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Anatomic location/size and number of lesions, inadequate volume of future liver remnant, or poor coexisting premorbid conditions preclude surgery in the majority of patients with hepatocellular carcinoma (HCC). Liver transplantation can cure some patients with poor liver function, but few patients are eligible because of scarcity of donors. Without specific anti-cancer treatment, the prognosis of HCC is poor. Various locoregional therapies are used to treat patients who are not candidates for surgery, and have emerged as tools for palliation, tumor down-staging, and bridging therapy prior to liver transplantation. Currently, local ablative therapy even competes with partial hepatectomy and liver transplantation as a primary treatment for small HCC. HCC is well suited to treatment with loco-regional therapy because it has a tendency to stay within the liver, with distant metastasis generally occurring late in the course of disease. This suggests that an effective local-regional therapy can have a great impact on HCC patients who are not candidates for surgical treatment. Loco-regional therapy can further be justified because patients with HCC usually die of liver failure consequent to intrahepatic growth resulting in liver tissue destruction, rather than extrahepatic metastases. Keywords: Hepatocellular carcinoma, Hepatectomy, Loco-regional therapy, TACE, Local ablation

Introduction: Ampullary adenocarcinoma (AAC) is a rare malignancy with great morphological heterogeneity, which complicates the prediction of survival and, therefore, clinical decision-making. The aim of this study was to develop and externally validate a prediction model for survival after resection of AAC. Materials and methods: An international multicenter cohort study was conducted, including patients who underwent pancreatoduodenectomy for AAC (2006–2017) from 27 centers in 10 countries spanning three continents. A derivation and validation cohort were separately collected. Predictors were selected from the derivation cohort using a LASSO Cox proportional hazards model. A nomogram was created based on shrunk coefficients. Model performance was assessed in the derivation cohort and subsequently in the validation cohort, by calibration plots and Uno's C-statistic. Four risk groups were created based on quartiles of the nomogram score. Results: Overall, 1007 patients were available for development of the model. Predictors in the final Cox model included age, resection margin, tumor differentiation, pathological T stage and N stage (8th AJCC edition). Internal cross-validation demonstrated a C-statistic of 0.75 (95% CI 0.73–0.77). External validation in a cohort of 462 patients demonstrated a C-statistic of 0.77 (95% CI 0.73–0.81). A nomogram for the prediction of 3- and 5-year survival was created. The four risk groups showed significantly different 5-year survival rates (81%, 57%, 22% and 14%, p < 0.001). Only in the very-high risk group was adjuvant chemotherapy associated with an improved overall survival. Conclusion: A prediction model for survival after curative resection of AAC was developed and externally validated. The model is easily available online via www.pancreascalculator.com.

Recent systematic review and meta-analyses showed laparoscopic hepatectomy for colorectal liver metastases is a beneficial alternative to open hepatectomy in selected patients, and it provides more favorable short-term outcomes such as less blood loss, lower blood transfusion rate, less overall morbidity, and shorter hospital stay. The introduction of robotic system may lower the hurdle for entry for practice into minimally invasive hepatectomy. The robotic surgical system is a sophisticated robotic platform designed to enable complex surgery in a minimally invasive approach. Well-known advantages of the robotic system included improved vision via 3-dimensional view, magnification, tremor suppression, and the dexterity of the instruments. Due to the current limited evidence, the oncological outcomes of robotic approach for colorectal liver metastasis are still unclear. Controlled trials are needed to compare the long-term oncological results after robot-assisted laparoscopic hepatectomy with those of open surgery or laparoscopic surgery.

Ampullary tumours are uncommon lesions with potential risk of malignancy. The management is excision by either endoscopic ampullectomy, pancreaticoduodenectomy or transduodenal excision. Endoscopic ampullectomy offers a less invasive approach, whereas pancreaticoduodenectomy allows radical excision of the tumour. They both carry their own limitations. Transduodenal excision of ampullary tumour offers significantly lower risks with low recurrence rate, and can be offered for benign or early grade tumours. Limited cases of laparoscopic transduodenal excision of ampullary tumours were reported in the literature, probably due to the technical difficulties in performing the operation, especially during the reconstruction of the pancreaticobiliary ducts with the laparoscopic approach. In the era with robotic surgical systems, the technical demanding procedures are greatly facilitated. Hence, we are writing to report a case of transduodenal excision of ampullary tumour with the robot assisted laparoscopic approach.

Introduction Right hepatectomy via the anterior approach without prior liver mobilization is an accepted technique and the liver hanging maneuver facilitates this procedure. Hepatic parenchymal transection remains a critical part of this operation during which excessive blood loss can occur. Control of blood loss is important in hepatectomy as excessive bleeding and blood transfusion are associated with increased postoperative morbidity/mortality rates and compromised long-term oncological outcomes in these patients. Methods A 5-steps stapling technique was developed to decrease blood loss during right hepatectomy using the anterior approach with the liver hanging maneuver. All consecutive patients who underwent elective right hepatectomy in our center using this technique from January 2014 to June 2015 were retrospectively studied. This study aimed to describe this technique and report the preliminary outcomes. Results Eleven patients with hepatitis B-related hepatocellular carcinoma (HCC) with cirrhosis underwent the 5-steps stapling technique for right hepatectomy using the anterior approach with the liver hanging maneuver. The mean blood loss, liver parenchymal transection time and operation time were 227.3 ± 91.4 ml (SD), 40.0 ± 7.8 min, and 261.8 ± 48.5 min, respectively. No patients developed postoperative bleeding or bile leak. There was no 90-day mortality. Conclusion The preliminary results of this 5-steps stapling technique for right hepatectomy using the liver hanging maneuver are encouraging as the technique resulted in little intraoperative blood loss and short operation time, and it caused no major complications and mortality.

Robotic partial hepatectomy has been advocated as an alternative to conventional laparoscopic partial hepatectomy, but studies supporting the efficacy or oncological outcomes of robotic partial hepatectomy are scarce in the last decade.This study compared the long-term oncological outcomes of robotic (n=100) and conventional laparoscopic hepatectomy (n=35) for hepatocellular carcinoma (HCC).Robotic group had a significant higher proportion of major hepatectomies (27% vs. 2.9%) and tumors located at or across posterosuperior segments (29% vs. 0%) than conventional laparoscopic group. For the perioperative outcomes, robotic group had a significant longer mean operation time (207.4 vs. 134.2 min). Both groups had similar blood loss (334.6 vs. 336 mL). There was no difference in morbidity (14% vs. 20%) and mortality rate (0% vs. 0%). Concerning oncological outcomes, there was no difference between 2 groups in R0 resection rate (96% vs. 91.4%), 5-year overall survival (65% vs. 48%), and disease-free survival (42% vs. 38%).Robotic approach is an acceptable alternative to laparoscopic partial hepatectomy for HCC. With the potential advantages of robotic system in performing major hepatectomy and resection of tumor in difficult segments, robotic surgery may have an impact on the therapeutic strategy of HCC.

