Precision Liver Surgery Research Articles

Ex-vivo Liver Resection and Autotransplantation for Liver Malignancy: A Large Volume Retrospective Clinical Study.

To assess the effectiveness of optimized ex-vivo liver resection and autotransplantation (ELRA) for treating liver malignancies. ELRA is a promising surgery for radical resection of conventionally unresectable tumors, despite the disappointing long-term prognosis during its' developmental stages. A recent multicenter study reported 5-year overall and disease-free survival rates (OS, DFS) of 28% and 20.8%, respectively. We retrospectively analyzed data of patients who underwent ELRA for advanced liver cancers between 2009 and 2022. We applied ELRA via our novel surgical indication classification system where the surgical risk with curative intent for advanced liver malignancy was controllable using the ex-vivo approach. The ELRA was optimized for determinacy, predictability, and controllability via the precision liver surgery paradigm (PLS). Thirty-seven cases with liver malignancies were enrolled. The operative time and anhepatic phase duration were 649.6±200.0 and 261.2±74.5 min, respectively, while the intraoperative blood loss was 1902±1192mL. Negative resection margins were achieved in all patients, and the 90-day morbidity at Clavien-Dindo IIIa/IIIb and mortality rates were 27.0% and 24.3%. Post-ELRA 1-, 3-, and 5-year actual OS rates were 62.2%, 37.8%, and 35.1%, respectively, and 1-, 3-, and 5-year actual DFS were 43.2%, 24.3%, and 18.9%, respectively. Long-term outcomes of ELRA under the PLS for advanced liver malignancy were favorable. Appropriate criteria for disease selection & surgical indications and optimized procedures together can improve surgical treatment and patient prognosis.

The evolution of anatomical hepatectomy: Past, present, and future

The liver contains a complex structure of blood vessels and bile ducts, and the vascular structure is highly variable. The anatomical segmentation of the liver is still controversial, and the Couinaud segmentation method based on the portal vein is more widely used in clinical practice. The treatment of liver tumors and other lesions is closely related to the liver anatomy. The mechanism of liver tumor invasion and metastasis is complex, and it is currently believed that tumor invasion mainly spreads along the portal vein. Anatomic liver resection is an important surgical method for liver diseases, especially liver tumors. This article reviews the vascular structure of the liver, the development of anatomical hepatectomy, blood flow control, surgical planning, intraoperative navigation, minimally invasive surgery, and precise hepatectomy. Anatomic liver resection is a part of precision liver surgery, which is becoming increasingly more precise in terms of surgical evaluation, surgical planning, and surgical operation. New technologies will facilitate precision surgery with less trauma and greater benefits for patients. With the development and advancement of technology, image-based surgical planning and intraoperative surgical navigation will become more widely used in precision liver surgery.

Research frontiers in precision therapy for liver cancer

Hepatocellular carcinoma (HCC), a fatal malignancy, is highly prevalent in China. Recently, tremendous achievements have been made in HCC, both in the clinical management and the understanding of cancer biology. The discovery and application of novel serum biomarkers, such as proteins, miRNAs, and cfDNA (cell-free circulating DNA) methylation will facilitate the early management of HCC. Improvements in radiological and computational technology have made the practice of precision liver surgery a true reality. The emergence of novel molecular targeted therapies, immunotherapy and their combinations has significantly prolonged patient survival rate, but the therapeutic breakthroughs are still needed. Integrated multi-omics analysis has broadened our understanding of HCC pathogenesis, providing an unprecedented molecular characterization of HCC and revealing new therapeutic opportunities. Technological innovations and revolutions such as single-cell sequencing, genome editing, and innovative drug research and development will greatly accelerate our understanding of HCC biology and bring new therapeutic opportunities. Nevertheless, HCC is a highly heterogeneous and treatment-refractory malignancy, therefore deep insights into the biology of the disease and novel therapies for HCC remain an unmet medical need.

Research progression and application of Laennec capsule in liver

The Laennec capsule of liver was first discovered and reported by French doctor Rene Theophile Hyacinthe Laennec in 1802.However, it has not received enough attention for more than 200 years since then. In recent years, with the rapid development of liver surgery represented by laparoscopic technology, and the deepening of the theory of precise liver surgery, the fine anatomical structure of liver Laennec capsule has returned to the vision of liver surgeons.Recent studies have demonstrated the presence of Laennec capsule in liver histology, covering the whole liver surface, and lining the surface of liver parenchyma around the Glisson pedicle and the main hepatic vein along the inflow and outflow channels of the liver. Based on the Laennec capsule approach, it is expected to unify the current approach of Glisson pedicle and the approach of hepatic vein, and provide a new theoretical basis for the liver surgery, and guide us in the standardization of liver surgeries.

