Introduction

Prone is a common position for endoscopic retrograde cholangiopancreatography (ERCP). However, patients need to rotate their neck up to 90^O to the right along the procedure time, which might cause post-procedure neck sprain. Furthermore, patients with limited neck rotation may have difficulty during intubation of the endoscope. We designed a pillow to have only one elevated corner, this was put under the right shoulder, and the height of the pillow gradually sloped down to the other 3 corners. We hypothesize that the elevation of the right shoulder by the pillow makes thoracic rotation to compensate the cervical rotation and this would reduce neck sprain, from overstretching neck muscle, and facilitate endoscope intubation.

Aims & Methods

This randomized, controlled study aimed to evaluate the efficacy of the ergonomic wedge pillow for patients undergoing prone ERCP. Patients aged between 18-80 years who were indicated for ERCP at King Chulalongkorn Memorial Hospital were recruited. Patients with limited neck rotation less than 30-degree, severe cervical spine diseases, endotracheal intubated, or informed consent could not be obtained were excluded. The patients were randomized to undergo ERCP using pillow (study group) or without pillow (control group), in 1:1 fashion. Neck pain was reported by patients at baseline (before ERCP), and 1 hour, 1 day, and 7 days after ERCP. Scope intubation difficulty was rated by endoscopists. Patients’ and endoscopists’ satisfaction scores were recorded by using scales of 0-10.

Results

A total of 256 patients (122 women and 134 men) were randomized to study (128 patients), and control (128 patients) groups. The baseline characteristics and base-line neck pain scores were not different between two groups. The pillow group required less assisting shoulder lift during scope intubation (9% vs 22%, respectively) (p = 0.002). The requirement of nasopharyngeal airway insertion was not different between the two groups (13% vs 17%, respectively) (p = 0.385). After ERCP, neck pain was reported at 1 hour, 1 day, and 7 days after ERCP in 25%, 20%, and 0% in study group, and 31%, 31%, and 0% in control group, respectively. The incidence of neck pain at 1 day was significantly lower in pillow group than control group (p = 0.044), especially for moderate to severe neck pain (4% vs 11%, respectively) (p = 0.032). Endoscopists’ satisfaction scores were significantly higher in pillow group than control group (9.6 vs 8.9, respectively) (p < 0.001). There was a trend of higher patients’ satisfaction scores in pillow than control groups, 9.7 vs 9.5, respectively, however, this did not reach a statistical significance (p = 0.081).

Conclusion

The ergonomic, wedge-shaped pillow reduced the difficulty score of scope intubation and required less assisting shoulder lifting during scope intubation when compared with control. This pillow significantly reduced the incidence of neck sprain, especially for moderate-to-severe pain, at 1 day after prone ERCP. The pillow had a higher endoscopist’s satisfaction score and a trend toward higher patients’ satisfaction score.

Introduction

Gallbladder carcinoma (GBC) is the most common malignant tumor of the biliary tract and the sixth malignancy of the gastrointestinal tract^{1, 2}. It is frequently diagnosed at an advanced stage due to non-specific symptoms and aggressive biological behavior³. Radical resection is the most effective treatment, yet reported 5-year survival rates following operation vary greatly, from 10% to 100%^4-6. Indeed, long-term survival appears in patients with early-stage tumors. These patients are usually diagnosed incidentally, after cholecystectomy for presumed benign gallbladder disease. As the growing number of laparoscopic cholecystectomies executed, incidental gallbladder carcinoma (iGBC) is a progressively relevant clinical issue^7,8.
Re-exploration and re-resection are currently recommended for T1b, T2, and T3 iGBC patients without definite distant metastasis⁹. The extent of re-resection involves a partial hepatectomy of segment IVB+V, either as wedge resection or multi-segments resection and hepatoduodenal lymph nodes dissection¹⁰. However, there are few data on the timing of re-resection, especially immediate re-resection and delayed re-resection.
In this study, we compared the outcomes of immediate and delayed re-resection in iGBC patients, and to define optimal re-resection time that may improve prognosis.

Aims & Methods

For incidental gallbladder carcinoma (iGBC) patients with T1b and higher tumors are recommended to undergo radical re-resection, it is not clear whether immediate re-resection is more beneficial to long-term survival compared with delayed re-resection. To assess whether immediate re-resection is more beneficial to long-term survival compared with delayed re-resection.
This single centre retrospective observational cohort study of patients with iGBC was conduct from June 2006 and February 2015. Patients who underwent radical re-resection for T1b or higher iGBC were enrolled. The oncological outcomes of patients who underwent immediate re-resection were compared with those of patients treated with delayed re-resection.

