Malignant Liver Disease Research Articles

Progress in research of radiofrequency ablation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world, and its incidence is on the rise. Surgical resection is the standard method for the treatment of primary or metastatic HCC. In the past ten years, the local ablation of liver tumor has become more and more mature, and it has been proved to be an effective method for the treatment of malignant liver diseases. Whether used alone or in combination, it can control the growth of the tumor to a certain extent and prolong the survival time. It also improves the quality of life. This article begins with the mechanism of radiofrequency ablation in the treatment of liver cancer, and introduces in detail the research progress in the treatment of small liver cancer, large liver cancer, huge liver cancer and metastatic liver cancer by radio frequency ablation and the evaluation of the curative effect after operation. Key words: Carcinoma, hepatocellular; Hepatectomy; Catheter ablation

Cell-free DNA testing: future applications in gastroenterology and hepatology.

The application of next-generation sequencing in clinical practice is increasing as accuracy and interpretation have improved and the cost continues to decline rapidly. Cell-free DNA is a unique source for next-generation sequencing that could change routine clinical practice in gastroenterology and hepatology. Testing of cell-free DNA in blood and fecal samples is an easy, rapid, and noninvasive method to assess for premalignant, malignant, metabolic, infectious, inflammatory, and autoimmune gastrointestinal and liver diseases. In this review, we describe cell-free DNA technologies, current applications of cell-free DNA testing, and proposed cell-free DNA targets for gastrointestinal and hepatic diseases, with a specific focus on malignancy. In addition, we provide commentary on how cell-free DNA can be integrated into clinical practice and help guide diagnosis, prognosis, disease management, and therapeutic response.

Identification of core genes and outcomes in hepatocellular carcinoma by bioinformatics analysis.

Hepatocellular carcinoma (HCC) is the most common malignant liver disease in the world. However, the mechanistic relationships among various genes and signaling pathways are still largely unclear. In this study, we aimed to elucidate potential core candidate genes and pathways in HCC. The expression profiles GSE14520, GSE25097, GSE29721, and GSE62232, which cover 606 tumor and 550 nontumour samples, were downloaded from the Gene Expression Omnibus (GEO) database. Furthermore, HCC RNA-seq datasets were also downloaded from the Cancer Genome Atlas (TCGA) database. The differentially expressed genes (DEGs) were filtered using R software, and we performed gene ontology (GO) and Kyoto Encyclopedia of Gene and Genome (KEGG) pathway analysis using the online databases DAVID 6.8 and KOBAS 3.0. Furthermore, the protein-protein interaction (PPI) network complex of these DEGs was constructed by Cytoscape software, the molecular complex detection (MCODE) plug-in and the online database STRING. First, a total of 173 DEGs (41 upregulated and 132 downregulated) were identified that were aberrantly expressed in both the GEO and TCGA datasets. Second, GO analysis revealed that most of the DEGs were significantly enriched in extracellular exosomes, cytosol, extracellular region, and extracellular space. Signaling pathway analysis indicated that the DEGs had common pathways in metabolism-related pathways, cell cycle, and biological oxidations. Third, 146 nodes were identified from the DEG PPI network complex, and two important modules with a high degree were detected using the MCODE plug-in. In addition, 10 core genes were identified, TOP2A, NDC80, FOXM1, HMMR, KNTC1, PTTG1, FEN1, RFC4, SMC4, and PRC1. Finally, Kaplan-Meier analysis of overall survival and correlation analysis were applied to these genes. The abovementioned findings indicate that the identified core genes and pathways in this bioinformatics analysis could significantly enrich our understanding of the development and recurrence of HCC; furthermore, these candidate genes and pathways could be therapeutic targets for HCC treatment.

