Minor Resections Research Articles

Combined liver and colorectal resections for synchronous metastases is safe and efficient when performed at a quaternary referral center

Presenter: Kevin Choong MD | City of Hope Cancer Center Background: The operative sequencing for patients with resectable synchronous colorectal liver metastases remains controversial. Retrospective institutional studies have shown relative safety and lower lengths of stay in combined versus staged resections. National database studies, however, have reported increased morbidity with combining major liver resection with concurrent colorectal resections. This has led to questions regarding this approach, especially in non-specialized centers. In this study, we hypothesize that combined colorectal and liver resections for synchronous metastases is both safe and efficient. Methods: A retrospective review of combined resections for synchronous colorectal liver metastases at a quaternary referral center from 2015-2020. Clinicopathologic and perioperative data was collected. Univariate and multivariate analyses were performed to identify risk factors for major post-operative complications. Results: One hundred one patients were identified, with 35 undergoing major liver resections (>3 segments) and 66 undergoing minor liver resections. Primary tumors were in the right colon in 20 (19.8%), the left colon in 57 (56.4%), and the rectum in 24 (23.8%). Patients who underwent minor liver resection had higher BMI (27.1 vs. 24.6, p = 0.04) and were more likely to be ASA 4 (36.3% vs. 17.1%, p = 0.04). Locoregional stage of the primary colorectal cancer did not differ between major and minor liver resections. The vast majority of patients (94%) received neoadjuvant therapy and there was no significant difference in the duration or regimen between those undergoing major or minor liver resection. Major liver resections were more likely to receive blood transfusions (28.6% vs. 9.1%, p = 0.01). However, estimated blood loss (433.4 ml vs. 352.2 ml, p = 0.19), case duration (451.9 min vs. 481.4 min, p = 0.27), and length of stay (9.7 days vs. 8.0 days, p = 0.18) were no different between major and minor liver resection. Post-operatively, patients undergoing major liver resection had higher rates of post-hepatectomy liver failure (34.2% vs. 7.6%, p = 1 (p1, no factors were associated with significantly increased odds of major complication. Conclusion: Combined resection for synchronous colorectal liver metastases when performed at a quaternary referral center is both safe and efficient.

Laparoscopic liver resections for gallbladder cancer and intrahepatic cholangiocarcinoma: the Mayo clinic experience

Presenter: Ron Pery MD | Mayo Clinic, Rochester Background: Gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (ICC) are aggressive malignancies where surgical resection offers the only meaningful chance of cure. Complete tumor removal with negative margins and adequate porta hepatis lymphadenectomy for tumor staging is the surgical standard of care in resectable cases according to the national comprehensive cancer network (NCCN) guidelines. The safety and oncological adequacy of laparoscopic liver resections for GBC and ICC have been questioned in the past and many surgeons were hesitant to consider it. Being a high-volume center of minimal invasive liver surgeries, this study aimed to describe the Mayo clinic experience with laparoscopic liver resections for GBC and ICC and to specifically ascertain their safety and oncological adequacy. Methods: The Mayo clinic database was used to identify patients who underwent curative intent laparoscopic liver resection for GBC or ICC between 01/2016 to 12/2020. Clinicopathological characteristics, operative details and outcomes of 33 patients were collected and analyzed with specific emphasis on resection margins, porta hepatis lymphadenectomy and post-operative complications. Results: 33 patients with GBC or ICC underwent curative-intent laparoscopic liver resection with or without porta hepatis lymphadenectomy in Mayo clinic between 01/2016 and 12/2020. The median age of patients was 65±11.8. Six (18%) patients underwent major liver resection with porta hepatis lymphadenectomy, fourteen (42%) patients underwent minor liver resection with porta hepatis lymphadenectomy; while five (16%) patients underwent major liver resection and eight (24%) patients underwent minor liver resection without portal lymphadenectomy. The mean operative time was 193 minutes (range 83-881) and the mean estimated blood loss (EBL) was 250cc (range 25-1700). There were two conversions (6%) to laparotomy due to failure to progress. Nineteen (58%) patients had no post-operative complications, five (15%) patients had minor post-operative complications (Clavien Dindo score ≤2) and nine (27%) patients had major post-operative complications (Clavien Dindo score ≥3) including one post-operative mortality (3%) due to portal vein thrombosis leading to fatal liver failure. The median in hospital length of stay was three days (range 1-39). On pathology, the mean tumor size was 36.5mm (range 15-150) and resection margins were negative in all specimens. Amongst the patients who underwent porta hepatis lymphadenectomy, the mean number of harvested lymph nodes was 4.5 (range 1-19) and eight (40%) patients have met the AJCC 8th edition staging manual cutoff of at least six harvested lymph nodes. Conclusion: When done by experienced minimal invasive liver surgeons in a high-volume center, laparoscopic liver resections for GBC and ICC are both feasible, safe and oncologically appropriate. While operative times, EBL and post-operative complications profiles are comparable to historic open controls, the in-hospital length of stay is shorter. As in open surgeries, an effort should be made to meet the AJCC 8th edition recommendation of at least six harvested lymph nodes for adequate tumor staging.

