Major Hepatectomy Research Articles

HPB SO19 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEONTM stapler

Abstract Background In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUSTM liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA). Method January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUSTM ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEONTM endovascular stapler was used from early 2021. Results 86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEONTM stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEONTM demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295). Conclusion The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEONTM endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.

Delayed return of gastrointestinal function after partial hepatectomy: a single-center cross-sectional study.

Introduction Partial hepatectomy (PH) remains associated with complication rates around 30-50%. Delayed return of gastrointestinal function (DRGF) has been reported in 10-20%. This study aimed to assess DRGF predictors after PH. Aim This retrospective study aimed to assess DRGF predictors after PH. Methods All patients who underwent PH between 01/2010 and 12/2019 were included. DRGF was defined as need of postoperative nasogastric tube (NGT). Independent DRGF predictors were identified with multivariable logistic binary regression. Results Overall, 501 patients were included. DRGF occurred in 82 patients (16%). A hundred-and-twelve patients (22%) underwent a minimally invasive approach and DRGF incidence was significantly lower in this group (p <0.001). DRGF was more frequent after major PH (p<0.001). DRGF occurred more often in patients with preoperative embolization (p<0.001), biliary anastomosis (p<0.001) and extrahepatic resection (p<0.001). Patients with DRGF had longer median operation duration (p<0.001), more biliary leaks/bilomas (p<0.001) and higher median blood loss (p<0.001). DRGF patients developed more pneumonias (p<0.001) and had longer median length of stay (p<0.001). On multivariable analysis, operation duration (p<0.001), major hepatectomy (p<0.001) and postoperative biloma/biliary leak (p<0.001) were independently associated with DRGF occurrence. Conclusion Postoperative DRGF occurred in 16% of the patients and was associated with longer length of stay. Surgery duration, major PH and postoperative biloma/biliary leak were found as independent predictors of DRGF.

HPB SO77 - Effects of Patient and Operative Variables on Isolation of Primary Human Hepatocytes

Abstract Background Isolation of human primary hepatocytes from tissue samples derived from therapeutic hepatectomy offers an important resource for a range of pharmacological and toxicology based experimental platforms, whilst simultaneously providing an opportunity to reduce the use of animal models. This study analysed the impact of a range of patient and operative derived variables on the yield and viability of isolated human primary hepatocytes. Method Excess hepatic tissue from resected liver parenchyma was sampled from consented patients undergoing major and minor hepatectomy for a range of oncological and non-oncological indications. Tissue dissociation and hepatocyte isolation was performed using a two-step collagenase perfusion procedure. Hepatocyte viability was calculated using the Trypan blue exclusion test while hepatocyte yield was calculated by the number of cells isolated divided by the tissue mass isolated from. Patient and operative variables were collected retrospectively from 25 patients in a prospectively maintained database. Results Samples from normal liver parenchyma achieved high hepatocyte viability and yields in all patients. Improved hepatoctye viability was associated with female sex, with a 2.9% increase in viability in samples from women (P&amp;lt;0.05). Patient age, BMI, operative indication, neo-adjuvant chemotherapy, as well as prolonged intra-operative Pringle time and blood loss did not significantly affect hepatocyte yield or viability, allowing use of primary human hepatocytes from a wide range of patients in a plethora of translational research experiments. Conclusion High levels of hepatocyte viability and yield are achievable across a broad range of patients, even in instances patients with high burdens of disease, prolonged Pringle time or higher levels of intra-operative blood loss. Tissue samples from consenting patients undergoing therapeutic liver resection provide an invaluable resource for various translational experimental platforms, including primary human hepatocytes. To date, more than 400 patients have donated tissue used in a range of basic science techniques, significantly reducing reliance on animal models.