Detection and Analysis of Circulating Epithelial Cells in Liquid Biopsies From Patients With Liver Disease

Epithelial cells in the circulation (circulating epithelial cells, or CECs) are analyzed as a non-invasive method to detect cancers; we investigated whether analysis of hepatocytes in the circulation can identify patients with chronic liver disease or hepatocellular carcinoma (HCC). We previously developed a cell-sorting device to isolate CECs from patient blood samples and combined it with an mRNA analysis system to identify CECs with liver-specific markers. We tested the ability of this device to detect CECs of hepatocyte origin in blood samples from healthy individuals (n=10), patients with chronic liver disease without HCC (n=39), and patients with HCC (n=54), using immunofluorescence. We confirmed hepatocyte origin using RNA-sequencing analysis. We found a similar concentration of circulating hepatocytes in blood samples from patients with chronic liver disease and HCC but an increased concentration from patients with advanced fibrosis compared to those without advanced fibrosis. Circulating hepatocytes isolated from patients with HCC had a different gene expression profile than those from patients with chronic liver disease. This system for detecting and analyzing circulating hepatocytes might be used in the evaluation of benign and malignant liver disease.

Expression of zinc transporters ZIP4, ZIP14 and ZnT9 in hepatic carcinogenesis—An immunohistochemical study

IntroductionDysregulation of both, systemic zinc levels and tissue-specific zinc transporters, is reported in chronic inflammatory and malignant liver disease (hepatocellular carcinoma, HCC). Aim of this study is to assess the expression level of three zinc transporters in liver tissue and HCC: ZIP4, ZIP14 and ZnT9. MethodsThe study is based on tissue samples obtained from 138 patients with histologically proven HCC. Tissue specimens from tumor (n = 138) and extra-lesional specimens (n = 72) were assessed immunohistochemically for the expression of the three zinc transporters. Expression levels were semi-quantitatively scored and statistically analyzed with respect to the etiology of HCC (alcohol, AFLD; non-alcoholic fatty liver disease, NAFLD; virus-hepatitis, VH) and survival. ResultsOverall, expression levels of ZIP4, ZIP14 and ZnT9 were significantly higher in HCC tissue than in adjacent extra-lesional liver tissue. Expression levels in tumor tissue and survival time revealed a negative correlation for ZIP4 and ZIP14, and in part for ZnT9 (nuclear staining) (p < 0.05), whereas cytoplasmic staining of ZnT9 did not correlate with survival. Furthermore, the expression level of ZIP4 in extra-lesional tissue showed inverse correlation with survival time. ConclusionThe upregulation of zinc transporters in hepatic carcinogenesis and its negative correlation with survival time implies a regulatory/functional link between zinc-homeostasis and development/progression of HCC that deserves to be further explored.

Diagnostic accuracy of sonoelastography in different diseases.

The objective of this study was to evaluate the diagnostic accuracy of sonoelastography in patients of primary and secondary health care settings. Google scholar, PubMed, Medline, Medscape, Wikipedia and NCBI were searched in October 2017 for all original studies and review articles to identify the relevant material. Two reviewers independently selected articles for evaluation of the diagnostic accuracy of sonoelastography in different diseases based on titles and abstracts retrieved by the literature search. The accuracy of sonoelastography in different diseases was used as the index text, while B-mode sonography, micro pure imaging, surgery and histological findings were used as reference texts. Superficial lymph nodes, neck nodules, malignancy in thyroid nodules, benign and malignant cervical lymph nodes, thyroid nodules, prostate carcinoma, benign and malignant breast abnormalities, liver diseases, parotid and salivary gland masses, pancreatic masses, musculoskeletal diseases and renal disorders were target conditions. The data extracted by the two reviewers concerning selected study characteristics and results were presented in tables and figures. In total, 46 studies were found for breast masses, lymph nodes, prostate carcinoma, liver diseases, salivary and parotid gland diseases, pancreatic masses, musculoskeletal diseases and renal diseases, and the overall sensitivity of sonoelastography in diagnosing all these diseases was 83.14% while specificity was 81.41%. This literature review demonstrates that sonoelastography is characterized by high sensitivity and specificity in diagnosing different disorders of the body.

Spurious Thrombocytopenia in Automated Platelet Count.

