Invasive Resection Research Articles

Changing trends in the minimally invasive surgery for chronic pancreatitis.

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Effectiveness of PET/CT and VATS for detecting and treating internal mammary lymph node metastasis: a case series.

We occasionally observed internal mammary lymph node metastases of breast cancer in a clinical setting. However, unlike a standard treatment in axillary metastasis, surgical resection for internal mammary lymph node metastasis is not prevalent because of unclear safety and benefits. Thus, we aimed to evaluate the diagnostic ability and clinical outcomes of positron emission tomography/computed tomography and video-assisted thoracoscopic surgery. We retrospectively investigated 34 patients with breast cancer with abnormal 18F-fluorodeoxyglucose uptake in internal mammary lymph nodes, at a single centre, between January 2015 and June 2022 and identified 11 female patients (mean age±SD, 51.5±12.9years) who underwent video-assisted thoracoscopic surgery resection. Positron emission tomography/computed tomography was used to determine the clinical stage. We reviewed the surgical pathology of eleven and two patients who underwent direct-view internal mammary lymph node resection to calculate the positive predictive value of positron emission tomography/computed tomography. Ipsilateral fluorodeoxyglucose accumulation was observed, with an average maximum standardized uptake value of 8.9 (range, 3.1-24.0). No perioperative complications occurred, and all patients who underwent video-assisted thoracoscopic surgery alone were discharged from the hospital on post-operative day 2 or 3. The estimated positive predictive value was 80%. All patients were alive, and seven of nine patients with metastasis were relapse-free, at a mean follow-up period of 17.9months (range, 1-51). However, two patients had recurrence at 16 and 14months after surgery for internal mammary lymph node relapse. Radiotherapy is the standard treatment for suspected internal mammary lymph node metastasis detected using positron emission tomography/computed tomography; however, we could safely perform minimally invasive video-assisted thoracoscopic surgery resection, leading to a definite pathological diagnosis.

Latest Findings on Minimally Invasive Anatomical Liver Resection.

Minimally invasive liver resection (MILR) is being widely utilized owing to recent advancements in laparoscopic and robot-assisted surgery. There are two main types of liver resection: anatomical (minimally invasive anatomical liver resection (MIALR)) and nonanatomical. MIALR is defined as a minimally invasive liver resection along the respective portal territory. Optimization of the safety and precision of MIALR is the next challenge for hepatobiliary surgeons, and intraoperative indocyanine green (ICG) staining is considered to be of considerable importance in this field. In this article, we present the latest findings on MIALR and laparoscopic anatomical liver resection using ICG at our hospital.

Minimally Invasive Anatomic Liver Resection for Hepatocellular Carcinoma Using the Extrahepatic Glissonian Approach: Surgical Techniques and Comparison of Outcomes with the Open Approach and between the Laparoscopic and Robotic Approaches.

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Abstract 763: Minimally invasive colorectal resection is associated with significantly elevated plasma levels of extracellular cold inducible RNA binding protein for a month after colorectal resection &amp; may promote the growth of residual metastases

