Chen-Guo Ker

Laparoscopic Liver Surgery for Patients with Hepatocellular Carcinoma

BackgroundLaparoscopic hepatectomy is feasible for hepatocellular carcinoma (HCC) today. This is a retrospective study of the patients with HCC treated by liver resection with a totally laparoscopic approach.MethodsThis study recruited 116 patients (92 male, 24 female) that underwent laparoscopic liver resection (LR) for HCC. Patients were divided into two groups: group I: (nxa0=xa097, 78 male,19 female) those with a volume of resection less than two segments; group II: (nxa0=xa019, 14 male, 5 female) those with a volume of resection of more than two segments. The distribution of the tumor-node–metastasis (TNM) stage of patients in the two groups was not significantly different.ResultsPatients resumed full diet on the second or third day after the operation, and the average length of hospital stay was 6 days. The operation time was 152.4xa0±xa0336.3 min and 175.8xa0±xa057.4 min, while blood loss was 101.6xa0±xa0324.4 mL and 329.2xa0±xa0338.0 ml, for groups I and II, respectively. Five patients (5.2%) in group I and three patients (15.8%) in group II required blood transfusion (pxa0=xa00.122). The mortality rate was zero among our patients and complication rates were 6.2% and 5.2% for groups I and II, respectively. The 1-year, 3-year, and 5-year survival rates were 85.4%, 66.4%, and 59.4% for group I, and 94.7%, 74.2%, and 61.7% for group II, respectively, with no significant difference between two groups (pxa0=xa00.1237).ConclusionLaparoscopic liver resection is a procedure of significant risk and is more technically demanding in comparison with traditional open method. There was no significant difference in survival rates, based on the volume of resection. Laparoscopic surgery should be performed in selected patients as the postoperative quality of life of patients is better than that with open resection.

CKS1B Overexpression Implicates Clinical Aggressiveness of Hepatocellular Carcinomas but Not p27Kip1 Protein Turnover: an Independent Prognosticator with Potential p27Kip1-Independent Oncogenic Attributes?

BackgroundThrough data mining the Stanford Microarray Database, the CKS1B transcript was found to be frequently upregulated in hepatocellular carcinomas (HCCs) with low alpha-fetal protein (AFP) expression. Together with SKP2, CKS1B is known to implicate p27Kip1 protein turnover promoting cell-cycle progression.MethodsCKS1B, p27Kip1, and SKP2 were immunostained in 75 HCCs and correlated with clinicopathological features, local recurrence-free survival (LRFS), and overall survival (OS). Silencing of CKS1B and SKP2 with interference short-hairpin RNA (shRNA) was performed in SK-Hep1 and Hep-3B cell lines.ResultsImmunohistochemically, increased CKS1B and SKP2, and attenuated p27Kip1 were all associated with tumor multiplicity (Pxa0<xa00.05) and increasing American Joint Committee on Cancer (AJCC) stage (Pxa0<xa00.05). Overexpression of CKS1B significantly correlated with advanced Okuda stages (Pxa0=xa00.048) and SKP2 overexpression (Pxa0=xa00.047). Neither CKS1B nor SKP2 was inversely related to p27Kip1, which was reinforced by no alteration in p27Kip1 abundance in HCC-derived cells with CKS1B or SKP2 silencing. Both CKS1B overexpression (Pxa0=xa00.0011 and Pxa0=xa00.0017) and p27Kip1 attenuation (Pxa0=xa00.0079 and Pxa0=xa00.0085) were predictive of OS and LRFS, respectively, while SKP2 overexpression was associated with worse OS alone (Pxa0=xa00.0043). Combined assessment of CKS1B and p27Kip1 was able to robustly distinguish three prognostically different groups (Pxa0<xa00.0001). In multivariate comparison, CKS1B overexpression represented the strongest independent adverse prognosticator [OS, Pxa0=xa00.0235, hazard ratio (HR): 4.193; LRFS, Pxa0=xa00.0204, HR: 4.262], followed by p27Kip1 attenuation (OS, Pxa0=xa00.0320, HR: 2.553; LRFS, Pxa0=xa00.0262, HR: 2.533).ConclusionsCKS1B protein overexpression in HCCs is implicated in clinical aggressiveness but not in p27Kip1 turnover, implying presence of p27Kip1-independent oncogenic attributes. The combined assessment of CKS1B and p27Kip1 immunoexpressions effectively risk-stratifies HCCs with different prognoses, which may aid in the management of this deadly malignancy.

