Objective: To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open surgery. Design: Demographic, ultrasonographic, and operative data of patients who underwent laparoscopic cholecystectomy were analyzed. Factors affecting conversion to open surgery were identified with statistical analysis. Setting: A tertiary referral center. Patients: Five hundred patients who underwent laparoscopic cholecystectomies at our institution between March 1991 and July 1994. The patients' data had been prospectively collected. Intervention: Standard laparoscopic techniques with selective preoperative endoscopic retrograde cholangiopancreatography. Main Outcome Measure: Conversion of laparoscopic cholecystectomy to open surgery for management of technical difficulties or intraoperative complications. Results: Increased risk of conversion with statistical significance was found in patients older than 65 years, obese patients, patients who underwent interval elective laparoscopic cholecystectomy for acute cholecystitis, patients with ultrasonographic findings of thickened gallbladder wall, patients seen during the early learning phase of the series, and patients whose surgery was performed by senior surgeons. Increased risk of conversion was not found with patients' sex, previous lower abdominal surgery, history of acute pancreatitis or cholangitis, impaired liver function on presentation, or emergency laparoscopic cholecystectomy for acute cholecystitis. Conclusions: Risk factors, including patient factors, presentation, preoperative ultrasonography, and surgical experience, all contributed to the possibility of conversion. Knowledge of these factors may help in arranging the operating schedule, psychological preparation for the procedure, and planning of the duration of convalescence.

Chi Leung Liu;上达 范;Edward C.S. Lai;Chung Mau Lo;Kent Man Chu

Archives of Surgery

1996-1

The success of liver transplantation (LT) for hepatocellular carcinoma (HCC) is enhanced by careful patient selection on the basis of the Milan criteria. The criteria are traditionally assessed by contrast CT, which is known to be affected by structural or architectural changes in cirrhotic livers. We aimed to compare dual-tracer (¹¹C-acetate and ¹⁸F-FDG) PET/CT with contrast CT for patient selection on the basis of the Milan criteria. Methods: Patients who had HCC and had undergone both preoperative dual-tracer PET/CT and contrast CT within a 1-mo interval were retrospectively studied. They then underwent either LT (n = 22) or partial hepatectomy (PH) (n = 21; HCC of ≤ 8 cm). Imaging data were compared with data from postoperative pathologic analysis for accuracy in assessment of parameters specified by the Milan criteria (tumor size and extent, vascular invasion, and metastasis), TNM staging, and patient selection for LT. Results: Dual-tracer PET/CT performed equally well in both LT and PH groups for HCC detection (94.1% vs. 95.8%) and TNM staging (90.9% vs. 90.5%). Contrast CT performed reasonably well in the LT group but not in the PH group for HCC detection (67.6% vs. 37.5%) and TNM staging (54.5% vs. 28.6%). In the LT group, the sensitivity and specificity of contrast CT for patient selection on the basis of the Milan criteria were 43.8% and 66.7%, respectively (comparable to values in the literature); the sensitivity and specificity of dual-tracer PET/CT were 93.8% and 100%, respectively (both Ps < 0.05). From the surgeon's perspective, we tended to perform transplantation for patients with higher diagnostic certainty (stricter CT criteria) because of a shortage of donor grafts. Patients who were not transplant candidates usually underwent up-front hepatectomy without the benefit of reassessment contrast CT, resulting in lower accuracies for the PH group. The overall sensitivity (96.8%) and specificity (91.7%) of dual-tracer PET/CT for patient selection for LT were significantly higher than those of contrast CT (41.9% and 33.0%, respectively) (both Ps < 0.05). Sources of error for contrast CT were related to cirrhosis or previous treatment and included difficulty in differentiating cirrhotic nodules from HCC (39%) and estimation of tumor size (14%). Overstaging of vascular invasion (4.6%) and extrahepatic metastases (4.6%) was infrequent. The rate of false-negative results of dual-tracer PET/CT was 4.7%. Conclusion: Dual-tracer PET/CT was significantly less affected by cirrhotic changes than contrast CT for HCC staging and patient selection for LT on the basis of the Milan criteria. The inclusion of dual-tracer PET/CT in pretransplant workup may warrant serious consideration.