Abstract Introduction: Cold-Inducible RNA-Binding Protein (CIRP) is similar to a class of stress-induced RNA binding proteins and is mostly found in the nucleus where it regulates transcription. In response to stress, CIRP moves to the cytoplasm where it regulates translation; a fraction of the cytoplasmic CIRP is released extracellularly (eCIRP). eCIRP is a damage-associated molecular pattern (DAMP) molecule that promotes inflammatory responses including TNF-alpha, IL-6, and HMGB production. Lymphocytes, macrophages, and PMN’s are activated after surgery and can generate eCIRP. Elevated eCIRP blood levels may impact macrophage function and induce immune tolerance that may promote tumor growth and progression. This study’s purpose was to measure plasma eCIRP levels before and for a month after MICR for CRC. Methods: CRC patients (pts) in an IRB approved data/tissue bank who underwent MICR for whom plasma was available were selected. Demographic, clinical and pathology data were reviewed. Plasma samples were collected preoperatively (preOp) and at 6 post-operative (Postop) time points (POD 1, 3, 7-13, 14-20, 21-27, 28-41); samples were processed and frozen until used. Late samples were bundled into 7-day blocks and considered as single time points. eCIRP levels were analyzed in duplicate using ELISA. The Wilcoxon paired t-test was used for analysis. Results: 83 CRC pts who underwent MICR were studied (colon 66%, rectal 34%; mean age 65); 26% had Hand assisted (HA) MIS (mean incision length[IL] 10.0±2.9cm) and 69% laparoscopic (LAP, mean IL 6.9±4.1cm) MICR. The cancer stage breakdown was; I, 30%; II, 32%; III, 35% and IV, 3%. The mean PreOp eCIRP level was 896.8± 757.0pg/ml; vs. preop levels increased mean plasma levels (p=&amp;lt;0.001) were noted on POD1 (2549± 2632pg/ml, n= 83), POD3 (1871± 1362pg/ml, n= 77), POD7-13 (1788± 1403pg/ml, n=57), POD14-20 (1473± 738.8pg/ml, n=30), and POD 21-27 (1681± 1375pg/ml, n= 21). With regard to MIS method, greater eCIRP increases were noted in the HA vs the Lap group from POD1-POD20 (p=0.01-0.04). Conclusions: Plasma eCIRP levels are elevated for a month after MICR for CRC (% change range 100-184) and peaked on POD1. The cause of the early increase may be the acute inflammatory response whereas the late elevations may be related to wound healing-related tissue remodeling. Higher mean levels in the HA vs Lap group suggests that the extent of surgical trauma impacts eCIRP levels postop. Previous studies noted increased post-MICR plasma levels of MCP-1, CHI3L1 and IL8 that stimulate macrophage activity. eCIRP, together with those proteins may promote macrophage recruitment and function and might promote the growth of residual tumor deposits postop. Further studies are warranted. Citation Format: Chandana S. K. Herath Mudiyanselage, Xiaohong Yan, Neil Mitra, Hansani N. Angammana, Doaa F. Morrar, Vincent Chia, Yanni Hedjar, Vesna Cekic, Jennifer L. Agnew, Richard L. Whelan. Minimally invasive colorectal resection is associated with significantly elevated plasma levels of extracellular cold inducible RNA binding protein for a month after colorectal resection &amp; may promote the growth of residual metastases [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 763.

Abstract 1304: Multiomic approaches to illuminate molecular drivers of breast cancer metastasis to the liver

Abstract The lack of knowledge around the mechanisms underlying metastatic progression is a major hurdle in achieving a durable response in the treatment of metastatic breast cancer (BC). Accordingly, effective therapies are not yet available, and the treatment of metastatic BC remains an unmet critical medical need. Circulating BC cancer cells can colonize the lungs, bone, brain, and liver generating metastatic lesions, which lead to poor outcomes. Liver metastases account for 30% of metastatic BC cases, therefore causing the greatest therapeutic challenge. The first line of therapy for BC liver metastasis is typically an invasive surgical resection, which unfortunately does not always resolve the metastatic lesion and requires further treatment. Unfortunately, there is currently no therapeutic standard of care (SOC) for BC liver metastasis, and therapy is selected based on the molecular profiling of primary tumor and metastasis biopsies. The scarcity of reliable and biologically relevant human experimental models, to provide a deep understanding of the molecular interactions underlying metastasis, is warranted. In this study, we exploit multiomic interrogation of breast cancer PDX models established from primary lesions, and metastasis of the liver, to uncover the molecular mechanisms underlying BC cells liver colonization. The results highlight global molecular differences between models derived from primary BC tumors and BC lesions collected from the liver. The analysis also reveals several genes at the DNA, RNA, and protein expression/activity level aiding in the adaptation of BC cell colonization in the liver. These novel findings provide insight into novel mechanisms of BC liver metastasis and highlight several targets suitable for future therapeutic intervention. Citation Format: Gilad Silberberg, Yaron Mosesson, Haia Khoury, Xuan Ren, Mara Gilardi, Art Hanson, Marianna Zipeto, Michael Ritchie. Multiomic approaches to illuminate molecular drivers of breast cancer metastasis to the liver [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1304.

Minimally invasive colonoscopy treatment of inflammatory fibroid polyps in the terminal ileum

To identify the characteristics of inflammatory fibroid polyps (IFP) in the terminal ileum and to investigate the methods, safety, and efficacy of colonoscopic minimally invasive dissection and resection therapies for its treatment. Colonoscopy and colonoscopic ultrasonography were used to diagnose patients with protruding mucosal lesions in the terminal ileum, and the results suggested a high suspicion of IFPs. Colonoscopic minimally invasive dissection and resection were performed for these patients, and IFP was confirmed by postoperative pathological examination and immunohistochemical staining. Twelve cases of IFP from April 2016 to December 2020 in our hospital were examined pathologically and immunohistochemically. The IFPs in the terminal ileum were all successfully excised by colonoscopy. There were no postoperative perforation, bleeding, or recurrence cases during the follow-up. The features of the lesions, as well as the efficacy of colonoscopic minimally invasive dissection and resection, were reviewed. Terminal ileum IFPs have corresponding colonoscopic and endoscopic ultrasonographic features. For IFPs less than 2 cm in size and within 10 cm of the ileocecal valve, removal by colonoscopy was proven less invasive, safe, and effective.

