Echinococcosis is a zoonotic disease that seriously threatened human health. The disease is widely distributed in China, including in Tibet Autonomous Region, Qinghai Province, Xinjiang Uygur Autonomous Region, Sichuan Province, and other places, which has become a social and economic burden in China. Human beings are mainly infected with alveolar echinococcosis (AE) and cystic echinococcosis (CE), which mainly involves liver, lung, brain, bone, and other organs or tissues. The surgical resection is the first line treatment, and antiparasitic agents therapy is the main supplementary or salvage treatment method. Currently, classic drugs mainly include albendazole and praziquantel, which use alone or in combination. There are also some attempts to treat echinococcosis, including broad-spectrum anti infective drugs such as nitrozotocin, cell proliferation inhibiting drugs such as bortezomib, metabolic drugs such as metformin, or traditional medicines such as Artemisinin. It was also suggested to adopt a cancer management model for echinococcosis, and the imaging follow-up time for CE after antiparasitic chemotherapy should be at least 3 years, and for AE should be at least 10 years. More importantly, measures such as education and vaccine inoculation should be taken to actively prevent and control the occurrence and spread of echinococcosis.
ObjectiveTo investigate the risk factors affecting severe postoperative complications (Clavien-Dindo classification Ⅲa or higher) in patients with end-stage hepatic alveolar echinococcosis (HAE) underwent ex vivo liver resection and autotransplantation (ELRA), and to develop a nomogram prediction model. MethodsThe clinical data of end-stage HAE patients who underwent ELRA at the West China Hospital of Sichuan University from January 2014 to June 2024 were retrospectively analyzed. The logistic regression was used to analyze the risk factors affecting severe postoperative complications. A nomogram prediction model was established basing on LASSO regression and its efficiency was evaluated using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. Simultaneously, a generalized linear model regression was used to explore the preoperative risk factors affecting the total surgery time. Test level was α=0.05. ResultsA total of 132 end-stage HAE patients who underwent ELRA were included. The severe postoperative complications occurred in 47 (35.6%) patients. The multivariate logistic analysis results showed that the patients with invasion of the main trunk of the portal vein or the first branch of the contralateral portal vein (type P2) had a higher risk of severe postoperative complications compared to those with invasion of the first branch of the ipsilateral portal vein (type P1) [odds ratio (OR) and 95% confidence interval (CI)=8.24 (1.53, 44.34), P=0.014], the patients with albumin bilirubin index (ALBI) grade 1 had a lower risk of severe postoperative complications compared to those with grade 2 or higher [OR(95%CI)=0.26(0.08, 0.83), P=0.023]. Additionally, an increased total surgery time or the autologous blood reinfusion was associated with an increased risk of severe postoperative complications [OR(95%CI)=1.01(1.00, 1.01), P=0.009; OR(95%CI)=1.00(1.00, 1.00), P=0.043]. The nomogram prediction model constructed with two risk factors, ALBI grade and total surgery time, selected by LASSO regression, showed a good discrimination for the occurrence of severe complications after ELRA [area under the ROC curve (95%CI) of 0.717 (0.625, 0.808)]. The generalized linear regression model analysis identified the invasion of the portal vein to extent type P2 and more distant contralateral second portal vein branch invasion (type P3), as well as the presence of distant metastasis, as risk factors affecting total surgery time [β (95%CI) for type P2/type P1=110.26 (52.94, 167.58), P<0.001; β (95%CI) for type P3/type P1=109.25 (50.99, 167.52), P<0.001; β (95%CI) for distant metastasis present/absent=61.22 (4.86, 117.58), P=0.035]. ConclusionsFrom the analysis results of this study, for the end-stage HAE patients with portal vein invasion degree type P2, ALBI grade 2 or above, longer total surgery time, and more autologous blood transfusion need to be closely monitored. Preoperative strict evaluation of the first hepatic portal invasion and distant metastasis is necessary to reduce the risk of severe complications after ELRA. The nomogram prediction model constructed based on ABLI grade and total surgery time in this study demonstrates a good predictive performance for severe postoperative complications, which can provide a reference for clinical intervention decision-making.
