Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy. METHODS: This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm2/m2 in men and <3.92 cm2/m2 in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher. RESULTS: Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390-11.200; p = 0.010). CONCLUSION: Sarcopenic obesity is an independent risk factor for severe postoperative complications.

[Experience of Using Immune Checkpoint Inhibitors and Chemotherapy in the Upper Gastrointestinal Tract at Our Hospital].

We investigated the gastric and esophageal cancer cases treated with immune checkpoint inhibitors and chemotherapy at our hospital. Out of 17 gastric cancer cases, 9 were treated with nivolumab(Nivo)plus S-1/oxaliplatin(SOX), 5 with Nivo plus 5-fluorouracil/Leucovorin/oxaliplatin(FOLFOX), and 3 with Nivo plus capecitabine/oxaliplatin(CapeOX), yielding a response rate of 35.3%. We also treated 3 cases of esophageal cancer. Two of these were treated with Nivo plus cisplatin/5- fluorouracil(CF)and 1 case with pembrolizumab(Pembro)plus CF, with a response rate of 33.3%. The incidence of Grade 3 or higher adverse events was 29.4% in gastric cancer and 33.3% in esophageal cancer, and no serious immune-related adverse events were observed. Further case accumulation and long-term studies are required to evaluate efficacy and adverse events in clinical practice.

Reevaluation of Makuuchi's criteria for resecting hepatocellular carcinoma: A Japanese nationwide survey.

AIM: Although Makuuchi's criteria are widely used to determine the cut-off for safe liver resection, there have been few reports of concrete data supporting their validity. Here, we verified the utility of Makuuchi's criteria by comparing the operative mortality rates associated with liver resection between hepatocellular carcinoma (HCC) patients meeting or exceeding the criteria. METHODS: A database was built using data from 15 597 patients treated between 2000 and 2007 for whom values for all three variables included in Makuuchi's criteria for liver resection (clinical ascites, serum bilirubin, and indocyanine green clearance) were available. The patients were divided into those fulfilling (n = 12 175) or exceeding (n = 3422) the criteria. The postoperative mortality (death for any reason within 30 days) and long-term survival were compared between the two groups. RESULTS: The operative mortality rate was significantly lower in patients meeting the criteria than in those exceeding the criteria (1.07% vs. 2.01%, respectively; p < 0.001). On multivariate analysis, exceeded the criteria was significantly associated with the risk for operative mortality (relative risk 2.08; 95% confidence interval (CI), 1.23-3.52; p = 0.007). Surgical indication meeting or exceeding the criteria was an independent factor for overall survival (hazard ratio 1.27; 95% CI, 1.18-1.36; p < 0.001). CONCLUSION: Makuuchi's criteria are suitable for determining the indication for resection of HCC due to the reduction in risk of operative mortality.

Laparoscopic-assisted modified Kugel herniorrhaphy for obturator hernia: a case report.

Obturator hernia (OH) is a relatively rare disease and there are various surgical procedures for treating it. We report the case of a patient with an OH who underwent laparoscopic-assisted modified Kugel herniorrhaphy. The patient was a 74-year-old woman admitted to our hospital with nausea and abdominal distension. A diagnosis of intestinal obstruction was made because abdominal computed tomography revealed incarcerated right OH. No apparent strangulation findings were observed, and reduction was performed under ultrasound guidance. Laparoscopic-assisted modified Kugel herniorrhaphy for OH was performed. There were no signs of the bowel necrosis. Pneumoperitoneum was temporarily discontinued, and the OH was repaired by the modified Kugel herniorrhaphy. Laparoscopy confirmed that the direct Kugel patch was placed at the appropriate position. Laparoscopic-assisted modified Kugel herniorrhaphy is considered to be safe and useful for patients with OH and is considered as one of the treatment options.

Validity of the Algorithm for Liver Resection of Hepatocellular Carcinoma in the Caudate Lobe.