Spurious thrombocytopenia is a well-known phenomenon observed with the widespread use of hematology analyzers (HAs). In this study, 355 specimens with pseudo-thrombocytopenia (PTCP) were evaluated via epidemiology, identification, remedies, and platelet (PLT) count. Data showed that anticoagulants such as citrate and/or heparin-dependent PTCP (16.0%) became increasingly common, whereas ethylenediaminetetraacetic acid (EDTA)-induced PTCP (49.1%) remained the most frequent. We note that that nearly half of the patients with PTCP had veritable decreased PLT counts, even after PLT levels had been corrected. Our findings suggest that there were seasonal changes in patients with PTCP: PLT levels were higher in spring, compared with other seasons, with winter levels being the lowest. There were higher risks of PTCP for individuals with malignant neoplasms, liver diseases, infection, and hematologic disease, compared with other conditions. PTCP is related to diseases, rather than being a simple phenomenon, and thus demands careful attention.

Role of Nerve Growth Factor (NGF) and Its Receptor Tyrosine Kinase A (TrK A) in Egyptian Cirrhotic Patients with Pruritus

Background: Pruritus is a distressing symptom of cholestatic, inflammatory, and malignant liver diseases. It is a common symptom in many biliary and cholestatic disorders such as primary biliary cirrhosis (PBC). Several mechanisms are generally accepted as possible explanations to the underlying basis of itch. However, the exact pathophysiology of pruritus in liver diseases remains unclear. The cutaneous and central neurobiology of pruritus is complex and underlies a regulation of variable mechanisms. At present, not all mechanisms including neuromediators and receptors are known. Objective: Our objective is to evaluate whether the expression pattern of NGF and its receptor TrK A has a role in pruritus in a group of Egyptian cirrhotic patients. Patients and Methods: Forty Patients with liver cirrhosis were enrolled in the study depending on clinical evidence of stigmata of chronic liver disease (e.g. jaundice, ascites, palmar erythema, spider naevi, etc.) and ultrasonographic features of liver cirrhosis (e.g. coarse echo texture, shrunken liver, etc.). Patients were divided into two groups. Group (1): included 20 patients cirrhotic patients without pruritus. Group (2): included 20 patients cirrhotic patients with pruritus. A group of age and sex matched healthy twenty volunteers as a control. Results: After evaluation of histopathological using hematoxylin and eosin stained sections (H&E) was done. There was positive correlation between NGF protein expression and severity of pruritus in cirrhotic patients with pruritus (r = 0.876, p value ≤ 0.001). Also there was positive correlation between TrK A protein expression and severity of pruritus in cirrhotic patients with pruritus (r = 0.44, p value ≤ 0.05). Conclusions: We report, for the first time, role of these proteins (NGF/TrK A) in the mechanism of pruritus in cirrhotic patients and may provide a potential target for new treatment of pruritus in cirrhotic.

Serum Gamma Glutamyl Transferase Activity in Liver Diseases

AIM: The aim is to review about serum gamma Glutamyl transferase level in liver diseases. BACKGROUND: Serum Gamma glutamyl transferase is a membrane bound glycoproteins enzyme,which catalysts the transfer of the gamma glutamyl moiety of glutathione to various peptide acceptor. Gamma glutamyl transferase is present in hepatocytes and biliary epithelial cells, renal tubules, pancreas and intestine. Normal level of gamma glutamyl transferase is 9 - 85 u/L .GGT activity is widely used as a highly sensitive biochemical marker in the majority of malignant and non malignant liver diseases. Elevated GGT level of more than 10 times is observed in alcoholism and 2.3 times greater in non-alcoholic fatty acid liver disease. Some drugs and conditions interfere with GGT levels. GGT levels can be increased by alcohol phenytoin (Dilantin), an anti-seizure medication, and phenobarbitol, an antiseizure medication and sedative, and decreased by clofibrate, an anticholesterol drug, and birth control pills. OBJECTIVE: The objective of the review is to address the role of serum gamma glutamyl transferase activity in liver diseases. REASON: Serum gamma Glutamyl transferase also used as a bio marker for various liver disease. So it's necessary for the medical professionals to take serum GGT into account for diagnosis of liver disease.