Basal Cell Carcinoma of the Nipple-areola Complex: A Case Report

Basal cell carcinoma (BCC) of the nipple‐areola complex is very rare. Only 24 cases were reported in the literature and 17 (70.8%) of these cases arose in men. Most of the cases were treated with simple excision. We report on a case of BCC of the nipple‐areola complex in a 46‐year‐old woman, treated with partial mastectomy. Metastasis to the axillary lymph nodes had been noted in 3 (12.5%) of the 24 reported cases of BCC of the nipple‐areola complex. Thus, we applied the concept of the sentinel lymph node to detect possible metastases of axillary lymph nodes, letting us avoid the unnecessary axillary lymph node dissection and possible future morbidity.

Handlebar Hernia With Jejunal and Duodenal Injuries: A Case Report

Traumatic abdominal wall hernia is an uncommon complication of abdominal blunt trauma. Handlebar hernia is even more infrequent. To the best of our knowledge, there are fewer than 30 cases of handlebar hernia reported in the English literature. Associated intra‐abdominal injuries are infrequent. We present a case of handlebar hernia with jejunal and duodenal injuries. Emergency surgical intervention included primary repair of the disrupted musculofascial defect and injuries of the duodenum and jejunum. Bile‐ stained discharge from the drain tube was noted, so a second operation was performed about 7 days after the first. Leakage from the sutured jejunal perforation and another irregular perforation in the posterior wall of the fourth portion of the duodenum were noted. The two perforations were debrided and repaired. The muscular and fascial defects were debrided and closed with interrupted sutures. The patient recovered smoothly and was discharged 30 days after the blunt injury. No other major complication was noted 11 months after surgery.

Laparoscopic subsegmentectomy for hepatocellular carcinoma with cirrhosis: a case report.

Laparoscopic liver resection is feasible for both benign and malignant disease with present laparoscopic techniques and technology. Laparoscopic liver tumor resection is indicated instead of the conventional hepatectomy if the tumor is located in the peripheral part of the liver. Here, we reported a case of a 73-year-old woman who accepted laparoscopic subsegmentectomy for hepatocellular carcinoma of segment 6. After traditional laparoscopic trocar was settled down under the low pneumoperitoneal pressure of 8 mm Hg, laparoscopic ultrasound allowed exact localization of lesions first and then transection line was marked. Then, dissection the liver parenchyma was carried out with laparoscopic microwave coagulator and ultrasonic aspirator gradually. After operation, she resumed full diet on the second day and was discharged on the 5th post-operative day with no complications and high patient satisfaction. She had follow-up study regularly in our clinic and was disease free at nine months. With the improvement of laparoscopic techniques and the development of new and dedicated technologies, laparoscopic hepatectomy has become feasible.

Giant Liver Cysts: Laparoscopic Fenestration vs. Percutaneous Aspiration with Alcohol Sclerosant Therapy

Background: Liver cysts are common and most of them are asymptomatic. Giant and symptomatic cysts can be treated by using various treatment modalities. Comparison of laparoscopic fenestration (LF) and echo-guided needle aspiration (ENA) combined with injection of alcohol as a sclerosant for ablation of the endothelium of the cysts was made in this study. Methods: Between 1996 and 2006, thirty-nine patients (15 males and 24 females) with non-parasitic liver cysts were encountered. A solitary cyst (Type I) was found in 15 patients (38%) and multiple cysts (Type II and III) in 24 patients (52%) based on imaging studies. Laparoscopic cyst fenestration was performed in 26 patients (67%), and 13 patients (33%) underwent percutaneous ENA. Results: Eight of the eleven patients (73%) having a Type I cyst had a more than 60% decrease of cyst size after LF treatments. In total, four out of 13 (31%) ENA patients and 12 out of 26 LF patients (46%) had a 60% decrease in size. There seemed to be some advantage of LF over ENA as regards the decrease of cyst volume, but the difference did not reach the significant level (p=0.565). Symptom recurrence was 19% (5/26) and 31% (4/13) for LF and ENA, respectively (P=0.447) after follow-up studies. Conclusions: The choice of LF or ENA must be based on an evaluation of the type of cystic lesions. The data obtained in this retrospective study allowed us to demonstrate the outcomes in terms of reduction in cyst volume, but the difference between the LF and ENA methods failed to show statistatical significance in this study.