Short Term Safety and Efficacy of Robotic Versus Laparoscopic Liver Resection: A Systematic Review and Meta Analysis

Introduction: Laparoscopic liver resection (LLR) remains technically challenging with its use limited to experienced surgeons. Robotic liver resection (RLR) may potentially produce favorable peri- and postoperative outcomes when compared to LLR. Methods: MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL databases were systematically reviewed to identify studies comparing robotic and laparoscopic partial hepatectomy (last search 5th August 2019). Quantitative comparative studies in English published since the introduction of RLR were identified for inclusion. Outcomes extracted include operative time (OT), estimated blood loss (EBL), conversion to open, perioperative transfusion requirement, post-operative complications, length of stay, R0 resection rate, and mortality. Sub-groups were defined as major, and minor resections. Meta-analysis and subgroup meta-analysis was carried out using a random effects model. Effect measures were odds ratio (OR) for dichotomous data and mean weighted difference (MWD) for continuous data. Results: Twenty-two non-randomised comparative studies with a total of 1890 patients (Robotic; n=836, Laparoscopic; n=1054) was included in analysis. Operative time was significantly longer for RLR [MWD=+39.8 minutes, 95% CI (21.1, 58.6), p< 0.001], but not significantly different in sub-group analysis. EBL, length of stay, conversion rate, transfusion, complication rate, R0 resection rate, and mortality was not significantly different between RLR and LLR nor in major or minor sub-groups [p>0.05]. Conclusion: RLR provides comparable peri- and postoperative outcomes to LLR, potentially being a preferable approach in complex and major liver resections due to the inherent advantages of the robotic platform. Further randomised controlled studies are required in establishing the role of robotics in liver resection.

One stage laparoscopic ICG guided liver resection for bilateral colorectal liver metastases

Purpose: Laparoscopic liver surgery has shown a widely diffused use in recent years, owing to its efficiency and safety, which is on par with open surgery. However, certain minimally invasive surgical interventions are yet considered to have a high degree of complexity, and can only be performed in specialized centers. Challenging surgical interventions include, major resections, minor resections in disadvantageous locations, anatomical resections of hepatocellular carcinomas, and multiple resections for bilobar hepatic metastases.

Relevance of Adipose Tissue Accumulation and Muscularity in Patients Undergoing Liver Resection

Introduction: Nutritional status is known to affect the quality of liver parenchyma. This study aimed to evaluate the relevance of the amount of adipose and muscular tissue assessed on computed tomography (CT) in patients undergoing liver resection. Methods: In this prospective observational study, 64 patients undergoing liver resection underwent preoperative CT assessment of height-normalized amount of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and total adipose tissue (TAT), smooth muscle (SM) and psoas muscle (PM). The primary outcome measure was early injury and function of remnant liver, as reflected by immediate (within 24 hours) and peak serum transaminases activity, international normalized ratio (INR), and bilirubin concentration. Results: Median SAT, VAT, TAT, SM, and PM were 65.4, 41.0, 115.1, 47.8, and 5.9 cm2/m2, respectively. TAT was significantly correlated with macro- (R=0.43; p=0.001) and microvesicular (R=0.36; p=0.007) liver steatosis, with stronger impact of subcutaneous than visceral fat. In patients undergoing minor resections (n=29), SM was positively correlated with early (R=0.53; p=0.004) and peak (R=0.43; p=0.020) bilirubin and SAT (R=0.43; p=0.031), VAT (R=0.51; p=0.007), and TAT (R=0.50; p=0.010) were positively correlated with early INR. Interestingly, in patients without relevant liver steatosis (< 30%), SAT (R=0.48; p=0.034) was additionally positively correlated with early aspartate transaminase activity and VAT (R=0.48; p=0.029) and TAT (R=0.55; p=0.010) with peak aspartate transaminase activity. Conclusion: Excessive amount of adipose tissue exacerbates injury and negatively influences early liver remnant function after minor liver resections. Increased muscularity may lead to increased bilirubin concentrations of undetermined clinical significance.