Anatomical and Surgical Considerations for Ileocolic Endometriosis

We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions. This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required. This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons. The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning. Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis CONCLUSION: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.

Minimally invasive versus open liver resection for hepatocellular carcinoma: a propensity score matching analysis of 224 patients.

To compare the peri-operative and long-term survival outcomes of minimally invasive liver resection (MILR) (robotic or laparoscopic) with open liver resection (OLR) in patients with hepatocellular carcinoma (HCC). Data of patients who underwent liver resection for HCC were reviewed from a prospectively collected database. Outcomes of MILR were compared with those of OLR. A propensity score matching analysis with a ratio of 1:1 was performed to minimise the potential bias in clinical pathological factors. From January 2003 to December 2017, a total of 705 patients underwent liver resection for HCC. Amongst them, 112 patients received MILR and 593 patients received OLR. After propensity score matching, there were 112 patients in each of the MILR and OLR groups. Patients were matched by age, sex, hepatitis status, presence of cirrhosis, platelet count, albumin level, bilirubin level, alkaline phosphatase (ALP) level, alanine transferase (ALT) level, creatinine level, tumour differentiation, tumour size, tumour number, presence of tumour rupture, presence of vascular invasion, extent of liver resection (minor/major) and difficulty score. The 1-, 3- and 5-year overall survival rates were 94.4%, 90.4% and 82.3% in the MILR group vs 95.4%, 80.5% and 71.8% in the open group (p = 0.240). The 1-, 3- and 5-year disease-free survival rates were 81.0%, 63.1% and 55.8% in the MILR group vs 79.1%, 58.1% and 45.7 in the open group (p = 0.449). The MILR group demonstrated significantly less blood loss (p < 0.001), less blood transfusion (p = 0.004), lower post-operative complications (p < 0.001) and shorter hospital stay (p < 0.001) when compared with the OLR group. Our data shows MILR yielded superior post-operative outcomes to OLR, with comparable survival outcomes.

Robotic esophageal surgery

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as astandard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, ahigher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

Robotic versus laparoscopic liver resection in posterosuperior region: a retrospective study of consecutive cases.

Minimally invasive liver resection of the posterosuperior region is considered a challenging procedure due to poor exposure and difficult bleeding control. A robotic approach is supposed to be advantageous in posterosuperior segmentectomy. Its benefits over laparoscopic liver resection (LLR) remain undetermined. This study compared robotic liver resection (RLR) and LLR in the posterosuperior region performed by a single surgeon. We retrospectively analyzed consecutive RLR and LLR performed by a single surgeon between December 2020 and March 2022. Patient characteristics and perioperative variables were compared. A 1:1 propensity score matched (PSM) analysis was performed between both groups. The analysis included 48 RLR and 57 LLR procedures in the posterosuperior region. After PSM analysis, 41 cases of both groups were retained. In pre-PSM cohort, the operative time in the RLR group was significantly shorter than in the LLR group (160 vs. 208min, P = 0.001), especially in radical resection of malignant tumors (176 vs. 231min, P = 0.004). The total Pringle maneuver duration was also markedly shorter (40 vs. 51min, P = 0.047), and the estimated blood loss in the RLR group was lower (92 vs. 150mL, P = 0.005). The postoperative hospital stay (POHS) in the RLR group was significantly shorter (5.4 vs. 7.5days, P = 0.048). In PSM cohort, operative time in the RLR group was also significantly shorter (163 vs. 193min, P = 0.036), and the estimated blood loss was lower (92 vs. 144mL, P = 0.024). However, the total Pringle maneuver duration and POHS showed no significant difference. The complications were similar between two groups in both pre-PSM and PSM cohorts. RLR in the posterosuperior region was as safe and feasible as LLR. RLR was associated with reduced operative time and blood loss than LLR.