99mTc-GSA scintigraphy and modified albumin–bilirubin score can be complementary to ICG for predicting posthepatectomy liver failure

BackgroundPosthepatectomy liver failure (PHLF) remains a severe complication after liver resection. This retrospective study investigated the correlation of three hepatic functional tests and whether 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy and modified albumin–bilirubin (ALBI) score are useful for predicting PHLF.MethodsThis retrospective cohort study included 413 consecutive patients undergoing hepatectomies between January 2017 and December 2020. To evaluate preoperative hepatic functional reserve, modified ALBI grade, indocyanine green clearance (ICG-R15), and 99mTc-GSA scintigraphy (LHL15) were examined before scheduled hepatectomy. Based on a retrospective chart review, multivariable logistic regression analysis adjusted for confounding factors was performed to confirm that mALBI, ICG-R15, and LHL15 are independent risk factors for PHLF.ResultsICG-R15 and LHL15 were moderately correlated (r = − 0.61) but this correlation weakened when ICG-R15 was about ≥ 20. Weak correlations were observed between LHL15 and ALBI score (r = − 0.269) and ALBI score and ICG-R15 (r = 0.339). Of 413 patients, 66 (19%) developed PHLF (20 grade A, 44 grade B, 2 grade C). Multivariable logistic regression analyses, major hepatectomy (P < 0.001), mALBI grade (P = 0.01), ICG-R15 (P < 0.001), and Esophagogastric varices (P = 0.007) were significant independent risk factors for PHLF. Subgroup analysis showed that ICG-R15 < 19, major hepatectomy, and mALBI grade and ICG-R15 ≥ 19, major hepatectomy, LHL15, and Esophagogastric varices were significant independent risk factors for PHLF (P = 0.033, 0.017, 0.02, 0.02, and 0.001, respectively).ConclusionLHL15, the assessment of Esophagogastric varices, and mALBI grade are complementary to ICG-R15 for predicting PHLF risk.

New criteria for preoperative liver function assessment with safety margins to avoid postoperative mortality during liver resection for hilar cholangiocarcinoma.

BackgroundDespite recent medical advancements, surgery for hilar cholangiocarcinoma is associated with high complication and mortality rates. This may be partly attributed to the absence of established preoperative liver evaluation criteria for safe surgery. This study aimed to propose a reliable indicator for safe and well-planned management of major hepatectomy with extrahepatic bile duct resection. MethodsWe included 150 patients who underwent major hepatectomy with extrahepatic bile duct resection between 2013 and 2021 in Japan. The risk factors for post-hepatectomy liver failure (PHLF) were retrospectively analyzed. ResultsPHLF was observed in 24 (16.0%) patients who underwent major hepatectomy with extrahepatic bile duct resection. In the multivariate analysis, the identified risk factors for PHLF were the ratio of future remnant liver volume to total liver volume (FRLV/TLV) ≤ 42% and indocyanine green clearance fraction of the future remnant liver (ICGK-F) ≤ 0.07. Patients with these two factors were significantly associated with PHLF compared with those with either one or none of the risk factors (60.0% vs 15.1% and 8.1%, respectively). ConclusionsThe combinational use of ICGK-F and FRLV/TLV is useful for preoperative liver function assessment with a safety margin to avoid PHLF and postoperative mortality in hepatectomy for hilar cholangiocarcinoma.

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.

Influence of major hepatectomy on gemcitabine-based chemotherapy for recurrent biliary tract cancer after surgery: a subgroup analysis of JCOG1113.

Major hepatectomy (MH) can increase the risk of adverse events (AEs) owing to impaired drug metabolism due to decreased liver volume and surgical injury. Thus, we performed this subgroup analysis using data from JCOG1113, a phase III trial comparing gemcitabine plus S-1 (GS) and gemcitabine plus cisplatin (GC) in patients with advanced and recurrent biliary tract cancer (BTC), to evaluate the effect of MH on the safety and efficacy of GC and GS regimens in patients with recurrent BTC. Of the 354 patients with advanced BTC enrolled in JCOG1113, 76 patients with postoperative recurrence (30 in the MH group and 46 in the non-MH group) were analyzed. Grade ≥ 3 platelet count decreased in both arms was more frequent in the MH group than in non-MH group (GC, 0.0 vs. 17.6%; GS, 3.9 vs. 15.4%). However, in the MH group, the white blood cell decreased (GC, 55.0 vs. 38.5%; GS, 23.1 vs. 7.7%) and anemia (GC, 15.0 vs. 11.8%; GS, 23.1 vs. 7.7%) were less common than in the non-MH group. The MH and non-MH groups showed no significant difference in overall survival (OS) in both GC [median OS, 23.0 in MH vs. 16.9months in non-MH (hazard ratio, 0.857; 95% CI 0.387-1.899)], and GS [median OS, 21.5 vs. 14.9months (hazard ratio, 0.670; 95% CI 0.310-1.447)] arms. The safety and efficacy of gemcitabine-based chemotherapy were comparable between patients who underwent MH and those who underwent other surgeries.

