Major Liver Resection Research Articles

Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis.

Sufficient liver function is crucial in extracellular matrix growth, hemostasis, and wound healing. Repeated abdominal surgery is a known risk factor for the development of wound complications. This study aimed to evaluate this high-risk constellation in patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) and repeated liver resections (RLR) in comparison to single liver resection (SLR). Forty patients who underwent ALPPS between 2011 and 2020 were evenly matched with patients undergoing RLR or SLR (n = 40 per group) using propensity scores. Postoperative outcomes were compared and factors associated with wound complications were analyzed. Postoperative wound complications were significantly more frequent in ALPPS group (p = 0.001). The reoperation rate was not significantly different between the three groups (p = 0.143). However, surgical reintervention due to wound complications occurred more frequently in the ALPPS group in relation to RLR and SLR (17.5% vs. 7.5% and 5% respectively). Length of stay was significantly longer in the ALPPS group (p = 0.033). ALPPS was an independent risk factor for postoperative wound complication (OR = 8.55, 95% CI:1.07-68.44, p = 0.043). Risk factor analysis identified age ≥ 60 years (OR = 27.64, 95% CI:3.09-246.75, p = 0.003), BMI ≥ 30kg/m2 (OR = 30.21, 95% CI:3.35-271.83, p = 0.002), and low postoperative albumin levels (OR = 168.41, 95% CI:7.76-3651.18, p = 0.001) as independent predictors of postoperative wound complications after major liver resection. Patients undergoing ALPPS and RLR are faced with a high risk of developing wound complications. Older age, obesity, a history of previous abdominal surgery, and a decreased postoperative albumin level were independent risk factors for wound complications.

HPB SO26 - Evaluation of Theatre Database Accuracy in a Tertiary HPB Center According to NCIP Standards in the UK

Abstract Background The goal of creating the NCIP (National Clinical Improvement Programme) theatre data set discovery information system is to allow NHS Improvement to evaluate how theatre data can improve the attribution of surgical activities, as documented in Hospital Episode Statistics (HES) Admitted Patient Care (APC) data, to individual consultants. The success of NCIP is at risk due to the inaccurate attribution of existing activity data to consultants. Method The NCIP theatre database for the Hepato-Pancreato-Biliary (HPB) surgery department was compiled over a 12-month period (from April 2022 to April 2023) and analyzed based on the operating consultant recorded in the operative notes, clinical letters, and the Carfelow system (admitting office records). Results In Nottingham University Hospitals (NUH), 143 major liver and pancreatic resections were performed, including 38 Whipple’s procedures (both classic and Pylorus-preserving Pancreatico-Duodenectomy), 19 Distal Pancreatectomies, and 86 Liver resections. Of these, only 58 patients (40.6%) had correct entries in the NCIP database regarding the operating surgeon. The NCIP data inaccuracies for the operating consultant were 65.8% (25/38) for Whipple’s procedures, 57.9% (11/19) for Distal Pancreatectomies, and 56.97% (49/86) for Liver resections. Conversely, the NCIP data was 100% accurate concerning the assigned consultant on Careflow, which matches the clinical letters from the outpatient clinic. Conclusion The gap between the NCIP database and the admitting office database leads to inaccurate attributions of surgical activity. This hinders learning and improvement efforts essential for achieving program benefits and prevents providers from complying with license conditions and delivering efficient healthcare services. To ensure accurate HES data, admitting officers should request proper communication and accurate consultant codes from consultant secretaries to ensure accurate data across the different hospital systems

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.

MS O11 - HPB Laparoscopic vs open liver resections for hepatocellular cancer in a tertiary care hepatobiliary unit; outcomes of cases over 10 years