Hepatic alveolar echinococcosis (HAE) is a severe zoonotic disease caused by Echinococcus multilocularis, primarily affecting the liver. Due to its insidious nature, the patients are often diagnosed at advanced stage, posing significant treatment challenges. We comprehensively examines the progress in surgical techniques for HAE management, focusing on various strategies across different disease stages. For the patients with early-stage HAE, ablation therapy has emerged as an effective treatment option. In the moderate to advanced cases, numerous surgical techniques and innovative approaches have been introduced, including laparoscopic surgery and liver transplantation, with particular emphasis on ex vivo liver resection and autotransplantation. These advancements offer more effective treatment options for the patients with advanced HAE. However, significant challenges persist, notably the preservation of adequate liver function while achieving complete lesion removal. Future research should prioritize the exploration and optimization of existing surgical methods, especially for advanced HAE cases. This includes refining surgical techniques through precise preoperative evaluation and staging, as well as developing novel surgical approaches to enhance safety and efficacy. Furthermore, multicenter and long-term follow-up prospective studies are crucial for validating the effectiveness of new surgical techniques and strategies. Through these concerted efforts, it is anticipated that the survival rates and quality of life for HAE patients will significantly be improved, marking a new era in the management of this complex disease.
Objective To explore the effect of ex-vivo liver resection and autologous liver transplantation (ERAT) combined with complicated hepatic venous reconstruction for end stage hepatic alveolar echinococcosis (AE). Method Theclinical data of one case with hepatic AE who treated in Organ Transplantation Center of Sichuan Provincial People’s Hospital in December 2017 was analyzed retrospectively. Results Pre-operative examination and intraoperative exploration revealed the hepatic vein (HV) and retrohepatic inferior vena cava (RHIVC) were invaded widely. We successfully initiated operation through vivo and ex-vivo hepatic AE resection, portal vein reconstruction, right/short/right inferior HV reconstruction into a wide mouth outflow with the assist of autogenous saphenous vein, and then piggyback autologous liver transplantation by wide mouth outflow-artificial inferior vena cava anastomosis (side to side). The operative time was 16 hours, and blood loss was 1 000 mL approximately. The patient was admitted routine treatment after hepatectomy. The inject low-molecular-weight heparin sodium was admitted for anticoagulant therapy 24 hours after operation. This patient recovered smoothly without bile leakage, bleeding, infection and liver failure, and so on. The patient was discharged uneventfully 14 days after operation, and there was no special situation during the6 months follow-up period. Conclusions ERAT is an ideal surgical method for end stage hepatic AE. Hepatic parenchymal transection and individual duct reconstruction, especially hepatic outflow reconstruction, are the key steps for ERAT.
ObjectiveTo discuss the clinical application of two-step hepatectomy for hepatic alveolar echinococcosis which invaded the second and the third porta hepatis.MethodsThe clinical data of 60 patients with hepatic alveolar echinococcosis invaded the second and the third porta hepatis who treated with two-step hepatectomy in West China Hospital of Sichuan University and The People’s Hospital of Ganzi Tibetan Autonomous Prefecture of Sichuan Province from Jan. 2013 to Jun. 2017 were analyzed retrospectively.ResultsSixty patients had underwent radical hepatectomy successfully and no death happened during perioperative period. The average operative time was 309.17 min (150–475 min) and intraoperative blood loss was 586.67 mL (100–3 000 mL). Forty-eight patients blocked the blood flowing into the liver, the average blocking time was 25.85 min (15–50 min); 24 patients suffered red blood cell suspension, the average amount was 3.79 U (2–8 U), and 9 patients were infused with fresh frozen plasma, the average amount was 527.78 mL (350–850 mL). The average of hospital stays was 17.5 days (7–39 days) and average of hospitalization cost was 49 323.43 yuan (28 045.32–61 243.15 yuan). The liver function indicators returned to normal within 7 days after operation. After operation, 3 patients suffered from biliary fistula, 3 patients suffered from pleural effusion, 3 patients suffered from peritoneal effusion, 10 patients suffered from effusion. According to the rank of complication: 10 patients were defined as grade Ⅰ, 3 patients were defined as grade Ⅱ, 6 patients were defined as grade Ⅲa. The average follow-up time of 60 patients was 14.47 months (1–31 months). No recurrence and death occurred during follow-up period.ConclusionThe two-step hepatectomy in treatment of hepatic alveolar echinococcosis invaded the second and the third porta hepatis can avoid the large flucyuations of intraoperative blood pressure and other vital signs, can increase the safety of surgery and reduce the difficulty and risk of surgery.