The Status of Liver Margin in Perihilar Cholangiocarcinoma: A Multicenter Study.

This study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination. LM is the largest margin in resected pCCA with undefined status and assessment method. 227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections. The LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20mm of the proximal ductal margin (DM). A proximal DM distance of<5mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5mm (P<0.001). Positive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20mm radius around the proximal DM, especially in patients with a proximal DM of<5mm.

Prognostic value of the advanced lung cancer inflammation index in intrahepatic cholangiocarcinoma

IntroductionThe advanced lung cancer inflammation index (ALI), which combines inflammation and nutrition data, was recently proposed as a prognostic biomarker. We assessed the impact of ALI on overall survival (OS) among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). MethodsPatients who underwent surgery for ICC were identified from an international cohort. ALI was calculated as body-mass index (BMI)∗albumin/neutrophil-to-lymphocyte ratio; patients were categorized into “low-” and “high-ALI” using log-rank statistics. The impact of ALI on OS was compared against other inflammatory markers (i.e., neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], systemic immune inflammation index [SII = platelets∗NLR]) using Harrell's Concordance index (C-index) and the Akaike Information Criterion (AIC). To minimize intergroup differences, propensity score matching was employed. ResultsAmong 1045 patients, more than one-half of individuals underwent major hepatectomy (n = 582, 55.7 %), median tumor size was 5.5 cm (IQR, 3.8–7.8), and median ALI was 38.9 (IQR 26.5–57.2). On multivariate analysis, low ALI was an independent risk factor for worse OS (HR 1.21, 95 % CI 1.01–1.46; p = 0.04). Patients with low ALI had worse 5-year OS (36.9 % vs. 49.9 %; p < 0.001), which remained significant after PSM (36.9 % vs. 41.3 %; p = 0.039). ALI had a comparable discriminatory ability compared with NLR, PLR, and SII (C-index: 0.646 vs. 0.644 vs. 0.640 vs. 0.641, respectively), yet had a lower AIC (5475.31 vs. 5546.80 vs. 5550.45 vs. 5548.62, respectively) suggesting slightly better model fit and accuracy. ConclusionsALI was an independent predictor of OS among patients undergoing surgery for ICC. Nutritional and inflammatory markers should be incorporated into predictive models to improve prognostic stratification.

Feasibility of major hepatectomy following preoperative chemotherapy for advanced perihilar cholangiocarcinoma

BackgroundThe safety of major hepatectomy following preoperative chemotherapy for perihilar cholangiocarcinoma (PHCC) is underexplored. This study evaluates the impact of preoperative chemotherapy on surgical outcomes and assesses chemotherapy-induced liver injury in patients with advanced PHCC. MethodsThis retrospective study included 62 PHCC patients who underwent surgery between January 2019 and January 2024. Patients were divided into an upfront surgery group (UFS, n = 31) and a preoperative chemotherapy group (POC, n = 31). Preoperative chemotherapy was indicated when R0/R1 resection was unachievable, complex surgery was needed, or future liver reserve was insufficient. Baseline characteristics, surgical procedures, postoperative complications, and pathological findings were compared. ResultsPostoperative complications were comparable between groups, with Clavien-Dindo grade ≥3a rates of 30.7 % in the POC group and 24.3 % in the UFS group. Despite longer operative times and hospital stays in the POC group, no significant differences in hepatotoxicity or pathological findings, including Kleiner and Rubbia-Brandt scores, were observed. Notably, a pathological complete response was achieved in 12.9 % of the POC group. ConclusionMajor hepatectomy following preoperative chemotherapy for PHCC is safe and does not increase the risk of postoperative complications or hepatotoxicity. Further studies are warranted to refine resectability criteria and optimize patient selection.

Association of Hospital Volume With Quality Care Outcomes Following Minor and Major Hepatectomy for Primary Liver Cancer.