A139 ONE OF THESE THINGS IS NOT LIKE THE OTHER: A CURIOUS CASE OF DISCORDANT ENDOSCOPIC OPTICAL EVALUATION

Abstract Background Optical evaluation has become the cornerstone of early gastrointestinal neoplasia management as it informs therapeutic decisions between minimally invasive endoscopic resection techniques and surgery. Purpose We report an unusual case of a subepithelial gastric inlet patch (GIP) with optical evaluation mimicking early squamous neoplasia Method Case Presentation: A 74-year-old male was referred for epigastric discomfort. On esophagogastroduodenoscopy, a 10-mm GIP was identified at 23cm from the incisors. Furthermore, a 15-mm polypoid lesion was identified at 25cm from the incisors on the contralateral wall. On optical evaluation, it was believed to be atypical but suspicious for squamous neoplasia (Figure 1). Histopathology of the lesion revealed a stratified squamous epithelium with an underlying focus on glandular mucosa. After a multidisciplinary team review, endoscopic submucosal dissection was performed, given the atypical optical characteristics of the lesion. Result(s) Histopathology of the lesion identified subepithelial gastric cardia-type mucosa with focal extension into the muscularis mucosae, most consistent with a subepithelial GIP. No neoplasia was identified. Image Conclusion(s) We describe an unusual case of subepithelial GIP. With the widespread availability of high-definition endoscopes equipped with image-enhanced endoscopy, this case highlights the optical characteristics of this likely underappreciated endoscopic finding. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The Pringle maneuver in the modern era: A review of techniques for hepatic inflow occlusion in minimally invasive liver resection.

During minimally invasive liver resection (MILR), the Pringle maneuver aims to minimize blood loss and provide a clear operative field, thereby identifying intrahepatic structures and facilitating safe parenchymal transection. Several techniques for using the Pringle maneuver in MILR have been described. This review presents various methods which have been reported in the literature. A systematic literature search used the MEDLINE/PubMed database from its earliest records to August 2022 using appropriate search headings and keywords. The primary outcome was identifying techniques for performing hepatic inflow occlusion during laparoscopic/robotic hepatectomy. Inclusion criteria consisted of publications describing technical steps to obtain hepatic inflow occlusion during minimally invasive hepatectomy. A literature search identified 23 relevant publications, and the full texts were examined. The techniques described in the reports can be broadly categorized into three groups: (1) the Rummel-tourniquet technique, (2) vascular clamp use, and (3) the Huang Loop technique. Various techniques have been used in MILR to achieve inflow confinement successfully. The authors prefer the modified Huang Loop technique because it is inexpensive, reliable, and quick to apply or release. Hepatobiliary surgeons are advised to familiarize themselves with these MILR techniques, which have proven effective and safe inflow occlusion.

Global survey on the surgical management of patients affected by colorectal cancer with synchronous liver metastases: impact of surgical specialty and geographic region

BackgroundConsensus on the best surgical strategy for the management of synchronous colorectal liver metastases (sCRLM) has not been achieved. This study aimed to assess the attitudes of surgeons involved in the treatment of sCRLM.MethodsSurveys designed for colorectal, hepato-pancreato-biliary (HPB), and general surgeons were disseminated through representative societies. Subgroup analyses were performed to compare responses between specialties and continents.ResultsOverall, 270 surgeons (57 colorectal, 100 HPB and 113 general surgeons) responded. Specialist surgeons more frequently utilized minimally invasive surgery (MIS) than general surgeons for colon (94.8% vs. 71.7%, p < 0.001), rectal (91.2% vs. 64.6%, p < 0.001), and liver resections (53% vs. 34.5%, p = 0.005). In patients with an asymptomatic primary, the liver-first two-stage approach was preferred in most respondents’ centres (59.3%), while the colorectal-first approach was preferred in Oceania (83.3%) and Asia (63.4%). A substantial proportion of the respondents (72.6%) had personal experience with minimally invasive simultaneous resections, and an expanding role for this procedure was foreseen (92.6%), while more evidence was desired (89.6%). Respondents were more reluctant to combine a hepatectomy with low anterior (76.3%) and abdominoperineal resections (73.3%), compared to right (94.4%) and left hemicolectomies (90.7%). Colorectal surgeons were less inclined to combine right or left hemicolectomies with a major hepatectomy than HPB and general surgeons (right: 22.8% vs. 50% and 44.2%, p = 0.008; left: 14% vs. 34% and 35.4%, p = 0.002, respectively).ConclusionThe clinical practices and viewpoints on the management of sCRLM differ between continents, and between and within surgical specialties. However, there appears to be consensus on a growing role for MIS and a need for evidence-based input.Graphical abstract

Minimally invasive resection of symptomatic bifid intrathoracic rib.

Intrathoracic ribs are rare congenital anomalies where a supra- or normonumerary rib follows an abnormal course within the thorax (1). Less than 10 cases have been reported in children, being commonly asymptomatic and usually found incidentally (2). Surgical treatment is seldom necessary due to the benign and asymptomatic presentation. However, in symptomatic cases, little is known about optimal treatment strategy. We report a unique case of a symptomatic intrathoracic rib that required surgical treatment by minimally invasive approach This article is protected by copyright. All rights reserved.

