Robotic anatomical resection for hepatocellular carcinoma located within segment 7 using the Glissonean approach.

Worldwide use of robotic-assisted hepatectomy has increased dramatically over the past two decades. The role of robotic liver surgery is still controversial, especially with respect to its long-term oncological outcomes in treating early-stage hepatocellular carcinoma (HCC). The Glissonean approach is a fundamental technique for anatomical resection using open and laparoscopic liver surgery. To our knowledge, there have been few reports on purely robotic anatomical segmentectomy 7 for HCC using the Glissonean approach have been described. The present study describes the technical details and surgical outcomes of totally robotic segmentectomy 7 using the Glissonean approach. Fourteen patients with HCC limited to segment 7 underwent segmentectomy 7 from January 2019 through April 2023 in our hospital. The surgical techniques, peri-operative, and oncological outcomes were analyzed. Purely robotic anatomical segmentectomy 7 using the Glissonean approach was safe and feasible with the technology described herein in all of the 14 patients. The peri-operative and oncological outcomes were better and/or comparable with those of other similar hepatic resections using open approach and/or laparoscopic approach. The median follow-up time was 18 months. Intrahepatic recurrence occurred in 2 (14.3%) patient within one year following surgery. The 3-year overall survival rate was 81%. Although technically challenging, the purely robotic segmentectomy 7 could be performed safely and simultaneously with oncological radicality using the Glissonean approach.

AEG-1 is associated with hypoxia-induced hepatocellular carcinoma chemoresistance via regulating PI3K/AKT/HIF-1alpha/MDR-1 pathway.

Hypoxia is a common characteristic of hepatocellular carcinoma (HCC) associated with reduced response to chemotherapy, thus increasing the probability of tumor recurrence. Astrocyte elevated gene-1 (AEG-1) has been involved in a wide array of cancer progression including proliferation, chemoresistance, angiogenesis and metastasis, but its effect on HCC chemoresistance induced by hypoxia is unclear. In this study, expression of AEG-1 and multiple drug resistance (MDR-1) were examined in HCC using immunohistochemical staining and RT-PCR. Furthermore, their expression levels were detected in HCC HepG2 cells in normoxia or hypoxia via RT-PCR and Western blot assays. Specific shRNAs were used to silence AEG-1 expression in HepG2 cells. Results showed AEG-1 and MDR-1 expression were higher in HCC tissues than in adjacent normal tissues. Incubation of HepG2 cells in hypoxia increased expression of AEG-1 and MDR-1, compared to incubation in normoxia. Exposure to hypoxia blunted sensitivity of HepG2 cells to Adriamycin, 5-fluorouracil and cis-platinum, as evidenced by modest alterations in cell viability and apoptosis rate, however the sensitivity was elevated with AEG-1 knockdown. PI3K/AKT/HIF-1/MDR-1 pathway was attenuated following AEG-1 knockdown in hypoxia. Based on these data, it was suggested that AEG-1 is associated with hypoxia-induced hepatocellular carcinoma chemoresistance via regulating PI3K/AKT/HIF-1/MDR-1 pathway. This study uncovered a novel potential target for development of an effective therapy against hypoxia-induced HCC chemoresistance.

Effect of the PA-MSHA vaccine on septic serum-induced inflammatory response.

Sepsis is defined as a complex clinical syndrome caused by a serious infection followed by an amplified and deregulated inflammatory response. The complex syndrome is associated with a high rate of morbidity and mortality, despite substantial clinical advances. A vaccine derived from the outer membrane proteins of the Gram-negative bacteria Pseudomonas aeruginosa (PA-MSHA) has been demonstrated to exhibit immune modulatory properties. In the present study, the effect of the PA-MSHA vaccine on the inflammatory response induced by serum from septic patients in peripheral blood mononuclear cells was determined. It was observed that PA-MSHA pretreatment inhibits the production of septic serum-induced tumor necrosis factor-α. In addition, PA-MSHA treatment increases interleukin-10 levels and promotes the generation of CD4+CD25+Foxp3+ T cells. Thus, the results of the current study provide mechanistic insight relevant to the potential application of PA-MSHA in the treatment of sepsis.