BACKGROUND: We aimed to validate our algorithm for resecting Hepatocellular carcinoma (HCC) in the caudate lobe based on tumor location, tumor size, and indocyanine green clearance rate. METHODS: Patients who underwent curative resections for solitary HCC in the caudate lobe were included. The surgical outcomes of patients with HCC in the caudate lobe were compared with those of patients with HCC in other sites of the liver. RESULTS: After one-to-one matching, the caudate-lobe group (n = 150) had longer operation time, greater amount of bleeding, lower weight of resected specimens, and shorter distance between tumor and resection line than the other-sites group (n = 150), but the complication rates were not different between the groups (38.0% vs. 34.1%, P = 0.719). After a median follow-up period of 3.0 years (range, 0.3-16.2 years), the median overall survivals were 6.5 (95% confidence interval [CI], 5.3-7.9) and 7.5 years (95% CI, 6.3-9.7) in the caudate-lobe and other-site groups, respectively (P = 0.430). Median recurrence-free survivals in the caudate-lobe group (1.9 years; 95% CI, 1.4-2.7) had a tendency to be shorter than those in the other-sites group (2.3 years; 1.7-3.4) (P = 0.052). CONCLUSIONS: Patients' survival and complication rates in the caudate-lobe group were comparable to those in the other-sites group; therefore, our algorithm for resecting HCC in the caudate lobe is of clinical use.

Evaluation of Safety-Related Outcomes of One-Segment and More-Than-One-Segment High-Level Hepatectomy in Hepatocellular Carcinoma Based on the Japanese Board Certification System.

BACKGROUND: We evaluated the impact of the Japanese board certification system for expert surgeons (JBCSES) on complications and survival outcomes in hepatectomy for hepatocellular carcinoma. METHODS: The postoperative outcomes of 493 patients who underwent high-level liver surgery involving one-segment (OSeg) hepatectomy and more-than-one-segment (MOSeg) resection were compared before and after JBCSES establishment. After the establishment of the JBCSES, the patients' postoperative outcomes were compared using propensity score matching (PSM) to determine the influence of expert surgeons. RESULTS: The establishment of the JBCSES was associated with a decrease in the overall postoperative complication rates after high-level liver surgery from 50.2 to 38.1% (P = 0.008) and a decrease in Clavien-Dindo class ≥ IIIb complications from 10.2 to 5.0% (P = 0.035). The 90-day mortality rate decreased from 5.1 to 0.7% (P = 0.003), and the 5-year survival rate increased from 51.4 to 63.9% (P = 0.009). Using PSM, a comparison of OSeg hepatectomies that involved expert surgeons (n = 48) and those that did not (n = 48) showed significantly lower intraoperative blood loss in surgeries involving an expert surgeon (mean, 340 vs. 473 mL; P = 0.033). There were no significant differences in complication rates or long-term prognosis between these groups. A comparison of MOSeg hepatectomies that involved expert surgeons (n = 26) and those that did not (n = 26) showed no significant difference in surgical factors, complications, or overall survival between the two groups. CONCLUSIONS: After establishment of the JBCSES, postoperative complication rates and mortality rates decreased and survival rates increased following liver surgery. Expert surgeon participation significantly decreased intraoperative blood loss during OSeg hepatectomies.

Arterial chemoembolisation with cisplatin versus epirubicin for hepatocellular carcinoma (ACE 500 study): A multicentre, randomised controlled phase 2/3 trial.

BACKGROUND: Transarterial chemoembolisation (TACE) is a treatment option for hepatocellular carcinoma (HCC), but the optimum agent for TACE remains unclear. We compared the efficacy of TACE with cisplatin versus with epirubicin in patients with unresectable HCC. METHODS: This multicentre, randomised, phase 2/3 trial was performed at 21 hospitals in Japan. Patients with liver-confined HCC, performance status 0-2, and Child-Pugh class A/B were randomised to receive TACE with cisplatin or epirubicin. Patients were stratified in accordance with the institution, Child-Pugh class, tumour size, tumour thrombosis, α-fetoprotein and prior treatment. The primary end-point was overall survival in the intention-to-treat population. Tumour response was evaluated in accordance with the Response evaluation criteria in solid tumours criteria. FINDINGS: Between 2008 and 2012, 455 patients were randomly assigned to undergo TACE with cisplatin (n = 228) or epirubicin (n = 227). Eleven patients were ineligible, and 444 patients were included in the full analysis. Twelve patients not receiving TACE were excluded, and 432 patients were included in the safety analysis set. In phase 2, disease control rates in cisplatin (91·7%) and epirubicin (91·8%) groups exceeded the predefined threshold of 70%, and the study proceeded to phase 3. After a median follow-up of 32·7 months (IQR = 15·3-49·3), median overall survival periods were 2·93 years (95% CI 2·60-3·79) and 2·74 years (95%CI 2·26-3·21), respectively (hazard ratio 0·90 [95% CI 0·71-1·15], p = 0·22). Median times to treatment failure were 1·38 and 1·46 years (hazard ratio 1·09 [95% CI 0·88-1·35], p = 0·88), response rates were 65·3% and 60·6% (p = 0·31), and serious adverse event rates were 49·8% and 48·3% (p = 0·56), respectively. No treatment-related deaths occurred in either group. INTERPRETATION: In our phase 2/3 randomised trial, cisplatin is not significantly superior to epirubicin in TACE for patients with HCC.