Laparoscopic liver resection under hemihepatic vascular inflow control has advantages over Pringle's maneuver, especially in patients with cirrhosis. From January 2016 to August 2016, 7 patients who underwent total laparoscopic left hepatectomy under hemihepatic vascular inflow occlusion using the extra-glissonian approach were included in this study. All were hepatitis B carriers and 4 had cirrhosis. The mean operation time was 247 minutes. The mean transection time was 110 minutes. No patient needed additional Pringle's maneuver. The mean intraoperative blood loss was 74 ml and no patient required blood transfusion. No open conversion happened. Postoperatively, no patient developed complications and there was no perioperative mortality. The mean resection margin was 2 cm. The mean hospital stay was 6 days. Upon a mean follow-up of 9 months, no patient developed tumor recurrence. The technique of total laparoscopic left hepatectomy using extra-glissonian approach was safe and feasible. The early surgical outcomes were good.

Highlights • Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has rarely been reported for patients with hepatocellular carcinoma (HCC). • ALPPS is feasible even in the context of HCC with a background of chronic hepatitis B related liver fibrosis. • The hypertrophy rate of the liver remnant was slower and the time needed between the two stages of the operation was longer., INTRODUCTION Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed for patients with predicted insufficient future liver remnant volumes to induce more rapid hepatic hypertrophy and increase resectability. In the medical literature, the use of ALPPS in hepatocellular carcinoma (HCC) has rarely been reported. PRESENTATION OF CASE We reported the use of ALPPS in a patient with primarily unresectable HCC arising from a background of hepatitis B related liver fibrosis. Preoperative computed tomography (CT) showed 2 large conglomerated tumors measuring 16 cm × 10.5 cm in liver segments 5, 6, 7 and 8, and at least 3 satellite nodules with the largest one measuring 3 cm around the main tumor and another 4 cm tumor in segment 4. Right trisectionectomy after ALPPS was successfully performed. He was discharged from hospital on postoperative day 13 after the second operation. Follow-up CT scan at 6 weeks after the second operation showed further hypertrophy of the liver remnant and no liver recurrence. DISCUSSION Our case showed that this novel strategy is feasible even in the context of a background of chronic hepatitis B related liver fibrosis, although the hypertrophy rate was a little bit slower and the time needed was longer. CONCLUSION ALPPS is also feasible in liver fibrosis. It gives hope to patients with HCC who previously were considered as having unresectable diseases. More studies are needed to further evaluate the effectiveness and oncological outcomes of ALPPS from these patients.

Background Surgery on patients with malignant obstructive jaundice carries increased risks of postoperative morbidity and mortality. Preoperative biliary drainage has been developed to reduce this procedure-related risks, but its role in patients who are going to receive pancreaticoduodenectomy for periampullary carcinoma is still controversial. Methods This article aimed at reviewing the current status of preoperative biliary drainage for patients with peri-ampullary tumors who were candidates for pancreaticoduodenectomy. A MEDLINE and PubMed database search from 1980 to 2013 was performed to identify relevant articles using the keywords "pancreaticoduodenectomy", "preoperative biliary drainage", "jaundice", "peri-ampullary neoplasm" and "carcinoma of pancreas". Additional papers were identified by a manual search of the references from the key articles. Results There were six randomized controlled trials (RCTs) and 5 meta-analyses on preoperative biliary drainage for patients with malignant obstructive jaundice. Most of the results of these studies could not be used to define the role of preoperative biliary drainage for patients who received pancreaticoduodenectomy for periampullary carcinoma because: first, the majority of these studies were on bypass or palliative resections; second, various pathologies with both proximal and distal biliary obstruction were included; third, there were different forms of percutaneous or endoscopic drainage procedures; fourth, there were different durations of preoperative drainage; and finally, there were variations in the definition of events and outcomes. There was only one RCT which included a homogeneous group of patients with carcinoma of pancreas who underwent pancreaticoduodenectomy. For patients with periampullary tumor, the RCTS and meta-analyses showed no benefit of preoperative biliary drainage. Instead, there were some concerns about the drainage-related complications and the increase in positive intraoperative bile culture rate and the associated infective complication rate postoperatively. Conclusion Routine preoperative biliary drainage showed no beneficial effect on the surgical outcome for patients with periampullary tumor. A selective approach of preoperative biliary drainage should be adopted for these patients. The optimal duration and modality of preoperative biliary drainage remain unclear.

Background With advances in technology, laparoscopic liver resection is widely accepted. Laparoscopic liver resection under hemihepatic vascular inflow occlusion has advantages over the conventional total hepatic inflow occlusion using the Pringle's maneuver, especially in patients with cirrhosis. Method From November 2011 to August 2012, eight consecutive patients underwent laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach with biliary bougie assistance. Results The types of liver resection included right hepatectomy ( n =1), right posterior sectionectomy ( n =1), left hepatectomy and common bile duct exploration ( n =1), segment 4b resection ( n =1), left lateral sectionectomy ( n =2), and wedge resection ( n =2). Four patients underwent right and 4 left hemihepatic vascular inflow occlusion. Four patients had cirrhosis. The mean operation time was 176.3 minutes. The mean time taken to achieve hemihepatic vascular inflow occlusion was 24.3 minutes. The mean duration of vascular inflow occlusion was 54.5 minutes. The mean intraoperative blood loss was 361 mL. No patient required blood transfusion. Postoperatively, one patient developed bile leak which healed with conservative treatment. No postoperative liver failure and mortality occurred. The mean hospital stay of the patients was 7 days. Conclusion Our technique of hemihepatic vascular inflow vascular occlusion using the lowering of hilar plate approach was safe, and it improved laparoscopic liver resection by minimizing blood loss during liver parenchymal transection.

A study of 7,388 consecutive patients after hepatic resection between 2011 and 2012 identified hepatolithiasis, cirrhosis, and intraoperative blood transfusion as the only independent risk factors of both incisional and organ/space surgical site infection (SSI). Patients with these conditions should be cared for with caution to lower SSI rates.

Introduction. Both hepatocellular carcinoma (HCC) presenting during pregnancy and HCC presenting with obstructive jaundice due to a tumor cast in the biliary tract are very rare. The management of these patients remains challenging.Presentation of Case. A 23-year-old lady presented with obstructive jaundice at 38 weeks of gestation. Investigations showed HCC with a biliary tumor thrombus. She received percutaneous transhepatic biliary drainage (PTBD) and caesarean section. Right hepatectomy, extrahepatic bile duct resection, and left hepaticojejunostomy were carried out when the jaundice improved. The postoperative course was uneventful. She was discharged home on postoperative day 10. Histopathology showed HCC with a tumor thrombus in the bile duct. The surgical margins were clear. One year after surgery, the mother was disease-free and the baby was well.Conclusion. With proper management, curative treatment is possible in a pregnant patient who presented with obstructive jaundice due to a biliary tumor thrombus from HCC.

