[A Case of Locally Advanced, Unresectable Pancreatic Cancer with Superior Mesenteric Artery Invasion Treated with FOLFIRINOX plus Radiation Therapy, followed by Conversion Surgery].

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

[A Case of Local Recurrent Liver Metastasis from Sigmoid Colon Cancer after Complete Histological Remission, Treated with Rehepatectomy].

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

Heterotopic ossification in primary rectal cancer with squamous cell carcinoma-like differentiation.

Objectives: Heterotopic ossification (HO), which occurs when bone tissue forms outside the skeleton, is extremely rare in rectal cancer. Adenocarcinoma is the histological type of all reported primary colorectal cancers with HO. However, in the present case, we observed areas of adenocarcinoma with squamous cell carcinoma-like differentiation. Here we conducted histopathological and immunohistochemical analyses to identify the mechanisms of HO development, to differentiate between adenocarcinoma and squamous cell carcinoma-like phenotypes, and to understand the associated prognostic implications. Case report: A 62-year-old woman was admitted to our hospital with symptoms of intermittent hematochezia without abdominal pain. Colonoscopy revealed stenosis with a protuberant mass in the rectum. Abdominopelvic contrast-enhanced computed tomography showed irregular wall thickness of the rectum, multiple lymph node metastases, and liver metastases. The rectal tumor exhibited calcified deposits with marked hyperintensity. We then performed Hartmann's operation and D3 lymph node resection. The biopsy specimen revealed tubular and solid adenocarcinoma nests and squamous carcinoma-like components over a necrotic extent without secreted mucin. She received chemotherapy (mFOLFOX6 with bevacizumab) as the first option and is alive 5 months after surgery. Conclusion: To the best of our knowledge, this is the first case of heterotopic ossification in a primary rectal cancer with squamous cell carcinoma-like differentiation that was surgically resected. This case suggests that BMP-2 transformed fibroblasts and pluripotent stem cells into osteocytes. We conclude that the squamous cell carcinoma-like lesion was squamous metaplasia of adenocarcinoma.

A case of Vp4 hepatocellular carcinoma with tumor thrombosis extending into the confluence of the splenic/portal vein achieved a good prognosis with emergent hepatectomy and postoperative adjuvant therapy with lenvatinib.

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

[A Case of Resection of Pancreatic Body Cancer Successfully Treated with GEM plus Nab-PTX].

The case was a 72-year-old man who had been on medication due to chronic pancreatitis since 2009 and was referred to our hospital because dilation of the main pancreatic duct was shown by abdominal ultrasonography. The contrast CT scan of the abdomen showed a 30 mm in size, poorly enhanced tumor at the body of the pancreas, which was suspected to invasion the celiac artery, common hepatic artery, and splenic artery. EUS showed a hypoechoic tumor with a diameter of 29× 24 mm. ERCP showed disruption of the pancreatic duct in the body of the pancreas, and cytological examination of the pancreatic juice showed a suspicious positive result. We diagnosed unresectable locally advanced pancreatic cancer in the body of the pancreas and underwent chemotherapy(gemcitabine plus nab-paclitaxel: GnP). Contrast-enhanced CT after 6 courses of GnP showed tumor shrinkage. FDG-PET/CT revealed a slightly in fluorine-18-deoxyglucose(FDG)accumulation in the tumor, but no accumulation around the blood vessels. Based on the above, it was judged that the tumor was possible radical resection, and surgery was performed. Intraoperative frozen section examination revealed no malignant findings in the tissues surrounding the main artery near the pancreatic body cancer, and distal pancreatectomy was performed. Histopathologically, the tumor showed findings of tubular adenocarcinoma, and the histological response to neoadjuvant therapy was Grade 2. We report a case in which conversion surgery was possible by chemotherapy.

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF. METHOD: A total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence. RESULTS: Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd's ratio: 1.082, 95% confidence interval: 1.007-1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53). CONCLUSIONS: Favorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period.

PURPOSE: The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy. METHODS: The subjects were 96 patients who underwent a 13C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test. RESULTS: The preoperative level of 13C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, 13C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a 13C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001). CONCLUSION: PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

Surgery for pancreatic tumors in the midst of COVID-19 pandemic.