Adiponectin (ADIPOQ) rs2241766 G/T polymorphism is associated with risk of cancer: evidence from a meta-analysis.

Associations between adiponectin (ADIPOQ) genetic polymorphisms (rs2241766 G/T and rs266729 G/C) and cancer risk have been extensively studied in the past decade, while conflicting results were reported. Therefore, this study would explore the associations by using a meta-analysis. The databases of Medline, Embase, and Wangfang were retrieved, and the latest updated time was 1 August 2012. Effect sizes of odds ratio and 95 % confidence interval (OR and 95 % CI) were calculated by using a fixed- or random-effect model. A total of 12 studies with 10,368 participants were identified for association between ADIPOQ rs2241766 G/T and risk of cancer, and ten studies with 12,665 participants were for association between ADIPOQ rs266729 G/C and risk of cancer. Overall combined analyses indicated that neither ADIPOQ rs2241766 G/T nor rs266729 G/C was associated with risk of cancer incidence (OR (95 % CI), 0.89 (0.61-1.30) for GG vs. TT and 0.94 (0.83-1.06) for G carriers vs. T carriers for rs2241766 G/T; 0.99 (0.85-1.16) for GG vs. CC and 0.96 (0.87-1.06) for G carriers vs. C carriers for rs266729 G/C). When stratified analyses were conducted according to the participants' ethnicity, sources of controls, types of cancer, and sample size, we found that G allele of ADIPOQ rs2241766 G/T was significantly associated with decreased risk of cancer based on population-based case-control studies (OR (95 % CI), 0.65 (0.50-0.85) for GG vs. TT and 0.88 (0.79-0.98) for G carriers vs. T carriers). In contrast, there was no association between rs266729 G/C polymorphism and risk of cancer when subgroup analyses were conducted. In summary, this meta-analysis indicated that ADIPOQ rs2241766 G/T rather than rs266729 G/C polymorphism was closely associated with risk of cancer development.

Meta-analyses of the associations between four common TGF-ß1 genetic polymorphisms and risk of colorectal tumor.

The associations between four common genetic polymorphisms of transforming growth factor-ß1 (TGF-ß1 -509 C > T, +869 T > C, +915 G > C, and -800 G > A) and risk of colorectal tumor (including adenoma and cancer) have been widely studied. To date, no conclusions could be available because of controversial results reported. Thus, we conducted a meta-analysis to further assess the associations. We searched the databases of Medline, Embase, and Wangfang to identify eligible studies, and latest update was on January 1, 2012. Odds ratio (OR) and 95% confidence interval (95%CI) were calculated to present the associations. Our meta-analysis indicated that TGF-ß1 -509 C > T, +869 T > C, +915 G > C, and -800 G > A were not associated with risk of colorectal adenoma (OR = 0.89 for C carriers vs. TT for -509 C > T, 1.03 for C carriers vs. TT for +869 T > C, 1.09 for C carriers vs. GG for +915 G > C, and 1.19 for A carriers vs. GG for 800 G > A). However, C allele of TGF-ß1 -509 C > T and A allele of -800 G > A were associated with increased risk of colorectal cancer (CRC), and OR (95%CI) was 1.23 (0.99-1.52) for CC vs. TT for -509 C > T and 6.64 (3.46-12.72) for A carriers vs. GG. The positive association between -509 C allele and risk of CRC was more obvious when subgroup analyses were conducted for population-based and large sample-sized studies as well as Caucasians. In contrast, we did not observed any associations between TGF-ß1 +869 T > C, +915 G > C, and risk of CRC. This study indicated that C allele of TGF-ß1-509 C > T and A allele of -800 G > A might contribute to the increased risk of CRC, and could be used as two of genetic marks for screening individuals at high risk of CRC. Because of modest limitation, large sample-sized studies were required to confirm the findings.