Results

A total of 78 patients were included. 31 patients underwent immediate re-resection and 47 patients underwent delayed re-resection. The baseline demography, extent of resection, resection margin, T stage, lymph node involvement and postoperative complications were similar between the two groups. Patients in immediate re-resection group had less intraoperative blood loss and shorter hospital stay compared with those in delayed re-resection group. Kaplan-Meier analysis indicates that the overall survival rate of patients with delayed re-resection significantly decreased than those with immediate re-resection. Multivariate analysis showed that delayed re-resection (HR = 5.110, 95%CI: 1.595-16.371, P = 0.006), R1 resection (HR = 4.502, 95%CI: 1.345-15.070, P = 0.015) and lymph node positivity (HR = 6.025, 95%CI: 1.286-28.220, P = 0.023) were adverse prognostic factors for overall survival.

Conclusion

Immediate re-resection for selected patients with incidental gallbladder carcinoma is oncologically superior to delayed approach. To improve iGBC detection and timely referral of iGBC patients to immediate re-resection may allow more patients to benefit from this operation.

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin.2015;65(1):5–29.
2. Kasumova GG, Tabatabaie O, Najarian RM, et al. Surgical Management of Gallbladder Cancer: Simple Versus Extended Cholecystectomy and the Role of Adjuvant Therapy. Ann Surg.2017;266(4):625-631.
3. Baiu I, Visser B. Gallbladder Cancer. JAMA.2018;320(12):1294.
4. Yuza K, Sakata J, Prasoon P, et al. Long-term outcomes of surgical resection for T1b gallbladder cancer: an institutional evaluation. BMC Cancer.2020;20(1):20.
5. L Lundgren, C Muszynska, A Ros, et al. Management of incidental gallbladder cancer in a national cohort. Br J Surg.2019;106(9):1216-1227.
6. Lendoire JC, Gil L, Duek F, et al. Relevance of residual disease after liver resection for incidental gallbladder cancer. HPB(Oxford).2012;14(8):548-553
7. K Søreide, R V Guest, E M Harrison, et al. Systematic review of management of incidental gallbladder cancer after cholecystectomy. Br J Surg.2019;106(1):32-45.
8. Steinert R, Nestler G, Sagynaliev E, et al. Laparoscopic cholecystectomy and gallbladder cancer. J Surg Oncol.2006;93:682–9.
9. Aloia TA, Jarufe N, Javle M, et al. Gallbladder cancer: expert consensus statement. HPB (Oxford).2015;17:681–90.
10. Goetze TO, Paolucci V. The prognostic impact of positive lymph nodes in stages T1 to T3 incidental gallbladder carcinoma: Results of the German Registry. Surg Endosc.2012;26:1382-1389.

Disclosure

No conflicts of interest regarding the current abstract.

Introduction

The clinical value of combined resection of important hepatic vessels in hilar cholangiocarcinoma remains controversial. We aimed to compare the short-term and long-term outcome of combined versus non-combined major vessel resection in patients undergoing radical resection for hilar cholangiocarcinoma.

Aims & Methods

This single centre retrospective cohort study of patients with hilar cholangiocarcinoma was conduct from January 2007 to December 2018. Patients who underwent radical re-resection were enrolled. The short-term and long-term clinical outcomes of the groups were compared after propensity score matching.

Results

A total of 310 patients were included. There was no statistically significant difference in perioperative clinical outcomes between VR group (PVR and AVR) and non-VR group after 1:2 PSM. Patients who received PVR had significantly longer OS (p=0.023) and DFS (p=0.010) compared to those in the non-PVR group. AVR group was associated with improved OS (p=0.036) and DFS (p=0.029) compared with non-AVR group following the curative-intent resection. The postoperative complications of combined VR would not worsen long-term survival for patients (OS: p=0.159; DFS: p=0.112).

Conclusion

Combined vascular resection (VR) would improve the long-term survival for patients with hilar cholangiocarcinoma. The postoperative complications of combined VR would not worsen long-term survival. Therefore, radical surgical resection should be actively performed in these patients.

Disclosure

The authors declare that they have no competing interests.