Regionalizing hepatic resections to high-volume hospitals (HVH) has improved outcomes, yet widened disparities in access. We sought to evaluate the association of hospital volume with quality care outcomes and overall survival (OS) between minor and major hepatectomy for primary liver cancer. The National Cancer Database identified patients with primary liver cancer who underwent minor/major hepatectomy (2009-2019). HVHs were defined by the top quartile in annual case volume (vs. the bottom three quartiles). Quality care outcomes (time to resection, margin status, length of stay, 30-day readmission, 30-day mortality, 90-day mortality) and OS were assessed using multivariable regression. Overall, 6,988 patients underwent minor hepatectomy and 4880 major hepatectomy. No differences in quality care outcomes or OS based on hospital volume for minor hepatectomy were observed (all p > 0.05). Treatment at HVHs for major hepatectomy was associated with decreased odds of 30-day and 90-day mortality events (all p < 0.05). Median OS was 40.2 months [IQR 21.7-66.6] at HVHs versus 33.5 [IQR 17.0-58.7] at low-volume hospitals which remained independently predictive of improved OS on multivariable analysis (HR 0.86, 95% CI 0.79-0.93). These results support regionalization to HVHs for major hepatectomy; however, minor hepatectomy can be safely performed at hospitals regardless of volume.

Effect of Preoperative Autologous Blood Storage in Major Hepatectomy for Perihilar Malignancy: A Randomized Controlled Trial.

To reappraise whether preoperative autologous blood donation reduces post-hepatectomy liver failure (PHLF) in major hepatectomy for perihilar malignancy. Autologous blood storage and transfusion are carried out to reduce the use of allogeneic blood transfusion during hepatectomy and prevent postoperative complications. However, the clinical benefit in major hepatectomy has been controversial. This randomized clinical trial included patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar malignancy. Eligible patients were randomly assigned (1:1) to undergo surgery with or without the use of autologous blood transfusion. The primary outcome was the incidence of clinically relevant PHLF (grade B/C according to the International Study Group of Liver Surgery definition). Between February 6, 2019, and May 12, 2023, 138 consecutive patients were enrolled in the study (blood storage group n=68, non-storage group n=70). Twenty-five patients who did not undergo resection were excluded; the remaining 113 patients were investigated as the full analysis set (blood storage group n=60, non-storage group n=53). Surgical procedures, operative time, and blood loss were not significantly different between the two groups. The incidence of PHLF was comparable (blood storage group n=10 [17%], non-storage group n=10 [19%]; P=0.760). There were also no between-group differences in other postoperative outcomes, including the incidence of Clavien-Dindo Grade Ⅲ or higher (72% vs. 72%, P=0.997) and median duration of hospital stay (25 vs. 29d, P=0.277). Autologous blood storage did not contribute to reducing the incidence of PHLF in patients undergoing major hepatectomy.

ThP5.2 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEON stapler

Abstract Introduction In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUS liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA). Methods January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUS ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEON endovascular stapler was used from early 2021. Results 86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEON stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEON demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295). Conclusion The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEON endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR.

The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Impact of the future liver remnant volume before major hepatectomy

IntroductionFollowing major liver resection, posthepatectomy liver failure (PHLF) is associated with a high mortality rate. As there is no therapy for PHLF available, avoidance remains the main goal. A sufficient future liver remnant (FLR) is one of the most important factors to reduce the risk for PHLF; however, it is not known which patients benefit of volumetric assessment prior to major surgery. MethodsA retrospective, bi-institutional cohort study was conducted including all patients who underwent major hepatectomy (extended right hepatectomy, right hepatectomy, extended left hepatectomy and left hepatectomy) between 2010 and 2023. ResultsA total of 1511 major hepatectomies were included, with 29.4 % of patients undergoing FLR volume assessment preoperatively. Overall, PHLF B/C occurred in 9.8 % of cases. Multivariate analysis identified diabetes mellitus, extended right hepatectomy, perihilar cholangiocarcinoma (pCCA), gallbladder cancer (GBC) and cirrhosis as significant risk factors for PHLF B/C. High-risk patients (with one or more risk factors) had a 15 % overall incidence of PHLF, increasing to 32 % with a FLR <30 %, and 13 % with an FLR of 30–40 %. Low-risk patients with a FLR <30 % had a PHLF rate of 21 %, which decreased to 8 % and 5 % for FLRs of 30–40 % and >40 %, respectively. For right hepatectomy, the PHLF rate was 23 % in low-risk and 38 % in high-risk patients with FLR <30 %. ConclusionPatients scheduled for right hepatectomy and extended right hepatectomy should undergo volumetric assessment of the FLR. Volumetry should always be considered before major hepatectomy in patients with risk factors such as diabetes, cirrhosis, GBC and pCCA. In high-risk patients, a FLR cut-off of 30 % may be insufficient to prevent PHLF, and additional liver function assessment should be considered.

