Liver Surgery Research Articles

Contribution of 3D virtual modeling in locating hepatic metastases, particularly “vanishing tumors”: a pilot study

Aim: This article aims to explore how three dimensions (3D) virtual modeling enhances accuracy and efficiency in detecting hepatic metastases, with a specific focus on “vanishing tumors” that are difficult to detect using traditional imaging techniques. It also aims to demonstrate the potential impact of these advanced technologies on improving diagnostic and treatment strategies for patients with liver cancer. Methods: Eight patients with liver metastases from colorectal cancer were studied using magnetic resonance imaging (MRI) and 3D virtual modeling to enhance surgical planning by accurately locating lesions. The concordance between these imaging techniques and the Gold Standard was assessed using Gwet’s AC1 coefficient, with statistical analysis performed through resampling methods and non-parametric tests due to non-normal AC1 distribution. Liver segmentation was conducted semi-automatically using SurgiPrint software, which is crucial for detecting lesions undetectable post-chemotherapy. The study’s evaluation model involved questionnaires for medical professionals across four cohorts, aiming to determine the 3D model’s effectiveness in identifying lesion locations for surgery. Results: This study investigated the efficacy of 3D virtual modeling in identifying hepatic metastases, particularly comparing its accuracy with traditional MRI in locating lesions. The findings indicate that MRI generally provided better concordance with the Gold Standard for lesion localization, except for a few experienced users who had prior familiarity with the 3D models. Despite the mixed results in accuracy, the study suggests potential benefits of 3D modeling in enhancing surgical planning and execution, particularly in detecting “vanishing” liver metastases that are difficult to visualize with standard imaging techniques. The research aligns with broader evidence indicating the utility of 3D models in improving outcomes in hepatic surgery by enabling more precise resections and reducing postoperative complications. However, the study also notes the challenge of quantifying the added value of 3D modeling due to the unique nature of each surgical case and the potential bias in the user experience with the technology. Conclusion: The conclusion of this study underscores the significant potential of 3D virtual modeling in enhancing the precision of locating and resecting hepatic metastases, particularly those elusive “vanishing tumors”. This research underscores the value of integrating advanced 3D imaging techniques into surgical practice, suggesting a paradigm shift toward more accurate and less invasive liver surgeries. Future studies should aim to further quantify the benefits of 3D modeling in surgical outcomes, investigate its utility across different surgical experiences, and explore the integration of artificial intelligence (AI) to maximize its effectiveness in clinical settings.

Simple Trocar Placement for Robotic Liver and Pancreatic Surgery: Multiple Access Devices at 5-cm Single Umbilicus Incision with 2 Robotic Ports.

Robotic trocars are recommended to be placed 6-8 cm apart, and assistant trocars are placed 7 cm away from the horizontal line of the robotic trocar placement. However, adhering to these rules may be difficult, particularly in lean patients. This study aims to demonstrate our standardized simple trocar placement, 5-cm single umbilicus incision + 2 ports for robotic liver resection (RLR) and robotic pancreaticoduodenectomy (RPD). During 2022-2024, patients undergoing RLR and RPD at The University of Tokyo were identified from a prospectively maintained database. Our standardized trocar placement consisted of multiple access devices at the 5-cm umbilicus incision, including two robotic trocars and one assistant trocar, and two other robotic trocars inserted to shape a hemi-circle around the surgical object. A total of 29 and 31 consecutive patients underwent RLR and RPD, respectively. The 5-cm single umbilicus incision + 2 ports method was used in 82.8% of patients undergoing RLR and 100% of patients undergoing RPD. No patients undergoing RLR developed hepatic insufficiency and bile leakage with the median postoperative hospital stay of 5 days. No patients undergoing RPD developed clinically relevant pancreatic fistula, delayed gastric emptying, and bile leakage with the median postoperative hospital stay of 8 days. Our standardized trocar placement technique is simple and widely feasible for lean-to-obese patients, allowing for RLR and RPD while minimizing incisions for patients.