Abstract Background Despite its established role in liver resection surgery, minimally invasive surgery is still not a favoured option in cases of hepatocellular cancer (HCC) due to perceived risks of intra- and post-operative surgical morbidity and poorer oncological outcomes. This study aims to look at the outcomes of liver resections performed for HCC cases over ten years comparing laparoscopic and open cohorts. Method A retrospective study including all liver resections for HCC cases performed in our tertiary care hepatobiliary unit between 2013 and 2022 (10 years) was conducted. Data on demographics, underlying degree of liver cirrhosis, types of liver resection and post-operative outcomes, including recurrence rates and resections margins were collected and reported using descriptive statistics. Survival analysis was performed with compared between these two groups with log rank test in GraphPad prism 10. Results 200 liver resections performed for HCC were grouped into laparoscopic and open cohorts containing 147 and 53 patients respectively. 21 (40%) laparoscopic cases had background liver cirrhosis as compared to 24 (16%) in open cases. Major liver resection comprised 9% and 43% of all cases and one and five patients had Grade B/C PHLF in laparoscopic and open groups. All 8 (4%) cases with 90-day mortality were from the open group. Negative resection margins (68% vs 71%), local recurrence (51% vs 47%) and overall survival (75 months vs 67 months (p=0.29)) were similar in laparoscopic and open groups, respectively. Conclusion Post-operative and oncological outcomes of liver resections for HCC were comparable in laparoscopic and open groups. Laparoscopic liver resections could be safely performed in patients with background liver cirrhosis.

Myeloid derived suppressor cells mediate hepatocyte proliferation and immune suppression during liver regeneration following resection.

Liver regeneration following resection is a complex process relying on coordinated pathways and cell types in the remnant organ. Myeloid-Derived Suppressor Cells (MDSCs) have a role in liver regeneration-related angiogenesis but other roles they may play in this process remain to be elucidated. In this study, we sought to examine the effect of G-MDSCs on hepatocytes proliferation and immune modulation during liver regeneration. Global gene expression profiling of regenerating hepatocytes in mice with CD11b+Ly6G+ MDSCs (G-MDSCs) depletion revealed disrupted transcriptional progression from day one to day two after major liver resection. Key genes and pathways related to hepatocyte proliferation and immune response were differentially expressed upon MDSC depletion. Hepatocytes cellularity increased when co-cultured with G-MDSCs, or treated with amphiregulin, which G-MDSCs upregulate during regeneration. Cytometry by time-of-flight (CyTOF) analysis of the intra-liver immune milieu upon MDSC depletion during regeneration demonstrated increased natural killer cell proportions, alongside changes in other immune cell populations. Taken together, these results provide evidence that MDSCs contribute to early liver regeneration by promoting hepatocyte proliferation and modulating the intra-liver immune response, and illuminate the multifaceted role of MDSCs in liver regeneration.

Initial Experience With Robotic Liver Resection in the United States.

This study's aim was to show the feasibility and safety of robotic liver resection (RLR) even without extensive experience in major laparoscopic liver resection (LLR). A single center, retrospective analysis was performed for consecutive liver resections for solid liver tumors from 2014 to 2022. The analysis included 226 liver resections, comprising 127 (56.2%) open surgeries, 28 (12.4%) LLR, and 71 (31.4%) RLR. The rate of RLR increased and that of LLR decreased over time. In a comparison between propensity score matching-selected open liver resection and RLR (41:41), RLR had significantly less blood loss (384 ± 413 vs 649 ± 646mL, P = .030) and shorter hospital stay (4.4 ± 3.0 vs 6.4 ± 3.7 days, P = .010), as well as comparable operative time (289 ± 123 vs 290 ± 132 mins, P = .954). A comparison between LLR and RLR showed comparable perioperative outcomes, even with more surgeries with higher difficulty score included in RLR (5.2 ± 2.7 vs 4.3 ± 2.5, P = .147). The analysis of the learning curve in RLR demonstrated that blood loss, conversion rate, and complication rate consistently improved over time, with the case number required to achieve the learning curve appearing to be 60 cases. The findings suggest that RLR is a feasible, safe, and acceptable platform for liver resection, and that the safe implementation and dissemination of RLR can be achieved without solid experience of LLR.

Failure to Rescue After Resection of Perhilar Cholangiocarcinoma in an International Multicenter Cohort.