Research advances in molecular classification for precision diagnosis and treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), a highly prevalent malignancy and one of the leading cause of cancer death in China, remains a major public health problem in the next decades. Owing to the tremendous achievements in early diagnosis, precision liver surgery, molecular targeted therapy and immunotherapy, we have witnessed significant improvements in the long-time survival of HCC patients, if properly treated. However, HCC is a highly heterogeneous disease. Even for patients within the same clinical stage, their clinical outcome and treatment efficacy vary significantly. Great efforts to improve the molecular classification of HCC patients are needed to foster precision medicine, paving the way for novel therapeutic strategies. Advances in multi-omics, single-cell analysis, molecular imaging and artificial intelligence will lead to better understanding of the molecular classification and refine precision treatment in HCC, ultimately excluding this neoplasm from the risk list of our Healthy China. Key words: Hepatic neoplasms; Molecular classification; Diagnosis; Treatment

Precise hepatectomy in the intelligent digital era.

In the past 20 years, the concept of surgery has undergone profound changes. Surgical practice has shifted from emphasizing the complete elimination of lesions to achieving optimal rehabilitation in patients. Collaborative optimization of surgery consists of three core elements, removal of lesions, organ protection and injury close monitoring, and controlled surgical intervention. As a result, the traditional surgical paradigm has quietly transformed into a modern precision surgical paradigm. In this review, we summarized the latest breakthroughs and applications of precision medicine in liver surgery. In addition, we also outlined the progresses that have been made in precision liver surgery, the opportunities and challenges that may encountered in the future.

Progress in precise treatment of liver surgery

After more than a hundred years of development, hepatic surgery has gradually developed from a traditional rough model to a precise model in the 21st century. The era of precision liver surgery, and even precision medicine has come. Under the guidance of precise concept, the therapeutic effect of all liver diseases, especially liver malignant tumors, has been significantly improved, and the quality of life of patients has been significantly improved. Precise hepatectomy, precise radiofrequency ablation and precise transcatheter arterial chemoembolization are the three magic weapons of precise treatment in liver surgery. The precise concept will be the future development direction of medicine. This article reviews the research progress of precise treatment in liver surgery in order to further promote the concept of precise treatment in liver surgery. Key words: Hepatectomy; Liver diseases; Precise radiofrequency ablation; Precisetreatment

Research of preoperative biliary drainage of malignant obstructive jaundice

The optimal management of malignant obstructive jaundice has been the subject of much debate among hepatobiliary surgeons. However, there is currently no universal agreement in the clinical role for preoperative biliary drainage to relief the jaundice. In this current era where precision liver surgery is widely pursued, it is necessary to define the role of preoperative drainage according to the different anatomical levels of biliary obstruction so as to achieve the best outcomes and eventual prognosis. Key words: Jaundice, obstructive; Drainage; Precision liver surgery

Application values of computer-assisted preoperative planning of hilar cholangiocarcinoma

To explore the application value of computer-assisted preoperative planning of hilar cholangiocarcinoma. Retrospective analyses were conducted for the clinical data of 47 patients with hilar cholangiocarcinoma undergoing radical resection plus hemihepatectomy from January to December 2013. According to whether computer-assisted preoperative planning was used, they were divided two groups of computer-assisted surgical planning (CASP) and without computer-assisted surgical planning (WCASP). Then we analyzed the data including preoperative examinations, preoperative planning, intraoperative findings and postoperative complications. There were 31 cases of hilar vascular invasion by tumor. Among 29 cases of CASP, left hepatic artery originated from left gastric artery (n = 6), right posterior bile duct drained into left hepatic bile duct (n = 1) and right posterior bile duct run into common hepatic bile duct (n = 2). The mean operative duration of CASP was (6.5 ± 1.3) h and the mean volume of intraoperative bleeding (672.0 ± 214.3) ml; while the mean operative duration of WCASP was (7.9 ± 2.9) h and the mean volume of intraoperative bleeding (870.0 ± 330.1) ml. By statistical analysis, the inter-group differences of mean operative duration had statistical difference (P = 0.028) and the inter-group differences of mean volume of intraoperative bleeding had statistical difference (P = 0.016). The ratio of first negative test in group CASP was higher than that of group WCASP and the inter-group differences had statistical significance (P = 0.043). But the inter-group rate of postoperative complications had no significant difference (P = 0.419). The computer-assisted surgical planning system provides accurate information so that an optimal surgical protocol may be designed by surgeons. And it has great application values in preoperative surgical planning for hilar cholangiocarcinoma and enjoys wide prospects in precise liver surgery.

Research advances on the evaluation of regional liver function based on the demand of precise liver surgery

Surgical resection is the best treatment for hepatocarcinoma. With the rapid development and cooperation of multi-disciplines, the liver surgery gradually towards a precise stage, and accurate evaluation of regional liver function preoperatively is demand for the development of precise liver surgery. Methods to assess function of liver at present include serological liver function and biochemical examination, clinical liver function scoring system, quantitative liver function test and imaging examination. Nuclide imaging technology and liver specificity enhanced MRI contrast agent are expected to achieve to evaluate regional liver function.