Clinical Case Summary

The hemangiomas represent the most common benign mesenchymal tumor of the liver. Most often they occur solitary. We distinguish several variants, and one of the rarest forms is so-called pedunculated hemangioma, which represents an exophytically growing lesion. Pedunculated hemangiomas can be asymptomatic, but due to the size and extrahepatic localization, they can compress the bile ducts, surrounding abdominal organs or vascular structures. Another potential manifestation is so-called Kasabach-Merritt syndrome, which presents with hemolytic anemia, thrombocytopenia, hypofibrinogenemia or prolonged prothrombin time. Most often, this syndrome manifests in childhood, it is very rare in adults. We presented a case of 65-year-old female patient was hospitalized at the internal department for severe pancytopenia in June 2022. On admission, the patient reported weight loss of 10 kg over the course of 6 months. She suffered from anemia, trombocytopenia and hypofibrinogenemia. During hospitalization, CT scan of the abdomen was made and showed a liver lesion in the S2/S3 segment a peripheral lesion (43x30 mm) and lobular tumor extending into the left subphrenic (120x94mm) compressing the spleen. Post-contrast, the lesion was nodularly filled at the periphery of the lesion, with gradual filling in the delayed phase - like a hemangioma.
The patient underwent a hematological examination with a conclusion of severe thrombocytopenia due to consumption coagulopathy, thrombocytopenia due to giant liver hemangioma. The patient was subsequently presented at a multidisciplinary seminar and partial resection of the hemangioma together with its extrahepatic part was indicated due to the risk of torsion. A left-sided bisegmentectomy of the liver was performed. The resection was subsequently sent for histological examination, which verifies a giant cavernous hemangioma. The postoperative course was without complications, some laboratory parameters gradually improved at discharge.

Disclosure

Fig. 1 A pedunculated hemangioma on an axial CT section of the abdomen p
using a contrast material - clear compression of the spleen to the spine
(archive of the University Hospital in Martin)

Introduction

Non-alcoholic steatohepatitis (NASH) is a chronic liver disease characterized by liver steatosis and inflammation which abnormal immune responses involved in pathogenesis, and there is no approved therapeutic drug. Rhein, one of the main bioactive components of Rheum palmatum, has exerted anti-inflammatory properties. However, the mechanism by which Rhein exerts beneficial effects against NASH is far from elucidated. Here, our study aimed to investigate the therapeutic effects of Rhein on liver steatosis and inflammation and elucidate the related mechanisms of immunoregulation.

Aims & Methods

Male C57BL/6 mice were given high-fat diet for 10 weeks to induce NASH, followed by Rhein suspension administration at a dose of 100mg/kg and 200mg/kg for 4 weeks. The therapeutic effect of NASH was estimated by body weight, liver weight, LW/BW, food intake, the liver appearance and the histological analysis of liver section stained with hematoxylin and eosin. The proportion of lymphocyte cells in the mesenteric lymph nodes (MLNs) was detected by flow cytometry.

Results

Our findings demonstrated that high-fat diet treatment resulted in severe liver inflammation and severe steatosis, while Rhein appreciably reverse these phenomenon, as evidenced by the reduction of body weight, liver wet weight, LW/BW, and liver size in mice. Histological analysis of liver section revealed that administration of Rhein exhibited improvement of severe steatosis, elimination of inflammatory cells and resolution of balloon-like changes when compared to mice in the HFD group. Interestingly, there were no significant differences in food intake among groups of mice, suggesting that the protective effect of Rhein is not achieved by inhibiting appetite. Mechanistically, flow cytometry analysis showed that higher Th1 and Th17 polarized response were detected in the MLN compartments in HFD-induced mice, evidenced by the detection of increased numbers of Th1 cells (CD3+CD4+IFN-γ+) and Th17 cells (CD3+CD4+IL-17+), and Rhein intervention showed significant decrease numbers of Th1 and Th17 in MLNs. In contrast, Rhein treatment significantly increased the numbers of Treg cells (CD3+CD4+Foxp3+) with anti-inflammatory effects in the MLN of NASH mice.

Conclusion

Our results provide novel insights into the protective role of Rhein in modulating the liver steatosis and inflammation, with therapeutic potential for immunology-targeted strategy in the treatment of NASH.

References

[1] Cheng L, Chen Q, Pi R, Chen J. A research update on the therapeutic potential of rhein and its derivatives. Eur J Pharmacol. 2021,899:173908. doi:10.1016/j.ejphar.2021.173908.
[2] Gebru YA, Gupta H, Kim HS, et al. T Cell Subsets and Natural Killer Cells in the Pathogenesis of Nonalcoholic Fatty Liver Disease. Int J Mol Sci. 2021,22(22):12190. doi:10.3390/ijms222212190

Disclosure

The authors declare that there are no conflicts of interest regarding the publication of this paper.