Background
Laparoscopic major hepatectomy (LMH) is evolving as an important surgical approach in hepatopancreatobiliary surgery. The present study aimed to evaluate the learning curve for LMH at a ...single centre.
Methods
Data for all patients undergoing LMH between January 1998 and September 2013 were recorded in a prospective database and analysed. The learning curve for operating time (OT) was evaluated using the cumulative sum (CUSUM) method.
Results
Of 173 patients undergoing major hepatectomy, left hepatectomy was performed in 28 (16·2 per cent), left trisectionectomy in nine (5·2 per cent), right hepatectomy in 115 (66·5 per cent), right trisectionectomy in 13 (7·5 per cent) and central hepatectomy in eight (4·6 per cent). Median duration of surgery was 270 (range 100–540) min and median blood loss was 300 (10–4500) ml. There were 20 conversions to an open procedure (11·6 per cent). Vascular clamping was independently associated with conversion on multivariable analysis (hazard ratio 5·95, 95 per cent c.i. 1·24 to 28·56; P = 0·026). The CUSUMOT learning curve was modelled as a parabola (CUSUMOT = 0·2149 × patient number2 − 30·586 × patient number − 1118·3; R2 = 0·7356). The learning curve comprised three phases: phase 1 (45 initial patients), phase 2 (30 intermediate patients) and phase 3 (the subsequent 98 patients). Although right hepatectomy was most common in phase 1, a significant decrease was observed from phase 1 to 3 (P = 0·007) in favour of more complex procedures.
Conclusion
The learning curve for LMH consisted of three characteristic phases identified by CUSUM analysis. The data suggest that the learning phase of LMH included 45 to 75 patients.
Safe in experienced hands
Background
Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could ...offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).
Methods
Data for all patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were reviewed retrospectively. Risk factors for conversion were determined using multivariable analysis. After propensity score matching, the outcomes of patients who underwent conversion were compared with those of matched patients undergoing laparoscopic hepatectomy who did not have conversion, operated on at the same centres, and also with matched patients operated on at another tertiary centre during the same period by an open laparotomy approach.
Results
Conversion was needed in 30 (13·5 per cent) of the 223 patients undergoing LMH. The most frequent reasons for conversion were bleeding and failure to progress, in 14 (47 per cent) and nine (30 per cent) patients respectively. On multivariable analysis, risk factors for conversion were patient age above 75 years (hazard ratio (HR) 7·72, 95 per cent c.i. 1·67 to 35·70; P = 0·009), diabetes (HR 4·51, 1·16 to 17·57; P = 0·030), body mass index (BMI) above 28 kg/m2 (HR 6·41, 1·56 to 26·37; P = 0·010), tumour diameter greater than 10 cm (HR 8·91, 1·57 to 50·79; P = 0·014) and biliary reconstruction (HR 13·99, 1·82 to 238·13; P = 0·048). After propensity score matching, the complication rate in patients who had conversion was higher than in patients who did not (75 versus 47·3 per cent respectively; P = 0·038), but was not significantly different from the rate in patients treated by planned laparotomy (79 versus 67·9 per cent respectively; P = 0·438).
Conclusion
Conversion during LMH should be anticipated in patients with raised BMI, large lesions and biliary reconstruction. Conversion does not lead to increased morbidity compared with planned laparotomy.
Conversion does not increase morbidity
Background
Although laparoscopic major hepatectomy (MH) is becoming increasingly common in several specialized centres, data regarding outcomes are limited. The aim of this study was to identify the ...risk factors for postoperative complications of purely laparoscopic MH at a single centre.
Methods
All patients who underwent purely laparoscopic MH between January 1998 and March 2014 at the authors' institution were enrolled. Demographic, clinicopathological and perioperative factors were collected prospectively, and data were analysed retrospectively. The dependent variables studied were the occurrence of overall and major complications (Dindo–Clavien grade III or above).
Results
A total of 183 patients were enrolled. The types of MH included left‐sided hepatectomy in 40 patients (21·9 per cent), right‐sided hepatectomy in 135 (73·8 per cent) and central hepatectomy in eight (4·4 per cent). Median duration of surgery was 255 (range 100–540) min, and median blood loss was 280 (10–4500) ml. Complications occurred in 100 patients (54·6 per cent), and the 90‐day all‐cause mortality rate was 2·7 per cent. Liver‐specific and general complications occurred in 62 (33·9 per cent) and 38 (20·8 per cent) patients respectively. Multivariable analysis identified one independent risk factor for global postoperative complications: intraoperative simultaneous radiofrequency ablation (RFA) (odds ratio (OR) 6·93, 95 per cent c.i. 1·49 to 32·14; P = 0·013). There were two independent risk factors for major complications: intraoperative blood transfusion (OR 2·50, 1·01 to 6·23; P = 0·049) and bilobar resection (OR 2·47, 1·00 to 6·06; P = 0·049).