The Changing Face of the Diagnosis of Chronic and Malignant Liver Diseases: Potential New Biomarkers

The early diagnosis of primary sclerosing cholangitis, hepatocellular carcinoma, and cholangiocarcinoma is often challenging. In a recent study in 134 patients (Arbelaiz, Hepatology 2017; 66: 1125-43), it was reported that specific proteins found in serum extracellular vesicles of patients with primary sclerosing cholangitis, hepatocellular carcinoma, or cholangiocarcinoma may be useful as noninvasive diagnostic and prognostic tools. This current article critically appraises this study.

Experience with the use of antithrombin III concentrate in a multidisciplinary clinic

Thrombosis and thromboembolism are one of the frequent serious and complications in all groups of patients and can lead to death. The purpose of our study was to analyze the clinical situations that required the use of antithrombin concentrate in the practice of intensive care units within the framework of a multidisciplinary hospital. A retrospective analysis was performed of the treatment of 38 patients with acquired antithrombin deficiency in 2016, which was treated with antithrombin. The analysis of the clinical situations that required the use of antithrombin concentrate revealed that the most frequent need for the use of the drug occurs in patients with malignant blood diseases, liver and kidney diseases and in patients with sepsis. Also, the calculation methods for determining the required dosage do not provide an optimal level of AT activity, and the efficacy of anticoagulant therapy does not depend on the total dosage of the drug administered.

High seroprevalence against hepatitis E virus in patients with chronic hepatitis C virus infection

BackgroundHepatitis E virus (HEV) genotype 3 is endemic in Europe. Superinfection with HEV in patients with underlying chronic liver disease can cause hepatic decompensation leading to increased morbidity and mortality. ObjectivesThe prevalence of anti-HEV antibodies was investigated in 204 patients with chronic hepatitis C virus (HCV) infection and different stages of fibrosis. Study designSera were analyzed for anti-HEV IgG, IgM and HEV RNA. ResultsThe median age of the patients was 55 years (IQR 40–62 years); 126 (62%) were men. Ninety-eight (48%) patients had a METAVIR fibrosis stage F2 or higher. The prevalence of anti-HEV IgG was 30% (62/204), which was significantly higher than among Swedish blood donors (17%, p<0.01). The prevalence of anti-HEV antibodies was associated with higher age (OR 1.08 (1.05–1.11); p<0.01). It was also higher for patients with a prior history of blood transfusion (48%) as compared to intravenous drug use (IDU; 26%) as the risk factor for acquisition of the HCV infection (OR 2.72 (1.2–6.19); p<0.02). The prevalence of anti-HEV IgG was also significantly higher in patients with significant fibrosis, i.e. ≥F2 (38%; OR 2.04 (1.11–3.76); p=0.02) and/or neoplasm (72%; OR 7.27 (2.46–21.44); p<0.01). ConclusionsWhen adjusted for age, the prevalence of anti-HEV antibodies was significantly higher in patients with previous or current malignant liver disease compared to blood donors. The lack of significant correlation between HCV and HEV infections indicate low level of transmission of HEV by IDU. HEV infections warrant more attention, especially in patients with preexisting liver disease.

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection. Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival. The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n=6), neuroendocrine tumor (n=1), and ocular melanoma (n=1) in addition to hepatocellular carcinoma (n=4). The median time from liver disease diagnosis to Y90 treatment was 5.5months (range 2-92months). The median time from Y90 treatment to surgery was 9.5months (range 3-20months). The surgical approach included right hepatectomy (n=3), extended right hepatectomy (n=5), extended left hepatectomy (n=1), segmentectomy with ablation (n=2), and segmentectomy with isolated liver perfusion (n=1). The hospital stay was 7days (range 4-31days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25months. Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.

Liver surgery in Italy. Criteria to identify the hospital units and the tertiary referral centersentitled to perform it.

During the last decades, liver surgery had an extraordinary evolution and diffusion thanks to a drastic reduction of operative mortality and morbidity rates. A debate is ongoing about the need for centralization of liver resections in tertiary referral centers. Robust evidences showed that complex surgical procedures have lower mortality rates when performed in high-volume centers. The present expert group reviewed the literature data and proposed guidelines to identify surgical units that should be entitled to perform liver surgery in Italy. Three separate types of requirements were identified. First, the hospital requirements that include the following criteria: (1) a hospital of 1st level according to the Italian law; (2) the presence of a dedicated hepatobiliary or hepatobiliopancreatic unit or a teamdedicated to liver surgery into a general surgery unit; (3) the mandatory presence of oncology, hepatology, radiology, interventional radiology, digestive endoscopy, intensive care, and pathology units; (4) the availability of a liver transplant team into the hospital or into another hospital within an established partnership; (5) a periodic multidisciplinary meeting. Second, the volume requirements: the unit has to perform more than 20 liver resections per year for malignant liver diseases with a 90-day mortality rate<3%. Finally, the organization requirements: the presence of specific diagnostic-therapeutic flowcharts for liver diseases.

