Comparison of clinical outcome between laparoscopic and open hepatectomy of high difficulty score for hepatocellular carcinoma: a propensity score analysis.

BACKGROUND: Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival. RESULTS: The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival. CONCLUSION: LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.

Comparison of post-hepatectomy long-term survival outcome between non-colorectal non-neuroendocrine and colorectal liver metastases: A population-based propensity-score matching analysis.

BACKGROUND: Hepatectomy is an established treatment for colorectal liver metastasis (CLM) or neuroendocrine liver metastasis. However, its role in non-colorectal non-neuroendocrine liver metastasis (NCNNLM) is controversial. This study aims to compare long-term survival outcomes after hepatectomy between NCNNLM and CLM in a population-based cohort. METHODS: From 2009 to 2018, curative hepatectomy were performed in 964 patients with NCNNLM (n â€‹= â€‹133) or CLM (n â€‹= â€‹831). Propensity score (PS) matching was performed. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival. RESULTS: There were 133 patients in the NCNNLM group and 266 patients in the CLM group. The mortality (1.5 â€‹% vs 1.5 â€‹%) and morbidity (19.5 â€‹% vs 20.3 â€‹%) rates were comparable between the two groups. There was no statistically significant difference in 5-year overall (48.9 â€‹% vs 39.8 â€‹%) and recurrence-free (25.1 â€‹% vs 23.4 â€‹%) survival rates between NCNNLM and CLM groups. A high pre-operative serum bilirubin level, severe postoperative complications and multiple tumors were independent prognostic factors for poor survival. CONCLUSION: Hepatectomy for selected patients with NCNNLM can achieve similar long-term oncological outcomes as those with CLM. High serum bilirubin, severe postoperative complication and multiple tumors are poor prognostic factors for survival.

Minimally invasive versus open liver resection for hepatocellular carcinoma: a propensity score matching analysis of 224 patients.

PURPOSE: To compare the peri-operative and long-term survival outcomes of minimally invasive liver resection (MILR) (robotic or laparoscopic) with open liver resection (OLR) in patients with hepatocellular carcinoma (HCC). METHODS: Data of patients who underwent liver resection for HCC were reviewed from a prospectively collected database. Outcomes of MILR were compared with those of OLR. A propensity score matching analysis with a ratio of 1:1 was performed to minimise the potential bias in clinical pathological factors. RESULTS: From January 2003 to December 2017, a total of 705 patients underwent liver resection for HCC. Amongst them, 112 patients received MILR and 593 patients received OLR. After propensity score matching, there were 112 patients in each of the MILR and OLR groups. Patients were matched by age, sex, hepatitis status, presence of cirrhosis, platelet count, albumin level, bilirubin level, alkaline phosphatase (ALP) level, alanine transferase (ALT) level, creatinine level, tumour differentiation, tumour size, tumour number, presence of tumour rupture, presence of vascular invasion, extent of liver resection (minor/major) and difficulty score. The 1-, 3- and 5-year overall survival rates were 94.4%, 90.4% and 82.3% in the MILR group vs 95.4%, 80.5% and 71.8% in the open group (p = 0.240). The 1-, 3- and 5-year disease-free survival rates were 81.0%, 63.1% and 55.8% in the MILR group vs 79.1%, 58.1% and 45.7 in the open group (p = 0.449). The MILR group demonstrated significantly less blood loss (p < 0.001), less blood transfusion (p = 0.004), lower post-operative complications (p < 0.001) and shorter hospital stay (p < 0.001) when compared with the OLR group. CONCLUSIONS: Our data shows MILR yielded superior post-operative outcomes to OLR, with comparable survival outcomes.

A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation.

BACKGROUND: Robotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP). METHODS: Between March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group. RESULTS: The two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group. CONCLUSION: Apart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Robotic versus open hemihepatectomy: a propensity score-matched study.

BACKGROUND: Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy. METHODS: Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio. RESULTS: After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P < 0.001) but the postoperative hospital stay was significantly shorter (median 5 days vs 6.5 days, P = 0.040) in the robotic group. When right and left hepatectomy were analyzed separately, the advantage of shorter hospital stay remained in left but not right hepatectomy. For patients with hepatocellular carcinoma, there was no difference between the two groups in 5-year overall and disease-free survival. CONCLUSION: Compared with the open approach, robotic hemihepatectomy has longer operation time but shorter hospital stay. Thus, use of robot is feasible and effective in hemihepatectomy with the benefit of shorter hospital stay.