Failure to rescue (FTR) is defined as the inability to prevent death after the development of a complication. FTR is a parameter in evaluating multidisciplinary postoperative complication management. The aim of this study was to evaluate FTR rates after major liver resection for perihilar cholangiocarcinoma (pCCA) and analyze factors associated with FTR. Patients who underwent major liver resection for pCCA at 27 centers were included. FTR was defined as the presence of a Dindo grade III or higher complication followed by death within 90 days after surgery. Liver failure ISGLS grade B/C were scored. Multivariable logistic analysis was performed to identify predictors of FTR and reported using odds ratio and 95% confidence intervals. In the 2186 included patients, major morbidity rate was 49%, 90-day mortality rate 13%, and FTR occurred in 24% of patients with a grade III or higher complication. Across centers, major complication rate varied from 19 to 87%, 90-day mortality rate from 5 to 33%, and FTR ranged from 11 to 50% across hospitals. Age [1.04 (1.02-1.05) years], ASA 3 or 4 [1.40 (1.01-1.95)], jaundice at presentation [1.79 (1.16-2.76)], right-sided resection [1.45 (1.06-1.98)], and annual hospital volume < 6 [1.44 (1.07-1.94)] were positively associated with FTR. When liver failure is included, the odds ratio for FTR is 9.58 (6.76-13.68). FTR occurred in 24% of patients after resection for pCCA. Liver failure was associated with a nine-fold increase of FTR and hospital volume below six was also associated with an increased risk of FTR.

Different biliary tract cancers, same operation: Importance of cancer origin in patients with hilar-invading tumors.

For patients with biliary tract cancer involving the hepatic hilum, major hepatic resection with extrahepatic bile duct resection may be required. In addition to perihilar cholangiocarcinoma (PHCC), the same extent of surgery is used in advanced gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (IHCC) with hilar involvement. Few studies compare prognostic factors and long-term outcomes across tumor types. This study compared risk characteristics and outcomes after surgery in all subtypes of biliary tract cancer with hilar involvement. Patients with biliary tract cancer with hilar involvement undergoing major liver resection and extrahepatic bile duct resection between 2011 and 2021 at a single center were retrospectively analyzed. The primary postoperative outcome was overall survival. Secondary outcomes were recurrence-free survival and postoperative complications. Survival analysis was performed with Cox regression analysis and Kaplan-Meier method. One-hundred and eight patients were included. Seventy-three (67%) had PHCC, 24 (22%) had GBC, and 11 (10%) had IHCC. Hilar-invading IHCC and GBC had more adverse histopathological factors like lymph node positivity (p = 0.021), higher number of positive nodes (p = 0.043), and larger tumor size (p < 0.001) compared with PHCC. Peritoneal invasion and lymph node positivity were significant independent predictors for survival (p = 0.011 and p = 0.004, respectively). Median overall survival was 29 months for PHCC, 22 months for GBC and 21 months for IHCC (p = 0.53). IHCC tended to recur earlier (p = 0.046) than GBC and PHCC (6, 15, and 18 months, respectively). Patients with biliary tract cancer with hilar involvement undergoing major liver resection and resection of extrahepatic bile ducts had similar overall survival regardless of subtype, while IHCC recurred earlier. Peritoneal cancer invasion was common in all subtypes, including PHCC, and was an independent prognostic factor. This finding may support routine reporting of peritoneal invasion-status in resected biliary tract cancer.

ThP5.14 - Assessing Adherence and Cost Implications of NICE Guidelines for Intravenous compared to Oral paracetamol use after Resuming Oral Diet Following Liver and Pancreas Resections

Abstract Aim For post-operative pain management NICE recommends not to offer intravenous paracetamol unless the person cannot take oral medicine [NG180] 1.6.6. Despite this recommendation, many patients continue to receive intravenous paracetamol whilst on oral diet. This audit aims to assess the adherence and cost implications of NICE guidelines for switching from IV to oral paracetamol once oral diet resumes following liver and pancreas resections. Method Data for 176 patients undergoing major liver or pancreas resections at the Royal Free Hospital London (January 2022 to October 2023) was collected retrospectively. This included the number of IV and oral paracetamol doses, resumption of oral diet post-operatively, and the total number of IV paracetamol doses whilst oral diet resumed. Costings for IV and oral paracetamol were established, and the total cost was calculated per patient. After a departmental presentation, the audit cycle was completed. Result The analysis of the initial dataset disclosed that 69% of patients were administered IV paracetamol while on an oral diet, incurring a cost of £9412/100 patients, in contrast to £18.5 for oral paracetamol. Following the intervention, there was a noteworthy enhancement in adherence to guidelines, reducing the average days of IV paracetamol administration after resuming oral diet from 4.08 days pre-intervention to 2.06 days post-intervention. Conclusion This improved adherence showed almost 50% cost reduction compared to first audit. In addition to this we can also expect early patient mobilization, enhanced recovery, and prompt discharges. This audit provides valuable insight into optimizing postoperative pain management strategies and resource utilization.

