Non-anatomical Resection Research Articles

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 <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.

The feasibility and safety of simultaneous bilateral video-assisted thoracic surgery for the treatment of bilateral pulmonary lesions.

The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral video-assisted thoracic surgery (VATS) for the treatment of bilateral pulmonary lesions. The data of 11 patients who received simultaneous bilateral pulmonary surgery using VATS in the Department of Thoracic Surgery of The Third Affiliated Hospital of Naval Medical University between January 2016 and August 2021 were retrospectively analyzed. The cases of four male and seven female patients, with a mean age of 57.54 ± 8.37 years (range, 44-67 years), were reviewed. Nonanatomic wedge resection, pulmonary segmentectomy or lobectomy via VATS were performed depending on each patient's situation. Mean 1 second forced expiratory volume (FEV1) was 2.55 ± 0.66 L(range, 1.49-3.88 L), mean intraoperative bleeding volume was 91.81 ± 49.56 mL(range, 30-150 mL), mean operating time was 273.72 ± 68.98 min(range, 132-390 min), and mean drainage duration was 5.27 ± 3.60 days(range, 2-14 days), with a mean total drainage volume of 1,515.90 ± 772.75 mL(range, 530-3,225 mL). Only one postoperative complication (air leakage) occurred, with an overall complication rate of 9.09%. The mean postoperative hospital stay was 8.81 ± 3.60 days (range, 5-18 days), and the mean total cost of hospitalization was 67,054.53 ± 20,896.49 RMB (range, 47,578.45-123,530.8 RMB). Simultaneous bilateral pulmonary surgery using VATS for the treatment of bilateral pulmonary lesions is safe and feasible and can therefore be considered after strict preoperative evaluation of the patient.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey.

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies. A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies. Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites. Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Chemoembolization as a minimally invasive treatment of primary malignant liver cancer

Background: Hepatocellular carcinoma (HCC) is the most common type of liver cancer and one of the most malignant neoplasms with high incidence and mortality in humans worldwide. The complex nature of the disease and its high resistance to systemic therapies result in poor prognosis for patients with advanced HCC. Case Report: In March 2017, the patient was admitted to the Department of Oncological Surgery, where a non-anatomical tumor resection was performed. Three years later, the patient developed a single change in segment 8 of the liver that was a relapse of the neoplastic process. Based on the Bracelon Criteria, the patient was qualified for the 1st stage of chemoembolization using the Seldinger method. In the presented patient as a result of the applied treatment, the neoplastic process was stabilized. Conclusion: The chemoembolization treatment that was applied to the presented patient turned out to be the correct treatment option. After only the first stage of chemoembolization, the patient regressed the neoplastic lesion.

Anatomical Resection Improved the Outcome of Intrahepatic Cholangiocarcinoma: A Propensity Score Matching Analysis of a Retrospective Cohort.

Intrahepatic cholangiocarcinoma (ICC) is the second most common liver malignancy after hepatocellular carcinoma (HCC), with a dismal prognosis and high heterogeneity. The oncological advantages of anatomical resection (AR) and nonanatomical resection (NAR) in HCC have been studied, but surgical strategies for ICC remain controversial with insufficient investigations. From Jan 2013 to Dec 2016, 3880 consecutive patients were retrospectively reviewed from a single center. Patients with ICC undergoing AR or NAR have been enrolled according to inclusion and exclusion criteria. Propensity score matching (PSM) analysis was performed between two groups with a 1 : 1 ratio. The primary endpoint was overall survival (OS), and the secondary endpoints included disease-free survival (DFS), intraoperative patterns, postoperative morbidity, mortality, complications and recurrence. A prognostic nomogram was developed by a multivariate Cox proportion hazard model. After PSM, 99 paired cases were selected from 276 patients enrolled in this study. Patients in the AR group achieved better 1-, 3-, and 5-year OS (70%, 46%, and 34%, respectively) and DFS (61%, 21%, and 10%, respectively) than patients in the NAR group with statistical significance after PSM analysis. The postoperative complications and recurrence patterns were comparable between the two groups. Multivariate analysis identified NAR, tumor size >5 cm, multiple tumors, and poor differentiation as independent risk factors for OS (p < 0.05). Selected patients can benefit most from AR, according to subgroup analysis. A prognostic nomogram based on six independent risk factors for OS and factors with clinical significance was constructed to predict OS in ICC patients. AR improved the long-term survival of ICC with comparable postoperative complications and similar recurrence patterns. AR is suggested in ICC patients with sufficient remnant liver volume. In addition to surgery strategy, malignant characteristics of tumors are risk factors for ICC prognosis.