Extent of hepatic resection impacts expense of care at no extra physiologic cost

Purpose: We sought to publish the differences in perioperative outcomes and costs in patients undergoing major and minor hepatectomy for liver tumors at a tertiary hepatobiliary center. Method: Patients undergoing hepatectomy were classified as major (≥3 segments) and minor (<3 segment) resections. Perioperative, cost and charge variables were tabulated. Statistically significant differences, defined as p<0.05, were determined by Student’s t-test. Results: 217 and 153 patients underwent major and minor hepatectomy respectively. There were no differences in age, gender, BMI or ASA score between the two groups. Estimated blood loss (p=0.0008), operative time (p=0.0001) and lesion size (p=0.0001) were significantly greater in patients with major hepatectomy vs minor hepatectomy. Length of stay (p=1.00), in hospital mortality (p=0.2) and 30 day mortality (p=0.54) were not significantly different between the two groups. Intraoperative (p=0.001), variable (p=0.002) and total costs (p=0.01) were significantly greater for patients undergoing major hepatectomy, but not postoperative (p=0.49), fixed (p=0.18) nor fixed indirect costs (p=0.09). Total hospital charges were significantly greater in patients undergoing major hepatectomy (p=0.001), but payments received was not (p=0.38). Conclusion: Major hepatectomy resulted in greater operative time, blood loss and total costs, surrogates of a technically more challenging resection than minor hepatectomy. Major hepatectomy led to greater hospital charges but not payments received. Mortality and length of stay are equivalent between major and minor hepatectomy.Tabled 1VID067MajorMinorTotal| p-ValuePatients (n)217153370EBL (mL)200(319±368.4)100(196±308.4)p=0.0008*Operative Time (minutes)289(300±116.6)216(240±121.7)p=0.0001*Size of Lesion (cm)5(6±3.9)3(4±3.3)p=0.0001*Length of Stay (days)4(5±3.9)3(5±5.1)p=1.0030 Day Mortality8 (4%)3 (2%)p=0.54Total Hospital Charges$187,286($201,749 ± $125,487.0)$144,944($162,294 ± $94,436.4)p=0.001*Total Cost$30,622($34,710 ± $29,055.5)$24,588($27,855 ± $17,673.7)p=0.01*Payments Received$19,508($42,993 ± $44,704.0)$18,037($38,620 ± $44,296.4)p=0.38 Open table in a new tab

Liver Drains after Surgery, a Real-life Snapshot among the HPB Community: the LI.DR.A.S. World-wide Survey