Magnetic resonance elastography-based prediction of hepatocellular carcinoma recurrence after curative resection.

BACKGROUND: Liver stiffness measurement using magnetic resonance elastography can assess the severity of liver fibrosis, which is significantly associated with recurrence after curative resection for hepatocellular carcinoma. The aim of this prospective study was to investigate whether preoperative liver stiffness measurement by magnetic resonance elastograhy can predict recurrence after curative resection for hepatocellular carcinoma. METHODS: Patients who underwent preoperative liver stiffness measurement and curative resection for hepatocellular carcinoma were enrolled in this study. Potential associations between liver stiffness measurement, along with other clinical and pathologic variables, and intrahepatic hepatocellular carcinoma recurrence were analyzed. RESULTS: In total, 156 patients were included in this study. During a median follow-up period of 25.1 months (range, 6.0-60.5 months), 72 (46.1%) patients with hepatocellular carcinoma had an intrahepatic recurrence. The median disease-free period after resection was 17.9 months (range, 1.0-60.5 months). In the multivariate analysis, liver stiffness measurement (hazard ratio, 1.27; 95% confidence interval, 1.11-1.43; P <.001) and vascular invasion (hazard ratio, 1.96; 95% confidence interval, 1.15-3.25; P = .013) were identified as independent predictors of recurrence. When the optimal cutoff point was set at 4.53 kPa using the minimal P value approach, the disease-free period after curative resection in 71 patients with a liver stiffness measurement value ≥4.53 kPa (11.3 months [range, 2.0-60.5 months]) was significantly shorter than that of 85 patients with a liver stiffness measurement value <4.53 kPa (22.5 months [range, 1.1-60.5 months]; P <.001). CONCLUSION: Liver stiffness measurement using magnetic resonance elastography is a useful preoperative predictor of intrahepatic recurrence after curative resection for hepatocellular carcinoma.

Impact of patient age on outcome after resection for hepatocellular carcinoma.

There is little information on the impact of aging on liver resection of hepatocellular carcinoma (HCC). The aim of study was to evaluate the prognostic impact of the patient's age on the long-term survival after resection of HCC. The postoperative outcomes of the 291 elderly (≥ 70 years) and 340 younger (< 70 years) patients underwent curative liver resection for HCC were analyzed using multivariate and propensity-score matching. Risk score were calculated from the results of Cox regression analysis. The overall survival rate was significantly lower in the elderly group than that in the younger group (p = 0.01). Factors related to overall survival were vascular invasion (absent vs. present, HR 2.25; 95% CI 1.52-3.33, p = 0.0001), albumin level (< 3.0 vs. ≥ 3.0 g/dl, HR 2.23; 95% CI 1.31-3.79, p = 0.003), and number of tumors (solitary vs. multiple, HR 1.68; 95% CI 1.24-2.27, p = 0.001). The results of risk-score analysis with a Cox proportional-hazards model indicated that the proportion of poor-risk patients was significantly higher in the elderly than in the younger group. Propensity-score matching analysis yielded 234 pairs of patients. There were no significant differences in baseline profiles or risk scores between the two groups (p = 0.43). There were also no significant differences in the overall survival between the two groups (p = 0.23). Advanced age does not have a significant impact on the outcomes of patients after resection of HCC.