Comparison of Anatomic and Non-Anatomic Liver Resection for Hepatocellular Carcinoma: A Retrospective Cohort Study.

Background and Objectives: The survival benefit of anatomical liver resection for hepatocellular carcinoma has not been elucidated yet. In this study, we aimed to investigate the effects of anatomic and non-anatomic liver resection on surgical outcomes in patients with hepatocellular carcinoma. Materials and Methods: A retrospective analysis of patients undergoing anatomic or non-anatomic resections due to hepatocellular carcinoma between March 2006 and October 2019 was conducted. Demographics, preoperative laboratory assessments, treatment strategies, and postoperative outcomes were analyzed. Results: The total cohort consisted of 94 patients, with a mean age of 63.1 ± 8.9 years, and 74.5% were male. A total of 41 patients underwent anatomic liver resection, and 53 patients underwent non-anatomic resection. The overall survival rates were found to be similar (5-year overall survival was 49.3% for anatomic resection and 44.5% for non-anatomic resection). Estimated median overall survival times were 58.5 months and 57.3 months, respectively (p = 0.777). Recurrence-free 1-, 3-, and 5-year survival rates were found to be 73.6%, 39.1%, and 32.8% in the non-anatomic resection group and 48.8%, 22.7%, and 22.7% in the anatomic resection group, respectively. Grade three or higher complication rates were found to be similar among the groups. Conclusions: This study did not find a difference between two surgical methods, in terms of survival. A tailored selection of the resection method should be made, with the aim of complete removal of tumoral lesions and leaving a suitable functional liver reserve, according to the parenchymal quality and volume of the liver remnant.

Liver surgeries in Iceland 2013-2017 - Comparison with Sweden in terms of quality registration

Cancers in the liver, bile duct system, gallbladder as well as metastases of the liver, have poor prognosis. Their treatment is comparable, with surgery being the most widespread, available curative treatment. Surgical treatment is anatomical or non-anatomical resection of the liver where the tumor and the adjacent liver tissue are removed. A list of patients diagnosed with cancer in the liver, bile duct system, gallbladder or metastases of the liver, during the time period 2013-2017, was obtained from the Icelandic Cancer Registry. Additional information was retrieved from medical records and entered into the electronic quality registration forms of Landspítalinn. A comparison was made between Sweden and Iceland. In total 108 patients were diagnosed with primary cancer of the liver, of which 24 (22%) underwent liver surgery. Of 264 diagnosed with liver metastases 38 (14%) underwent surgical treatment. A total of 63% of all reported cases were discussed at a multidisciplinary team meeting in Iceland but 93% in Sweden (p<0.0001). A sum of 29 patients (43%) developed complications within 30 days of surgery. Number of partial liver resections per 100.000 inhabitants were 2-8 in Iceland versus 4-13 in Sweden. The difference was even more apparent in patients with liver metastases. Liver surgeries performed in Iceland seem to be comparable to Sweden in terms of complications and post operative mortality. In Iceland, considerably fewer operations are performed per capita, especially on liver metastases which could be explained by the fact that fewer patients are discussed at multidisciplinary team meetings.

EP02.03-026 Is Ratio of Surgical Margin to Nodule Size a Prognostic Factor in Stage 1 Adenocarcinoma?

The most common non-anatomical resection is wedge resection for the patients with comorbidities and limited pulmonary function. We investigated, the ratio of surgical margin to nodule size (SM/NS) as a prognostic factor.

Understanding Racial Differences in Lung Cancer Surgery Through a Statewide Quality Collaborative.

