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PurposeLimited studies have compared the efficacy of postoperative adjuvant therapies in HCC patients with microvascular invasion (MVI). In this study we assess the efficacy of postoperative adjuvant conservative therapy (CT), trans-catheter arterial chemoembolization (TACE) and radiotherapy (RT) in HCC patients with MVI.ResultsKaplan-Meier survival analysis revealed that patients in the RT group have significantly improved RFS (RT vs TACE: p = 0.011; RT vs CT: p < 0.001) and OS (RT vs. TACE: p = 0.034; RT vs CT: P < 0.001) compared to TACE and CT groups. Further, subgroup analysis based on the degree of MVI and surgical margin width showed that patients with narrow surgical margin have significantly longer RFS and OS after adjuvant RT than the TACE and CT, independent of degree of MVI. Multivariate analysis indicated that MVI classification is the independent prognostic factor associated with RFS and OS.Materials and MethodsBetween July 2008 and December 2015, 136 HCC patients with MVI were divided into three groups according to their adjuvant therapies. Survival outcomes namely relapse-free survival (RFS) and overall survival (OS) of the three groups were analyzed.ConclusionsAdjuvant radiotherapy following hepatectomy could result in better survival outcomes for HCC patients with MVI than TACE or CT.

OBJECTIVESThere are conflicting views regarding the status of valve-sparing root replacement (VSRR) as a proper treatment for acute type A aortic dissection (AAAD). Our goal was to compare the early and late outcomes of VSRR versus those of the Bentall procedure in patients with AAAD.METHODSWe performed a systematic review and meta-analysis of 9 studies to compare the outcomes of VSRR with those of the Bentall procedure in patients with AAAD. We focused on the following issues: early and late mortality rates, re-exploration, thromboembolization/bleeding events, infective endocarditis and reintervention rates.RESULTSA total of 706 patients with AAAD who underwent aortic root surgery were analysed; 254 patients were treated with VSRR and 452 with the Bentall procedure. VSRR was associated with a reduced risk of early death [odds ratio (OR) 0.34; 95% confidence interval (CI) 0.21–0.57] and late death (OR 0.34; 95% CI 0.21–0.57) compared with the Bentall procedure. No statistically significant difference was observed between the VSRR and Bentall groups with pooled ORs (OR 0.77; 95% CI 0.47–1.27, OR 0.61; 95% CI 0.32–1.18 and OR 0.71; 95% CI 0.23–2.15) for re-exploration, thromboembolization/bleeding and postoperative infective endocarditis, respectively. An increased risk of reintervention was observed for the VSRR compared to the Bentall group (OR 3.79; 95% CI 1.27–11.30). The pooled rate of reintervention incidence was 1.6% (95% CI 0.0–3.7%) and 0.4% (95% CI 0.0–1.3%) for the VSRR and the Bentall groups, respectively.CONCLUSIONSVSRR in patients with AAAD can be performed in experienced centres with excellent short- and long-term outcomes compared to those with the Bentall procedure and thus should be recommended especially for active young patients.

Patients with acute type A aortic dissection and certain serious medical conditions were more likely to die in the hospital if they underwent emergency nighttime surgical procedures.

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Background: This study is to establish prediction tools for in-hospital rupture of type A aortic dissection (TAAD) patients, to better guide emergency surgical triage and patient counselling. Methods: We retrospectively evaluated 1,133 consecutive patients with TAAD from January 2010 to December 2016. The study population was divided into training and testing datasets in a 70:30 ratio for further analysis using Random Forest. Results:The Random Forest classification model was developed with the training dataset and 16 variables were confirmed as 'important': age, BMI, gender, syncope, lower limb numbness/pain, acute phase of the TAAD, BP >160 mmHg at admission; acute liver dysfunction, WBC >15×10 9 /L, aortic size, aortic height index (AHI), periaortic hematoma, pleural effusion, brachiocephalic artery involvement, renal artery involvement, and hemopericardium. Validation of the model showed good discrimination with an AUC, sensitivity, specificity, positive predictive value and negative predictive value of 0.994, 1.000, 0.987, 0.998 and 1.000, respectively, in the training dataset, and 0.752, 0.990, 0.514, 0.945 and 0.857, respectively, in the testing dataset.Conclusions: An easy-to-use tool to predict in-hospital rupture for TAAD patients was developed and validated (http://47.107.228.109/). Periaortic hematoma is the strongest predictor. Simple clinical information such as syncope can be very useful in in-hospital rupture risk stratification.

Background: Clinical examination alone is neither sensitive nor specific for predicting flap necrosis, so several technologies, including indocyanine green angiography, thermal imaging (using the FLIR ONE), and near-infrared spectroscopy, have been developed to supplement perfusion assessment. This study aims to compare the accuracy of these three methods for intraoperatively predicting clinical flap necrosis in a rat perforator flap model. The authors hypothesized that near-infrared spectroscopy, assessing oxygenation rather than direct perfusion, would yield significantly different predictions. Methods: A 10 × 3-cm epigastric perforator flap was elevated in 14 adult male rats weighing 250 ± 50 g. Flap perfusion was assessed immediately after flap elevation using thermal imaging, near-infrared spectroscopy, and indocyanine green angiography. Measurements were correlated to the clinical endpoint and gold standard of flap necrosis on postoperative day 7. Results: All three technologies detected significant differences in perfusion along flap length (all p < 0.001), and were associated with significant differences in the odds of developing flap necrosis (all p < 0.001). The areas under the receiver operating characteristic curves were 0.948 for indocyanine green angiography as an absolute value, 0.873 for relative changes with thermal imaging, and 0.792 for tissue oxygenation. The sensitivity, specificity, and accuracy for indocyanine green angiography measured as an absolute value were the highest at 97.8, 87.5, and 92 percent, respectively. Conclusions: Indocyanine green angiography most accurately predicted flap necrosis in this study; however, tissue oximetry and thermal imaging were also capable of predicting necrosis and represented potentially less expensive or more readily available alternatives for objective perfusion assessment. Additional research can further delineate their roles and cost-efficacy in clinical practice.

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