoing radical resection of hepatocellular carcinoma were enrolled in this comparative study at Nan fang Hospital. 118 patients with liver resection under precise hepatectomy were assigned to precise resection group and 56 patients with liver resection under Pringle maneuver were assigned to occlusion group. The two groups were compared in terms of preoprational clinical pathological and laboratory data ,volume of intraoperative bleeding and blood transfusion , postoperative hepatic function recovery,hospitalization days,and postoperative tumor-free survival rate of 1,2 years. Results There was no significant difference between the two groups in the sex,age,liver disease,preo-pration albumin,ALT,AST,alcohol intake and liver cirrhosis(P>0.05). No differences between the two groups were found about the volume of intraoperative bleeding and blood transfusion as well as surgery cost (P > 0.05). The recovery of hepatic function was accelerated and the incidence of complications ,hospitalization days and peri-od of drainage were significantly reduced in the precise resection group compared with the occlusion group (P <0.05). The 1,2-years postoperative tumor-free survival rate was 79.7%(94/118),60.9%(46/118)in the precise group and 50.0%(28/56),46.4%(26/56) in the occlusion group ,with significant difference between them (χ2=4.741,8.722,P<0.05). Conclusions For early-stage liver cancer patients,the precise hepatectomy during radical resection results in quick recovery and fewer complications ,thus it should be the first choice of clinical operation.
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Objeetive To compare the clinical value of early enteral nutrition (EEN) and combined enteral nutrition (EN) and parenteral nutrition (PN) in patients with hepatocellular carcinoma (HCC) after precise hepatectomy.Methods The prospective study was conducted.The clinical data of 60 HCC patients who underwent precise hepatectomy in the Affiliated Drum Tower Hospital of Nanjing University Medical School between January 2013 and December 2014 were collected.All patients were allocated into the EN group and combined EN+PN group by random number table method.Patients in the EN group and combined EN+PN group respectively received EEN and early combined EN+PN at 24 hours postoperatively for 7 days,total nutrient intakes between groups were consistent,with an average daily intake of nitrogen-feeding of 0.2 g/(kg · d) and an average daily intake of nonprotein calories of 25 kcal/(kg · d).Observation indicators:(1) comparison of nutritional indexes between groups;(2) comparison of liver function between groups;(3) comparison of postoperative conditions between groups.Measurement data with normal distribution were represented as-x±s.Comparisons at the same time between groups were respectively analyzed using the group-design t test.Comparisons of count data were analyzed using the chi-square test.Ordinal data were analyzed by the nonparametric test.Comparison of repeated measurement data were done using the repeated measures ANOVA.Results Sixty patients were screened for eligibility,and 30 in each group.(1) Comparison of nutritional indexes between groups:levels of albumin (Alb),globulin,prealbumin and hemoglobin (Hb) and lymph nodes count in the EN group were respectively (41±4)g/L,(28±4) g/L,(188±37) mg/L,(139± 17) g/L,(1.6±0.6) × 109/L before operation and (32±4) g/L,(23±5)g/L,(114±41)mg/L,(121±19)g/L,(1.1±0.7) ×109/L at 1 day postoperative1y and (34±5)g/L,(26±4) g/L,(169± 41) mg/L,(113 ± 16) g/L,(1.9 ± 1.1) × 109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=2.23,4.45,8.96,5.21,2.18,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =9.79,8.53,9.81,4.56,5.77,P＜0.05) and between 1 and 8 days postoperatively (t =5.55,6.31,4.69,3.99,8.26,P＜0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=3.48,5.12,6.37,8.20,P＜0.05) and no statistically significant difference in lymph nodes count (t =2.48,P＞0.05).Levels of Alb,globulin,prealbumin and Hb and lymph nodes count in the combined EN+PN group