CYP1B1 Leu432Val polymorphism and colorectal cancer risk among Caucasians: a meta-analysis.

Studies investigating the association between cytochrome P450 1B1 (CYP1B1) Leu432Val (432 C/G, rs1056836) polymorphism and colorectal cancer (CRC) risk report conflicting results. The aim of this study was to quantitatively summarize the evidence for such a relationship. Two investigators independently searched the Medline, Embase, China National Knowledge Infrastructure, and Chinese Biomedicine Databases. Summary odds ratios (ORs) and 95% confidence intervals (95% CIs) for CYP1B1 polymorphism and CRC were calculated in a fixed-effects model and a random-effects model when appropriate. The pooled ORs were performed for co-dominant model (GG vs. CC, GC vs. CC), dominant model (GG + GC vs. CC), and recessive model (GG vs. GC + CC). This meta-analysis included ten case-control studies, which included 8,466 CRC cases and 9,301 controls. Overall, the variant genotypes (GG and GC) of the 432 C/G were not associated with CRC risk when compared with the wild-type CC homozygote (GG vs. CC, OR = 1.01, 95% CI = 0.93-1.10; GC vs. CC, OR = 0.97, 95% CI = 0.90-1.04), without any between-study heterogeneity. Similarly, no associations were found in the dominant and recessive models (dominant model, OR = 0.98, 95% CI = 0.92-1.05; recessive model, OR = 1.03, 95% CI = 0.96-1.11). Limiting the analysis to the studies within Hardy-Weinberg equilibrium, the results were persistent and robust. When stratifying for country, matched control and source of controls, no evidence of significant association was observed in any subgroup. No publication bias was found in the present study. No association is found between the CYP1B1 Leu432Val polymorphism and risk of CRC among Caucasians.

Null-margin bisegmentectomy VII-VIII for hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: Preservation of functional liver parenchyma should be a priority in hepatic surgery to avoid postoperative liver failure and enhance the opportunity to perform repeat resection in case of tumor recurrence. METHODOLOGY: A tumor localized in segments VII, VIII and adhering to or compressing the middle hepatic vein sometimes indicates a need to perform bisegmentectomy VII-VIII without surgical margin. From June 2006 to June 2011, fourteen patients with such a tumor underwent null-margin bisegmentectomy VII-VIII in our hospital. We retrospectively review our experience with this uncommon and technique-challenging hepatic resection. RESULTS: Mean intraoperative blood loss was estimated to be 300 mL and only four patients required blood transfusions less than 4U each person. Mean postoperative hospitalization was 11.2 days. Postoperative complications were encountered in 28.5% of patients and there was no postoperative mortality. Median overall and disease-free survivals were 35 and 23 months, respectively. CONCLUSIONS: The lack of ability to obtain an adequate surgical margin should not be considered as a contraindication for hepatectomy of HCC. In patients with impaired liver functional reserve and with right superiorly located tumors, the preservation of the middle hepatic vein should take priority and null-margin bisegmentectomy VII-VIII for HCC should be recommended.

Null-margin mesohepatectomy for centrally located hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: Anatomic mesohepatectomy is often anatomically restricted by the hilar structure and, therefore, difficult to perform with an adequate resection margin. Especially, in the case of a tumor which is in contact without infiltration with the critical intrahepatic vessels, mesohepatectomy has to be performed without a surgical margin. METHODOLOGY: From January 2005 to December 2009, thirty-seven patients with centrally located HCC underwent anatomic mesohepatectomy without resection margin in our hospital. The surgical techniques, clinicopathological characteristics and outcomes were reviewed. RESULTS: Mean operative time was 210 minutes (range 130 to 310 minutes) and mean intraoperative blood loss was 950 mL (range 150 to 4,500 mL). Mean postoperative hospitalization was 12.6 days (range 10 to 32 days). Postoperative complications were encountered in 37.8% of patients. The 1-, 3-, and 5-year recurrence-free survival rate was 75.1%, 39.3%, 22.5%, respectively, and the 1-, 3- and 5-year overall survival rate was 91.9%, 60.4%, 28.5%, respectively. CONCLUSION: Null-margin mesohepatectomy is an oncologically radical but parenchyma-sparing hepatic resection. In patients with impaired functional liver reserve and with centrally located tumors in contact without infiltration with major vessels, expected zero resection margins should not be considered as a contraindication for surgery, and null-margin mesohepatectomy should be recommended as a reasonable surgical option.

