Partial hepatectomy for ruptured hepatocellular carcinoma.

BACKGROUND: Improvements in surgical technique and perioperative care have made partial hepatectomy a safe and effective treatment for hepatocellular carcinoma (HCC), even in the event of spontaneous HCC rupture. METHODS: A consecutive cohort of patients who underwent partial hepatectomy for HCC between 2000 and 2009 was divided into a ruptured group and a non-ruptured group. Patients with ruptured HCC were further divided into emergency and staged hepatectomy subgroups. Mortality and morbidity, overall survival and recurrence-free survival (RFS) were compared. Prognostic factors for overall survival and RFS were identified by univariable and multivariable analyses. RESULTS: A total of 1233 patients underwent partial hepatectomy for HCC, of whom 143 had a ruptured tumour. The morbidity and mortality rates were similar in the ruptured and non-ruptured groups, as well as in the emergency and staged subgroups. In univariable analyses, overall survival and RFS were lower in the ruptured group than in the non-ruptured group (both P < 0·001), and also in the emergency subgroup compared with the staged subgroup (P = 0·016 and P = 0·025 respectively). In multivariable analysis, spontaneous rupture independently predicted poor overall survival after hepatectomy (hazard ratio 1·54, 95 per cent confidence interval 1·24 to 1·93) and RFS (HR 1·75, 1·39 to 2·22). Overall survival and RFS after hepatectomy for ruptured HCC in the emergency and staged subgroups were not significantly different in multivariable analyses. CONCLUSION: Spontaneous rupture predicted poor long-term survival after hepatectomy for HCC, but surgical treatment seems possible, safe and appropriate in selected patients.

A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy.

BACKGROUND AND AIM: Selective hepatic vascular exclusion (SHVE) has not been widely used because of difficulty in extrahepatic isolation of hepatic veins. This study aims to compare the results of SHVE using tourniquets or Satinsky clamps on major hepatic veins in partial hepatectomy for liver tumors involving the roots of hepatic veins. METHODS: Between June 2008 and March 2012, a randomized controlled trial was performed on patients undergoing liver resection to compare selective hepatic vascular exclusion using tourniquets or Satinsky clamps in partial hepatectomy. In the tourniquet group, the hepatic veins were completely isolated and occluded with tourniquets. In the Satinsky clamp group, the hepatic veins were dissected on the anterior and side walls only and they were clamped directly by Satinsky clamps. RESULTS: The time for dissecting hepatic veins was significantly shorter in the Satinsky clamp group (7.5 ± 6.6 min vs 21.3 ± 7.4 min) than the tourniquet group. In the tourniquet group, 5 hepatic veins could not be completely isolated and encircled. In 4 additional patients the hepatic vein was slightly torn during dissection. These 9 patients received successful occlusion using Satinsky clamps. In the Satinsky group, all occlusion of the hepatic vein was successful. There was a significant difference in the success rate in hepatic vein occlusion using the Satinsky and the tourniquet groups 60/60 vs 51/60, P = 0.0018. CONCLUSIONS: Both techniques of hepatic vein occlusion were safe and efficacious. As the use of Satinsky clamps is safer, easier and took less time, it is recommended.

Laparoscopic versus open repair for strangulated groin hernias: 188 cases over 4 years.

INTRODUCTION: Currently transabdominal pre-peritoneal and totally extraperitoneal repairs are the two standard laparoscopic approaches for groin hernia repair. However, they are still largely reserved for uncomplicated elective cases. To determine whether laparoscopic groin hernia repair can achieve similar results for acute strangulated hernias as laparoscopic cholecystectomy for acute cholecystitis, we analyzed and compared the results of emergency laparoscopic surgery and open repair for strangulated groin hernias performed by our team over the past 4 years. METHODS: This is a retrospective analysis of prospectively collected data. We analyzed the results of patients admitted between January 2007 and January 2011 who were diagnosed with acute strangulated groin hernia and underwent emergency open or laparoscopic hernia repair during the same admission. Patients' demographic details, mode of presentation, type of hernia, intraoperative findings, operative time, postoperative course and complications were compared. RESULTS: In total, 188 patients fulfilled the criteria for emergency surgical repair of strangulated groin hernias; 57 received laparoscopic and 131 received open repairs. The mean operative time was 79.82 ± 29.571 min and 80.75 ± 35.161 min, respectively. More laparotomies were performed in the open group (19 vs 0). The wound infection rate was significantly higher in the open group (12 vs 0). The mean hospital stay was shorter in the laparoscopic group (4.39 days vs 7.34 days). There was no mesh infection in either group. Recurrence occurred one case in the laparoscopic group and in three cases in the open group. CONCLUSIONS: Emergency laparoscopic repair for strangulated groin hernias is feasible and appears to have a lower morbidity relative to open repair. Further study should be performed to evaluate its full potential.

Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins.

BACKGROUND: Control of bleeding is crucial during liver resection, and several techniques have been developed to achieve this. This study compared the safety and efficacy of selective hepatic vascular exclusion (SHVE) and Pringle manoeuvre in partial hepatectomy for liver tumours compressing or involving major hepatic veins. METHODS: All patients undergoing liver resection between January 2003 and December 2010 for liver tumours compressing or involving one or more major hepatic veins were identified retrospectively from a prospective institutional database. Either SHVE or Pringle manoeuvre was used to minimize blood loss during hepatectomy. Data on demographics and the intraoperative and postoperative course were analysed. RESULTS: From the database of 3900 patients, 1420 were identified who underwent liver resection for tumours encroaching on major hepatic veins using either SHVE (550) or the Pringle manoeuvre (870). Intraoperative blood loss (mean(s.d.) 480(210) versus 830(340) ml; P = 0·007) and transfusion requirements (mean(s.d.) 1·3(0·6) versus 2·9(1·4) units; P = 0·008) were significantly less in the SHVE group. In the Pringle group, hepatic vein injury resulted in major intraoperative bleeding of over 1000 ml in 65 patients (7·5 per cent) and air embolism in 14 (1·6 per cent), and three patients (0·3 per cent) died during surgery, whereas there was no major bleeding, air embolism or intraoperative death in the SHVE group. Postoperative liver failure, multiple organ failure and in-hospital death were significantly more common in the Pringle group (P = 0·019, P = 0·032 and P = 0·004 respectively). CONCLUSION: SHVE was more efficacious than the Pringle manoeuvre in minimizing intraoperative bleeding and air embolism during partial hepatectomy for tumours encroaching on major hepatic veins, and decreased the postoperative liver failure rate.

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review.

BACKGROUND: There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. METHOD: A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms "common bile duct stones,""cholecystectomy,""bile duct exploration,""ERCP" (endoscopic retrograde cholangiography), and "endoscopic sphincterotomy." RESULTS: There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. CONCLUSION: Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one-stage management had the advantage of providing a shorter hospital stay.

Single-incision transabdominal preperitoneal and totally extraperitoneal repair for inguinal hernia: early experience from a single center in Asia.

INTRODUCTION: Laparoscopic inguinal hernia repair is currently one of the most commonly performed minimally invasive surgical procedures. In recent years, single-incision operations have been developed to further reduce the invasiveness of the surgery. Herein, we report our early experience with single-incision laparoscopic inguinal hernia repair in Asia, with both the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches. METHODS: This is a retrospective review of prospectively collected data on a cohort of consecutive patients with inguinal hernia who underwent single-incision laparoscopic inguinal hernia repair in a minimal access surgical center in Hong Kong between January 2010 and January 2011. RESULTS: Our cohort consists of 15 patients who underwent single-incision laparoscopic inguinal hernia; 13 were unilateral and two were bilateral hernias. The mean age was 59.8 years old (range, 28-74 years). The overall mean operative time was 59.53 min (range, 25-120 min). For unilateral hernia repair, the mean operative time was 56 min (range, 25-75 min) and 48.5 min (range, 41-55 min) for TAPP and TEP, respectively. In all cases single-incision laparoscopic hernia repair was successfully performed, no additional trocars were required, and there were no conversions to conventional laparoscopic or open inguinal hernia repair. All patients were discharged on the same day as the procedure. CONCLUSION: Single-incision laparoscopic inguinal hernia is feasible in both TEP and TAPP approaches. The procedure should be performed by laparoscopic surgeons with a high level of experience in single-incision surgery. Further randomized trials should be performed to evaluate the full potential and clinical application of single-incision TAPP and TEP.