The spread of the new coronavirus (COVID-19) infection in 2020 has had a significant impact on the treatment of cancer worldwide. During the COVID-19 pandemic, the biggest challenge for pancreatic surgeons is the difficulty in providing oncological care. In this review article, from the standpoint of surgeons, we explain the concept of triaging of patients with pancreatic tumors under the COVID-19 pandemic, and the actual impact of COVID-19 on the treatment of patients with pancreatic tumors. The most vital points in selecting the best therapeutic approach for patients with pancreatic tumors during this pandemic are (1) Oncologists need to tailor the treatment plan based on the COVID-19 phase, tumor malignant potential, and patients' comorbidities; and (2) Optimal treatment for pancreatic cancer should be planned according to the condition of each patient and tumor resectability based on national comprehensive cancer network resectability criteria. To choose the best therapeutic approach for patients with pancreatic tumors during this pandemic, we need to tailor the treatment plan based on elective surgery acuity scale (ESAS). Newly established ESAS for pancreatic tumor and flowchart indicating the treatment strategy of pancreatic cancer, are feasible to overcome this situation.

Transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure in adult patients.

OBJECTIVES: We evaluated the clinical outcomes of transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure in adults. METHODS: One-hundred-and-thirty-one consecutive adults with acute appendicitis were treated with the intention of performing transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure from July 2012 to December 2017. The procedure completion rate and outcomes were examined. To evaluate the risk factors for conversion, the background data were compared between the patients in whom the procedure was completed versus those in whom the procedure was uncompleted. RESULTS: The procedure was completed in 113 of 131 patients (86.3%). Single-site surgery was completed in 117 patients (89.3%). The median operation time was 79 (range 30-270) minutes and median intraoperative blood loss was 10 (range 0-394) ml. Postoperative complications occurred in 17 patients (13.0%). Postoperative hospital stay was 6 (range 1-27) days. The 18 patients in whom the procedure could not be completed comprised four patients in whom the stapler was used for intraabdominal stump closure, and 14 patients who were converted to multiport laparoscopic surgery or open surgery. Multivariate analysis showed that the independent risk factors for conversion were age, preoperative abscess, and peri-appendiceal fat density. Receiver operating characteristic curve analysis showed that the cutoff value of peri-appendiceal fat density for conversion was -40.51 Hounsfield units. CONCLUSIONS: Transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure was safe in adults with acute appendicitis. The risk factors for conversion were age ≥60 years, preoperative abscess, and peri-appendiceal fat density ≥-40.51 Hounsfield units.

Resection of pancreatic and splenic metastases from alveolar soft part sarcoma: a case report.

BACKGROUND: We present a case of pancreatic and splenic metastases following alveolar soft part sarcoma (ASPS), which was successfully treated by surgery. CASE PRESENTATION: A 41-year-old male was referred to our hospital in 2012. Computed tomography (CT) showed the presence of a pancreatic tumor. In 2002, the patient had undergone surgical resection of an ASPS of the anal region. In 2009, during follow-up, CT revealed lung metastases, which prompted surgical resection of the lung, followed by resection of the head skin in 2011. Abdominal ultrasonography (US) revealed the presence of isodense masses sized 34 mm in the pancreatic head and 60 mm within the spleen. The contrast-enhanced US revealed a solitary lesion with enhancement. Contrast-enhanced CT revealed solitary lesions with enhancement within the pancreatic head, spleen, and liver. The patient underwent metastasectomies from the pancreas, spleen, and liver. The patient was discharged on postoperative day 22 without recurrence for 18 months after metastasectomy. Twelve years after primary resection and 2 years after metastasectomy, the patient died as a consequence of multiple metastases. CONCLUSIONS: We have presented a rare case of pancreatic and spleen metastases from ASPS. Resection by radical metastasectomy was successful without morbidity. Thus, for improved survival of patients with multiple metastases from ASPS, metastasectomy may be indicated. If multiple metastases are resectable, surgical approaches may be the preferred treatment.

A case of hepatocellular adenoma with pedunculated development and difficulty in diagnosis.