Conclusion
Purely laparoscopic MH is feasible and safe. Simultaneous RFA and bilobar resection should probably be avoided.
Careful with bilobar resections
B7-H3 is a new member of the B7 ligand family and regulates T-cell responses in various conditions. However, the role of B7-H3 in tumour immunity is largely unknown. The purpose of this study was to ...evaluate the clinical significance of B7-H3 expression in human pancreatic cancer and the therapeutic potential for cancer immunotherapy.
We investigated B7-H3 expression in 59 patients with pancreatic cancer by immunohistochemistry and real-time PCR. Furthermore, we examined the anti-tumour effect of B7-H3-blocking monoclonal antibody in vivo in a murine pancreatic cancer model.
Tumour-related B7-H3 expression was abundant in most human pancreatic cancer tissues and was significantly higher compared with that in non-cancer tissue or normal pancreas. Moreover, its expression was significantly more intense in cases with lymph node metastasis and advanced pathological stage. B7-H3 blockade promoted CD8(+) T-cell infiltration into the tumour and induced a substantial anti-tumour effect on murine pancreatic cancer. In addition, the combination of gemcitabine with B7-H3 blockade showed a synergistic anti-tumour effect without overt toxicity.
Our data show for the first time that B7-H3 may have a critical role in pancreatic cancer and provide the rationale for developing a novel cancer immunotherapy against this fatal disease.
Background
Despite the gradual diffusion of laparoscopic liver resection, the feasibility and results of laparoscopic two‐stage hepatectomy (TSH) for bilobar colorectal liver metastases (CRLM) have ...not been described frequently. This study aimed to evaluate the feasibility, safety and oncological outcomes of laparoscopic TSH for bilobar CRLM.
Methods
All patients eligible for laparoscopic TSH among those treated for bilobar CRLM from 2000 to 2013 were included. Demographics, tumour characteristics, surgical procedures, and short‐ and long‐term outcomes were analysed.
Results
Laparoscopic TSH was planned in 34 patients with bilobar CRLM, representing 17·2 per cent of all 198 patients treated for bilobar CRLM. Thirty patients received preoperative chemotherapy, and 20 had portal vein occlusion to increase the volume of the remnant liver. Laparoscopic resection of the primary colorectal tumour was integrated within the first‐stage hepatectomy in 11 patients. After a median interval of 3·1 months, 26 patients subsequently had a successful laparoscopic second‐stage hepatectomy, including 18 laparoscopic right or extended right hepatectomies. The mortality rate for both stages was 3 per cent (1 of 34), and the overall morbidity rate for the first and second stages was 50 per cent (17 of 34) and 54 per cent (14 of 26) respectively. Mean length of hospital stay was 6·1 and 9·0 days respectively. With a median follow‐up of 37·8 (range 6–129) months, 3‐ and 5‐year overall survival rates in patients who completed TSH were 78 and 41 per cent respectively. The 3‐ and 5‐year disease‐free survival rates were 26 and 13 per cent respectively.
Conclusion
Laparoscopic TSH for bilobar CRLM is safe and does not jeopardize long‐term outcomes in selected patients.
For expert centres
Asthma is associated with increased numbers of T-cells in the lung. CC chemokine receptor (CCR)5 and CXC chemokine receptor (CXCR)3 have been reported to play important roles in the lung T-cell ...homing pathway, and may be potential targets for asthma therapy. The aim of the present study was to investigate the role of CCR5 and CXCR3 in allergen-induced acute asthma and to determine whether a novel small-molecule compound, TAK-779, targeting CCR5 and CXCR3 can attenuate allergic airway responses. Mice were sensitised with ovalbumin (OVA). mRNA expression of chemokine receptors in the lung were measured after the challenge with either aerosolised phosphate-buffered saline or OVA. OVA-sensitised mice were also treated with TAK-779. Respiratory function was measured, bronchoalveolar lavage was performed, and blood and lung samples were obtained. OVA challenge increased CCR3, CCR5 and CXCR3 expression in the lung. Treatment with TAK-779 significantly attenuated altered respiratory function and pulmonary allergic inflammation. The beneficial effect was associated with reduced expression of CCR5 and CXCR3 in the lung. These data demonstrate that blockade of CC chemokine receptor 5 and CXC chemokine receptor 3 using TAK-779, a synthetic nonpeptide compound, can prevent the development of asthma features in a mouse model. Thus, CC chemokine receptor 5 and CXC chemokine receptor 3 may be potential targets for asthma therapy.
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