Objective: To investigate the influential factors for failure of enhanced recovery after surgery(ERAS) from hepatectomy for hepatocellular carcinoma(HCC) patients and then to establish a risk prediction model. Methods: The relevant clinical data of 180 patients with HCC undergoing hepatectomy at Department of Hepatic Surgery, Affiliated Provincial Hospital, Anhui Medical University from January 2016 to June 2017 were analyzed retrospectively.There were 149 male patients and 31 female patients aging of (56.5±11.0)years(from 33 to 84 years old). The factors affecting postoperative failure of ERAS of HCC patients were identified by univariate and multivariate analyses, and then, all the obtained factors and their statistical values were used to establish the risk prediction model. Results: A total of 23 patients failed in the ERAS protocol(12.8%). The preoperative total bilirubin (TBIL), alanine aminotransferase(ALT) and amount of intraoperative bleeding were independent risk factors for failure of ERAS from hepatectomy(all P<0.05). The obtained risk prediction model was presented as follows: risk coefficient(R)=0.114×(TBIL)+ 0.082×(ALT)+ 0.008×(amount of intraoperative bleeding). At the cut of value of R=7.90, the area under the ROC curve of this model for predicting failure of ERAS was 0.866(95%CI: 0.788-0.945, P<0.01), with the sensitivity and specificity of 69.6% and 91.1%, respectively.External validation results indicated that the scoring system had good differential ability(area under the ROC curve=0.889, 95%CI: 0.811-0.967, P<0.01). Conclusions Higher level of preoperative TBIL(>21 μmol/L) and ALT(>50 U/L) and the larger amount of intraoperative bleeding (more than 400 ml) are independent risk factors for failure of ERAS inpatients undergoing hepatectomy for HCC and the established prediction model may have certain value for risk assessment.

Objective To evaluate the safety and efficacy of precise hepatectomy in treatment of hepatolithiasis. Methods Clinical data of 93 patients with hepatolithiasis who underwent hepatectomy in Anhui Provincial Hospital between January 2013 and January 2017 were analyzed retrospectively. The patients were divided into precise hepatectomy group (precise group, n=59) and conventional resection group (conventional group, n=34) according to different surgical procedures. There were 28 males and 31 females in precise group, with an average age of (56±5) years old. There were 18 males and 16 females in conventional group, with an average age of (56±4) years old. The informed consents of all patients were obtained and the local ethical committee approval was received. The operation time, intraoperative blood loss, postoperative length of stay, postoperative ALT, AST level between two groups were compared by t test or Kruskal-Wallis rank sum test. The incidence of postoperative complication was compared by Chi-square test. Results The operation time was (210±61) min in precise group, significantly longer than (157±60) min in conventional group (t=1.586, P<0.05). The intraoperative blood loss was (386±99) ml in precise group, significantly less than (518±153) ml in conventional group (t=-1.421, P<0.05). The median postoperative length of stay was 8(6-10) d in precise group, significantly shorter than 10(8-15) d in conventional group (Z=-2.018, P<0.05).The ALT and AST level at postoperative 1 d was respectively (214±87) and (368±106) U/L in precise group, significantly lower than (594±133) and (625±165) U/L in conventional group, (t=-3.395, -2.047; P<0.05). The incidence of postoperative complication was 8.5% (5/59) in precise group, significantly lower than 23.5%(8/34) in conventional group (χ2=4.066, P<0.05). Conclusions Compared with conventional hepatectomy, precise hepatectomy possesses advantages of smaller surgical trauma, less intraoperative blood loss and lower incidence of postoperative complication. It has better clinical application value.