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.

Outcome of the novel description of arterial position changes after major liver resections: retrospective study.

After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes. All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann-Whitney test and the Kruskal-Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality. A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042). Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality.

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.

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.

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.

Rescue liver transplantation for post-hepatectomy liver failure- single center retrospective analysis

IntroductionLiver transplantation (LT) is a well-established method applied for the treatment of various liver diseases, including primary and secondary malignancies, as well as acute liver failure triggered by different mechanisms. In turn, liver failure (PHLF) is the most severe complication observed after liver resection (LR). PHLF is an extremely rare indication for LT. The aim of the present study was to assess the results of LT in patients with PHLF.MethodsRelevant cases were extracted from the prospectively collected database of all LTs performed in our center. All clinical variables, details of the perioperative course of each patient and long-term follow-up data were thoroughly assessed.ResultsBetween January 2000 and August 2023, 2703 LTs were carried out. Among them, six patients underwent LT for PHLF, which accounted for 0.2% of all patients. The median age of the patients was 38 years (range 24–66 years). All patients underwent major liver resection before listing for LT. The 90-day mortality after LT was 66.7% (4 out of 6 patients), and all patients experienced complications in the posttransplant course. One patient required early retransplantation due to primary non-function (PNF). The last two transplanted patients are alive at 7 years and 12 months after LT, respectively.ConclusionsIn an unselected population of patients with PHLF, LT is a very morbid procedure associated with high mortality but should be considered the only life-saving option in this group.

Jehovah playing his part: A tale of giant hemangioma – Can we do major liver resections without blood or blood products?

Jehovah playing his part: A tale of giant hemangioma – Can we do major liver resections without blood or blood products?

Influence of steatosis and fibrosis on the outcome after major liver resection of perihilar cholangiocarcinoma

Influence of steatosis and fibrosis on the outcome after major liver resection of perihilar cholangiocarcinoma

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases.

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

The predictors of intra-operative surgical expenses in liver resection for hepatocellular carcinoma

Abstract Background This study aimed to clarify the expenses associated with various items and predictors of intraoperative expenses in liver resection for hepatocellular carcinoma (HCC). Materials and Methods A total of 562 patients with HCC who underwent liver resection from January 2015 to December 2019 were enrolled in this retrospective study. The direct variables of total intraoperative expenses were the summation of surgeon’s fee, anesthetic fee, fees for pharmacy, and disposable supplies, which were analyzed based on surgeons’ seniority, patients’ demographic features and comorbidity, clinical features of HCC, and complexity of surgery and surgical approach. Results Of the total cost, 43.3% accounted for expenses of disposing supplies, 32.8% for surgeons’ fees, 15.9% for anesthetic fees, and 8.12% for pharmacy fees. A hierarchical model of multivariate regression analysis showed that the total expenses and that of disposable supplies were significantly higher in surgeons with seniority of over 26 years (p &lt; 0.001) and those having a specialization of robotic surgery (p &lt; 0.001). Further, the complexity and robotic approach of surgery predicted the total expenses (R2 = 0.862, p &lt; 0.001). Robotic approach and its disposable supplies and major liver resection increased by 93.2% and 20.1% (p &lt; 0.001) of total expenses when compared to open liver resection or partial liver resection, respectively. Conclusion The study found that the robotic approach, disposable supplies, and complexity of surgery were the most important predictors of total intraoperative expenses for patients with HCC. Therefore, a cost-effectiveness analysis should be conducted to define the surgical value of the robotic approach for HCC resection.

Evolution of minimally invasive liver surgery in France over the last decade.

Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from -1.8% (-3.9; -0.3) per year in 2013-2018 to -5.9% (-7.9; -3.9) per year in 2018-2022 (p = 0.013). This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.