Paclitaxel ameliorates fibrosis in hepatic stellate cells via inhibition of TGF-beta/Smad activity.

AIM: To investigated if paclitaxel can attenuate hepatic fibrosis in rat hepatic stellate cells (RHSCs). METHODS: RHSCs were cultured in vitro and randomly assigned to four groups: normal control group (treated only with Dulbecco's Modified Eagle's Medium), Taxol group (200 nmol/L paclitaxel was added to the cell culture), transforming growth factor (TGF)-beta group (5 ng/mL recombinant human TGF-beta1 was added to the cell culture), and TGF-beta + Taxol group. TGF-beta signaling cascade and status of various extracellular matrix proteins were evaluated by real time reverse transcriptase polymerase chain reaction and Western blotting. RESULTS: The paclitaxel treatment markedly suppressed Smad2/3 phosphorylation. This was associated with attenuated expression of collagen I and III and fibronectin in RHSCs. CONCLUSION: These data indicate that 200 nmol/L paclitaxel ameliorates hepatic fibrosis via modulating TGF-beta signaling, and that paclitaxel may have some therapeutic value in humans with hepatic fibrosis.

[Study on correlation of JAK/STAT signal pathway with progression and prognosis in hepatocellular carcinoma].

AIM: To investigate the expression of JAK/STAT signal pathway in human hepatocellular carcinoma, and to evaluate its clinical significance in the progression and prognosis in hepatocellular carcinoma. METHODS: 196 patients with hepatocellular carcinoma were examined for the expression of JAK-1 protein and STAT-3 protein by SABC immunohistochemistry. RESULTS: The positive expression rates of JAK-1 protein and STAT-3 protein in patients with hepatocellular carcinoma were significantly higher than those in 20 cases of normal liver tissue (P=0.02 and 0.01, respectively). There was no significant relation between the positive expression rates of JAK-1 protein and STAT-3 protein and patients'sex, age, tumor size, and cirrhosis of the hepatocellular carcinoma tissues (all P>0.05). The JAK-1 protein and STAT-3 protein were expressed more frequently in hepatocellular carcinoma tissues with incomplete capsule (P=0.01 and 0.008, respectively), venous tumor emboli (both P=0.02), poorly differentiated (P=0.01 and 0.009, respectively) or clinical III-IV stage (P=0.02 and 0.008, respectively) than in those with complete capsule, no venous tumor emboli, maturely differentiated or clinical I-II stage. Cox proportional hazard regression model analysis indicated that the expression of JAK-1 protein and STAT-3 protein was significantly correlated with the prognosis of patients with hepatocellular carcinoma. CONCLUSION: The results suggest that the over-expression of JAK/STAT signal pathway may be an important feature of hepatocellular carcinoma.

Overexpression of polo-like kinase1 predicts a poor prognosis in hepatocellular carcinoma patients.

AIM: To elucidate the role of overexpressed polo-like kinase1 (PLK1) in hepatocellular carcinoma (HCC). METHODS: We prospectively collected clinicopathological, immunohistochemical and semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) data from 135 HCC patients undergoing successful hepatectomy. The correlations between PLK1 mRNA expression and clinicopathologic variables were analyzed by Mann-Whitney U test. Prognostic factors were identified by univariate and multivariate analyses. RESULTS: Immunohistochemical results showed overexpression of PLK1 was mainly found in tumor tissues compared with tumor-free tissue. A similar mRNA result was obtained by semi-quantitative RT-PCR. A total of 111 samples were positive for PLK1 mRNA expression. The positive expression was correlated with venous invasion, tumor nodules and Edmondson grade. Furthermore, 1, 3, 5-year survival rates in the positive expression group were significantly lower than the negative control group. Multivariate analysis showed that positive PLK1 expression was an independent risk factor for HCC. CONCLUSION: PLK1 could be a potential biomarker for diagnosis and therapy for HCC.

