Changes in and challenges regarding the surgical treatment of hepatocellular carcinoma in China.

Hepatocellular carcinoma (HCC) is a common malignant tumor with a high morbidity and mortality in China and elsewhere in the world. Due to its tumor heterogeneity and distant metastasis, patients with HCC often have a poor prognosis. A surgical treatment such as a radical hepatectomy is still the treatment of choice for patients with HCC in current clinical practice. However, the high rate of recurrence and rate of metastasis after surgery diminishes the survival of and prognosis for these patients. In an era of targeted therapy and immunotherapy, the surgical treatment of HCC must change. This review focuses on the definition, feasibility, and criteria with which to evaluate neoadjuvant therapy for HCC in order to provide a new perspective on surgical treatment of HCC.

Caprio and Merola: Latin American Contribution to the Development of Liver Surgery.

Regarding the history of liver surgery, Latin American pioneers have only occasionally been mentioned in the Anglo-Saxon literature. One of such rare cases was Uruguayan surgeon Gerardo Caprio, who in 1931 published a report about a resection of the left lobe of the liver. This was done during an uneventful period in the development of ideas on this surgical technique, following the remarkable advances made in the last quarter of the 19th Century. The anatomic and liver manipulation concepts used by Caprio had been developed by Merola in reports dating back to 1916 and 1920, which revealed well-grounded disagreements with the most renowned anatomists of the time. This paper discusses Merola and Caprio's academic profile by analyzing their publications, the knowledge base and experience that led the latter to perform such liver resection, and the surgical principles applied to it, which would only be formally adopted worldwide 20 years later.

Caprio, Mérola y los orígenes de la cirugía hepática en el Uruguay / Caprio & Mérola: the origins of liver surgery in Uruguay / Caprio, Mérola e os origens da cirurgia hepática no Uruguai

En la historia de la cirugía hepática los pioneros latinoamericanos han sido escasamente mencionados en la literatura anglosajona. Tal vez una excepción sea el trabajo del cirujano uruguayo Gerardo Caprio, que publicó su informe sobre una resección del lóbulo izquierdo del hígado, en 1931, en un período oscuro de las ideas sobre esta técnica quirúrgica, luego del fuerte impulso que tuviera en los últimos 25 años del siglo XIX. Los conceptos anatómicos y de la movilización hepática utilizados por Caprio fueron desarrollados por Mérola en comunicaciones que realizadas entre 1916 y 1920, las cuales incluso muestran fundadas discrepancias con los grandes anatomistas de la época. El presente trabajo analiza el perfil académico de Mérola y Caprio a través de un análisis de sus publicaciones, en cuanto a las bases de conocimiento y experiencia que impulsaron a Caprio a realizar esa hepatectomia y describir los principios quirúrgicos aplicados en la misma, que se consolidarían en el mundo recién 20 años después.

Regarding the history of liver surgery, Latin American pioneers have only occasionally been mentioned in Anglo-Saxon literature. One of such rare cases was Uruguayan surgeon Gerardo Caprio, who in 1931 published a report about a resection of the left lobe of the liver. This was done during an uneventful period in the development of ideas on this surgical technique, following the remarkable advances made in the last quarter of the 19th Century. The anatomic and liver manipulation concepts used by Caprio had been developed by Mérola in reports dating back to 1916 and 1920, which revealed well-grounded disagreements with the most renowned anatomists of the time. This paper discusses Mérola and Caprio's academic profile by analyzing their publications, the knowledge base and experience that led the latter to perform such liver resection, and the surgical principles applied to it, which would only be formally adopted worldwide twenty years later.

Na história da cirurgia hepática, os pioneiros latino-americanos pouco foram mencionados na literatura anglo-saxônica. Tal vez uma exceção seja o trabalho do cirurgião uruguaio Gerardo Caprio, que publicou uma ressecção do lobo esquerdo do fígado em 1931, em um período sombrio de as idéias sobre esta técnica cirúrgica, após o forte impulso que teve nos últimos 25 anos do século XIX. Os conceitos anatômicos e a mobilização hepática utilizada pelo Caprio foram desenvolvidos por Mérola em comunicações que datam de 1916 a 1920, que até mesmo mostre desentendimentos claros com os grandes anatomistas da época. Este artigo analisa o perfil acadêmico de Mérola e Caprio através de uma análise de suas publicações, em termos de bases de conhecimento e experiência que levaram a esta hepatectomia e aos princípios cirúrgicos aplicados nele, que seria consolidado em o mundo apenas 20 anos depois.