ALKBH5 Protects Against Hepatic Ischemia–Reperfusion Injury by Regulating YTHDF1-Mediated YAP Expression

Ischemia/reperfusion (I/R) injury with severe cell death is a major complication involved in liver transplantation and resection. The identification of key regulators improving hepatocyte activity may provide potential strategies to clinically resolve I/R-induced injury. N6-methyladenosine (m6A) RNA modification is essential for tissue homeostasis and pathogenesis. However, the potential involvement of m6A in the regulation of hepatocyte activity and liver injury has not been fully explored. In the present study, we found that hepatocyte AlkB homolog H5 (ALKBH5) levels were decreased both in vivo and in vitro I/R models. Hepatocyte-specific ALKBH5 overexpression effectively attenuated I/R-induced liver necrosis and improved cell proliferation in mice. Mechanistically, ALKBH5-mediated m6A demethylation improved the mRNA stability of YTH N6-methyladenosine RNA-binding protein 1 (YTHDF1), thereby increasing its expression, which consequently promoted the translation of Yes-associated protein (YAP). In conclusion, ALKBH5 is a regulator of hepatic I/R injury that improves hepatocyte repair and proliferation by maintaining YTHDF1 stability and YAP content. The ALKBH5–m6A–YTHDF1–YAP axis represents promising therapeutic targets for hepatic I/R injury to improve the prognosis of liver surgery.

Rates of Textbook Outcome Achieved in Patients Undergoing Liver and Pancreatic Surgery

Backgorund: Textbook outcome (TO) is a composite measure that reflects the most desirable surgical results as a single indicator. The aim of this study was to assess the achievement of TO at a hepatopancreatobiliary (HPB) surgery unit in a Spanish tertiary hospital. Methods: We performed a retrospective observational study of all consecutive patients who underwent HPB surgery over a 4-year period. Morbidity according to the Clavien-Dindo classification at 30 days, hospital stay, risk of morbidity and mortality according to the POSSUM, and mortality and readmissions at 90 days were recorded. TO was considered when a patient presented no major complications (≥IIIA), no mortality, no readmission, and no prolonged length of stay (≤75th). Results: 283 patients were included. Morbidity >IIIA was reported in 21.6%, and 5.7% died; the median postoperative stay was 4 days. TO was achieved in 56.2% of patients. Comparing patients who presented TO with those who did not, significant differences were recorded for the type of procedure and the expected risk of morbidity and mortality calculated according to the POSSUM scale. There were significant differences between patients with major resections (TO rates: major hepatectomy (46.3%) and major pancreatectomy (52.5%)) and those with minor resections (TO rates minor hepatectomy (67.7%) and minor pancreatectomy (40.4%)). Conclusions: TO is a useful management tool for assessing postoperative results.

Clinical characteristics and treatment outcomes of women with recurrent uterine leiomyosarcoma

ObjectiveTo determine the clinical characteristics and treatment outcomes of women with recurrent uterine leiomyosarcoma (uLMS).MethodsWe conducted a retrospective cohort study to evaluate the clinical characteristics and survival of women with recurrent uLMS and identify prognostic factors.ResultsOverall, 71 patients with first recurrence of uLMS were included in our study. 19 patients (26.8%) received systemic therapy and 52 patients (73.2%) received secondary cytoreductive surgery (SCS). In SCS subgroup (n = 52), a complete resection with no residual disease was performed in 47 patients (90.4%). 38.5% (20/52) patients received non-reproductive organ surgeries. 10 (19.2%) patients had received thoracic surgery because of lung-only recurrence. Bowel, bladder surgery was performed in 8 (15.4%), 3 (5.8%) patients, respectively. 1 (1.9%) patient had received liver surgery. The median follow-up duration was 38.7 months (range: 2.7-317.6 months). 41 (57.7%) patients died during follow-up. 5-year OS for the entire cohort was 52.9%. Patients experienced first recurrence after initial diagnoses within 12 months (n = 24) had a worse 5-year OS than those after 12 months (n = 47) (17.0% vs. 69.1%, P < 0.001). 5-year OS for the SCS and non-SCS subgroup was 62.0% and 28.0%, respectively (P < 0.001). Multivariate analysis showed time to fist recurrence within 12 months (HR = 4.60, 95% CI: 1.49–14.4, P = 0.008) was an independent predictor of decreased 5-year OS in SCS subgroup.ConclusionsSCS is an important treatment choice for recurrent uLMS and seems to have benefited patients. Time to fist recurrence within 12 months is an independent predictor of decreased 5-year OS in SCS subgroup.

