Objective: The aim of this study was to evaluate the short- and long-term outcome of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for hepatitis-related hepatocellular carcinoma (HCC). Summary Background Data: ALPPS has been advocated for future liver remnant (FLR) augmentation in liver metastasis or noncirrhotic liver tumors in recent years. Data on the effect of ALPPS in chronic hepatitis or cirrhosis-related HCC remained scarce. Methods: Data for clinicopathological details, portal hemodynamics, and oncological outcome were reviewed for ALPPS and compared with portal vein embolization (PVE). Tumor immunohistochemistry for PD-1, VEGF, and AFP was evaluated in ALPPS and compared with PVE and upfront hepatectomy (UH). Results: From 2002 to 2018, 148 patients with HCC (hepatitis B: n = 136, 92.0%) underwent FLR modulation (ALPPS, n = 46; PVE: n = 102). One patient with ALPPS and 33 patients with PVE failed to proceed to resection (resection rate: 97.8% vs 67.7%, P < 0.001). Among those who had resections, 65 patients (56.5%) had cirrhosis. ALPPS induced absolute FLR volume increment by 48.8%, or FLR estimated total liver volume ratio by 12.8% over 6 days. No difference in morbidity (20.7% vs 30.4%, P = 0.159) and mortality (6.5% vs 5.8%, P = 1.000) with PVE was observed. Chronic hepatitis and intraoperative indocyanine green clearance rate ≤39.5% favored adequate FLR hypertrophy in ALPPS. Five-year overall survival for ALPPS and PVE was 46.8% and 64.1% (P = 0.234). Tumor immunohistochemical staining showed no difference in expression of PD-1, V-EGF, and AFP between ALPPS, PVE, and UH. Conclusions: ALPPS conferred a higher resection rate in hepatitis-related HCC with comparable short- and long-term oncological outcome with PVE.

Background Management errors during pre-hospital care, triage process and resuscitation have been widely reported as the major source of preventable and potentially preventable deaths in multiple trauma patients. Common tools for defining whether it is a preventable, potentially preventable or non-preventable death include the Advanced Trauma Life Support (ATLS Ò ) clinical guideline, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS). Therefore, these surrogated scores were utilized in reviewing the study's trauma services. Methods Trauma data were prospectively collected and retrospectively reviewed from January 1, 2018, to December 31, 2018. All cases of trauma death were discussed and audited by the Hospital Trauma Committee on a regular basis. Standardized form was used to document the patient's management flow and details in every case during the meeting, and the final verdict (whether death was preventable or not) was agreed and signed by every member of the team. The reasons for the death of the patients were further classified into severe injuries, inappropriate/delayed examination, inappropriate/delayed treatment, wrong decision, insufficient supervision/guidance or lack of appropriate guidance. Results A total of 1913 trauma patients were admitted during the study period, 82 of whom were identified as major trauma (either ISS [ 15 or trauma team was activated). Among the 82 patients with major trauma, eight were trauma-related deaths, one of which was considered a preventable death and the other 7 were considered unpreventable. The decision from the hospital's performance improvement and patient safety program indicates that for every trauma patient, basic life support principles must be followed in the course of primary investigations for bedside trauma series X-ray (chest and pelvis) and FAST scan in the resuscitation room by a person who meets the criteria for trauma team activation recommended by ATLS Ò . Conclusion Mechanisms to rectify errors in the management of multiple trauma patients are essential for improving the quality of trauma care. Regular auditing in the trauma service is one of the most important parts of performance improvement and patient safety program, and it should be well established by every major trauma center in Mainland China. It can enhance the trauma management processes, decision-making skills and practical skills, thereby continuously improving quality and reducing mortality of this group of patients.

A 43-year-old woman was referred to the University of Hong Kong-Shenzhen Hospital in August 2016 with a 10-year history of hepatolithiasis. Computed tomography (CT) of the abdomen demonstrated multiple stones in the right posterior portion of the liver, the common biliary duct, and the gallbladder. Dilatation and inflammation of both intra-and extra-hepatic ducts were apparent and an elective right hepatectomy along with a Roux-en-Y hepaticojejunostomy was arranged. Preoperative physical examination was normal apart from hypertension (168/105 mm Hg). Laboratory tests revealed a microcytic, hypochromic anaemia (haemoglobin, 97 g/L), hyperuricaemia, and mildly elevated alkaline phosphatase. Liver/renal function, clotting profile, chest X-ray, and electrocardiogram were all normal. General anaesthesia was induced intravenously with propofol and remifentanil using a target-controlled infusion (Marsh model) under the guidance of the Bispectral Index monitoring system (Covidien, Boulder [CO], US). Tracheal intubation was performed following administration of rocuronium and anaesthesia maintained intravenously with intermittent positive pressure ventilation in oxygen and air. The patient was positioned for right internal jugular vein (IJV) cannulation.Pre-insertion sonographic evaluation of the right cervical region (SonoSite M-Turbo, Bothell [WA], US) using a linear, high-frequency transducer (HFL38, 6-13 MHz) revealed only a single pulsatile vessel that was non-compressible and suggestive of the right carotid artery. The characteristic pulsatile blood flow was confirmed by Doppler. There was no evidence of the right IJV despite repositioning of the patient's head, use of minimal pressure on the probe with colour flow mapping, and the application of Valsalva manoeuvre. Ultrasonography of the left side showed normal anatomy with good size of IJV. Following a brief discussion, the consultant anaesthetist and the surgeon decided to proceed with surgery without a central venous catheter. At the end of liver resection, the patient began to develop hypotension that was marginally responsive to fluid

Highlights Complicated gallstone disease during pregnancy can be successfully managed by combined laparoscopic cholecystectomy and exploration of common bile duct through trans-cystic duct approach. This approach is safe and can cure cholecystitis and choledocholithiasis in one goal. This approach avoids ionizing radiation to the developing fetus.

The grading scale based on TOF-MRAsi could be a new empirical approach for pial collateral evaluation. The clinical use of the proposed approach for identifying patients with total occlusion of middle cerebral artery with a high risk of poor outcome requires evaluation in further studies.