ObjectiveTo explore the clinical application of in vivo hepatectomy with preservation of retrohepatic inferior vena cava (IVC) for hepatic alveolar echinococcosis (HAE) with the invasion of IVC. MethodsThe clinicopathologic data of a complicated HAE patient with large lesion (maximum cross-section 12.6 cm×9.6 cm), infiltrative growth, unclear boundary with surrounding tissues, and invasions of diaphragm and IVC (invasion length up to 4.6 cm) admitted to the Department of Liver Surgery in the West China Hospital of Sichuan University in December 2021 was retrospectively collected. The three-dimensional reconstruction of the liver model was performed by Mimics Medical 21.0 software before operation. The invading IVC of the right liver lesion was measured and the resection was simulated. During the operation, the HAE lesion and the affected IVC were gradually separated from IVC by the hemostatic forceps, and the residual lesions were gradually removed. ResultsIn this patient, the HAE lesion of right liver was resected, the IVC was entirely preserved, and the resection of liver was consistent with the preoperative three-dimensional reconstruction plan. The operation time was 275 min, the bleeding was approximately 500 mL. On the first day after the operation, the alanine aminotransferase and aspartate aminotransferase were increased, no obvious abnormalities were observed in the plasma albumin and bilirubin, the patient recovered and was discharged on the seventh day after the operation. No complications occurred after the operation, and no recurrence or metastasis of HAE was observed during follow-up period. ConclusionsHepatectomy with preservation of retrohepatic IVC for HAE with invasion of IVC is safe and effective. Taking albendazole regularly after surgery will help maintain disease-free survival.
ObjectiveTo explore the effect of hepatic outflow reconstruction with allograft vascular in ex-vivo liver resection and autologous liver transplantation.MethodThe clinical data of a patient with end-stage hepatic alveolar echinococcosis admitted to the Organ Transplantation Center of Sichuan Provincial People’s Hospital in August 2019 who underwent the ex-vivo liver resection and autologous liver transplantation combined with hepatic vein reconstruction with allograft vascular were analyzed retrospectively.ResultsThe patient, a 44-year-old female, was admitted to Sichuan Provincial People’s Hospital for “pain in the right abdomen accompanied by skin and sclera yellow staining for 6+ months and aggravated for 20+ d”. When the patient was admitted, the general condition was poor, such as hyperbilirubin and hypoproteinemia. The body mass was 45 kg and the standard liver volume was 852 mL. The hydatid lesions corroded the first and second hilum of the liver, the right hepatic vein and the posterior inferior vena cava. It was difficult to reconstruct the outflow tract of the hepatic vein in vivo, and it was extremely difficult to completely remove the hydatid lesions in vivo. After admission, the patient was generally in a good condition after the PTCD treatment, then after discussion and rigorous evaluation, the ex-vivo hepatectomy combined with autologous liver transplantation was required. The operative time was 15 h and the intraoperative blood loss was approximately 2 000 mL. After the operation, the routine treatment was performed, the antiviral treatment was continued, the international standardized ratio value was monitored at 1.5–2.5, and the anti-immune rejection drugs were not needed. The patient was transferred to the general ward on the 4th day after the operation, and there were no bile leakage, bleeding, infection and other complications. the result of postoperative pathological diagnosis was the alveolar echinococcosis. The re-examination of enhanced CT on 1 week after the operation suggested that the hepatic outflow tract of allograft vascular reconstruction was unobstructed, no stenosis and no thrombosis occurred. The patient was following-up at present.ConclusionsIn treatment of end-stage hepatic alveolar echinococcosis by autologous liver transplantation, reconstruction of hepatic outflow should be individualized. Allograft venous vessels could be used as ideal materials due to their advantages of matched tube diameter and length, no anti-rejection, and low risk of infection.