Laparoscopic Diagnosis of Tiny Nodules of Hepatocellular Carcinoma in Cirrhotic Liver

Purpose: Cirrhosis due to virus hepatitis was commonly in Taiwan. These patients were frequently to develop hepatocellular carcinoma (HCC) during the clinical follow-up study. We try to use laparoscopic examination for pathological diagnosis of suspicious tiny cancer lesions directly from the liver surface in cirrhotic liver. Methods: Twenty-one (M:F= 17:4) patients of cirrhosis due to hepatitis B (n=16) and hepatitis C (n=5) encounter for study. In case of tiny nodules (diameter ＜ 10mm) were found and candidated for the laparoscopic examination for obtaining the tissue pathology. Results: Laparoscopic examination revealed extensive macro-nodular cirrhosis in all patients. However, there were some distinguish nodules with yellowish discoloration, so call ”yellow nodule” found in 16 patients and not in 5 patients. By removing these nodules for frozen pathologic study and proved HCC in 14 from yellow nodules and one from non-yellow nodules patients (87.5% vs. 12.5%, P=0.045). In those patients, the serum α-fetoprotein were found within normal range ＜20 iu/ml) in 3, 20-40 iu/ml in 7, 40-100 iu/ml in 6, and ＞200 iu/ml in 5 patients. In addition to the early diagnosis of HCC from regeneration nodule, these nodules could be removed with laparoscopic sub-segmentectomy or enucleation simultaneously. The mean tumors sizes were 8.6mm for HCC and 5.8mm in diameter for regeneration nodule. The survival times were ranged from 16 to 53 months with mean of 39.7months. Conclusions: Early diagnosis of tiny cancer lesion from cirrhotic liver was not easy sometimes. We strongly suggested that the early diagnosis of yellow tiny nodule was an important finding in the high-risk patients especially who have a family history of HCC.

A Study of VEGF and VEGF-d in the Patients of Liver Cancer

Purpose: The presence of Vascular Endo-thelial Growth Factor (VEGF) and VEGF-d had relationship with the capillary for-mation of vessels and lymph vessels. There-fore, we try to conduct this study to verify the result of serum levels of VEGF and VEGF-d and clinical results after operative resection.Methods: Thirty-two patients (22 in male & 10 in female) were encountered in this study. In those patients were proved to be hepato-cellular carcinoma (HCC) with pathologic study after tumor resection. The serum level of VEGF and VEGF-d were measured with ELISA methods. The valuables were an-alyzed according to the tumor size, diff-erentiation, type of tumor and metastasis as well.Results: The values of VEGF and VEGF-d according to the size of tumor were shown in the figure 1, The serum VEGF-d level was found 615.2± 161.5 ng/dl higher in the group of small tumor less than 3cm. The serum values of VEGF-d in the group of no recurrence, metastasis, intra-abdominal metastasis, and lung metastasis were found 412.9± 46.5, 613.3± 149.0, 583.5± 171.8, 701.9± 235.6 ng/dl respectively. Long distance metastasis has the higher serum level of VEGF-d.Conclusion: The high level of VEGF and VEGF-d was found in the group of extra-hepatic metastasis, moderate differentiation and diffuse type of HCC. Therefore, in case of high level of VEGF-d was noted, it is necessary to care the possibility of early recurrence or metastasis.

Role of Capsular Formation in Hepatocellular Carcinoma

Background: The liver tumor nodules may be surrounded by a distinct fibrous capsule of a variable thickness, and may be infiltrated by tumor cells. Therefore, we try to demonstrate morphological features of the capsular invasion to estimate the relationship with tumor recurrence and survival time.Patients and Methods: There were 99 patients having available data for this study from for analyzing the tumor lesions from for analyzing the tumor lesions survival time.Results: The capsular invasion were found negative in 40.4%(40/99) and positive in 59.6%(59/99) respectively. Capsular invasion was found 13(61.9%), 39(63.9%) and 7(41.1%) in the group of well, moderatedly and poorly differentiation group respectively. The tumor free was found 41.9%(18/43) and 22.4 %(13/58) in the patients with capsular invasion or non-invasion respectively. However, the recurrent time were 10.6 and 11.3 months respectively and there was no significant difference(p＞0.05).Conclusion: The tumor free for the patients of HCC after surgical resection with negative capsular invasion was longer. The recurrent time was not significant different and might be due to the time for capsular development is needed. Hence, at early stage of capsular formation, the invasiveness of cancer cells was occurred easily.

Villous Adenoma of the Duodenum Coexisting with Chronic Pancreatitis and Abscess Formation: Report of a Case

Villous adenoma of the duodenum is rare and may present with gastrointestinal bleeding, obstructive jaundice, vague abdominal discomfort, acute pancreatitis and malignant change. A 64 years old woman presented to us with LUQ pain and fever for 20 days. Abdominal sonography and computed tomography showed a cystic mass lesion (4.3cm×3.8cm) at pancreatic tail. Duodenoscopy revealed a papillary tumor below the Ampulla Vater. A communication between the tumor and the pancreatic duct was noted when endoscopic retrograde pancreatogram was performed. A pancreatic abscess was found at the time of laparotomy. After abscess drainage and antibiotic therapy, the patient underwent a second stage pancreatoduodenectomy. Pathological examination revealed features of villous adenoma and chronic pancreatitis. The tumor measured 3cm×2.2cm×l.7cm in size and had a lumen communicating with the major pancreatic duct.