Surgical Resection is Preferred in Selected Solitary Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Backgrounds: Sorafenib is the standard care for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT), though it offers limited survival. This study was designed to compare clinical outcomes between liver resection (surgery) and trans-arterial chemoembolization plus radiotherapy (TACE-RT) as the initial treatment modality for resectable treatment-naïve solitary HCC combined with subsegmental (Vp1), segmental (Vp2), and lobar (Vp3) PVTT. Methods: From the institutional HCC registry, we identified 116 patients diagnosed with resectable treatment-naïve HCC with Vp1-Vp3 PVTT based on radiologic images who received surgery (n=44) or TACE-RT (n=72) as a primary treatment between 2010 and 2015. A propensity score matching (PSM) model was created. Results: The TACE-RT group had a higher tumor burden (tumor size, extent, and markers) than the surgery group. Cumulative patient survival curve in the surgery group was significantly higher than in the TACE-RT group before and after PSM. Liver function was relatively well-preserved in the surgery group compared with the TACE-RT group. TACE-RT group, male, increased alkaline phosphatase, and increased platelet count were predisposing factors for patient death in resectable treatment-naïve solitary HCC with PVTT. Conclusions: The present study suggests that surgery should be considered as an initial treatment in resectable treatment-naïve solitary HCC with Vp1-Vp3 PVTT.

Surgery in autoimmune pancreatitis

Introduction: Autoimmune pancreatitis (AIP) is a disease that may mimic malignant pancreatic lesions both in terms of symptomatology and imaging appearance. The aim of the present study is to analyse experiences of surgery in patients with AIP in one of the largest European cohorts. Methods: We performed a single-centre retrospective study of patients diagnosed with AIP at the Department of Abdominal Diseases at Karolinska University Hospital in Stockholm, Sweden, between January 2001 and October 2020. Results: There were 159 patients diagnosed with AIP, and among them 35 (22.0%) patients had surgery: 20 (57.1%) males and 15 (42.9%) females; average age at surgery was 59 years (range 37-81). Follow-up period after surgery was 67 months (range 1-235). AIP type 1 was diagnosed in 28 (80%) patients and AIP type 2 in 7 (20%) patients. Malignant and premalignant lesions were diagnosed in 8 (22.9%) patients for whom AIP was not the primary differential diagnosis but, in all cases, it was described as a simultaneous finding and recorded in retrospective analysis in histological reports of surgical specimens. Conclusions: Diagnosis of AIP is not always straightforward, and, in some cases, it is not easy to differentiate it from the malignancy. Surgery is generally not indicated for AIP but might be considered in patients when suspicion of malignant/premalignant lesions cannot be excluded after complete diagnostic work-up.

The Effect of Celiac Neurolysis and Splanchnicectomy on Survival in Unresectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

<b><i>Background:</i></b> Intractable pancreatic pain is one of the most common symptoms of patients with pancreatic ductal adenocarcinoma (PDAC). Celiac neurolysis (CN) and splanchnicectomy were already described as effective methods to manage abdominal pain in unresectable PDAC, but their impact on overall survival (OS) has not yet been established. <b><i>Objective:</i></b> We aimed to investigate the impact of CN and splanchnicectomy on the survival of patients with unresectable pancreatic cancer. <b><i>Methods:</i></b> A systematic review of PubMed and Cochrane Library according to predefined searching terms was conducted in March 2020. Hazard ratios (HR) of OS data were calculated using the Mantel-Haenszel model for random effects or fixed effects. <b><i>Result:</i></b> Four randomized-controlled trials (RCTs) and 2 non-RCTs with a total of 2,507 patients were identified. The overall pooled HR did not reveal any relevant effect of CN and splanchnicectomy on OS (HR: 1.03; 95% CI: 0.81–1.32), which was also underlined by the sensitivity analysis of RCTs (HR: 1.0; 95% CI: 0.72–1.39) and non-RCTs (HR: 1.07; 95% CI: 0.71–1.63). However, subgroup analyses depending on tumor stage revealed that CN or splanchnicectomy was associated with a worsened OS in AJCC (American Joint Committee on Cancer) stage III patients with unresectable PDAC (HR: 1.22; 95% CI: 1.03–1.45), but nor for AJCC stage IV patients (HR: 1.27; 95% CI: 0.9–1.80). <b><i>Conclusion:</i></b> Although only few data are currently available, this systematic review with meta-analysis showed that in unresectable PDAC, CN or splanchnicectomy is associated with a worsened survival in stage III PDAC patients, with no effect on stage IV PDAC patients. These data call for caution in the usage of CN or splanchnicectomy in stage III PDAC and for further studies addressing this observation.

PREVENTION OF INCISIONAL HERNIA AFTER OPEN HEPATO-PANCREATO-BILIARY SURGERY: A SYSTEMATIC REVIEW

Introduction Most hepato-pancreato-biliary (HPB) procedures are still performed through open approach. Incisional hernia (IH) is one of the most common complications after open surgery. To date, published data on IH after HPB surgery are scarce, therefore the aim of this study was to assess the current evidence regarding incidence, risk factors, and prevention. Methods Medline/PubMed (1946-2020), EMBASE (1947-2020), and the Cochrane library (1995-2020)) were searched for studies on IH in open HPB surgery. Animal studies, editorials, letters, reviews, comments, short case series and liver transplant, laparoscopic or robotic procedures were excluded. The protocol was registered with PROSPERO (CRD42020163296). Results A total of 5 079 articles were retrieved. 8 studies were finally included for the analysis. The incidence of IH after HPB surgery ranges from 7.7% to 38.8%. The identified risk factors were body mass index, surgical site infection, ascites, Mercedes or reversed T incisions and previous IH. Prophylactic mesh might be safe and effective. Conclusions IH after open HPB surgery is still an important matter. Some of the risk factors are specific for the HPB operations and the incision type should be carefully considered. Randomised controlled trials are required to confirm the role of prophylactic mesh after HPB operations.

