Non-anatomical Resection Research Articles

Impact of anatomic resection on long-term survival in patients with hepatocellular carcinoma with T1–T2 disease or microscopic vascular invasion

BackgroundThis study aimed to clarify potential candidates for anatomic resection (AR) among patients with pathological T1–T2 (pT1–T2) hepatocellular carcinoma (HCC) and to determine whether AR is effective for HCC with microscopic vascular invasion (MVI). MethodsWe retrospectively analyzed 288 patients with pT1a (n = 50), pT1b (n = 134) or pT2 (n = 104) HCC who underwent curative-intent resection between 1990 and 2010. Surgical outcomes were compared between patients who underwent AR (n = 189) and those who underwent nonanatomic resection (NAR; n = 99) according to pT category and MVI status. ResultsPatients who underwent AR were more likely to have good hepatic functional reserve and an aggressive primary tumor than those who underwent NAR. When patients were stratified according to pT category, AR had a more favorable impact on survival than NAR only in patients with pT2 HCC in univariate (5-year survival, 51.5% vs. 34.6%; p = 0.010) and multivariate analysis (hazard ratio 0.505; p = 0.014). However, AR had no impact on survival in patients with pT1a or pT1b HCC. In patients with MVI (n = 57), AR achieved better survival than NAR (5-year survival, 52.0% vs. 16.7%; p = 0.019) and was an independent prognostic factor (hazard ratio 0.335; p = 0.020). In patients without MVI (n = 231), there was no significant difference in survival between the two groups (p = 0.221). ConclusionAR was identified as an independent factor in improved survival in patients with pT2 HCC or HCC with MVI.

The Comparison of Surgical Margins and Type of Hepatic Resection for Hepatocellular Carcinoma With Microvascular Invasion.

The objective of this study was to investigate the impact of surgical margin and hepatic resection on prognosis and compare their importance on prognosis in patients with hepatocellular carcinoma (HCC). The clinical data of 906 patients with HCC who underwent hepatic resection in our hospital from January 2013 to January 2015 were collected retrospectively. All patients were divided into anatomical resection (AR) (n = 234) and nonanatomical resection (NAR) group (n = 672) according to type of hepatic resection. The effects of AR and NAR and wide and narrow margins on overall survival (OS) and time to recurrence (TTR) were analyzed. In all patients, narrow margin (1.560, 1.278-1.904; 1.387, 1.174-1.639) is an independent risk factor for OS and TTR, and NAR is not. Subgroup analysis showed that narrow margins (2.307, 1.699-3.132; 1.884, 1.439-2.468), and NAR (1.481, 1.047-2.095; 1.372, 1.012-1.860) are independent risk factors for OS and TTR in patients with microvascular invasion (MVI)-positive. Further analysis showed that for patients with MVI-positive HCC, NAR with wide margins was a protective factor for OS and TTR compared to AR with narrow margins (0.618, 0.396-0.965; 0.662, 0.448-0.978). The 1, 3, and 5 years OS and TTR rate of the two group were 81%, 49%, 29% versus 89%, 64%, 49% (P = .008) and 42%, 79%, 89% versus 32%, 58%, 74% (P = .024), respectively. For patients with MVI-positive HCC, AR and wide margins were protective factors for prognosis. However, wide margins are more important than AR on prognosis. In the clinical setting, if the wide margins and AR cannot be ensured at the same time, the wide margins should be ensured first.

Effectiveness of indocyanine green fluorescence imaging in resection of hepatoblastoma.

The present research aimed to analyze the application of indocyanine green (ICG) fluorescence contrast technique in the resection of hepatoblastoma (HB) in children, and to discuss the use of ICG in the surgery of HB and the value of guidance. We retrospectively analyzed the data of 23 children with HB resected using ICG fluorescence contrast technique at the Children's Hospital of Nanjing Medical University from June 2020 to September 2022, including 16 boys and 7 girls, aged 5days to 80months. The patients were administered with an ICG injection of 0.1mg/kg around 24-48h before surgery. The surgical margin was detected by real-time fluorescence imaging and confirmed by postoperative pathology. All primary lesions showed bright fluorescence in 23 HB cases. 22 had clear borders with normal liver tissue, while one neonatal case showed no difference between tumor and background. 13 anatomic resection and 10 non-anatomic resection were performed with ICG fluorescence navigation. The surface of the residual liver was scattered with multiple tumor fluorescence, which was then locally enucleated according to the fluorescence. 22 isolated specimens were dissected and fluorescently visualized. Pathology identified deformed, vacuolated and densely arranged hepatocytes resembling pseudo-envelope changes without tumor residual, due to the compression of the tissue at the site of circumferential imaging. The ring ICG fluorescence imaging of HB indicates the tumor resection boundary effectively, especially in multiple lesions cases.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Abstract 734: Comprehensive validation of high-risk clinicopathologic features in early-stage, node-negative non-small cell lung cancer