Background: Although several trials have been conducted, the management of liver drains remains controversial among HPB surgeons. We conducted a world-wide survey to define actual clinical drain practices adopted by liver surgeons in the EA-HPBA, A-HPBA and AP-HPBA communities. Methods: An open survey consisting of 30 questions was prepared and then published on Google – Form, which was then delivered by email to members of the three major chapters of the international hepato-pancreato-biliary association (IHPBA). Results: 191 HPB surgeons responded to the web-survey. Twenty (10.5%) respondents were from the Asian-Pacific region, while 15 (7.9%) were from North America, 13 (6.8%) from South America and 143 (74.9%) from Europe and Africa. One hundred-twelve surgeons (58.6%) reported routine use of abdominal drains liver resection. Eighty-eight (46.1%) respondents responded that drain removal was driven by low volume and low bilirubin levels in the drains; 85 (44.5%) surgeons usually consider removal of the drain on 2-3 post-operative days (POD). In case of minor liver resection, 97 (50.8%) surgeons reported using drains only in select cases. When a major resection (>=3 liver segments) is performed, 134 (70.2%) surgeons preferred to always use a drain. Among patients with cirrhosis, 87 (45.5%) surgeons reported the routine use of drains, while 84 (44.0%) respondents considered drains only selectively. The lack of drains was most prevalent among surgeons from North America (12, 80%); in contrast, 14 (70.0%) surgeons in Asian-Pacific region, 87 (60.8%) in Europe and Africa and 8 (61.5%) in South America were more inclined to employ liver drains routinely (p=0.014). Among surgeons whose practice is mostly mini-invasive liver surgery (n=31), 23 (74.2%) reported draining only in selected cases, while the proportion of surgeons who use drains selectively among surgeons who performed mainly open liver resections was lower (n=56, 35.0%)(p<0.001). Conclusion: Despite several RCTs, use of drains at the time of liver resection remains highly variable. In particular, surgeons from North America, as well as surgeons who predominantly perform minimally-invasive hepatectomy, are much less likely to employ abdominal drains at the time of liver resection.

Status of minimally invasive HPB surgery in the UK from consultant and trainee perspectives

Introduction: This survey took a snapshot of current attitudes towards minimally invasive HPB surgery from a consultant and trainee perspective. Methods: Two google surveys were emailed to all identified HPB centres in the UK to consultants and trainees (ST5+). The questionnaire contained 33 and 31 questions respectively regarding minimally invasive HPB practice and training. Results: Thirty-five HPB consultants completed the survey. The most common indications for conversion to open surgery were failure to progress in 91.4% (n=32), excessive intraoperative blood loss in 85.7% (n=30) and access issues in 85.7% (n=30). The majority (78.8%, n=26) of HPB surgeons surveyed undertook MIDP while 21.2% (n=7) did not as they deferred them to other surgeon(s) who regularly performed them. Only one consultant undertook minimally invasive pancreaticoduodenectomy (MIPD), robotically; 48.4% (n=15) declared not performing MIPDs as they were not convinced MIS is superior to an open approach. Eighty-five-point seven percent (n=30) performed minimally invasive minor liver resection and segmentectomy (MImLRS), 70.6% (n=24) reported better outcomes with an MIS approach, 23.5% (n=8) reported no difference in outcomes between the MIS and open approaches. Seventy percent (n= 5) performed minimally invasive major liver resection (MIMLR) laparoscopically and 30% (n=3) robotically; 56.3% (n=17) reported equivalent or better outcomes with an open approach while 23.3% (n=7) reported better outcomes with MIMLR. Half of polled HPB trainees did not have access to laparoscopic HPB procedures (excluding laparoscopic cholecystectomy); 22.2% (n=4) of trainees had a mentor in laparoscopic HPB procedures. Forty-four-point four percent of trainees (n=8) reported going to laparoscopic courses on cadaveric/live models while 44.4% (n=8) used internet-based media to improve their laparoscopic skills; 72.2% (n=13) desired an extension to training (or fellowship) to consolidate their laparoscopic training. Conclusion: MImLRS and MIDP would appear to be accepted approaches by most HPB consultants which correlates with a perception that outcomes are better/comparable to open approaches. This is less clear for MIPD and MIMLR. HPB trainees suffer from a lack of laparoscopic HPB exposure leading to seek further laparoscopic HPB experience with fellowships post certificate of completion of training.

Resection of liver segments VII-VIII: is right hepatic vein reconstruction advisable?

To improve the treatment outcomes in patients with primary and metastatic liver tumors localized in segments VII-VIII involving the right hepatic vein and its branches. There were 16 surgical interventions including resection of liver segment VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction. All procedures were carried out at the Department of Liver and Pancreatic Tumors of the Blokhin National Medical Cancer Research Center for the period 2016-2020. The cause of surgery was colorectal cancer liver metastases in 8 patients, hepatocellular carcinoma in 2 cases, angiomyolipoma in 1 case and metastases of uterine cancer in 1 patient. Minor liver resection was additionally performed in 5 cases. Median surgery time was 150 (80-220) min, intraoperative blood loss - 400 (100-2000) ml. Afferent blood flow was blocked in 4 patients for 14 (12-25) min. None patient had intraoperative signs of impaired venous outflow. Biliary fistula in postoperative period occurred in 1 patient. No complications were noted in other cases. Median postoperative hospital-stay was 13 (9-19) days. There were no specific complications in long-term postoperative period that could be associated with venous outflow blockade through the right hepatic vein. Existing vessels and intrahepatic collaterals de novo can provide adequate venous outflow into the middle hepatic vein and short hepatic veins during resection of liver segments VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction and the absence of inferior right hepatic vein.

