Objective To evaluate application of anterior approach combined with selective hepatic vein(s) occlusion in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for giant hepatocellular carcinoma (HCC) in right lobe. Method The clinical data of 9 patients underwent the ALPPS in the First Affiliated Hospital of Guangxi Medical University from January 2017 to September 2017 were retrospectively analyzed. Results Six cases underwent the complete ALPPS, 3 cases lost because it couldn’t match the standard for the second step. After the first step, The average increased volume of the future liver remnant (FLR) was 139.1 cm3 (46.4–291.6 cm3), and the average increased volume rate of FLR was 37.8% (15.1%–76.2%). The average blood loss was 356 mL (200–600 mL). In the second step, 4 cases underwent the right hemihepatectomy and 2 cases underwent the extend right hemihepatectomy, the average blood loss was 617 mL (300–1 400 mL). There was no bile fistula, liver failure, and death. Conclusions Preliminary results of limited cases in this study show that application of anterior approach combined with selective hepatic vein(s) occlusion is a safe and feasible strategy in ALPPS for giant HCC in right lobe. This strategy is conformity with the " no touch” principle of oncology surgery, and reduces blood loss and decreases complications. Long-term oncological result of ALPPS in HCC patients with cirrhosis is unknown.
ObjectiveTo summarize experiences of diagnosis and treatment of intraperitoneal mass after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in treatment of hepatocellular carcinoma (HCC).MethodThe clinicopathologic data of a 40 years old case of HCC with intraperitoneal mass after ALPPS in the First Affiliated Hospital of Guangxi Medical University were retrospectively analyzed.ResultsThe patient was admitted to this hospital because of abdominal pain and abdominal distension for 5 d. The intraperitoneal mass was found and its nature was not clear on year 1 after ALPPS on admission. After discussion of multidisciplinary team (MDT), the exploratory laparotomy and abdominal tumor resection were planned to perform. The intraperitoneal mass and appendix were removed, the resected tissues were diagnosed as chronic inflammation and retroperitoneal abscess caused by perforation of suppurative appendicitis, respectively. The anti-infection and symptomatic support treatment were strengthened to perform after operation, the patient discharged after recovery. The patient was followed up so far, the general condition was good, and there was no clinical recurrence.ConclusionsFor patient underwent ALPPS, regular follow-up should be paid attention to. If intraperitoneal mass is found and nature is not clear, MDT discussion should be performed so as to make a more reasonable treatment plan. After exclusion of contraindications, surgical treatment should be carried out to furthest benefit patients.
Objective To observe the expression levels of nuclear factor kappa B （NF-κB）， vascular endothelial growth factor （VEGF）， and CD31 in portal vein and surrounding tissues of rats during the formation process of cavernoustransformation of portal vein （CTPV）， and try to search the relationship between NF-κB， VEGF， and the angiogenesisof portal areas， as well as the significance and the role of NF-κB and VEGF in the formation process of CTPV. Methods One hundred and ten Sprague-Dawley （SD） rats were randomly （random number method） divided into sham operation group and model group. The partial constriction operations on portal vein were performed in model rats with a blunt 21Gcaliber to establish CTPV animal models （model group）， while the exploratory operations on portal vein， not constriction，were performed in rats of sham operation group. All specimens （portal vein and surrounding tissues） were fixed in formalinand made into paraffin blocks. Each specimen was tested by immunohistochemistry for the expressions of NF-κB， VEGF， and CD31， then optical density （OD） of NF-κB expression and the mean integral optical density （IOD） of VEGF expressionwere measured by using Image Pro Plus 6.0 software， and microvessel density （MVD） was calculated under microscope. Results Nucleoplasm ratio of OD value of NF-κB， mean IOD value of VEGF， and MVD value in 1， 2， 3， 4， and 6 weeks after operation didn’t significantly differed from that of before operation in sham operation group （P＞0.05）， but higher at all time points after operation in model group （P＜0.01）. Compared with sham operation group， nucleoplasm ratio of OD value of NF-κB， mean IOD value of VEGF， and MVD value were significantly higher in 1， 2， 3， 4， and 6 weeks after operation in model group （P＜0.01）. NF-κB and VEGF， NF-κB and MVD， VEGF and MVD were positively correlated with each other （r=0.654 6，P＜0.01；r=0.620 7， P＜0.01；r=0.636 9， P＜0.01） in model group. Conclusion NF-κB and VEGF may relate to the formation of CTPV， and may involve in the angiogenesis.