Abstract Objective: Current guidelines recommend adjuvant therapy for patients with completely resected non-small cell lung cancer (NSCLC) with high-risk clinical or pathologic features. Despite this, the relationship between these features and cancer recurrence is poorly elucidated. Methods: We conducted a retrospective cohort study using a uniquely compiled dataset from the US Veterans Health Administration (VHA) including all Veterans with pathologic early-stage (≤5cm, N0) NSCLC receiving definitive surgical treatment (2010-2016). Based on National Comprehensive Cancer Network guidelines, we evaluated 6 high-risk features: tumor size, tumor grade, visceral-pleural invasion, lymphovascular invasion, non-anatomic wedge resection, and adequacy of nodal sampling. We developed a score reflecting the relationship between these high-risk features and recurrence, using a multivariable competing risk model (death as competing event). The score performance was then tested in an external cohort from the National Cancer Database (NCDB). Results: The study included 3,799 Veterans. The median follow-up was 7.1 years. Recurrence was detected in 800 (21.1%) patients. The association between high-risk features and cancer recurrence were as follows: tumor size (e.g., 31-40mm vs. 0-10mm, multivariable-adjusted hazard ratio, aHR 1.676, 95% CI 1.229-2.285, p=0.001), tumor grade (e.g., III vs. I, aHR 1.884, 95% CI 1.448-2.449, p<0.001), visceral-pleural invasion (aHR 1.096, 95% CI 0.905-1.329, p=0.35), lymphovascular invasion (aHR 1.747, 95% CI 1.441-2.117, p<0.001), non-anatomic wedge resection (aHR 1.335, 95% CI 1.101-1.619, p=0.003), and adequacy of nodal sampling (e.g., 1-4 lymph nodes vs. ≥10 lymph nodes, aHR 1.392, 95% CI 1.149-1.687, p<0.001). Using these parameters, a score was created reflecting the association between high-risk features and recurrence. The score ranged from 0-36, with higher scores reflecting higher cumulative incidence of recurrence. The score was further divided into low- (0-11, n=1,263, 33.3%; 5-yr recurrence risk 13.0%), moderate- (12-15, n=1,134, 29.9%; 5-yr recurrence risk 19.0%), and high-risk (16-36, n=1,402, 36.9%; 5-yr recurrence risk 27.1%) categories. Higher scores were also associated with diminished overall survival (median OS, low-risk: 9.0 yrs; moderate-risk: 7.3 yrs; high-risk: 5.4 yrs). The score was further tested in a cohort of 63,232 patients from the NCDB and higher scores remained associated with worse overall survival (median OS, low-risk: 9.4 yrs; moderate-risk: 8.0 yrs; high-risk: 6.3 yrs). Conclusions: High-risk clinicopathologic features are associated with dramatically higher risk of recurrence and worse overall survival. Multivariable assessment of these features using a comprehensive yet pragmatic score may help to standardize adjuvant treatment eligibility following curative intent resection. Citation Format: Brendan T. Heiden, Daniel B. Eaton, Su-Hsin Chang, Yan Yan, Martin W. Schoen, Bindiya G. Patel, Theodore S. Thomas, Bryan F. Meyers, Benjamin D. Kozower, Varun Puri. Comprehensive validation of high-risk clinicopathologic features in early-stage, node-negative non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 734.

