The learning curve of laparoscopic liver resection after the Louisville statement 2008: Will it be more effective and smooth?

BACKGROUND: Laparoscopic liver resection (LLR) has been proven to be feasible and safe. However, it is a difficult and complex procedure with a steep learning curve. The aim of this study was to evaluate the learning curve of LLR at our institutions since 2008. METHODS: One hundred and twenty-six consecutive LLRs were included from May 2008 to December 2014. Patient characteristics, operative data, and surgical outcomes were collected prospectively and analyzed. RESULTS: The median tumor size was 25 mm (range 5-90 mm), and 96 % of the resected tumors were malignant. 41.3 % (52/126) of patients had pathologically proven liver cirrhosis. The median operation time was 216 min (range 40-602 min) with a median blood loss of 100 ml (range 20-2300 ml). The median length of hospital stay was 4 days (range 2-10 days). Six major postoperative complications occurred in this series, and there was no 90-day postoperative mortality. Regarding the incidence of major operative events including operation time longer than 300 min, perioperative blood loss above 500 ml, and major postoperative complications, the learning curve [as evaluated by the cumulative sum (CUSUM) technique] showed its first reverse after 22 cases. The indication of laparoscopic resection in this series extended after 60 cases to include tumors located in difficult locations (segments 4a, 7, 8) and major hepatectomy. CUSUM showed that the incidence of major operative events proceeded to increase again, and the second reverse was noted after an additional 40 cases of experience. Location of the tumor in a difficult area emerged as a significant predictor of major operative events. CONCLUSIONS: In carefully selected patients, CUSUM analysis showed 22 cases were needed to overcome the learning curve for minor LLR.

Risk factors for post-pancreaticoduodenectomy bleeding and finding an innovative approach to treatment.

BACKGROUND: This study is to determine the risk factors and outcome for post-pancreaticoduodenectomy bleeding, and to assess the roles of surgery and intravascular intervention in its management. METHODS: Post-pancreaticoduodenectomy data of 628 patients were analyzed with regards to post-pancreaticoduodenectomy bleeding. RESULTS: Post-pancreaticoduodenectomy bleeding occurred in 58 patients (9.2%) and led to death in 23 patients. Pancreatic leakage and intra-abdominal abscess were independent risk factors for both extraluminal and intraluminal post-pancreaticoduodenectomy bleeding. The most common source of bleeding was the gastroduodenal artery (n = 9, 24.3%), and 8 of these patients (88.9%) experienced gastroduodenal artery bleeding in late post-pancreaticoduodenectomy bleeding. Hemostasis for post-pancreaticoduodenectomy bleeding was achieved by surgery in 22 patients (78.6%) and intravascular intervention in 7 patients (58.3%). Transarterial embolization for gastroduodenal artery bleeding did not deteriorate liver function in most patients except for 1 who died of hepatic failure. CONCLUSIONS: The placement of metallic clips on the gastroduodenal artery stump during a pancreaticoduodenectomy is helpful in identifying overlooked intermittent sentinel bleeding during angiography. Transarterial embolization for gastroduodenal artery bleeding could not guarantee against hepatic failure. The intravascular placement of a covered stent is the preferred procedure to avoid the complete interruption of arterial blood supply to the liver.

Better Overall Survival for Breast Cancer Patients by Adding Breast Ultrasound to Follow-Up Examinations for Early Detection of Locoregional Recurrence-A Survival Impact Study.

We retrospectively reviewed patient records to evaluate the effectiveness of our 15 y of ultrasound (US) surveillance of recurrent breast disease in comparison with mammography (MM) and clinical examination. From 4796 stage 0-III breast cancer patients who had received surgical treatment, we identified locoregional recurrence (LRR) in 161 patients. The mean age of the 161 patients was 48 y (27-82 y), and the mean follow-up interval was 77.2 mo (11-167 mo). The methods of LRR detection, sites of LRR and overall survival (OS) were examined. Multivariate Cox survival analysis showed significantly better survival in groups detected by US (hazard ratio = 0.6, p = 0.042). The 10-y LRR OS by detection types for US (n = 69), clinical examination (n = 78) and MM (n = 8) were 58.5%, 33.1% and 100%, respectively (p = 0.0004). US was seen with better OS associated with the effective early detection of non-palpable LRR breast cancer, which is mostly not detectable on MM.

Sonographic elastography improves the sensitivity and specificity of axilla sampling in breast cancer: a prospective study.

We describe a study to determine whether elastography of axillary lymph nodes (LNs) combined with B-mode ultrasound (US) is capable of differentiating the benign from the metastatic state in patients with breast cancer. B-mode US, elastography and fine-needle aspiration of 90 axillary lymph nodes from 89 female patients with breast cancer are described in this report. Five elastographic patterns were observed as defined by the percentages of high elasticity according to pattern of distribution and degree of hardness of the target LNs. B-mode US and elastography scores were combined to give the final scores. Sensitivity and specificity were 80% and 88%, respectively, for B-mode US alone, 86% and 90% for elastography alone and 84% and 98% for the combined assessment to differentiate the benign from the malignant state. The combination of B-mode US and elastography is capable of identifying metastatic axillary LNs from benign enlargement in patients with breast cancer.