Wei-Dong Duan

Robotic-assisted laparoscopic anatomic hepatectomy in China: initial experience.

OBJECTIVE To assess the feasibility and safety of robotic-assisted laparoscopic anatomic hepatectomy. BACKGROUND The development of minimally invasive surgery has led to an increase in the use of laparoscopic hepatectomy. However, laparoscopic hepatectomy remains technically challenging and is not widely developed. Robotic surgery represents a recent evolution in minimally invasive surgery that is being used increasingly for complex minimally invasive surgical procedures. Herein, we report our initial experience with robotic-assisted laparoscopic anatomic hepatectomy in 13 consecutive patients. PATIENTS AND METHODS Between April and July 2009, 13 consecutive patients underwent robotic-assisted laparoscopic anatomic hepatectomies for benign and malignant hepatic diseases. Major hepatectomies were performed in 9 patients, left lateral sectionectomies in 4 patients. Eight major hepatectomies were for malignant diseases and 5 hepatectomies (1 left hepatectomy and 4 left lateral sectionectomies) were for benign diseases. All the robotic-assisted hepatectomy procedures were performed anatomically with hilum dissection. Prior to starting the parenchymal transaction, vascular control of the portal vessels was carried out whenever possible. These robotic-assisted laparoscopic anatomic hepatectomies were compared with 20 traditional laparoscopic hepatectomies and 32 open resections that were contemporaneous and cohort-matched. RESULTS All 13 robotic-assisted laparoscopic anatomic hepatectomies were performed successfully in the manner of pure laparoscopic resection. No conversion to laparotomy or hand-assisted laparoscopic resection occurred. Despite its longer operative time (338 minutes) and higher hospital cost (

Poor prognosis for hepatocellular carcinoma with transarterial chemoembolization pre-transplantation: Retrospective analysis

12,046), robotic liver surgery compared favorably with traditional laparoscopic hepatectomy and open resection in blood loss (280 vs. 350, 470 mL), transfusion requirement (0 vs. 3 of 20, 4 of 32), use of the Pringle maneuver (0 vs. 3 of 20, 6 of 32) and overall operative complications (7.8% vs. 10%,12.5%). Neither ascites nor transient hepatic decompensation occurred in the robotic group. The surgical margins in all 8 patients with malignant lesions were negative and as yet, no intrahepatic recurrences or metastases have been observed in the robotic group. The mean postoperative stay was shorter with the traditional laparoscopic procedure (5.2 days) than with robotic (6.7 days)or open surgery (9.6 days). Conversions from traditional laparoscopic to open and hand-assisted laparoscopic resection occurred in 2 patients (10.0%) who underwent right hemihepatectomy and left hepatectomy, respectively. CONCLUSIONS These preliminary results show that robotic-assisted laparoscopic anatomic hepatectomy is safe and feasible with a much lower complication and conversion rate than traditional laparoscopic hepatectomy or open resection. The robotic surgical system may broaden the indications for laparoscopic hepatactomy, and it enabled the surgeon to perform precise laparoscopic liver resection which required hylum dissection, hepatocaval dissection, endoscopic suturing, and microanastamosis. However, more long-term, evidence-based outcomes will be necessary to prove its efficacy, and further research on its cost-effectiveness is still required.

Aggressive hepatectomy for the curative treatment of bilobar involvement of type IV-A bile duct cyst.