Precision Surgery of Colorectal Liver Metastases in the Current Era: A Systematic Review

Liver resection for colorectal liver metastases (CRLM) is widely considered the treatment with the highest curative potential. However, not all patients derive the same oncological benefit, underlining the need for better patient stratification and treatment allocation. In this context, we performed a systematic review of the literature to determine the role of RAS status in selecting the optimal surgical strategy. Evidence comparing anatomical with non-anatomical resections depending on RAS mutational status was scarce and conflicting, with two studies reporting superiority in mutated RAS (mutRAS) patients and two studies reporting equivalent outcomes. The rate of incomplete microscopic resection (R1) was found to be increased among mutRAS patients, possibly due to higher micrometastatic spread lateral to the primary lesion. The impact of R1 resection margins was evaluated separately for mutRAS and wild-type patients in three studies, of which, two indicated an additive detriment to long-term survival in the former group. In the current era of precision surgery, RAS status can be utilized to predict the efficacy of liver resection in the treatment of CRLM, avoiding a potentially morbid operation in patients with adverse tumor profiles.

Anterior hepatic resection: A simple and safe technique for reducing the antero-posterior diameter of the liver graft for small pediatric recipients.

The techniques involved in neonatal and infantile transplantation require approaches that can sculpt a left lateral segment (LLS) to the right shape and size and avoid large-for-size syndrome. The aim of this article is to describe the anterior hepatic resection (AHR) of the LLS in pediatric LDLT. A retrospective anatomical study of preoperative image studies, description of the technique for AHR, and short-term results. The AHR was performed in eight cases. All donors were male, with average age, BW, and BMI of 28.3 ± 5.9 years, 74.2 ± 9.3 kg, and 24.3 ± 2.6 kg/m2, respectively. Donors were discharged at an average of 3.6 ± 0.8 days. The median recipient age and BW at transplantation were 6.9 (2.7 to 11) months and 5.9 (3.9 to 8) kg, respectively, and the recipient-to-donor body weight ratio (RDBW) was <0.1 in all but one case. The mean percentage reduction in graft weight and in the antero-posterior diameter were 33.2% ± 5.5% and 38.3% ± 12.6%, respectively. The average (SD) GRWR was 4.8% ± 1.7% before all the resections and 3.5% ± 1.0% after the procedures. Seven patients were primarily closed. After LLS resection, a nonanatomical anterior resection of the LLS was accomplished without hilar vascular dissection to segments II/III. The final liver graft allowed primary abdominal wall closure in all but one patient, with meaningful adjustments in GRWR. AHR proved to be simple, safe, reproducible, and effective in the presented case series.

Long-term outcomes of anatomic vs. non-anatomic resection in intrahepatic cholangiocarcinoma with hepatolithiasis: A multicenter retrospective study.

The benefits of anatomic resection (AR) vs. non-anatomic resection (NAR) in patients with primary intrahepatic cholangiocarcinoma (ICC) with hepatolithiasis (HICC) are unclear. This study aimed to compare the long-term outcomes of AR vs. NAR in patients with HICC. A total of 147 consecutive patients with HICC who underwent R0 hepatectomy were included. Overall survival (OS) and recurrence-free survival (RFS) following AR vs. NARs were compared using a 1:1 propensity score matching (PSM) analysis. A subgroup analysis was also conducted according to whether there are lymph node metastases (LNM). In a multivariate analysis, CA 19-9 (>39 U/L), microvascular invasion, LNM, and NAR were independent risk factors for poor RFS and OS rates, whereas multiple tumors were independent risk factors for OS. AR had better 1-, 3-, and 5-year RFS and OS rates than NAR (OS: 78.7, 58.9, and 28.5%, respectively, vs. 61.2, 25.4, and 8.8%, respectively; RFS: 59.5, 36.5, and 20.5%, respectively, vs. 38.2, 12.1, and 6.9%, respectively). After PSM, 100 patients were enrolled. The NAR group also had significantly poorer OS and RFS (OS: 0.016; RFS: p = 0.010) than the AR group. The subgroup analysis demonstrated that in HICC without LNM, OS and RFS were significantly poorer in the NAR group than the AR group, while no significant differences were observed in HICC with LNM before or after PSM. Anatomic resection was associated with better long-term survival outcomes than NAR in patients with HICC, except for patients with LNM.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection.