Objective To evaluate the application of three-dimensional visualization technique in precise hepatectomy for patients with massive hepatocellular carcinoma (HCC). Methods 64 patients with massive HCC who underwent hepatectomy in Anhui Provincial Hospital Affiliated to Anhui Medical University between January 2014 and January 2016 were enrolled in this prospective study. The informed consents of all patients were obtained and the local ethical committee approval was received. According to the will of patients and their families, these patients were divided into precise group and conventional group. There were 34 cases in precise group, including 28 males and 6 females, with an average age of (54±6) years old. There were 30 cases in conventional group, including 26 males and 4 females, with an average age of(56±7) years old. In precise group, liver volume, tumor location and size and relation with the adjacent vessels were assessed precisely, and surgical protocol was planned and simulated using CT three-dimensional visualization technique before operation. Precise hepatectomy was performed using cavitron ultrasound surgical aspirator (CUSA) or ultrasonic scalpel with the guidance of color Doppler ultrasound. Patients were treated according to the concept of enhanced recovery after surgery after operation. Patients in conventional group received routine CT or MRI before operation, liver resection with clamping method was performed and the porta hepatis was occluded using Pringle maneuver during the operation. Patients received routine nursing and rehabilitation treatments after operation. Intraoperative situation and postoperative liver function of patients between both groups were compared by t test, and the rates were compared by Chi-square test. Results The median length of operation was 229(57-352) min in precise group, significantly more than 138(61-282) min in conventional group (Z=1.752, P<0.05). The postoperative 1 d ALT and AST was respectively 425(24-1 299) and 390(15-1 484) U/L in precise group, significantly lower than 574(42-3 533) and 670(76-3 795) U/L in conventional group (Z=-2.099, -2.677; P<0.05). The postoperative length of hospital stay was 6.2(3.0-19.0) d in precise group, significantly less than 9.5(5.0-30.0) d in conventional group (Z=-2.387, P<0.05). Postoperative complications occurred in 3 patients in precise group and 9 patients in conventional group, where significant difference was observed (χ2=4.691, P<0.05). No death case was observed in precise group, while 1 case died of postoperative liver failure in conventional group. Conclusions Compared with conventional liver resection, three-dimensional visualization technique can be used in precise hepatectomy for patients with massive HCC. It has the advantages of less trauma, higher safety and faster postoperative recovery.

Objective To explore the clinical efficacy of anatomic liver resection in treatment of hepatocellular carcinoma (HCC) with microvascular invasion (MVI).Methods The retrospective cohort and case-control study was conducted.The clinical data of 150 HCC patients with MVI who were admitted to the Anhui Medical University Affiliated Provincial Hospital from June 2007 to June 2012 were collected.Sixty patients undergoing anatomic liver resection were allocated into the AR group and 90 undergoing non-anatomic liver resection in the NR group.Patients in the AR group underwent anatomic liver resection according to results of preoperative ICG R15 test,and patients in the NR group underwent non-anatomic liver resection.Observation indicators:(1) operation situations:operation time,volume of intraoperative blood loss,number of patients with blood transfusion;(2) postoperative recovery situations:time of drainage-tube removal,duration of hospital stay,Clavein grade of complication within 30 days postoperatively,number of patients with hepatic failure within 30 days postoperatively and number of death within 30 days postoperatively;(3) follow-up:postoperative median survival time,5-year overall survival rate and 5-year tumor-free survival rate;(4) prognostic factors analysis of 150 HCC patients with MVI.Measurement data with normal distribution were represented as-x±s and comparison between groups was analyzed using the independent-sample t test.Count data were represented as the chi-square test or Fisher exact probability.The survival rate was calculated using the Kaplan-Meier method and survival analysis was done using Log-rank test.The univariate analysis and multivariate analysis were done using the COX regression model.Results (1) Operation situations:all the 150 patients received successful radical resection of HCC.Operation time,numbers of patients with volume of intraoperative blood loss ≥ 500 mL and with volume of intraoperative blood loss ＜ 500 mL and number of patients with blood transfusion were (165±39) minutes,12,48,15 in the AR group and (136±30)minutes,34,56,38 in the NR group,respectively,with statistically significant differences between the 2 groups (t =29.172,x2=5.351,4.673,P＜0.05).(2) Postoperative recovery situations:time of drainage-tube removal and duration of hospital stay were (2.7± 1.1)days and (5.2± 1.3) days in the AR group,(3.8±1.6)days and (7.1±2.3)days in the NR group,respectively,with statistically significant differences between the 2 groups (t =4.641,5.812,P＜0.05).Numbers of patients with grade Ⅰ-Ⅱ of Clavein grade and with grade Ⅲ-Ⅳ and number of death within 30 days postoperatively were 45,15,1 in the AR group and 61,29,2 in the NR group,respectively,with no statistically significant difference between the 2 groups (x2 =0.906,P＞0.05).Number of patients with hepatic failure within 30 days postoperatively in the AR and NR group were respectively 4 and 17,with a statistically significant difference (x2=4.467,P＜0.05).(3) Follow-up:all the 150 patients were followed up for 1-106 months,with a median time of 26 months.The postoperative median survival time,5-year overall survival rate and 5-year tumor-free survival rate were 46 months,33.3％,21.7％ in the AR group and 18 months,15.6％,2.2％ in the NR group,respectively,with statistically significant differences in overall survival and tumor-free survival between the 2 groups (x2=23.718,63.932,P＜ 0.05).(4) Prognostic factors analysis of 150 HCC patients with MVI:result of univariate analysis showed that maximum diameter of tumor,tumor capsule,TNM stage,Edmondson grade and surgical procedures were relative factors affecting overall survival and tumor-free survival of HCC patients with MVI,with statistically significant differences (x2=5.519,2.790,13.639,8.321,42.470,31.057,15.963,19.594,23.718,63.932,P＜ 0.05).Result of multivariate analysis showed that missing tumor capsule,stage Ⅲ-Ⅳ of TNM stage,grade Ⅲ-Ⅳ of Edmondson grade and non-anatomic liver resection were independent factors affecting poor overall survival and tumor-free survival of HCC patients with MVI,and maximum diameter of tumor ＞5 cm was an independent factor affecting poor overall survival of HCC patients with MVI,with a statistically significant difference [HR =0.527,0.683,0.333,0.522,0.576,0.514,0.523,0.268,95％ confidence interval (CI):0.355-0.782,0.475-0.983,0.219-0.504,0.361-0.755,0.389-0.852,0.358-0.737,0.342-0.800,0.174-0.413;HR=0.559,95％CI:0.370-0.845,P＜0.05].Conclusions Anatomic liver resection in the treatment of HCC patients with MVI is safe and effective,with good short-term and long-term outcomes,and it can also improve prognosis of patients.Missing tumor capsule,stage Ⅲ-Ⅳ of TNM stage,grade Ⅲ-Ⅳ of Edmondson grade and non-anatomic liver resection are independent factors affecting poor overall survival and tumor-free survival of HCC patients with MVI,and maximum diameter of tumor ＞5 cm is an independent factor affecting poor overall survival of HCC patients with MVI.

Objective To investigate the effects of multimodal analgesia of parecoxib and fentanyl on perioperative immune functions in patients of hepatocellular carcinoma (HCC).Methods Eighty HCC patients scheduled for hepatectomy were randomly divided into two groups:parecoxib sodium combined with fentanyl group (group P,40 cases) and fentanyl group (group C,40 cases).The percentages of CD3 +,CD4+,CD8+,CD4+/CD8+ T cells,CD3-CD16+ CD56+ (NK),interleukin-4 (IL-4),interferon-γ (IFN-γ) and the ratio of IFN-γ/IL-4 were detected at the following time points:30 minutes before induction of anesthesia (T0),at the end of the surgery (T1),24 h after surgery (T2) and 72 h after surgery (T3).The analgesic effects were estimated by visual analogue scale (VAS) after surgery.Total fentanyl consumption and adverse effects were also recorded.Results The percentages of CD3 + T cells were significantly lower in group C than that in group P at T2 (t =2.155,P ＜0.05).The percentages of NK in group P were recovered nearly to baseline (T0) at T2,which was higher than that of group C (t =2.791,P ＜0.05).In group C,the percentages of CD3 + T cells and NK has not recovered to baseline at T3 (respectively t =3.065,3.231,P ＜ 0.05).In group P,IL-4 serum levels were significantly lower than those in group C,while IFN-γ serum levels were significantly higher than those in group C at T2 (respectively t =2.173,2.100,P ＜0.05).From T2 to T3,the ratio of IFN-γ/IL-4 significantly increased in group P than those in group C (respectively t =3.259,2.203,P ＜ 0.05).VAS scores at rest and on cough in group P were significantly lower than those in group C at 2 h,6 h,12 h and 24 h after operation (respectively t =8.661,9.726,9.147,7.109,P＜0.05;t =8.569,9.614,9.144,8.509,P＜0.05).The total fentanyl consumption in group P was lower than that in group C (t =2.636,P ＜ 0.05).There were no significant differences regarding the incidence of adverse effects between the two groups.Conclusions Perioperative multimodal analgesia of parecoxib sodium combined with fentanyl enhances the analgesic efficacy,and reduces the dosage of opioid consumption,helps recover the cell immunity function of HCC patients after hepatectomy.

ObjectiveTo explore the application value of individualized surgical treatment based on the CT portal venograpy (CTPV) classiifcation in cirrhotic portal hypertension.MethodsOne hundred and iffty-six patients with cirrhotic portal hypertension who received surgical treatment in Anhui Province Hospital between June 2010 and December 2014 were enrolled in this prospective study. According to different surgical procedures, the patients were divided into two groups: the individualized surgery based on CTPV classiifcation group (classification group) and traditional surgery group (traditional group). Among the 84 patients in the classiifcation group, 56 were males and 28 were females with the age ranging from 19 to 67 years old and the median of 45 years old. Among the 72 patients in the traditional group, 47 were males and 25 were females with the age ranging from 23 to 62 years old and the median of 43 years old. The informed consents of all patients were obtained and the local ethical committee approval was received. The patients in the classiifcation group underwent individualized surgery according to the pre-operative CTPV classiifcation, while the patients in the traditional group underwent splenectomy + pericardial devascularization. The effects of two surgical procedures on the portal hypertension, intraoperative and postoperative conditions and postoperative survival rate of the patients were observed. The observation indexes of two groups were compared usingt test and survival analysis was conducted using Kaplan-Meier method and Log-rank test.ResultsThe postoperative free portal pressure (FPP) in the classiifcation group was (27±3) cmH2O (1 cmH2O=0.098 kPa), signiifcantly lower than (33±8) cmH2O in the traditional group (t=-3.355,P<0.05). The FPP decrease range before and after surgery in the classiifcation group was (13±6) cmH2O, signiifcantly higher than (9±5) cmH2O in the traditional group (t=3.016,P<0.05). The length of surgery and intraoperative blood loss in the classiifcation group were respectively (188±84) min and (378±49) ml, significantly less than (240±76) min and (463±57) ml in the traditional group (t=-2.687,-3.015;P<0.05). The postoperative length of stay and hospitalization expense in the classiifcation group were respectively (12±4) d and (31 000 ± 15 000) yuan, signiifcantly lower than (15±5) d and (36 000±15 000) yuan in the traditional group (t=-2.061,-2.104;P<0.05). The 1, 3-year accumulative survival rate were respectively 94.05% and 85.71% in the classiifcation group, and were respectively 87.50% and 68.05% in the traditional group. The overall survival rate in the classiifcation group was signiifcantly higher than that in the traditional group (χ2=7.000,P<0.05).ConclusionsPre-operative CTPV classification and individualized surgical treatment for patients with cirrhotic portal hypertension can effectively reduce the portal vein pressure and has the advantages of smaller injury and better prognosis.

Objective To explore the way and the effect of surgical treatment of primary hepatic carcinoma with diaphragmatic invasion.Method Clinical data of 37 primary hepatic carcinoma patients with diaphragmatic muscle invasion undergoing enbloc liver resection in Anhui Provincial Hospital between January 2008 and January 2014 were retrospectively analyzed.Control group comprised 54 liver cancer patients without diaphragm involvement.Results All cases underwent surgery successfully,no significant statistical differences were found between pre-operation clinical data of two groups.The operation time of the group with diaphragmatic invasion is slightly longer than that of the group without (149.4 ± 23.4 min vs 137.9 ±24.6 min,t =2.228,P =0.028);meanwhile,there was no obvious difference between blood loss of the two groups (449.5 ±304.1 ml vs 304.1 ±222.3 ml,t =0.678,P =0.499).There were no significantly statistical differences in other aspects between the two groups such as postoperative pulmonary infection,pleural effusion,infection of the incision,mortality and hospitalization time.Based on Kaplan Meier-log-rank test analysis,it is found that the two groups had no significant differences in disease-free survival and overall survival (P1 =0.982,P2 =0.906).Conclusions Hepatic carcinoma patients with diaphragmatic invasion are still indicated for liver resection with a favorable prognosis.

Objective To investigate the occurrence of postoperative pain of hepatectomy and its possible related factors.Methods The clinical data of 555 cases undergoing hepatectomy was analyzed retrospectively,and the related influencing factors on postoperative pain of hepatectomy were analyzed by univariate analysis and multivariate logistic regression.Results Moderate postoperative pain was reported in 255 cases among 555 patients who underwent hepatic resection (with an incidence of 45.95％).Incision pain which was often sharp was most common,followed by postoperative complication caused pain.According to whether the postoperative pain occurred or not,all cases were divided into postoperative pain group (n =255) and non-postoperative pain group (n =300),univariate analysis showed that age (P ＜0.01),surgical history (P ＜ 0.01),surgical approach (P ＜ 0.01),incision length (P ＜ 0.01),xiphoid removal(P ＜ 0.01),the final outcome of incision (P ＜ 0.01),complications (P ＜ 0.01) were significantly different between the two groups.Logistic multiple regression analysis showed that the independent influencing factors of postoperative pain included surgical history (P =0.001),surgical approach (P =0.005),incision length (P =0.000),xiphoid process removal (P =0.001),complications (P =0.000).Conclusions The postoperative pain of hepatectomy has a high incidence.Surgical history,surgical approach,incision length,xiphoid process,removal and postoperative complications are the independent impact factors of postoperative pain.

Objective To investigate the experience of diagnosis and treatment of abdominal penetrating injury with large vessels damage.Methods The clinical data of 18 patients with abdominal large vessels injuries in our hospital from Jan 2003 to oct 2014 were analyzed retrospectively.Results 18 cases of large vessels injuries,accounting for 16.21％ during the same period of all penetrating wounds (18/111),emergency laparotomy was performed.There were 8 cases of arterial injury,4 cases of concurrent arteriovenous injury,6 cases of venous injury,Arterial and venous broken walls were repaired,splenic artery and venous ligation and splenectomy were performed.Vascular repair success rate was 100％,Intraoperative blood loss was 500-6 000 ml,average (3 750 ±670) ml.Operating time varied from 2.5 to 7 h,average (3.9 ±0.8) h.All patients were cured.12 cases were followed-up for 2-36 months,mean follow-up time was (15 ± 7) months,ultrasonography showed normal blood flow without complications.Conclusions Emergency surgical exploration and limited fluid resuscitation is the most effective therapy in abdominal penetrating injury involving large vessels.

Liver cancer is one of the most common cancers worldwide and the third leading cause of cancer death.Partial hepatectomy and liver transplantation are the most effective therapies.However, postoperative tumor metastasis and recurrence are the main obstacles in the long-term survival.Liver cancer stem cells (LCSCs) within cancer tissues are associated with tumor occurrence, proliferation and tolerance to current therapy and are regarded as the major root of metastasis and recurrence.Eradication of LCSCs is a novel therapy of liver cancer.In this review, surface markers of LCSCs and mechanisms of pro-metastasis and recurrence, circulating LCSCs,microenvironment of LCSCs and their roles in the metastasis and relapse are summarized.