Dong Jiahong

The Pringle manoeuvre should be avoided in hepatectomy for cancer patients due to its side effects on tumor recurrence and worse prognosis.

Curative hepatectomy is still the best therapeutic strategy for liver cancer treatment up to now. The Pringle manoeuvre has been commonly used to avoid massive blood loss during operation since its advent, which greatly accelerates the advance of liver surgery and oncological surgery. In the past century, more attentions have been paid to different effects of ischemia-reperfusion injury elicited by Pringle manoeuvre. Theses include its impacts on complex metabolic, immunological, and microvascular changes, which altogether might contribute to hepatocellular damage and dysfunction, and contribute to haemodynamic instability. Despite these adverse impacts, the short-term outcome of affected patients under hepatectomy was greatly improved with the advances of surgical techniques and perioperative management in recent years. While the long-term prognosis remains unsatisfactory due to a high incidence of intra/extrahepatic recurrence. The reason for it was not totally elucidated. Furthermore, the effect of the Pringle manoeuvre on the prognosis of oncologic patients and behavior of the tumor cell was not deliberately mentioned. This point was put forward to the front-desk by the specific phenomenon from recent animal studies. It is showed that ischemia-reperfusion injury of the liver remnant may be a significant factor to promote the tumor recurrence and metastasis. If it is a truth in human, there must be a big challenge to the Pringle manoeuvre. So we hypothesized that the long-term prognosis of cancer patients could be worsened by the ischemia-reperfusion injury elicited by Pringle manoeuvre during the hepatectomy and it should be revised, or even, avoided in future hepatectomy for oncologic patients. The less surgical stress including ischemia-reperfusion injury in the hepatic resection without Pringle manoeuvre might contribute to a better prognosis. To get a deeper understanding, prospective randomized clinical trials need to be done. It is surely supposed to provide more important information about the long-term effects of the Pringle manoeuvre, and to our hypothesis.

Sustained methylene blue staining to guide anatomic hepatectomy for hepatocellular carcinoma: Initial experience and technical details.

BACKGROUNDnThe boundary of the target hepatic segment within the liver parenchyma cannot be marked by the use of a conventional anatomic hepatectomy approach. This study describes a novel methylene blue staining technique for guiding the anatomic resection of hepatocellular carcinoma (HCC).nnnMETHODSnBetween February 2009 and February 2012, anatomic hepatectomy was performed in 106 patients with HCC via a novel, sustained methylene blue staining technique. Sustained staining was achieved by injecting methylene blue into the distal aspect of the portal vein after exposing Glissons sheath. The hepatic pedicle was immediately ligated, and the hepatic parenchymal transection was performed along the interface between methylene blue stained tissue and unstained tissue.nnnRESULTSnAnatomic hepatectomies included subsegmentectomy (nxa0=xa016), monosegmentectomy (nxa0=xa057), multisegmentectomy (nxa0=xa027), and hemihepatectomy (nxa0=xa06). The portal vein was injected successfully with methylene blue in 100% of cases, and complete staining of the target hepatic segment was achieved in 98 of 106 (92.5%) cases. Mean intraoperative bleeding was 360xa0±xa090xa0mL, and the postoperative complication rate was 24.5% (26/106). No perioperative mortality occurred. Operative margins were all negative on pathologic examination. Mean duration of postoperative follow-up was 40xa0months (range, 24-60). No local recurrence (around the operative margin) occurred.nnnCONCLUSIONnThis novel technique of achieving sustained staining by injecting methylene blue then immediately ligating the hepatic pedicle is simple and feasible. It can guide the selection of the operative margin during hepatic parenchyma transection to improve the accuracy of anatomic hepatectomy for the treatment of HCC.

Complete radio frequency ablation of hepatocellular carcinoma adjacent to the main bile duct and blood vessels between the first and the second hepatic portal.