Development and validation of a novel nomogram predicting 10-year actual survival after curative hepatectomy for hepatocellular carcinoma.

INTRODUCTION: Although hepatectomy is a curative treatment modality for hepatocellular carcinoma (HCC), the associated 10-year long-term actual survival are rarely reported. This study aims to develop and validate a predictive nomogram for 10-year actual survivors with HCC. MATERIALS AND METHODS: From 2004 to 2009, 753 patients with curative hepatectomy for HCC (development set, n = 325; validation set, n = 428) were included. In development set, comparison of clinic-pathological data was made between patients surviving ≥10 years and those surviving <10 years. Good independent prognostic factors identified by multivariate analysis were involved in a nomogram development, which was validated internally and externally using validation set. RESULTS: On multivariate analysis, five independent good prognostic factors for 10-year survival were identified, including young age (OR = 0.943), good ASA status (≤2) (OR = 2.794), higher albumin level (OR = 1.116), solitary tumor (OR = 2.531) and absence of microvascular invasion (OR = 3.367). A novel nomogram was constructed with C-index of 0.801 (95% CI 0.762-0.864). A cut-off point of 167.5 had a sensitivity of 0.794 and specificity of 0.730. Internal validation using bootstrap sampling and external validation using validation set revealed C-index of 0.792 (95% CI, 0.741-0.853) and 0.761 (95% CI, 0.718-0.817). CONCLUSION: A novel nomogram for 10-year HCC survivor using age, ASA status, preoperative albumin, tumor number and presence of microvascular tumor invasion was developed and validated with high accuracy.

The utility of genome-wide cell-free DNA screening in the prenatal diagnosis of Pallister-Killian syndrome.

OBJECTIVE: To report genome-wide cell-free DNA (cfDNA) screening facilitating the diagnosis of Pallister-Killian syndrome (PKS). METHODS: This is a retrospective cohort analysis of positive genome-wide cfDNA screening results showing increased signal from chromosome 12 and the detection of PKS. The genome-wide cfDNA screening results and the subsequent investigations were reviewed. RESULTS: Three singleton pregnancies (3/29007) from 2016 to 2017 yielded positive results indicating large gains on the entire p-arm of chromosome 12. In two cases, multiple structural abnormalities were detected by prenatal ultrasound and the couples opted for termination of pregnancy. Chromosomal microarray performed on fetal skin tissues of the two abortuses detected mosaic tetrasomy 12p, consistent with PKS. In the third case, karyotype and chromosomal microarray performed on an amniotic fluid sample also showed mosaic tetrasomy 12p. In each of the three cases, genome-wide cfDNA screening revealed a large gain on chromosome 12p; subsequent prenatal or postnatal diagnostic testing confirmed the diagnosis of PKS. CONCLUSION: We report the ability of genome-wide cfDNA screening to provide early suspicion and facilitate the subsequent genetic diagnosis of PKS. As genome-wide cfDNA screening becomes increasingly available, incidental diagnosis of partial aneuploidies is expected to increase.

Prospective double-blinded randomized controlled trial of Microwave versus RadioFrequency Ablation for hepatocellular carcinoma (McRFA trial).

BACKGROUND: Microwave (MWA) and radiofrequency ablation are the commonly used local ablation for hepatocellular carcinoma (HCC). Studies comparing both techniques are scarce. The aim of this study was to compare the efficacy of MWA versus RFA as a treatment for HCC. METHODS: Patients with HCC who were suitable for local ablation were randomized into MWA or RFA. All patients were followed up regularly with contrast-enhanced computed tomography (CT) performed at 1, 3, 6 and 12 months after ablation. Both patients and the radiologists who interpreted the post-procedure CT scans were blinded to the treatment allocation. Treatment-related morbidity, overall and disease-free survivals were analyzed. RESULTS: A total of 93 patients were recruited. Among them, 47 and 46 patients were randomized to MWA and RFA respectively. Patients in two groups were comparable in baseline demographics and tumor characteristics. With a median follow-up of around 30 months, there were no significant difference in the treatment-related morbidity, overall and disease-free survivals. MWA had a significantly shorter overall ablation time when compared with RFA (12 min vs 24 min, p < 0.001). CONCLUSIONS: MWA is no different to RFA with respect to completeness of ablation and survivals. It is, however, as safe and effective as RFA in treating small HCC.

Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma: Result from Two Combined Randomized Controlled Trials.

BACKGROUND: Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. METHODS: Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. RESULTS: There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16-30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. CONCLUSION: IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16-30 min. TRIAL REGISTRATION: NCT00730743 and NCT01759901 ( http://www.clinicaltrials.gov ).

Ablative Chemoembolization for Hepatocellular Carcinoma: A Prospective Phase I Case-Control Comparison with Conventional Chemoembolization.

Purpose To evaluate the feasibility, safety, and treatment effectiveness of ablative chemoembolization (ACE) in the treatment of hepatocellular carcinoma (HCC) and compare with a similar patient cohort who underwent conventional transarterial chemoembolization (cTACE). Materials and Methods This was a prospective phase I nonrandomized study conducted between March 2013 and October 2016 in accordance to the Declaration of Helsinki and Declaration Good Clinical Practice with written informed consent. There were 36 men and eight women (median age, 64 years [interquartile range, 58-74] and 74.5 years [interquartile range, 70-80], respectively). The primary end points were treatment safety and tumor response. The secondary end points were time to progression, progression-free survival, conversion to partial hepatectomy, and viable HCC within the tumor specimen. The end points of the study group (n = 22) were compared with those of a case-matched control group (n = 22) of patients who underwent conventional cTACE during the same period by using a Pearson χ2 test. Results Treatment with ACE was successfully completed in all patients without adverse effects. The complete response (CR) rates by patient or by tumor were both 100%. The median time to progression and median progression-free survival were significantly longer in the study group than in the control group (both were 28 months vs 10 months, respectively; P < .001). The number of patient conversions to hepatectomy was seven for ACE and three for cTACE. In the tumor specimens, viable tumor was found in two of eight specimens that underwent ACE and three of three that underwent cTACE. Conclusion ACE is a feasible, safe, and well-tolerated treatment for patients with HCC; it is highly effective and may be more effective than cTACE in achieving CR. © RSNA, 2017 Online supplemental material is available for this article.

Does Intermittent Pringle Maneuver Increase Postoperative Complications After Hepatectomy for Hepatocellular Carcinoma? A Randomized Controlled Trial.

BACKGROUND: In a previous study, we have shown that intermittent Pringle maneuver (IPM) might increase postoperative complications after hepatectomy for various indications. Complications which thought to be related to IPM were ascites, pleural effusion, wound infection and intra-abdominal collection. The aim of this study was to test the hypothesis that applying IPM during hepatectomy for hepatocellular carcinoma (HCC) could increase postoperative complications. METHODS: Between January 2013 and October 2016, eligible patients who received elective open hepatectomy for HCC were randomized to have IPM or no Pringle maneuver (NPM). Occurrence of various types of postoperative complications was specifically looked for. A routine postoperative day 5 abdominal ultrasound examination and chest X-ray were done to detect and grade any radiological ascites, pleural effusion and intra-abdominal collection. RESULTS: Fifty IPM and 50 NPM patients with histological proven HCC were recruited for final analysis. Demographics and operative parameters were comparable between the two groups. The postoperative complication rates were similar (IPM 36.0 vs. NPM 28.0%, P = 0.391). However, in the IPM group, more patients developed radiological posthepatectomy ascites (42.0 vs. 22.0%, P = 0.032) and pleural effusion (66.0 vs. 38.0%, P = 0.005). In patients with histologically proven cirrhosis, there were 28 IPM and 25 NPM patients. Again, there was no difference in postoperative complication rate but more radiological posthepatectomy ascites and pleural effusion in the IPM group. CONCLUSION: This trial was not able to detect a difference in postoperative complications whether IPM was applied or not, but use of IPM was associated with more subclinical ascites and pleural effusion. (ClinicalTrials.gov NCT01759901). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT01759901.

Robotic Liver Resection For Primary Hepatolithiasis: Is It Beneficial?