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

Right Hepatectomy (Réglée) for Liver Metastasis Post Pancreatic Adenocarcinoma – Case Report

Background Metastatic tumors of the liver are the most common hepatic malignant disease, responsible for more than 95% of the total. The size and number of metastases of the liver varies considerably. They maintain the anatomo-pathologic features of the primary cancer, but often are complicated by central necrosis. Pancreatic tumors often metastasize to the liver because of venous drainage to the portal vein. In cases of this occurrence, the disease is considered to be at stage IV with minimal to no consideration for a surgical approach despite the late improvements in liver resection and more efficient chemotherapy. There is a severely limited number of studies for patients undergoing liver resection for liver metastases that arise after a surgical treatment of pancreatic adenocarcinoma. However, these studies, which take in consideration the surgical liver resection versus chemotherapy alone in patients with metachronous metastases of pancreatic cancer demonstrate a significantly longer survival rate. Case presentation The 65 y/o male patient­­­­­­ was diagnosed one year prior to the current events with an adenocarcinoma of the pancreas tail, for which he underwent the surgical procedure of pancreatic tail resection and splenectomy. Ten months after the surgery he complains of fever and body temperature of 38 - 39°C. Despite taking antibiotics for over a month and a half he has no improvement. He is hospitalized in a febrile state, asthenic and pale skin and mucosa. Following an MRI the diagnosis leans towards a liver metastasis. A right réglée hepatectomy is performed. The patient tolerated the procedure well and was discharged in good health. Discussion Determining the amount of liver parenchyma to be removed is an important decision. Anatomic resections mostly include two or more hepatic segments, whereas non-anatomic resection involves the resection of the metastases with a margin of healthy tissue (segmentectomy). The decision concerning the extent of resection is more relevant for the post-operative chemotherapy in colorectal metastasis, where an effort is made to conserve as much as possible remnant liver tissue. A preoperative chemotherapy allows more patients to be considered resectable, but may damage hepatic function and increase the risk of post-operative liver insufficiency. Conclusion In conclusion, hepatic resection for metastatic non-colorectal non-neuroendocrine tumors is safe and is linked to better outcomes in chosen patients. However primary tumour type and disease-free intervals seem to be important variables. Sometimes, hepatic resection may be the only option offering a potential cure, so it should be considered in some patients with liver metastases of non-colorectal non-neuroendocrine tumors. Keywords: General Surgery, Right Hepatectomy, Liver Metastasis, Pancreatic Adenocarcinoma. DOI: 10.7176/JEP/14-9-07 Publication date: March 31 st 2023

Primary Hepatic Choriocarcinoma with Pregnancy: A Diagnostic and Therapeutic Challenge

Choriocarcinoma occurs mainly in the gonads, but an extragonadal origin has been reported, albeit infrequently. Primary hepatic choriocarcinoma (PHC) is a rare malignancy, with only 11 cases reported. Most cases reported were in males, with none reported in pregnant females. A 23-year-old primigravida presented with a large liver lesion involving the right lobe of the liver at 28 weeks of pregnancy. Preoperative imaging was suggestive of hepatocellular carcinoma. She underwent a non-anatomical resection of the liver lesion. Surprisingly, her postoperative histopathology revealed a diagnosis of PHC. Her blood workup showed elevated beta human chorionic gonadotrophin. She underwent a termination of her pregnancy at 32 weeks. Before initiating adjuvant chemotherapy four weeks after surgery, a whole-body PET scan revealed multiple bi-lobar liver and pelvic deposits. After a multidisciplinary team discussion, she was started on adjuvant chemotherapy. She is currently under regular follow-up, seven months post-surgery. PHC, one of the vascular lesions of the liver, poses a diagnostic and therapeutic challenge, warranting a multidisciplinary approach.

Combined Endoscopic–Laparoscopic Surgery (CELS) in the Management of Early Colorectal Lesions

AbstractOver 14 million colonoscopies are performed annually in the United States. With the growing number of colonoscopies comes corresponding increases in the rates of colectomies performed for benign polyps. These advanced adenomas have the potential, if removed early, to promote decreased rates of colon cancer and improve patient survival. Difficult to resect polyps may be located at colonic flexures, tortuous turns in the colon, the ileocecal valve, or the appendiceal orifice presenting a unique challenge to endoscopic resection. Various advanced endoscopic techniques are now available for the resection of these polyps such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection, but these techniques have a steep learning curve and are technically challenging. For the community colorectal surgeon, relatively simpler options include combined endoscopic and laparoscopic surgery (CELS) and full-thickness laparo-endoscopic colonic excision (FLEX) for either the endoscopic or laparoscopic removal of challenging polyps. The FLEX procedure resembled a nonanatomic wedge resection of the colon with polyp, while CELS resembles a laparoscopically augmented EMR. With the technical success rate for CELS reportedly between 74 and 97%, the postoperative complication rate of less than 5%, and polyp recurrence rates bordering less than 2%, these procedures have the capacity to safely facilitate the complete removal of difficult-to-resect endoscopic polyps. The purpose of this review is to both provide recommendations for CELS and FLEX utilization for the resection of polyps and describe our operative techniques and tips and tools for increasing the efficacy of these procedures.

