The global incidence of benign biliary tract diseases is high. Not only its anatomical variations are complex and the disease heterogeneity is strong, but also its preoperative assessment methods, surgical techniques and diagnostic and treatment strategies need to be improved. Consequently, patients have many perioperative complications and a poor long-term prognosis. According to the anatomical characteristics of the biliary tract and the pathophysiological characteristics of benign biliary diseases, we propose the surgical treatment concept of benign biliary tract diseases with the removal of the diseased bile duct tree drainage as the core, which is different from the traditional biliary surgery that takes “patency and obstruction” as the focus of treatment, and “alleviates symptoms” as the treatment goal. Through a series of improvements such as preoperative evaluation, surgical planning, surgical operations, and postoperative management, we have designed a series of innovative diagnosis and treatment strategies and procedures with the goal of curing biliary diseases, with a view to changing the diagnosis and treatment status of biliary surgery. We hope that can change the current the diagnosis and treatment status of biliary surgery.
Hepatic alveolar echinococcosis (HAE) is a severe zoonotic disease caused by Echinococcus multilocularis, primarily affecting the liver. Due to its insidious nature, the patients are often diagnosed at advanced stage, posing significant treatment challenges. We comprehensively examines the progress in surgical techniques for HAE management, focusing on various strategies across different disease stages. For the patients with early-stage HAE, ablation therapy has emerged as an effective treatment option. In the moderate to advanced cases, numerous surgical techniques and innovative approaches have been introduced, including laparoscopic surgery and liver transplantation, with particular emphasis on ex vivo liver resection and autotransplantation. These advancements offer more effective treatment options for the patients with advanced HAE. However, significant challenges persist, notably the preservation of adequate liver function while achieving complete lesion removal. Future research should prioritize the exploration and optimization of existing surgical methods, especially for advanced HAE cases. This includes refining surgical techniques through precise preoperative evaluation and staging, as well as developing novel surgical approaches to enhance safety and efficacy. Furthermore, multicenter and long-term follow-up prospective studies are crucial for validating the effectiveness of new surgical techniques and strategies. Through these concerted efforts, it is anticipated that the survival rates and quality of life for HAE patients will significantly be improved, marking a new era in the management of this complex disease.
Objective To systematically evaluate effects of enhanced recovery after surgery (ERAS) programme on clinical outcomes of liver resection during perioperative period. Methods The randomized controlled trials (RCTs) of comparing ERAS programme with traditional care programme in patients underwent liver resection were searched by Wanfang, VIP, CNKI, PubMed, Embase, and Cochrane Library databases from inception to January 2016. The quality of the included RCT was assessed independently according to the Cochrane handbook–version 5.1.0 by two reviewers. Meta-analysis was conducted for the eligible RCTs by using RevMan 5.3.0. Results Seven RCTs containing 844 patients were included in this meta-analysis. There were 35 cases of benign tumor, 809 cases of malignant tumor. The ERAS programmes were performed in 415 patients, while the traditional care programmes were performed in 429 patients. Compared with the traditional care programme, the overall complications rate and the Dindo-Clavien grade Ⅰ complications rate were significantly lower〔OR=0.59, 95%CI (0.41, 0.87),P=0.007;OR=0.45, 95%CI (0.27, 0.76),P=0.002〕, the hospital stay and the first anal exhaust time were significantly shorter〔WMD=–2.66, 95%CI (–3.64, –1.69),P<0.000 01;WMD=–20.25, 95%CI (–32.08, –8.42),P=0.000 8〕 in the ERAS programme, but there was no statistically significant difference of the Dindo-Clavien grade Ⅱ–Ⅳ complications rate between these two groups〔OR=0.93, 95%CI (0.53, 1.63),P=0.80〕. Conclusions ERAS is a safe and effective programme in liver resection during perioperative period. Future studies should define active elements to optimize postoperative outcomes for liver resection.