Nuclear magnetic resonance based metabolomics and liver diseases: Recent advances and future clinical applications.

Metabolomics is defined as the quantitative measurement of the dynamic multiparametric metabolic response of living systems to pathophysiological stimuli or genetic modification. It is an "omics" technique that is situated downstream of genomics, transcriptomics and proteomics. Metabolomics is recognized as a promising technique in the field of systems biology for the evaluation of global metabolic changes. During the last decade, metabolomics approaches have become widely used in the study of liver diseases for the detection of early biomarkers and altered metabolic pathways. It is a powerful technique to improve our pathophysiological knowledge of various liver diseases. It can be a useful tool to help clinicians in the diagnostic process especially to distinguish malignant and non-malignant liver disease as well as to determine the etiology or severity of the liver disease. It can also assess therapeutic response or predict drug induced liver injury. Nevertheless, the usefulness of metabolomics is often not understood by clinicians, especially the concept of metabolomics profiling or fingerprinting. In the present work, after a concise description of the different techniques and processes used in metabolomics, we will review the main research on this subject by focusing specifically on in vitro proton nuclear magnetic resonance spectroscopy based metabolomics approaches in human studies. We will first consider the clinical point of view enlighten physicians on this new approach and emphasis its future use in clinical "routine".

EUS-Guided Liver Fine Needle Biopsy With a 19-Gauge SharkCore Needle in Patients Undergoing EUS to Evaluate for Biliary Disease

Introduction: Non Malignant Liver biopsies are currently performed via a percutaneous approach and transjugular approach. EUS guided liver fine needle Aspiration FNA of non malignant liver disease has been reported in the literature. EUS guided liver biopsy using a novel 19 Gauge Fine Needle Biopsy (FNB) (SharkCore, Medtronic) offers an alternative to produce a biopsy with preserved tissue architecture. Our aim is to describe the initial experience using a novel FNB needle in the evaluation of liver disease in patients undergoing EUS for biliary disease evaluation in the setting of abnormal liver function tests. Methods: This is a retrospective case series from April 2015 to May 2015, in a tertiary medical center of patients referred for EUS evaluation of biliary disease in the setting of abnormal liver function tests. We reviewed six patients with abnormal liver function tests, who had normal biliary EUS evalutions. Two passes with 19 Gauge FNB SharkCore needle using the saline wet technique and high suction (20cc) were used. The specimens were put in formalin and sent for pathology evaluation, number of intact portal triads, intact core specimen length, stage and grade of liver disease. Post EUS FNB complications were monitor at one week follow up.Figure 1Figure 2Figure 3Results: We evaluated 6 EUS guided FNB liver biopsies in 6 patients (50% women), ages (33-76) with abnormal liver function tests and a normal biliary EUS evaluation. The pathology was consistent with alcohol liver disease (33.3%), drug induced liver toxicity (16.7%), autoimmune liver disease (16.7%), and NASH (33.3%). The mean number of intact portal tracts 9.83 (range 7-18), all specimens where adequate for pathological evaluation. Median intact core specimen length was 34.4 mm (range 21mm to 65.9mm). The average grade of liver disease 1.7 (range 1-2) and stage 2.2 (range 0-3). Post EUS FNB 33.3% of patient complained of right upper quadrant pain and all resolved after one dose of pain medication. There were no reported complications and persistent pain at one week follow up. Conclusion: A novel EUS guided FNB 19 G needle (SharkCore) provided adequate pathological yield and safety profile. EUS guided FNB is an alternative to liver biopsy in patients undergoing EUS for biliary disease exclusion, it provides adequate tissue architecture it is relatively safe. Larger prospective studies are needed to fully understand the role of EUS guided liver FNB.