[Application of damage control surgery in serious pediatric abdominal surgery].

OBJECTIVE: Damage control surgery (DCS) deals with the complex surgical problems by stages. This study investigated the application of DCS in serious pediatric abdominal surgery. METHODS: The clinical data of 49 children with serious abdominal diseases (age: 4 months to 10 years) were retrospectively studied. Of them, 32 children underwent damage control surgery (DCS) and 17 children underwent conventional operation. The preoperative critical severity score (CSS), postoperative temperature, blood pH and prothrombin time (PT), and the treatment outcome were compared between the DCS and the conventional operation groups. RESULTS: No significant difference was found in the preoperative CSS between the two groups. There were significant differences in postoperative blood pH and PT values between the two groups (p<0.05). As for postoperative temperature, there was no statistical difference between the two groups, yet the tendency of temperature recovery in the DCS group was milder than that in the conventional operation group. Twenty-seven children (84.4%) were successfully cured in the DCS group, while 9 children (52.9%) in the conventional operation group (p<0.05). CONCLUSIONS: The curative effect of DCS surpasses the conventional operation in children with serious abdominal diseases, suggesting that DCS is of value in the management of serious pediatric abdominal diseases.

Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach.

BACKGROUND: Isolated segmentectomy VIII is a technically demanding operative procedure and is reported only rarely. To our knowledge, no reports on anatomic segmentectomy based on an intrahepatic approach have been described. For cirrhotic patients with hepatocellular carcinoma (HCC) limited to segment VIII, this is a parenchyma-preserving hepatectomy that can be tolerated. METHODS: Eighteen patients with HCC underwent anatomic segment VIII segmentectomy from January 2005 to January 2008 in our institution. The operative techniques, postoperative, and oncologic outcomes were reviewed. RESULTS: Anatomic segmentectomy VIII was feasible with the technology described herein in all patients. The perioperative and oncologic outcomes were comparable with those of other similar hepatic resections. The median follow-up time was 28 months. The 3-year survival rate was 65%. CONCLUSION: Although complex and technically demanding, an intrahepatic Glissonian approach for anatomic segmentectomy of segment VIII is an oncologically radical but parenchyma-sparing hepatic resection. In terms of preserving greater functioning liver parenchyma, it may be a safe and effective alternative to extensive hepatectomy.

Anatomic mesohepatectomy with extrahepatic control of hepatic veins.

BACKGROUND/AIMS: Intraoperative bleeding remains a major concern during mesohepatectomy because of doubled area of cut surface and proximity to important intrahepatic vascular structures. Preliminary extrahepatic exposure and looping of the main hepatic veins with the possibility of clamping them in association with total or partial vascular inflow occlusion, can lead to substantially reducing intraoperative bleeding. METHODOLOGY: From January 2003 to July 2008, preliminary exposure and looping of the main hepatic veins was performed in 67 patients undergoing mesohepatectomy. Among these patients, mesohepatectomy was performed with clamping of more than one of the main hepatic veins in 47 patients. We report the results obtained in those patients. RESULTS: Total vascular inflow occlusion with Pringle maneuver or partial vascular inflow occlusion based on an intrahepatic approach was used in all patients. The amount of intraoperative blood loss averaged (580 +/- 308) (range 180 to 4500) ml. No macroscopic tumor residue was encountered. There were no hospital deaths and the morbidity rate was 25.7%. The mean hospital stay was 11.2 days (range, 9-26). CONCLUSIONS: Our study showed that preliminary extrahepatic control of the main hepatic veins was a safe and technically feasible maneuver. During mesohepatectomy, clamping more than one of the main hepatic veins, in association with total or partial vascular inflow occlusion, is efficacious in reducing intraoperative bleeding.