Background Open right anterior sectionectomy, which involves resection of liver segments 5 and 8, has been reported to have similar postoperative mortality rates as right hepatectomy, but it has a decreased risk in developing posthepatectomy liver failure. Totally laparoscopic right anterior sectionectomy is technically demanding and has rarely been reported in hepatocellular carcinoma (HCC) patients with cirrhosis. Methods Our experience in carrying out totally laparoscopic right anterior sectionectomy on four consecutive HCC patients with cirrhosis from November 2016 to August 2017 using the extraglissonian approach formed the basis of this report. Results All four patients had hepatitis B-related HCC. The mean operation time was 502 ± 55 minutes. All patients underwent intermittent Pringle's Maneuver with cycles of clamp/unclamp times of 15/5 minutes for the left-sided liver transection plane, and intermittent right hemihepatic vascular inflow occlusion with cycles of clamp/unclamp times of 30/5 minutes for the right-sided liver transection plane. The mean Pringle's Maneuver time was 58.8 ± 11.4 minutes and the mean right hemihepatic vascular inflow occlusion time was 66.3 ± 11.1 minutes. The mean intraoperative blood loss was 512 ± 301 mL. No patients required any blood transfusion. There was no conversion to open surgery. Postoperative complications included intra-abdominal bleeding requiring reoperation for hemostasis (n = 1), intra-abdominal collection requiring percutaneous drainage (n = 1), and right pleural effusion requiring percutaneous drainage (n = 1). There was no 90-day postoperative mortality. The mean hospital stay was 10.7 ± 2.9 days. After a median follow-up of 10 (range, 6-16) months, one patient developed HCC recurrence in the liver remnant. Conclusion Totally laparoscopic right anterior sectionectomy using the extraglissonian approach was technically feasible and safe in expert hands. More data are needed to assess the long-term oncological survival outcomes.

Low central venous pressure (CVP) affects hemodynamic stability and tissue perfusion. This prospective study aimed to evaluate the optimal CVP during partial hepatectomy for hepatocellular carcinoma (HCC).Ninety-seven patients who underwent partial hepatectomy for HCC had their CVP controlled at a level of 0 to 5 mmHg during hepatic parenchymal transection. The systolic blood pressure (SBP) was maintained, if possible, at 90 mmHg or higher. Hepatitis B surface antigen was positive in 90 patients (92.8%) and cirrhosis in 84 patients (86.6%). Pringle maneuver was used routinely in these patients with clamp/unclamp cycles of 15/5 minutes. The average clamp time was 21.4+/-8.0 minutes. These patients were divided into 5 groups based on the CVP: group A: 0-1 mmHg; B: 1.1-2 mmHg; C: 2.1-3 mmHg; D: 3.1-4 mmHg and E: 4.1-5 mmHg. The blood loss per transection area during hepatic parenchymal transection and the arterial blood gas before and after liver transection were analyzed.With active fluid load, a constant SBP ≥90 mmHg which was considered as optimal was maintained in 18.6% in group A (95% CI: 10.8%-26.3%); 39.2% in group B (95% CI: 29.5%-48.9%); 72.2% in group C (95% CI: 63.2%-81.1%); 89.7% in group D (95% CI: 83.6%-95.7%); and 100% in group E (95% CI: 100%-100%). The blood loss per transection area during hepatic parenchymal transection decreased with a decrease in CVP. Compared to groups D and E, blood loss in groups A, B and C was significantly less (analysis of variance test, P0.05). Compared with the baseline, the blood oxygenation decreased significantly when the CVP was reduced. Base excess and HCO3- in groups A and B were significantly decreased compared with those in groups C, D and E (P0.05).In consideration of blood loss, SBP, base excess and HCO3-, a CVP of 2.1-3 mmHg was optimal in patients undergoing partial hepatectomy for HCC.

Background Improvements in surgical technique and perioperative care have made partial hepatectomy a safe and effective treatment for hepatocellular carcinoma (HCC), even in the event of spontaneous HCC rupture. Methods A consecutive cohort of patients who underwent partial hepatectomy for HCC between 2000 and 2009 was divided into a ruptured group and a non-ruptured group. Patients with ruptured HCC were further divided into emergency and staged hepatectomy subgroups. Mortality and morbidity, overall survival and recurrence-free survival (RFS) were compared. Prognostic factors for overall survival and RFS were identified by univariable and multivariable analyses. Results A total of 1233 patients underwent partial hepatectomy for HCC, of whom 143 had a ruptured tumour. The morbidity and mortality rates were similar in the ruptured and non-ruptured groups, as well as in the emergency and staged subgroups. In univariable analyses, overall survival and RFS were lower in the ruptured group than in the non-ruptured group (both P < 0·001), and also in the emergency subgroup compared with the staged subgroup (P = 0·016 and P = 0·025 respectively). In multivariable analysis, spontaneous rupture independently predicted poor overall survival after hepatectomy (hazard ratio 1·54, 95 per cent confidence interval 1·24 to 1·93) and RFS (HR 1·75, 1·39 to 2·22). Overall survival and RFS after hepatectomy for ruptured HCC in the emergency and staged subgroups were not significantly different in multivariable analyses. Conclusion Spontaneous rupture predicted poor long-term survival after hepatectomy for HCC, but surgical treatment seems possible, safe and appropriate in selected patients.