BACKGROUND: Primary hepatolithiasis is a disease characterized by primary biliary ductal abnormality with stone formation predominantly within the intrahepatic bile ducts. Its management is difficult, but liver resection has emerged as a promising treatment option. METHODS: Robotic liver resection (RLR) has been adopted in our center for the management of patients with hepatolithiasis. The operative and short-term outcomes of this cohort of patients were compared with a historical cohort of patients using open approach (OLR). A subgroup analysis was performed for left lateral sectionectomy. RESULTS: Between September 2010 and April 2015, 15 RLRs were performed on patients with primary hepatolithiasis. The historical cohort consisted of 42 OLRs with operation done between January 2005 and January 2014. No differences were found in patient demographics, disease characteristics, or types of resection. No operative deaths occurred, and no difference was seen in complication rates. RLR had significantly less blood loss (100 vs. 235 ml; p = 0.011) and shorter hospital stays (6 vs. 8 days; p = 0.003). After a median follow-up of 19.4 months for RLRs and 79.2 months for OLRs (p < 0.001), there were no differences in residual stone rate, recurrent stone rate, or rate of recurrent cholangitis. Subgroup analysis of lateral sectionectomy (10 RLRs vs. 27 OLRs) revealed similar outcomes, i.e., less blood loss and shorter hospital stays in RLR. CONCLUSIONS: Robotic liver resection reduces blood loss and shortens hospital stays compared with OLR. A longer follow-up is needed to assess the long-term outcomes of RLR regarding prevention of recurrent stones and cholangitis.

A minimally invasive strategy for Mirizzi syndrome: the combined endoscopic and robotic approach.

BACKGROUND: Mirizzi syndrome (MS) is a rare complication of gallstone disease. Despite the fact that successful laparoscopic treatments have been reported, open surgery remains the gold standard approach for this disease due to technical difficulties involved. METHODS: A minimally invasive strategy combining endoscopic retrograde cholangiopancreatography (ERCP) and robotic surgery for the management of MS was implemented in early 2012. This consisted of a preoperative ERCP for definitive diagnosis and endoscopic stent insertion. Robotic surgical approach was used during operation to facilitate gall bladder removal and suture of defect over common duct. ERCP was repeated postoperatively for stent removal. Patient demographics and treatment outcomes were collected prospectively. A historical cohort of patients with MS who underwent conventional surgery between 1999 and 2011 was identified for comparison of treatment outcomes. RESULTS: Five patients with MS were managed with this strategy. Robotic subtotal cholecystectomy was successfully performed in all the patients without conversion or morbidity. When compared with a historical cohort of 17 patients who underwent surgery for MS, this group of patients had significantly less conversion and shorter hospital stay though the operation time was longer. It also showed less blood loss and less postoperative complications but these were not statistically significant. CONCLUSION: Mirizzi syndrome can be effectively managed with a minimally invasive approach by adopting a robot-assisted surgery together with a planned pre- and postoperative ERCP.

Evaluation of a pharmacist-managed anemia service in pregnant patients.

PURPOSE: Studies have shown the positive impact pharmacist-managed services have on patient care. However, little information is available on services for pregnant patients. This study contributes to the current literature by providing data on the impact of a pharmacist-managed service on outcomes in pregnant patients with iron-deficiency anemia. METHODS: This was a retrospective, data-only, multicenter study comparing pregnant patients with iron-deficiency anemia managed by a pharmacist (n = 100) to those who received standard care (n = 100). During the study period, patients were 16 years of age or older and pregnant with concurrent iron-deficiency anemia. The percentage of patients with a hemoglobin level above goal (>11.0 g/dL) at delivery, the mean hemoglobin level at delivery, and the type of iron supplementation were compared between the groups. RESULTS: The percentage of patients with a hemoglobin level of greater than 11.0 g/dL at delivery was 87% for the pharmacist-managed group compared to 71% for the group receiving standard care (P < 0.01). The mean hemoglobin level at delivery was significantly higher in the pharmacist-managed group than in the group receiving standard care, at 12.1 g/dL vs 11.6 g/dL, respectively (P < 0.1). There was no difference between the groups in the percentage of patients receiving blood transfusions (4% vs 3%; P = 0.56). The percentage of patients who received intravenous iron was significantly lower in the pharmacist-managed group than in the group receiving standard care (8% vs 21%; P < 0.01). Most patients in the pharmacist-managed group received oral ferrous sulfate (81%). CONCLUSION: This study showed that including pharmacists in the management of pregnant patients with iron-deficiency anemia significantly improved patient hemoglobin levels at delivery.