Intrahepatic Glissonian access for mesohepatectomy in cirrhotic patients.

BACKGROUND/AIMS: For treatment of centrally located hepatocellular carcinoma (HCC), mesohepatectomy is a technically demanding procedure. The technique of an intrahepatic access to Glissonian pedicles achieves a safe inflow blood control of the liver segments to be resected and allows the anatomical removal of the tumor-bearing segment(s). No reports have mentioned the use of an intrahepatic access for mesohepatectomy in cirrhotic livers. METHODOLOGY: Seventeen consecutive patients underwent mesohepatectomy between January 1, 2005, and September 30, 2007. All these patients had hepatocellular carcinoma. The surgery was performed by making 3 small incisions around the hilar-plate, the gallbladder bed, and the round ligament. With a standardized method, the right anterior and left medial sheaths were reached by combining these incisions. RESULTS: Mesohepatectomy was feasible with the proposed technique in all patients. No patients experienced massive bleeding during the operation, and 14 patients did not require blood transfusion. Minor postoperative complications were observed in 8 patients and resolved with conservative management. No hospital mortality occurred. CONCLUSIONS: Intrahepatic Glissonian access for mesohepatectomy in cirrhotic patients is safe and effective. It may reduce intraoperative blood loss and the need for the Pringle maneuver.

[Laparoscopic partial gastrectomy: Analysis of 18 procedures].

OBJECTIVE: To explore the laparoscopic partial gastrectomy and the indications. METHODS: Eighteen patients who underwent laparoscopic partial gastrectomy from August 2005 to May 2006 were analyzed retrospectively. RESULTS: Sixteen patients (including 6 with gastric cancer, 9 with duodenal ulcer, and 1 with gastric multiple polyps) underwent laparoscopic partial gastrectomy. The other two patients underwent an open surgical procedure (1 patient with the tumor size large than 6 cm, and the other patient with bleeding after loosening one clip). The rate of intraoperative subcutaneous emphysema was 5.88% (1/17), and no death occurred. The operation time was (285+/-30)min on average, the estimated blood loss was (130+/-50)mL, and the hospitalization was (11+/-4)d. One case of obstruction of distal loop happened after the surgery, and the rate was 6.25% (1/16). The patients were followed up for 1 approximately 9 months postoperatively. Trocar puncture-site metastases occurred in one patient. CONCLUSION: Laparoscopic partial gastrectomy is safe and feasible with skillful laparoscopic technique and with restricted indications, and the surgical outcome may be similar to that of the open surgery.

Bisegmentectomy VII-VIII for hepatocellular carcinoma in cirrhotic livers.

BACKGROUND/AIMS: Preservation of nontumorous liver parenchyma should be a priority in hepatic surgery in order to avoid the risk of life-threatening liver failure and maximize the possibility of repeat resection. METHODOLOGY: A tumor localized in segments VII, VIII and infiltrating the main trunk of the superior right hepatic vein usually indicates a need to perform a right hepatectomy. With the presence of a stout inferior right hepatic vein, bisegmentectomy VII, VIII can be carried out without the risk of hepatic congestion in the remaining segment VI. We retrospectively review our experience with this rare and challenging hepatic resection. RESULTS: In 23 of 715 patients with primary hepatocellular carcinoma, the tumor was localized in segments VII, VIII and involved with the superior right hepatic vein. Eleven underwent bisegmentectomy VII, VIII. Mean operative blood loss was estimated to be 300mL (200-1200mL), and only three patients required blood transfusions less than 2U each person. No patient had postoperative life-threatening liver failure and there was no postoperative mortality. All resection margins were negative. Median overall and disease-free survivals were 31 and 11 months, respectively, with five patients alive and disease-free. CONCLUSIONS: Bisegmentectomy VII and VIII is an oncologically radical but parenchyma-preserving liver resection. Though a rare hepatic resection, it can be performed safely with low morbidity and mortality in selected patients.

