Correlation of pathological examination with indocyanine green (ICG) intensity gradients: a prospective study in patients with liver tumor.

BACKGROUND: Intraoperative indocyanine green (ICG) fluorescence imaging has been shown to be a new and innovative way to illustrate the optimal resection margin in hepatectomy for hepatocellular carcinoma. This study investigated its accuracy in resection margin determination by looking into the correlation of ICG intensity gradients with pathological examination results of resected specimens. METHODS: This was a prospective, single-center, non-randomized controlled study. Patients who had liver tumors indicating liver resection were recruited. The hypothesis was that the use of intraoperative near-infrared/ICG fluorescence imaging would be a promising guiding tool for removing hepatocellular carcinoma with a better resection margin. Patients were given ICG (0.25 mg/kg) 1 day before operation. Resected specimens were inspected under a fluorescent imaging system. Biopsies were taken from tumors and normal tissue. Color signals obtained from ICG fluorescence imaging were compared with biopsies for analysis. RESULTS: Twenty-two patients were recruited for study. The median size of their tumors was 2.25 cm. One patient had resection margin involvement. Under ICG fluorescence, the tumors typically lighted up as yellow color, wrapped by a zone of green color. Tumors of 17 patients (77.3%) displayed yellow color and were confirmed malignancy, while tumors of 12 patients (54.5%) displayed green color and were confirmed malignancy. Receiver operating characteristic curve was used to measure the sensitivity and specificity of the green color to look for a clear resection margin. The area under the curve was 85.3% (p = 0.019, 95% confidence interval 0.696-1.000), with a sensitivity of 0.706 and specificity of 1.000. CONCLUSION: The use of ICG fluorescence can be helpful in determining resection margins. Resection of tumor should include complete resection of the green zone shown in the fluorescence image.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma.

BACKGROUND: The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown. METHODS: A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center. RESULTS: Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p < 0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p = 0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p = 0.50) and blood loss (0.2 vs. 0.2L, p = 0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p = 0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p = 0.003). CONCLUSIONS: 3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial.

OBJECTIVE: To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified. METHODS: This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures. RESULTS: Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380). CONCLUSION: ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct. TRIAL REGISTRATION: The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). REGISTRATION NUMBER: UW17-492.

Is vocal cord asymmetry seen on transcutaneous laryngeal ultrasonography a significant predictor of voice quality changes after thyroidectomy?

BACKGROUND: Vocal cord asymmetry (VCA) on laryngoscopic examination (LE) may suggest voice impairment after thyroidectomy, but LE may cause patient discomfort. We aimed to correlate the presence of postoperative VCA assessed by noninvasive transcutaneous laryngeal ultrasonography (TLUSG) with voice quality changes after thyroidectomy. METHODS: A total of 169 patients scheduled for thyroidectomy completed two validated voice symptoms questionnaires-the GRBAS (grade, roughness, breathiness, asthenia, strain) scale and the voice impairment score (VIS)-and underwent TLUSG and LE at 1 day before and 7-10 days after thyroidectomy. Postoperative VCA was apparent in 51 patients on TLUSG (group I), whereas there was no VCA in the other 118 patients (group II, controls). The GRBAS scale and VIS results were compared between the groups. RESULTS: Before operation, the two groups had comparable preoperative GRBAS and VIS status. After operation, the "grade" and "roughness" components on the GRBAS scale were significantly worse in group I than in group II: 0.24 versus 0.07 (p = 0.016) and 0.33 versus 0.14 (p = 0.022), respectively. "Grade" and "roughness" in the GRBAS scale significantly worsened after the operation in group I: from 0.04 to 0.24 (p = 0.008) and from 0.02 to 0.33 (p = 0.001), respectively. They did not change in group II. Also, the overall VIS was significantly worse after thyroidectomy in group I: 4.97 versus 12.97 (p < 0.001). CONCLUSIONS: VCA seen on TLUSG significantly correlated with "grade" and "roughness" components on the GRBAS scale and the overall VIS. Thus, VCA might be used as a surrogate of postoperative voice changes.