Is there a benefit of intravenous lidocaine during liver surgery?: A propensity-score weighting analysis.

Is there a benefit of intravenous lidocaine during liver surgery?: A propensity-score weighting analysis.

Targeting S100A9-TLR2 axis controls macrophage NLRP3 inflammasome activation in fatty liver ischemia reperfusion injury

Abstract Liver ischemia reperfusion (IR) injury significantly impacts clinical outcomes by increasing the risk of hepatic dysfunction after liver surgery. Fatty livers are more susceptible to IR stress. Recent studies have demonstrated that S100A9 plays a crucial role in both IR injury and the progression of liver steatosis. Nevertheless, the precise mechanisms underlying these effects remain unclear. In our study, transcriptome analysis of fatty livers subjected to IR insult in mice identified S100A9 as an important mediator. Employing loss-of-function approaches, we investigated the immune regulatory function of S100A9 and its downstream signaling in fatty liver IR injury. As expected, S100A9 emerged as one of the most significantly upregulated genes during the reperfusion stage in fatty livers. Genetic knockdown of S100A9 markedly ameliorated liver pathological damage, evidenced by reduced macrophage/neutrophil infiltration as well as the decreased expression of proinflammatory factors. Transcriptome/functional studies revealed that S100A9 triggered liver inflammatory response via regulating Toll-like receptor 2 (TLR2)/Activating transcription factor 4 (ATF4) signaling. Additionally, TLR2 expression was notably increased in macrophages from ischemic fatty livers. In vitro, recombinant S100A9-stimulated macrophages exhibited the elevated production of proinflammatory factors and TLR2/ATF4 pathway activation. Intriguingly, S100A9 facilitated ATF4 nuclear translocation and enhanced NEK7/NLRP3 inflammasome activation in macrophages. In conclusion, our study identified S100A9 as a key regulator responsible for macrophage NLRP3 inflammasome activation and subsequent inflammatory injury in fatty liver IR process. Targeting TLR2/ATF4 signaling may offer a novel therapeutic strategy for mitigating S100A9-mediated liver injury.

Intraoperatively measured prehepatectomy portal vein pressure as a useful predictor of posthepatectomy liver failure.

Predicting posthepatectomy liver failure (PHLF) may be a critical requirement for liver disease patients undergoing hepatectomy. This study retrospectively analyzed the impact of the intraoperatively measured portal vein pressure (PVP) prior to hepatectomy on the prediction of PHLF in hepatectomized patients. A total of 334 hepatectomized patients in whom the PVP was intraoperatively measured before resection at our institution were enrolled in the present study. Outcomes were assessed according to the International Study Group of Liver Surgery definition and the severity of PHLF grading. Thirty-nine of the 334 patients (11.6%) developed grade B/C PHLF. The following factors were significantly associated with grade B/C PHLF in a univariate analysis: indocyanine green retention rate after 15min, Child-Pugh score, prehepatectomy PVP, and transfusion (each P < 0.0001). A prehepatectomy PVP value of 19.5 cmH2O was the optimal cutoff value for predicting grade B/C PHLF. In a multivariate analysis, prehepatectomy PVP (≥ 19.5 cmH2O) was selected as the most relevant risk factor for grade B/C PHLF (P = 0.0003, hazard ratio: 5.96, 95% CI: 1.80-19.70). Prehepatectomy PVP can serve as a useful predictor of the risk of PHLF in patients who have undergone hepatectomy. The results emphasize the possibility of reducing the planned extent of hepatic resection when the prehepatectomy PVP value measured intraoperatively exceeds 19.5 cmH2O, and the importance of predicting the PVP before the operation.