were respectively (42±4)g/L,(28±6)g/L,(188±29)g/L,(142±16)g/L,(1.6±0.6)×109/L before operation and (31±5)g/L,(20±5) g/L,(96±31) g/L,(124± 16) g/L,(0.9±0.4) × 109/L at 1 day postoperatively and (34±4)g/L,(24±4)g/L,(143±18)g/L,(115±18)g/L,(1.4±0.7)×109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=3.21,7.35,4.36,7.78,3.19,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =11.95,5.38,9.91,4.84,6.22,P＜0.05) and between 1 and 8 days postoperatively (t =9.45,7.66,4.98,3.15,4.79,P＜ 0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=9.31,8.44,6.57,5.25,P＜0.05).There were no statistically significant difference in lymph nodes count (t =3.11,P＞ 0.05) and in changing trends of Alb,globulin,prealbumin,Hb and lymph nodes count (F=8.54,3.83,7.21,6.33,3.91,P＞0.05).Levels of prealbumin at 8 days postoperatively were statistically different between groups (t =3.00,P＜0.05).(2) Comparison of liver function between groups:levels of alanine transaminase (ALT),aspartate transaminase (AST),alkaline phosphatase (ALP),glutamyl-transpeptidase (GGT),total bilirubin (TBil),direct bilirubin (DBil) and C-reactive protein (CRP) in the EN group were respectively (44±37)U/L,(44±30) U/L,(90± 29) U/L,(85 ± 49) U/L,(15.7± 5.4) μmol/L,(4.6± 2.3) μmol/L,(4.5 ± 3.2) mg/L before operation and (411±375)U/L,(379±323)U/L,(68±26)U/L,(55±49)U/L,(20.3±10.7)μmol/L,(7.8±5.5) μmol/L,(47.9± 30.6) mg/L at 1 day postoperatively and (107± 58) U/L,(43± 21) U/L,(100± 42) U/L,(111±71)U/L,(19.7±10.6) μmol/L,(8.8±5.9) μmol/L,(28.3±23.0) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.48,9.44,1.73,5.03,8.42,6.09,6.69,P＜0.05) and between pre-operation and 1 day postoperatively (t=5.12,5.36,5.35,0.45,2.88,3.82,6.95,P＜ 0.05).There were statistically significant differences in levels of ALT,TBil,DBil and CRP between pre-operation and 8 days postoperatively (t =6.71,4.14,5.96,6.33,P＜0.05) and in levels of ALT,AST,ALP,GGT and CRP between 1 and 8 days postoperatively (t =6.23,5.55,3.14,3.56,4.99,P＜0.05).There were no statistically significant difference in levels of AST,ALP and GGT (t =0.13,0.98,1.11,P＞0.05) and in levels of TBil and DBil (t =0.08,0.23,P＞0.05).Levels of ALT,AST,ALP,GGT,TBil,DBil and CRP in the combined EN+PN group were respectively (41±38) U/L,(43±25) U/L,(100±89) U/L,(106±46) U/L,(17.9±9.8) μmol/L,(6.2±3.6) μmol/L,(3.7±2.3)mg/L before operation and (462±409)U/L,(494±162)U/L,(73±53)U/L,(75±57)U/L,(28.1±18.8)μmol/L,(9.1±6.1) μmol/L,(40.7±26.2) mg/L at 1 day postoperatively and (90±47) U/L,(42± 16) U/L,(95±40) U/L,(110±66) U/L,(22.5± 14.5) μmol/L,(8.2±8.1) μmol/L,(26.9±24.6) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.96,3.73,6.94,3.88,7.97,4.14,5.25,P＜0.05) and between before operation and 1 day postoperatively (t=5.72,4.96,3.95,0.88,2.83,4.13,6.11,P＜0.05).There were statistically significant differences in levels of ALT and CRP between pre-operation and 8 days postoperatively (t =4.22,6.77,P＜0.05) and in levels of ALT,AST,ALP and GGT between 1 and 8 days postoperatively (t=7.01,5.21,4.38,6.15,P＜0.05).There were no statistically significant difference in levels of AST,ALP,GGT,TBil and DBil (t =0.29,1.65,1.92,0.33,P＞0.05) and in levels of TBil,DBil and CRP (t =0.09,0.37,0.58,P＞0.05).There was no statistically significant difference in changing trends of ALT,AST,ALP,GGT,TBil,DBil and CRP of 2 groups (F=7.18,2.23,3.94,5.88,4.72,2.17,6.53,P＞0.05) and in above indexes among pre-operation,1 and at 8 days postoperatively (t=0.27,0.42,0.91,0.12,0.96,0.24,0.59,0.32,0.49,1.27,0.88,0.07,1.07,1.45,0.23,1.11,0.88,0.32,0.35,0.93,0.21,P＞0.05).(3) Comparison of postoperative conditions between groups:times of initial defecation were respectively (3.2± 1.0) days and (4.2± 1.2) days in the EN group and combined EN +PN group,showing a statistically significant difference (t =3.21,P＜ 0.05).Conclusion EEN and combined EN+PN are safe and feasible in HCC patients after precise hepatectomy,and also can improve liver function recovery,but EEN has advantages of promoting protein synthesis and gastrointestinal function recovery.
