Teng-Wei Chen

Aggressive hepatic resection for patients with pyogenic liver abscess and APACHE II score ≥15

BACKGROUND Most liver abscesses resolve after antimicrobial therapy or percutaneous tube drainage (PD). The aim of this study was to evaluate the results of hepatic resection (HR) for patients with pyogenic liver abscesses and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score > or =15. METHODS We compared the clinical outcomes of 81 patients with APACHE II scores > or =15 undergoing PD and/or HR. RESULTS The failure rate (3 of 65) and double-treatment rate (32 of 65) in the PD group were significantly higher than in the HR group (3 of 35 vs 0 of 35; P = .0002). The mortality rate in the PD group was significantly higher than the other 2 groups (14 of 46 vs 2 of 19 and 1 of 16; P = .038). The length of hospital stay was significantly shorter and antibiotic use less in the HR group than in the PD group (P < .05). CONCLUSIONS Aggressive HR for patients with liver abscesses and APACHE II scores > or =15 produced better clinical outcomes.

Liver transplantation is an alternative treatment of hepatocellular carcinoma beyond the Milan criteria

BACKGROUND The decision to perform liver transplantation (LT) or liver resection (LR) for patients with hepatocellular carcinoma (HCC) who are beyond the Milan criteria remains controversial. METHODS We retrospectively analyzed outcome data for 179 patients with HCC beyond the Milan criteria who were treated with LR (n = 135) or LT (n = 44). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status. RESULTS Patients who underwent LR group were significantly older, had a lower TNM stage, and were more likely to have unilateral disease and noncirrhotic liver. Significantly more patients in the LR group had recurrence (53.3% vs 29.5%) or died (61.5% vs 43.2%) than patients in the LT group. Recurrence-free survival rates were 11.9% for the LR group and 61.5% for the LT group. The median overall survival duration showed no statistically difference between the LR group (28.0 months) and the LT group (50.0 months). CONCLUSIONS LT may be the better choice for patients with HCC beyond the Milan criteria.

Hepatic hemodynamic changes during liver transplantation: A review

Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.

Ectopic pancreas presenting as ampulla of vater tumor

Ectopic pancreas is relatively rare and is defined as pancreatic tissue that is situated abnormally, has no contact with the normal pancreas, and has its own ductal system and blood supply. It is usually an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific and depend on the site of the lesion and the different complications encountered. Heterotopic pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach (25%-60%) or the duodenum (25%-35%). Herein, we report a patient presenting with symptoms of ampullary tumor with obstructive jaundice, but the imaging study did not suggest the possibility of ectopic pancreas preoperatively.

Role of Nasogastric Tube Insertion after Gastrectomy

Nasogastric decompression has been routinely used in most abdominal operations to prevent the consequences of postoperative ileus. Most surgeons traditionally continue to use nasogastric decompression, believing that its use facilitates better surgical field and reduces complications such as nausea, vomiting, aspiration, and anastomotic leakage caused by postoperative ileus. The aim of the study was to evaluate whether gastric cancer surgery could be performed safely without nasogastric decompression. Patients and Methods: We enrolled 151 patients who had been surgically treated for gastric adenocarcinoma at the Tri-Service General Hospital from January 2005 to December 2005. The mean age was 55.4 years (range 25-72 years). 76 patients (Group A) were randomized into the intubated group and the other 75 patients (Group B) were randomized into the tubeless group. All patients received epidural pain control. Postoperative complications, preoperative serum albumin levels, mean time to first orally feeding, passage of stools, hospital stay and cost of hospitalization were recorded. Results: Between the two groups, there were no significant differences in preoperative clinical characteristics, age, stage and operative parameters. The complication rate, length of hospital stay, and time to pass flatus were not different in the two groups. Only the postoperative complication rate in those patients of Group A with low serum albumin level was significantly lower than that of patients without nasogastric tube. Conclusion: There were no significant differences with respect to improvement of postoperative complications when comparing gastric cancer patients who underwent gastrectomy with or without nasogastric tube insertion.