Objective?To approach feasibility, safety, and the application range of pure laparoscopic resection （PLR）, hand-assisted laparoscopic resection （HALR）, and robotic liver resection （RLR） in the minimally invasive liver resection （MILR）. Methods?The clinical data of 128 patients underwent MILR in the Surgical Department of the Shanghai Ruijin Hospital from September 2004 to January 2012 were analyzed retrospectively. According to the different methods, the patients were divided into PLR group, HALR group, and RLR group. The intraoperative findings and postoperative recovery of patients in three groups were compared.?Results?There were 82 cases in PLR group, 3 cases of which were transferred to open surgery；the mean operating time was （145.4±54.4） minutes （range：40-290 minutes）；the mean blood loss was （249.3±255.7） ml （range：30-1 500 ml）；abdominal infection was found in 3 cases and biliary fistula in 5 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （7.1±3.8） days （range：2-34 days）. There were 35 cases in HALR group, 3 cases of which were transferred to open surgery；the mean operating time was （182.7±59.2） minutes （range：60-300 minutes）；the mean blood loss was （754.3±785.2） ml （range：50-3 000 ml）；abdominal infection was found in 1 case, biliary fistula in 2 cases, and operative incision infection in 2 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （15.4±3.7） days （range：12-30 days）. There were 11 cases in RLR group, 2 cases of which were transferred to open surgery； the mean operating time was （129.5±33.5） minutes （range：120-200 minutes）； the mean blood loss was （424.5±657.5） ml （range：50-5 000 ml）； abdominal infection was found in 1 case and biliary fistula in 1 case after operation, but all recovered after conservative treatment； the mean length of hospital stay was （6.4±1.6） days （range：5-9 days）. The operating time （P=0.001） and length of hospital stay （P=0.000） of the RLR group were shortest and the blood loss （P=0.000） of the PLR group was least among three groups. Conclusions?Minimally invasive resection is a safe and feasible. Different surgical procedures should be chosen according to different cases. The robotic liver resection provides new development for treatment of liver tumor.
Evidence from numerous animal models and clinical studies in recent years has demonstrated that macrophages play an important role in the regulation of liver fibrosis regression. The safety and efficacy of utilizing autologous macrophages for the treatment of liver fibrosis have been demonstrated in patients and shows promising application prospects, but the therapeutic effects need to be improved. Cirrhotic liver undergoes a process of marked extracellular matrix degradation after partial hepatectomy surgery, and single-cell sequencing identified multiple restorative macrophage subsets that express different matrix metalloproteinases (MMPs) at high levels. Future efforts to further characterize this population of macrophages and improve their enrichment in the liver may allow macrophage therapy to be a highly effective strategy to reverse liver fibrosis.
ObjectiveTo investigate the risk factors affecting severe postoperative complications (Clavien-Dindo classification Ⅲa or higher) in patients with end-stage hepatic alveolar echinococcosis (HAE) underwent ex vivo liver resection and autotransplantation (ELRA), and to develop a nomogram prediction model. MethodsThe clinical data of end-stage HAE patients who underwent ELRA at the West China Hospital of Sichuan University from January 2014 to June 2024 were retrospectively analyzed. The logistic regression was used to analyze the risk factors affecting severe postoperative complications. A nomogram prediction model was established basing on LASSO regression and its efficiency was evaluated using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. Simultaneously, a generalized linear model regression was used to explore the preoperative risk factors affecting the total surgery time. Test level was α=0.05. ResultsA total of 132 end-stage HAE patients who underwent ELRA were included. The severe postoperative complications occurred in 47 (35.6%) patients. The multivariate logistic analysis results showed that the patients with invasion of the main trunk of the portal vein or the first branch of the contralateral portal vein (type P2) had a higher risk of severe postoperative complications compared to those with invasion of the first branch of the ipsilateral portal vein (type P1) [odds ratio (OR) and 95% confidence interval (CI)=8.24 (1.53, 44.34), P=0.014], the patients with albumin bilirubin index (ALBI) grade 1 had a lower risk of severe postoperative complications compared to those with grade 2 or higher [OR(95%CI)=0.26(0.08, 0.83), P=0.023]. Additionally, an increased total surgery time or the autologous blood reinfusion was associated with an increased risk of