This study aimed to clarify the incidence of hepatitis B virus (HBV) reactivation and its significance on long-term survival after partial hepatectomy in patients with HBV-related hepatocellular carcinoma (HCC), who had preoperative low HBV-DNA level of less than 2000 IU/mL.HBV reactivation is a frequent complication of systemic chemotherapy in hepatitis B surface antigen-positive patients. Surgery and anesthesia result in a generalized state of immunosuppression in the immediate postoperative period. Data on HBV reactivation and its significance after partial hepatectomy are unclear.Consecutive patients from January 2006 to December 2007 were retrospectively studied.HBV reactivation happened in 19.1% of patients in 1 year. There were 28 patients whose HBV reactivation was detected after the diagnosis of HCC recurrence. On multivariate analysis, hepatitis B e antigen (HBeAg) positivity, preoperative HBV-DNA above the lower limit of quantification (≥200 IU/mL), Ishak inflammation score of greater than 3, preoperative transarterial chemoembolization (TACE), operation time of more than 180 minutes, blood transfusion, and without prophylactic antiviral therapy were significantly associated with an increased risk of HBV reactivation. HBV reactivation negatively influenced postoperative hepatic functions. The posthepatectomy liver failure rate in patients with HBV reactivation was significantly higher than in those without reactivation (11.8% vs 6.4%; P = 0.002). The 3-year disease-free survival (DFS) rate and overall survival (OS) rates after resection in patients with HBV reactivation were significantly lower than those without reactivation (34.1% vs 46.0%; P = 0.009, and 51.6% vs 67.2%; P0.001, respectively). HBeAg positivity, detectable preoperative HBV-DNA level, high Ishak inflammation score, preoperative TACE, long operation time, and blood transfusion were independent risk factors for HBV reactivation, whereas prophylactic antiviral therapy was a protective factor. HBV reactivation, HBeAg positivity, HBV-DNA level of 200 IU/mL or more, tumor diameter greater than 5 cm, presence of satellite nodules, presence of portal vein tumor thrombus, blood transfusion, and resection margin less than 1.0 cm were independent risk factors for DFS. A HBV-DNA level of 200 IU/mL or more, an Ishak fibrosis score of 4 or greater, a tumor diameter greater than 5 cm, the presence of satellite nodules, the presence of portal vein tumor thrombus, a resection margin less than 1.0 cm, no prophylactic antiviral therapy, and HBV reactivation were independent risk factors for OS.HBV reactivation was common after partial hepatectomy for HBV-related HCC with a preoperative low HBV-DNA level of less than 2000 IU/mL. Routine prophylactic antiviral treatment should be given before partial hepatectomy.

The aim of this study was to compare the results of surgical resection with three-dimensional conformal radiotherapy (3D-CRT) in the treatment of resectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Transarterial chemoembolization (TACE) was given to both groups of patients when possible. A retrospective study of 371 patients with resectable HCC with PVTT was conducted in two tertiary referral centers. The treatment of choice for these patients in one center was surgical resection. In the other center it was 3D-CRT. In the radiotherapy group (RG, n = 185), patients received 3D-CRT to the tumor and PVTT for a total radiation dose of 30–52 Gy (median 40 Gy). In the surgical group (SG, n = 186), patients underwent surgical resection. TACE was applied after surgery or 3D-CRT and then was repeated every 4–6 weeks if the patient tolerated the treatment. The median survival was 12.3 months for RG and 10.0 months for SG. The 1-, 2-, and 3-year overall survivals were 51.6, 28.4, and 19.9 %, respectively, for RG and 40.1, 17.0, and 13.6 %, respectively, for SG (p = 0.029). Stepwise multivariate analysis showed that the extent of PVTT and mode of treatment were independent risk factors of overall survival. The most common cause of death after treatment was liver failure as a consequence of progressive intrahepatic disease. 3D-CRT gave better survival than surgical resection for HCC with PVTT.

Introduction The two current standard laparoscopic approaches for inguinal hernia repair are transabdominal preperiotneal and totally extraperitoneal. Single-incision repairs have been explored in an effort to further reduce the invasiveness of the surgery. However, with single incision, surgeons need to possess special skills and require special instruments. Needlescopic inguinal hernia repair could represent a more attractive alternative. Using a transumbilical incision, an almost scarless transabdominal preperiotneal can be achieved. In the present study, we report our experience of scarless needlescopic transabdominal preperiotneal inguinal hernia repair. Patients and Methods This is a prospective analysis of a cohort of patients with inguinal hernia who underwent elective scarless needlescopic transabdominal preperiotneal repair. Patient demographic data, type of hernia, operative time, perioperative and postoperative course, pain score and final patient satisfaction score were all recorded for analysis. Results In March 2011, four patients received scarless needlescopic transabdominal preperiotneal for inguinal hernia repair. Their average age was 57.25 years. The mean operative time was 79.5 min. The patients were discharged on the same day. There were no postoperative complications. Conclusion Scarless needlescopic transabdominal preperiotneal inguinal hernia repair is feasible and safe, and is well accepted by patients. Further studies will be conducted to evaluate its full potential.

Aim The aim of the present study was to evaluate the efficacy of laparoscopic management for strangulated groin hernias. Patients and Methods From January 2007 to December 2009, the perioperative and long-term results of a consecutive series of patients who underwent laparoscopic repair of strangulated groin hernia were retrospectively analysed. The demographic data of patients, types of hernia, levels of peritoneal contamination, details of surgical techniques, hernia contents, conversion rate, operation time, postoperative complications, follow-up time and recurrent rate were recorded. Results A total of 43 patients with strangulated groin hernia admitted via casualty during the study period were managed by the laparoscopic approach in our unit. We operated on 36 inguinal hernias, 10 femoral hernias and three obturator hernias; five of these were recurrent hernias, and six patients had concurrent groin hernias. We adopted a totally extraperitoneal (TEP) approach for 37 patients and the transabdominal preperitoneal (TAPP) approach for four patients with femoral hernias; two obturator hernias were repaired by board ligaments. None required conversion. One patient had a small perforation of the small bowel during reduction of hernia content, which was repaired primarily; the TEP approach was performed subsequently. None had postoperative infection. One patient had haematoma, and five patients had seroma; all were treated conservatively. The mean operation time was 75 min. The mean postoperative hospital stay was 3.5 days. For those younger than 60 years, the mean postoperative hospital stay was 1.7 days. The mean follow-up time was 14 months. There were no recurrences. Conclusion For selected patients, laparoscopic repair for strangulated groin hernias is safe and feasible, with a low rate of infection, complications and recurrence.

In 1952, Lortat-Jacob reported the first successful anatomic right hepatectomy for cancer [1]. It is through better understanding of hepatic segmental anatomy and refinements in intraoperative ultrasound (IOUS) that anatomical segment-based liver resection gradually matures in the past 30 years [2–5]. Segment-based liver resection allows maximal preservation of non-tumorous liver parenchyma while achieving adequate tumor resection margins. Segment-based liver resection then further develops into subsegment-based liver resection.

Summary 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.

Purpose This article reviews the role of selective internal irradiation (SIR) with yttrium-90 ( 90 Y) microspheres for hepatocellular carcinoma (HCC). Methods and Materials Studies were identified by searching Medline and PubMed databases for articles from 1990 to 2009 using the keywords "selective internal irradiation," "hepatocellular carcinoma," "therapeutic embolization," and "yttrium-90." Results 90 Y microspheres are a safe and well-tolerated therapy for unresectable HCC (median survival range, 7 -21.6 months). The evidence was limited to cohort studies and comparative studies with historical control. 90 Y microspheres have been reported to downstage unresectable HCC to allow for salvage treatments with curative intent, act as a bridging therapy before liver transplantation, and treat HCC with curative intent for patients who are not surgical candidates because of comorbidities. Conclusions 90 Y microsphere is recommended as an option of palliative therapy for large or multifocal HCC without major portal vein invasion or extrahepatic spread. It can also be used for recurrent unresectable HCC, as a bridging therapy before liver transplantation, as a tumor downstaging treatment, and as a curative treatment for patients with associated comorbidities who are not candidates for surgery.