[Highly-selective regional vascular exclusion for large liver tumor resection].

OBJECTIVE: To evaluate the highly-selective regional vascular exclusion in the risk hepatectomy for liver tumor. METHODS: Short hepatic veins were ligated and divided followed by the dissection, and isolation of the inflow and outflow vessels of the tumor-bearing lobe, which were completely devascularized after the occlusion of these vessels. The blood loss volume, postoperative recovering situation of the liver function and the incidence of complication were observed in 68 cases. RESULTS: Main hepatic veins were dissected and isolated exo-hepatically in 65 cases. In the other 3 cases, the main hepatic veins were blocked by Satin skin clamp applied longitudely along the inferior vena cava. Hepatic pedicle was routinely excluded.The amount of blood loss was from 400 to 1200 (600+/-200) mL and 26 (65%) cases didn't receive transfusion.There was no operative mortality and liver function failure. Surgical complications included subphrenic abscess in 2 cases and bile leakage in 2 cases, which were cured conservatively. CONCLUSION: Highly-selective regional exclusion of hepatic blood flow during the risk hepatectomy is safe and effective to prevent massive bleeding and to reduce the incidence of liver failure.

Surgical treatment of primary duodenal adenocarcinoma.

BACKGROUND/AIMS: Our purpose was to review the outcome of the patients with primary duodenal adenocarcinoma and determine factors influencing survival. METHODOLOGY: Over a 10-year period, 43 patients with this disease were identified. Data were analyzed to assess the outcomes of treatment and predictors of survival. RESULTS: Patients had symptoms present for an average of 6 months. The most common symptom was obstructive jaundice, observed in 55.8% of the cases. Based on symptomology, primary duodenal adenocarcinoma may be classified into three categories: icteric, obstructive and illusive. The upper gastrointestinal contrast study and esophagogastroduodenoscopy were the most effective diagnostic tests, showing an accuracy of 79.5% and 86.8%, respectively. A curative resection was performed in 28 of the 43 patients (65.1%), a conventional pancreatoduodenectomy in 11, segmental duodenal resection in 16 and gastroduodenectomy in 1. The overall 5-year survival rate was 27%, which was 42 percent after curative resection. CONCLUSIONS: The respectability of the primary lesion was associated with increased survival. An aggressive surgical approach should be pursued. Pancreaticoduodenectomy is usually required for tumors of the first and second portion of the duodenum. Segmental resection may be appropriate for selected patients, especially for cancers of the distal duodenum.

Anterior approach for complete isolated caudate lobectomy.

BACKGROUND/AIMS: Complete isolated caudate lobectomy is a technique-demanding procedure that entails the surgeon's judgement and precise knowledge of liver anatomy. METHODOLOGY: All consecutive patients who underwent complete isolated caudate lobectomy were studied. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) or wedge excisions of the caudate lobe were excluded. All patients were followed-up to date. RESULTS: Thirteen patients met the inclusion criteria (9 male, 4 female). Mean age (+/-SD) was 47 (+/-9) years. Primary diagnoses included hepatocellular carcinoma, hemangioma and adenoma. Margins were negative in all but two patients. Intraoperative US showed no tumor embolus within the main hepatic veins. Mean (+/-SD) operative time was 245 (+/-45) minutes, and estimated blood loss was 680 (+/-210) mL. Median blood transfusion was 420mL (range, 0 approximately 2500mL). Complications included bile leak in one patient, ascites in 2. Median length of hospitalization was 13 days (range, 11-21). There was no perioperative mortality. CONCLUSIONS: Complete isolated resection of the caudate lobe using the anterior approach should be the first choice for treatment of a tumor located in the caudate lobe alone, although the procedure is extremely difficult and highly dangerous.