severe postoperative complications [OR(95%CI)=1.01(1.00, 1.01), P=0.009; OR(95%CI)=1.00(1.00, 1.00), P=0.043]. The nomogram prediction model constructed with two risk factors, ALBI grade and total surgery time, selected by LASSO regression, showed a good discrimination for the occurrence of severe complications after ELRA [area under the ROC curve (95%CI) of 0.717 (0.625, 0.808)]. The generalized linear regression model analysis identified the invasion of the portal vein to extent type P2 and more distant contralateral second portal vein branch invasion (type P3), as well as the presence of distant metastasis, as risk factors affecting total surgery time [β (95%CI) for type P2/type P1=110.26 (52.94, 167.58), P<0.001; β (95%CI) for type P3/type P1=109.25 (50.99, 167.52), P<0.001; β (95%CI) for distant metastasis present/absent=61.22 (4.86, 117.58), P=0.035]. ConclusionsFrom the analysis results of this study, for the end-stage HAE patients with portal vein invasion degree type P2, ALBI grade 2 or above, longer total surgery time, and more autologous blood transfusion need to be closely monitored. Preoperative strict evaluation of the first hepatic portal invasion and distant metastasis is necessary to reduce the risk of severe complications after ELRA. The nomogram prediction model constructed based on ABLI grade and total surgery time in this study demonstrates a good predictive performance for severe postoperative complications, which can provide a reference for clinical intervention decision-making.
ObjectiveTo summarize short-term and long-term effects of ex vivo liver resection followed by autotransplantation (Abbreviation: autotransplantation) in treatment of advanced hepatic alveolar echinococcosis (HAE).MethodThe clinical data and follow-up data of 17 patients with advanced HAE who underwent autotransplantation from November 2016 to July 2019 in the Ganzi Tibetan Autonomous Prefecture People’s Hospital were retrospectively analyzed.ResultsThe autotransplantations were performed successfully in the 17 patients with advanced HAE. Ten patients underwent the inferior vena cava (IVC) reconstruction with autologous saphenous veins, 5 patients underwent the artificial revascularization, 1 patient underwent the direct anastomosis of the original IVC, and 1 patient didn’t reconstructed (the retroperitoneal collateral circulation was abundant). The mean liver graft mass was 681.3 g (365–1 350 g) and operation time was 11.5 h (9–16 h). The median anhepatic period was 312 min (175–450 min), blood loss was 2 000 mL(950–4 500 mL), red blood cell suspension transfusion was 6.4 U (1–20 U), and fresh frozen plasma was 1.1 L (0.8–2.0 L). The postoperative hospital stay was 5 to 45 d with an average of 25.6 d. There were 4 patients with the postoperative hepatic enveloping effusion, 1 patient with bile leakage, and 1 patient with bile duct stenosis. All of them were treated and cured, and no death occurred. The follow-up time of 17 patients was 3 to 35 months with an average of 9.5 months, no recurrence of HAE and distant metastasis were observed.ConclusionsIn highlands, autotransplantation in treatment of advanced HAE patients with different IVC reconstruction is satisfactory, but it has a higher risk and is difficult. Choice of intraoperative reconstruction materials, judgment of posterior peritoneal collateral circulation, presence or absence of tension in end-to-end anastomosis of the IVC require precise consideration. At the same time, anticoagulation therapy and complications management are difficult, and it is only suitable for plateau medical center with rich experience.
ObjectiveTo investigate the effect of intermittent Pringle (IP) and continuous hemi-hepatic vascular inflow occlusion (CHVIO) on the prognosis of patients with hepatocellular carcinoma (HCC) complicated with cirrhosis in laparoscopic liver resection (LLR).MethodsRetrospective analysis of consecutive 107 LLR patients with HCC complicated with liver cirrhosis at West China Hospital of Sichuan University between January 2015 and December 2017 was performed. Patients were divided into an IP group and a CHVIO group according to the method of hepatic vascular occlusion, intraoperative and postoperative outcome indicators and short-term prognosis were compared between the two groups.ResultsPatients in the IP group had shorter operative time [(237+90) min vs (285+118) min, P=0.041] and less blood loss [(279+24) mL vs (396+35) mL, P=0.012], without a significant increase in postoperative liver function [including ALT, AST, TBIL, and ALB], postoperative complications, induced flow, 1-year disease-free survival, and1-year survival (P>0.05).ConclusionsIP can reduce the operative time and blood loss in patients with HCC complicated with cirrhosis in LLR, and will not lead to deterioration of liver function, it is a recommended hepatic inflowocclusion method.
