Insufficient future liver remnant is one of the main reasons for initially unresec-table of hepatocellular carcinoma (HCC). Surgical or interventional treatments can promote the hyper-trophy of insufficient remnant liver, thus enabling the post-conversion resection of HCC. Commonly used methods to promote liver hypertrophy include portal vein ligation, portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and liver venous depriva-tion. All of these four treatmental methods can promote liver hypertrophy, but there are also certain differences in terms of safety and the efficiency of promoting liver hypertrophy. With the continuous development of concepts and methods in surgical treatment, local non-surgical treatment and systemic therapy of HCC, individualized, multi-mode, and multi-dimensional comprehensive treatments guided by the concept of multidisciplinary comprehensive treatment and combined with the specific situation of patients, team diagnosis and treatment experience, and technical conditions, are being widely used in the conversion therapy of HCC with insufficient future liver remnant, and help to further improve the survival prognosis of HCC patients. Herein, the authors comprehensively review relevant research progress and elaborate on the strategies, methods, and future development trends of conversion therapy for HCC with insufficient future liver remnant.

Insufficient future liver remnant is one of the main reasons for initially unresec-table of hepatocellular carcinoma (HCC). Surgical or interventional treatments can promote the hyper-trophy of insufficient remnant liver, thus enabling the post-conversion resection of HCC. Commonly used methods to promote liver hypertrophy include portal vein ligation, portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and liver venous depriva-tion. All of these four treatmental methods can promote liver hypertrophy, but there are also certain differences in terms of safety and the efficiency of promoting liver hypertrophy. With the continuous development of concepts and methods in surgical treatment, local non-surgical treatment and systemic therapy of HCC, individualized, multi-mode, and multi-dimensional comprehensive treatments guided by the concept of multidisciplinary comprehensive treatment and combined with the specific situation of patients, team diagnosis and treatment experience, and technical conditions, are being widely used in the conversion therapy of HCC with insufficient future liver remnant, and help to further improve the survival prognosis of HCC patients. Herein, the authors comprehensively review relevant research progress and elaborate on the strategies, methods, and future development trends of conversion therapy for HCC with insufficient future liver remnant.

Objective:To study the expression of forkhead box P1 (FOXP1) in intrahepatic cholangiocarcinoma (ICC), and its clinicopathological and prognostic significance.Methods:The clinical data of ICC patients treated with radical resection at Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 1, 2013 to December 12, 2019 were retrospectively analysed. Of 48 ICC patients, there were 24 males and 24 females, with age of (59.1±10.1) years old (range 42 to 83 years old). Their clinicopathological data, including age, gender, tumor size, degree of differentiation, and staging were recorded. Immunohistochemical method was used to detect the expression of FOXP1 protein in ICC cancer tissues and the corresponding adjacent normal tissues. Kaplan-Meier method was used to calculate survival rates and to construct survival curves of patients. Cox regression model was used to analyze factors affecting prognosis of patients.Results:Forty-eight ICC cancer tissues and 40 corresponding paracancerous tissues were collected. The positive rates of FOXP1 proteins in ICC were significantly lower than the adjacent normal tissues [54.2%(26/48) vs. 92.5%(37/40), χ 2=15.76, P<0.05]. The degrees of tumor differentiation, lymph node metastasis, organ invasion and TNM staging were related to expression of FOXP1 ( P<0.05). Forty-two patients were followed-up with a median follow-up time of 11.5 (7.75, 19.25) months. Cox multivariate analysis revealed that invasion to adjacent organs, lymph node metastasis, high TNM staging (stage Ⅲ) and negative expression of FOXP1 were independent risk factors affecting overall survival of ICC patients. The overall survival and recurrence-free survival of FOXP1-positive ICC patients were 17.5 months and 15.5 months, which were significantly higher than the 14.0 months and 11.1 months, respectively, in FOXP1-negative patients. Conclusion:Negative FOXP1 expression was closely correlated with aggressive biological behavior and poor prognosis of ICC. FOXP1 may be used as new diagnostic and therapeutic targets.

Objective To assess the effects of limited hepatectomy on liver regeneration and function recovery of cirrhotic animal model.Methods Cirrhotic rat models were first prepared by intraperitoneal injection of CCL4.After that,the cirrhotic animal models underwent 20％ hepatectomy (n =30).The cirrhotic animals that underwent sham operation (n =30) and normal animals that underwent 20％ hepatectomy (n =30) were used as control groups.From the time when cirrhotic models were prepared to 3 months after 20％ hepatectomy,the hepatic function,coagulation function were tested regularly.Western blotting and real-time PCR were carried out to test the protein and gene expression of TGF-β,HGF and PCNA.Results Hepatic fibrosis and cirrhosis were observed during the preparation of cirrhotic rat models by intraperitoneal injection of CCL4.The hepatic function and coagulation function of cirrhotic models were partly recovered 3 month after 20％ hepatectomy.The gene and protein expression levels of TGF-β in the liver of animal model get higher during the preparation of cirrhotic rat models.However,the gene and protein expression levels of TGF-β get lower in cirrhotic model undergoing 20％ hepatectomy,when compared with that in cirrhotic animals (sham operation) and normal animals (20％ hepatectomy).Furthermore,the gene and protein expression levels of HGF and PCNA get higher in cirrhotic model undergoing 20％ hepatectomy,when compared with that in cirrhotic animals (sham operation) and normal animals (20％ hepatectomy).Conclusions Experimental limited hepatectomy facilitates the liver regeneration and function recovery of cirrhotic animal model,which may provide a novel method for the prevention and treatment of cirrhosis using limited hepatectomy technique.