Hepatocellular adenoma (HCA) is a benign hepatocyte-derived epithelial tumor. HCA is associated with oral contraceptive use among Caucasian populations. We report a case of hepatocellular adenoma with a pedunculated protuberance and high protein induced by vitamin K absence or antagonist-II (PIVKA-II) levels, which made diagnosis challenging. The patient was a 22-year-old woman. In a medical check-up, a high γ-GTP level was detected and a 115-mm solid mass was found in her lower abdomen via abdominal ultrasonography. A blood test showed a high PIVKA-II level. Abdominal CT showed a tumor in the lower abdomen. Contrast-enhanced CT showed a blood vessel thought to be the left hepatic artery connecting to the mass, and a blood vessel thought to be the left hepatic vein returning from the mass to the inferior vena cava. In EOB-MRI, uneven enhancement was observed after contrast imaging, but washout in the equilibrium phase was unclear. Parenchymal hepatocyte phases showed a pale, non-uniform, high signal. These findings indicated that the tumor was derived from the left lobe of the liver and was suggestive of HCC. Surgical resection was then performed. A pathological examination led to a diagnosis of HCA, corresponding to unclassified HCA. The WHO classification of tumors of the digestive system based on an immunohistological examination includes HNF1α-inactivated HCA, ß-catenin-activated HCA, inflammatory HCA, and unclassified HCA. In summary, our patient had a large HCA with pedunculated protrusion into the extrahepatic pelvic cavity. This case was challenging to diagnose because of abnormally high PIVKA-II levels, and it was resected laparoscopically.

Highly sensitive diagnostic method for colorectal cancer using the ratio of free DNA fragments in serum.

OBJECTIVES: The correlations of the ratio of long-/short-chain DNA fragments in blood with the existence of cancer and the clinicopathological features of colorectal cancer (CRC) were examined. The potential use of this ratio for diagnostic screening was evaluated. METHODS: DNA concentrations were amplified using Alu247 for long-chain DNA fragments and Alu115 for long- and short-chain DNA fragments. The Alu247/115 ratio was calculated for 60 patients with CRC and 24 healthy volunteers. The correlation of the Alu247/115 ratio with clinicopathological variables and the efficacy of this ratio as a tumor marker were examined. The Alu247/115 ratio cut-off value was set using a receiver operating characteristic (ROC) curve. RESULTS: The Alu247/115 ratio was significantly higher in patients with CRC than in healthy volunteers (P<0.001). The Alu247/115 ratio was also significantly higher in patients with Dukes stage A or B CRC than in healthy volunteers (P=0.034) as well as in patients with Dukes C or D CRC than in those with Dukes A or B CRC (P=0.016). Among patients with CRC, the Alu247/115 ratio was significantly higher in those with than without venous invasion (P=0.031). Using the cut-off value set from the ROC curve, the sensitivity of the Alu247/115 ratio was significantly higher than that of the carcinoembryonic antigen level (P=0.004) or the carbohydrate antigen 19-9 level (P<0.001). CONCLUSION: Our data suggest that the Alu247/115 ratio is a promising tool for highly sensitive and early detection of CRC.

[Safety and Efficacy of TAS-102 with Bevacizumab for the Treatment of Unresectable Metastatic Colorectal Cancer - A Case Report].

Chemotherapywith TAS-102 with bevacizumab(Bmab)is a new treatment for metastatic colorectal cancer. A 67-year-old male patient with synchronous multiple liver metastases was treated with TAS-102 with Bmab as a fifth-line chemotherapy. It was demonstrated that liver metastases decreased in size by1 3%bycomputed tomography(CT)after 3 months of TAS-102 with Bmab therapy. The Grade 3 or worst adverse event that was experienced was neutropenia. The patient was able to continue treatment with TAS-102 with Bmab for 6 months. TAS-102 with Bmab treatment was safetyand efficacious as a late-line chemotherapytreatment for metastatic colorectal cancer.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan.

OBJECTIVES: To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. METHODS: This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. RESULTS: Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. CONCLUSION: These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

Laparoscopic sigmoidectomy combined with uterus excision for colouterine fistula caused by sigmoid colon diverticulitis: A case report.

A case of colouterine fistula caused by colonic diverticulitis that was successfully treated laparoscopically is presented. A 74-year-old woman visited us with lower abdominal discomfort and vaginal excretion with minor fecal contamination. Mild tenderness was observed in her lower abdomen. Blood examinations revealed elevated white blood cell count and C-reactive protein. Sigmoid colon diverticulitis was revealed on CT, and her condition was diagnosed as colouterine fistula. Hinchey classification was stage I. After 2 weeks of conservative therapy, her symptoms were reduced, and the white blood cell count and C-reactive protein level decreased. However, fecal contaminated vaginal excretion continued. The patient underwent laparoscopic sigmoidectomy combined with uterus excision, and she has been in good health for the 3 years since the operation. Although colouterine fistula is usually treated with open surgery, patients with controlled and well-localized inflammation may be good candidates for a laparoscopic approach.