The relationship between tear severity, fatty infiltration, and muscle atrophy in the supraspinatus.

BACKGROUND: Fatty infiltration and muscle atrophy have been described as interrelated characteristic changes that occur within the muscles of the rotator cuff after cuff tears, and both are independently associated with poor outcomes after surgical repair. We hypothesize that fatty infiltration and muscle atrophy are two distinct processes independently associated with supraspinatus tears. MATERIALS AND METHODS: A retrospective review of 377 patients who underwent shoulder magnetic resonance imaging at one institution was performed. Multivariate analysis was performed based on parameters including age, sex, rotator cuff tear severity, fatty infiltration grade, and muscle atrophy. RESULTS: A total of 116 patients (30.8%) had full-thickness tears of the supraspinatus, 153 (40.6%) had partial thickness tears, and 108 (28.7%) had no evidence of tear. With increasing tear severity, the prevalence of substantial fatty infiltration (grade ≥2) increased: 6.5% of patients with no tears vs 41.4% for complete tears (P < .001). Similarly, the prevalence of supraspinatus atrophy increased with worsening tear severity: 36.1% of no tears vs 77.6% of complete tears (P < .001). Multivariate analysis demonstrated a significant independent association between fatty infiltration and muscle atrophy when taking into account sex, age, and tear severity. CONCLUSIONS: Fatty infiltration and muscle atrophy are independently associated processes. Fatty infiltration is also related to increasing age, muscle tear severity, and sex, whereas muscle atrophy is related to increasing age but not tear severity. In patients without rotator cuff tears, fatty infiltration and atrophy prevalence increased independently with increasing age.

Pre-operative predictors of post-hepatectomy recurrence of hepatocellular carcinoma: can we predict earlier?

BACKGROUNDS AND PURPOSE: To determine the predictors for recurrence in patients receiving curative hepatectomy for hepatocellular carcinoma (HCC). METHODS: From January 2001 to July 2007, all patients having hepatectomy for first occurrence HCC with curative intent were identified from a prospectively collected database. Prognostic factors for recurrence and survival after resection were analyzed. RESULTS: A total of 235 patients were included. With a median follow-up of 50.2 (0.07-125.1) months, the recurrence rate was 57.0%. The 1-, 3-, and 5-year overall survival rates were 83.9%, 66.0%, and 58.1% respectively. Multivariate analysis demonstrated that multi-focal lesions (HR: 2.93, P < 0.001), alpha-fetoprotein (AFP) level greater than 100 ng/ml (HR: 1.74, P = 0.002) and history of tumor rupture (HR: 2.84, P = 0.003) were independent risk factors for recurrence of HCC after hepatectomy. CONCLUSIONS: Predictors for HCC recurrence can be identified before operation. These important parameters should be considered before and after contemplating curative resection for HCC patients and for risk stratification in future clinical trials for neoadjuvant or post-resection adjuvant therapy. The possible use of neoadjuvant or adjuvant treatment to improve survival should be addressed by further trials.

Comparison of Survival Outcomes in Transarterial Ethanol Ablation and Liver Resection for Solitary Hepatocellular Carcinoma ≤ 5 cm in Patients Stratified by Liver Function.