Objective To investigate the feasibility of spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy for the treatment of pancreatic cystic tumor of body and tail.Methods The clinical data of a female patient with pancreatic cystic tumor of body and tail who was admitted to the Sun Yat-Sen Memorial Hospital of the Sun Yat-Sen University in March 2013 were retrospectively analyzed.Spleen-and splenic vesselspreserving laparoscopic distal pancreatectomy was determined as the optimal therapeutic method according to the physical examination and the results of computered tomography scan.Laparoscopic or open operation combined with distal pancreatectomy and splenectomy would be carried out as a candidate choice once it is hard to separate the splenic artery and vein from distal pancreas or to control the serious vessels hemorrhage.The patient was followed up by outpatient examination every 1 to 3 months up to March 2015.Results Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy was finished successfully.The operation time and volume of intraoperative blood loss were 192 minutes and 50 mL,respectively.The patient took out-of-bed for activity at postoperative day 1 without complications.The multiple severe microcystic pancreatic adenoma was confirmed by postoperative pathological examination,with a maximum diameter of 3.5cm.The leakage tube was removed at postoperative day 5.The levels of serum amylase at postoperative day 1,3,5 were normal.The patient was discharged at postoperative day 8 and got regular follow-up without bleeding,pancreatic fistula,infection and a symptom of epigastric pain or discomfort.Conclusion Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy has advantages of less traumas,faster postoperative recovery and a preservation of normal splenic function,deserving clinical application.

ObjectiveTo investigate the clinical application value of early enteral nutrition after laparoscopic hepatectomy for hepatocellular carcinoma (HCC).MethodsA total of 49 patients with HCC undergoing laparoscopic hepatectomy in Sun Yat-sen Memorial Hospital of Sun Yat-sen University between November 2013 and June 2014 were included in this prospective study. These patients were divided into the enteral nutrition group and the parenteral nutrition group according to the random number table method. Twenty-five patients were divided into the enteral nutrition group, among them, 20 were males and 5 were females with the average age of (49±17) years old. Twenty-four patients were divided into the parenteral nutrition group, among them, 18 were males and 6 were females with the average age of (51±14) years old. The informed consents of all patients were obtained and the local ethical committee approval had been received. The patients in the enteral nutrition group were given Ensure nutrient solution orally 24 h after operation for 7 d and the patients in the parenteral nutrition group were given parenteral nutrition 24 h after operation for 7 d. The total human albumin supplemented volume, recover time of gastrointestinal function, length of hospital stay after operation and hospitalization expenses of the two groups were compared. The nutritional support associated complications were observed. The data of the two groups were compared usingt test or Wilcoxon rank-sum test.ResultsThe total human albumin supplemented volume after operation of the enteral nutrition group was (40±11) g, which was signiifcantly lower than (45±10) g of the parenteral nutrition group(t=-16.089,P<0.05). The recovery time of gastrointestinal function after operation of the enteral nutrition group was (25±8) h, which was signiifcantly shorter than (43±11) h of the parenteral nutrition group (t=-36.928,P<0.05). The length of hospital stay after hepatectomy of the enteral nutrition group was (8±2) d, which was signiifcantly lower than (10±3) d of parenteral nutrition group (t=-12.025,P<0.05). The total hospitalization expenses of the enteral nutrition group were RMB 45,000 (37,000-61,000) yuan, which were signiifcantly lower than RMB 49,000 (42,000-67,000) yuan of the parenteral nutrition group (Z=-18.495,P<0.05). Five patients in the enteral nutrition group and 8 patients in the parenteral nutrition group developed abdominal distention and diarrhea, which were alleviated by adjusting doses or infusion speed. ConclusionsEarly enteral nutrition after laparoscopic hepatectomy for HCC is beneifcial to the postoperative recovery of gastrointestinal function and may effectively reduce the ifnancial burden of patients. Moreover, its overall curative effect is better than that of parenteral nutrition.