To evaluate the technical feasibility and safety of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy, using the robotic surgical system.This is a report of the use of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy on 2 patients with recurrent pyogenic cholangitis. Both had past history of side-to-side choledochoduodenostomy with complications of Sump syndrome and benign biliary stricture, respectively.Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy was completed successfully in these 2 patients. Both patients recovered from the operation, except for 1 patient who had minor bile leakage over the anastomosis 4 days after operation, which subsided after conservative treatment. The mean operating time was 300 minutes and 400 minutes, respectively. The blood loss was 20 mL and 10 mL, respectively. They were able to tolerate liquids on the second postoperative day. They were discharged 6 and 11 days after the operation, respectively.Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible and safe procedure. However, more large-scale studies with long-term follow-up results are needed.

Background This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). Methods From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). Results Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). Conclusions SILC was feasible and safe for properly selected patients in experienced hands.

The aim of this study was to determine the role of Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) as a prognostic marker and a monitor marker of recurrence after curative resection of hepatocellular carcinoma (HCC). From December 2002 to May 2004, 395 consecutive patients with HCC who underwent curative partial hepatectomy were included in the study. The tumor characteristics and clinical outcomes of patients with positive preoperative and postoperative AFP-L3 were compared with those with negative results. A high ratio of AFP-L3 to total AFP was an indicator of pathologic aggressiveness. Patients with positive preoperative AFP-L3 had significantly earlier recurrence (median time to recurrence 22.0 ± 2.4 months vs 45.0 ± 6.9 months, P

Background Reports on percutaneous cryoablation to treat patients with HCC are sparse in the medical literature. This study aimed to determine the safety and efficacy of percutaneous cryotherapy for unresectable or recurrent hepatocellular carcinoma (HCC). Methods The results of 40 patients with unresectable HCC and 26 patients with recurrent HCC treated with ultrasound-guided percutaneous cryotherapy from January 2006 to June 2009 were retrospectively analyzed. Results We used percutaneous cryotherapy to treat 76 tumors in 40 patients with unresectable and 76 tumors in 26 patients with recurrent HCC. The size of the tumors was 2.8 ± 1.7 cm (mean ± S.D.). The mean number of treatment sessions for unresectable and recurrent HCC were 1.7 and 1.4, respectively. All cryotherapy procedures were technically successful. No procedure-related death was observed. The overall complication rate was 12.1%. Patients with unresectable HCC had 1-, and 3-year overall survival rates of 81.4%, and 60.3%, while the disease-free survival rates at 1 year and 3 years were 67.6% and 20.8%, respectively. Patients with recurrent HCC had 1-, and 3-year overall survival rates of 70.2%, and 28.8%, while the disease-free survival rates at 1 year and 3 years were 53.8% and 7.7%, respectively. Conclusion Ultrasound-guided percutaneous cryotherapy was safe and efficacious in the treatment of unresectable and recurrent HCC. Further randomized trials are needed to compare the safety and efficacy of cryotherapy with other forms of percutaneous treatment so that an unbiased therapeutic strategy can be devised.

Background Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes. Methods A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality. Results A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay. Conclusions All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.

Background and objectives In the past, right hepatectomy via the anterior approach has been regarded as one of the many standard approaches for hepatectomy. However, total laparoscopic right hepatectomy from the anterior approach has been regarded as technically challenging. We report our experience in using the anterior approach in total laparoscopic right hepatectomy for hepatocellular carcinoma (HCC). Methods From June 2013 through December 2015, five consecutive patients underwent total laparoscopic right hepatectomy using the anterior approach, but without the hanging maneuver. Results The mean operative time was 360 (range, 300-480) minutes, and the mean blood loss was 340 (110-600) mL. No patient needed any blood transfusion. There was no conversion to open surgery. Ascites, pleural effusion, and bile leakage occurred in 2, 1, and 1 patients, respectively. No patients expired as a result of the surgery or liver failure. The mean hospital stay was 7 (4-15) days. All patients had R0 resection. After a mean follow-up of 22 (8-33) months, no patients experienced recurrence of disease. Conclusion Total laparoscopic right hepatectomy using the anterior approach is feasible and safe.

This study aimed to evaluate the perioperative and long-term results of partial hepatectomy for patients with complicated bilateral primary hepatolithiasis.Hepatolithiasis is best managed by a multidisciplinary approach. Definitive treatment can be offered using endoscopic, percutaneous, laparoscopic, or open surgical approaches. Partial hepatectomy is only indicated for recurrent, troublesome, localized, and severe disease affecting the liver.From January 2000 to December 2006, 136 consecutive patients who underwent bilateral (n = 54) or unilateral (n = 82) hepatectomy for biliary strictures and bilateral primary hepatolithiasis in our center were included in this study. All patients had concomitant bile duct exploration. Their perioperative and long-term outcomes were analyzed.The immediate stone clearance rates after bilateral and unilateral hepatectomy were 81.5% and 65.9%, respectively. Additional postoperative choledochoscopic lithotripsy raised the clearance rates to 85.2% and 81.7%, respectively. The hospital mortality rates were 5.6% and 0%, respectively, and the complication rates were 46.3% and 46.3%, respectively. The 5-year overall survival rates were 98% and 91.5%, respectively.In selected patients with biliary strictures and bilateral hepatolithiasis, partial hepatectomy associated with choledochoscopic lithotripsy is a safe and efficacious treatment, with a high immediate stone clearance rate, a low long-term stone recurrence rate and good long-term survival.

Inflammatory myofibroblastic tumor (IMT) is a rare condition. The aim of the present study was to evaluate the clinical characteristics and surgical outcomes for IMT of the liver in our large cohort of patients. From January 2001 to December 2007, all patients with a pathological diagnosis of IMT of the liver who underwent partial hepatectomy were retrospectively analyzed. During the study period, 64 patients underwent partial hepatectomy for IMT of the liver in our tertiary referral center. The commonest clinical presentation was abdominal pain (53%), followed by fever (41%); 15.6% of patients were asymptomatic. Preoperative diagnosis of IMT was suspected in only five patients (8%). The indications for surgery included suspicion of malignancy (60.9%), uncertain diagnosis (40.6%), symptomatic disease (26.6%), and spontaneous rupture (3.1%). The postoperative complication rate was low (17.2%). There was no hospital mortality. After a median follow-up of 30 months, no patient developed recurrence. Although there are various treatment options for IMT of the liver, surgical resection for good risk patients is preferred.

A good postoperative outcome after partial hepatectomy is highly dependent on limiting operative blood loss. This study evaluated the feasibility and efficacy of the tourniquet method compared with the Pringle maneuver in laparoscopic liver resection for hepatocellular carcinoma (HCC) in the left liver. A retrospective, nonrandomized, comparative study for laparoscopic liver resection for HCC in the left liver using the Pringle maneuver (group A) or the tourniquet method (group B) was initiated in our center between March 2004 and October 2008. Sixteen patients (group A) underwent laparoscopic liver resection using the Pringle maneuver, and 13 patients (group B) underwent laparoscopic liver resection using the tourniquet method. No differences in operation time, operative blood loss, perioperative blood transfusion, and perioperative morbidity were found between the two groups. Both groups had no postoperative mortality. The liver enzymes were significantly elevated in group A compared with group B. Group B patients also had significantly faster recovery of liver function. The postoperative hospital stay for group B was significantly shorter than group A (mean, 5.6 days vs. 8.3 days). Both techniques of vascular control were equally safe, efficacious, and feasible for patients undergoing laparoscopic left-sided liver resection. The tourniquet method gave a wider safety margin for patients with chronic liver disease with a compromised hepatic reserve by causing less ischemia-reperfusion injury to the remnant liver.

To evaluate the effect of preoperative transarterial chemoembolization (TACE) for resectable large hepatocellular carcinoma (HCC).Resection of HCC is potentially curative, but local recurrence is very common. There is currently no effective neoadjuvant or adjuvant therapy.From July 2001 to December 2003, 108 patients (hepatitis B carrier = 98.1%) with resectable HCC (or =5 cm) was randomly assigned to preoperative TACE treatment (n = 52) or no preoperative treatment (control group) (n = 56).Five patients (9.6%) in the preoperative TACE group did not receive surgical therapy because of extrahepatic metastasis or liver failure. The preoperative TACE group had a lower resection rate (n = 47, 90.4% vs. n = 56, 100%; P= 0.017), and longer operative time (mean, 176.5 minutes vs. 149.3 minutes; P= 0.042). No significant difference was found between the 2 groups in operative blood loss, surgical morbidity, and hospital mortality.At a median follow-up of 57 months, 41 (78.8%) of 52 patients in the preoperative TACE group and 51 (91.1%) of 56 patients in the control group had recurrent disease (P= 0.087). The 1-, 3-, and 5-year disease-free survival rates were 48.9%, 25.5%, and 12.8%, respectively, for the preoperative TACE group and 39.2%, 21.4%, and 8.9%, respectively, for the control group (P= 0.372). The 1-, 3-, and 5-year overall survival rates were 73.1%, 40.4%, and 30.7%, respectively, for the preoperative TACE group and 69.6%, 32.1%, and 21.1%, respectively, for the control group (P= 0.679).Preoperative TACE did not improve surgical outcome. It resulted in drop-out from definitive surgery because of progression of disease and liver failure.

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.

Objective: In this prospective randomized trial, we attempted to find out if 1 dose of postoperative adjuvant intra-arterial iodine-131-labeled lipiodol could reduce the rate of local recurrence, and increase disease-free and overall survival for patients with hepatocellular carcinoma (HCC). This study evaluated the long-term outcome. Background: Resection of HCC is potentially curative, but local recurrence is common. However, there is currently no effective adjuvant therapy. Early results after closing the trial (Lau et al. Lancet 1999;353:797-801) showed that 1 dose of intra-arterial 131 I-lipiodol given after curative resection significantly decreased the rate of recurrence, and increased disease-free and overall survival. Methods: Patients who underwent curative resection for HCC and recovered within 6 weeks were randomly assigned one 1850 MBq dose of 131 I-lipiodol or no further treatment (controls). We compared rates of recurrence, and long-term disease-free and overall survival (the primary endpoints) between the 2 groups by intention-to-treat. Results: Between April 1992 and August 1997, we recruited 43 patients: 21 were randomized to receive intra-arterial 131 I-lipiodol and 22 to receive no adjuvant treatment. 131 I-lipiodol had no significant toxic effects. During a median follow-up of 66 (range, 3-198) months, there were 10 (47.6%) recurrences among the 21 patients in the adjuvant treatment group, compared with 14 (63.6%) in the control group (P = 0.29). The actuarial 5-year disease-free survival in the treatment and control groups was 61.9% and 31.8%, respectively (P = 0.0397). The actuarial 5-year overall survival in the treatment and control groups was 66.7% and 36.4%, respectively (P = 0.0433). The actuarial 7-year disease-free survival in the treatment and control groups was 52.4% and 31.8%, respectively (P = 0.0224). The actuarial 7-year overall survival in the treatment and control groups was 66.7% and 31.8%, respectively (P = 0.0243). The actuarial 10-year disease-free survival in the treatment and control groups was 47.6% and 27.3%, respectively (P = 0.0892). The actuarial 10-year overall survival in the treatment and control groups was 52.4% and 27.3%, respectively (P = 0.0905). Conclusions: In patients with HCC, adjuvant intra-arterial 131 I-lipiodol after curative liver resection provided survival benefit on the disease-free survival and overall survival, although the difference became statistically insignificant at 8 years after randomization.

Surgical resection with complete extirpation of the tumor gives the best chance of a cure for patients with hepatocellular carcinoma (HCC). However, the resectability of HCC at the time of diagnosis is low (10-30%). This article reviews the use of salvage surgery following tumor downstaging to treat unresectable HCC.A Medline search was undertaken from 1966 to 2005 to identify articles using the keywords "liver neoplasm," "hepatocellular carcinoma," "tumor downstaging," and "unresectable." Additional papers were identified by a manual search of the references from the key articles.Eight to eighteen percent of patients with unresectable HCC responded well enough to the initial palliative treatment to downstage HCC to allow salvage surgical resection. The reported five-year survival rate after salvage surgery following tumor downstaging varied from 24.9 to 57%.Although it is still unknown whether the outcome of salvage surgery following tumor downstaging is comparable to those of resectable tumors after primary resection, one clear message is that salvage surgery following tumor downstaging gives good long-term results and the possibility of a cure in a proportion of patients with unresectable HCC. The role of salvage surgery after tumor downstaging in improving disease-free and overall survival in patients with unresectable HCC should be investigated further by prospective randomized controlled trials.

From the limited but available information, we traced the history of developments of liver surgery and transplantation in China. Liver surgery first started in the late 1950s in China, and it soon flourished mainly because of the great demand in liver surgery and the emergence of a number of giants in liver surgery. We recognized and honoured the important contributions of these Chinese pioneers in portal hypertension, recurrent pyogenic cholangitis, hepatocellular carcinoma and liver transplantation.

Tumor diameter, number and position, liver function, and general health of a patient must be considered when evaluating radiofrequency ablation (RFA) for hepatocellular carcinoma. There are three primary approaches to RFA: percutaneous, laparoscopic, and open. The main goal in each of the RFA approaches is capability of safely achieving complete tumor ablation with adequate ablation margins. The choice of the different approaches for RFA should be tailored to the individual patient according to the tumor volume and location.