Tan To Cheung;Chi Lai Ho;Chung Mau Lo;Sirong Chen;See Ching Chan;S. H.Chok Kenneth;James Y. Fung;Albert Chi Yan Chan;William Sharr;Thomas Yau;T. P.Poon Ronnie;上达 范

Journal of Nuclear Medicine

2013-2

上达 范

2011-1-1

BACKGROUND: The role of hepatic resection for large hepatocellular carcinoma (HCC) larger than 10 cm remains unclear. STUDY DESIGN: Perioperative and longterm outcomes of 120 patients with HCC larger than 10 cm who underwent resection (group A) were compared with 368 patients with smaller HCC (group B). The prognostic factors in group A were analyzed. RESULTS: A higher proportion of patients underwent major hepatic resection in group A than in group B (90% versus 57.6%, p = 0.001), but the hospital mortality was similar (5.0% versus 4.6%, p = 0.874). Group A had worse longterm overall survival (median 18.8 months versus 62.8 months, p < 0.001) and disease-free survival (median 5.5 months versus 25.4 months, p < 0.001) than group B. Macroscopic residual tumor, macroscopic venous invasion, and multiple tumors were identified as independent prognostic factors in group A. The median survival of patients with residual tumor and those with curative resection was 7.7 months and 20.8 months, respectively. The median survival of patients with curative resection of solitary HCC larger than 10 cm without macroscopic venous invasion was 38.0 months; that of patients with both macroscopic venous invasion and multiple tumors was only 10.5 months. CONCLUSIONS: Hepatic resection is a safe and effective treatment for HCC larger than 10 cm when liver function reserve is satisfactory and when curative resection can be expected. Patients with solitary HCC larger than 10 cm without macroscopic venous invasion can enjoy longterm survival after surgery, and we propose hepatic resection as a standard treatment for this group of patients.

Ronnie Tung Ping Poon;上达 范;John Wong

Journal of the American College of Surgeons

2002

A cutaneous stoma in the Roux limb of hepaticojejunostomy (hepaticocutaneous jejunostomy) was used for stone extraction in two children who had hepatolithiasis (14.5 and 15.5 years, respectively) after operation for choledochal cysts. In constructing the hepaticocutaneous jejunostomy, a short, straight proximal limb from the skin to the bilioenteric anastomosis is mandatory. It provides a pathway, superior to the T-tube tract, for repeated stone extraction, which can be performed under sedation, thus obviating repeat laparotomies. The stoma allows flexible choledochoscopy, balloon dilatation of intrahepatic duct strictures, and extraction of intrahepatic stones using grasping forceps, baskets, and balloons. The electrohydraulic lithotriptor may be applied to fragment larger stones.

Htut Saing;K. L. Chan;G. H. Mya;W. Cheng;上达 范;F. L. Chan

Journal of Pediatric Surgery

1996-2

BACKGROUND: Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS: Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score >25; n=75) and allow-score group (MELD score <25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS: In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P<0.001), mechanical ventilation (21.3% vs 0%; P<0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P<0.001); more blood was transfused during operation (7 vs 2 units; P<0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P<0.001) and hospital (21 vs 15 days; P=0.015) after transplantation; more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS: Although the high-score group had significantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.

Kenneth S.H. Chok;See Ching Chan;James Y.Y. Fung;Tan To Cheung;Albert C.Y. Chan;上达 范;Chung Mau Lo

Hepatobiliary and Pancreatic Diseases International

2013

Biliary complications of living donor liver transplantation remain common. The complications of biliary leakage and stricture result in substantial recipient morbidity. A major focus of liver transplantation research is the prevention and reduction of these complications through identification of the multiple factors that are conducive to them. Such factors include the donor bile duct anatomy and quality, and the techniques of donor hepatectomy, recipient hepatectomy, and ductal reconstruction. A low threshold for re-exploration for possible bile leakage prevents development of uncontrolled sepsis. Return of good graft function can usually be expected after successful early endoscopic treatment. Contingent measures of percutaneous transhepatic dilatation and stenting, and revision hepaticojejunostomy have to be exercised with utmost care to avoid hepatic artery injury which may results in graft loss.