Algorithm for Resecting Hepatocellular Carcinoma in the Caudate Lobe.

OBJECTIVE: To propose an algorithm for resecting hepatocellular carcinoma (HCC) in the caudate lobe. BACKGROUND: Owing to a deep location, resection of HCC originating in the caudate lobe is challenging, but a plausible guideline enabling safe, curable resection remains unknown. METHODS: We developed an algorithm based on sublocation or size of the tumor and liver function to guide the optimal procedure for resecting HCC in the caudate lobe, consisting of 3 portions (Spiegel, process, and caval). Partial resection was prioritized to remove Spiegel or process HCC, while total resection was aimed to remove caval HCC depending on liver function. RESULTS: According to the algorithm, we performed total (n = 43) or partial (n = 158) resections of the caudate lobe for HCC in 174 of 201 patients (compliance rate, 86.6%), with a median blood loss of 400 (10-4530) mL. Postoperative morbidity (Clavien grade ≥III b) and mortality rates were 3.0% and 0%, respectively. After a median follow-up of 2.6 years (range, 0.5-14.3), the 5-year overall and recurrence-free survival rates were 57.3% and 15.3%, respectively. Total and partial resection showed no significant difference in overall survival (71.2% vs 54.0% at 5 yr; P = 0.213), but a significant factor in survival was surgical margin (58.0% vs 45.6%, P = 0.034). The major determinant for survival was vascular invasion (hazard ratio 1.7, 95% CI 1.0-3.1, P = 0.026). CONCLUSIONS: Our algorithm-oriented strategy is appropriate for the resection of HCC originating in the caudate lobe because of the acceptable surgical safety and curability.

Selection of patients with esophageal varices for liver resection of hepatocellular carcinoma.

The presence of esophageal varices (EV) is a phenotype of portal hypertension, and the indications of liver resection for hepatocellular carcinoma (HCC) in patients with concomitant EV are conflicting. This retrospective study aimed to elucidate if there is justification for liver resection in patients with EV. The surgical outcomes were compared between the patients who underwent resection for HCC with EV (EV group) and those without EV (non-EV group) after propensity-score matching. More bleeding was prevalent (P < 0.001) and refractory ascites was more frequently observed (P = 0.031) in the EV group (n = 277) compared with the non-EV group (n = 277); however, the numbers of patients with morbidities (P = 0.740) and re-operation (P = 0.235) were not significantly different between the two groups. After a median follow-up period of 3.0 years, the median overall and recurrencefree survival periods of patients with EV were 4.8 years (95% confidence interval [CI], 4.1-5.9) and 1.7 years (1.5-2.0), respectively, and were significantly shorter than those of patients without EV (7.6 years [95% CI, 6.3.9.7], P < 0.001, and 2.2 years [1.9-2.5], P = 0.016). On multivariate analysis, the independent factors for overall survival in the EV group were indocyanine green clearance rate at 15 minutes, des-gamma carboxyprothrombin, and the presence of multiple tumors. Considering that liver resection for patients with EV can be safely performed, it should not be contraindicated. However, surgical outcomes of these patients were unsatisfactory, suggesting that candidates for resection for HCC should be carefully selected.

Comparison of the surgical outcomes in patients with synchronous versus metachronous multiple hepatocellular carcinoma.

Multiplicity is one of the characteristics of hepatocellular carcinoma (HCC), and patients with multiple HCC (≤ 3 nodules) are recommended as candidates for liver resection. To confirm the validity of resecting multiple HCC, we compared the surgical outcomes in patients with synchronous and metachronous multiple HCC. Patients who underwent resection for multiple HCC (2 or 3 nodules) were classified into the "synchronous multiple HCC" group, while those undergoing resection for solitary HCC and repeated resection for 1 or 2 recurrent nodules within 2 years after initial operation were classified into the "metachronous multiple HCC" group. After one-to-one matching, longer operation time and more bleeding were seen in the synchronous multiple HCC group (n = 98) than those in the metachronous multiple HCC group (n = 98); however, the complication rates were not different between the two groups. The median overall survival times were 4.0 years (95% CI, 3.0-5.9) and 5.9 years (4.0-NA) for the synchronous and metachronous multiple HCC (after second operation) groups, respectively (P = 0.041). The recurrence-free survival times were shorter in the synchronous multiple HCC group than in the metachronous multiple HCC group (median, 1.5 years [95% CI, 0.9-1.8] versus 1.8 years, [1.3-2.2]) (P = 0.039). On multivariate analysis, independent factors for overall survivals in the synchronous multiple HCC group were older age, cirrhosis, larger tumor, and tumor thrombus. Taken together, resection of metachronous multiple HCC still has good therapeutic effect, even better than synchronous multiple HCC, so resection is suggested for metachronous multiple HCC.