Immunoglobulin G4-associated sclerosing cholangitis mimicking cholangiocarcinoma.

Immunoglobulin G4-related lymphoplasmacytic sclerosing disease is an emerging disease. Recently, it has been shown to be responsible for autoimmune pancreatitis-induced strictures of the bile duct mimicking cholangiocarcinoma. Making a diagnosis of immunoglobulin G4-associated sclerosing cholangitis requires a high index of suspicion. The differential diagnoses include primary sclerosing cholangitis, cholangiocarcinoma, and pancreatic cancer. The preoperative diagnosis is likely to be missed due to the lack of specific symptoms; a clinical presentation that may mimic other disorders, especially malignant biliary strictures; and the lack of specific imaging features. This article reports on a 51-year-old man with immunoglobulin G4-associated sclerosing cholangitis without autoimmune pancreatitis. He underwent resection of his extrahepatic bile duct with a hepaticojejunostomy. The diagnosis was confirmed after a histopathological examination. This case highlights the obstacles to making a preoperative diagnosis of immunoglobulin G4-associated sclerosing cholangitis.

Liver resection under total vascular exclusion with or without preceding Pringle manoeuvre.

BACKGROUND: Adequate control of bleeding is crucial during liver resection. This study analysed the safety and efficacy of hepatectomy under total hepatic vascular exclusion (THVE) in patients with tumours encroaching or infiltrating the hepatic veins and/or the inferior vena cava (IVC). METHODS: All patients undergoing liver resection with THVE between January 2000 and July 2006 were identified from a prospectively collected database containing 2400 patients. Data on patient demographics, surgical procedure and outcome were collected. RESULTS: A total of 87 patients scheduled for liver resection under THVE were identified, 77 with malignant tumours and ten with benign disease. THVE could not be used in two patients (2 per cent) owing to haemodynamic intolerance during trial clamping. Seventeen patients received simultaneous clamping of the portal triad and vena cava, and 68 had portal triad clamping followed by concomitant portal and vena cava clamping. The mean(s.d.) duration of THVE was 28.3(7.5) and 18.7(5.2) min respectively. Overall postoperative complication and operative mortality rates were 53 and 2 per cent respectively. Mean(s.d.) hospital stay was 16.8(4.7) days. CONCLUSION: Major hepatic resection for tumours encroaching on the hepatic veins or IVC can be carried out under THVE with reasonable morbidity and mortality.

Hepatic resection for colorectal liver metastases.

INTRODUCTION: Nearly 50 percent of patients who have colorectal carcinoma will develop liver metastases, which is frequently the cause of death. Liver resection is the only curative treatment for patients with colorectal metastases confined to the liver. However, liver resection can be performed in only ten percent of patients. A strategy to improve resectability and outcome of patients with colorectal liver metastases is needed. METHODS: The progress and outcome of patients, who had colorectal liver metastases and underwent liver resection in a tertiary surgical centre between January 1998 and December 2002, were retrospectively studied. RESULTS: During the five-year study period, 42 patients with colorectal liver metastasis underwent hepatic resection. 36 patients received primary liver resection. Six patients with initially unresectable disease received salvage surgery after tumour downstaging with systemic chemotherapy. Five of the 42 patients needed repeat liver resection for recurrent colorectal liver metastases. The hospital mortality rate was 2.1 percent. 11.9 percent of patients had major postoperative complications. The median survival was 49 months. The one-, three- and five-year overall survival rates after resection were 91 percent, 54 percent, and 37 percent, respectively; and the recurrence rate was 76 percent. The five-year survival rate with salvage surgery after tumour downstaging was 34 percent, and the corresponding figure, after repeat liver resection, for recurrent liver metastases was 27 percent. CONCLUSION: Hepatic resection for colorectal metastases confined to the liver resulted in reasonably good long-term survival, with acceptably low operative mortality and morbidity. Our results were compatible with the international standard of liver resection for colorectal liver metastases.

Liver surgery and transplantation in China: Progress and Challenges.

From the limited but available information, we traced the history of developments of liver surgery and transplantation in China. Liver surgery first started in the late 1950s in China, and it soon flourished mainly because of the great demand in liver surgery and the emergence of a number of giants in liver surgery. We recognized and honoured the important contributions of these Chinese pioneers in portal hypertension, recurrent pyogenic cholangitis, hepatocellular carcinoma and liver transplantation.

