Eric C. H. Lai

The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review.

Objective:To review the current status of radiofrequency ablation (RFA) in the management of hepatocellular carcinoma (HCC). Summary Background Data:The development of local ablative therapy has been 1 of the major advances in the treatment of HCC. Its role in the management of HCC is still rapidly evolving. Methods:Studies were identified by searching Medline, and PubMed databases for articles from January 1997 to April 2008 using the keywords “radiofrequency ablation,” “hepatocellular carcinoma” and “ablation of HCC.” Additional papers were identified by a manual search of the references from the key articles. Randomized controlled trials, nonrandomized comparative studies, cohort studies, were reviewed. Cohort studies with follow-up of less than 12 months and case reports were excluded. Results:Five aspects of RFA were analyzed: (1) RFA in comparison with other local ablative therapies; (2) RFA for unresectable HCC; (3) RFA as bridging therapy before liver transplantation; (4) RFA as primary treatment for resectable HCC; and (5) RFA for recurrent HCC after partial hepatectomy. Ten RCTs, 8 nonrandomized controlled trials and 26 cohort studies were included in this analysis. Conclusions:The evidence in the medical literature showed RFA was more effective than other local ablative therapies, and supported its use in the treatment of unresectable small HCC, recurrent small HCC, and as bridging therapy before liver transplantation, and as a primary treatment in competition with partial hepatectomy for resectable small HCC.

A prospective, randomized, controlled trial of preoperative transarterial chemoembolization for resectable large hepatocellular carcinoma.

Objective:To evaluate the effect of preoperative transarterial chemoembolization (TACE) for resectable large hepatocellular carcinoma (HCC). Summary Background Data:Resection of HCC is potentially curative, but local recurrence is very common. There is currently no effective neoadjuvant or adjuvant therapy. Methods:From July 2001 to December 2003, 108 patients (hepatitis B carrier = 98.1%) with resectable HCC (≥5 cm) was randomly assigned to preoperative TACE treatment (n = 52) or no preoperative treatment (control group) (n = 56). Results:Five patients (9.6%) in the preoperative TACE group did not receive surgical therapy because of extrahepatic metastasis or liver failure. The preoperative TACE group had a lower resection rate (n = 47, 90.4% vs. n = 56, 100%; P= 0.017), and longer operative time (mean, 176.5 minutes vs. 149.3 minutes; P= 0.042). No significant difference was found between the 2 groups in operative blood loss, surgical morbidity, and hospital mortality. At a median follow-up of 57 months, 41 (78.8%) of 52 patients in the preoperative TACE group and 51 (91.1%) of 56 patients in the control group had recurrent disease (P= 0.087). The 1-, 3-, and 5-year disease-free survival rates were 48.9%, 25.5%, and 12.8%, respectively, for the preoperative TACE group and 39.2%, 21.4%, and 8.9%, respectively, for the control group (P= 0.372). The 1-, 3-, and 5-year overall survival rates were 73.1%, 40.4%, and 30.7%, respectively, for the preoperative TACE group and 69.6%, 32.1%, and 21.1%, respectively, for the control group (P= 0.679). Conclusions:Preoperative TACE did not improve surgical outcome. It resulted in drop-out from definitive surgery because of progression of disease and liver failure.

The Role of Conservative Treatment in Idiopathic Granulomatous Mastitis

Abstract:  Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast that mimics carcinoma of the breast. Its etiology and treatment remain unclear. A retrospective review of nine women with histopathologic diagnosis of IGM was performed. The women had a mean follow‐up of 18.7 months and a mean age of 45.7 years (range 32–83 years). The main presentation was breast mass (100%). Clinically and radiologically, 55.6% of the women were suspected to have malignancy. One patient was treated with lumpectomy without recurrence. Eight patients were treated with expectant management with close regular surveillance. No surgery was performed and no medications were given. Fifty percent of the patients had spontaneous complete resolution of disease after a mean interval of 14.5 months. These four patients had no recurrence. Fifty percent of patients had static disease. In conclusion, it is important to differentiate IGM from carcinoma of the breast. Tissue biopsy remains the gold standard to confirm the diagnosis. Expectant management with close regular surveillance is the treatment of choice.

