Laparoscopic or robotic surgery accounts for an increasing proportion of liver surgery. However, the lack of haptic feedback results in a certain amount of risk. The use of laparoscopic ultrasound (LUS) enables the operator to observe internal structures of the liver in real time to easily avoid the main blood vessels. It also allows for the detection of tumor boundaries and the extent of tumor thrombi, considerably improving the success rate of the operation. Besides its advantages in detecting small lesions that are not detectable through preoperative imaging, thus assisting diagnosis and staging, the LUS can also be used to monitor ablation therapy, portal vein puncture staining, and lesion blood perfusion. Recent advances in technology like contrast-enhanced intraoperative ultrasound and real-time virtual sonography can help surgeons better perform laparoscopic surgery. For liver surgeons, LUS is an essential technique for safely performing laparoscopic surgery, making their proficiency in the use of LUS vital. This article reviews the application of LUS in laparoscopic hepatic resection of liver tumors and the new technology of LUS to help liver surgeons understand the current application status of LUS and the future research directions.

Since the laparoscopic liver resection（LLR）had been first published for nearly 30 years，it has gradually developed into one of the standard radical operation for hepatocellular carcinoma（HCC）. In selected patients，LLR has achieved oncological curative effect that is not inferior to open liver resection，and its advantages are increasingly recognized. LLR could be divided into anatomic and non-anatomic liver resection，depending on whether the liver is pre-dissected or blocked from inflow and /or outflow. They have their own scope of application，advantages and disadvantages. How to choose laparoscopic anatomic liver resection or laparoscopic non-anatomic liver resection for HCC remain controversial．Combined with relevant literature and personal experience，this paper briefly discusses the selection and standardization of laparoscopic radical liver resection for HCC.

回顾性分析了2015年12月至2018年11月施行胸腔镜辅助微波消融治疗的6例Ⅶ、Ⅷ段膈顶部小肝癌患者的临床资料。所有患者均完成胸腔镜下微波消融治疗，无中转开腹手术。5例肿瘤初次达到完全消融，1例肿瘤消融不完全者经补救消融后达到完全消融；1例因合并严重脾功能亢进术后腹腔内渗血，经保守治疗后好转。术后随访时间8～43个月，所有患者局部消融部位病变无进展，3例肝内复发，1例发生胸腰椎转移。我们认为本方法安全可行，是一种治疗Ⅶ、Ⅷ段膈顶部小肝癌较为有效的治疗手段，但需严格把握手术适应证。

目的 探讨吲哚菁绿(ICG)荧光成像技术在肝癌切除术中识别微小肝癌的可行性和临床价值.方法 选取2016年12月至2017年9月中国医科大学附属盛京医院肝胆脾外科行肝癌切除术的患者59例.探测并记录肝癌切除术后离体标本中肿瘤及其周边肝组织的荧光显影情况,同时切取呈高亮显影的微小病灶(直径0.2～2.0 cm)及无显影的非癌性肝组织(直径=1 cm),后者作为对照,均行常规病理学检查.应用统计学方法分析肝癌及瘤周微小显影灶显影结果的影响因素.结果 59例患者中有50例肝癌显像,26例患者的离体标本探测出微小的瘤周显影灶;共发现微小显影灶65枚,其中4枚经病理证实为肝癌.统计学分析结果显示,肿瘤直径越大越易显影(P<0.05),肝癌肿瘤分化程度与其剖面荧光显影模式存在显著相关性(P<0.05).未找到瘤周微小显影灶显像的明显相关因素.在探测范围内,ICG荧光成像技术探测出肝癌瘤周微小癌灶的正确率为34.40％.结论 ICG荧光成像技术在检测肝表面微小肝癌方面有一定的临床价值.

BACKGROUND Undifferentiated embryonal sarcoma of the liver (UESL) is a rare liver malignancy originating from primary mesenchymal tissue. The clinical manifestations, laboratory tests, and imaging examinations of the disease lack specificity and the preoperative misdiagnosis rate is high. The overall prognosis is poor and survival rate is low. AIM To investigate the diagnosis, treatment, and prognosis of UESL. METHODS We performed a retrospective, single-center cohort study in Shengjing Hospital of China Medical University, which is a central hospital in northeast China. From 2005 to 2017, we recruited 14 patients with pathologically confirmed UESL. We analyzed the clinical manifestations, laboratory tests, imaging examinations, pathological examinations, therapy, and prognosis of these patients. RESULTS There were nine males and five females aged 2-60 years old included in the study. The major initial symptoms were abdominal pain (71.43%) and fever (57.14%). Preoperative laboratory tests revealed that seven patients had increased leukocyte levels, four showed a decrease in hemoglobin levels, seven patients had increased glutamyl transpeptidase levels, nine had increased lactate dehydrogenase levels, and three showed an increase in carbohydrate antigen 199. There was no difference in the rate of misdiagnosis in preoperative imaging examinations of UESL between adults and children (6/6 vs 5/8, P = 0.091). The survival rate after complete resection was 6/10, while that after incomplete resection was 0/4 (P = 0.040), suggesting that complete resection is important to improve survival rate. In total, five out of the eight children achieved survival. During the follow-up, the maximum survival time was shown to be 11 years and minimum survival time was 6 mo. Six adult patients relapsed late after surgery and all of them died. CONCLUSION Preoperative imaging examination for UESL has a high misdiagnosis rate. Multidisciplinary collaboration can improve the diagnostic accuracy of UESL. Complete surgical resection is the first choice for treatment of UESL.

Background Hepatocellular carcinoma (HCC) is still the most common cause of cancer-related mortality worldwide and accumulating studies report that HCC is frequently linked to chronic inflammation. G-protein alpha-subunit (GNAS)-activating mutations have recently been reported to form a rare subgroup of inflammatory liver tumors. In this study, we investigated the roles of GNAS in inflammation-related HCC progression and its underlying mechanism. Methods Lipopolysaccharides (LPS) and diethylnitrosamine were employed to stimulate HCC cells to an induced inflammatory response. qRT-PCR, immunohistochemistry and immunoblotting were performed to detect the expression of GNAS in HCC tissues and cell lines. Expression levels of proinflammatory cytokines were detected by qRT-PCR and ELISA. N6-methyladenosine (m6A) methylation of GNAS mRNA was detected by RNA-binding protein immunoprecipitation (RIP). Transcription factors activation profiling plate array was performed to investigate the underlying mechanism in GNAS promoting interleukin-6 (IL-6) expression in HCC cells. HCC cell invasion was determined by transwell assay in vitro, and tumorigenesis was assessed with a subcutaneous xenograft mouse model of HCC. Results We found that LPS stimulation promotes GNAS expression in HCC cells through increasing m6A methylation of GNAS mRNA. The high expression level of GNAS promotes LPS-induced HCC cell growth and invasion by interacting with signal transducer and activator of transcription 3 (STAT3). Furthermore, GNAS knockdown inhibits LPS induced-IL-6 expression in HCC cells by suppressing STAT3 activation. Moreover, we found that GNAS promotes LPS-induced STAT3 activation in HCC cells through inhibiting long non-coding RNA TPTEP1 interacting with STAT3. In addition, GNAS expression promotes HCC development in mice and is related to poor survival. Conclusions Our findings for the first time indicate a tumor-promoting role of GNAS in inflammation-related HCC progression and provide a novel potential target for HCC therapy.

目的 比较微波消融辅助腹腔镜肝切除与单纯腹腔镜肝切除治疗肝癌的临床疗效.方法 回顾性分析2013年1月至2016年6月在中国医科大学附属盛京医院行腹腔镜肝切除手术的70例原发性肝癌临床资料,将其分为微波消融辅助腹腔镜肝切除组(微波辅助组,n =40)和单纯腹腔镜肝切除组(单纯切除组,n=30).比较两组的临床疗效及预后.结果 两组手术时间、术后住院时间、术后进食时间、术后切缘复发情况及术后肝功能指标比较均无统计学差异(P＞0.05).微波辅助组术中出血量显著低于对照组[(36.2±12.3)ml vs (186.7±16.2)ml,P＜0.01],术后拔管时间显著短于对照组[(3.3±1.0)d vs(5.2±1.3)d,P＜0.01].微波辅助组和单纯切除组术后1年、2年的无瘤生存率比较无统计学差异(89.4％ vs 87.8％,65.5％ vs 42.8％,P＞0.05).微波辅助组术后1年、2年的总体生存率高于单纯切除组(100％ vs 91.7％,90.9％ vs 68.8％,P＜0.05).结论 微波消融辅助腹腔镜肝切除相比于单纯腹腔镜肝切除治疗肝癌术中出血更少、更安全,预后更好.

目的 探讨肝血管瘤术中应用自体血回输技术的优势、存在的问题和应用指征.方法 纳入中国医科大学附属盛京医院2014年4月至2018年10月接受手术治疗且术中应用自体血回输的肝血管瘤病人的临床资料,根据肿瘤位置、肿瘤直径将51例病例资料分为"简单组"和"复杂组".分析病人围手术期指标和术后并发症.结果 两组病人性别、年龄、肿瘤数量、肝门阻断情况及手术方式差异无统计学意义(P>0.05),但"复杂组"肿瘤直径大于"简单组"(P=0.035)."复杂组"的手术时间、失血量和回输血量均高于"简单组"(P<0.05)."简单组"和"复杂组"中分别有1例和5例额外输入异体血,但二者差异无统计学意义(P>0.05);两组病人术后胃肠道功能恢复时间、留置引流管时间、术后住院时间差异均无统计学意义(均P>0.05);术后并发症主要包括盆腹腔积液、胸腔积液、肺不张、胆汁漏和术后腹腔内出血,两组差异均无统计学意义(均P>0.05)."复杂组"中未输异体血的病例术后血常规及凝血功能指标均无较大波动,可在短期内恢复正常.所有病人围手术期未见过敏、溶血、发热等输血相关不良反应.结论 肝血管瘤术中应用自体血回输疗效可靠且安全,有一定经济效益.位于肝4a段、6段、7段和尾状叶的肿瘤,以及位于肝左外叶、4b段、5段和8段且瘤体≥10 cm的肿瘤更符合应用指征.

PURPOSE:In this study, we evaluated the efficacy of microwave ablation-assisted laparoscopic hepatectomy (MLH) for the management of hepatocellular carcinoma (HCC) in cirrhotic patients. METHODS:Data from HCC patients with liver cirrhosis who underwent laparoscopic hepatectomy (LH) or MLH in Shengjing Hospital (Shenyang, China) were retrospectively analyzed from January 2013 to June 2017. The demographic characteristics, clinical features, intraoperative parameters and surgical outcomes were analyzed and compared. Propensity scores matching (PSM) analysis was used to minimize bias. RESULTS:A total of 54 patients were enrolled in the MLH group and 39 patients in the LH group. Following 1:1 matching by PSM analysis, 26 patients were selected from each group. Compared to the LH group, patients in the MLH group had significantly decreased intraoperative bleeding (48.0 vs. 203.9 ml, p < .0001) and reduced demand for hepatic inflow occlusion (0 vs. 6, p = .009). No significant difference was observed in average operation time (155.7 vs. 148.5 min) and postoperative hospitalization time (8.3 vs. 9.3 d) between the MLH and LH groups. Similarly, the 1-year and 3-year recurrence-free survival (RFS) rates as well as the 1-year and 3-year overall survival (OS) rates of the MLH and LH groups were not significantly different (83.1 vs. 82.4% and 64.6 vs. 36.6% as well as 100 vs. 95.8% and 93.8 vs. 59.1%, respectively: p > .05). CONCLUSIONS:MLH significantly decreased intraoperative bleeding and reduced the need for hepatic occlusion without compromising the surgical outcome. Therefore, microwave ablation could be a valuable tool for LH in HCC patients with cirrhosis.

肝门板的概念于1957年由Couinaud首先提出.历经60多年的探索与实践,与其相关的肝门板显露技术包括下降肝门板技术、Glisson鞘外肝蒂解剖技术等已在开放与腹腔镜下解剖性肝切除的血流阻断与处理、肝门部复杂肿瘤的切除,以及肝胆管结石和高位胆管损伤狭窄修复手术等方面的应用越来越广泛,且为减低围肝门区手术难度,增加手术安全性提供了更多的技术保障,已成为肝胆外科医生的临床必修课.

BACKGROUND This study investigated the effect of 70% portal vein ligation (PVL), a widely used procedure for inducing rapid liver regeneration, on the expression of autophagy-related proteins in non-ligated liver lobes in rats. MATERIAL AND METHODS Rats were subjected to either sham (n=30, major portal vein branches were exposed but kept intact) or PVL (n=30, major portal vein branches were double-ligated) operations. Liver samples were collected 12, 24, 48, 72, and 168 h after the operation. Liver volume, liver color, non-ligated liver percentage, and the expressions of light chain (LC) 3, beclin 1, and cyclin D1 in the non-ligated liver lobes were determined. RESULTS When compared to sham rats, increased (P<0.001) growth of the non-ligated liver lobes was observed in PVL rats as early as 12 h after surgery; an increased (P≤0.001) LC3 II/I ratio was observed in the non-ligated lobes of PVL rats as early as 24 h after surgery. Increased expressions of beclin 1 (P≤0.001) and cyclin D1 (P<0.001) were observed in the non-ligated lobes of PVL rats from 12 to 72 h after surgery and from 12 to 168 h after surgery, respectively, when compared to sham rats. In the non-ligated lobes, the expressions of beclin 1 and cyclin D1 were linearly and positively correlated with the LC3 II/I ratio. CONCLUSIONS Autophagy is activated in the non-ligated liver after PVL. Both beclin 1 and cyclin D1 are linearly and positively correlated with autophagy activity in the PVL-induced rapid liver regeneration model.

肝脏良性肿瘤(benign liver tumors,BLTs)除肝血管瘤外,较为少见,但一直是临床肝胆外科专家争议较多的问题.近年来,随着影像学技术的发展,肝脏良性病变的检出率不断提高,也积累了较为丰富的诊治经验,要切实提高对BL T s的规范化诊治水平,则还需做大量的探索与实践.

目的 比较手术切除与经导管动脉化疗栓塞术(TACE)治疗肝细胞癌合并Ⅰ/Ⅱ型门静脉癌栓(portal vein tumor thrombus,PVTT)病人的疗效.方法 选取中国医科大学附属盛京医院肝胆脾外科和介入科2012年6月至2017年12月收治的58例肝细胞癌合并Ⅰ/Ⅱ型门静脉癌栓(程氏分型)的病人为研究对象,分为外科切除治疗组(28例)和TACE治疗组(30例),比较两组长期生存率,并分析病人总体生存的独立危险因素.生存分析使用Kaplan-Meier法和Log-rank检验.多因素分析使用Cox比例风险回归模型.结果 外科切除治疗组的中位生存期为13.0个月,0.5、1、2、3年生存率分别为74.7％、54.1％、29.2％、14.6％;TACE治疗组的中位生存期为6.4个月,0.5、1、2、3年生存率分别为53.3％、23.3％、13.3％、8.9％ (P=0.036).多因素分析显示多个肿瘤(HR=2.578;95％CI:1.365,4.868,P=0.004),天冬氨酸转氨酶(AST) ＞34 U/L(HR=2.509;95％CI:1.266,4.972,P=0.008)是影响长期生存的独立影响因素.结论 对于肝细胞癌伴Ⅰ/Ⅱ型门静脉癌栓病人,外科手术切除治疗明显好于TACE治疗,多个肿瘤和AST＞34 U/L是病人术后总体生存的独立影响因素.

Hepatocellular carcinoma (HCC) is the sixth-most common cancer and the third leading cause of cancer-related death in the world. However, 40-70% patients eventually suffer from postoperative recurrence within 5 years. HCC recurrence after surgery severely affects prognosis of the patients. Nevertheless, there is an opportunity to improve patients' prognosis if doctors and researchers can recognize the importance of a standardized perioperative management and study it in clinical and pre-clinical settings. Hence, based on our own experience and published studies from other researchers, we develop this consensus regarding multidisciplinary management of locally recurrent and metastatic hepatocellular carcinoma after resection. This consensus consists of the entire course of recurrent hepatocellular carcinoma (RHCC) management, including prediction of recurrence, prevention, diagnosis, treatment and surveillance of RHCC. Consensus recommendations are presented with grades of evidences (Ia, Ib, IIa, IIb, III and IV), and strength of recommendations (A, B, C, D and E). We also develop a decision-making path for RHCC treatment, which can intuitively demonstrate the management for RHCC. It is hoped that we may make some effort to standardize the management of RHCC and ultimately understand how to improve outcomes.

手术切缘是影响肝癌术后复发的重要因素之一.阴性手术切缘(R0)可以降低肝癌术后复发率,但手术切缘的大小和术后复发及预后的关系研究结果尚不统一.在满足剩余肝体积足够的情况下,≥1 cm是多数情况下推荐的手术切缘标准.但肝癌的术后复发受多种因素影响,是手术彻底性和手术安全性之间的平衡问题.肝癌治疗效果的提高是一个系统工程,R0仅是其中的目标或问题之一.根据肿瘤的生物学和影像学特点,借助越来越先进的检查和治疗技术,个体化的多学科综合治疗仍将是降低肝癌术后复发、改善预后最为重要的手段或途径.

Objective To explore how to reasonably use antibiotics to prevent surgical site infection (SSI) after hepatectomy for hepatocellular carcinoma. Methods Retrospective analysis was carried out for the clinical data of 281 patients with liver cancer who underwent open hepatectomy in Shengjing Hospital from May 2009 to July 2015 and conformed to the inclusion criteria. According to different antibiotic application regimen in perioperative period, the patients were divided into ertapenem group (n = 57, treated with single dose of ertapenem before surgery) and non-ertapenem group (n = 224, treated with non-ertapenem antibiotics before and after surgery). The incidence of SSI was compared between two groups. Results The total incidence of SSI was 16.4％ (46/281). There were significant differences in incidences of SSI [3.5％(2/57) vs 19.6％(44/224) ]and organ/space infection [3.5％(2/57) vs 16.1％(36/224) ]between ertapenem group and non-ertapenem group(P ＜ 0.05, P ＜ 0.01). There were no significant differences in the infection rates of surgical incision [1.8％ (1/57) vs 7.6％ (17/224) ]and the infection rates of fungus/methicillin-resistant staphylococcus aureus (MRSA) [0 (0/57) vs 3.1％ (7/224) ]between ertapenem group and non-ertapenem group (all P ＞ 0.05). In nonertapenem group, the infection rate of fungus/MRSA in patients with antibiotic use time less than 6 days was significantly lower than that in patients with antibiotic use time more than or equal to 6 days [0.7％ (1/135) vs 6.7％ (6/89), P ＜ 0.05]. Conclusions Preoperational use of single dose of ertapenem can effectively prevent the occurrence of SSI after hepatectomy in patients with hepatocellular carcinoma. The use of antibiotics after operation does not further reduce the incidence of SSI, on the contrary, long time application could increased the risk of fungal/MRSA infection.

A 14-year-old girl presented with right upper abdominal swelling for two months. Physical examination revealed palpable hepatomegaly. Her laboratory analysis revealed a mild anemia (HGB: 108 g/L). The tests for liver function were normal. The Child-Pugh score was A grade. The tests for hepatitis B and C viruses were negative.

Objective. This study aimed to assess whether a single dose of ertapenem prophylaxis was more effective than other antibiotics to prevent surgical site infection (SSI) after selective hepatectomy for hepatocellular carcinoma (HCC). Methods. The data from HCC patients with open hepatectomy between January 2012 and June 2017 in Shengjing Hospital were retrospectively analyzed. These patients were divided into two groups: ertapenem(ER) group, where a single dose of ER was administered; non-ertapenem(NER) group, where NER antibiotics were administered. The SSI rates were compared between two groups before and after matching the propensity scores. Results. The enrolled patients consisted of 78 in the ER group and 197 in the NER group. After matching the propensity scores, each group was down-selected to 65 patients. The SSI rate among the matched 130 patients was 14.6%, 7.7% occurred in the ER group and 21.5% in the NER group (P<0.05). The SSI rates in organ/space of the ER and NER groups were 3.1% and 13.8%, respectively (P<0.05). Conclusions. A single dose of ER before surgery was more effective in mitigating SSI after selective hepatectomy compared with other antibiotics use. The results imply that the selection of both antibiotics and administration timing is important for the efficacy in preventing SSI.

Background/Aims Hepatic ischemia-reperfusion (I/R) injury is a serious concern during hepatic vascular occlusion. The objectives of this study were to assess effects of three techniques for hepatic vascular occlusion on I/R injury and to explore the underlying mechanisms. Methods Liver cirrhotic rats had undertaken Pringle maneuver (PR), hemihepatic vascular occlusion (HH), or hepatic blood inflow occlusion without hemihepatic artery control (WH). Levels of tumor necrosis factor alpha (TNF-α), nuclear factor kappa B (NF-κB), toll-like receptor 4 (TLR4), TIR-domain-containing adapter-inducing interferon-β (TRIF), and hemeoxygenase 1 (HMOX1) were assayed. Results The histopathologic analysis displayed that liver harm was more prominent in the PR group, but similar in the HH and WH groups. The HH and WH groups responded to hepatic I/R inflammation similarly but better than the PR group. Mechanical studies suggested that TNF-α/NF-κB signaling and TLR4/TRIF transduction pathways were associated with the differential effects. In addition, the HH and WH groups had significantly higher levels of hepatic HMOX1 (P < 0.05) than the PR group. Conclusions HH and WH confer better preservation of liver function and protection than the Pringle maneuver in combating I/R injury. Upregulation of HMOX1 may lead to better protection and clinical outcomes after liver resection.

Objective This article aims to compare the outcomes between hepatic resection and microwave ablation for patients with hepatitis virus-related hepatocellular carcinoma (HCC) and portal hypertension in early stage,in order to evaluate the safety and efficacy of hepatic resection.Methods A series of 89 hepatitis virus-related HCC and portal hypertension in BCLC early stage from 2012 to 2016 were retrospectively analyzed.Patients were divided into 2 groups:hepatic resection group (n =41) and microwave ablation group (n =48).Then the predictive factors of prognosis were analyzed and the outcomes of survival rate were compared.Results As compared with the microwave ablation group,Patients in the liver resection group had bigger tumor sizes (3.6 ± 1.7 cm vs.2.4± 0.95 cm,P =0.01) and better liver reserve function (ICG R15＞10％:19％ vs.66.7％,P =0.01) than in the microvave ablation group.Univariate and multivariate analysis revealed that the AFP level ＞400 μg/L (P =0.019) and perioperative blood transfusion (P =0.001) were predictive factors of overall survival in the entire study population of 89 patients with HCC and portal hypertension in BCLC early stage.Although the overall survival of hepatic resection group and microwave ablation group was comparable (P =0.908),the hepatic resection group had better outcomes of the recurrence-free survival (P =0.033).Conclusions Under the premise of good liver reserve function,the hepatic resection is a safe and effective option for patients with HCC and portal hypertension in BCLC early stage.And microwave ablation is applicable for the patients with small HCC and poor liver reserve function.