Indocyanine green fluorescence-navigated laparoscopic metastasectomy for peritoneal metastasis of hepatocellular carcinoma: a case report

BackgroundIndocyanine green (ICG) can selectively accumulate in primary hepatocellular carcinoma (HCC) and its extrahepatic metastases. ICG fluorescence imaging is an extremely sensitive intraoperative tool for detecting HCC foci and can be used to detect impalpable tumors in laparoscopic surgery. Here, we report a case of a 75-year-old man who underwent peritoneal metastasis resection of HCC using a laparoscopic near-infrared imaging system and ICG fluorescence-navigated surgery.Case presentationA 75-year-old man was referred to our department for peritoneal metastasis resection of HCC. Two years before admission, he had undergone transarterial embolization and segmentectomy of segment 6 with open surgery for ruptured HCC. Computed tomography revealed a 12-mm peritoneal metastatic lesion on the abdominal wall near the cut surface of the liver. No other metastases were observed; resection of the solitary metastasis was scheduled. ICG (0.5 mg/kg body weight) was intravenously injected, 72 h preoperatively. An endoscopic, ICG near-infrared fluorescence imaging system revealed clear green fluorescence, indicating peritoneal metastasis of HCC on the abdominal wall. The tumor was resected with adequate surgical margin by partially resecting the liver and diaphragm, followed by histological confirmation as peritoneal metastasis of HCC. No recurrence was observed after 12 months of follow-up.ConclusionsICG fluorescence can be useful in laparoscopic surgery for identifying peritoneal metastasis

The Effect of Three-Dimensional Preoperative Simulation on Liver Surgery

BackgroundIn the past decade, three-dimensional (3D) simulation has been commonly used for liver surgery. However, few studies have analyzed the usefulness of this 3D simulation. The aim of this study was to evaluate the effect of 3D simulation on the outcome of liver surgery.MethodsWe retrospectively analyzed 240 consecutive patients who underwent liver resection. The patients were divided into two groups: those who received 3D preoperative simulation (“3D group”, n = 120) and those who did not undergo 3D preoperative simulation (“without 3D group”, n = 120). The perioperative outcomes, including operation time, blood loss, maximum aspartate transaminase level, length of postoperative stay, postoperative complications and postoperative mortality, were compared between the two groups. The predicted resected liver volume was compared with the actual resected volume.ResultsThe median operation time for the 3D group was 36 min shorter than that for the without 3D group (P = 0.048). There were no significant differences in other outcomes between the two groups. A subgroup analysis revealed that the operation time of repeated hepatectomy and segmentectomy for the 3D group was shorter than that for the without 3D group (P = 0.03). There was a strong correlation between the predicted liver volume and the actual resected liver weight (r = 0.80, P < 0.001).ConclusionThese findings demonstrate that 3D preoperative simulation may reduce the operation time, particularly for repeated hepatectomy and segmentectomy

Novel 3-dimensional virtual hepatectomy simulation combined with real-time deformation