Mils for HCC: the state of art.

After an initial skepticism, minimally invasive liver surgery (MILS) gained popularity and is nowadays a consolidated option in specialized centers for the surgical treatment of selected patients affected by both benign and malignant liver diseases. Nevertheless, the role of MILS in the surgical treatment of hepato-cellular carcinoma (HCC) developed on the background of chronic liver disease is still a matter of debate. The indications and the current evidences on MILS for HCC are discussed in this paper. MILS being less invasive and harmful for the patients proved to offer a reduction in post-operative morbidity and specific benefits have been highlighted in case of patients affected by HCC and chronic liver disease. In fact, by minimizing liver manipulation and mobilization and by preserving the collateral blood and lymphatic flow, MILS seems to reduce the incidence of post-operative ascites and post-operative liver failure without compromising the oncologic outcomes. This has been confirmed by an analysis of 21 comparative studies and 5 metanalyses comparing MILS and open surgery for HCC. With an adequate surgical training, MILS for HCC can be undertaken safely even in case of major hepatectomies and technically demanding operations such as resections of posteriorly located tumors proved to be feasible in specialized centers. Therefore, with an appropriate patients' selection, MILS for HCC is becoming the preferred option for the surgical treatment of HCC in cirrhotic patients.

Imaging of the postoperative liver: review of normal appearances and common complications

Several benign and malignant liver diseases may require surgical treatment for cure, including anatomical resections based on the segmental anatomy of the liver, non-anatomical (wedge) resections, and surgical management of biliary cysts. The type of surgery depends not only on the location and the nature of the disease, but also on the expertise of the surgeon. Whereas ultrasonography is often the first-line imaging examination in case of suspected postoperative complication, multidetector computed tomography (MDCT) is of greater value for identifying normal findings after surgery, early postoperative pathologic fluid collections and vascular thromboses, and tumor recurrence in patients who have undergone hepatic surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for depicting early postoperative bile duct injuries and ischemic cholangitis that may occur in the late postoperative phase. Both MDCT and MRCP can accurately depict tumor recurrence. Radiologists should become familiar with these surgical procedures to better understand postoperative changes, and with the normal imaging appearances of various postoperative complications to better differentiate between complications and normal findings.

Pioneering Robotic Liver Surgery in Germany: First Experiences with Liver Malignancies.

Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients. These procedures maybe improved by robotic techniques, which add several innovative features. In Germany, we were the first surgical department implementing robotic assisted minimally invasive liver resections. Between June 2013 and March 2015, we performed robotic based minimally invasive liver resections in nine patients with malignant liver disease. Five off these patients suffered from primary and four from secondary liver malignancies. We retrospectively analyzed the perioperative variables of these patients and the oncological follow up. Mean age of the patients was 63 years (range 45-71). One patient suffered from intrahepatic cholangiocellular, four from hepatocellular carcinoma, and four patients from colorectal liver metastases. In six patients, left lateral liver resection, in two cases single segment resection, and in one case minimally invasive guided liver ablation were performed. Five patients underwent previous abdominal surgery. Mean operation time was 312 min (range 115-458 min). Mean weight of the liver specimens was 182 g (range 62-260 g) and mean estimated blood loss was 251 ml (range 10-650 ml). The mean tumor size was 4.4 cm (range 3.5-5.5 cm). In all cases, R0 status was confirmed with a mean margin of 0.6 cm (range 0.1-1.5 cm). One patient developed small bowel fistula on postoperative day 5, which could be treated conservatively. No patient died. Mean hospital stay of the patients was 6 days (range 3-10 days). During a mean follow up of 12 months (range 1-21 months), two patients developed tumor recurrence. Robotic-based liver surgery is feasible in patients with primary and secondary liver malignancies. To achieve perioperative parameters comparable to open settings, the learning curve must be passed. Minor liver resections are good candidates to start this technique. But the huge benefits of robotic-based liver resections should be expected in extended procedures beyond minor liver resections with the currently available technology.

Editorial introductions

Editorial introductions