Vijay G. Menon

Hepaticojejunostomy Using Short-Limb Roux-en-Y Reconstruction

IMPORTANCE When performing biliary reconstruction, one of the long-standing tenets of surgery is that Roux-en-Y (RY) reconstruction should use a long hepatic limb to decrease the risk for postoperative cholangitis. However, this practice is not well supported and may also make postoperative biliary endoscopy difficult. While some authors recommend Roux limbs of up to 75 cm, we have routinely used a Roux length of 20 cm to facilitate possible postoperative endoscopic access. OBJECTIVE To review our experience with short-limb RY hepaticojejunostomy (HJ) and examine the short-term and long-term outcomes following this procedure, as well as the success of future biliary interventions. DESIGN Retrospective medical record review of all patients who underwent short-limb RYHJ by 2 surgeons (N.N.N. and S.D.C.). SETTING Tertiary care, university-affiliated teaching hospital. PARTICIPANTS One hundred patients who underwent RYHJ were identified, with 30 of those patients being excluded owing to creation of an RYHJ to intrahepatic bile ducts with concomitant liver resection. MAIN OUTCOMES AND MEASURES Patient records were reviewed to determine the incidence of postoperative cholangitis and biliary stricture. Secondary outcomes were the need for postoperative biliary endoscopy and success rates for endoscopic biliary interventions. RESULTS Seventy patients underwent short-limb RYHJ over an 11-year period (2001-2012). Indications included benign stricture (n = 18), malignant stricture (n = 12), choledochal cyst (n = 5), choledocholithiasis (n = 3), idiopathic cholangitis (n = 2), and deceased donor or live donor liver transplant (n = 30). Seven patients, including 4 liver transplant patients, developed clinical or radiographic evidence of postoperative biliary stricture, and all patients underwent successful endoscopic cholangiography. Four of these patients required dilation and/or stone extraction, which were accomplished endoscopically in all cases. CONCLUSIONS AND RELEVANCE Short-limb RYHJ is safe and associated with a low incidence of postoperative complications. In addition, biliary intervention, when indicated, can be performed endoscopically with a high degree of success. In the absence of any evidence demonstrating longer limbs to be superior, we recommend using short-limb RY reconstruction for HJ.

Recurrent hepatocellular carcinoma after liver transplant: identifying the high-risk patient.

BACKGROUND Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is rarely curable. However, in view of the advent of new treatments, it is critical that patients at high risk for recurrence are identified. METHODS Patients undergoing LT for HCC at a single centre between 2002 and 2010 were reviewed and data on clinical parameters and explant pathology were analysed to determine factors associated with HCC recurrence. All necrotic and viable tumour nodules were included in explant staging. All patients underwent LT according to the United Network for Organ Sharing (UNOS) Model for End-stage Liver Disease (MELD) tumour exception policies. RESULTS Liver transplantation was performed in 122 patients with HCC during this period. Rates of recurrence-free survival in the entire cohort at 1 year and 3 years were 95% and 89%, respectively. Thirteen patients developed HCC recurrence at a median of 14 months post-LT. In univariate analysis the factors associated with HCC recurrence were bilobar tumours, vascular invasion, and stage exceeding either Milan or University of California San Francisco (UCSF) Criteria. Multivariate analysis showed pathology outside UCSF Criteria was the major predictor of recurrence; when pathology outside UCSF Criteria was found in combination with vascular invasion, the predicted 3-year recurrence-free survival was only 26%. CONCLUSIONS Explant pathology can be used to predict the risk for recurrent HCC after LT, which may allow for improved adjuvant and management strategies.

Universal multifunctional HD video system for minimally invasive open and microsurgery

BackgroundLaparoscopy has familiarized most surgeons with the benefits of a surgical video system, including the ability to magnify fine structures, to display the operative field on a monitor for improved intraoperative communication, and to capture video footage for documentation and education. Use of intraoperative video systems during open surgery is far less common and the potential benefits of this have not been well explored. In this report we describe a simple video system that is applicable to both laparoscopic and open surgery.MethodsWe employed a standard laparoscopic HD camera (1080p) and telescope for initial laparoscopy. In cases requiring laparotomy, a mechanical arm is attached to the operating table and the camera is mounted without the telescope; this provides video display of the open surgical field. In cases requiring dissection or anastomosis of minute structures, a prototype telescope made for open cases is attached to the same camera; this provides improved magnification and illumination for the surgeon. Microsurgical components can then proceed with the surgeon working off the video monitor at a more convenient posture and with the benefits of video display.ResultsThis multifunctional HD video system for open abdominal surgery has been utilized in 98 complex hepatopancreaticobiliary surgeries. Clear benefits include (1) improved intraoperative communication, (2) improved teaching of bystanders, (3) improved visualization of minute structures, and (4) improved capture and utilization of surgical video and images for education. In an analysis of patients who underwent pancreaticoduodenectomy (PD) with this system, there was a trend toward fewer pancreatic leaks and shorter length of stay but slightly longer operative time compared to PD prior to implementation of this system.ConclusionsThis system can be employed with little added cost over a standard laparoscopy setup and has the potential to be widely utilized in surgical education programs.