Alpha-Fetoprotein in Predicting Survival of Patients with Ruptured Hepatocellular Carcinoma after Resection.

Background/Aim: Alpha-fetoprotein (AFP) had been used as a prognostic factor in hepatocellular carcinoma but it was unknown what level of AFP could predict the survival of patients with ruptured hepatocellular carcinoma (rHCC) after resection. This retrospective study was to identify the best cutoff value of AFP for this prediction.Methods: Data of patients having hepatectomy for rHCC from 1989 to 2015 were reviewed. The receiver operating characteristic curve and Youden's index were used to identify the cutoff value of AFP affecting survival. The patients were then divided into two groups by the cutoff for comparison.Results: Totally 114 patients were included. An AFP level of 256 ng/ml was found to affect survival (area under curve 63.1%, 95% confidence interval 0.514-0.748, p = 0.027; sensitivity 0.6, specificity 0.706). The 114 patients were divided into Group A (AFP < 256 ng/ml, n = 56) and Group B (AFP ≥ 256 ng/ml, n = 58). The median AFP level was 13.0 ng/ml (range, 2-253 ng/ml) in Group A and 11206.5 ng/ml (range, 259-481,000 ng/ml) in Group B (p < 0.001). Group A had a larger proportion of patients receiving transarterial embolization at the time of rupture, and the time to hepatectomy was longer in this group. Patients in Group B had more blood loss, more complications, larger tumors, and more cases of macrovascular/microvascular invasion. Overall survival (p = 0.013) and disease-free survival (p = 0.024) were significantly better in Group A. On multivariate analysis, AFP ≥ 256 ng/ml was an independent risk factor for overall survival.Conclusion: AFP ≥ 256 ng/ml had an adverse impact on the survival of patients with rHCC after resection.

Sarcopenia in pancreatic cancer - effects on surgical outcomes and chemotherapy.

Sarcopenia is found in up to 65% of pancreatic cancer patients. The definition and diagnostic methods for sarcopenia have changed over the years, and the measurement of skeletal muscle mass with cross-sectional imaging has become the most popular way of assessment, although the parameters measured vary among different studies. It is still debatable that there is an association between sarcopenia and postoperative pancreatic fistula, but most studies showed a higher risk in patients with sarcopenic obesity. Long-term survival is worse in sarcopenic patients, as shown by meta-analysis. Sarcopenia is also associated with decreased survival and higher toxicity in patients receiving chemotherapy, and chemotherapy also tends to potentiate sarcopenia. Treatment for sarcopenia still remains an area for research, although oral supplements, nutritional modifications and exercise training have been shown to improve sarcopenia.

Prospective Study on Sexual Dysfunction in Male Chinese Liver Transplant Recipients.

In patients with end-stage liver disease, hypogonadism and erectile dysfunction are often seen. This study was to determine the incidence of erectile dysfunction before and after liver transplantation (LT) with correlation to change in sex hormone levels from a Chinese cohort. This prospective longitudinal study was registered with The University of Hong Kong Clinical Trials Centre (HKUCTR-1563). The Institutional Review Board approval number is UW-12-273. The study period was from January 2012 to December 2016. Adult male patients with end-stage liver disease enlisted for LT were recruited on informed written consent. All recruited patients were to complete a cross-sectional cohort questionnaire-International Index of Erectile Function, version 5 (IIEF5)-and to receive serum sex hormone checks before and after LT. Twenty-eight patients who underwent LT were included in the analysis. The included patients had significantly reduced prolactin ( p < .001) and 17-beta-estradiol ( p = .024) after LT. There was also a significant drop of IIEF5 score at 1 month after LT, but the score returned to pre-LT level at 6 months. This study demonstrated that there was improvement in sex hormone levels after LT, namely, normalization of estradiol level and lowering of prolactin and progesterone levels. However, improvement in sex hormone levels did not translate into improvement of erectile dysfunction.

Prognostic value of preoperative alpha-fetoprotein (AFP) level in patients receiving curative hepatectomy- an analysis of 1,182 patients in Hong Kong.