Persistent racial disparities in lung cancer incidence, treatment, and survival are well documented. Given the importance of surgical resection for lung cancer treatment, racial disparities in surgical quality were investigated using a statewide quality collaborative. This retrospective study used data from the Michigan Society of Cardiothoracic Surgeons General Thoracic database, which includes data gathered for the Society of Thoracic Surgeons General Thoracic Surgery Database at 17 institutions in Michigan. Adult patients undergoing resection for lung cancer between 2015 and 2021 were included. Propensity score-weighting methodology was used to assess differences insurgical quality, including extent of resection, adequate lymph node evaluation, 30-day mortality, and 30-day readmission rate between white and black patients. The cohort included 5073 patients comprising 357 (7%) black and 4716 (93%) white patients. The black patients had significantly higher unadjusted rates of wedge resection than the white patients, but after propensity score-weighting for clinical factors, wedge resection did not differ from lobectomy (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.78-1.49; P = 0.67). The black patients had fewer lymph nodes collected (incidence rate ratio [IRR], 0.77; 95% CI, 0.73-0.81; P < 0.0001) and lymph node stations sampled (IRR, 0.89; 95% CI, 0.84-0.94; P < 0.0001). The black patients did not differ from the white patients in terms of mortality (OR, 0.65; 95% CI, 0.19-2.34; P = 0.55) or readmission (OR, 0.79; 95 % CI, 0.49-1.27; P = 0.32). The black patients had longer hospital stays (OR, 1.08; 95% CI, 1.02-1.14; P = 0.01). In a statewide quality collaborative that included high-volume centers, black patients received a less extensive lymph node evaluation, with fewer non-anatomic wedge resections performed, and a more limited lymph node evaluation with lobectomy.

Anatomical liver resection improves surgical outcomes for combined hepatocellular-cholangiocarcinoma: A propensity score matched study

BackgroundThe efficacies of anatomical resection (AR) and non-anatomical resection (NAR) in the treatment of combined hepatocellular-cholangiocarcinoma (cHCC-CCA) remain unclear. This study aimed to compare the prognostic outcomes of AR with those of NAR for cHCC-CCA.MethodPatients diagnosed with pathology-confirmed cHCC-CCA, and who underwent curative resection at Tongji hospital between January 2010 and December 2019 were included in this retrospective study. A one-to-one propensity score matching (PSM) analysis was used to compare the long-term outcomes of AR to those of NAR.ResultsA total of 105 patients were analyzed, of whom 48 (45.7%) and 57 (54.3%) underwent AR and NAR, respectively. There were no significant differences in short-term outcomes between the two groups, including duration of postoperative hospital stay, the incidence of perioperative complications, and incidence of 30-day mortality. However, both, the 5-year overall survival (OS) and recurrence-free survival (RFS) rates of AR were significantly better than those of NAR (40.5% vs. 22.4%, P=0.002; and 37.3% vs. 14.4%, P=0.002, respectively). Multivariate analysis showed that NAR, multiple tumors, larger-sized tumors (>5 cm), cirrhosis, lymph node metastasis, and vascular invasion were independent risk factors for poor prognoses. Stratified analysis demonstrated similar outcomes following AR versus NAR for patients with tumors > 5cm in diameter, while AR had better survival than NAR in patients with tumors ≤5 cm in diameter. After PSM, when 34 patients from each group were matched, the 5-year OS and RFS rates of AR were still better than those of NAR.ConclusionPatients with cHCC-CCA who underwent AR had better long-term surgical outcomes than those who underwent NAR, especially for those with tumors ≤5 cm in diameter. However, no differences in the risk of surgical complications were detected between the two groups.

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection.

IntroductionAlthough there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method.MethodsWe present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique.ResultsSix of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality.ConclusionsThe SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.