AIM To investigate whether transarterial chemoembolization (TACE) before liver transplantation (LT) improves long-term survival in hepatocellular carcinoma (HCC) patients. METHODS A retrospective study was conducted among 204 patients with HCC who received LT from January 2002 to December 2010 in PLA General Hospital. Among them, 88 patients received TACE before LT. Prognostic factors of serum α-fetoprotein (AFP), intraoperative blood loss, intraoperative blood transfusion, disease-free survival time, survival time with tumor, number of tumor nodules, tumor size, tumor number, presence of blood vessels and bile duct invasion, lymph node metastasis, degree of tumor differentiation, and preoperative liver function were determined in accordance with the Child-Turcotte-Pugh (Child) classification and model for end-stage liver disease. We also determined time of TACE before transplant surgery and tumor recurrence and metastasis according to different organs. Cumulative survival rate and disease-free survival rate curves were prepared using the Kaplan-Meier method, and the log-rank and χ(2) tests were used for comparisons. RESULTS In patients with and without TACE before LT, the 1, 3 and 5-year cumulative survival rate was 70.5% ± 4.9% vs 91.4% ± 2.6%, 53.3% ± 6.0% vs 83.1% ± 3.9%, and 46.2% ± 7.0% vs 80.8% ± 4.5%, respectively. The median survival time of patients with and without TACE was 51.857 ± 5.042 mo vs 80.930 ± 3.308 mo (χ(2) = 22.547, P < 0.001, P < 0.05). The 1, 3 and 5-year disease-free survival rates for patients with and without TACE before LT were 62.3% ± 5.2% vs 98.9% ± 3.0%, 48.7% ± 6.7% vs 82.1% ± 4.1%, and 48.7% ± 6.7% vs 82.1% ± 4.1%, respectively. The median survival time of patients with and without TACE before LT was 50.386 ± 4.901 mo vs 80.281 ± 3.216 mo (χ(2) = 22.063, P < 0.001, P < 0.05). TACE before LT can easily lead to pulmonary or distant metastasis of the primary tumor. Although there was no significant difference between the two groups, the chance of metastasis of the primary tumor in the group with TACE was significantly higher than that of the group without TACE. CONCLUSION TACE pre-LT for HCC patients increased the chances of pulmonary or distant metastasis of the primary tumor, thus reducing the long-term survival rate.

Graft cholangiopathy: etiology, diagnosis, and therapeutic strategies.

Objective:To analyze the risk and benefit of aggressive hepatectomy for the curative treatment of bilobar bile duct cysts (BDCs) of type IV-A. Background:Conventional surgical treatment of bilobar BDCs of type IV-A is extrahepatic cyst excision, followed by biliodigestive anastomosis. The role of hepatectomy in the treatment of bilobar BDCs remains unclear. Methods:Between January 2006 and December 2011, a total of 28 patients with bilobar BDCs who underwent an aggressive hepatectomy were identified from a prospective database. Perioperative and long-term outcomes in these patients were compared with 18 patients with bilobar BDCs who received conventional surgical treatment. Results:Patient characteristics such as age, sex, and clinical presentation were similar in both groups. Cystic dilatation of bile ducts was curatively resected in all 28 patients undergoing aggressive hepatectomy. Postoperative morbidity (57.1% vs 22.2%, P = 0.020), but not mortality (3.6% vs 0%, P = 1.000), in patients who underwent aggressive hepatectomy was significantly increased when compared with those who received conventional surgical treatment. Clearance rate of intrahepatic stones was significantly higher after aggressive hepatectomy than that after conventional surgical treatment (100.0% vs 45.5%, P < 0.001). Twenty-seven of 28 patients (96.4%), except 1 patient who met in-hospital death, achieved a symptom-free status after aggressive hepatectomy during a mean follow-up of 31 months. In contrast, during a mean follow-up of 37 months, 7 patients (38.9%, 7/18) remained free of biliary symptoms after conventional surgical treatment. The long-term outcomes between aggressive hepatectomy and conventional surgical treatment were significantly different (P < 0.001). In addition, no malignant transformation occurred after aggressive hepatectomy. However, intrahepatic cholangiocarcinoma has developed in the remnant BDC in 2 of 18 patients (11.1%) receiving conventional surgical treatment during follow-up. Conclusions:Aggressive hepatectomy, a challenging procedure, provides an efficient treatment option for some selected patients with bilobar BDCs of type IV-A. The role of aggressive hepatectomy in the curative treatment of bilobar BDCs of type IV-A should be paid particular attention in the future.

Efficacy of liver transplantation for acute hepatic failure: a single-center experience

BACKGROUND Graft cholangiopathy has been recognized as a significant cause of morbidity, graft loss, and even mortality in patients after orthotopic liver transplantation. The aim of this review is to analyze the etiology, pathogenesis, diagnosis and therapeutic strategies of graft cholangiopathy after liver transplantation. DATA SOURCE A PubMed database search was performed to identify articles relevant to liver transplantation, biliary complications and cholangiopathy. RESULTS Several risk factors for graft cholangiopathy after liver transplantation have been identified, including ischemia/reperfusion injury, cytomegalovirus infection, immunological injury and bile salt toxicity. A number of strategies have been attempted to prevent the development of graft cholangiopathy, but their efficacy needs to be evaluated in large clinical studies. Non-surgical approaches may offer good results in patients with extrahepatic lesions. For most patients with complex hilar and intrahepatic biliary abnormalities, however, surgical repair or re-transplantation may be required. CONCLUSIONS The pathogenesis of graft cholangiopathy after liver transplantation is multifactorial. In the future, more efforts should be devoted to the development of more effective preventative and therapeutic strategies against graft cholangiopathy.

Traditional surgical planning of liver surgery is modified by 3D interactive quantitative surgical planning approach: a single-center experience with 305 patients

BACKGROUND Acute hepatic failure (AHF) is a devastating clinical syndrome with a high mortality rate. The outcome of AHF varies with etiology, but liver transplantation (LT) can significantly improve the prognosis and survival rate of such patients. This study aimed to detect the role of LT and artificial liver support systems (ALSS) for AHF patients and to analyze the etiology and outcome of patients with this disease. METHODS A retrospective analysis was made of 48 consecutive patients with AHF who fulfilled the Kings College Criteria for LT at our center. We analyzed and compared the etiology, outcome, prognosis, and survival rates of patients between the transplantation (LT) group and the non-transplantation (N-LT) group. RESULTS AHF was due to viral hepatitis in 25 patients (52.1%; hepatitis B virus in 22), drug or toxic reactions in 14 (29.2%; acetaminophen in 6), Wilson disease in 4 (8.3%), unknown reasons in 3 (6.3%), and miscellaneous conditions in 2 (4.2%). In the LT group, 36 patients (7 underwent living donor LT, and 29 cadaveric LT) had an average model for end-stage liver disease score (MELD) of 35.7. Twenty-eight patients survived with good graft function after a follow-up of 27.3+/-4.5 months. During the waiting time, 6 patients were treated with ALSS and 2 of them died during hospitalization. The 30-day, 12-month, and 18-month survival rates were 77.8%, 72.2%, and 66.7%, respectively. In the N-LT group, 12 patients had an average MELD score of 34.5. Four patients were treated with ALSS and all died during hospitalization. The 90-day and 1-year survival rates were only 16.7% and 8.3%, respectively. CONCLUSIONS Hepatitis is the most prominent cause of AHF at our center. Most patients with AHF, who fulfill the Kings College Criteria for LT, did not survive longer without LT. ALSS did not improve the prognosis of AHF patients, but may extend the waiting time for a donor. Currently, LT is still the most effective way to improve the prognosis of AHF patients.

Outcomes of liver transplantation for end-stage biliary disease: A comparative study with end-stage liver disease

BACKGROUND Decision making and surgical planning are to achieve the precise balance of maximal removal of target lesion, maximal sparing of functional liver remnant volume, and minimal surgical invasiveness and therefore, crucial in liver surgery. The aim of this prospective study was to validate the accuracy and predictability of 3D interactive quantitative surgical planning approach (IQSP), and to evaluate the impact of IQSP on traditional surgical plans based on 2D images. METHODS A total of 305 consecutive patients undergoing hepatectomy were included in this study. Surgical plans were created by traditional 2D approach using picture archiving and communication system (PACS) and 3D approach using IQSP respectively by two groups of physicians who did not know the surgical plans of the other group. The two surgical plans were submitted to the chief surgeon for selection before operation. The specimens were weighed. The two surgical plans were compared and analyzed retrospectively based on the operation results. RESULTS The two surgical plans were successfully developed in all 305 patients and all the 3D IQSP surgical plans were selected as the final decision. Total 278 patients successfully underwent surgery, including 147 uncomplex hepatectomy and 131 complex hepatectomy. Twenty-seven patients were withdrawn from hepatectomy. In the uncomplex group, the two surgical plans were the same in all 147 patients and no statistically significant difference was found among 2D calculated resection volume (2D-RV), 3D IQSP calculated resection volume (IQSP-RV) and the specimen volume. In the complex group, the two surgical plans were different in 49 patients (49/131, 37.4%). According to the significance of differences, the 49 different patients were classified into three grades. No statistically significant difference was found between IQSP-RV and specimen volume. The coincidence rate of territory analysis of IQSP with operation was 92.1% (93/101) for 101 patients of anatomic hepatectomy. CONCLUSIONS The accuracy and predictability of 3D IQSP were validated. Compared with traditional surgical planning, 3D IQSP can provide more quantitative information of anatomic structure. With the assistance of 3D IQSP, traditional surgical plans were modified to be more radical and safe.