For many years, partial hepatectomy and liver transplantation have been considered as the only forms of curative treatment for hepatocellular carcinoma (HCC). Unfortunately, only 10–20 % of HCC is resectable. Anatomic location, size or number of lesions, inadequate liver remnant, or comorbid conditions preclude surgery in the majority of patients. Orthotopic liver transplantation can cure some patients with poor liver function due to underlying cirrhosis, but few patients are eligible because of advanced stage of HCC at initial diagnosis and because of scarcity of liver donors, especially in some parts of the world. Currently, radiofrequency ablation (RFA) is commonly used in patients with small HCC confined to the liver, especially when the tumors are unresectable because of poor general condition of the patients or because of compromised liver function. Using RFA as a bridge to liver transplantation results in low treatment morbidity and favorable HCC responses and reduces drop-out rate of patients while on the liver transplant waiting list due to HCC progression. Local ablative therapy now competes with partial hepatectomy and liver transplantation as the primary treatment for patients with small HCC. The application of RFA has a number of potential advantages in patients with HCC. The procedure is relatively safe and well tolerated, and its complication rates in most reported series are low. Data have accumulated to support the safety and effectiveness of RFA in selected patients. To achieve good treatment outcomes, proper clinical assessment and patient selection are important. This chapter introduces the clinical assessment and patient selection for RFA [1].

Minimally invasive approaches to pancreatoduodenectomy have been very difficult technically. Robotic systems offer many advantages, as use of the robot overcomes several of the obstacles of conventional laparoscopic surgery by increasing dexterity, restoring proper hand-eye coordination in an ergonomically comfortable position, and improving visualization. A robotic approach can facilitate several steps of the pancreatoduodenectomy, including dissection of the pancreas from major vascular structures, lymph node dissection, resection of the uncinate process, and construction of the pancreatobiliary anastomoses.

Purpose To further improve the effectiveness and prognosis of primary hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), the current status of treatment for HCC with PVTT was reviewed. Methods A Medline search was undertaken to identify articles using the keywords "HCC", "PVTT" and "therapy". Additional papers were identified by a manual search of the references from the key articles. Results PVTT, as a common complication of HCC, was divided into type I ∼ IV. The therapeutic approach is mainly composed of five types: surgical resection, regional interventional therapy, radiotherapy, combination therapy, targeted therapy. All of these therapeutic approaches were separately evaluated in detail. Conclusions For those resectable tumors, the better choice for treatment of HCC with PVTT should be hepatectomy and removal of PVTT. For those unresectable tumors, TACE (especially the super-selective TACE) has been the preferred palliative treatment, the other regional interventional therapy and/or radiotherapy could improve the therapeutic effects. The multidisciplinary treatments may further improve the quality of life and prolong the survival period for the HCC patients associated with PVTT.

Background: Jaundice occurs in 5–44% of patients with hepatocellular carcinoma (HCC). It is an important clinical presentation as the different aetiological causes of jaundice in HCC determine the therapeutic approach and the prognosis. This article aims to review the classification, management and prognosis of patients with jaundice associated with HCC. Methods: A Medline search was undertaken to identify articles using the key words ‘hepatocellular carcinoma’, ‘jaundice’ and ‘tumour thrombus’. Additional articles were identified by a manual search of the references from the key articles. Results: Patients with jaundice due to hepatic parenchymal insufficiency (hepatocellular type) have a very dismal prognosis. For patients with biliary obstruction due to HCC (icteric type), the reported 1-, 3- and 5-year survival rates after curative resection were 57.1–100%, 20–47% and 6.7–45%, respectively. The mean survival after palliative biliary drainage alone was less than 6 months but when biliary drainage was combined with other palliative treatment, the mean survival could be up to 1 year. Conclusions: It is important to differentiate the hepatocellular type from the icteric type of HCC. For patients with the icteric type of HCC, curative liver resection can achieve a survival comparable to that in patients without jaundice. For patients with unresectable icteric type of HCC, treatment can provide improvement in patient’s quality of life and survival.

Background: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a new pathological entity. It is diagnosed with increasing frequency. However, its natural history and management are still not well defined. Methods: A Medline search was undertaken to identify articles using the keywords "intraductal papillary mucinous neoplasms of pancreas", "pancreatic neoplasms", and "pancreatic cyst". Additional papers were identified by a manual search of the references from the key articles. Results: Surgical resection is the only treatment which can produce a cure. The reported overall 5-year survival for IPMN after surgical resection varies from 36% to 77%; for noninvasive IPMN, 77% to 100% and for invasive IPMN, 27% to 60%. The overall recurrence rate was 7% to 43%. IPMN can recur either as disseminated disease or as isolated pancreatic remnant recurrence even after surgical resection with negative margins. Conclusions: Based on the available evidence, patients with IPMN should undergo complete surgical resection. The extent of pancreatic resection and the intra-operative management of resection margins remain controversial. Balancing the risk of recurrence and the morbidity of total pancreatectomy, routine total pancreatectomy for IPMN is not recommended. Total pancreatectomy should only be reserved for patients with resectable but extensive IPMN which involves the whole pancreas. Regular monitoring for disease recurrence is important after surgery as there is a risk of recurrence in both non-invasive and invasive IPMN, and repeat resection for an isolated recurrence in the pancreatic remnant gives good results

Objective: To study the clinical characteristics, investigations, management and pathology in adult colonic intussusception. Methods: A retrospective study of seven adult patients who were operated on for the diagnosis of colonic intussusception in our department from January 1999 to September 2003 was carried out. The case records of the seven patients were retrieved. Their clinical presentations, investigations, operative records and pathology were studied. Results: The mean age of the patients was 67.4 years. There were four men and three women. Five of the patients presented with chronic non-specific symptoms and the other two patients presented with acute symptoms. Transabdominal ultrasonography (USG) and computed tomography (CT) scan were used for investigation. In the majority of the patients (87.5%), radiological features of intussusception were shown by USG or CT scan. All seven patients underwent laparotomy exploration with bowel resection. Six patients (85.7%) had lead points with definable pathology. Within the lead points, five patients had primary malignant lesions. Conclusion: With more liberal use of imaging techniques, more adult intussusception can be diagnosed before explorative surgery. Ultrasound would be an ideal tool for initial evaluation. In view of the high chance of associated malignancy, adult colonic intussusception should be resected without prior reduction at the time of surgery.