Objective To compare therapeutic effects of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and transcatheter arterial chemoembolization (TACE) on patients with advanced hepatocellular carcinoma. Methods Thirty-five patients with advanced hepatocellular carcinoma admitted in the Department of Hepatobiliary and Pancreatic Surgery of Shiyan Taihe Hospital Affiliated to Hubei University of Medicine from August 1, 2014 to August 1, 2015 were randomly divided into ALPPS group and TACE group, in which 17 cases treated by the ALPPS and 18 cases treated by the TACE. The survival, changes of liver function and life quality, postoperative complications and mortality were compared in these two groups. The follow-up was performed by the telephone and the outpatient. Results ① The baselines such as the age, gender, diameter of tumor, complications had no significant differences in these two groups (P>0.05). ② The changes of liver function and life quality after operation in the ALPPS group were significantly better than those in the TACE group (P<0.05). ③ The complications after operation were observed in 5 cases (there were 2 cases of bile leakage, 1 case of intraabdominal bleeding, 1 case of peritoneal effusion, and 1 case of pulmonary infection) in the ALPPS group, which in 13 cases (there were 6 cases of nausea and vomiting, 4 cases of liver function damage, 2 cases of granulocytopenia, 1 case of fever) in the TACE group. The rate of the overall complications in the ALPPS group was significantly lower than that in the TACE group (5/17versus 13/18, P=0.018). ④ The overall survival in the the ALPPS group was significantly better than that in the TACE group (P=0.024). During follow-up period, the deaths happened in 3 cases duo to hepatocellular carcinoma and 1 case duo to traffic accident, 1 case was lost on month 8, 12 cases were still alive in the ALPPS group; the deaths happened in 10 cases duo to hepatocellular carcinoma, 1 case duo to coronary disease, and 1 case duo to cerebral infarction, 6 cases were still alive in the TACE group. Conclusion Preliminary results of limited cases in this study show that ALPPS has a better effect than TACE on patients with advanced hepatocellular carcinoma.
ObjectiveTo evaluate the clinical value of color Doppler ultrasound in diagnosing prehepatic portal hypertension. MethodsA retrospective analysis was performed to analyze the results of color Doppler ultrasonography in 9 patients with prehepatic portal hypertension diagnosed between June 2012 and January 2015, including vessel diameter, shape, nature and direction of blood flow, and fistula blood flow spectrum. ResultsAmong the 9 patients, the color Doppler ultrasound found 3 patients with regional portal widened, increased and faster blood flow with the emergence of low-impedance spectrum artery, splenic vein widened with returning blocked and flocculent substance within the splenic vein lumen, irregular or streak-shaped low weak echo during splenic vein reduction, and unstable or weakened blood flow velocity. Two patients were confirmed with splenic vein thrombosis by ultrasound and other imaging methods with significantly reduced blood in splenic vein. For the other four patients with regional portal hypertension, obvious abnormalities in portal system were not detected by color Doppler ultrasound, but they were checked with other methods. The ultrasound positive diagnosis of the 9 patients was 5, with 4 missed. ConclusionThe color Doppler ultrasound has some values in screening, diagnosis and follow-up of prehepatic portal hypertension, but it can also be influenced by many factors with a high missed diagnosis rate. Carefully observing the portal system lumen structure, internal echo and blood flow combined with other imaging studies, and emphasizing clinical history of the patients can further improve diagnostic accuracy.
ObjectiveTo explore it's advantages and disadvantages through analyzed the data of associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) operation in 3 cases of liver cancer patients with cirrhosis. MethodsThe data of 3 patients perfomed ALPPS operation were retrospectively analyzed, through the preoperative evaluation, intraoperative and postoperative treatment points analyzed to explore the pros and cons. ResultsOne case died of hepatic failure, and the remaining two cases were still alive. The highest score of MELD of liver failure in death case was 18.8 scores, and the other cases of MELD score were decreased after second operation. The average increased volume of liver was 225 mL, and the liver volume was significantly increased (P=0.002). ConclusionsALPPS make a portion of huge liver cancer patients combining with cirrhosis having a chance to surgery. But it is necessary to consider in patients with preoperative state, surgical risk, prognosis and economic conditions,in order to determine whether patients can benefit from ALPPS.
Objective To review the advancement of surgical therapy for cavernous transformation of portal vein. Methods The relevant literatures on therapy for cavernous transformation of portal vein in recent years were collected and reviewed. Results The main symptoms of the patients are repeated haematemesis and hemafecia, hypersplenotrophy and hypersplenia. Most cases can be detected by ultrasonography or portal venography. Splenectomy and by-pass technique plus disconnection are the preferred operation. Conclusion Therapy for cavernous transformation of portal vein will be further developed.