High platelet count as a poor prognostic factor for liver cancer patients without cirrhosis.

A low platelet count, one of parameters of portal hypertension, is clinically a predictor of postoperative mortality, while platelets induce tumor development during growth factor secretion. In this study, we retrospectively investigated whether high platelet count negatively affects the survival of patients with hepatocellular carcinoma (HCC). Patients undergoing initial and curative resection for HCC were included. Surgical outcomes were compared between the high platelet (platelet count ≥ 20 × 104/µL) and control (< 20 × 104/µL) groups in patients without cirrhosis and between the low platelet (< 10 × 104/µL) and control (≥ 10 × 104/µL) groups in patients with cirrhosis. Among patients without cirrhosis, tumor was larger (P < 0.001) and tumor thrombus was more frequent (P < 0.001) in the high-platelet group than in the control group. After a median follow-up period of 3.1 years (range 0.2-16.2), median overall survival was 6.3 years (95% confidence interval [CI], 5.3-7.8) and 7.6 years (6.6-10.9) in the high-platelet (n = 273) and control (n = 562) groups, respectively (P = 0.027). Among patients with cirrhosis, liver function was worse (P < 0.001) and varices were more frequent (P < 0.001) in the low-platelet group. The median overall survival of patients in the low-platelet group (n = 172) was significantly shorter than that of patients in the control group (n = 275) (4.5 years [95% CI, 3.7-6.0] vs. 5.9 years [4.5-7.5], P = 0.038). Taken together, thrombocytopenia indicates poor prognosis in HCC patients with cirrhosis, while thrombocytosis is a poor prognostic predictor for those without cirrhosis.

Favorable outcomes of surgical resection for extrahepatic recurrent hepatocellular carcinoma.

AIM: Repeat resection for intrahepatic recurrent hepatocellular carcinoma (HCC) is effective for the long-term survival of patients; however, little is known about the surgical outcomes of extrahepatic nodules. The aim of this study is to investigate whether resection can contribute to the survival of patients with extrahepatic recurrent HCC. METHODS: Under the conditions that intrahepatic recurrent HCC was absent or controlled by locoregional therapies, patients who had resectable extrahepatic recurrent HCC in the lymph nodes, adrenal gland, peritoneum, lung, or brain were included in this study. The survival of patients who did (Surgical group) and did not (Non-surgical group, underwent other therapies) undergo resection for extrahepatic recurrent HCC was compared. RESULTS: Thirty-eight and 26 patients were included in the Surgical and Non-surgical groups, respectively. No patient had severe postoperative complications. After a median follow-up of 1.2 (range, 0.2-8.8) years, the median cumulative incidence of extrahepatic recurrent HCC was 1.2 years (95% confidence interval [CI], 0.4-3.5) in the Surgical group. The median overall survival was 5.3 (95% CI, 2.5-8.8) and 1.1 (0.8-2.3) years in the Surgical and Non-surgical groups, respectively (P < 0.001). The 5-year rates of survival were 60.5% and 9.1% in the Surgical and Non-surgical groups, respectively. Surgical resection, α-fetoprotein, disease-free interval, and metastasis at the adrenal gland were the independent factors for overall survival. CONCLUSIONS: Due to the favorable surgical outcomes, resection should be considered as one of the therapeutic choices for patients with extrahepatic recurrent HCC if intrahepatic recurrent HCC can be controlled by locoregional therapies.

Six autoantibodies as potential serum biomarkers of hepatocellular carcinoma: A prospective multicenter study.