PURPOSE: To compare the survival outcomes of patients treated with transarterial ethanol ablation (TEA) with those treated with liver resection (LR) for solitary HCC less than 5 cm in diameter, in patients stratified according to liver function using ALBI grade. MATERIALS AND METHODS: This retrospective study approved by the Institutional Committee included all treatment-naïve patients with solitary HCC (≤ 5 cm) and Child-Pugh score 5, and who had received TEA (33 patients) or LR (192 patients) between 2004 and 2012. Treatment outcomes were compared between patients treated with TEA and LR after a period of at least 7 years of follow-up. Comparison was repeated for those patients with ALBI grade 2 or 3. RESULTS: Both overall survival (OS, months) and recurrence-free survival (RFS months) were significantly longer in the LR group (OS: LR 129.7[119.5, 140], TEA 69.1[55.9, 82.3], P < 0.0001; RFS: LR 91.3[43.5, 139.1], TEA 13.8 [11, 16.5], P < 0.0001). In patients with ALBI grade 2 or 3, there was no significant difference between the groups in OS or RFS (OS: LR 43.1[0, 91.2], TEA 55.4 [43.7, 67.2], P = 0.65; RFS: LR 17.8 [11.4, 24.2], TEA 11.9 [6.7, 17.1], P = 0.132). Transient epigastric discomfort and low-grade fever without consequence occurred in 8 patients (8/33 or 24.2%) in the TEA group. CONCLUSION: The overall survival after LR for HCCs ≤ 5 cm was superior to that after TEA but similar when compared in patients with ALBI grade 2 or 3, the ALBI grade is useful for patient selection for TEA or LR for HCCs ≤ 5 cm.

CNS regeneration after chronic injury using a self-assembled nanomaterial and MEMRI for real-time in vivo monitoring.

To speed up the process of central nervous system (CNS) recovery after injury, the need for real-time measurement of axon regeneration in vivo is essential to assess the extent of injury, as well as the optimal timing and delivery of therapeutics and rehabilitation. It was necessary to develop a chronic animal model with an in vivo measurement technique to provide a real-time monitoring and feedback system. Using the framework of the 4 P's of CNS regeneration (Preserve, Permit, Promote and Plasticity) as a guide, combined with noninvasive manganese-enhanced magnetic resonance imaging (MEMRI), we show a successful chronic injury model to measure CNS regeneration, combined with an in vivo measurement system to provide real-time feedback during every stage of the regeneration process. We also show that a chronic optic tract (OT) lesion is able to heal, and axons are able to regenerate, when treated with a self-assembling nanofiber peptide scaffold (SAPNS). FROM THE CLINICAL EDITOR: The authors of this study demonstrate the development of a chronic injury model to measure CNS regeneration, combined with an in vivo measurement system to provide real-time feedback during every stage of the regeneration process. In addition, they determined that chronic optic tract lesions are able to heal with axonal regeneration when treated with a self-assembling nanofiber peptide scaffold (SAPNS).

The presence of fatty infiltration in the infraspinatus: its relation with the condition of the supraspinatus tendon.

PURPOSE: We aim to determine the prevalence of fatty infiltration and tears in the infraspinatus and to identify any associated risk factors. METHODS: Shoulder magnetic resonance imaging scans from 2006 to 2009 were reviewed. Arthrograms, inflammatory arthropathies, neoplasms, and fractures were excluded. Rotator cuff tears were graded in 4 categories: no tear, partial tear, and complete tear with and without retraction. Fatty infiltration was graded by radiologists using the modified Goutallier classification. Supraspinatus muscle atrophy (size) was measured by use of the ratio of the cross-sectional area of the muscle to the supraspinatus fossa on a sagittal T1-weighted sequence. RESULTS: Three hundred seventy-seven scans were included. The prevalence of infraspinatus tears was as follows: no tear, 74.8%; partial tear, 17.5%; complete tear, 3.2%; and complete tear with retraction, 4.5%. Fatty infiltration of grade 2 or higher was found in 18.1% of the infraspinatus without tears, 39.4% with partial tears, 66.7% with a complete tear, and 82.4% with a complete tear with retraction. In the infraspinatus without tears, increasing fatty infiltration was correlated with the severity of a concomitant supraspinatus tear. Fatty infiltration of grade 2 or higher in the infraspinatus without tears was found in 7.8% of shoulders with an intact supraspinatus, 18.6% with a partial supraspinatus tear, 23.5% with a complete supraspinatus tear, and 54.6% with a retracted complete supraspinatus tear. Supraspinatus muscle atrophy was correlated with infraspinatus fatty infiltration. CONCLUSIONS: Increased infraspinatus fatty infiltration was correlated with the severity of an infraspinatus tear. However, substantial fatty infiltration of the infraspinatus was seen even in the absence of a tear, and it was correlated with a worsening severity of a concomitant supraspinatus tear and atrophy. Concern over tear progression and increasing fatty infiltration of the infraspinatus may impact the management of isolated supraspinatus tendon tears. LEVEL OF EVIDENCE: Level IV, prognostic case series.