AIM: To develop a novel 3-dimensional (3D) virtual hepatectomy simulation software, Liversim, to visualize the real-time deformation of the liver.METHODS: We developed a novel real-time virtual hepatectomy simulation software program called Liversim. The software provides 4 basic functions: viewing 3D models from arbitrary directions, changing the colors and opacities of the models, deforming the models based on user interaction, and incising the liver parenchyma and intrahepatic vessels based on user operations. From April 2010 through 2013, 99 patients underwent virtual hepatectomies that used the conventional software program SYNAPSE VINCENT preoperatively. Between April 2012 and October 2013, 11 patients received virtual hepatectomies using the novel software program Liversim; these hepatectomies were performed both preoperatively and at the same that the actual hepatectomy was performed in an operating room. The perioperative outcomes were analyzed between the patients for whom SYNAPSE VINCENT was used and those for whom Liversim was used. Furthermore, medical students and surgical residents were asked to complete questionnaires regarding the new software.RESULTS: There were no obvious discrepancies (i.e., the emergence of branches in the portal vein or hepatic vein or the depth and direction of the resection line) between our simulation and the actual surgery during the resection process. The median operating time was 304 min (range, 110 to 846) in the VINCENT group and 397 min (range, 232 to 497) in the Liversim group (P = 0.30). The median amount of intraoperative bleeding was 510 mL (range, 18 to 5120) in the VINCENT group and 470 mL (range, 130 to 1600) in the Liversim group (P = 0.44). The median postoperative stay was 12 d (range, 6 to 100) in the VINCENT group and 13 d (range, 9 to 21) in the Liversim group (P = 0.36). There were no significant differences in the preoperative outcomes between the two groups. Liversim was not found to be clinically inferior to SYNAPSE VINCENT. Both students and surgical residents reported that the Liversim image was almost the same as the actual hepatectomy.CONCLUSION: Virtual hepatectomy with real-time deformation of the liver using Liversim is useful for the safe performance of hepatectomies and for surgical education

Ultra-High-Resolution Computed Tomography of the Lung: Image Quality of a Prototype Scanner

Purpose: The image noise and image quality of a prototype ultra-high-resolution computed tomography (U-HRCT) scanner was evaluated and compared with those of conventional high-resolution CT (C-HRCT) scanners. Materials and Methods: This study was approved by the institutional review board. A U-HRCT scanner prototype with 0.25 mm × 4 rows and operating at 120 mAs was used. The C-HRCT images were obtained using a 0.5 mm × 16 or 0.5 mm × 64 detector-row CT scanner operating at 150 mAs. Images from both scanners were reconstructed at 0.1-mm intervals; the slice thickness was 0.25 mm for the U-HRCT scanner and 0.5 mm for the C-HRCT scanners. For both scanners, the display field of view was 80 mm. The image noise of each scanner was evaluated using a phantom. U-HRCT and C-HRCT images of 53 images selected from 37 lung nodules were then observed and graded using a 5-point score by 10 board-certified thoracic radiologists. The images were presented to the observers randomly and in a blinded manner. Results: The image noise for U-HRCT (100.87 ± 0.51 Hounsfield units [HU]) was greater than that for C-HRCT (40.41 ± 0.52 HU; P <.0001). The image quality of U-HRCT was graded as superior to that of C-HRCT (P <.0001) for all of the following parameters that were examined: margins of subsolid and solid nodules, edges of solid components and pulmonary ves sels in subsolid nodules, air bronchograms, pleural indentations, margins of pulmonary vessels, edges of bronchi, and interlobar fissures. Conclusion: Despite a larger image noise, the prototype U-HRCT scanner had a significantly better image quality than the C-HRCT scanners

Diverse Effects of FK506 on the Apoptosis of Hepatocytes and Infiltrating Lymphocytes in an Allografted Rat Liver.

BACKGROUND: The current study investigated whether FK506 (FK) regulates the apoptotic systems in allografted rat liver and the contribution of Fas/Fas-ligand system and Bcl-2 family during acute rejection. MATERIALS AND METHODS: The recipients were divided into three groups, the allo, the allo-FK, and the syn group. Rats were euthanized 1, 3, 5, and 7 d after OLT. Apoptotic activity was explored using terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay. The expression of Fas/Fas-ligand and Bcl-2/Bax in the grafted livers was investigated by Western blotting and immunohistochemistry. RESULTS: The apoptotic index (AI) of hepatocytes in the allo-FK group was less than that in the allo group. Fas in the allo group was more intense than that in the allo-FK group in the periportal areas on day 1 and 3, while Bcl-2 in the allo group was less intense than that in the allo-FK group in the pericaval areas at all time-points after OLT. CONCLUSION: FK provides beneficial antiapoptotic effects on hepatocytes in the grafted rat livers through both the down-regulation of Fas expression in the periportal areas and the up-regulation of Bcl-2 expression in the pericaval areas

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362