The Feasibility and Benefits of in Vivo Swine Training Model for Laparoscopic Liver Resections among General Surgery Residents

Background: Laparoscopic liver resections (LLR) are gaining popularity worldwide, however, a proper and efficient training model is lacking, mainly for residents and young surgeons. The aim of our study is to assess the feasibility and benefits of a “step-by-step” training model in LLR created for residents as part of a continuous training program. Methods: From May 2017 to October 2018, 30 residents who previously participated in laparoscopic surgery workshops at “Prof. Sergiu Duca” training centre, Cluj-Napoca, Romania, participated in a “step-by-step” guided LLR protocol workshop on swine (Stage 1) aiming to analyse its feasibility. The protocol consisted of performing cholecystectomy, liver mobilization, minor and major resections. Their performance Results in terms of operative time, blood loss, conversion, trainers' intervention and intraoperative mortality, were recorded. Twenty-four of these residents (6 dropped out as they turned seniors) were later compared to 24 senior surgeons who neither followed the protocol nor performed LLR previously (Stage 2), and to another 24 residents who weren't part of a training program but followed the protocol (Stage 3), aiming to assess its' benefits. Results: All residents fully completed the surgical procedures. Trained residents obtained better operative times and less blood loss compared to senior surgeons (p< 0,017), however, the remaining parameters were comparable. When compared to non-trained residents, the trained ones had significantly better results only in operative times (p< 0,001). Conclusion: A continuous LLR “step-by-step” training program on swine for residents is feasible. It can be successfully applied with clear benefits on practical skills.

A review of 125 cases of laparoscopic right- and left-hepatectomy in Cleveland clinic

Presenter: Federico Aucejo MD | Cleveland Clinic Foundation Background: The early series of laparoscopic liver resections (LLR) were often non-anatomic minor resections, but recent surgical/instrumental advantages enable surgeons to apply LLR to anatomical major resection. Although major LLR has been established in some Asian/European experienced centers, the pure major LLR is still not widely accepted in the US. In our institute, we gradually increased the number of LLR and we have been trying to achieve similar quality and safety with major LLR as with open hepatectomy. The aim of this study was to introduce our institute’s series of laparoscopic right- and left- hepatectomy. Methods: This study included patients who underwent formal hemi-hepatectomy using laparoscopic approach between 1/2008-1/2021. Chronological trends in surgical approach and patient outcomes were assessed. Results: During the study period, 125 patients underwent formal hemi-hepatectomy using laparoscopic approach including hand-assisted approach. The median patient age was 52 years old (range: 20-87) and most of patients were male (69/125, 55.2%). The median body mass index was 27.5 (range: 18.9-39.9). The indication for surgery was as follows: 19 benign tumor, 67 malignant tumor, and 39 live donor. The breakdown of malignant tumor was as follows: colorectal metastases: 27, hepatocellular carcinoma: 16, intrahepatic cholangiocarcinoma: 15, neuroendocrine metastases: 2, others: 7. The trend in case numbers during the study period is shown in Figure A. The case number increased after 2017 and most of the cases were completed after 2017 (101 cases: 80.8 %). Of the 125, 62 patients underwent right hepatectomy (pure-laparoscopic: 53, hand-assisted: 9, converted to open: 13, Figure B) and 63 patients underwent left hepatectomy (pure-laparoscopic: 59, hand-assisted: 4, converted to open: 4, Figure C). The use of hand-assisted approach decreased significantly over time. Open conversion also significantly decreased after revising surgical procedures and instruments in 2018. The median operative time was 434 minutes in right hepatectomy and 360 minutes in left hepatectomy, respectively (Figure D). The Post-operative complications (Clavian-Dindo grade ≥2) was seen in 25 patients (16 in right and 9 in left). Postoperative mortality was seen in one patient who underwent right hepatectomy. Conclusion: Pure-laparoscopic hemi-hepatectomy is now established as standard procedure in our institute. The chronological technical and instrumental refinement in our institute, as well as current our standardized right and left videos will be presented.