Objective To determine the value of contrast-enhanced ultrasound (CEUS) in the differentiation of primary liver cancer (PLC) and hepatic alveolar echinococcosis (HAE). Methods The data of 56 patients with PLC or HAE were collected between January 2010 and May 2015. Grayscale and CEUS features of the patients were analyzed retrospectively. The frequency of each imaging finding, including calcification, arterial enhancement, and internal enhancement were evaluated and compared. Results Statistically significant difference of the proportion of gender and age were detected between the two groups (P=0.013, 0.002). Thirty-eight PLC lesions were detected in 32 patients. The diameters of PLC lesions were 3-10 cm with an average of (5.6±2.1) cm. Thirty-two HAE lesions were found in 24 patients. The diameters of HAE lesions were 4-12 cm with an average of (9.1±4.4) cm. Statistically significant difference of lesion size and the incidence rate of calcification (5.3% vs. 75.0%) were seen between PLC and HAE (P<0.001). Peripheral enhancement were seen in 100.0% (38/38) PLC lesions, including 84.2% (32/38) hyperenhancement and 15.8% (6/38) dendritic hyperenhancement. All PLC lesions demonstrated hypoenhancement in late phase. Irregular peripherally hyperenhancement both in arterial and late phase were detected in 43.8% (14/32) HAE lesions. The other 56.2% (18/32) HAE lesions showed no peripheral enhancement both in arterial and late phase. No internal enhancement were seen in HAE lesions. The presence of arterial enhancement (100.0% vs. 43.8%) and absence of internal enhancement (0 vs. 100.0%) were significantly different between PLC and HAE (P<0.001). Conclusions PLC is predicted by arterial phase hyperenhancement and late phase hypoenhancement on CEUS. HAE is predicted with calcification on baseline sonography and internal non-enhancement on CEUS. Arterial phase enhancement is less common and less intensive in HAE than in PLC which also contributes to the differentiation of these lesions.
Objective To evaluate effects of three-dimensional (3D) visualized reconstruction technology on short-term benefits of different extent of resection in treating hepatic alveolar echinococcosis (HAE) as well as some disadvantages. Methods One hundred and fifty-two patients with HAE from January 2014 to December 2016 in the Department Liver Surgery, West China Hospital of Sichuan University were collected, there were 80 patients with ≥4 segments and 72 patients with ≤3 segments of liver resection among these patients, which were designed to 3D reconstruction group and non-3D reconstruction group according to the preference of patients. The imaging data, intraoperative and postoperative indicators were recorded and compared. Results The 3D visualized reconstructions were performed in the 79 patients with HAE, the average time of 3D visualized reconstruction was 19 min, of which 13 cases took more than 30 min and the longest reached 150 min. The preoperative predicted liver resection volume of the 79 patients underwent the 3D visualized reconstruction was (583.6±374.7) mL, the volume of intraoperative actual liver resection was (573.8±406.3) mL, the comparison of preoperative and intraoperative data indicated that both agreed reasonably well (P=0.640). Forty-one cases and 38 cases in the 80 patients with ≥4 segments and 72 patients with ≤3 segments of liverresection respectively were selected for the 3D visualized reconstruction. For the patients with ≥4 segments of liver resection, the operative time was shorter (P=0.021) and the blood loss was less (P=0.047) in the 3D reconstruction group as compared with the non-3D reconstruction group, the status of intraoperative blood transfusion had no significant difference between the 3D reconstruction group and the non-3D reconstruction group (P=0.766). For the patients with ≤3 segments of liver resection, the operative time, the blood loss, and the status of intraoperative blood transfusion had no significant differences between the 3D reconstruction group and the non-3D reconstruction group (P>0.05). For the patients with ≥4 segments or ≤3 segments of liver resection, the laboratory examination results within postoperative 3 d, complications within postoperative 90 d, and the postoperative hospitalization time had no significant differences between the 3D reconstruction group and the non-3D reconstruction group (P>0.05). Conclusion 3D visualized reconstruction technology contributes to patients with HAE ≥4 segments of liver resection, it could reduce intraoperative blood loss and shorten operation time, but it displays no remarkable benefits for ≤3 segments of liver resection.
Objective To discuss the clinical application of two-stage hepatectomy for multiple and huge hepatic alveolar echinococcosis. Methods The clinical data of 7 patients with multiple hepatic alveolar echinococcosis treated with two-staged hepatectomy in West China Hospital of Sichuan University and The people's Hospital of Ganzi Tibetan Autonomous Prefecture of Sichuan Province from August, 2013 to June, 2016 were analyzed retrospectively. The preoperative diagnose was definite according to CT and (or) MRI, serological and life in the epidemic area. The patients, which the future liver remnant was less than 30% according to CT, received two-staged hepatectomy. Epigastric enhancement CT, liver function and blood routine examination were reviewed monthly after the first surgery, the second surgery was operated after 3 monthes, epigastric ultrasound, enhancement CT or MRI, liver function, blood routine examination and serological were adopted in 1, 6, and 12 months and each year after the second operation. Results The liver function was normal in 7 days after two operations and no complications after the first suegery, one patient developd with biliary fistula after the second surgery, no recurrence or death occurred during the followed-up period. Conclusion The two-stage hepatectomy can be operated in multiple and huge alveolar echinococcosis to reduce surgery risk and cost, shorten hospital stays and improve quality of life.