ObjectiveTo investigate the expression of Lgr5 protein in regeneration tissue of remnant liver after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and its significance.MethodsA total of 120 male SD rats (200–240 g) were randomly equally divided into sham operation (SO) group, portal vein ligation (PVL) group, and ALPPS group using random number table method. The liver regeneration rate (LRR), liver function (AST and ALT), and the expressions of Ki-67 and Lgr5 in the right middle lobe of the liver were observed at day 1, 2, 4, and 7 after surgery.ResultsCompared with SO group, the LRRs and the Ki-67 protein expression positive rates and Lgr5 related protein expression levels in the right middle lobe of liver tissue were increased in the PVL group and ALPPS group at day 1, 2, and 4 after surgery (P<0.05), and the LRR was still increased at day 7 after surgery (P<0.05). The LRRs at day 4 and 7 after surgery in the ALPPS group were higher than those in the PVL group (P<0.05), the Ki-67 protein expression positive rates and Lgr5 related protein expression levels at day 2 and 4 after surgery in the ALPPS group were higher than those in the PVL group (P<0.05). The AST and ALT levels at day 1 and 2 after surgery in the ALPPS group and PVL group were higher than those in the SO group (P<0.05), which at day 1 after surgery in the ALPPS group were higher than those in the PVL group (P<0.05), but which returned to normal on day 4 after surgery.ConclusionsALPPS could promote liver regeneration better. Lgr5 is closely related to liver regeneration after ALPPS. Liver stem cells might be involved in liver regeneration after ALPPS.
ObjectiveTo investigate the role of endoplasmic reticulum stress in liver regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).MethodsSeventy-two C57bl/6 mice were randomly divided into ALPPS group, portal vein ligation group (PVL group), and sham operation group (Sham group), 24 mice in each group. And then one-stage ALPPS operation, simple PVL, and sham operation will be performed. Six mice were randomized selected of the three groups on the 1st, 2nd, 4th, and 7th day after surgery, respectively, the liver weight to body weight ratio (FLR/BW) of each group was measured, and the liver tissues were taken for immunohistochemical staining to calculate the proportion of Ki-67 positive cells, Western blot was used to detect the expression levels of X-box binding protein 1 (XBP1) and inositol-requiring enzyme 1α (IRE1α) proteins.Results① FLR/BW: On the 4th day and the 7th day after operation, the FLR/BW of the Sham group, PVL group, and ALPPS group increased in sequence at the same time, and the difference between the three groups was statistically significant (P<0.05). ② Ki-67 positive cell ratio: On the 2nd day after operation, the ratio of Ki-67 positive cells in the Sham group, PVL group, and ALPPS group increased sequentially, and the difference between the two groups was statistically significant (P<0.05). On the 4th day after operation, the ratio of Ki-67 positive cells in the PVL group and the ALPPS group were still higher than that of the Sham group (P<0.05). ③ Expression levels of XBP1 and IRE1α: On the 2nd and 4th postoperative day, the expression levels of XBP1 and IRE1α in the ALPPS group were higher than those in the Sham group and the PVL group (P<0.05). On the 7th day after surgery, the expression levels of XBP1 and IRE1α in the ALPPS group were higher than those in the Sham group (P<0.05), while compared with the PVL group, the expression level of XBP1 in the ALPPS group was still higher (P<0.05).ConclusionsALPPS-induced liver regeneration is more advantageous than traditional PVL in mice. It may be attributed to the obvious endoplasmic reticulum stress activation after ALPPS leading to the up-regulation of IRE1α-XBP1 expression, which is involved in the regulation of hepatocyte cell cycle and promotes hepatocyte proliferation, thus promoting rapid liver regeneration.
ObjectiveTo summarize the pathogenesis, epidemiology, and risk factors of portal vein thrombosis after splenectomy, and combined with the latest advances in clinical prevention, diagnosis, and treatment of portal vein thrombosis after splenectomy, so as to provide some references for clinical prevention and treatment in the future.MethodLiteratures on portal vein thrombosis after splenectomy were collected and reviewed.ResultsThe incidence of portal vein thrombosis after splenectomy was high and its occurrence was the result of multiple factors. It was mainly related to the change of splenic venous blood flow mechanics after splenectomy. In terms of diagnosis, enhanced CT scan was the first choice. Currently, there was no consensus on treatment options, which mainly focused on individualized treatment and emphasized that preventive anticoagulant use of low-molecular-weight heparin may reduce the risk of portal vein thrombosis.ConclusionThe concept of tertiary prevention of portal vein thrombosis after splenectomy should be established, and individualized treatment should be adopted in combination with the patient’s condition.