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Introduction: To report our experience in palliative hepaticojejunostomy for advanced malignant biliary obstruction by means of robotic approach Methods: Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction was performed in nine patients from May 2009 to April 2014. Results: During the study period, robotic hepaticojejunostomy for advanced malignant biliary obstruction was completed successfully in nine patients. Roux-en-Y hepaticojejunostomy and double (hepaticojejunostomy, and gastrojejunostomy) bypass were performed in five and four patients, respectively. The mean operating time was 212.8 minutes. The mean blood loss was 38.7 mL. The overall complication rate was 22.2%. Bile leak complication occurred in one patient only. There was no procedure-related mortality. The mean postoperative hospital stay was 13.3 days. Five patients received palliative systemic chemotherapy after bypass surgery. The mean survival time was 11.1 months. During follow up, only three patients with cholangiocarcinoma had recurrent biliary obstruction after end-to-side hepaticojejunostomy due to tumor progression, and needed percutaneous transhepatic biliary drainage. Among these nine patients, there were a total of eight episodes of readmission in four patients due to tumor-related symptoms or complications. Conclusions: Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction had a low complication rate and was associated with an improved quality of life.

Objective: Based on a large series of histopathologically confirmed hepatic angiomyolipomas, we retrospectively studied the typical diagnostic features of hepatic angiomyolipoma and proposed a treatment strategy for this disease. Materials and methods: From December 1997 to December 2007, 74 consecutive patients who received definitive treatment for hepatic angiomyolipoma, at a single tertiary center, were studied. Results: There was a marked female predominance (54 females vs. 20 males) and the mean age was 42 years. Forty patients had no symptoms and the tumors were detected incidentally during a medical check-up. From this study, we proposed the typical diagnostic features of hepatic angiomyolipoma to be the absence of risk factors for malignancy, normal tumor marker levels, and typical imaging features on ultrasound (USG), abdominal contrast computed tomography (CT), or magnetic resonance imaging (MRI). Only 23% of patients could have been diagnosed before surgery using these features. One patient (1.4%) had a malignant angiomyolipoma, and died with distant metastases 14 months after surgery. After a median follow-up of 64 months, there was no recurrence in the other 73 patients. Conclusion: Patients with typical diagnostic features suggestive of hepatic angiomyolipoma could be observed with regular surveillance. Definitive treatment should be performed when the tumor has symptoms/complications, when the tumor is enlarging, or when a malignant lesion cannot be ruled out.

While hepatic resection or local ablative therapy may provide a potentially curative treatment for hepatocellular carcinoma (HCC), more than half of these patients develop recurrent HCC within 5 years after treatment. Thus identification of any therapy which can decrease or delay the incidence of recurrence will improve the results of treatment. However, no chemopreventive agent has been approved for HCC. Methods: A MEDLINE database, Embase, Cancerlit (National Cancer Institute), and CBM (Chinese Biomedical Database) search from 1990 to 2009 was performed to identify relevant articles using the keywords “hepatocellular carcinoma,” “vitamin analogue,” and “chemoprevention.” Additional papers were identified by a manual search of the references from the key articles. The fixed effect model was used for a meta-analysis. Results: Oral administration of acyclic retinoids (vitamin A analogue), and menatetrenone (vitamin K2 analogue) have been tested as chemopreventive agents after hepatic resection or local ablative therapy for HCC. There were one and four randomised, controlled trials (RCTs) which evaluated the efficacy of polyprenoic acid and menatetrenone, respectively. All studies were conducted in Japan. One RCT showed the preventive effect of polyprenoic acid in lowering the incidence of HCC recurrence after hepatic resection or percutaneous ethanol injection, and this effect lasted up to 199 weeks after randomization (or 151 weeks after completion of retinoid administration). Four RCTs evaluated the preventive efficacy of menatetrenone on HCC recurrence after hepatic resection or local ablative therapy. The results of three studies, as well as the meta-analysis of all four studies, showed significantly better tumour recurrencefree survival. The beneficial effect on the overall survival was less definite. Conclusion: There is evidence to suggest that chemopreventive therapy after partial hepatectomy or local ablative therapy is beneficial in prolonging disease-free survival, but the evidence is less for an effect on the overall survival. To confirm the beneficial role of vitamin A or K analogues in the chemoprevention of HCC further and larger randomised trials are now required.

Inflammatory myofibroblastic tumour (IMT) is a rare neoplasm. Generally, these lesions have a benign behaviour, but the possibility of malignant transformation exists. We report the rare case of a 43-year-old woman with metachronous IMTs in the spleen and the liver. The patient was treated with laparoscopic splenectomy and partial hepatectomy. The patient recovered uneventfully. This case emphasizes the difficulties in diagnosis and the possibility of a metachronous occurrence.

Choledochal cyst is a rare disease in adults. Excellent results have been achieved with proper management. However, malignancy complicating choledochal cyst still carries a dismal prognosis despite radical surgery. The aim of this study was to review the clinical course and operative results of the disease in adulthood, with emphasis on the occurrence of malignancy. Methods: A retrospective review of adult patients who underwent surgery for choledochal cysts in a 12-year period was performed. Results: Of the 25 adults, 80% were female and the median age was 30 years. A total of 32% of patients had previous drainage procedures for their choledochal cyst disease. Malignancy was noted in five patients (20%). There were significantly more males among the patients with malignancy than among those with benign disease (60% vs 10%), a greater number of older patients (median age, 39 vs 27 years) and more impaired liver function tests, but there was no difference in terms of incidence of previous drainage procedures between the two groups. There was no operative mortality; operative morbidity was 36%. No significant long-term complications were noted in the benign group but three of the five patients with malignancy died or developed recurrence within a few months after surgery. Conclusion: The prognosis for patients with malignancy complicating choledochal cyst remains poor despite aggressive radical surgery such as Whipple's operation or additional hepatectomy. Malignancy should be suspected in older and male patients who present with jaundice or impaired liver function tests. Total cyst excision and hepaticojejunostomy is an effective and safe treatment for patients with the common type I choledochal cyst in order to reduce the chance of subsequent development of malignancy.