Objective
To evaluate the safety and efficacy of surgical resection for the second and the third hepatic portal tumor.
Methods
The clinical data of 39 patients who underwent surgical resection of the second and the third hepatic portal tumor were analyzed from May 2012 to May 2017 in our hospital. Among them, there were 29 patients with primary liver cancer, 6 patients with hepatic hemangioma, 2 patients with focal liver hyperplasia, and 2 patients with liver metastasis from colon cancer.
Results
Right liver resection was performed in 11 patients, left liver resection in 7 patients, left outer lobe resection in 6 patients, right trefoil excision in 5 patients, Ⅴand Ⅷ segment resection in 4 patients, Ⅶ and Ⅷ segment resection in 4 patients, local resection in 2 patients. In the resection, there were 16 patients without interruption of hepatic inflow, 21 patients with interrupted portal blood flow, 2 patients with total hepatic blood flow occlusion. The operative time of the 39 patients was 150–270 min (mean of 190 min), the intraoperative blood loss was 100–2 000 mL (mean of 680 mL). Postoperative bile leakage occurred in 2 patients, bleeding occurred in 1 patient, and no liver failure occurred. Twenty-six patients were followed-up of 31 liver cancer patients, and the follow-up time was 3–40 months, the median time was 8 months. During follow-up period, 12 patients died, 9 patients died of tumor recurrence, 3 patients died from liver failure. Of 8 patients, 5 patients with benign liver disease were followed-up for 7–18 months with living healthy, and the median time was 9 months.
Conclusion
The risk of surgical resection of tumors invaded the second and the third hepatic portal is mainly the accurate functional assessment of residual liver and the correct treatment of the main branches of the hepatic veins.
ObjectiveTo summarize the key operative points and efficacy of ex-vivo ex-vivo liver resection and autologous liver transplantation (ELRA) using various vascular materials for hepatic vein reconstruction in the treatment of end-stage hepatic alveolar echinococcosis (HAE). MethodThe clinicopathologic data of a patient with end-stage HAE who underwent ELRA combined with complex hepatic vein reconstruction were retrospectively analyzed. ResultsThe patient was a 60-year-old male who was admitted to the Sichuan Provincial People’s Hospital due to giant alveolar hydatid in the liver, with a body weight of 60 kg and a standard liver volume of 1 024.5 mL. The imaging showed that the hydatid invaded the first and second hepatic portals, middle hepatic vein, left hepatic vein, and retrohepatic inferior vena cava. The three-dimensional reconstruction of CT showed that the residual liver volume was 1 270.6 mL. The patient received supportive treatment after admission and underwent ELRA following strict evaluation. Intraoperatively, it was found that the multiple hepatic veins and retrohepatic inferior vena cava were widely invaded. The liver was split in vivo and the mass was excised ex vivo by “in vivo first” principle. The hepatic vein was repaired and reconstructed into a wide mouth outflow tract using allogeneic veins, autologous inferior mesenteric vein, and hepatic round ligaments, then performed the autotransplantation by wide mouth outflow-artificial inferior vena cava anastomosis (end to side). The operative time was 16 h, and the intraoperative blood loss was approximately 2 000 mL. FK506 was orally administered after operation, and low-molecular-weight heparin sodium was administered 24 h later for anticoagulation. The patient was returned to the general ward on the 6th day after the operation, and the enhanced CT scan showed that the hepatic outflow tract was unobstructed, without stenosis and thrombosis, and the patient was discharged on day 18 after the operation. The patient was pathologically diagnosed with alveolar echinococcosis. ConclusionsFrom the results of this case, combination of multiple vascular materials to reconstruct the hepatic outflow tract is an optional procedure for ELRA in treatment of end-stage HAE. Strict preoperative evaluation, skillful vascular anastomosis technique, and postoperative anticoagulation are important measures to maintain patency of postoperative reconstruction vessel.