Delayed introduction of immunosuppressive regimens in critically ill patients after liver transplantation

AIM To evaluate the outcomes of patients with end-stage biliary disease (ESBD) who underwent liver transplantation, to define the concept of ESBD, the criteria for patient selection and the optimal operation for decision-making. METHODS Between June 2002 and June 2014, 43 patients with ESBD from two Chinese organ transplantation centres were evaluated for liver transplantation. The causes of liver disease were primary biliary cirrhosis (n = 8), cholelithiasis (n = 8), congenital biliary atresia (n = 2), graft-related cholangiopathy (n = 18), Carolis disease (n = 2), iatrogenic bile duct injury (n = 2), primary sclerosing cholangitis (n = 1), intrahepatic bile duct paucity (n = 1) and Alagilles syndrome (n = 1). The patients with ESBD were compared with an end-stage liver disease (ESLD) case control group during the same period, and the potential prognostic values of multiple demographic and clinical variables were assessed. The examined variables included recipient age, sex, pre-transplant clinical status, pre-transplant laboratory values, operation condition and postoperative complications, as well as patient and allograft survival rates. Survival analysis was performed using Kaplan-Meier curves, and the rates were compared using log-rank tests. All variables identified by univariate analysis with P values < 0.100 were subjected to multivariate analysis. A Cox proportional hazard regression model was used to determine the effect of the study variables on outcomes in the study group. RESULTS Patients in the ESBD group had lower model for end-stage liver disease (MELD)/paediatric end-stage liver disease (PELD) scores and a higher frequency of previous abdominal surgery compared to patients in the ESLD group (19.2 ± 6.6 vs 22.0 ± 6.5, P = 0.023 and 1.8 ± 1.3 vs 0.1 ± 0.2, P = 0.000). Moreover, the operation time and the time spent in intensive care were significantly higher in the ESBD group than in the ESLD group (527.4 ± 98.8 vs 443.0 ± 101.0, P = 0.000, and 12.74 ± 6.6 vs 10.0 ± 7.5, P = 0.000). The patient survival rate in the ESBD group was not significantly different from that of the ESBD group at 1, 3 and 5 years (ESBD: 90.7%, 88.4%, 79.4% vs ESLD: 84.9%, 80.92%, 79.0%, χ(2) = 0.194, P = 0.660). The graft-survival rates were also similar between the two groups at 1, 3 and 5 years (ESBD: 90.7%, 85.2%, 72.7% vs ESLD: 84.9%, 81.0%, 77.5%, χ(2) = 0.003, P = 0.958). Univariate analysis identified MELD/PELD score (HR = 1.213, 95%CI: 1.081-1.362, P = 0.001) and bleeding volume (HR = 0.103, 95%CI: 0.020-0.538, P = 0.007) as significant factors affecting the outcomes of patients in the ESBD group. However, multivariate analysis revealed that MELD/PELD score (HR = 1.132, 95%CI: 1.005-1.275, P = 0.041) was the only negative factor that was associated with short survival time. CONCLUSION MELD/PELD criteria do not adequately measure the clinical characteristics and staging of ESBD. The allocation system based on MELD/PELD criteria should be re-evaluated for patients with ESBD.

An Innovative Surgical Management of Complicated Bile Duct Variant in Emergency Living Donor Adult Liver Transplantation: Initial Experience

BACKGROUND The manipulation of immunosuppression therapy remains challenging in patients who develop infectious diseases or multiple organ dysfunction after liver transplantation. We evaluated the outcomes of delayed introduction of immunosuppression in the patients after liver transplantation under immune monitoring with ImmuKnow assay. METHODS From March 2009 to February 2014, 225 consecutive liver recipients in our institute were included. The delayed administration of immunosuppressive regimens was attempted in 11 liver recipients with multiple severe comorbidities. RESULTS The median duration of non-immunosuppression was 12 days (range 5-58). Due to the infectious complications, the serial ImmuKnow assay showed a significantly low ATP level of 64±35 ng/mL in the early period after transplantation. With the development of comorbidities, the ImmuKnow value significantly increased. However, the acute allograft rejection developed when a continuous distinct elevation of both ATP and glutamyltranspeptidase levels was detected. The average ATP level measured just before the development of acute rejection was 271±115 ng/mL. CONCLUSIONS The delayed introduction of immunosuppressive regimens is safe and effective in management of critically ill patients after liver transplantation. The serial ImmuKnow assay could provide a reliable depiction of the dynamics of functional immunity throughout the clinical course of a given patient.

Precision in Liver Surgery

Background: The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the dile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high MELD score patients. Methods: The common hepatic duct (CHD) and the LHD of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed. Results: Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (Four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up, significant differences (P<0.05) were found when two stages were compared. Conclusions: Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant RHDs in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.