Application of ultrasound-guided intranodal lymphangiography in the diagnosis and treatment of chylous ascites after abdominal surgery

PurposeChylous leakage is a serious and challenging postoperative complication. The purpose of this study was to explore the application of ultrasound-guided intranodal lymphangiography in the diagnosis and treatment of chylous ascites following abdominal surgery.Material and methodsTen patients with chylous ascites after abdominal surgery after ineffective conservative treatment such as low-fat diet, parenteral nutrition, and negative pressure drainage were included in this single-center retro­spective study. Of these 10 patients, 9 developed chylous ascites after liver surgery, and 1 after a radical gastrectomy.ResultsLymphangiography was successfully performed in all 10 patients. The average dosage of lipiodol used was 4.5 ml (range 3.5-7.0 ml). No procedure-related complications were observed after excluding unrelated factors. During lymphangiography, lipiodol leakage was directly observed in 3 cases, and in the other 5 cases, it was detected through abdominal computed tomography post-lymphangiography. Chylous ascites resolved solely through lymphangiography in 6 patients without requiring additional surgical intervention.ConclusionsLymphangiography may help identify leakage sites in patients with chylous ascites unresponsive to conservative treatment and could potentially be effective in treating chylous ascites following abdominal surgery.

Experience-based transition to robotic surgery in an experienced program in minimally invasive hepatobiliary surgery.

The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program. Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method. In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning. This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections.

Electroencephalographic depression after abruptly increasing partial pressure of end-tidal carbon dioxide: a case series

BackgroundProlonged electroencephalographic depression during surgery is associated with poor outcomes for patients. However, the published literature on electroencephalographic depression caused by a sudden increase in the partial pressure of end-tidal carbon dioxide (PETCO2) is lacking.Case presentationWe report four patients who were scheduled for laparoscopic liver surgery under general anesthesia. During the process of EEG monitoring with Sedline, four patients experienced electroencephalographic depression closely after a sudden increase in PETCO2. The four patients showed that electroencephalographic depression mainly manifested as a slow in EEG frequency, a reduction in the amplitude and power of EEG, and a decrease in spectral edge frequency. Patient state index was elevated in three cases.ConclusionsTo summarize, our patients showed EEG depression when PETCO2 suddenly increased, which suggests that clinical doctors should be alert to electroencephalographic depression when the PETCO2 abruptly increases. EEG monitoring devices should be applied in patients with possible hypercapnia. Anesthesiologists must comprehensively interpret the raw EEG, spectral edge frequency, and density spectral array data, in addition to patient sedation index values.

Hepatic Hilum Variations and Their Clinical Considerations in the Liver: A Systematic Review and Meta-Analysis.

Background: The liver has a region called the hepatic hilum (HH) where structures enter and exit: anteriorly, the left and right hepatic ducts; posteriorly, the portal vein; and between these, the left and right hepatic arteries. The objective of this review is to know how variants in structures of the hepatic hilum are associated with clinical alterations of the liver. Methods: The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. The methodological quality was evaluated with an assurance tool for anatomical studies (AQUA). The pooled prevalence was estimated using a random effects model. Results: A total of six studies met the selection criteria established in this study for meta-analysis. The prevalence of hepatic hilus variants was 9% (CI = 5% to 13%), and the heterogeneity was 83%. The other studies were analyzed descriptively and with their respective clinical considerations in the presence of the variant, such as the high incidence of the Michels type III variant; among the portal vein variants, the type III variant of the Cheng classification stands out and in biliary anatomy, and the IIIa variant stands out according to the Choi classification. Conclusions: This review allowed us to know in detail the anatomical variants of HH; the structure with which the greatest care should be taken is the hepatic artery because of the probability of metastatic processes due to increased blood distribution in the hepatic lobules. Finally, we believe that new anatomical and clinical studies are needed to improve our knowledge of the relationship between HH variants and liver alterations or surgeries.

Predictors for 30-day mortality in hepatocellular carcinoma patients undergoing liver resection

Hepatocellular carcinoma (HCC) ranks among the most prevalent and fatal liver cancers globally. Liver surgery, particularly resection, offers the potential for cure but poses challenges, especially in Indonesia, where patients often present in advanced stages. This study aimed to determine the intraoperative and perioperative factors associated with 30-day mortality of HCC patients undergoing liver resection at a tertiary referral hospital. The study included HCC patients undergoing liver resection at Karadi General Hospital, Semarang, Indonesia, between January 2018 and September 2023. Demographic data, intraoperative, perioperative, and postoperative factors were collected, with the primary outcome being 30-day mortality. Factors influencing 30-day survival were assessed using a log-rank test and the survival analysis employed Kaplan-Meier curves. Among 58 HCC patients who had liver resection, 62.1% were males, with a mean age was 57.27±9.56 years old. Preoperative comorbidities, notably hepatitis B, affected 34.4% of patients. Child-Pugh Score categorized 91.4% as class A. The study found a 30-day mortality rate of 10.3% with no subsequent increase in incidence. The failure-to-rescue rate (FTR) of this study was found to be 46%. Factors associated with 30-day mortality were Child-Pugh classification (p&lt;0.001), intraoperative bleeding (p=0.001), creatinine levels (p=0.005), Clavien-Dindo classification (p&lt;0.001), and posthepatectomy liver failure (PHLF) (p&lt;0.001). This study suggests that pre-operative (Child-Pugh classification), intraoperative (blood loss volume) and postoperative factors (Creatinine level, Clavien-Dindo classification, and PHLF) could predict the mortality rate of HCC patients undergoing liver resection.

Optimal results through enhanced recovery: Achieving textbook outcomes with high compliance in elective liver surgery.

Existing studies suggest a positive correlation between high compliance with enhanced recovery programs (ERP) and improved outcomes. While individual outcome measures have advantages, composite benchmarks, such as textbook outcome (TO), offer a more comprehensive assessment of healthcare performance. Given the link between ERP and postoperative outcomes, this study aims to investigate the impact of ERP on TO attainment after liver surgery (LS). A prospective multicenter cohort of patients undergoing LS and exposed to ERP from 2016 to 2022 in France was analyzed. The primary outcome was to compare the rates of TO achieved between patients with high ERP compliance (>70%) and those with low ERP compliance (<70%) after LS. A total of 706 patients were included in the study, and 217 (30.7%) achieved TO: 170 patients with high ERP compliance (24%) versus 47 patients (6.6%) with low ERP compliance attained TO (p<0.001). High ERP compliance was associated to an increased likelihood of achieving TO [odds ratio (OR)=1.49 (95% CI: 1.01, 2.24); p=0.049], while cholangiocarcinoma [OR=0.11 (95% CI: 0.02, 0.39); p=0.003], high complexity LS [OR=0.22 (95% CI: 0.13, 0.36); p<0.001], intraoperative hypotension requiring vasopressors [OR=0.29 (95% CI: 0.10, 0.68); p=0.010], and post-operative ileus [OR=0.08 (95% CI: 0.00, 0.37); p=0.013] were negatively associated to the likelihood of achieving TO. Patients with high ERP compliance after LS experience elevated rates of TO, compared to those with low ERP compliance.

Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience.