Primary hepatic neuroendocrine tumor with sarcoid like granulomas: A case report

Primary hepatic neuroendocrine tumor (PHNET) is a rare entity comprising 0.3% of all neuroendocrine tumors. Tumors coexisting with granulomas are occasionally noted with malignancies in the lymph nodes draining the tumor or within the primary tumor itself. Tumor-related sarcoid reactions are noted only in carcinomas and its association with a NET has been extremely rare.: We report a case of PHNET in a 63-year male who presented with various comorbidities who was incidentally detected with a liver space-occupying lesion (SOL). Contrast enhanced CT scan of the abdomen revealed a well-defined exophytic mass in the liver involving segment 6. Subsequently, 68Ga DOTANOC PET/CT scanning revealed somatostatin receptor-expressing well-defined lesion measuring 5.1 x 5.0 cm in segment 6 (SUV MAX 19). A diagnosis of either a primary or a metastatic neuroendocrine tumor was made and non-anatomical wedge resection of the tumor was done with a detailed exploration of the abdominal cavity to look for a primary focus that did not reveal any other lesion or mass. Histologically, the tumor was confirmed to be a Neuroendocrine Tumor along with the presence of tumor-related sarcoid like granulomas in the adjoining hepatic parenchyma.: Diagnosis of a PHNET requires a combination of a negative abdominal survey at the time of the operative procedure, pathologic evaluation of specimen, and a negative imaging workup for extrahepatic NET in both the pre and postoperative settings.

Impact of anatomical liver resection on patient survival in KRAS-wild-type colorectal liver metastasis: A multicenter retrospective study

BackgroundLiver resection is a standard therapy for colorectal liver metastasis. However, the impact of anatomical resection and nonanatomical resection on the survival in patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated colorectal liver metastasis remain unclear. We investigated whether anatomical resection versus nonanatomical resection improves survival in colorectal liver metastasis stratified by Kirsten rat sarcoma mutational status. MethodsAmong 639 consecutive patients with colorectal liver metastasis who underwent primary liver resection between January 2008 and December 2017, 349 patients were excluded due to their unknown Kirsten rat sarcoma mutational status, or due to receiving anatomical resection with concomitant non-anatomical resection, radiofrequency, or R2 resection. Accordingly, 290 patients with colorectal liver metastasis were retrospectively assessed. The relationships between resection types and survival were investigated in Kirsten rat sarcoma-wild-type and -mutated groups. ResultsAnatomical resection was performed in 77/186 (41%) and 44/104 (42%) patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated genetic statuses, respectively. For both, the clinical-pathologic factors were comparable, except a larger maximum tumor size and surgical margin were observed in anatomical resection cases. Anatomical resection patients had significantly longer recurrence-free survival and overall survival than nonanatomical resection cases in the Kirsten rat sarcoma-wild-type group (recurrence-free survival, P < .001; overall survival, P = .005). No significant recurrence-free survival or overall survival differences were observed between Kirsten rat sarcoma-mutated anatomical resection and non-anatomical resection (recurrence-free survival, P = .132; overall survival, P = .563). Although, intrahepatic recurrence in Kirsten rat sarcoma-wild-type and -mutated colorectal liver metastasis was comparable (P = .973), extrahepatic recurrence was increased in Kirsten rat sarcoma-mutated versus -wild-type colorectal liver metastasis (P < .001). ConclusionIn contrast to Kirsten rat sarcoma-mutated colorectal liver metastasis with higher extrahepatic recurrence after liver resection, local liver control via anatomical resection improved the postoperative survival in patients with Kirsten rat sarcoma-wild-type colorectal liver metastasis.

Indocyanine green fluorescence-guided laparoscopic hepatectomy versus conventional laparoscopic hepatectomy for hepatocellular carcinoma: A single-center propensity score matching study.