Tract embolization with gelatin sponge after percutaneous transhepatic portal vein intervention.

Bleeding from the puncture tract after percutaneous transhepatic portal vein intervention can become life-threatening. To date, studies about tract embolization with gelatin sponge after percutaneous transhepatic portal vein intervention are only with small numbers of patients, or non-consecutive or pediatric patients with a relatively small sheath in diameter. To evaluate the safety and efficacy of tract embolization with gelatin sponge strips after percutaneous transhepatic poral vein access. Between September 2017 and February 2024, 100 consecutive patients (61 men, 39 women; mean age = 53 ± 15 years) underwent a total of 105 portal vein interventions using a percutaneous transhepatic approach. Tract embolization for the removal of 6-8 Fr sheath was performed using gelatin sponge strips in all procedures, including 71 portal vein embolization before major hepatectomy, 27 portal balloon venoplasty or stent placement after liver transplantation, and seven other interventions. No bleeding occurred after tract embolization with gelatin sponge strips. Minor portal vein thrombosis was detected in three procedures after liver transplantation and in one procedure for portal vein stenosis caused by essential thrombocytopenia. Thrombosis occurred in the punctured portal vein branch in all procedures. Thrombosis was not clinically relevant in any patient, and it was difficult to differentiate whether thrombosis was caused by sheath placement or the inserted gelatin sponge. Tract embolization with gelatin sponge strips after percutaneous transhepatic portal vein intervention is a safe and feasible method for preventing hemorrhage from the puncture tract.

Minimally invasive surgery approaches in major liver resection for hepatocellular carcinoma

Over the past two decades, minimally invasive liver resection (MILR) has progressively become the standard for minor resection of hepatocellular carcinoma (HCC). In contrast, its implementation in major hepatectomy has been slower due to its higher technical complexity and morbidity. However, studies published in recent years have demonstrated that minimally invasive major hepatectomy (MIMH) is safe and feasible with less blood loss, fewer complications, earlier recovery, decreased hospital stay, and improved cosmetic outcomes compared with open surgery. This review examines the current status of MIMH, focusing on the respective strengths and weaknesses of the laparoscopic and robotic approaches, as well as assessing their cost-effectiveness and possible future directions. The earlier introduction of laparoscopic liver resection has led to its widespread utilization as a safe and accurate alternative to open hepatectomy. Of note is that the robotic approach has also been increasingly utilized, demonstrating better perioperative outcomes and decreased need for conversion to open hepatectomy vs. the laparoscopic approach. Advantages associated with the robotic approach include the three-dimensional large visual field and instrumental flexibility, allowing for improved bleeding control. Even though evidence has been slowly accumulating regarding long-term outcomes, most studies report no notable differences between open, robotic, and laparoscopic resection for HCC. Regarding cost-effectiveness, MIMH has been characterized by higher operating room and anesthesia costs, especially for robotic procedures that require highly expensive equipment. The increase in cost is often offset by the lower morbidity and, thus, shorter hospital stays associated with MIMH. Future developments, such as the implementation of artificial intelligence and augmented reality, may potentially maximize the safety and applicability of MIMH and, in time, lead to improved postoperative and oncological outcomes.

Pattern and extent of intrahepatic infiltration of perihilar cholangiocarcinoma - A case-control study based on liver panoramic digital pathology.