ObjectiveTo investigate the safety and curative effect of laparoscopic microwave coagulation combined with hepatectomy for liver cirrhosis complicated with hepatocellular carcinoma (HCC).MethodsClinical data of 58 patients with liver cirrhosis complicated with HCC diagnosed and treated in Sun Yat-sen Memorial Hospital of Sun Yat-sen University between Janunary 2009 and November 2013 were retrospectively studied. The patients were divided into the microwave coagulation combined with hepatectomy group (the combination group) and the simple microwave coagulation group (the coagulation group) according to different treatment methods. Among the 37 patients in the combination group, 29 were males and 8 were females with average age of (54±9) years old. Among the 21 patients in the combination group, 17 were males and 4 were females with average age of (58±10) years old. The informed consents of all patients were obtained and the local ethical committee approval had been received. The patients in the coagulation group only underwent laparoscopic microwave coagulation, while the patients in the combination group underwent hepatectomy after marking a incision line 1-2 cm from the tumor edge and undergoing microwave coagulation. The intraoperative blood loss and the duration of operation of two groups were observed. The comparison of the intraoperative blood loss and the duration of operation were conducted using Wilcoxon rank-sum test and the survival analysis was conducted using Log-rank test and Z test.ResultsThe intraoperative blood loss of the combination group was 146 (58-250) ml, which was signiifcantly higher than 13 (10-25) ml of the coagulation group (Z=7.824,P<0.05). The duration of operation of the combination group was 177 (83-275) min, which was signiifcantly longer than 93 (36-135) min of the coagulation group (Z=8.650,P<0.05). The 3-year cumulative survival rate and 1-, 3-year disease free survival of the combination group were respectively 97%, 83%, 92%, which were signiifcantly higher than 64%, 71%, 43% of the coagulation group (Z=10.054, 9.011, 7.112;P<0.05).ConclusionsLaparoscopic microwave coagulation combined with hepatectomy for liver cirrhosis complicated with HCC is safe and effective. The long-term curative effect is better than that of simple laparoscopic microwave coagulation.

OBJECTIVETo evaluate the feasibility, safety and long-term outcomes of laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma (HCC) following previous resection.

METHODSBetween January 2003 and January 2011, 14 patients with recurrent HCC were carefully selected to undergo repeat laparoscopic hepatectomy, among which 9 patients were male, 5 patients were female, and the average age was 54 years. Prior to re-resection, all patients had undergone at least one open hepatectomy for HCC. The perioperative and long-term outcomes of these patients were retrospectively analyzed.

RESULTSRepeat laparoscopic hepatectomy for these 14 patients were successfully performed without major perioperative complications. The mean operative time, intraoperative blood loss and hospital stay were (124 ± 82) minutes, (112 ± 43) ml and (7 ± 4) days, respectively. The mean follow-up period was 23 months (range 14 to 42 months). At the time of follow-up, 11 patients were still alive, among which 3 patients developed recurrent disease and 8 patients remained disease free. One patient died of liver dysfunction at 21 months, and another 2 patients died of tumor recurrence at 17, 31 months, respectively.

CONCLUSIONLaparoscopic surgery for recurrent HCC remains a viable option for repeat hepatectomy in selected patients who have undergone open hepatectomy.

Adult ; Aged ; Carcinoma, Hepatocellular ; surgery ; Female ; Follow-Up Studies ; Hepatectomy ; methods ; Humans ; Laparoscopy ; Laparotomy ; Liver Neoplasms ; surgery ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; surgery ; Retrospective Studies

Objective To investigate the value of three dimensional (3D) laparoscopic anatomical hepatectomy for liver tumors. Methods Clinical data of 10 patients with liver tumors who underwent 3D laparoscopic anatomical hepatectomy in Sun Yat-sen Memorial Hospital of Sun Yat-sen University from September to November 2013 were analyzed retrospectively. There were 7 males and 3 females with age ranging from 36 to 62 years old and the median age of 49 years old. The primary disease were primary liver cancer (n=8), hepatic hemangioma(n=2). The informed consents of all patients were obstained and the ethical committee approval was received. All the patients underwent 3D laparoscopic anatomical hepatectomy through endotracheal general anesthesia. The operators and assistants wore special 3D glasses. After the 3D laparoscope was inserted through the navel incision, operation channels were established by putting 3 to 4 trocars (5 mm or 10 mm) at different positions of upper abdomen respectively, and then anatomical hepatectomy was performed according to the diseased region. The operaton procedures, intraoperative blood loss, length of hospital stay and postoperative complications of patients were observed. Results All the 10 patients underwent anatomical hepatectomy through 3D laparoscope, and no case converted to open surgery during the operation. Three cases received right hemihepatectomy, 3 cases received segment Ⅴ+Ⅵ hepatectomy, 2 cases received hepatic left lateral lobectomy, 1 case received mesohepatectomy, and 1 case received segment Ⅴ hepatectomy. The average operation duration of patients who underwent right hemihepatectomy was (270±26)min, segment Ⅴ+Ⅵ hepatectomy was (122±8)min, hepatic left lateral lobectomy was (90±7)min, mesohepatectomy was 245 min, and segment Ⅴ hepatectomy was 95 min. The intraoperative blood loss was (483±104), (233±29), (125±35), 450, 180 ml, and the length of hospital stay was (17±5), (11±1), (9±1), 13, 10 d accordingly. Liver disfunction was observed in 1 case out of the patients after right hemihepatectomy. Right lower lung infection was observed in the patient after mesohepatectomy. No complication was observed in the other 8 patients after operations. Conclusions The 3D laparoscope has a certain advantage in dissecting the intrahepatic ductal structures precisely, and can help to control the intraoperative blood loss. It is applicable to anatomical hepatectomy for liver tumors, especially to hemihepatectomy.