In cases where hepatocellular carcinoma cannot be surgically removed either due to the capacity of hepatic functional reserve or the special location of the tumor, a radiofrequency ablation (RFA) is recognized to be an effective and minimally invasive treatment. However, when the tumor is adjacent to the main bile duct and blood vessels, it is feared that due to the “heat-sink effect” of the blood and the possible damage to the duct and blood vessels, complete tumor ablation is hard to achieve. We report here a case of complete RFA of hepatocellular carcinoma, adjacent to the main bile duct and blood vessels between the first and the second hepatic portal, with emphasis on the safety of the approach for complete ablation of the tumor.

Effect of the pringle maneuver on tumor recurrence of hepatocellular carcinoma after curative resection (EPTRH): a randomized, prospective, controlled multicenter trial

BackgroundHepatic resection is currently still the best choice of therapeutic strategies for liver cancer, but the long-term survival rate after surgery is unsatisfactory. Most patients develop intra- and/or extrahepatic recurrence. The reasons for this high recurrence rate are not entirely clear. Recent studies have indicated that ischemia-reperfusion injury to the liver may be a significant factor promoting tumor recurrence and metastasis in animal models. If this is also true in humans, the effects of the Pringle maneuver, which has been widely used in hepatectomy for the past century, should be examined. To date, there are no reported data or randomized controlled studies examining the relationship between use of the Pringle maneuver and local tumor recurrence. We hypothesize that the long-term prognosis of patients with liver cancer could be worsened by use of the Pringle maneuver due to an increase in the rate of tumor recurrence in the liver remnant. We designed a multicenter, prospective, randomized surgical trial to test this hypothesis.MethodsAt least 498 eligible patients from five participating centers will be enrolled and randomized into either the Pringle group or the non-Pringle group in a ratio of 1:1 using a permuted-blocks randomization protocol. After the completion of surgical intervention, patients will be included in a 3-year follow-up program.DiscussionThis multicenter surgical trial will examine whether the Pringle maneuver has a negative effect on the long-term outcome of hepatocellular carcinoma patients. The trial will also provide information about prognostic differences, safety, advantages and disadvantages between Pringle and non-Pringle surgical procedures. Ultimately, the results will increase the available information about the effects of ischemia-reperfusion injury on tumor recurrence, which will be of immense benefit to general surgery.Trial registrationhttp://www.clinicaltrials.gov NCT00725335

Alcohol consumption might be beneficial for the patients with resectable liver cancer due to its induction of tolerance to the ischemia-reperfusion injury

Up to now, curative hepatectomy remains the best treatment for patients with liver cancer, during which ischemia/reperfusion injuries of the liver is inevitable. While the ischemia/reperfusion is a major cause of morbidity and mortality in patients undergone hepatectomy and transplantation, so how to reduce it to an acceptable level and to enhance the tolerance of liver to ischemia/reperfusion injury seem to be an eternal challenge for the hepatobiliary surgeon. Considering the broad protective effect of alcohol, we rationally proposed that the protection induced by ethanol consumption might take place without creature species limitation and without organ specific. To our interests, the liver is the most important place where the alcohol mainly metabolized in our body. The metabolic process of alcohol subsequently induces oxidative stress and inflammatory reaction to the liver. If it simulates the same effect as it acts on other organs, alcohol consumption might be advantageous to the liver undergone subsequent ischemia/reperfusion injuries. Since we are not trying to cure diseases occurring only in rats, the likely relevance of human liver injury should be carefully considered. To adequately evaluate our hypothesis that ethanol preconditioning before liver surgery may do good for the patients due to its induction of the tolerance of the liver to ischemia and reperfusion injuries, at least two studies need to be performed in future. The objective is to find out a simple and effective method to prevent the ischemia/reperfusion injuries during hepatectomy as well as other liver surgery and improve the perioperative outcome of the affected patients. Whether alcohol consumption can protect the liver ischemia/reperfusion injuries both from animals to human, or can only take effect in experiments, or neither of them? All these questions might be answered by the presumed studies. Of course, it would be more useful to testify the true effects of ethanol preconditioning in a clinical situation.