Video-microscopy for use in microsurgical aspects of complex hepatobiliary and pancreatic surgery: a preliminary report

BACKGROUND The use of loupe magnification during complex hepatobiliary and pancreatic (HBP) surgery has become routine. Unfortunately, loupe magnification has several disadvantages including limited magnification, a fixed field and non-variable magnification parameters. The aim of this report is to describe a simple system of video-microscopy for use in open surgery as an alternative to loupe magnification. METHODS In video-microscopy, the operative field is displayed on a TV monitor using a high-definition (HD) camera with a special optic mounted on an adjustable mechanical arm. The set-up and application of this system are described and illustrated using examples drawn from pancreaticoduodenectomy, bile duct repair and liver transplantation. RESULTS This system is easy to use and can provide variable magnification of ×4-12 at a camera distance of 25-35 cm from the operative field and a depth of field of 15 mm. This system allows the surgeon and assistant to work from a HD TV screen during critical phases of microsurgery. CONCLUSIONS The system described here provides better magnification than loupe lenses and thus may be beneficial during complex HPB procedures. Other benefits of this system include the fact that its use decreases neck strain and postural fatigue in the surgeon and it can be used as a tool for documentation and teaching.

Abstract 4686: MicroRNA mir-93 activates oncogenic c-Met/PI3K/Akt pathway targeting PTEN in hepatocellular carcinoma

Background; The incidence rate of hepatocellular cellular carcinoma (HCC) has been rapidly increasing globally; however, no effective systemic therapy has been established for advanced HCC after first line therapy with Sorafenib fails. Combining the immediate need for more effective therapy and emerging reports on epigenetic events in HCC, we aimed to identify specific micro RNA (miR) regulating oncogenic pathways in HCC to serve as potential therapeutic targets. Materials and Methods; We performed initial screening by miR array analysis in 6 HCC cell lines, as well as stage I-IV HCC paraffin-embedded archival tissue (PEAT) specimens (n=47) which were compared to normal livers and liver cirrhosis specimens (n=74). IHC staining analysis of c-Met and miRs expression by qRT-PCR were performed using cell lines and PEAT specimens. The effect on miR levels on recombinant HGF treatment of HCC cells was assessed. We performed functional miR assays by luciferase-vectors with 3′ untranslated sequences (3′UTR) targeted to specific miR binding regions transfected to HCC cells. c-Met/PI3K/Akt pathway analysis was examined using qRT-PCR and western blot analysis. Biological functional activities of miR in HCC were assessed using proliferation, migration, invasion, and 3D sphered colony assays. Chemosensitivity of HCC kinase inhibitors, Sorafenib and Tivantinib on HCC cell lines were examined using a cell viability assay. Results; We identified that miR-93 was expressed over 10-fold in HCC cell lines compared to normal liver cells via screening by miR array analysis. miR-93 expression was significantly upregulated in HCC PEAT specimens compared to normal and cirrhosis liver specimens (p=0.002). miR-93 expression was shown to have a significant correlation with IHC staining of c-Met protein in HCC PEAT. In vitro studies demonstrated that the HCC cells treated with recombinant HGF (50 μM; 24 hr) induced overexpression of miR-93. Focusing on miR-93 target genes, miR-93 was demonstrated to interfere with the PTEN expression through binding of specific 3′ UTR regions. miR-93 oncogenic effects were shown to regulate phosphorylation of Akt by suppressing PTEN. We demonstrated that miR-93 was silencing tumor-related pathway genes, whereby its function is controlling c-Met/PI3K/Akt signal transduction. It was confirmed that inhibiting miR-93 expression (anti-miR) would suppress proliferation, migration, and invasion of HCC cells. Anti-miR treatment of HCC cell lines significantly enhanced chemosensitivity against kinase inhibitors, Sorafenib (p=0.021) and Tivantinib (p Conclusion: Our results indicated that miR-93 is targeting PTEN involved in tumorigenesis of HCC through the oncogenic c-Met/PI3K/Akt pathway. We demonstrated that anti-miR-93 enhances chemosensitivity against Sorafenib and Tivantinib in HCC. miR-93 is a potential therapeutic target to mitigate chemosensitivity to kinase inhibitors in HCC. Note: This abstract was not presented at the meeting. Citation Format: Katsuya Ohta, Hiromitsu Hoshino, Keisuke Hata, Jinhua Wang, Sharon Huang, Vijay Menon, Steven Colquhoun, Dave S. B. Hoon. MicroRNA mir-93 activates oncogenic c-Met/PI3K/Akt pathway targeting PTEN in hepatocellular carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4686. doi:10.1158/1538-7445.AM2014-4686

Erratum to: Universal multifunctional HD video system for minimally invasive, open and microsurgery

The online version of the original article can be found under doi:10.1007/s00464-012-2552-5.N. N. Nissen (&) V. G. Menon S. D. ColquhounLiver Transplant and Hepatobiliary Surgery, Department ofSurgery, Cedars-Sinai Medical Center, 8635 W Third Street,Suite 590W, Los Angeles, CA 90048, USAe-mail: nicholas.nissen@cshs.orgJ. Williams G. BerciMinimally Invasive Surgery Research Division, Department ofSurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048,USA