See Ching Chan;上达 范

Hepatology International

2008

Background Hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is rare. The aim of the present study was to determine the prognosis of HCC with BDTT after a hepatectomy. Methods A retrospective analysis was performed on all HCC patients with BDTT having a hepatectomy from 1989 to 2012. The outcomes in these patients were compared with those in the control patients matched on a 1:6 ratio. Results Thirty-seven HCC patients with BDTT having a hepatectomy (the BDTT group) were compared with 222 control patients. Patients in the BDTT group had poorer liver function (43.2% had Child-Pugh B disease). More patients in this group had a major hepatectomy (91.9% versus 27.5%, P = 0.001), portal vein resection (10.8% versus 1.4%, P = 0.006), en-bloc resection with adjacent structures (16.2% versus 5.4%, P = 0.041), hepaticojejunostomy (75.7% versus 1.6%, P < 0.001) and complications (51.4% versus 31.1%, P = 0.016). The two groups had similar hospital mortality (2.7% versus 5.0%, P = 0.856), 5-year overall survival (38.5% versus 34.6%, P = 0.59) and 5-year disease-free survival (21.1% versus 20.8%, P = 0.81). Multivariate analysis showed that lymphovascular permeation, tumour size and post-operative complication were significant predictors for worse survival whereas BDTT was not. Discussion A major hepatectomy, extrahepatic biliary resection and hepaticojejunostomy should be the standard for HCC with BDTT, and long-term survival is possible after radical surgery.

Tiffany C.L. Wong;Tan To Cheung;Kenneth S.H. Chok;Albert C.Y. Chan;Wing Chiu Dai;See Ching Chan;Ronnie T.P. Poon;上达 范;Chung Mau Lo

HPB

2015-5-1

Background: Long-term survival of patients with hepatocellular carcinoma (HCC) after liver transplantation is affected mainly by recurrence of HCC. There is the opinion that the chance of recurrence after 2 years post-transplantation is remote, and therefore lifelong surveillance is not justified because of limited resources. The aims of the present study were to determine the rate of late HCC recurrence (≥2 years after transplantation) and to compare the long-term patient survival outcomes between cases of early recurrence (<2 years after transplantation) and late recurrence. Patients: A total of 139 adult HCC patients having liver transplantation during the period from July 1994 to December 2007 were included in the analysis. The median follow-up period was 55 months. Thirty-two patients received deceased-donor grafts and 107 received living-donor grafts. Results: Hepatocellular carcinoma recurrence occurred in 24 (17.3%) patients, among them 22 (86%) had living-donor grafts and 7 (5%) developed late recurrence. Patients in the early recurrence group and patients in the late recurrence group had comparable demographics and disease pathology. The former group, when compared with the latter, had significantly worse overall survival at 3 years (13.3 versus 100%) and 5 years (6.67 versus 71.4%) (log-rank test; p < 0.001). Conclusions: Both early recurrence and late recurrence of HCC after liver transplantation were not uncommon, mostly detected at a subclinical stage. Regular and long-term surveillance with imaging and blood tests is essential for early detection.

Kenneth S.H. Chok;See Ching Chan;Tan To Cheung;Albert C.Y. Chan;上达 范;Chung Mau Lo

World Journal of Surgery

2011-9

Radiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients. To evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA. From April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (n∈=∈101), laparoscopic (n∈=∈17), or open approaches (n∈=∈91). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients. The mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26 months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child-Pugh grade (risk ratio [RR]∈=∈2.918, 95% confident interval [CI] 1.704-4.998, p∈=∈0.000), tumor size (RR∈=∈1. 231, 95% CI 1.031-1.469, p∈=∈0.021), and pattern of recurrence (risk ratio [RR]∈=∈1.464, 95% CI 1.156-1.987, P∈=∈0.020) were identified as independent prognostic factors for overall survival. The tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.

Kelvin K. Ng;Ronnie T. Poon;Chung Mau Lo;Jimmy Yuen;Wai Kuen Tso;上达 范

Journal of Gastrointestinal Surgery

2008-1