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Introduction. Pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV) reconstruction are often required to achieve complete (R0) resection for pancreatic head cancer (PHC) with tumor invasion of the SMV. Augmented reality (AR) technology can be used to assist in determining the extent of SMV involvement by superimposing virtual 3-dimensional (3D) images of the pancreas and regional vasculature on the surgical field. Materials and Methods. Three patients with PHC and tumor invasion of the SMV underwent AR-assisted PD with SMV resection and reconstruction following preoperative computed tomography scanning. Preoperative imaging data were used to reconstruct 3D images of anatomical structures, including the tumor, portal vein (PV), SMV, and splenic vein (SV). Using AR software installed on a smart phone, the reconstructed 3D images were superimposed on the surgical field as viewed in a smart phone display to provide intermittent navigational assistance to the surgeon in identifying the boundaries of PHC tumor invasion for resection of the vessels involved. Result. All patients successfully completed the operation. Intraoperative AR applications displayed virtual images of the pancreas, SMV, bile duct, common hepatic artery (CHA), and superior mesenteric artery (SMA). Two patients required end-to-end anastomosis for reconstruction of the SMV. One patient required allogenic vascular bypass to reconstruct the SMV-PV juncture with concomitant reconstruction of the SV-SMV confluence by end-to-side anastomosis of the SV and bypass vessel. Postoperative pathology confirmed R0 resections for all patients. Conclusion. AR navigation technology based on preoperative CT image data can assist surgeons performing PD with SMV resection and reconstruction.

BackgroundThe aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intraoperative stenting to treat portal vein cavernous transformation. MethodsIn total, 13 portal vein cavernous transformation patients underwent traditional Meso-Rex bypass surgery (Group A, n=8), modified Meso-Rex bypass without stent implantation (Group B, n=1) and modified Meso-Rex bypass with intraoperative stent implantation (Group C, n=4). ResultsIn Group A, the bypass diameter was 2-6 mm (median 3.3 mm) and blood flow velocity 25-115 cm/s (median 75 cm/s) 1 month after Meso-Rex bypass surgery, with open bypass times of 0-59 months (median 16 months); 5 patients in this group developed postoperative Meso-Rex bypass occlusions. One patient in Group B needed a thrombectomy and stent implantation during a second surgery 2 days after the modified Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group C, the average Meso-Rex bypass diameter was 5.5-6.5 mm (median 6 mm) and the bypass vessels remained open in all patients, with blood flow rates of 45-100 cm/s (median 76.5 cm/s) 1 month after Meso-Rex bypass, up to the endpoint (12-26 months, median 18 months). The rate of bypass occlusions in Group A and Group C were 25%, 0%; 25%, 0% and 50%, 0% at 1 month, 3 months and 1 year, respectively, after Meso-Rex bypass surgery.ConclusionsOur novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.

Background. We applied augmented reality (AR) techniques to flexible choledochoscopy examinations. Methods. Enhanced computed tomography data of a patient with intrahepatic and extrahepatic biliary duct dilatation were collected to generate a hollow, 3-dimensional (3D) model of the biliary tree by 3D printing. The 3D printed model was placed in an opaque box. An electromagnetic (EM) sensor was internally installed in the choledochoscope instrument channel for tracking its movements through the passages of the 3D printed model, and an AR navigation platform was built using image overlay display. The porta hepatis was used as the reference marker with rigid image registration. The trajectories of the choledochoscope and the EM sensor were observed and recorded using the operator interface of the choledochoscope. Results. Training choledochoscopy was performed on the 3D printed model. The choledochoscope was guided into the left and right hepatic ducts, the right anterior hepatic duct, the bile ducts of segment 8, the hepatic duct in subsegment 8, the right posterior hepatic duct, and the left and the right bile ducts of the caudate lobe. Although stability in tracking was less than ideal, the virtual choledochoscope images and EM sensor tracking were effective for navigation. Conclusions. AR techniques can be used to assist navigation in choledochoscopy examinations in bile duct models. Further research is needed to determine its benefits in clinical settings.