BackgroundIndocyanine green fluorescence-guided laparoscopic hepatectomy (ICG-guided LH) is increasingly used for the treatment of hepatocellular carcinoma (HCC). However, whether ICG-guided LH can improve surgical outcomes remains unclear. This study aimed to investigate the short-term outcomes and survival outcomes of ICG-guided LH versus common laparoscopic hepatectomy (CLH) for HCC.MethodsWe conducted a retrospective analysis of 104 ICG-guided LH and 158 CLH patients from 2014 to 2020 at our center. To avoid selection bias, 81 ICG-guided LH and 81 CLH cases were analyzed after 1:1 propensity score matching (PSM). The baseline data and results were compared between the two groups.ResultsThe baseline characteristics of both groups were comparable after matching. There was a significant difference in operative time: longer in the ICG-guided LH group than in the CLH group (p=0.004). However, there was no significant difference in operative time in anatomical resection between the two groups (p=0.987). There was a significant difference in operative time in non-anatomical resection: longer in the ICG-guided LH group than in the CLH group (p=0.001). There were no significant differences in positive surgery margin, blood loss, blood transfusion rate, postoperative complication rate, postoperative length of hospital stay, mortality within 30 days, and mortality within 90 days. The ICG-guided LH group appeared to have a trend towards better overall survival (OS), but there was no significant difference in OS (P=0.168) and recurrence-free survival (RFS) (P=0.322) between the two groups.ConclusionsAlthough ICG fluorescence-guided LH is a timelier procedure to perform, it is a safe and effective technique with the advantages of intraoperative positioning, low postoperative complication rates, and potential to improve OS.

Initial experience with robotic liver resection: Audit of 120 consecutive cases at a single center and comparison with open and laparoscopic approaches.

Surgical outcomes and utility of robotic liver resection (RLR) are undefined. We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n=58) and anatomic (AR, n=62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n=103) were compared to those of open (OLR, n=495) or laparoscopic (LLR, n=451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR. Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR. RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.

Non-Intubated Thoracic Surgery: Standpoints and Perspectives.

Non-intubated video-assisted thoracic surgery (NI-VATS) combines the advantages of a non-intubated surgery with the benefits of a minimally invasive approach. First, NI-VATS is performed in the case of fragile patients when general anesthesia and/or orotracheal intubation can be foreseen as inconvenient. However, NI-VATS indications have been increasingly extended to different patient conditions, considering the increasingly assessed safety and feasibility of the procedure. Currently, the NI-VATS approach is used worldwide for different thoracic surgery procedures, including the management of malignant pleural effusion, surgical treatment of empyema, anatomical and non-anatomical lung resection, and other indications. In fact, this approach has shown to be less impactful than VATS under general anesthesia, allowing for shortened hospitalization and faster recovery after surgery. Besides, NI-VATS is associated with fewer pulmonary complications, less respiratory distress, and a mild systemic inflammatory reaction. For these reasons, this approach should be considered not only in patients with poor cardiac or respiratory function (general functional reserve), but also in other eligible conditions.We explored the anesthetic and surgical aspects of such an approach, including the management of analgesia, cough reflex, depth of sedation, and intraoperative technical issues to put this approach in perspective.

Impact of the extent of lung resection on postoperative outcomes of pulmonary metastasectomy for colorectal cancer metastases: an exploratory systematic review.

BackgroundPulmonary metastasectomy (PM) with curative intent has become a widely accepted treatment for lung metastases from solid tumours in selected patients, with low perioperative morbidity and mortality. In particular, PM is strongly recommended in selected patients with secondary lesions from colorectal cancer (CRC), due to its excellent postoperative prognosis. Nevertheless, the impact of the extent of PM on recurrence and survival remains controversial. This review aimed at assessing differences in short- and long-term postoperative outcomes depending on the extent of lung resection for lung metastases.MethodsA systematic literature review of studies comparing anatomical and non-anatomical resections of lung metastases was performed (Prospective Register of Systematic Reviews Registration: 254931). A literature search for articles published in English between the date of database inception and January 31, 2021 was performed in EMBASE (via Ovid), MEDLINE (via PubMed) and Cochrane CENTRAL. Retrospective studies, randomised and non-randomised controlled trials were included. The Cochrane Collaboration tool was used to determine the risk of bias for the primary outcome for included studies.ResultsOut of 432 papers, three retrospective non-randomised studies (1,342 patients) were selected for systematic reviewing. Although our search design did not exclude any primary tumour histology, all selected studies investigated surgical resection of lung metastases from CRC. Because of variations in the compared surgical approaches to pulmonary metastases, a meta-analysis proved unfeasible. There was a tendency to perform anatomical resections for larger metastases. Multivariate analyses revealed that anatomical resections were protective for recurrence-free survival (RFS), while the impact of such procedures on overall survival (OS) remained uncertain. A significantly higher incidence of resection-margin recurrences was observed in patients who underwent non-anatomical resections.DiscussionAnatomical resections of lung metastases from CRC seem to be associated with improved RFS. However, well-constructed comparative clinical trials focusing on the extent of PM are needed.