Measures to Prevent Pancreatic Fistula After Pancreatoduodenectomy: A Comprehensive Review

OBJECTIVE To review the current evidence on the efficacy of various interventions directed toward prevention of pancreatic fistula after pancreatoduodenectomy. DATA SOURCES A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles. STUDY SELECTION Case reports were excluded from this study. DATA EXTRACTION Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also. DATA SYNTHESIS The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality. CONCLUSION More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.

Laparoscopic Liver Resection for Hepatocellular Carcinoma: Ten-Year Experience in a Single Center

HYPOTHESIS Laparoscopic hepatectomy and open hepatectomy for hepatocellular carcinoma (HCC) have the same surgical outcome. DESIGN Nonrandomized comparative study. SETTING Tertiary referral center. PATIENTS Twenty-five consecutive patients with HCC undergoing laparoscopic hepatectomy from January 1, 1998, through December 31, 2007, and a retrospective control group of 33 patients who underwent open hepatectomy for HCC during the same period. The 2 groups were matched in terms of demographic data, tumor size, and severity of cirrhosis. INTERVENTIONS Laparoscopic hepatectomy. MAIN OUTCOME MEASURES Surgical morbidity rate, mortality rate, and survival. RESULTS One patient in the laparoscopic group underwent conversion to an open approach. The median operating time and blood loss were 150 minutes and 200 mL, respectively. The resections were R0 in 22 patients (88%) and R1 in 3 (12%). The hospital mortality and morbidity rates were 0% and 16% (4 patients), respectively. The 3-year overall and disease-free survival rates were 60% and 52%, respectively. There was no difference in surgical morbidity rate, hospital mortality rate, and midterm survival results between the 2 groups. The laparoscopic approach resulted in a shorter hospital stay. CONCLUSIONS Laparoscopic hepatectomy for HCC is feasible and safe in selected patients. Midterm survival is also favorable. The laparoscopic approach has the benefit of a shorter hospital stay. However, the procedure should be performed by a surgical team expert in hepatobiliary and laparoscopic surgery in properly selected patients.

Adjuvant intra-arterial iodine-131-labeled lipiodol for resectable hepatocellular carcinoma: a prospective randomized trial-update on 5-year and 10-year survival.

Objective:In this prospective randomized trial, we attempted to find out if 1 dose of postoperative adjuvant intra-arterial iodine-131-labeled lipiodol could reduce the rate of local recurrence, and increase disease-free and overall survival for patients with hepatocellular carcinoma (HCC). This study evaluated the long-term outcome. Background:Resection of HCC is potentially curative, but local recurrence is common. However, there is currently no effective adjuvant therapy. Early results after closing the trial (Lau et al. Lancet 1999;353:797–801) showed that 1 dose of intra-arterial 131I-lipiodol given after curative resection significantly decreased the rate of recurrence, and increased disease-free and overall survival. Methods:Patients who underwent curative resection for HCC and recovered within 6 weeks were randomly assigned one 1850 MBq dose of 131I-lipiodol or no further treatment (controls). We compared rates of recurrence, and long-term disease-free and overall survival (the primary endpoints) between the 2 groups by intention-to-treat. Results:Between April 1992 and August 1997, we recruited 43 patients: 21 were randomized to receive intra-arterial 131I-lipiodol and 22 to receive no adjuvant treatment. 131I-lipiodol had no significant toxic effects. During a median follow-up of 66 (range, 3–198) months, there were 10 (47.6%) recurrences among the 21 patients in the adjuvant treatment group, compared with 14 (63.6%) in the control group (P = 0.29). The actuarial 5-year disease-free survival in the treatment and control groups was 61.9% and 31.8%, respectively (P = 0.0397). The actuarial 5-year overall survival in the treatment and control groups was 66.7% and 36.4%, respectively (P = 0.0433). The actuarial 7-year disease-free survival in the treatment and control groups was 52.4% and 31.8%, respectively (P = 0.0224). The actuarial 7-year overall survival in the treatment and control groups was 66.7% and 31.8%, respectively (P = 0.0243). The actuarial 10-year disease-free survival in the treatment and control groups was 47.6% and 27.3%, respectively (P = 0.0892). The actuarial 10-year overall survival in the treatment and control groups was 52.4% and 27.3%, respectively (P = 0.0905). Conclusions:In patients with HCC, adjuvant intra-arterial 131I-lipiodol after curative liver resection provided survival benefit on the disease-free survival and overall survival, although the difference became statistically insignificant at 8 years after randomization.

Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCT

BACKGROUND & AIMS The aim of this randomized comparative trial (RCT) is to compare partial hepatectomy (PH) with transcatheter arterial chemoembolization (TACE) to treat patients with resectable multiple hepatocellular carcinoma (RMHCC) outside of Milan Criteria. METHODS This RCT was conducted on 173 patients with RMHCC outside of Milan Criteria (a solitary tumor up to 5 cm or multiple tumors up to 3 in number and up to 3 cm for each tumor) who were treated in our centre from November 2008 to September 2010. The patients were randomly assigned to the PH group or the TACE group. The primary outcome measure was overall survival (OS) from the date of treatment. A multivariate Cox proportional hazards regression analysis was performed to assess the prognostic risk factors associated with OS. RESULTS The 1-, 2-, and 3-year OS rates were 76.1%, 63.5%, and 51.5%, respectively, for the PH group compared with 51.8%, 34.8%, and 18.1%, respectively, for the TACE group (Log-rank test, χ(2)=24.246, p<0.001). Multivariate Cox proportional hazards regression analysis revealed the type of treatment (hazard ratio, 0.434; 95% CI, 0.293 to 0.644, p<0.001), number of tumor (hazard ratio, 1.758; 95% CI, 1.213 to 2.548, p=0.003) and gender (hazard ratio, 0.451; 95% CI, 0.236 to 0.862, p=0.016) were significant independent risk factors associated with OS. CONCLUSIONS PH provided better OS for patients with RMHCC outside of Milan Criteria than conventional TACE. The number of tumor and gender were also independent risk factors associated with OS for RMHCC.

Salvage Surgery Following Downstaging of Unresectable Hepatocellular Carcinoma

Objective:We reported here a series of 49 patients with unresectable hepatocellular carcinoma (HCC) who underwent nonsurgical treatment to downstage the disease followed by salvage surgery, their long-term outcome, and pattern of recurrence. Summary Background Data:Most HCC patients present with unresectable disease and are treated with chemotherapy or intra-arterial therapy with a palliative intent. Occasionally, there are good responses to treatment so that salvage surgery becomes feasible afterward. However, long-term outcomes of these patients are seldom reported. Methods:Patients with unresectable hepatocellular carcinoma, from September 1993 to June 2002, who received salvage surgery after downstaging by systemic chemotherapy, intra-arterial yttrium-90 microspheres, or sequential treatment were included in this study. Systemic chemotherapy consisted of combination doxorubicin, cisplatin, interferon-alpha and 5-fluorouracil (5-FU), or single-agent doxorubicin. The choice of treatment was according to stage of disease and contemporary clinical trial protocol. Survival, recurrence pattern, and surgical outcome were studied. Results:There were 49 patients in this study with 40 males and 9 females, age ranged from 12 to 69 years. Forty patients (81.6%) were hepatitis B positive. Thirty-two patients had combination chemotherapy alone (65.3%), 8 patients had single agent chemotherapy alone (16.3%), 4 patients received intra-arterial yttrium-90 microspheres alone (8.2%), and 5 patients received sequential therapy (10.2%). Twenty-eight (57.1%) patients received major hepatic resection. Thirteen patients (26.5%) had complete necrosis of the tumor after treatment. Twenty-one patients (42.9%) had recurrence after surgery, and 14 of them were intrahepatic recurrence. The median survival was 85.9 months. The 1-year, 3-year, and 5-year survival rates were 98%, 64%, and 57%, respectively. Conclusions:Salvage surgery after successful downstaging can provide long-term control of disease in a small proportion of patients with unresectable hepatocellular carcinoma.

MIRIZZI SYNDROME: HISTORY, PRESENT AND FUTURE DEVELOPMENT

Background:  Mirizzi syndrome was reported in 0.3–3% of patients undergoing cholecystectomy. The distortion of anatomy and the presence of cholecystocholedochal fistula increase the risk of bile duct injury during cholecystectomy.

Management of bile duct injury after laparoscopic cholecystectomy: a review.

Background:  Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long‐term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy.