Zhang Wen

Background The spleen has been reported to inhibit liver regeneration following hepatectomy; however, the underlying mechanisms remain poorly understood. In particular, its role in future liver remnant (FLR) regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) warrants investigation. Aim To evaluate the relationship between splenic volume changes and FLR regeneration following ALPPS-stage I in patients with massive hepatocellular carcinoma (HCC). Methods Clinical data from 65 HCC patients who underwent ALPPS between 2018 and 2021 were retrospectively analyzed. Liver and spleen volumes were measured pre- and post-ALPPS-stage I use the IQQA-Liver system. The kinetic growth rate (KGR) of the FLR was calculated. Pearson correlation and logistic regression were used to identify predictors of FLR hypertrophy. Receiver operating characteristic (ROC) curves were constructed to determine cutoff values for splenic predictors. Results Following ALPPS-stage I, FLR volume significantly increased from 35.57%±8.51–54.31%±11.19% of standard liver volume (SLV) (P < 0.001), with a median KGR of 4.65%/day. Splenic volume also increased (218.65 ± 84.77 cm³ vs. 252.69 cm³, P < 0.001). Preoperative splenic volume and spleen volume/SLV ratio negatively correlated with KGR (r = -0.240, P = 0.027; r = -0.218, P = 0.041). Multivariate analysis identified splenic volume (OR = 0.991, P = 0.043), platelet count (OR = 1.014, P = 0.013), Indocyanine Green Retention Rate at 15 min (ICG-R15) (OR = 0.670, P = 0.010), and CNLC stage (P = 0.001) as independent predictors of FLR regeneration. ROC analysis showed that splenic volume > 265.29 cm³ (AUC = 0.645) and spleen volume/SLV ratio > 0.1997 (AUC = 0.646) predicted poor FLR hypertrophy. One- and two-year survival rates were 80.77% and 68.18%, respectively. Conclusion Preoperative splenic volume is an independent predictor of FLR regeneration after ALPPS. Combined evaluation of splenic volume, platelet count, and liver function may improve patient selection, reduce the risk of postoperative liver failure, and optimize surgical outcomes.

Background: There has been controversial for the treatment of the posterolateral tibial plateau fractures (PTPF). This study aimed to evaluate clinic outcomes of the lateral locking compression plate (LCP) postposition, analyze the feasibility of LCP postposition through anatomical measurement, and address the potential problems of LCP postposition through the biomechanical assessment. Methods: 39 patients with PTPF undergoing LCP fixation between June 2019 and June 2022 were retrospectively evaluated. All cases were divided into two group: Group A (15 cases) employed plate transverse arm postpositioning with posterolateral (PL) fracture fixation using two raft screws, while Group B (24 cases) utilized non-postpositioning with fixation by a single raft screw. Surgical duration, intraoperative blood loss, the change of lateral tibial plateau angle (LTPA), lateral tibial plateau posterior slope angle (LPSA) and fracture collapse between immediate postoperative and last follow up, range of motion (ROM), HSS knee score, and Lysholm knee score were recorded. CT measurements of the fibular head superior space and LCP transverse arm were taken in 50 healthy adult knees to assess postposition feasibility. Finally, three fracture models were established using finite element analysis: Model A with plate postposition and PL split fracture fixed by two raft screws of transverse arm, Model B with plate non-postposition and PL split fracture fixed by one raft screw, and Model C with plate non-postposition and PL split fracture fixed by one raft screw and anterior–posterior tension screws. Loadings of 250N, 500N, and 750N were applied for the analysis of the displacement degree, von Mises stress distribution. Results: Results indicate comparable operative duration and intraoperative hemorrhage between groups. Complications were minimal in both groups. Group A demonstrated superior outcomes in terms of radiographic parameters, functional scores, and fracture collapse prevention. CT measurements revealed compatibility in 72% of healthy knees with the postpositioning technique. Finite element analysis indicated favorable biomechanical stability. Conclusion: Not all patients with PTPF were applicable to the management of the plate postposition and two raft screws fixation, even though this technique exerted good biomechanical stability and achieved satisfactory clinic outcomes. When the PL fracture was fixed by only raft screw through LCP owing to various reasons, two anterior–posterior tension screws might be necessitated to maintain the fracture stability.

Objective: The treatment for posterolateral tibial plateau fractures (PTPF) have been subjects of controversy. We conducted a study to improve the fixation of PTPF through a lateral approach.Methods: We utilized 40 synthetic tibias and categorized the fracture models into five groups based on the locking compression plate (LCP) and T-distal radius plate (TPP) via various forms of fixation with screws through the posterolateral (PL) fracture fragments. I: Two-screw fixation using two locking screws (LPTL). Ⅱ: Two-screw fixation with both variable angle locking screws (LPTV). Ⅲ: One-screw fixation with one locking screw (LPOL). Ⅳ: One-screw fixation with one locking screw and two anteroposterior lag screws (LPOLTL). Ⅴ: a distal radius plate with three locking screws (TPP). Biomechanical tests were conducted to observe the axial compression displacement of the PL fracture fragments at force levels of 250 N, 500 N, and 750 N, as well as to determine the failure load and the axial stiffness for each respective group.Results: Under a 750 N load condition, the displacements within the five experimental groups exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. However, there were no significant differences between Group V and Group II, Group I and Group IV (p > 0.05), and only Group Ⅲ demonstrated a displacement exceeding 3 mm. The failure load and the axial stiffness exhibited the same trend. Conversely, statistical significance was identified among the remaining group compared with Group Ⅲ (p < 0.05). Regarding the finite element analysis, the maximum displacements for the five models under the load of 750 N exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. The following trends were observed in maximum von Mises stresses for these models under the load of 750 N: Ⅴ < Ⅱ < Ⅳ< Ⅰ < Ⅲ.Conclusion: It is crucial to address the inadequate mechanical strength associated with single screw fixation of LCP for fixing PL fractures in a clinical setting. The biomechanical strength of two-screw fixation surpasses that of single-screw fixation. Introducing variable-angle screws can further enhance the fixation range. Furthermore, the addition of two lag screws threaded from anterior to posterior can compensate the mechanical stability, when PL fracture is fixed with single screw in clinic.

CD4+CD25+ regulatory T cells decreased future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy

Background: Hypoxia is a key factor in the development of hepatocellular carcinoma (HCC), which is the most common primary liver cancer with poor prognosis. The current study aimed to identify the potential prognostic biomarkers of the hypoxia-associated gene signature in patients with HCC, and to further explore the relationship between hypoxia and immune infiltration. Methods: After the determination of differentially expressed genes (DEGs) using the HCC transcriptome data of The Cancer Genome Atlas database and hypoxia-related gene set, the prognosis-associated genes were identified using univariate Cox regression analysis. Then, the hypoxia prognosis model was established via multivariate Cox regression analysis, with functional annotation conducted using Gene Set Enrichment Analysis. CIBERSORT was utilized to analyze the degree of tumor immune invasion, and an International Cancer Genome Consortium cohort to verify the reliability of the prognosis model. Expression levels of hypoxia-associated genes were detected by real-time quantitative polymerase chain reaction in HCC samples. Results: 3 genes (ENO1, SAP30, and STC2) constructed the hypoxia prognosis model. The patients were subdivided into 2 groups based on median risk score, with a high hypoxic score indicating poor prognosis of HCC. The hypoxia signature could be employed as an independent prognostic factor in HCC. In addition, the proportion of macrophages was higher in the high-risk group. Conclusion: The hypoxia-associated signature could be a potential prognostic marker of HCC and provides a different perspective for immunotherapy of HCC.

Change of tumor-infiltrating lymphocyte of associating liver partition and portal vein ligation for staged hepatectomy for hepatocellular carcinoma

Background: Primary liver cancer is the third leading cause of cancer-related deaths worldwide in 2020, and hepatocellular carcinoma (HCC) is the major pathological type. Patients with HCC complicated with portal vein tumor thrombosis (PVTT) have a poor prognosis, and controversies regarding treatment options exist among international scholars. Patients with VP4 or Cheng’s type III classification are generally considered ineligible for surgical treatment.Methods: We retrospectively analyzed three cases of HCC with PVTT who underwent a novel modified surgical procedure. The procedure included portal vein thrombectomy and portal vein ligation with liver parenchymal separation for the resection of the tumor thrombus involving the main portal vein trunk and for the isolation of the giant tumor. The three cases were then treated with targeted drugs postoperatively.Results: One case developed acute renal failure in the perioperative period, and the renal function gradually recovered after the treatment. The two remaining cases recovered uneventfully postoperatively. The prognosis of the three patients was encouraging. Only one patient died of lung metastasis after 13 months, and the remaining patients were still alive after 41 and 21 months, respectively.Conclusions: We provide a new possible surgical option for patients with advanced HCC with PVTT. The surgical procedure was inspired by associating liver partition with portal vein ligation for staged hepatectomy and portal vein thrombectomy. The survival time was significantly prolonged after the patients underwent thrombectomy, tumor isolation, and postoperative nonsurgical treatment. Hence, the combination of liver partition and portal vein ligation after thrombectomy for tumor isolation has the potential for the treatment of advanced HCC with PVTT.

Primary hepatic neuroendocrine carcinoma (PHNEC) manifests as a rare type of liver tumor. PHNEC is not specifically clinical or radiographical and is often misdiagnosed and mistreated. Here, we present a case report of PHNEC in a 50-year-old woman who was admitted to our department with concealed pain in the right upper abdomen. The initial diagnosis was a probable hepatic space-occupying lesion with tumor bleeding. The patient was subjected to a partial right hemihepatectomy, cholecystectomy, partial resection of the lower lobe of the right lung, partial resection of the diaphragm, and resection of the right perirenal fat sac to alleviate her symptoms. After surgery, gene sequencing was performed to determine the possible cause of the condition. However, five months after discharge, the patient was hospitalized again because of retroperitoneal and peritoneal multiple metastases. Nine months after surgery, the patient died. This case is likely to aid in furthering our understanding of PHNEC to improve the future diagnosis and treatment of this disease.

Surgical resection remains the best choice for the treatment of liver tumors. Hepatectomy combined with artificial vascular reconstruction has been proven as an alternative to treating tumors involving the main hepatic veins. As the cutting-edge surgical technique, robotic liver surgery is a novel procedure expanding the field of minimally invasive approaches, especially in complex reconstruction. This study reports, for the first time, on a robotic hepatectomy with middle hepatic vein (MHV) reconstruction using an expanded polytetrafluoroethylene (ePTFE) graft for a patient with hepatic adenoma. The tumor, which was located in segment 8, was adjacent to the MHV. Robot-assisted resection of segment 4 and partial segment 8, and MHV reconstruction using a ePTFE graft were performed. During the post-operative examination and follow-up, the blood flow of the ePTFE graft was patent, and liver function recovered well. Thus, robotic hepatectomy with MHV reconstruction is a safe, minimally invasive, and precise surgery that may provide a novel approach for patients with liver tumors that are invading or adjacent to the main hepatic veins.