Navigated, gap-balanced, adjusted mechanical alignment achieves alignment and balancing goals in a very high percentage but with partially non-anatomical resections.

Navigated, gap-balanced adjusted mechanical alignment (AMA) including a 0° varus tibial cut and modification of angles and resections of the femoral cuts to obtain optimal balance accepting minor axis deviations. Objectives of this study were (1) to analyse to what extent AMA achieves the goals for leg alignment and gap balance, and (2) in what percentage non-anatomical cuts are needed to achieve these goals. Out of 1000 total knee arthroplasties (TKA) all varus knees (hip-knee-ankle (HKA) angle < 178°; n = 680) were included. All surgeries were performed as computer assisted surgery (CAS) in AMA technique. CAS data at the end of surgery were analysed with respect to HKA and gap-sizes. All bone cuts were quantified. Depending on the amount of deformity, a subgroup analysis was performed. It was analysed whether the amount of deformity influences the non-anatomical cuts by correlation analysis. AMA reached the goals for postoperative HKA (3° corridor) in 636 cases (93.5%). While extension and flexion gap balance were achieved in more than 653 cases (96%), flexion and extension gap size were equalled in 615 knees (90.4%). The resections of the lateral tibia plateau and distal and posterior medial femoral condyle were anatomical (Tibia: 7.0 ± 1.7mm; medial condyle distal: 7.8 ± 1.4mm; medial posterior: 8.2 ± 1.8mm). The number of non-anatomical resections for those cuts were low; 67 (9.9%); 24 (3.5%); 32 (4.7%). For the medial tibia plateau and the lateral posterior condyle, the cuts were non-anatomical in a high percentage of cases; Tibia: 606 (89.1%), lateral posterior condyle: 398 (58.5%). Moderate but significant correlations were found between resection differences and amount of deformity (medio-lateral: tibia: 0.399; distal femur: 0.310; posterior femur: 0.167). No correlations were found between resection differences and gap values. AMA reaches the intended target for HKA and gap balance in over 612 (90%) of cases and maintains the medial femoral condyle anatomically. Non-anatomical tibial resection causes increased external rotation of the femoral component and by that non-anatomical cut of the posterior lateral condyle. Nonanatomical resections of AMA might be one reason for the persisting high rate of unsatisfied patients after TKA. Anatomical and individual alignment philosophies might help to reduce this rate of dissatisfaction.

Pure laparoscopic versus open left lateral sectionectomy for hepatocellular carcinoma: A propensity score matching analysis.

Backgrounds/AimsAnatomical resection has superior oncologic outcomes over non-anatomical resection in hepatocellular carcinoma, and left lateral sectionectomy is the simplest and easiest perform anatomical resection procedure among liver resections. The purpose of this study was to find out the safety and feasibility of pure laparoscopic left lateral sectionectomy (PLLLS) for hepatocellular carcinoma.MethodsPatients who underwent left lateral sectionectomy at a tertiary referral hospital, from August 2007 to April 2019 were enrolled in this retrospective study. After matching the 1 : 3 propensity score, 17 open and 51 pure laparoscopic cases were selected out of 102 cases of total left lateral resection for hepatocellular carcinoma. The group was analyzed in terms of patient demographics, preoperative data, and postoperative outcomes.ResultsDuring the study period, there was no open conversion case. The mean operative time and complication were not statistically significant different between the two groups. There was no statistically significant difference in disease-free survival and overall survival had no statistical between the two groups. There were no mortality cases, and postoperative hospital stay was significantly shorter in the PLLLS group than in the open left lateral sectionectomy (OLLS) group.ConclusionsThe oncologic outcomes and complication rate were the same in the PLLLS and OLLS groups. However, the hospital stay was shorter in the PLLLS group than in the OLLS group. The present study findings demonstrate that the PLLLS is a safe and feasible procedure for hepatocellular carcinoma.