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

A randomized comparison of an adhesive gelatin sponge and a plain collagen sponge for hemostatic control during canine liver surgery.

To compare the effectiveness of a modified surface gelatin sponge to a plain collagen sponge for hemostasis of parenchymal hepatic bleeding. Prospective, randomized trial of two hemostatic agents. A total of 45 dogs undergoing elective liver surgery were randomly allocated into two groups: 22 in the adhesive gelatin (AG) group and 23 in the plain collagen (PC) group. A total of 20 patients per group underwent liver biopsy to create a uniformly sized bleeding surface, with the remaining patients (AG = 2, PC = 3) undergoing liver lobectomy. Evaluation of hemostatic effectiveness and tissue adhesion of each sponge type was performed by the operating surgeon using structured scoring systems. Hemostatic parameters were primarily evaluated at the liver biopsy site to maintain homogeneity of bleeding surface size. For the liver biopsy group (n = 40), 5 min after hemostatic sponge application, 10/20 dogs were bleeding in the PC group, compared to 2/20 in AG group (p = .0138). The PC bleeding was significantly higher than AG across the 3 to 6 min evaluation period (p < .001). When surgeons tested the adhesion of the sponge across the whole cohort (n = 45), AG scored 2 (of 3) against 1 for PC (p < .001). In group PC, 5/23 sponges dislodged during abdominal lavage and preparations for closure and had to be replaced due to recurrence of bleeding, compared with no AG sponges dislodging (p = .042). There were no further complications related to the use of either sponge. In the dogs with hepatic parenchymal incision, use of an adhesive gelatin sponge improved intraoperative attachment and haemostatic effectiveness, compared to a collagen sponge. Based on our clinical experience in these cases, adhesive gelatin sponges could be considered an effective option when selecting a hemostatic agent for liver surgery in dogs.

A new frontier in biostatistics: evaluating the accuracy of ChatGPT-4 vs. R in analysing liver resection data

Background The rise of ChatGPT-4’s Data Analyst tool presents a new frontier for biostatistical computations. This study evaluates the reliability and improvements of ChatGPT-4 Data Analyst tool by comparing it to R package in performing biostatistical analysis on liver surgery patients. Methods Utilizing data from LiverGroup.org, we conducted our comparative study between October 2023 and March 2024. The variables analyzed by the R package and ChatGPT-4 Data Analyst included age, sex, hospital stay duration, income group, and mortality. Analysis on ChatGPT-4 were performed using two methods: a holistic prompt which included all-at-once analysis were requested and segmented prompts, one-by-one test request for analysis. After the analysis figures were requested from ChatGPT-4, comparison with R package figures was done. Results Descriptive analysis including N (%), Standard Deviation, and (25th–75th Percentile) were consistent between ChatGPT-4 March version and R with a minor variation in the holistic approach on the analysis performed in October. The inferential statistical results of ChatGPT-4 showed inconsistencies in October 2023 while March 2024 revealed accurate results with Crosstabulations, Kruskal Wallis, Wilcoxon Rank Sum, T-test, Pearson’s Chi-squared, and Fisher’s Exact test p-value. ChatGPT-4 March 2024 version was able to inform the user with possible inaccuracies in certain tests (Mann-Whitney U Test: Hospital stay vs mortality p value, Levene’s Test p-value: Age vs mortality, and Fisher’s Exact Test: Odds ratio gender vs. mortality 95% CI). The survival curve and box-and-whisker plot generated by ChatGPT-4 in March 2024 matched those generated by R package except for the CI of survival curve. Conclusions The high accuracy of ChatGPT-4 in certain biostatistical analysis has reached the point where it can replace established statistical software like R for some purposes. Artificial intelligence tools show significant promise but should still be used in conjunction with traditional methods to ensure precision in complex analysis. Consensus on the use of these tools is needed by the scientific community.

Soluble TREM2 reflects liver fibrosis status and predicts postoperative liver dysfunction after liver surgery.