Handling of hilar vasculature in living donor right hepatectomy using extrahepatic Glissonean approach

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured the glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson is carried out towards the central direction suggest to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on recipient.

Identification and validation of hub genes predicting prognosis of hepatocellular carcinoma

Introduction: Selecting the hub genes associated with hepatocellular carcinoma (HCC) to construct a COX regression model for predicting prognosis in HCC patients. Methods: Using HCC patient data from the ICGC and TCGA databases, screened for 40 core genes highly correlated with histological grade of HCC. Univariate and multivariate COX regression analysis were performed on the genes highly associated with HCC prognosis and the model was established. The expression of those genes was measured by immunohistochemistry in 110 HCC patients who underwent the surgery in The First Affiliated Hospital of Wenzhou Medical University. The survival of HCC patients was analyzed by the Kaplan-Meier method. Results: Eight genes (CDC45, CENPA, MCM10, MELK, CDC20, ASF1B, FANCD2 and NCAPH) were correlated with prognosis, and the same result was observed in 110 HCC patients. Using the regression model, the HCC patients in the training set were classified as high- and low-risk groups. The overall survival (OS) of patients in the high-risk group was shorter than that in the low-risk group, the same results were obtained in verification set. Conclusion: This study found that the risk model according to these eight genes can be used as a predictor of prognosis in HCC. These genes may become alternative biomarkers and therapeutic targets and provide new therapeutic strategies for HCC.

Rescue partial ALPPS for left hemihepatectomy with reconstruction of the middle hepatic vein

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70 with an intrahepatic cholangiocarcinoma (ICC) in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization (PVE). The FLR volume increased to 71.3%, however, the non-congestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue ALPPS (Associating Liver Partition and Portal vein occlusion for Staged hepatectomy) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie’s line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

Usefulness of carcinoembryonic antigen doubling time in prognosis prediction after curative resection of locally recurrent rectal cancer: A retrospective study

Introduction: Given that doubling time is an indicator of tumor growth, we assessed the usefulness of carcinoembryonic antigen doubling time (CEA-DT) in prognosis prediction after curative resection for locally recurrent rectal cancer. Methods: During January 1986 to December 2016, 33 patients with locally recurrent rectal cancer who underwent curative resection at our hospital were retrospectively reviewed. The primary endpoint was the 3-year recurrence-free survival (RFS) rate. The Kaplan-Meier method was used to compare RFS rates and evaluate univariate and multivariate analyses for factors associated with oncologic outcomes, including CEA-DT. CEA-DT was classified into two groups: the short and long CEA-DT groups. Results: The 3-year overall survival and RFS rates were 62.6% and 42.4%, respectively. In multivariate analyses, CEA-DT was an independent risk factor for poor RFS. The 3-year RFS rate was significantly better in the long CEA-DT group than in the short CEA-DT group (58.8% vs. 25.0%, p = 0.0063). Conclusion: CEA-DT is a useful prognostic factor that can be assessed before surgery for locally recurrent rectal cancer. Long CEA-DT may indicate a favorable prognosis. Contrarily, short CEA-DT is associated with poor prognosis; therefore, further treatment intervention is necessary for patients with short CEA-DT.

Impact of Acute Inflammation on the Survival Outcomes of Patients with Resected Pancreatic Ductal Adenocarcinoma

<b><i>Introduction:</i></b> The impact of acute inflammation on cancer progression is still not well elucidated. Pancreatic head cancer is occasionally associated with acute cholangitis. C-reactive protein (CRP) is a biomarker that indicates presence of acute inflammation. <b><i>Methods:</i></b> We reviewed the patients’ data with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy between 2004 and 2018. <b><i>Results:</i></b> Two hundred ninety-one patients were included. Median preoperative CRP was 0.45 mg/dL (0–18.9). Median follow-up duration was 22 months (4–152). The 1-, 3-, and 5-year overall survival (OS) rates were 76.4%, 32.2%, and 22.9%, respectively. Recurrence occurred in 168 cases (57.7%). The 1-, 3-, and 5-year disease-free survival (DFS) rates were 53.9%, 27.1%, and 21.9%, respectively. The median OS was higher in normal CRP patients (27 months) than those with elevated CRP (18 months) (log-rank 0.038). The median DFS was higher in normal CRP patients (17 months) than those with elevated CRP (9 months) (log-rank &#x3c; 0.001). Predictive factors for OS included BMI, CRP, adjuvant therapy, positive lymph nodes, and microvascular invasion. Predictive factors for DFS included CRP, positive lymph nodes, and microvascular invasion. <b><i>Conclusion:</i></b> Preoperative CRP was an independent poor prognostic factor for OS and DFS of patients with resected PDAC.

Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation

<b><i>Introduction:</i></b> Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. <b><i>Methods:</i></b> Between 2015 and 2018, patients with delayed gastric emptying 8–10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. <b><i>Results:</i></b> Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9–15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. <b><i>Conclusion:</i></b> Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.