Serum autoantibodies have been reported to react with tumor-associated antigen (TAA) in various cancers. This multicenter study evaluated the diagnostic and prognostic value of six autoantibodies against a panel of six hepatocellular carcinoma (HCC)-associated antigens, including Sui1, p62, RalA, p53, NY-ESO-1 and c-myc. A total of 160 patients with HCC and 74 healthy controls were prospectively enrolled from six institutions. Serum antibody titers were determined by enzyme-linked immunosorbent assays. The sensitivities were 19% for Sui1, 18% for p62, 17% for RalA, 11% for p53, 10% for NY-ESO-1 and 9% for c-myc. Overall sensitivity of the TAA panel (56%) was higher than that of α-fetoprotein (41%, P < .05). The combined sensitivity of the TAA panel and α-fetoprotein was significantly higher than that of α-fetoprotein alone (P < .001). The difference in overall survival of TAA panel-positive and panel-negative patients was significant when the Stage I/II patients were combined (P = .023). Overall survival was worse in NY-ESO-1 antibody-positive than in NY-ESO-1 antibody-negative patients (P = .002). Multivariate analysis found that positivity for the TAA panel was independently associated with poor prognosis (P = .030). This TAA panel may have diagnostic and prognostic value in the patients with HCC.

Impact of marginal resection for hepatocellular carcinoma.

PURPOSE: The surgical margin for liver resection to treat hepatocellular carcinoma (HCC) is occasionally < 1 mm. This study determined the impact of a surgical margin < 1 mm [marginal resection (MR)] on the types of recurrence and the prognosis in solitary HCC. METHODS: The data of 454 patients undergoing curative liver resection for solitary HCC in our institution were analyzed. The patients were divided into the MR (n = 90) and non-MR (n = 364) groups. The clinicopathological data and outcomes after liver resection were compared. A case-matching analysis using a propensity scoring method was also performed. RESULTS: The recurrence-free survival was significantly and overall survival was marginally significantly lower in the MR group than in the non-MR group (p = 0.012-0.051, respectively). According to a multivariate analysis, MR was not a significant independent factor for recurrence-free survival (p = 0.056). After propensity score matching, there were no significant differences in the recurrence-free and overall survival between the two groups (p = 0.375-0.496, respectively). Furthermore, there were no significant differences in the intrahepatic recurrence patterns between the two groups before and after matching. CONCLUSION: MR for solitary HCC might be sufficient in patients with a limited liver functional reserve.

Liver Resection Versus Embolization for Recurrent Hepatocellular Carcinoma.

BACKGROUND: Despite curative resection, hepatocellular carcinoma (HCC) has a high probability of recurrence. We validated the potential role of liver resection (LR) for recurrent HCC. METHODS: Patients with intrahepatic recurrence with up to three lesions were included. We compared survival times of patients undergoing their first LR to those of patients undergoing repeated LR. Then, survival times of the patients who had undergone LR and transcatheter chemoembolization (TACE) for recurrent HCC after propensity score matching were compared. RESULTS: After a median follow-up period of 3.1 years (range, 0.2-16.3), median overall survival times were 6.5 years (95% CI 6.0-7.0), 5.7 years (5.2-6.2), and 5.1 years (4.9-7.3) for the first LR (n = 1234), second LR (n = 273), and third LR (n = 90) groups, respectively. Severe complications frequently occurred in the first LR group (p = 0.059). Operative times were significantly longer for the third LR group (p = 0.012). After the first recurrence, median survival times after one-to-one pair matching were 5.7 years (95% CI 4.5-6.5) and 3.1 years (2.1-3.8) for the second LR group (n = 146) and TACE group (n = 146), respectively (p < 0.001). The median survival time of the third LR group (n = 41) (6.2 years; 95% CI 3.7-NA) was also longer than that of TACE group (n = 41) (3.4 years; 1.8-4.5; p = 0.010) after the second recurrence. CONCLUSIONS: Repeated LR for recurrent HCC is the procedure of choice if there are three or fewer tumors.

Patients' prognosis of intrahepatic cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma after resection.

