Chun-Nan Yeh

Hepatic Resection and Prognosis for Patients With Hepatocellular Carcinoma Larger Than 10 cm: Two Decades of Experience at Chang Gung Memorial Hospital

AbstractBackground: Although screening programs in high-risk populations have facilitated the detection of small hepatocellular carcinoma (HCC), some HCC patients continue to present with advanced, large tumors. However, reports of hepatic resection for HCC larger than 10 cm (L-HCC) are limited. This study aims to determine the clinicopathologic factors that influence the prognosis of hepatic resection for L-HCC. Methods: The clinical features of 211 L-HCC patients undergoing hepatic resection were reviewed. Clinical features and factors influencing the outcome of 985 patients with HCC smaller than 10 cm (S-HCC) were used for comparison. Results: Of 1196 surgically resected HCCs, 211 (17.6%) were L-HCC. Multivariate logistic regression analysis showed that the presence of dull abdominal pain, a low indocyanine green retention rate value, a high percentage of alfa fetoprotein (AFP) >400 ng/mL, major hepatectomy, absence of tumor capsule formation, satellite lesions, and vascular invasion were the seven main independent factors differentiating L-HCC from S-HCC patients. Significantly worse overall survival was noted in L-HCC patients, especially those with tumor rupture, satellite lesions, AFP >400 ng/mL, and blood loss of >1 L during surgery. Conclusions: Hepatic resection, when feasible, is safe and is the preferred treatment for L-HCC patients. However, overall and disease-free survival for L-HCC are worse than for S-HCC. Disease-free survival for L-HCC patients undergoing hepatic resection is significantly influenced by a high value of alkaline phosphatase and by AFP. Overall survival for L-HCC patients undergoing hepatic resection is significantly influenced by a high value of AFP, blood loss, tumor rupture, and satellite lesions.

Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis.

BackgroundA bleeding pseudoaneurysm in patients with chronic pancreatitis is a rare and potentially lethal complication. Optimal treatment of bleeding peripancreatic pseudoaneurysm remains controversial. This study reports on experience at Chang Gung Memorial Hospital (CGMH) in managing of bleeding pseudoaneurysms associated with chronic pancreatitis.MethodsThe medical records of 9 patients (8 males and 1 female; age range, 28 – 71 years; median, 36 years) with bleeding pseudoaneurysms associated with chronic pancreatitis treated at CGMH between Aug. 1992 and Sep. 2004 were retrospectively reviewed. Alcohol abuse (n = 7;78%) was the predominant predisposing factor. Diagnoses of bleeding pseudoaneurysms were based on angiographic (7/7), computed tomographic (4/7), ultrasound (2/5), and surgical (2/2) findings. Whether surgery or angiographic embolization was performed was primarily based on patient clinical condition. Median follow-up was 38 months (range, 4 – 87 months).ResultsAbdominal computed tomography revealed bleeding pseudoaneurysms in 4 of 7 patients (57%). Angiography determined correct diagnosis in 7 patients (7/7, 100%). The splenic artery was involved in 5 cases, the pancreaticoduodenal artery in 2, the gastroduodenal artery in 1, and the middle colic artery in 1. Initial treatment was emergency (n = 4) or elective (n = 3) surgery in 7 patients and arterial embolization in 2. Rebleeding was detected after initial treatment in 3 patients. Overall, 5 arterial embolizations and 9 surgical interventions were performed; the respective rates of success of these treatments were 20% (1/5) and 89% (8/9). Five patients developed pseudocysts before treatment (n = 3) or following intervention (n = 2). Pseudocyst formation was identified in 2 of the 3 rebleeding patients. Five patients underwent surgical treatment for associated pseudocysts and bleeding did not recur. One patient died from angiography-related complications. Overall mortality rate was 11% (1/9). Surgery-related mortality was 0%.ConclusionAngiography is valuable in localizing bleeding pseudoaneurysms. In this limited series, patients with bleeding pseudoaneurysms associated with chronic pancreatitis treated surgically seemingly obtained good outcomes.