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Primary liver cancer (PLC) includes hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (CC).In recent years, the incidence of PLC has increased significantly in the world.At present, the therapy for liver cancer tends to diversify, but surgical resection is still the first choice and the most effective treatment for HCC in general.As the biomedical, evidence-based medicine, and medical humanities are proposed, to achieve the best therapeutic effect and minimize the trauma has become the goal of modem surgery.Moreover, this could promote the transformation of surgical model from traditional experiential surgery to precision surgery.Besides, as the critical techniques of treating HCC in preoperative evaluation,operative procedures, perioperative management and the innovation of surgical instruments develop fast, precise liver resection has come into being.And now this concept is getting more and more attention from hepatobiliary surgeons.In this paper, the progress on the application of precise liver resection in the treatment of PLC is reviewed based on the preoperative evaluation and intraoperative procedures.
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Hepatic hemangioma is a common benign tumor of liver,while hepatic hemangioma with a diameter ＞ 3 cm is rarely seen in clinical practice.A female patient with a giant hepatic hemangioma (diameter =48 cm) received tumor resection via chest and abdomen joint incision at the Peking Union Medical College Hospital on April 10,2012.The patient received exploratory laparotomy for hepatic tumor via chest and abdomen joint incision 22 years ago,while the operation was failed due to intraoperative bleeding.The success of the operation benefited from comprehensive application of computed tomography angiography reconstruction technique,three-dimensional liver reserve function assessment,intraoperative controlled low central venous pressure,total hepatic vascular exclusion and precise hepatectomy technique.
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Objective To evaluate the effect of enteral nutritional support for the liver cancer patients with precise hepatetomy under fast track process model. Methods 82 patients were prospectively randomized into enteral nutrition group (n = 41) and parenteral nutrition (n = 41). The hemoglobin (HB), total protein (TP), albumin (ALB) and total lymphocyte count (TLC) were measured on 3 days before operation and 7 days after operation respectively. The two groups were compared in terms of time for anal exhaust and defecation after surgery , the postoperative hospital stay, the gastrointestinal adverse reactions and complications after surgery. Results The nutrition and immunity indicators on day 7 after operation were significantly poorer and lower than on day 3 before operation in the parenteral nutrition group (P0.05). Conclusion Enteral nutritional support under fast track process model for the liver cancer patients undergoing precise resection could improve clinical outcome.
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Objective To evaluate the clinical efficacy of 1 aparoscopic anatomical hepatectomy (LaHt)in the treatment of liver cancer by comparing with Open precise hepatectomy (OHt).Methods Forty-six cases of liver tumor hepatectomy were collected by the none randomized controlled trails (non-RCTs) from January 2011 to December 2013 in Department of Hepato-Biliary-Pancreatic Surgery,Nanjing Drum Tower Hospital.According to the operation method,they were divided into two groups,including 19 cases of LaHt group and 27 cases of OHt group.Compare differences of their operation time,intraoperative blood loss,time of Pringle maneuver,and postoperative hospital stay,time of postoperative gastrointestinal function recovery,Serum liver function index,pathological tumor margin,postoperative complications,total hospitalization expenditures.Results (1) No perioperative mortality was observed in the 2 groups.(2) Compared with OHt group,LaHt group had shorter Pringle maneuver time with statistical significance (P ＜ 0.05,F =8.662) ; while,LaHt group also had less hemorrhage and shorter operation time than OHt group,although statistical significance did not existed (P ＞ 0.05,F =1.481,F =0.539).(3) Compare with OHt group,postoperative gastrointestinal function recovery of LaHt group was faster while postoperative length of hospital stay of LaHt group was shorter with obviously statistical significances existed (P ＜ 0.01,F =7.691,F =11.408).(4) The liver function index serum ALT,AST of LaHt group is lower compared to that of OHtgroup postoperative dayl and 3,however,only the day 3 AST had statistical significance (P ＜ 0.05,F =4.226).LaHt group had lower CRP level than OHt group on both day 1 and 3 after surgery,but there was no statistical significance(P ＞ 0.05,F =0.792,F =0.007).Serum TB and DB varied little between LaHt and OHt group on both day 1 and 3 after surgery without statistical significance (P ＞ 0.05,F =2.002,F =0.021,F =0.442,F =1.392).(5) The average hospital charges for the patients in LaHt group is higher than that in OH group,but there was still no statistical significance (P ＞ 0.05,F =0.046).(6) Although there was no significant difference between LaHt and OH in positive/negative excision margin ratio (P ＞0.05,x2 =1.453),there was 1 case of excision margin residues in LaHt group which would have negative effects on the prognoses.Conclusions Laparoscopic hepatectomy is a safe and feasible surgical approach,with minimally invasive advantage for treatment of liver cancer.However,compared with open precise hepatectomy,there are still some deficiencies in terms of radical curative aspect.