The management and prognosis of patients with hepatocellular carcinoma: what has changed in 20 years?

BACKGROUND & AIMS: There has been remarkable progress in the management of hepatocellular carcinoma (HCC) during the last several decades, but its effect on the prognosis of HCC patient needs clarification. We analysed the changes that affected prognosis of HCC patients diagnosed over two different eras. METHODS: A retrospective study of 1318 patients diagnosed with HCC from 1986 to 2012 was conducted. Analysis was done according to two cohorts, cohort 1 (patients diagnosed with HCC from 1986 to 1992) and cohort 2 (patients diagnosed from 2006 to 2012). RESULTS: Hepatitis B virus was the most common cause of liver disease for both cohorts (66.2% and 66.0%). The proportion of patients with Barcelona Clinic Liver Cancer stage 0/A was significantly lower in cohort 1 than in cohort 2 (14.4% vs. 39.5%, P < 0.001). The proportions of patients diagnosed during surveillance and general health check-up were significantly higher in cohort 2 than in cohort 1 (28.6% vs. 10.6% and 26.3% vs. 7.9%, respectively) while those diagnosed during symptomatic evaluation was significantly higher in cohort 1 than in cohort 2 (45.1 vs. 81.4%, P < 0.001). Surgical resection rate was similar between the two cohorts (26.1% vs 26%) while the transcatheter arterial chemoembolization rate which was the highest in cohort 1 (40.6%) was overtaken by radiofrequency ablation in cohort 2 (55%) at BCLC stage 0/A. Median survival duration in cohort 2 was significantly longer than cohort 1 (65.0 vs. 7.9 months, P < 0.001). CONCLUSIONS: Implementation of national cancer surveillance and the advancement of treatment modalities have likely led to early detection of HCC and improvements in prognosis over the last 20 years.

[Colorectal liver metastases: history, sciences and clinical practices]. / Métastases hépatiques d'origine colorectale: histoire, sciences et pratiques.

Colorectal liver metastasis is one of the best-known clinical models of multidisciplinary approach. Chemotherapy, targeted therapies, surgery and interventional radiology permitted to obtain up to 40 months of survival in palliative intent for liver metastases only and between 40 to 50% of overall survival in curative intent. Genetic, epigenetic, cellular and tissular processes are more and more well described but attempts to link biological knowledge to clinical practice are still faint. The cut-off between curative and palliative intents is progressively pushed away but consequently, its signification is less clear. Maybe an additional intermediary new concept should be added, the metastatic disease chronicisation? Evaluating the patient benefice is difficult and should stand on progression free survival as surrogate marker.

Ton That Tung's livers.

Born in the early 20th century, the Vietnamese surgeon Ton That Tung received his medical education in French colonial Indochina at the fledgling l'Ecole de Médecine de Hanoi, the first indigenous medical school in Southeast Asia. The benefactor of a postgraduate position at the medical school, Ton That Tung subsequently obtained his surgical training at the Phù Doãn Hospital in Hanoi and concurrently developed a passion for the study of liver anatomy, pathology, and surgery. His contributions to an understanding of liver anatomy based on meticulous dissection of autopsy specimens antedated and rivaled later work by the famous Western anatomists Couinaud, Healey, Schroy, and others. Ton That Tung's contributions, however, were overshadowed by the intense national struggles of the Vietnamese to establish independent rule and self-governance from the French and by eventual alignment with eastern bloc Communist countries, thus isolating much of his work behind the "Iron Curtain" until well after the end of the Cold War. Nevertheless, Ton That Tung remains a pioneer in liver anatomy and liver surgery. His commitment to surgical science and, more importantly, to the Vietnamese people stands as a tribute to the tireless pursuit of his ideals.

The past and present of liver suture.

Since the first attempts at resecting parts of diseased livers in the late nineteenth century, hemorrhage has been the main obstacle for surgeons. One of the first hemostasis techniques in liver resection was liver suture. The idea of suturing the liver in order to perform resection was proposed by a team of Russian and Polish surgeons from Kharkiv University in today's Ukraine. The liver suture became widely popular and has been used in various forms throughout the surgical world. Further into the twentieth century, it has lost much of its popularity; however, over more than 100 years of existence it has seen several peaks in interest. Currently, it is still being used by some liver surgeons as it is one of the cheapest ways of obtaining a bloodless liver parenchyma transection.