Comment on "Robotic Distal Pancreatectomy, a Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers".

Comment on "Robotic Distal Pancreatectomy, a Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers".

Correlation Between Indocyanine Green Fluorescence Patterns and Grade of Differentiation of Hepatocellular Carcinoma: A Western Prospective Cohort Study.

Background. Most of the available evidence on the use of indocyanine green (ICG) fluorescence in clinical practice consists of articles published by surgeons of the Asian-Pacific area. We performed a prospective cohort study to assess the patterns of ICG fluorescence in Western hepatocellular carcinoma (HCC) counterparts.Methods. From April 2019 to January 2022, a total of 31 consecutive patients who underwent laparoscopic liver resection (LLR) for superficial HCC were enrolled in this prospective study. All patients underwent laparoscopic staging with both laparoscopic ultrasound (LUS) and ICG fluorescence imaging.Results. A total of 38 hepatocellular carcinomas (HCCs) were enrolled: 23 superficial (surfacing at the liver's Glissonian capsule), 5 exophytic, 5 shallow (<8mm from the hepatic surface) and 5 deep (>10mm from the hepatic surface). The detection rate with preoperative imaging (abdominal CT/MRI), LUS, ICG fluorescence and combined modalities (ICG and LUS) was 97.4%, 94.9%, 89.7% and 100%, respectively. The five deep seated lesions underwent ultrasound-guided laparoscopic thermal ablation. The other 33 HCCs were treated with minimally invasive liver resection. Intraoperative ultrasound patterns were registered for each single nodule resected. The ICG fluorescence pattern was classified in two types: total fluorescence (all the tumoral tissue showed strong and homogeneous fluorescence), n = 9/33 (27.3%), and non-total fluorescence (partial and rim fluorescence), n = 24/33 (72.7%). There was a statistical correlation between ICG patterns and grade of differentiation. Almost all lesions with uniform fluorescence pattern were well-differentiated HCCs (G1-G2), while partial and rim-type fluorescence pattern were more common among moderately and poorly differentiated HCCs (G3-G4) (88.9% vs 11.1%, 37.5% vs 62.5%, P = .025, respectively).Conclusions. ICG fluorescence imaging could be used to identify early the grade of HCC, ie intraoperatively, thus influencing the intraoperative treatment.

Short and long-term outcomes after minimally invasive liver resection for single small hepatocellular carcinoma: An analysis of 714 patients from the IGoMILS (Italian group of minimally invasive liver surgery) registry

BackgroundWidespread use of minimally invasive liver surgery (MILS) contributed to the reduction of surgical risk of liver resection for hepatocellular carcinoma (HCC). Aim of this study was to analyze outcomes of MILS for single ≤3 cm HCC. MethodsPatients who underwent MILS for single ≤3 cm HCC (November 2014 - December 2019) were identified from the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) Registry. ResultsOf 714 patients included, 641 (93.0%) were Child-Pugh A; 65.7% were limited resections and 2.2% major resections, with a conversion rate of 5.2%. Ninety-day mortality rate was 0.3%. Overall morbidity rate was 22.4% (3.8% major complications). Mean postoperative stay was 5 days. Robotic resection showed longer operative time (p = 0.004) and a higher overall morbidity rate (p < 0.001), with similar major complications (p = 0.431). Child-Pugh B patients showed worse mortality (p = 0.017) and overall morbidity (p = 0.021), and longer postoperative stay (p = 0.005). Five-year overall survival was 79.5%; cirrhosis, satellite micronodules, and microvascular invasion were independently associated with survival. ConclusionsMILS for ≤3 cm HCC was associated with low morbidity and mortality rates, showing high safety, and supporting the increasing indications for surgical resection in these patients.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis. After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria. 637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B. Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

Minimally Invasive Video-Assisted Thoracoscopic One-Stage Resection of Left Atrial Myxoma and Right Upper Lobectomy for Lung Cancer: Case Report

We report a case of a 74-year-old man with diagnosis of concomitant primary cardiac tumor and right upper lobe of lung cancer. Both tumors were evaluated to be resectable with no further metastasis. A one-stage resection of both tumors through right mini-thoracotomy with endoscopic assistance was performed. The cardiac tumor resection during cardiopulmonary bypass was performed first, followed by right upper lobectomy and lymph nodes dissection with the same incision and position. Short-term results were satisfying and previous literature was reviewed to evaluate this method.