Ching‐Ning Chong

Meta‐analysis: the efficacy of anti‐viral therapy in prevention of recurrence after curative treatment of chronic hepatitis B‐related hepatocellular carcinoma

Aliment Pharmacol Ther 2011; 33: 1104–1112

Liver stiffness measurement by transient elastography as a predictor on posthepatectomy outcomes.

Background:Liver fibrosis and cirrhosis are well-known risk factors for morbidity after hepatectomy. Liver stiffness measurement (LSM) using transient elastography is a new method for detection of hepatic fibrosis and cirrhosis with high accuracy. Whether LSM can predict posthepatectomy outcomes has not been studied. Methods:This was a prospective cohort study in which consecutive patients underwent hepatectomy for various indications from February 2010 to July 2011. All patients received detailed preoperative assessments including LSM and indocyanine green (ICG) clearance test. The primary outcome was major postoperative complication. Results:One hundred five patients with a mean age of 59 years were included; 75 (71.4%) had chronic viral hepatitis and 76 (72.4%) had hepatocellular carcinoma. Thirty-four patients (32.4%) received major hepatectomy. The median ICG retention rate at 15 minutes was 4.2 (0.1%–32%) and the median LSM was 9.4 (3.3–75 kPa). For posthepatectomy outcomes, only LSM but not ICG showed significant correlation with major postoperative complications on receiver operating characteristic curves, with area under the curve of 0.79 (P < 0.001). Using the calculated cutoff at 12.0 kPa, LSM had sensitivity of 85.7% and specificity of 71.8% in the prediction of major postoperative complications. It was also an independent prognostic factor for major postoperative complications by multivariate analysis. The operative blood loss and transfusion rate were also significantly higher in patients with LSM >12.0 kPa. Conclusions:High LSM (>12.0 kPa) predicted worse posthepatectomy outcomes. Preoperative LSM was better than ICG test in the prediction of major postoperative complications. It was a useful preoperative investigation for risk stratification before hepatectomy.

Antiviral therapy improves post‐hepatectomy survival in patients with hepatitis B virus‐related hepatocellular carcinoma: a prospective‐retrospective study

The effect of antiviral therapy on the post‐hepatectomy long‐term survival in patients with hepatitis B virus (HBV)‐related hepatocellular carcinoma (HCC) remains uncertain.

Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study

BACKGROUND Recurrent pyogenic cholangitis (RPC) is still a common disease in East Asia. The present study reviews the operative results for this disease in a single centre. METHODS The records of 85 patients who underwent surgical treatment for RPC from August 1995 to March 2008 were retrospectively reviewed. RESULTS Patients included 35 men and 50 women with a median age of 61 years. Types of surgery included: hepatectomy (65.9%); hepatectomy plus drainage (9.4%); drainage alone (14.1%), and percutaneous choledochoscopy (10.6%). There was no operative mortality. Complications occurred in 40% of patients and half the complications involved wound infections. The overall incidences of residual stone, stone recurrence and biliary sepsis recurrence were 21.2%, 16.5% and 21.2%, respectively, over a median follow-up of 45.4 months. The drainage-alone group and percutaneous choledochoscopy group had higher incidences of residual stone, stone recurrence and biliary sepsis recurrence. In hepatectomy patients, regardless of whether or not a drainage procedure had been performed, rates of residual stone, stone recurrence and biliary sepsis recurrence were 15.6%, 7.8% and 9.4%, respectively, over a median follow-up of 42.7 months. CONCLUSIONS Hepatectomy is safe and yields the best treatment outcome for RPC. It should be considered as the treatment of choice for suitable patients with RPC.

Percutaneous radiofrequency ablation versus surgical radiofrequency ablation for malignant liver tumours: the long-term results

BACKGROUND Radiofrequency ablation (RFA) has been used to treat hepatocellular carcinoma (HCC) and liver metastases for more than 10 years with promising early outcomes. Preliminary results comparing percutaneous and surgical approaches have shown no difference in short-term outcomes. In this study, the longer-term outcomes were presented. METHODS Patients with liver malignancies treated by RFA were prospectively studied from 2003 to 2011. Post-ablation assessment by computed tomography (CT) scan and serum biochemistry was performed at regular intervals. Recurrence rates and long-term survival were analysed. RESULTS A total of 233 patients with liver malignancies (75.5% HCC and 24.5% liver metastases) were analysed. Three RFA approaches were used (percutaneous 58.4%, laparoscopic 9.4% and open 32.2%). The median follow-up time was 29 months. Complete ablation was achieved in 83.7%, with no difference between the two approaches. More wound and chest complications were observed in the surgical group. Intra-hepatic recurrences were observed in 69.5%; extra-hepatic recurrences were detected in 22.3%, with no difference between the two groups. There was no statistical difference between the two approaches in overall 1-, 3- and 5-year survival. CONCLUSION An extended period of follow-up in patients with liver malignancies showed that RFA is an effective treatment. No difference was demonstrated between the percutaneous and surgical approach, in terms of recurrence and survival.

Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial

The aim of this retrospective review was to assess the clinical outcomes of laparoscopic cholecystectomy for acute cholecystitis since the conclusion of a randomized controlled trial in 1997.

Ruptured gastroduodenal artery pseudoaneurysm as the initial presentation of chronic pancreatitis

Gastroduodenal artery pseudoaneurysm is a rare but life threatening complication of pancreatitis. Diagnosis and management of it remain challenging. Surgical treatment was associated with a high mortality. Percutaneous transarterial embolization of bleeding artery has recently been advocated as a definitive therapy and can be attempted as the initial measure to control bleeding. We herein report a case of chronic pancreatitis presented with ruptured pseudoaneurysm of gastroduodenal artery which was successfully controlled with transarterial embolisation.

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

AbstractBackgroundMirizzi 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. MethodsA 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.ResultsFive 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.ConclusionMirizzi syndrome can be effectively managed with a minimally invasive approach by adopting a robot-assisted surgery together with a planned pre- and postoperative ERCP.

Letter: pre‐ and post‐operative anti‐viral therapy is important for patients with hepatitis B virus‐related hepatocellular carcinoma

SIRS, We read with interest the article by Chong et al., which focused on the efficacy of anti-viral therapy with nucleos(t)ide analogues in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) following hepatectomy. The authors reported that use of anti-viral therapy improved overall 5-year survival and was associated with better liver function reserve at the time of recurrence, making a larger proportion of patients eligible to receive curative treatment for recurrence. Increasing evidence supporting the benefit of anti-viral therapy has paradoxically made it more difficult to test this idea rigorously in a randomised controlled trial because of the ethical issues around a placebo control. To compensate for this challenge, the authors adopted an intriguing prospective–retrospective study design that nevertheless may overestimate the efficacy of anti-viral therapy. One reason for this is that the authors compared cohorts from different time periods, 1999–2010 for the control group and 2010–2012 for the anti-viral therapy group. Advances in surgical techniques and perioperative care in recent decades 4 lead to the unbalanced hospital mortality (4% vs. 0.4%, P = 0.012) and complication rates (46.7% vs. 27.2%, P < 0.001) for patients with HBV-related HCC. In addition, median follow-up in the anti-viral therapy group was only 39.2 months, which is too short to reliably calculate 5-year (60 m) overall survival. As a result, the authors’ results cannot reliably be compared with those of a recent multivariate analysis from a randomised control trial, which reported that anti-viral therapy is a strong independent predictor of late recurrence. We agree with Chong and colleagues’ conclusion that anti-viral therapy improved patient liver function in their cohort, given that mortality due to liver failure was significantly more prevalent in the control group despite a lower rate of cirrhosis. At the same time, those authors failed to address the potential impact of HBV reactivation on their results. They reported that overall survival was higher for patients who started anti-viral therapy after hepatectomy than for those who started it before surgery or for those who did not start it at all. Hepatic resection may cause HBV reactivation, which can lead to fulminant hepatitis, liver failure or even death. Since anti-viral therapy has been shown to significantly reduce the rate of HBV reactivation, it may be more appropriate to initiate anti-viral therapy before resection. This should be examined directly in appropriately designed studies.

Modification of right hepatectomy results in improvement outcome: a retrospective comparative study

OBJECTIVE To evaluate any change in the operative and survival outcomes in patients undergoing a right hepatectomy after adoption of the no-clamp technique using a radiofrequency dissecting sealer (TissueLink™) in liver resection. METHODS In all, 58 consecutive patients who underwent a right hepatectomy from July 2003 to December 2007 (Group 1) were compared with 66 consecutive patients who underwent a right hepatectomy from January 1999 to June 2003 (Group 2). In group 1, a liver transection was performed with a cavitron ultrasonic surgical aspirator (CUSA) and TissueLink™ without hilar clamping whereas in group 2, a liver transection was performed with CUSA and diathermy with routine continuous hilar clamping. RESULTS For the operative outcomes, there was significantly less blood loss (median 450 vs. 900 ml, P < 0.001) in group 1. The complication rate was also significantly lower in group 1 (22.4% vs. 47.0%, P = 0.004). In subgroup analysis for patients with hepatocellular carcinoma (HCC), the overall survival rate was significantly better in group 1; 1-, 3- and 5-year survival rates were 78%, 72% and 57% in group 1 vs. 72%, 44% and 39% in group 2, respectively (P = 0.048). CONCLUSIONS When compared with the retrospective cohort, a right hepatectomy utilizing TissueLink™ without hilar clamping was feasible with potential benefits in surgical outcomes.