BACKGROUND: The value of alpha-fetoprotein (AFP) as a prognostic indicator in patients with hepatocellular carcinoma (HCC) has been proposed in recent studies, but the evidence so far is still contradictory. This analysis aims to evaluate the prognostic value of preoperative AFP level in patients undergoing curative resection. METHODS: This retrospective study reviewed the prospectively collected data of all patients who underwent initial liver resection for HCC at Queen Mary Hospital during the period from March 1999 to March 2013. Patients with palliative resection, positive margin after pathological examination or distant metastasis were excluded from the study. Survival of patients with AFP level of <20, 20-400 and >400 ng/mL were compared with Kaplan-Meier analysis. Subgroup analysis was performed according to tumour stage (7th edition UICC staging) and tumour size. The optimal cutoff value was determined by area under receiver operating characteristic curve. RESULTS: A total of 1,182 patients were included. Best overall (OS) and disease free survival (DFS) was observed in patients with AFP level <20 ng/mL. Progressively worse outcomes were seen for patients with increasing level of AFP. The median OS were 132.9, 77.2 and 38.4 months for patients with AFP <20, 20-400 and >400 ng/mL respectively (P<0.001). The median DFS for these three groups were 55.6, 25 and 8.4 months respectively (P<0.001). There was significant difference in both OS and DFS among all 3 groups. With subgroup analysis according to tumour stage (stage I and II versus stage III and IV) and tumour size (5 cm or less versus larger than 5 cm), such difference was still observed and remained statistically significant. Optimal cutoff value by discriminant analysis was 12,918.3 ng/mL for OS and 9,733.3 ng/mL for DFS. CONCLUSIONS: This study demonstrates that AFP is a significant prognostic indicator in HCC. Despite tumour stage and size, high level of AFP is associated with poorer OS and DFS. Whether the level of AFP should be included in current staging systems, or treatment protocols, is yet to be determined.

Surgical management of neuroendocrine tumor-associated liver metastases: a review.

Liver metastasis is common among patients who suffer from neuroendocrine tumors (NETs). Radical surgery is the standard treatment whenever possible but there is still controversies concerning the treatment strategies such as resection of the primary, role of debulking surgery, liver transplantation (LT) and neoadjuvant or adjuvant therapies. This article aims to review the current evidence available, together with some latest updates, focusing on the surgical management.

Left hepatectomy in a patient with a Fontan circulation.

Patients with a Fontan circulation face the long term risk of cardiac cirrhosis and the subsequent development of hepatocellular carcinoma (HCC). A hepatectomy operation imposes significant risk on such patients as the Fontan circulation can be severely compromised. Here we present a 24-year-old woman post-Fontan operation who successfully underwent a left hepatectomy, and discuss the anaesthetic and surgical management.

Laparoscopic colorectal resections with and without routine mechanical bowel preparation: A comparative study.

BACKGROUND: The benefit of mechanical bowel preparation (MBP) in patients undergoing laparoscopic colorectal resections remains a question. This study aimed to evaluate the effect of omitting MBP on patients undergoing laparoscopic bowel resections. METHODS: The outcomes of patients who underwent elective colorectal resections for cancer of colon and upper rectum without MBP were compared to a retrospective cohort who had MBP. RESULTS: There were 97 patients in the No-MBP group and 159 patients in the MBP group. Their mean age, operative risk, tumor size and stage of disease were similar. There were no significant differences in operative time and estimated blood loss. The anastomotic leakage rate was 1.0% in the No-MBP group and 0.6% in the MBP group, (p = 1.00). Wound infection rate were 4.1% and 3.8% in the No-MBP group and the MBP group respectively (p = 1.00). Overall surgical morbidity rate was 11.3% in the No-MBP group and 8.2% in the MBP group (p = 0.40). Conversion rates were 5.2% in the No-MBP group and 6.9% in the MBP group, (p = 0.57). CONCLUSION: The omission of mechanical bowel preparation does not increase surgical morbidities in patients undergoing laparoscopic bowel resections. It also has no effect on operating time and conversion rate.