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Objective To study the anatomical structure and the distribution of the right posterior sectional Glissonean pedicle so as to provide the anatomical basis for liver resection of the right posterior section.Method By studying the morphological features of the right posterior sectional Glissonean pedicle through peeling and dissecting 20 adult corpses without liver pathological.Result In 95％ of the right posterior sectional Glissonean pedicles there were shared branches.The angle between the GRL/GRA was 81.4° ± 13.8°.In 30％,the right posterior sectional Glissonean pedicle presented as a Y or a V.In a Y shaped,the angle between G6/G7 was 71 ° ±3.92°.The shapes of 70％ of the right posterior sectional Glissonean pedicle presented as a C.The number of branches at the tertiary level was between 3-8.Conclusion The distribution of the right posterior sectional of the Glissonean pedicle did not entirely fit the description of Couinaud's segments.Obvious individual differences existed.Under this circumstance,understanding the anatomy of the right posterior sectional Glissonean pedicle before carrying out partial hepatectomy would be helpful in reducing surgical risks and postoperative complications.
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Hepatectomy is the treatment of choice for huge ( ＞ 10 cm) hepatocellular carcinoma.However,the resection is more difficult and risky due to a huge space occupied by the tumor and vascular invasion.Precise hepatectomy is a new concept of liver surgery in the 21st century.The goal of which is the least invasive,most parenchymal preserving and optimal recovery.A male patient with a huge hepatocellular carcinoma (diameter =22.5 cm) received precise hepatectomy in the Department of Hepatobiliary Surgery of Fuzhou General Hospital of Nanjing Military Area.By using the digital medical technology and procedure of liver surgery planning system,the tumor and the whole structure of the liver were three dimensionally reconstructed,and the planning of resection was made.During surgery,the right liver artery and the right.porta hepatis were ligated and the right hemihepatic vessels were occluded.We accomplished right hepatectomy by accurate resection according the precisely planned preoperation,with less bleeding or no bleeding surgical field and rapid recovery.
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ObjectiveTo study the role of hepatic arteriography before precise hepatectomy in primary liver cancer,Methods207 patients with primary liver cancers resected from 2005 to 2010 at Air Force General Hospital of Chinese PLA were studied retrospectively.There were 81 patients who received routine hepatectomy and 126 who received precise hepatectomy with hepatic arteriography before surgery.ResultsAnalysis showed that precise hepatectomy was superior to routine hepatectomy for lesions less than 1.0 cm (81.48％ vs 18.18％),with less operative time (168.20±35.81 min vs 221.75±30.33 min),volume of resection,blood loss (168.20±35.81 min vs 221.75±30.33 min),transfusion rate (256.13±185.24 ml vs 436.97±590.12 ml),and hospital stay (20.53± 12.41 d vs 25.72±17.27 d),(all P＜0.05).Hepatic arteriography did not affect liver function before precise hepatectomy.ConclusionsHepatic arteriography was significantly better in showing blood vessels of the primary liver cancer,and in detecting liver metastases or satellite lesions of less than 1.0 cm before surgery.
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ObjectiveTo evaluate the feasibility of a three-dimensional (3 D) operation planning system for precise hepatectomy in patients with giant hcpatocellular carcinoma (HCC).MethodsThe clinical data of 34 patients with giant HCC who received precise hepatectomy at the First Affiliated Hospital of Sun Yat-sen University from May 2009 to May 2011 were retrospectively analyzed.Preoperative evaluation was done based on the computed tomography data,and the resection margin and the volume of resectcd liver were calculated using simulation.The predicted resected liver volume and resection margins were compared with the results of the actual operations.All data were analyzed using the t test,and the correlation between predicted and the actual values was analyzed by calculating Pearson correlation coefficients.Results Hepatic and tumor tissues and the hepatic vessels were reconstructed three-dimensionally using the 3D preoperative simulation software.The volume of simulated resected liver and the length of resection margin were ( 2112 ± 1550 ) ml and ( 12 ± 6) mm,respectively,while the volume of actual resected liver and the length of resection margin were (2031 ± 1411 )ml and ( 12 ± 6)mm,respectively.The predicted and the actual values were statistically correlated ( r =0.961,0.923,P ＜ 0.05 ).There was no significant difference between the predicted and the actual values ( t =1.549,1.143,P ＞ 0.05 ).All patients received precise hepatectomy,and no hepatic failure or death was observed. Conclusion The 3D operation planning system can accurately evaluate the condition of the liver and simulate hepatectomy,and could contribute to safer and more curative precise hepatectomy in patients with giant HCC.