How to transect the liver? A history lasting more than a century.

There is a close relationship between blood loss during transection and unfavorable outcome. Many different methods have been used in order to cut the parenchyma, while leaving vital structures intact, coagulate small vessels and seal small biliary ducts. The first method described was the finger-fracture technique and, alternatively, the clamp-crushing method using a small forceps. With this technique, the liver is crushed between the 'jaws', and the vessels and bile ducts are successively ligated and divided. Technological research using different sources of energy developed the water jet dissectors and the ultrasonic dissectors. The CUSA® has been widely adopted for the fascinating way it could selectively destroy and aspirate parenchyma leaving vascular structures almost intact. Several studies have been addressed to clarify these critical points. However, in the majority of cases they are underpowered to demonstrate clear advantages of one method over the others. In conclusion, the evidence suggested no superiority of other techniques over clamp-crushing. But it must be taken into account that it requires strictly hepatic pedicle clamping. The devices available should be used within the limits of each instrument, as well as the surgical skills of the surgeon. Probably the best option should be a combined approach.

History of hepatic surgery.

This article describes the development of hepatic surgery from old anecdotes to spectacular progress achieved during the last 25 years. The door to this evolution was opened by anatomists who paved the way for a few courageous hepatic surgeons, who performed pioneering work between 1960 to 1980. Then, hepatic surgery and transplantation became widely accepted for the treatment of many diseases. Surgery on the liver has become safer with low postoperative mortality as a result of the creation of centers of excellence offering multidisciplinary expertise and technical innovation.

James Cantlie's early messages for hepatic surgeons: how the concept of pre-operative portal vein occlusion was defined.

In 1897, James Cantlie from Scotland published his findings of an autopsy on a patient in which the right side of the liver was atrophied whereas the left side of the liver showed a marked hypertrophy. He noted the hepatic vessels to the atrophied side to be obliterated. From this observation, he drew two important conclusions. First, that the transition of the atrophied part to the hypertrophied part defined the anatomical mid-line of the liver, according to the portal division of blood supply to the liver. This line we now know as Cantlie's line which he described connecting the fundus of the gallbladder with the centre of the inferior vena cava. Second, he foresaw that the potential of one half of the liver to hypertrophy when the other half is deprived of its blood supply, could be used to the advantage of hepatic resection. It would take another 85 years, however, before the first clinical, pre-operative portal vein embolization was carried out in Japan in 1982.

Current status of hepatic surgery in Korea.

Since the first liver resection was carried out in Korea in 1959, there have been remarkable changes in the field of surgery. With technical advancement and the improvement of perioperative care, liver resections are widely performed and surgical mortality is approaching zero. In the early 1990s, liver transplantation evolved as a feasible option in the treatment of end-stage liver disease in Korea, with successful adult living-donor liver transplantation (LDLT) as one of the greatest achievements. Various innovations in surgical approaches have been introduced. We review the current status of hepatic surgery in liver disease in Korea.

Current status of hepatic surgery in Korea / 대한간학회지

Since the first liver resection was carried out in Korea in 1959, there have been remarkable changes in the field of surgery. With technical advancement and the improvement of perioperative care, liver resections are widely performed and surgical mortality is approaching zero. In the early 1990s, liver transplantation evolved as a feasible option in the treatment of end-stage liver disease in Korea, with successful adult living-donor liver transplantation (LDLT) as one of the greatest achievements. Various innovations in surgical approaches have been introduced. We review the current status of hepatic surgery in liver disease in Korea.

Current status of hepatic surgery in Korea / 대한간학회지

Since the first liver resection was carried out in Korea in 1959, there have been remarkable changes in the field of surgery. With technical advancement and the improvement of perioperative care, liver resections are widely performed and surgical mortality is approaching zero. In the early 1990s, liver transplantation evolved as a feasible option in the treatment of end-stage liver disease in Korea, with successful adult living-donor liver transplantation (LDLT) as one of the greatest achievements. Various innovations in surgical approaches have been introduced. We review the current status of hepatic surgery in liver disease in Korea.