Background: The aim of the present study was to review the long-term result of patients with carcinoma of gallbladder with adequate investigations and aggressive surgical resection. Methods: A retrospective study was carried out on patients with carcinoma of gallbladder treated at the Division of Hepatopancreatobiliary Surgery, the Chinese University of Hong Kong from January 1997 to December 2002. Results: Of the 47 patients with carcinoma of gallbladder, 28 patients were treated symptomatically because they were found to have metastatic disease (n = 22), unresectable disease (n = 2) or poor associated medical disease (n = 4). One patient had carcinoma in-situ after laparoscopic cholecystectomy. No further treatment was considered necessary. The remaining 18 patients (38.3%) came to laparotomy after preoperative investigations with ultrasonography, computed tomography, endoscopic or percutaneous cholangiography, and visceral angiography. Laparoscopy and laparoscopic ultrasound were used in the later part of the study. Radical cholecystectomy was carried out in 14 patients (77.8%). The in-hospital mortality rate was 5.3% and the surgical morbidity was 31.6%. The remaining four patients underwent palliative cholecystectomy because of the extent of the disease. The overall 5-year survival for the 47 patients was 19.1%, for the 18 patients who came to laparotomy was 44.4%, and for the 14 patients who underwent resection with curative intent was 57.1%. Conclusions: With adequate preoperative investigations, and the use of laparoscopy and laparoscopic ultrasound, radical resection was possible in the majority of patients who came to laparotomy for carcinoma of gallbladder. Aggressive radical resection gave good results.

INTRODUCTIONCancer in pregnancy is rare and hepatocellular carcinoma (HCC) during pregnancy is even rarer. Due to limited experience, management of these patients remains challenging.PRESENTATION OF CASEA 33-year old pregnant lady presented with HCC at 28 weeks of gestation. She underwent synchronous cesarean section and right hepatectomy at 32 weeks of gestation. The post-operative course was uneventful. She was discharged home on day 10 after surgery. Histolopathology confirmed HCC. The surgical resection margins were clear. At a follow-up of 3 months after surgery, the mother was disease free and the infant was well.DISCUSSIONHCC during pregnancy is extremely rare. The experience in its management and outcomes are lacking. In managing any patient diagnosed with a malignant neoplasm in pregnancy, both the mother and the fetus have to be considered.CONCLUSIONWith adequate preoperative assessment and a good management strategy, good results can be obtained for both the mother and the baby for a pregnant patient with HCC.

Objective: We reported here a series of 49 patients with unresectable hepatocellular carcinoma (HCC) who underwent nonsurgical treatment to downstage the disease followed by salvage surgery, their long-term outcome, and pattern of recurrence. Summary Background Data: Most HCC patients present with unresectable disease and are treated with chemotherapy or intra-arterial therapy with a palliative intent. Occasionally, there are good responses to treatment so that salvage surgery becomes feasible afterward. However, long-term outcomes of these patients are seldom reported. Methods: Patients with unresectable hepatocellular carcinoma, from September 1993 to June 2002, who received salvage surgery after downstaging by systemic chemotherapy, intra-arterial yttrium-90 microspheres, or sequential treatment were included in this study. Systemic chemotherapy consisted of combination doxorubicin, cisplatin, interferon-alpha and 5-fluorouracil (5-FU), or single-agent doxorubicin. The choice of treatment was according to stage of disease and contemporary clinical trial protocol. Survival, recurrence pattern, and surgical outcome were studied. Results: There were 49 patients in this study with 40 males and 9 females, age ranged from 12 to 69 years. Forty patients (81.6%) were hepatitis B positive. Thirty-two patients had combination chemotherapy alone (65.3%), 8 patients had single agent chemotherapy alone (16.3%), 4 patients received intra-arterial yttrium-90 microspheres alone (8.2%), and 5 patients received sequential therapy (10.2%). Twenty-eight (57.1%) patients received major hepatic resection. Thirteen patients (26.5%) had complete necrosis of the tumor after treatment. Twenty-one patients (42.9%) had recurrence after surgery, and 14 of them were intrahepatic recurrence. The median survival was 85.9 months. The 1-year, 3-year, and 5-year survival rates were 98%, 64%, and 57%, respectively. Conclusions: Salvage surgery after successful downstaging can provide long-term control of disease in a small proportion of patients with unresectable hepatocellular carcinoma.

We describe the first reported case of tracheal necrosis following a thyroidectomy. This complication resulted in massive subcutaneous emphysema and pneumomediastinum. which required emergency exploration of the neck to decompress the trapped air. We also discuss the suggested etiology and management of this rare condition.

Objectives/Hypothesis Nasopharyngectomy is a well-established treatment option for recurrent nasopharyngeal carcinoma. Over a period of 4 years and 3 months, in a total of 43 patients, 45 nasopharyngectomies were performed. Thirty-one patients with follow-up ranging from 12 to 58 months were studied. Twenty-two patients (58%) survived; of these, 18 patients (82%) remained disease free. All patients who developed repeat recurrence or died (n = 12) had a high recurrent T-stage tumor, skull base involvement, multiple recurrences, positive surgical margins, or concurrent neck node metastasis. These factors are poor prognostic parameters and might mitigate the indications for aggressive salvage surgery. However, low recurrent T-stage tumor without neck metastasis carries a good prognosis. Modern minimally invasive surgery carries minimal morbidity. Study Design A retrospective study was made to determine prognostic indicators in patients treated with salvage surgery for recurrent nasopharyngeal carcinoma. Methods Medical records were analyzed for all patients who had received nasopharyngectomy for recurrent nasopharyngeal carcinoma from March 1997 to June 2001. They were followed up from March 1997 to January 2002. Recurrent T stage, nodal metastasis, surgical approach, surgical margins, and pathological nodal status, together with surgical mortality, morbidity, and the delivery of postoperative irradiation, were compared with survival. Results In all, 43 patients underwent 45 nasopharyngectomies over a period of 4 years and 3 months. Patients with less than 1 year of follow-up were excluded. Four patients with residual disease, who represent a more favorable group, and five patients with planned debulking, nasopharyngectomy, and postoperative stereotactic irradiation were also excluded. The study group comprised 25 men and 6 women (ratio of 4:1) with age ranging from 26 to 69 years (mean age, 49.5 y). In 28 patients (90.3%), the recurrence of nasopharyngeal carcinoma was their first recurrence; in 3 patients (9.7%), the recurrences were second recurrences. Twenty-two patients (71%) survived, achieving a mean survival of 28.5 months. Nine patients died with a mean interval of 7.8 months (range, 1–14 mo). Of the nine patients who died, six (67%) had T3 or T4 tumor, four (44.4%) had concurrent recurrent neck disease, and five (55.5%) had positive surgical margins. Two patients died of perioperative meningitis. Fifteen (83.3%) of the 18 disease-free survivors had a low recurrent T-stage tumor. Mean intervals for development of repeat recurrence or distant metastasis were 16 and 7.9 months, respectively. Conclusions High recurrent T stage, skull base involvement, repeated recurrence before surgery, nodal metastasis, and positive surgical margins carry a poor prognosis. This is particularly evident with high T stage and concurrent nodal metastasis. However, patients with low T stage have a survival advantage and benefit most from surgical treatment.