Liver Resection for Patients with Hepatocellular Carcinoma and Child B Liver Function: A Single-center Experience

Objectives: Liver resection is the first-line treatment option for patients with hepatocellular carcinoma (HCC). Whether patient with HCC and Child B liver function can performed liver resection is still controversial. Methods: From January 2012 to June 2018, Child B patients with HCC who underwent liver resection were enrolled in this study. Perioperative complications and risk factors for long-term survival were analyzed. Results: During the study period, 186 Child B patients perform liver resection. Of these, 140 patients (75.3%) were presented with cirrhosis, 154 (82.8%) with ascites, 98 (52.7%) with portal hypertension, and the median tumor size was 7.2 cm. Forty-one patients performed laparoscopic liver resection, and 40 patients received additional splenectomy. Most patients (77.4%) only underwent minor resection and non-anatomical hepatectomy. The minor and major surgical complication was 31.2% and 24.7%, respectively. The 1-, 3-, and 5-year disease-free and overall survival were 49.8% and 69.5%, 33.8% and 47.5%, 24.5% and 30.4%, respectively. The laparoscopic procedure achieved similar long-term survival but better perioperative outcomes. Among those with portal hypertension, patients received additional splenectomy achieved better oncological outcomes. Multivariate analysis showed that portal hypertension (HR 1.490, 95% CI 0.979-2.269, P=0.043), tumor size >5 cm (HR 1.928, 95% CI 1.276-2.914, P=0.002), macrovascular invasion (HR 1.746, 95% CI 1.116-2.733, P=0.015). Conclusions: Liver resection achieved long-term survival in some selective patients with HCC and Child B liver function, especially for those with small tumor size, and without portal hypertension and macrovascular invasion. A laparoscopic procedure could decrease surgical complications and splenectomy could prolong long-term survival.

A Comparative Study of an Integrated Ultrasonic/Bipolar Sealing Device versus an Articulating Bipolar Sealing Device for Laparoscopic Liver Surgery

Purpose: Hemostatic devices are able to seal and cut tissue with the application of different energy modalities, and are routinely used in open and laparoscopic liver surgery (LLS). The aim of this study is to compare the outcome of Thunderbeat (TB), an integrated ultrasonic/bipolar sealing device, versus Enseal (ES), an articulating bipolar sealing device, in LLS. Methods: A retrospective analysis of a prospectively maintained database was conducted in a single center from September 2011 to September 2020. The primary endpoint was evaluation of difference in blood loss between the two hemostatic devices. Secondary endpoints consisted of complications, operative time, hospital stay, and mortality. Results: 352 patients were identified who underwent LLS, either by using TB (n=105) or ES (n=247). The TB and ES group were comparable in terms of sex, comorbities, extension of resection, and surgical difficulty scores (IWATE and Southampton). Median blood loss was significantly lower with TB (50 mL (IQR: [20-120]) compared to ES (100 mL (IQR: [50-250]) (p<0.0001). The amount of blood loss was highest for anatomical major and lowest for minor resections, and increased proportionally with difficulty scores. Use of cavitron ultrasonic surgical aspirator (CUSA) was associated with an increase in blood loss in both TB and ES (100 mL (IQR: [50-300]) vs. 175 mL (IQR: [100-400]); p<0.0001). Median operative time was considerably shorter in TB (115 min (IQR: [45-300])) compared to ES (140 min (IQR: [40-370])) (p=0.0008). The Pringle maneuver was more often applied in TB (27.6%) compared to ES (13.8%) (p=0.0036). However, by adjusting for variables influencing blood loss in a generalized linear model, the type of hemostatic device remained a significant contributing factor in blood loss (p=0.0164). The postoperative complication rate was similar for bleeding (TB 0% vs. ES 1.2%; p=0.5574) and biliary leak (TB 1.0% vs. ES 1.6%; p=1.0000), and there was no significant difference in 90-day mortality (TB 0% vs. ES 0.8%; p=1.0000). Median hospital stay was shorter for TB compared to ES (2 days (IQR: [1-4]) vs. 4 days (IQR: [3-6]); p<0.0001) although this might be explained by the introduction of an enhanced recovery after surgery (ERAS) clinical pathway in June 2015. Conclusion: The integrated ultrasonic/bipolar sealing device is superior compared to the articulating bipolar sealing device in LLS in terms of perioperative blood loss without an increase in complications.