How Far Can We Go with Laparoscopic Liver Resection for Hepatocellular Carcinoma? Laparoscopic Sectionectomy of the Liver Combined with the Resection of the Major Hepatic Vein Main Trunk.

Although the reports of laparoscopic major liver resection are increasing, hepatocellular carcinomas (HCCs) close to the liver hilum and/or major hepatic veins are still considered contraindications. There is virtually no report of laparoscopic liver resection (LLR) for HCC which involves the main trunk of major hepatic veins. We present our method for the procedure. We experienced 6 cases: 3 right anterior, 2 left medial, and 1 right posterior extended sectionectomies with major hepatic vein resection; tumor sizes are within 40-75 (median: 60) mm. The operating time, intraoperative blood loss, and postoperative hospital stay are within 341-603 (median: 434) min, 100-750 (300) ml, and 8-44 (18) days. There was no mortality and 1 patient developed postoperative pleural effusion. For these procedures, we propose that the steps listed below are useful, taking advantages of the laparoscopy-specific view. (1) The Glissonian pedicle of the section is encircled and clamped. (2) Liver transection on the ischemic line is performed in the caudal to cranial direction. (3) During transection, the clamped Glissonian pedicle and the peripheral part of hepatic vein are divided. (4) The root of hepatic vein is divided in the good view from caudal and dorsal direction.

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy.

AIM: To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy. METHODS: This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery. Of the 80 patients who underwent LH, 22 had prior abdominal surgeries, including hepatectomy (n = 12), pancreatectomy (n = 3), cholecystectomy and common bile duct excision (n = 1), splenectomy (n = 1), total gastrectomy (n = 1), colectomy with the involvement of transverse colon (n = 3), and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen (n = 1). Clinical indicators including operating time, blood loss, hospital stay, and morbidity were compared among the groups. RESULTS: Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver. However, there were no conversions to laparotomy in this group. In the 58 patients without a history of upper abdominal surgery, the median operative time was 301 min and blood loss was 150 mL. In patients with upper abdominal surgical history or repeat hepatectomy, the operative times were 351 and 301 min, and blood loss was 100 and 50 mL, respectively. The median postoperative stay was 17, 13 and 12 d for patients with no history of upper abdominal surgery, patients with a history, and patients with repeat hepatectomy, respectively. There were five cases with complications in the group with no surgical history, compared to only one case in the group with a prior history. There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history, or with repeat hepatectomy. CONCLUSION: LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.

Recent advances in the surgical treatment of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The treatment of HCC is complex and complicated by the severity of associated chronic liver disease, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC, with an expected 5-year survival of 38%-61% depending on the stage of the disease. Improved liver function assessment, increased understanding of segmental liver anatomy from advanced imaging studies, and surgical technical progress are important factors that have led to reduced mortality in patients with HCC. The indication for LR may be expanded due to emerging evidences from laparoscopic hepatectomies and combined treatments with newly developed chemotherapies. Liver transplantation (LT) is considered as an ideal treatment for removal of existing tumors and the injured/preneoplastic underlying liver tissue with impaired liver function and the risk of multicentric carcinogenesis that results from chronically injured liver. However, LT is restricted to patients with minimal risk of tumor recurrence under immunosuppression. The expansion of criteria for LT in HCC patients is still under trial and discussion. Limited availability of grafts, as well as the risk and the cost of transplantation have led to considerable interest in expansion of the donor pool, living donor-related transplantation, and combined treatment involving LR and LT. This highlight presents evidence concerning recent studies evaluating LR and LT in HCC patients. In addition, alternative therapies for the treatment of early stage tumors and the management of patients on transplant waiting lists are discussed.

Recent advances in liver resection for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The association of HCC with chronic liver disease (CLD) is well known and making treatment complex and challenging. The treatment of HCC must take into consideration, the severity of CLD, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the important factors that have led to reduced mortality, with an expected 5 year survival of 38-61% depending on the stage of the disease. However, the procedure is applicable to <30% of all HCC patients, and 80% of the patients after LR recurred within 5 years. There are recent advances and prospects in LR for HCC in several aspects. Three-dimensional computed tomography imaging assisted preoperative surgical planning facilitates unconventional types of LR. Emerging evidences of laparoscopic hepatectomy and prospects for the use of newly developing chemotherapies as a combined therapy may lead to expanding indication of LR. LR and liver transplantation could be associated rather than considered separately with the current concepts of "bridging LR" and "salvage transplantation."

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease.

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.