Laparoscopic cholecystectomy in 226 cirrhotic patients

AbstractsBackground: Since 1987, laparoscopic cholecystectomy (LC) has been widely used as the favored treatment for gallbladder lesions. However, cirrhosis and portal hypertension have been considered relative or absolute contraindications to LC. This study aimed to assess the safety of LC in cirrhotic patients. Method: The medical records of 226 cirrhotic patients with gallbladder lesions who had undergone LC from 1991 to 2000 were reviewed, including demographics, severity of cirrhosis, laboratory data, operative morbidity, operative mortality, and hospital stay. Furthermore, the clinical features and outcomes of 4030 patients with gallbladder lesions without cirrhosis that had undergone LC were also summarized for comparison. Results: Of 4256 patients with gallbladder lesions that had undergone LC, 226 (5.6%) had cirrhotic livers. The cirrhotic group patients clearly exhibited the trends of older age, worse liver function, higher blood loss, and higher mortality compared to the noncirrhotic group patients. Conclusions: This study presents the clinical features and outcomes of 226 cirrhotic patients who underwent LC. LC, once considered contraindicated in patients with cirrhosis, is a feasible procedure for most Childs A and B patients with cholecystolithiasis. Minor morbidity, an acceptable conversion rate, and shorter hospital stay can be achieved by applying LC to treat cirrhotic patients. However, appropriate preoperative preparations and meticulous operative techniques are required to reduce blood loss during laparoscopy and even mortality.

Hepatic Resection of the Intraductal Papillary Type of Peripheral Cholangiocarcinoma

BackgroundPeripheral cholangiocarcinoma (PCC) can be grossly classified into mass-forming, periductal-infiltrating, and intraductal papillary (IP) types. Information on IP-PCC patients undergoing hepatectomy is sparse because of the small number of cases.MethodsThe clinical features of 40 IP-PCC patients undergoing hepatectomy between 1977 and 2000 were reviewed. The clinical features of 94 PCC patients without IP growth undergoing hepatectomy were used for comparison.ResultsIP-PCC and non–IP-PCC groups had similar age distributions (P = .674), sex ratios (P = .079), and positive rates for serum carcinoembryonic antigen and CA 19–9 (P = .121 and .795, respectively). The two groups also exhibited similar rates of association between hepatolithiasis and PCC (P = .230). However, more IP-PCC patients exhibited signs during admission, and more had ALT values >36 IU/L; they also had smaller tumors, more mucobilia association, and tumors in earlier stages and had undergone more postoperative chemotherapy. Multivariate logistic regression analysis showed that only ALT >36 IU/L differentiated IP-PCC from non–IP-PCC patients. The two groups exhibited similar operative mortality (P = 1.0). Follow-up ranged from 1.6 to 125.2 months (mean and median, 44.6 and 5.7 months, respectively). The 1-, 3-, and 5-year overall survival rates were 72.9%, 41.2%, and 24.7%, respectively, in the IP-PCC group and 43.3, 6.03%, and 2.01% in the non–IP-PCC group. The prognosis was favorable for the IP-PCC patients (P < .00001), particularly for IP-PCC patients who received curative hepatectomy (P = .013).ConclusionsIP-PCC patients had significantly better survival than non–IP-PCC patients, and aggressive curative hepatic resection is associated with a longer survival.

Prognostic factors of primary small bowel adenocarcinoma: univariate and multivariate analysis.

BackgroundAdenocarcinoma of the small bowel is relatively less common than malignancies of the esophagus, stomach, and colorectum. In small bowel adenocarcinoma, various prognostic factors influence the disease-free status and overall survival rates.Materials and MethodsEighty patients who were diagnosed with small bowel adenocarcinoma and treated at our institute between 1983 and 2003 were retrospectively reviewed.ResultsThe patients included 40 men and 40 women with an age range of 15 to 93 years (median: 62 years). Only 51.3% of patients were accurately proved preoperatively to have a malignancy by endoscopic biopsy. Sixty patients underwent surgical treatment, and 45 of those patients had curative resection. The follow-up period ranged from 2.5 to 229.7 months, with a median of 9.1 months. The cumulative 1-, 3-, and 5-year survival rates for all patients (excluding 3 patients who died in the immediate postoperative period) were 43.6%, 22.8%, and 17.5%, respectively. The cumulative 1-, 3-, and 5-year disease-free survival rate for all 43 patients with curative resection (excluding 2 patients who died in the immediate postoperative period) was 54.9%, 30.5%, and 27.4%, respectively. Meanwhile, multivariate analysis with Cox proportional hazards analysis demonstrated that earlier tumor stages (stages I and II) and curative resection were two independent factors influencing favorable overall survival. Lymph node metastasis was the only independent factor predicting poor disease-free survival in patients undergoing curative resection.ConclusionsPoor prognosis of small bowel adenocarcinoma may be related to a delay in the diagnosis and treatment of the disease. Curative resection is the aim of surgical treatment for small bowel adenocarcinoma. Lymph node metastasis at presentation of the disease predicts tumor recurrence and distant metastasis after curative surgical treatment.

Surgical treatment and prognostic analysis for gastrointestinal stromal tumors (GISTs) of the small intestine: before the era of imatinib mesylate

BackgroundGastrointestinal stromal tumors (GISTs), the most common type of mesenchymal tumors of the gastrointestinal (GI) tract, demonstrate positive kit staining. We report our surgical experience with 100 small intestine GIST patients and identify predictors for long-term disease-free survival (DFS) and overall survival (OS) to clarify the difference between high- and low-risk patients.MethodsThe clinicopathologic and follow-up records of 100 small intestine GIST patients who were treated at Chung Gung Memorial Hospital between 1983 and 2002 were retrospectively reviewed. Clinical and pathological factors were assessed for long-term DFS and OS by using a univariate log-rank test and a multivariate Cox proportional hazard model.ResultsThe patients included 52 men and 48 women. Their ages ranged from 27 to 82 years. Among the 85 patients who underwent curative resection, 44 (51.8%) developed disease recurrence (liver metastasis was the most common form of recurrence). The follow-up period ranged from 5 to 202 months (median: 33.2 months). The 1-, 3-, and 5-year DFS and OS rates were 85.2%, 53.8%, and 43.7%, and 91.5%, 66.6%, and 50.5%, respectively. Using multivariate analysis, it was found that high tumor cellularity, mitotic count >5/50 high-power field, and a Ki-67 index ≧10% were three independent factors that were inversely associated with DFS. However, absence of tumor perforation, mitotic count < 5/50 high power field, and tumor with low cellularity were predictors of long-term favorable OS.ConclusionTumors with low cellularity, low mitotic count, and low Ki-67 index, which indicate low risk, predict a more favorable DFS for small intestine GIST patients undergoing curative resection. Absence of tumor perforation with low mitotic count and low cellularity, which indicates low risk, can predict long-term OS for small intestine GIST patients who have undergone curative resection.

Hepatocellular carcinoma and vitamin D: A review

The non‐classical actions of vitamin D, namely antiproliferation, pro‐differentiation, pro‐apoptosis, anti‐inflammation, and immune regulation, have received great attention during the past decade. Increasing evidence from epidemiological studies showing the inverse association between vitamin D status and incidence of many forms of cancer as well as biochemical studies has suggested that vitamin D deficiency may play a role in the cause and progression of these types of cancer. Recently, vitamin D and its analogs have been deemed as potential regimen to treat a variety of cancers alone or in combination with other drugs. Although, the epidemiologic evidence regarding the association of vitamin D and hepatocellular carcinoma (HCC) is still inconclusive, biochemical evidence clearly indicates that HCC cells are responsive to the inhibitory effect of vitamin D and its analogs. In this review, we discuss the current status of HCC and its treatment, the source, metabolism, functions, and the mechanism of actions of vitamin D, and the biochemical studies of vitamin D analogs and their implications in the prevention and treatment of HCC.

Hepatic Resection for Hepatocellular Carcinoma with Obstructive Jaundice due to Biliary Tumor Thrombi

ABSTRACTHepatocellular carcinoma (HCC) with obstructive jaundice due to biliary tumor thrombi is uncommon, and few studies have examined the outcome of hepatectomy for HCC with this unusual entity. This study examined the clinicopathologic factors influencing the outcomes of 17 HCC patients with obstructive jaundice due to biliary tumor thrombi undergoing hepatectomy. The clinical features of 17 HCC patients with obstructive jaundice due to biliary tumor thrombi (group A) undergoing hepatectomy from 1986 to 1998 were reviewed. The clinical features and factors influencing the outcome of 555 HCC patients without biliary tumor thrombi (group B) undergoing hepatectomy were used for comparison. Of 572 patients with surgically resected HCCs, 17 (3.0%) were classified into group A. Right upper quadrant pain, physical signs of jaundice, low albumin level, elevated bilirubin level, small tumor size, more vascular invasion, and tumor rupture were characteristic of group A patients. Multivariate stepwise logistic regression analysis revealed no independently significant factor differentiating group A patients from group B patients. The disease-free survival was similar between the group A and B patients, although group B patients exhibited significantly better overall survival (p = 0.014). Vascular invasion may adversely influence overall survival in group A patients undergoing hepatic resection (p = 0.0709). When feasible, hepatic resection is the preferred treatment for HCC patients with obstructive jaundice due to biliary tumor thrombi. It can achieve a disease-free survival comparable to that of HCC patients without biliary tumor thrombi. However, HCC patients with biliary tumor thrombi had significantly worse overall survival than did those without biliary tumor thrombi, especially those with concomitant vascular invasion.

Laparoscopic treatment for Mirizzi syndrome

Background: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease resulting in obstructive jaundice and remains surgically challenging. Mirizzi syndrome is generally considered a contraindication to laparoscopic surgery. We present the surgical experience of 11 consecutive patients with Mirizzi syndrome who were diagnosed correctly preoperatively and treated laparoscopically. Methods: From January 1991 to December 2001, 4,560 patients underwent laparoscopic cholecystectomy for gallbladder lesions, 11 (0.24%) of whom were diagnosed with Mirizzi syndrome. Results: The 11 patients diagnosed with Mirizzi syndrome included four men and seven women, with ages ranging from 21 to 72 years (median, 54). There were 10 patients with Mirizzi syndrome type I (one was caused by gallbladder cancer in the neck), and 1 patient with type II, according to McSherry’s classification. Right upper quadrant abdominal pain was the most common symptom, occurring in all 11 patients. All 11 patients were diagnosed correctly preoperatively by endoscopic retrograde cholangiography (ERCP) with 100% sensitivity. Four of the 11 patients (36.4%) were converted to open procedure. The postoperative course was uneventful, except for one patient complicated with a residual common bile duct stone. Hospital stay ranged from 4 to 33 days (median, 7). Conclusions: Mirizzi syndrome is an uncommon disorder. Preoperative suspicion is crucial for correct preoperative diagnosis. ERCP is the most useful tool for correct preoperative diagnosis and consequent prevention of common bile duct injury during operation. Should Mirizzi syndrome be diagnosed, laparoscopic treatment is a feasible and safe procedure, especially for type I Mirizzi syndrome.

Clinicopathological Factors Predicting Long-term Overall Survival after Hepatectomy for Peripheral Cholangiocarcinoma

Peripheral cholangiocarcinoma (PCC) is clinically challenging because patients typically do not present until the disease is relatively advanced. Three-year to 5-year survival rates even with resection thus remain dismal. This study aimed to determine the clinicopathological factors for predicting overall survival longer than 5 years in PCC patients treated with hepatectomy. From 1977 to 1997, the clinicopatholgical features of 11 PCC patients who underwent hepatectomy with long-term overall survival (group A) were reviewed. Comparison was made with the clinical features and factors influencing the outcome of 70 PCC patients who survived less than 5 years after hepatectomy (group B). Of 81 PCC patients undergoing hepatectomy, 11 (13.6%) were 5-year survivors. The 81 PCC patients comprised 32 men and 49 women, with a mean age of 56.0 years (range: 34–83 years). Univariate analysis showed that female gender, absence of physical findings, a higher percentage of presence of mucobilia, early staged tumor, intraductal papillary tumor growth, and curative hepatic resection were more frequent in group A patients than group B patients. However, multivariate logistic regression analysis showed that absence of physical findings, presence of mucobilia, early staged tumor, and curative hepatic resection were the four independent factors differentiating group A from B patients. The 1-, 3-, 5-, and 10-year survival rates of the group A patients were 100%, 100%, 100%, and 40%, whereas those of the group B patients were 46.0%, 9.5%, 0%, and 0%, respectively. Absence of physical findings, presence of mucobilia, early staged tumor, and curative hepatectomy could independently predict PCC patients with long-term overall survival after hepatectomy.