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study

Purpose of the studyPostoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining...

Developing a minimally-invasive anaesthesiological approach to non-intubated uniportal video-assisted thoracoscopic surgery in minor and major thoracic surgery.

BackgroundNon-intubated uniportal video-assisted thoracoscopic surgery (niVATS) is a novel approach to major and minor lung resection. It benefits from a holistic anesthesiological concept with adequate pain relief and sedation in a minimal-invasive setup allowing thoracic procedures under spontaneous breathing. At present no anesthesiological gold standard for niVATS exists. The primary aim of our retrospective observational study was to evaluate feasibility and safety of minimally invasive niVATS for both minor and major pulmonary resections at our institution.MethodsAll 88 consecutive patients scheduled for niVATS minor or major thoracic procedures were included into the study. Anaesthesia was performed according to a departmental niVATS algorithm including both regional anaesthesia and sedation. Patient characteristics and early outcome data including intraoperative and postoperative findings were compared between groups. Prediction scores for postoperative complications (LAS VEGAS, ARISCAT, ThRCRI) were calculated and compared.ResultsNo early mortality and a low overall morbidity rate of 28.4% were encountered. Conversion to orotracheal intubation was required in 6.8% of all cases. Postoperative pulmonary complications occurred in 15.9% of total cases and were lower than predicted by both LAS VEGAS and ARISCAT respectively. Cardiac complications were found in 1.1% and lower than predicted by ThRCRI. A persistent air leak occurred in 11.4% of total cases and was significantly higher in major resection. Postoperative chest tube duration and hospital length of stay in the major resection group exceeded times reported by other groups.ConclusionsniVATS appears to be safe in both minor and major thoracic procedures. A minimally invasive anaesthesiological approach foregoing central iv lines, arterial blood pressure measurement and urinary catheterization is feasible. Our niVATS protocol appears to be a viable alternative for both minor and major thoracic procedures in selected patients.

Parenchymal transection in robotic liver resection: results of 70 resections using the Vessel Sealer

Aim : There is no standard technique for transection of the hepatic parenchyma during robotic liver resection. The aim of this study was to describe the outcomes of robotic liver resections using the Vessel Sealer for parenchymal transection. Methods : This is a post hoc analysis of a prospective database. All consecutive patients who underwent robotic liver resection in the Regional Academic Cancer Centre, Utrecht, Netherlands, between August 2015 and January 2019 were included. Results : A total of 70 robotic liver resections were performed, including 60 minor resections (86%) and ten hemihepatectomies (14%). Five procedures (7%) were converted. Mean parenchymal transection time was 43 ± 26 min. Median blood loss was 150 mL (interquartile range 40-300). Ten patients (14%) suffered from a major complication, and three patients (4%) had bile leakage postoperatively. One patient died from post-hepatectomy liver failure. Conclusion : Based on the results of this series, consisting of 60 minor liver resections and 10 hemihepatectomies, we conclude that the use of the Vessel Sealer during the parenchymal transection in liver resection is feasible and safe.

A simple and clinically applicable model to predict liver-related morbidity after hepatic resection for hepatocellular carcinoma.