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Liver cancer is a common malignancy.Its incidence ranks sixth among malignant tumors,and it is the third most common cause of cancer death worldwide.Extended hepatectomy,hepatectomy following chemotherapy and repeat or staged hepatectomy are being widely used to prolong the survival time of patients with hepatic neoplasms.Although advances in perioperative management and operative techniques have improved the safety and extended the indications for hepatectomy over the past 2 decades,postoperative hepatic failure is still a severe complication which causes perioperative mortality.In this review,current advances in preoperative evaluation of the condition of patients,precise hepatectomy,postoperative assessment of the hepatic function and therapeutic strategies for postoperative hepatic failure are introduced.
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Objective To investigate the efficacy of precise hemihepatectomy guided by middle hepatic vein(MHV),and to study the value of preoperative hepatic vein evaluation.Methods The clinical data of 68 patients who received hemihepatectomy at the Nanjing Drum Tower Hospital from October 2007 to September 2009were prospectively studied.Of the 68 patients,30 received precise hemihepatectomy guided by MHV(precise group)and 38 received anatomical hemihepatectomy(traditional group).The types of hepatic vein in the precise group were evaluated and classified preoperatively.The operation time,operative blood loss,volume of blood transfusion,liver function,morbidity and length of hospital stay of the 2 groups were compared.All data were analyzed using the t test,rank sum test,chi-square test and Fisher exact probability.Results According to the Nakamura's classification,there were 17(57%)patients with type Ⅰ,8(27%)with type Ⅱ and 5(16%)with type Ⅲ;according to the Kawasaki's classification,there were 11 patients with type Ⅰ(37%)and 19 with type Ⅱ(63%).There were 13 patients received right hepatectomy with MHV preservation,15 received left hepatectomy with MHV preservation,1 received right hepatectomy without MHV preservation and 1 received left hepatectomy without MHV preservation.There were no significant difference in the volume of operative blood loss and blood transfusion,level of alanine transaminase,total bilirubin,cholinesterase at postoperative day 3,total length of hospital stay and length of postoperative hospital stay between the 2 groups(t = 1.07,0.92,0.07,0.21,0.63,0.63,0.75,P ＞ 0.05).The operation time,levels of albumin at postoperative day 3 and complication rate were (342 ± 113)minutes,(35 ±3)g/L and 40%(12/30)in the precise group,and(270 ±73)minutes,(33 ±3)g/Land 66%(25/38)in the traditional group,respectively,with significant differences between the 2 groups(t =2.79,2.19;x2 =4.49,P＜0.05).The positive rates of the resection margin were 5%(1/19)in the precise group and 35%(8/23)in the traditional group,there was a significant difference between the 2 groups(P ＜0.05).ConclusionPreoperative hepatic vein evaluation and precise hemihepateetomy guided by MHV can preserve the functional liver tissues with venous drainage,achieve adequate tumor-free resection margin and reduce the postoperative complication rate.
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Objective To investigate the guiding significance of medical image three-dimensional visualization system (MI-3DVS) in precise hepatectomy. Methods The clinical data of 45 patients with hepatic neoplasms who were admitted to the Zhujiang Hospital from June 2008 to September 2010 were prospectively analyzed. The preoperative image data of the liver were three-dimensionally reconstructed by MI-3DVS. According to the distribution of the intrahepatic portal veins and hepatic veins, the liver was divided into different sections,and then tumors can be located within these hepatic segments. The volume percentage of residual liver and volume of liver resected were detected. Evaluation of surgical resectability and surgery simulation were done before operation. Results According to the distribution of the intrahepatic portal veins and hepatic veins, all patients were divided into seven types: 21 patients were with normal type which was the same as Couinaud type, six with nondivided type, 11 with non-divided right liver type, four with non-divided left liver type, one with right hepatic vein type, one with double middle hepatic vein type and one with right posterior vein type. Thirty-nine patients received open hepatectomy, and the volume percentage of the residual liver was 74% ± 17%. Postoperative pathological examination confirmed that all the 39 patients were with hepatocellular carcinoma. Six patients received transcatheter arterial chemoembolization. No severe complications such as acute hepatic failure, bleeding, bile leakage were detected. All patients were followed up for six months, and they survived with or without tumor. Conclusion MI-3DVS has guiding significance in preoperative assessment and perioperative guidance for precise hepatectomy.