The extent of intrahepatic infiltration of perihilar cholangiocarcinoma (PHCC) remains unclear. This research aimed to explore the pattern and extent of intrahepatic infiltration of PHCC to guide surgical treatment and pathological research. This study included 62 patients diagnosed with PHCC who underwent major hepatectomy. A whole-mount digital liver pathology system (WDLPS) for hepatectomy specimens greater than 10 × 10cm was used to panoramically assess the intrahepatic infiltration extent of PHCC. The distal intrahepatic infiltration (DIHI) and radial liver invasion (RLI) were important parts of intrahepatic infiltration for PHCC explored by WDLPS. The study confirmed that 75.8% of PHCCs had RLI and the infiltration distance in all patients were within 15,000 µm, 62.9% of PHCCs had DIHI greater than 1cm away from the main tumor in liver parenchyma. The recurrence-free survival rates and overall survival rates of patients with DIHI were poorer than the patients without DIHI (P＜0.0001, P=0.0038). Arterial invasion on the resected side could be an excellent predictor. A total of 105 liver lobes were resected from 62 PHCC patients. The invasion rates of the left lateral, left medial, right anterior, and right posterior lobe of PHCC were 79%, 100, 100%, and 69% respectively. The presence of DIHI in most PHCCs was a significant predictor of poor postoperative recurrence and survival. Based on the extent of intrahepatic infiltration, minor hepatectomy was not suitable as the curative surgery for PHCC. Major hepatectomy and liver transplantation were the ideal radical treatment.

Single large hepatocellular carcinoma > 5 cm with surgical indication: is it mandatory a major hepatectomy? a propensity-score weighted analysis.

Single large hepatocellular carcinoma >5cm (SLHCC) traditionally requires a major liver resection. Minor resections are often performed with the goal to reduce morbidity and mortality. Aim of the study was to establish if a major resection should be considered the best treatment for SLHCC or a more limited resection should be preferred. A multicenter retrospective analysis of the HE.RC.O.LE.S. Group register was performed. All collected patients with surgically treated SLHCC were divided in 5 groups of treatment (major hepatectomy, sectorectomy, left lateral sectionectomy, segmentectomy, non-anatomical resection) and compared for baseline characteristics, short and long-term results. A propensity-score weighted analysis was performed. 535 patients were enrolled in the study. Major resection was associated with significantly increased major complications compared to left lateral sectionanectomy, segmentectomy and non-anatomical resection (all p<0.05) and borderline significant increased major complications compared to sectorectomy (p=0.08). Left lateral sectionectomy showed better overall survival compared to major resection (p=0.02), while other groups of treatment resulted similar to major hepatectomy group for the same item. Absence of oncological benefit after major resection and similar outcomes among the 5 groups of treatment was confirmed even in the sub-population excluding patients with macrovascular invasion. Major resection was associated to increased major post-operative morbidity without long-term survival benefit; when technically feasible and oncologically adequate, minor resections should be preferred for the surgical treatment of SLHCC.

Realizing Textbook Outcomes Following Liver Resection for Hepatic Neoplasms with Development and Validation of a Predictive Nomogram

Background‘Textbook Outcome’ (TO) represents an effort to define a standardized, composite quality benchmark based on intraoperative and postoperative endpoints. This study aimed to assess the applicability of TO as an outcome measure following liver resection for hepatic neoplasms from a low- to middle-income economy and determine its impact on long-term survival. Based on identified perioperative predictors, we developed and validated a nomogram-based scoring and risk stratification system.MethodsWe retrospectively analyzed patients undergoing curative resections for hepatic neoplasms between 2012 and 2023. Rates of TO were assessed over time and factors associated with achieving a TO were evaluated. Using stepwise regression, a prediction nomogram for achieving TO was established based on perioperative risk factors.ResultsOf the 1018 consecutive patients who underwent liver resections, a TO was achieved in 64.9% (661/1018). The factor most responsible for not achieving TO was significant post-hepatectomy liver failure (22%). Realization of TO was independently associated with improved overall and disease-free survival. On logistic regression, American Society of Anesthesiologists score of 2 (p = 0.0002), perihilar cholangiocarcinoma (p = 0.011), major hepatectomy (p = 0.0006), blood loss >1500 mL (p = 0.007), and presence of lymphovascular emboli on pathology (p = 0.026) were associated with the non-realization of TO. These independent risk factors were integrated into a nomogram prediction model with the predictive efficiency for TO (area under the curve 75.21%, 95% confidence interval 70.69–79.72%).ConclusionTO is a realizable outcome measure and should be adopted. We recommend the use of the nomogram proposed as a convenient tool for patient selection and prognosticating outcomes following hepatectomy.