Predictors of the outcomes of acute-on-chronic hepatitis B liver failure

AIM To identify the risk factors in predicting the outcome of acute-on-chronic hepatitis B liver failure patients. METHODS We retrospectively divided 113 patients with acute-on-chronic liver failure-hepatitis B virus (ACLF-HBV) and without concurrent hepatitis C or D virus infection and hepatocellular carcinoma into two groups according to their outcomes after anti-HBV therapy. Their demographic, clinical, and biochemical data on the day of diagnosis and after the first week of treatment were analyzed using the Mann-Whitney U test, Fishers exact test, and a multiple logistic regression analysis. RESULTS The study included 113 patients (87 men and 26 women) with a mean age of 49.84 years. Fifty-two patients survived, and 61 patients died. Liver failure (85.2%), sepsis (34.4%), and multiple organ failure (39.3%) were the main causes of death. Multivariate analyses showed that Acute Physiology and Chronic Health Evaluation (APACHE) II scores ≥ 12 [odds ratio (OR) = 7.160, 95% CI: 2.834-18.092, P < 0.001] and positive blood culture (OR = 13.520, 95% CI: 2.740-66.721, P = 0.001) on the day of diagnosis and model for end-stage liver disease (MELD) scores ≥ 28 (OR = 8.182, 95% CI: 1.884-35.527, P = 0.005) after the first week of treatment were independent predictors of mortality. CONCLUSION APACHE II scores on the day of diagnosis and MELD scores after the first week of anti-HBV therapy are feasible predictors of outcome in ACLF-HBV patients.

Gum Chewing in Patients with Subtotal Gastrectomy

The purpose of this study was to report the efficacy of gum chewing (GC) in gastric cancer patients who underwent D2 subtotal gastrectomy. Patients and Methods: 26 patients were enrolled in this study. 13 patients received GC after D2 subtotal gastrectomy (group A) and 13 did not (group B). All patients had received epidural pain control. The mean times to first bowel movement, orally feeding, passage of stools, and hospital discharge as well as cost of hospitalization were recorded. Results: Between the two groups, there were no significant differences with respect to preoperative clinical characteristics, stage and operative parameters. The times to first flatus and passage of stools and the hospital stay were shorter in group A. Also the cost of hospitalization was lower in group A, but there were no significant differences. Conclusion: Although GC is a safe, non-expansive and physiologic method, this study suggests that there is no significant improvement of postoperative bowel motility of gastric cancer patients who underwent D2 gastrectomy. This implies that the cephalic-vagal reflex plays a major role in sham feeding.

Primary Malignant Mesothelioma of the Greater Omentum: Report of a Case

We report a rare case of primary malignant mesothelioma of the greater omentum. To our knowledge, only one other such case has been described in the English literature. The patient was a 61-year-old Taiwanese woman without any history of exposure to asbestos, who presented with lower back pain. Abdominal sonography and computed tomography showed a 12 × 9 × 9-cm3 mass occupying the lower abdomen. Laparotomy revealed a tumor in the greater omentum, invading the posterior wall of the uterus, without diffuse mesenteric thickening or multiple small nodules in the peritoneum. We performed en bloc resection of the mass, which involved omentectomy, hysterectomy, and bilateral salpingo-oophorectomy. Microscopically, the tumor cells were arranged in a tubulopapillary pattern lined by a single layer of uniform, cuboidal cells. A pattern of sclerotic stroma with irregular glandular elements was also recognized. Immunohistochemically, the tumor cells showed strong positivity for calretinin. The final pathologic diagnosis was malignant mesothelioma. The patient did not receive chemotherapy or radiotherapy, and has remained in good health without any evidence of recurrence for almost 3 years since her operation.

Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy.

AIM To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery. METHODS Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth II (BII) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression. RESULTS Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semi-liquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BII reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BIIgroup vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BII group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BII group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001). CONCLUSION This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.

Transarterial chemoembolization for intrahepatic multiple recurrent HCC after liver resection or transplantation

BACKGROUND Transarterial chemoembolization (TACE) can reduce tumor progression and help achieve good locoregional effect in hepatocellular carcinoma (HCC) patients with intrahepatic multiple recurrence (IHMR) after liver resection (LR). The effect of TACE on HCC patients with IHMR after liver transplantation (LT) remains unclear. The purpose of this study was to investigate the effect of TACE on IHMR after LR or LT. MATERIAL AND METHODS This hospital-based retrospective study included 968 and 180 HCC patients who had undergone LR or LT, respectively, in the past decade. Parameters included clinical characteristics, alpha-fetoprotein level, Child classification, tumor stage at first treatment, tumor size at recurrence, and recurrence and survival status. The groups were compared using the t test or chi-square test, and univariate and multivariate analyses were performed. Survival and recurrence were analyzed by the Kaplan-Meier method. Differences were significant at P<0.05. RESULTS During follow-up, 112 patients had IHMR: 101 after LR and 11 after LT. Age, sex distribution, and HCV infection rate differed significantly between the LR and LR groups. All patients in the LT group who had recurrent HCC died within 3 years. The risk factors for death from tumor recurrence included a larger tumor size at recurrence, poor Child classification at recurrence, hyperbilirubinemia, hypoalbuminemia, and no TACE treatment. In Cox regression analysis, only vessel invasion, Child class C, and no TACE treatment were independent risk factors for death from tumor recurrence. CONCLUSIONS TACE is beneficial for treating IHMR in patients after LR or LT.