Feasibility of reduced-size orthotopic liver transplantation with fatty grafts and its potential regeneration in rats.

BACKGROUND AND AIMSnWe undertook this study to determine the minimum necessary volume of various grades of fatty liver grafts in reduced-size orthotopic liver transplantation (ROLT) and to elucidate the property of fatty liver regeneration.nnnMETHODSnBy modified two-cuff technique, ROLT of different rats was performed with various grades and volumes of fatty liver grafts. The survival rate, graft-to-recipient body weight ratio (GRWR), standard liver volume (SLV) and liver function were detected to determine appropriate steatotic grafts that could be safely adopted in ROLT.nnnRESULTSnIn grade II macrovesicular steatosis (MaS) grafts, the 1-week survival rate of 70% ROLT was significantly worse (25%). In grafts with microvesicular steatosis (MiS) undergoing 70%, 60%, and 50% ROLT, 7-day survival decreased according to the graft volume (75%, 75%, and 33.3%). Proliferating cell nuclear antigen (PCNA) and 5-bromo-2-deoxyuridine (BrdU) labeling index in normal liver graft reached the highest on postoperative day (POD) 3, whereas in fatty grafts the expression peak was on POD 7. Liver regeneration ratios of normal liver graft were higher than mild MaS graft, but grade II MaS grafts hardly regenerated. When compared with moderate MaS grafts B2 (70% ROLT) and mild MaS grafts A3 (60%) groups, the disparities of alanine aminotransferase and total bilirubin were significant.nnnCONCLUSIONSnIn successful and long-term survival of rat ROLT, MiS or grade II MaS livers could be safely used as grafts only when their GRWR >2.29+/-0.20 (or 2.28+/-0.12) % and SLV >60%; MaS livers in grade II should not be used as grafts. Hepatic regeneration potential of mild MaS or MiS with any grade graft is not obviously impaired after ROLT, but delayed proliferative peak and prolonged cell proliferative cycle are shown.

Evaluation on social and economic benefits of day surgery laparoscopic cholecystectomy in 1240 patients

Objectiveu3000To evaluate the social and economic benefits of day surgery laparoscopic cholecystectomy(LC/DS).Methodsu3000Clinical datum of 1240 patients undergoing LC/DS and 476 cases undergoing routine LC at General Hospital of Chinese People′s Liberation Army from November 2009 to December 2010 were retrospectively studied.Rate of conversion to open procedure，complications，length of stay in hospital，medical costs and patient satisfaction rate were compared between patients received LC/DS and routine LC.Data was analyzed using SPSS 16.0，differences between two groups were assessed using t tests for continuous variables and chi-square tests for categorical variables.Resultsu3000The average age in patients of LC/DS group was 52.3 years.1236 cases were preformed by LC and conversion to laparotomy occurred in 4 patients，the conversion rate was 0.16% as two cases of gallbladder carcinoma were excluded.Six (0.48%) complications developed.The severe complications of bile duct injury and stomach or bowel injury did not happen in LC/DS group.The average age in patients of routine LC group was 51.9 years.Eight (1.68%) patients required conversion to the open technique.Eleven (2.31%) complications including one bile duct injury and one colon injury developed in routine LC group.None of the patients died as a result of LC in both LC/DS and routine LC groups.Rate of conversion to open operation was 0.16%and 1.68%(χ2＝11.2086，P＝0.0008) in LC/DS and routine LC groups respectively，complication was 6 and 11 cases (χ2＝11.706，P＝0.001)，length of stay in hospital was (1.6±0.6)and(4.8±0.9)days (t＝85.244，P＝0.0000)，medical costs was (8028±338)and(9016±266)Yuan (RMB)(t＝57.32，P＝0.0000)，patient satisfaction rate was 95.4% and 95.7% respectively (χ2＝0.125，P＝0.723).Conclusionsu3000Implementation of the day surgery laparoscopic cholecystectomy resulted in a significant reduction in medical resource use，including a decreased length of stay and total cost of care.This procedure is worth promoting in China.