Aim To evaluate the application value of a three-dimensional (3D) printing model in the training of choledochoscopy techniques. Materials and methods Imaging data from two patients with biliary dilatation were used to produce two 3D reconstruction models which were subsequently constructed into 3D printing models (No. 1 and No. 2). Four hepatobiliary surgeons evaluated the anatomical accuracy and academic teaching value of the printed models. Twenty resident trainees with no prior experience in any kind of endoscopic techniques were randomly and symmetrically divided into two groups. The training group (A) used the 3D model No. 1 in the learning of biliary tract anatomy and practice techniques of choledochoscopy. The control group (B) got the virtual 3D image of the same model on computer for learning. After 4 weeks, the model No. 2 was used to reassess the trainees’ subjective and objective progress in anatomy familiarity and choledochoscopy manipulations. Results All consulted surgeons agreed that the 3D models realistically reproduced the anatomy of the biliary system. All trainees in group A agreed or strongly agreed that the 3D models provided good anatomical realism, enhanced their experience in the training of choledochoscopy techniques, and aided in their learning of biliary anatomy. With the practice went on, they increased the accuracy and showed a reduction in operation time on the model No. 1. During final examination with model No. 2, the rate of correct anatomical structure identification in training group was significantly higher than group B (p

Summary Aim To evaluate the prognostic significance of the epithelial cell adhesion molecule (EpCAM) expression in HCC, the relationship between EpCAM with ductular reactions and other clinical features. Methods From 2001 to 2003, 106 HCC patients who underwent curative resection in Eastern Hepatobiliary Hospital were enrolled. The expression of EpCAM in tumoral tissues and ductular reactions in paired non-tumoral tissues was assessed by immunohistochemistry. EpCAM was evaluated with prognosis, ductular reactions and other clinical variables. Results HCC expressing high level of EpCAM showed more aggressively than usual progressed HCC. High EpCAM expression was associated with poor overall survival and recurrence free survival. (P = 0.0005, 0.0019, respectively). A close association was found between tumoral EpCAM expression and peritumoral ductular reactions. Patients with high level of ductular reactions tended to have higher EpCAM expression than those with low level (P = 0.016). Conclusion HCC stratification by EpCAM may reflect different prognosis. EpCAM expression correlated with ductular reactions may be a result of unregulated activation and differentiation blockage of progenitor cells.

Background There are still several controversies and ambiguities in the aspects of primary hepatic squamous cell carcinoma and primary hepatic adenosquamous carcinoma. To further clarify the specific features of these two infrequent diseases and provide beneficial propose for clinical decision, we did this retrospective study. Methods We reviewed the clinical features and outcomes of three primary hepatic squamous cell carcinoma (SCC) patients and six primary hepatic adenosquamous carcinoma (ASC) patients from January 1998 to December 2011 in Eastern Hepatobiliary Surgery Hospital in China. Meanwhile, 40 hepatocellular carcinoma (HCC) patients and 26 metastatic hepatic SCC or ASC patients who were hospitalized in the same period were also reviewed to make a comparison. In order to find out the definite survival information of SCC and ASC patients, 30 previous studies containing 37 primary hepatic SCC (16) and ASC (21) patients were reviewed, and their information of survival was analyzed together with the included patients in our hospital. Results Serum tumor markers showed significant differences between primary hepatic SCC/ASC and HCC patients, especially for serum alpha fetal protein (AFP) level and carbohydrate antigen 19-9 (CA 19-9). On the pathologic performance, primary SCC/ASC tumor was rarely accompanied with tumor capsule. They presented peripheral hepatic lymph node metastasis more likely and showed low proportion of microvascular invasion. The median survival time of primary hepatic SCC/ASC patients after liver resection (LR) was 15 months. And the 1-, 3-, 5-year survival rates after LR were 60%, 24%, and 12%, respectively. Significant difference was not discovered when SCC and ASC patients were compared with HCC patients (P = 0.294). The median survival time after LR for primary SCC and ASC patients was respectively 23 months and 13 months. Conclusions The comprehensive application of some clinical characteristics, histopathologic features, and imaging findings may be useful for us in making definite diagnoses for primary hepatic SCC and ASC patients preoperatively. And the treatment of liver resection was effective for those patients who met the selection criteria for liver resection.