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (ICC) are classified into one category, but comparison of prognosis of the two carcinomas remains controversial. The aim of the current study was to investigate surgical outcomes for patients with ICC or cHCC-CC who underwent resection in order to elucidate whether the classification of ICC and cHCC-CC is justified. Subjects were 61 patients with ICC and 29 patients with cHCC-CC who underwent liver resection from 2001 to 2017. Clinic-pathological data from the two groups were compared. Tumor number and vascular invasion were independent risk factors for recurrence-free survival (RFS) in both groups (P < .001 for both). Of note, for patients with ICC, tumor cut-off size of 5 cm showed statistical significance in median RFS (>5 cm vs ≤5 cm, 0.5 years vs 4.0 years, P = .003). For patients with cHCC-CC, tumor cut-off size of 2 cm showed statistical significance in median RFS (>2 cm vs ≤2 cm, 0.6 years vs 2.6 years, P = .038). The median RFS of patients with cHCC-CC was 0.9 years (95% confidence interval: 0.3-1.6), which was poorer than that of patients with ICC (1.3 years, 0.5-2.1) (P = .028); the rate of RFS at 5 years was 0% and 37.7% respectively. Our study supports the concept of classifying ICC and cHCC-CC into different categories because of a significant difference in RFS between the two.

Antimicrobial prophylaxis for 1 day versus 3 days in liver cancer surgery: a randomized controlled non-inferiority trial.

PURPOSES: This study compared the effectiveness of 1-day vs 3-days antibiotic regimen to prevent surgical site infection (SSI) in open liver resection. METHOD: We performed a randomized controlled non-inferiority trial in 480 patients at 39 hospitals across Japan (registered as UMIN000002852). Patients with hepatocellular carcinoma scheduled to undergo resection were randomly assigned to receive either a 1-day regimen for antimicrobial prophylaxis, or a 3-day regimen. The primary endpoint was the incidence of SSI. RESULTS: Among 480 randomized patients, 232 assigned to the 1-day regimen and 235 to the 3-day regimen were included in the full analysis set. Baseline characteristics of the two groups were well balanced. SSI was diagnosed in 22 patients (9.5%) in the 1-day group vs 23 patients (9.8%) in the 3-day group (difference, - 0.30; 90% CI - 4.80 to 4.19% [95% CI - 5.66% to 5.05%]; one-sided P = 0.001 for non-inferiority), meeting the non-inferiority hypothesis. In both groups, remote site infection (16 [6.9%] vs 22 [9.4%], P ˂ 0.001 for non-inferiority) and drain-related infection (5 [2.2%] vs 4 [1.7%], P ˂ 0.001 for non-inferiority) were comparable. CONCLUSION: To prevent SSI in liver cancer surgery, a 1-day regimen of flomoxef sodium is recommended for antimicrobial prophylaxis because of confirming the non-inferiority to longer usage.

Liver resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy.

AIM: Although radiofrequency ablation (RFA) is an effective local treatment of hepatocellular carcinoma (HCC), local recurrence is relatively frequent. We aimed to elucidate the validity of salvage liver resection for recurrent HCC after RFA. METHODS: Patients who underwent liver resection for recurrent HCC after RFA (LR after RFA) and those who underwent second liver resection for recurrent HCC (second LR) were included. The short-term outcomes were compared between the two groups. The survival rates between the two groups were compared after propensity-score matching to adjust for the variables, including patient background, liver function, and tumor status. RESULTS: Major resection was frequently carried out in the LR after RFA group, but there was no significant difference both in operative data and complication rate between LR after RFA (n = 54) and second LR (n = 266) groups. After a median follow-up period of 1.8 years (range, 0.2-10.5), the median overall survival was 4.4 years (95% confidence interval [CI], 2.2 - not applicable) and 5.6 years (95% CI, 4.5-7.3; P = 0.023) in the LR after RFA group (n = 54) and second LR group (n = 54), respectively, and recurrence-free survival was 1.3 years (0.4-2.2) and 1.2 years (0.5-1.8, P = 0.469), respectively. The only independent factor for overall survival of the LR after RFA group was local recurrence (hazard ratio, 2.73; 1.06-9.00). CONCLUSIONS: Salvage liver resection of recurrent HCC after RFA could be recommended due to the safety of the procedure, especially in patients without local tumor progression after RFA.