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Objective To evaluate precise hepatectomy for liver metastases of colorectal cancer. Methods The clinical data of 85 patients with liver metastases of colorectal cancer who were admitted to the Cancer Hospital of Tianjin Medical University from October 2006 to October 2009 were retrospectively analyzed. Forty-two patients received precise hepatectomy(precise group) and 43 received routine hepatectomy (routine group). Evaluation of the hepatic and renal functions and detection of the tumors' condition were done before carrying out anatomical liver resection for patients in the routine group. Hepatic functional reserve of patients in the precise group was detected by indocyanine green excretion test. Hepatic artery, hepatic vein and portal vein were three-dimensionally reconstructed according to the data of computed tomography. The liver volume and residual liver volume of the patients were calculated. Hepatic resection was guided by intra-operative ultrasound in the precise group. Periand postoperative conditions and the results of follow-up of patients in the two groups were compared. All data were analyzed using the t test or chi-square test. Results No perioperative mortality was observed in the two groups.Time of hepatic blood flow occlusion and blood loss were (35±25)minutes and (685 ± 524) ml in the routine group, and (64±39) minutes and (486±360) ml in the precise group, respectively, with a significant difference between the two groups(t=4.116,-2.033, P＜0.05). The volumes of blood transfusion of the routine group and the precise group were (228±398) ml and (160±330)ml, respectively, with no significant difference between the two groups (t=-0.861, P＞0.05). The postoperaive levels of alanine transaminase at day 1 and day 7 were (672±284)U/L and (332±161)U/L in the routine group, and (344±158)U/L and (125 ±93) U/L in the precise group, respectively, with a significant difference between the two groups (t=-6.541,-7.232,P＜0.05). The length of hospital stay and postoperative mobidity were (18±10)days and 26% (11/43) in the routine group, and (12±6)days and 7%(3/42) in the precise group, respectively, with a significant difference between the two groups (t=- 3.915, x2=5.251, P＜0.05). The 1-year tumor recurrence rate and 1-year survival rate were 37% (16/43) and 88% (38/43) in the routine group, and 21% (9/42) and 93% (39/42) in the precise group, with no significant difference between the two groups (x2= 0.110, 0. 501, P＞0.05). Conclusion Precise hepatectomy is superior to routine hepatectomy in aspect of minimal trauma, quick recovery, efficacy and safety.
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Precise hepatectomy is the application of minimally invasive concept in hepatic surgery. There are big challenges for surgeons to choose the proper approaches to achieve the aim of precise hepatectomy. How to choose therapeutic strategy, chemotherapy, radiotherapy, liver transplantation or radiofrequency ablation? How to choose the operation type, laparoscopic surgery, transabdominal surgery or Da Vinci robot-assisted surgery? How to choose the surgical instruments during hepatectomy? Although answers for these questions are various, the principle is unchangeable, which is providing minimal injury, less blood loss, fast recovery, little expense and good prognosis. The concept of precise hepatectomy includes precise judgment of liver function and careful preparation before operation, and also the elaborate nursing and multi-disciplinary cooperation during operation, as well as the fast track surgery after operation. Precise hepatectomy requires surgeons take the safety and effectiveness of the operations into account, and the conditions of hospitals, the skills and experiences of the surgeons should also be evaluated before operation. Finally, the economic condition of the patients should be considered and proper application of advanced equipments should be emphasized.
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ObjectiveTo study the application of three-dimensional simulated surgical technique in precise hepatectomy. MethodsFrom July 2009 to February 2010, 16 patients with primary liver cancer underwent preoperative simulated imaging and three-dimensional simulation of liver resection.The 3D extent of simulated hepatectomy and actual hepatectomy was compared and analyzed. ResultsThe shape and the extent of the liver resected were very similar in the simulated and the actual hepatectomies. The mean differences in the length, breadth and depth of the remnant livers were 0. 6118 cm,0. 4490 cm and 0. 3199 cm, respectively. ConclusionsSimulation hepatectomy could predict the extent of the actual liver resection, and provided accurate guidance and preoperative planning for precise hepatectomy.