Background & AimsChronic liver disease (CLD) represents a major risk for mortality and, while challenging, early detection is key to improve overall outcome. Triggering receptor expressed on myeloid cells 2 (TREM2)-expressing macrophages and systemic levels of soluble TREM2 (sTREM2) appear critical in the development of CLD and seem relevant in its detection. The aim of this study was to examine sTREM2 as a marker for early CLD and its potential to predict posthepatectomy liver failure (PHLF) in patients undergoing partial hepatectomy. MethodsSTREM2 was assessed in plasma of 108 patients undergoing liver resection. Blood was drawn prior to surgery (preop) and on the first and fifth postoperative day. ResultsPreop sTREM2 levels were similar across different indications for resection (p=0.091). Higher preop sTREM2 levels were associated with advanced hepatic fibrosis (p=0.030) and PHLF (p=0.007). Fibrosis-4 index (FIB-4) (p=0.619) and Model for End Stage Liver Disease (MELD) (p=0.590) did not show a difference between patients grouped by their CLD. Comparing the area under the curve from receiver operating characteristic analysis, sTREM2 (AUC=0.708) outperformed FIB-4 (AUC=0.529), MELD (AUC=0.587), Child-Pugh grading (AUC=0.570) and liver maximum capacity test (LiMAx) (AUC=0.516) in predicting PHLF. Similarly, in uni- and multivariate analysis only sTREM2 proved predictive for PHLF (p=0.023). A high- (p=0.003) and low-risk cutoff (p=0.011) for systemic sTREM2 levels were able to identify patients at risk for adverse outcome after surgery. Finally, high sTREM2 was associated with decreased overall survival after liver surgery (p<0.001). ConclusionsCirculating sTREM2 shows sensitivity for early-stage, asymptomatic liver disease, irrespective of the underlying indication for liver surgery. Assessment of CLD via sTREM2 monitoring could improve early detection of CLD and improve outcome after liver surgery. Impact and ImplicationsSoluble TREM2 (sTREM2) has previously been established to correlate with the degree of chronic liver disease. We found that even in patients undergoing liver resection, who generally do not suffer from end stage liver disease, sTREM2 reflects liver fibrosis status and predicts postoperative development of liver dysfunction. This is especially relevant for liver surgeons and patients, as postoperative liver dysfunction is the main reason for postoperative mortality. Our findings are also important for hepatologists, as early detection of liver fiboris and cirrhosis is paramount for overall patient survival and we can show that even in a cohort with a median MELD of 6, sTREM2 is able to distuinguish patients based on their liver fibrosis status.

Short-Term Surgical Outcomes After Robotic Liver Surgery: A Propensity-Score Matched Analysis With Conventional Open Liver Surgery at a High-Volume Centre in Denmark.

The aim of this study was to investigate the perioperative outcomes of robotic liver surgery (RLS) and Open liver surgery (OLS) in a centre with a high number of operations. A 1:1 propensity score matched (PSM) analysis of a retrospective database of RLS and OLS was performed. Cumulative sum (CUSUM) analysis was performed to identify learning curves. After PSM analysis, operative time was significantly longer in the RLS group (p<0.001). Estimated blood loss was significantly lower in the RLS group (p<0.001). Transfusion rates were significantly lower in the RLS group. The length of hospital stay was shorter in the RLS group (3.5vs6.3days, p<0.001). Readmission rates were significantly lower in the RLS group (p<0.049). CUSUM analysis showed a learning curve for at least 8 low-intermediate RLS procedures and 27 advanced-Expert RLS procedures. RLS has many advantages, including being safe to perform, less blood loss and faster postoperative recovery compared with OLS.

A novel concept of preoprative care - short-term fasting to improve outcomes in liver surgery: Study in mice

A novel concept of preoprative care - short-term fasting to improve outcomes in liver surgery: Study in mice