Background & aimHepatic resection is a treatment option for patients with hepatocellular carcinoma (HCC). However, factors associated with candidacy for resection and predictive of liver-related morbidity after resection for HCC remain unclear. This study aimed to assess candidacy for liver resection in patients with HCC and to design a model predictive of liver-related morbidity after resection.MethodsA retrospective analysis of 1,565 patients who underwent liver resection for HCC between January 2016 and December 2017 was performed. The primary outcome was liver-related morbidity, including post-hepatectomy biochemical dysfunction (PHBD), ascites, hepatic encephalopathy, rescue liver transplantation, and death from any cause within 90 days. PHBD was defined as international normalized ratio (INR) > 1.5 or hyperbilirubinemia (> 2.9 mg/dL) on postoperative day ≥ 5.ResultsThe 1,565 patients included 1,258 (80.4%) males and 307 (19.6%) females with a mean age of 58.3 years. Of these patients, 646 (41.3%) and 919 (58.7%) patients underwent major and minor liver resection, respectively. Liver-related morbidity was observed in 133 (8.5%) patients, including 77 and 56 patients who underwent major and minor resection, respectively. A total of 83 (5.3%) patients developed PHBD. Multivariate analysis identified cut-off values of the platelet count, serum albumin concentration, and ICG R15 value for predicting liver-related morbidity after resection. A model predicting postoperative liver-related morbidity was developed, which included seven factors: male sex, age ≥ 55 years, ICG R15 value ≥ 15%, major resection, platelet count < 150,000/mm3, serum albumin concentration < 3.5 g/dL, and INR > 1.1.ConclusionHepatic resection for HCC was safe with 90-day liver-related morbidity and mortality rates of 8.5% and 0.8%, respectively. The developed point-based scoring system with seven factors could allow the prediction of the risk of liver-related morbidity after resection for HCC.

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation

BackgroundAlthough laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS).MethodsAn international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS.ResultsOverall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.ConclusionThis international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Minimally invasive versus open right hepatectomy: comparative study with propensity score matching analysis

BackgroundMinimally invasive liver resections (MILRs) have been increasingly performed in recent years. However, the majority of MILRs are actually minor or limited resections of peripheral lesions. Due to the technical complexity major hepatectomies remain challenging for minimally invasive surgery. The aim of this study was to compare the short and long-term outcomes of patients undergoing minimally invasive right hepatectomies (MIRHs) with contemporary patients undergoing open right hepatectomies (ORHs)MethodsConsecutive patients submitted to anatomic right hepatectomies between January 2013 and December 2018 in two tertiary referral centers were studied. Study groups were compared on an intention-to-treat basis after propensity score matching (PSM). Overall survival (OS) analyses were performed for the entire cohort and specific etiologies subgroupsResultsDuring study period 178 right hepatectomies were performed. After matching, 37 patients were included in MIRH group and 60 in ORH group. The groups were homogenous for all baseline characteristics. MIRHs had significant lower blood loss (400 ml vs. 500 ml, P = 0.01), lower rate of minor complications (13.5% vs. 35%, P = 0.03) and larger resection margins (10 mm vs. 5 mm, P = 0.03) when compared to ORHs. Additionally, a non-significant decrease in hospital stay (ORH 9 days vs. MIRH 7 days, P = 0.09) was observed. No differences regarding the use of Pringle’s maneuver, operative time, overall morbidity or perioperative mortality were observed. OS was similar between the groups (P = 0.13). Similarly, no difference in OS was found in subgroups of patients with primary liver tumors (P = 0.09) and liver metastasis (P = 0.80).ConclusionsMIRHs are feasible and safe in experienced hands. Minimally invasive approach was associated with less blood loss, a significant reduction in minor perioperative complications, and did not negatively affect long-term outcomes.

Minimally invasive vs traditional liver resection in managing small hepatocellular carcinoma

Background Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Surgical technique and equipment have been evolved to overcome technical limitations, making LLR safe and feasible. Surgeons develop skills in a stepwise approach, beginning with low complexity operations for benign diseases and reaching high-complexity surgeries for malignant cases and living donor organ harvesting. Patients and methods In this prospective randomized study, a comparison between laparoscopic and open resection was done to compare short-term results regarding intraoperative details, postoperative management, and complications. This study was conducted on 30 patients with hepatocellular carcinoma (HCC): 15 (50%) patients were treated by LLR (group A), whereas the other 15 (50%) patients were treated by open liver resection (group B). Results Regarding the demographic data, the presence of past history of medical condition, and the preoperative laboratory results, no statistically significant difference was found. The mean operative time has a statistically significant difference between the two groups, with decreased operative time in the laparoscopic group (P Conclusion LLR is a safe and feasible treatment option for HCC in cirrhotic patient needing minor resection at laparoscopic liver segments II, III, IVa, V, and VI. LLR for HCC has superior short-term and comparable oncological outcomes to open liver resection. LLR should be performed for carefully selected patients and by an expert surgical team.