Hemostasis in liver surgery: Indonesian Society of Digestive Surgeons (IKABDI) consensus statements

Liver resection is a complex operation with bleeding control as one of the most crucial factors. It is essential to determine the amount of bleeding to predict the mortality and morbidity after liver surgery. With technology and scientific development, liver resection can use open or laparoscopic surgical techniques supported by various energy devices and medical management. However, the main goal is to remove the tumor with adequate negative margins and good flow. Indonesian Society of Digestive Surgeons agreed to have an agreement using the Modified Delphi method consisting of twenty digestive surgeons. The consensus was established for hemostasis management choices as surgical and medical strategies in liver surgery. The surgical strategies recommendation include performing anatomical resection in primary hepatic tumor and non-anatomical resection for liver metastases; using of Glissonean Pedicle approach as an inflow control option; doing routine intermittent pringle maneuvers; prohibiting total vascular exclusion; and making a statement that no particular energy device preferred for transecting the liver parenchyma. For medical strategies, consensus recommends limiting the transfusion of PRC or any other blood components, antifibrinolytic's role as hemostatic agents, and using fibrin sealant and matrix coagulant sheets for hemostatic agents in liver surgery. These recommendations reflect current knowledge and can be reviewed if new findings are discovered. Hopefully, this consensus can be a valuable guide for surgeons, especially those practicing in Indonesia, to provide low mortality and morbidity in liver resection.

Independent of the preoperative coronal deformity, adjusted mechanical alignment leads in a high percentage to non-anatomical tibial and femoral bone cuts.

The technique of adjusted mechanical alignment (AMA) in total knee arthroplasty (TKA) has been described to achieve alignment and balancing goals in varus knees in a high percentage, albeit at the price of non-anatomical bone cuts. The purpose of this study was to analyze (1) whether AMA achieves similar alignment and balancing results in different types of deformity and (2) whether they can be achieved without altering the native anatomy. A series of 1000 patients with hip-knee-ankle (HKA) angles from 165° to 195° were analyzed. All patients were operated using AMA technique. According to the preoperative HKA angle, three groups of knee phenotypes (varus, straight, valgus) were defined. The bone cuts were analyzed for being anatomic (< 2mm deviation of individual joint surface) or non-anatomic (> 4mm deviation of individual joint surface). AMA reached the goals for postoperative HKA in over 93% in every group (varus: 636 cases, 94%, straight: 191 cases, 98%, valgus: 123 cases, 98%). In 0° extension, the gaps were balanced in varus knees in 654 cases (96%), in straight knees in 189 cases (97%) and in valgus knees in 117 cases (94%). A balanced flexion gap was found in a similar number of cases (varus: 657 cases, 97%, straight: 191 cases, 98%, valgus: 119 cases, 95%). In the varus group, non-anatomical cuts were performed at the medial tibia (89%) and the lateral posterior femur (59%). The straight group showed similar values and distribution for non-anatomical cuts (medial tibia: 73%; lateral posterior femur 58%). Valgus knees showed a different distribution of values, being non-anatomical at the lateral tibia (74%), distal lateral femur (67%) and posterior lateral femur (43%). In all knee phenotypes, the AMA goals were achieved in a high percentage by altering the patients' native anatomy. In varus knees, the alignment was corrected by non-anatomical cuts at the medial tibia, and in valgus knees at the lateral tibia and the lateral distal femur. All phenotypes showed non-anatomical resections on the posterior lateral condyle in approximately 50% of cases. III.

Awake uniportal VATS sublobar lung resections in high-comorbidity patients: Single-center early post-operative outcomes.

Awake minimally invasive Uniportal Video Assisted Thoracic Surgery (U-VATS) represents the last challenge in thoracic surgery that could change the future scenario for high comorbidity patients with early-stage non-small cell lung cancer (NSCLC). We report a single center preliminary experience of awake thoracoscopic uni-portal anatomic and non-anatomic sub-lobar resections in this setting. We retrospectively analyzed data collected on a prospective database of patients undergoing U-VATS awake sub-lobar lung resections for NSCLC between September 2021 and September 2022. Inclusion criteria were clinical stage I disease; contraindication to standard lobectomy due to high respiratory function impairment; general anesthesia considered at high risk based on the American Society of Anesthesiologist score and on the Charlson Comorbidity Index. All patients underwent a standardized awake non-intubated anesthesia protocol approved by our institutional board. They were n = 10 patients: n = 8 wedge resections; n = 2 segmentectomies. We had n = 1 (10%) conversion to standard general anesthesia and n = 1 laryngeal mask support but maintaining spontaneous breathing. N = 5 patients (50%) needed an Intensive Care Unit recovery (mean time = 17.20 h). Mean chest tube duration and Hospital stay were 2.0 and 3.5 days respectively. We did not register 30- days postoperative mortality. Awake thoracic surgery is a feasible technique, and it could be performed also in high comorbidities' patients without a high rate of complications and allows to operate patients that so far were considered borderline for surgery.

Non-anatomical liver resection for hepatocellular carcinoma: the SegSubTe classification to overcome the problem of heterogeneity

BackgroundThe superiority of anatomical resection (AR) vs. non-anatomical resection (NAR) in the surgical management of hepatocellular carcinoma (HCC) is debated. ARs are well-defined procedures, whereas the lack of NAR standardization results in heterogeneous outcomes. This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor. MethodsA single-center retrospective analysis of pre- and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted. The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section (segmental, subsegmental or terminal next to the tumor) of vascular pedicles feeding the HCCs; then, the population was divided in “SegSubTe-IN” or “SegSubTe-OUT” groups, and the tumor recurrence and survival were analyzed. ResultsNinety-seven patients who underwent NAR were included; 76% were SegSubTe-IN and 24% were SegSubTe-OUT. Total disease recurrence, local recurrence and cut-edge recurrence in the SegSubTe-IN vs. SegSubTe-OUT groups were 50% vs. 83% (P = 0.006), 20% vs. 52% (P = 0.003) and 16% vs. 39% (P = 0.020), respectively. SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis. One-, three-, and five-year disease-free survival rates in the SegSubTe-IN vs. SegSubTe-OUT groups were 81%, 58% and 35% vs. 46%, 21% and 11%, respectively (P < 0.001). ConclusionsThe SegSubTe classification is a useful tool to stratify and standardize NAR for HCC, aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

Surgical Strategies for Combined Hepatocellular-Cholangiocarcinoma (cHCC-CC).

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a tumor entity presenting features of hepatocellular and cholangiocellular epithelial differentiation. Due to the likeness between cHCC-CC, HCC and CC, accurate pretherapeutical diagnosis is challenging and advanced stages are prevalent. Radical oncological surgery is the only curative therapeutical option in patients with cHCC-CC. To reach this goal a profound understanding of this rare liver tumor is crucial. Factors such as clinicopathological characteristics, growth patterns and biological behavior are of central importance. To explore onco-surgical strategies and aspects for complete resection of cHCC-CC and to answer important key questions, an extensive review of the literature was conducted to answer the following questions: What are the best surgical options? Is there a significance for nonanatomical resections? Is there a prognostic value of concomitant lymphadenectomy? What about multimodal concepts in local advanced cHCC-CC? The role of minimally invasive liver surgery (MILS) including the role of robotic liver surgery for cHCC-CC will be discussed. While liver transplantation (LT) is standard for patients with unresectable HCC, the role of LT in cHCC-CC patients is still controversial. How can patients with high risk for early tumor recurrence be identified to avoid aggressive surgical treatment without clinical benefit? The comprehensive understanding of this challenging liver tumor will help to improve future treatment options for these patients.

The segsubte classification of non-anatomical liver resections for hepatocellular carcinoma

Background: The superiority of hepatic anatomical resection (AR) vs. non-anatomical resection (NAR) in the surgical management of hepatocellular carcinoma (HCC) is debated. ARs are well defined, whereas the lack of NAR standardisation results in heterogeneous outcomes. The aim of this study is to introduce the SegSubTe classification for NAR with purpose of determining the appropriateness of the level of surgical section of the vascular pedicles feeding the tumor.

RARE PRESENTATION OF HEMANGIOMA-LIKE HEPATOCELLULAR CARCINOMA WITH INFREQUENT SYMPTOMS OF LOWER GASTROINTESTINAL BLEEDING AND ATYPICAL RADIOLOGICAL FEATURES-A CASE REPORT

Hepatocellular carcinoma can mimic benign lesions like liver haemangioma with atypical image findings and can manifest in an acute emergency where a diagnostic dilemma is encountered that can alter the phase of management. We hereby present a case of a 70-year-old male patient with multiple medical comorbidities who presented to us initially in June 2021 with a history of blunt trauma abdomen. Ultrasound abdomen imaging was suggestive of bleeding from liver hemangioma. The patient underwent emergency exploratory laparotomy and hemostasis was achieved. After being clinically better he underwent angioembolisation of the bleeding vessels; unfortunately, he presented one year later with bleeding per rectum. On re-evaluation, imaging features were again consistent with giant liver hemangioma infiltrating ascending and transverse colon. Tumour markers were negative. Being nonamenable to angioembolisation at this setting he underwent exploratory laparotomy unblock right hemicolectomy + non-anatomical liver resection (segment 6, part of 5,7) on October 2022 based on intraoperative findings. Surprisingly the histopathology report was that of hepatocellular carcinoma (HCC). Detailed searching made us able to find these sorts of discordant presentations of HCC with negative tumor markers and atypical imaging findings. The patient was referred to our medical oncology department for expert management. The incidence of direct invasion of HCC to the gastrointestinal tract is approximately 0.5–2%. Colonic metastasis is uncommon in patients with HCC. The diagnosis of HCC is generally made by radiologic hallmarks of dynamic contrast imaging. Sometimes large HCCs may have atypical radiological contrast enhancement patterns thus mimicking hemangioma.

HPB P35 Fluorescence guided resection of Liver Tumours: Same day administration of indocyanine green with SPY- Colour Segmented Fluorescence imaging to identify tumours intra-operatively

Abstract Background Indocyanine green (ICG) fluorescence imaging is a real-time navigation tool that has shown promising liver surgery results. Several regimes have been described regarding optimum timing and dose of ICG administration. Visually different fluorescent enhancement patterns correlate with different pathologies to aid the identification of lesions intra-operatively. This study aims to present our experience with using the Colour Segmented Fluorescence (CSF) model and same-day administration of low dose ICG in the resection of liver tumours. Methods We present a single surgeon (SA) experience using indocyanine green fluorescence image-guided surgery (I-FIGS) at University Hospitals Plymouth, UK. I-FIGS was used between November 2020 and March 2022 in 15 patients with suspected liver tumours. ICG was administered intravenously at a dose of 0.02 to 0.03 mg/kg IV 2–3 hours prior to liver surgery. Using the SPY CSF mode, the image is scaled to NIRF fluorescence intensity to identify the liver tumours and their margins intra-operatively. Results A total of fifteen patients (eight males) with a median age of 71 years (36–86) underwent I-FIGS during the study period. Of these, 67% underwent laparoscopic liver surgery, 78% underwent non-anatomical resections, and 33% underwent re-do liver surgery. The average size of the tumour was 40.6 mm, and median number of tumours was one. All lesions were visible in CSF mode, and all had a signet ring appearance. The histology of the tumours confirmed a well to moderately differentiated colorectal metastasis in 13 (86%) patients and hepatoma in two patients. R0 resection was achieved in 11 (76%) of patients. In two patients with R1 resection, the tumour was right on the right hepatic vein, and R0 would not have been possible. The resection margins were clear in two other patients but &amp;lt;1mm. The overall false positive rate in our experience with I-FIGS was 3%. Conclusions In our limited experience, low-dose ICG administered at least 2–3 hours prior to surgery can accurately identify liver tumours and their margins in CSF mode. Superficially located lesions are easily identifiable under CSF mode, and CSF mode helped us identify the lesions and mark the resection margin. The use of ICG is an important advancement in liver surgery, and further research is needed to optimise image interpretation and correlate with clinical resection outcomes.