Surgical practice in Hong Kong.

Surgery in Hong Kong has undergone a significant evolution over the past century. The quality of surgical care, medical education, surgical training and academic research has improved significantly through the joint efforts of the two universities, the government and the surgical colleges over these years. Surgical practice in Hong Kong continues to change also with the development of specialties/subspecialties, the changing pattern of disease and the development of new and effective treatments. Areas of clinical excellence in oesophageal cancer, hepatocellular carcinoma (HCC) and nasopharyngeal cancer (NPC) have gradually developed in these areas in Hong Kong. With the ongoing Westernisation and continued economic development in Hong Kong, some previously uncommon diseases will become more common. The surgical service in Hong Kong will need to continue to change to meet the new challenges in the future

Intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a new pathological entity. It is diagnosed with increasing frequency. However, its natural history and management are still not well defined. METHODS: A Medline search was undertaken to identify articles using the keywords "intraductal papillary mucinous neoplasms of pancreas", "pancreatic neoplasms", and "pancreatic cyst". Additional papers were identified by a manual search of the references from the key articles. RESULTS: Surgical resection is the only treatment which can produce a cure. The reported overall 5-year survival for IPMN after surgical resection varies from 36% to 77%; for non-invasive IPMN, 77% to 100% and for invasive IPMN, 27% to 60%. The overall recurrence rate was 7% to 43%. IPMN can recur either as disseminated disease or as isolated pancreatic remnant recurrence even after surgical resection with negative margins. CONCLUSIONS: Based on the available evidence, patients with IPMN should undergo complete surgical resection. The extent of pancreatic resection and the intra-operative management of resection margins remain controversial. Balancing the risk of recurrence and the morbidity of total pancreatectomy, routine total pancreatectomy for IPMN is not recommended. Total pancreatectomy should only be reserved for patients with resectable but extensive IPMN which involves the whole pancreas. Regular monitoring for disease recurrence is important after surgery as there is a risk of recurrence in both non-invasive and invasive IPMN, and repeat resection for an isolated recurrence in the pancreatic remnant gives good results.

The continuing challenge of hepatic cancer in Asia.

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. The number of new cases is estimated to be 564,000 per year. About 80% of all cases are found in Asia. The goal of HCC management is "cancer control"--a reduction in its incidence and mortality as well as an improvement in the quality of life of patients with HCC and their family. Overall, 80% of HCC can be attributed to chronic hepatitis B and C infection. Prevention of infection with hepatitis B and C virus is the key strategy to reduce the incidence of HCC in Asia. Liver resection and liver transplantation remain the options that give the best chance of a cure. In the past two decades, operative mortality and surgical outcome of liver resection and liver transplantation for HCC have improved. Progress also has been made in multi-modality therapy which can increase the chance of survival and improve the quality of life for patients with advanced HCC. Many challenges are still present in Asia, such as the high prevalence of chronic hepatitis, the low resection rate of HCC, the high postoperative recurrence and the severe shortage of cadaveric organ donor. This article aims to discuss the development and challenges in the prevention and management of HCC in Asia.

The use of stereotactic navigation guidance in minimally invasive transnasal nasopharyngectomy: a comparison with the conventional open transfacial approach.

The purpose of this paper is to study the efficacy of applying stereotactic navigation guidance to nasopharyngectomy via a minimally invasive transnasal approach as compared with the conventional open transfacial approaches. The nasopharynx is the centre of the anterior skull base, which is remote from the surface of the facial skeleton. It is well known that there are several surgical approaches for access to resect tumours from the nasopharynx. However, the open techniques have been associated with much morbidity and only provide access to, and identification of, the ipsilateral internal carotid artery that forms the lateral boundary and resection limit of the nasopharynx. The coupling of stereotactic navigation guidance and a minimally invasive transnasal approach for nasopharyngectomy allows the surgeon to identify and protect the internal carotid artery bilaterally at the nasopharynx. This technique reduces operating time and morbidity to a minimum and yet is oncologically sound for resecting nasopharyngeal lesions. We compare 15 patients who underwent the stereotactic navigation guidance approach with 20 patients who received a conventional open transfacial approach.