Application of enhanced recovery after surgery in the precision liver surgery

The application of enhanced recovery after surgery (ERAS) in hepatectomy is safe and feasible. The related researches of the clinical strategies of ERAS involved in colonic surgery instead of management of basic diseases of liver, and the influence of portal hypertension and hepatitis B virus infection on the ERAS has not been emphasized. According to the clinical strategies of ERAS in colon surgery, the basic diseases and the characteristics of liver were focused, and the clinical strategies of ERAS in the era of precision liver surgery were proposed. Through concerted efforts of the multidisciplinary team and a joint of surgeons, nurses and patients, the establishment of multicentre clinical studies under guidance of evidence-based medicine(EBM) will show clearly a development direction of the clinical strategies of ERAS in the era of precision liver surgery. Key words: Precision liver surgery; Enhanced recovery after surgery; Perioperative period

Clinical value of precision liver surgery concept in the treatment of primary liver cancer

Objective To investigate the clinical value of precision liver surgery concept in the treatment of primary liver cancer.Methods The clinical data of 141 patients with primary liver cancer who were admitted to the No.81 Hospital of PLA from January 2009 to October 2011 were retrospectively analyzed.The three-dimensional reconstruction,preoperative evaluation and virtual surgery were done based on the data of imaging examination.Hepatic functional reserve evaluation was done based on the condition of patients.The blood flow was occluded in selected patients according to the results of ultrasonography,and the tumor was anatomically resected.Patients were followed up via phone call or out-patient examination till January 2014.The survival rate was calculated by Kaplan-Meier method.Results Three-dimensional reconstruction was done in 77 patients preoperatively.Thirty-nine patients received ICG R15 test to detect the liver functional reserve and 95 received intraoperative color Doppler uhrasonography.The operation was successfully done on 141 patients.Four patients underwent total inflow occlusion,48 underwent partial inflow occlusion in the hepatic pedicle by Pringle maneuver.Eighty-nine patients did not receive inflow occlusion.The proportion of patients who received anatomical hepatectomy was 85.11％ (120/141).The operation time,volume of intraoperative blood loss,number of patients who received blood transfusion,volume of peritoneal drainage at postoperative day 0 were (188 ± 56) minutes,(230 ± 100) mL,12 and (147 ± 58)mL,respectively.The peak levels of postoperative alanine transaminase,aspartate transaminasc and total bilirubin were (219 ± 121) U/L,(214 ± 104) U/L and (32 ± 14) μmol/L,respectively.Eight patients were complicated with thoracic effusion,subphrenic infection,peritoneal effusion and bile leakage,and 5 patients were complicated with pulmonary infection and incisional infection,with the complication rate of 9.22％ (13/141) after the operation.All the patients were cured after symptomatic treatment,without occurrence of hepatic failure or perioperative death.The duration of postoperative hospital stay was (11.0 ± 2.6) days.There were 130 patients with hepatocellular carcinoma and 11 patients with cholangiocarcinoma.The mean diameter of tumors resected was (5.8 ± 1.7) cm,and the resection margin of 1 patient was positive.One hundred and thirty eight patients were followed up for (40 ± 10) months,and the 1-,2-,3-year survival rates were 91.5％,75.9％and 65.2％,and the survival time was (43 ± 5) months.Conclusion Precision liver surgery has advantages of few postoperative complications and better short-and long-term efficacy. Key words: Liver neoplasms; Precision liver surgery

Construction of painless ward in the era of precision liver surgery

The progress of liver surgery is characterized by precision,minimal invasion and effectiveness in the 21 st century.Establishment of painless liver surgery ward and implementation of pain management in the perioperative period are not only the central content of enhanced recovery after surgery,but also one of the core connotation in precision liver surgery research.Conducting training programs for medical staffs,emphasizing health education of pain,selecting the reasonable pain assessment strategy,combination of preemptive analgesia and multimodal analgesia in the perioperative period and paying attention to individualized analgesia are important contents of construction of painless liver surgery ward.To carry out multicentre clinical study energetically,explore clinical pathway for the construction of painless ward and perioperative analgesic model are the development orientation for the construction of painless liver surgery ward. Key words: Precision liver surgery; Painless ward

Precision liver surgery

Continnous theoretical and technological progress in the face of increasing expectations for quality of health care and progress in medical technology has transformed the surgical paradigm.Based on the historical trends and technique advances,a novel paradigm of Precision Surgery has been proposed,which is featuring certainty-based practice to ensure the best results for each patient with multi-objective optimization of therapeutic effectiveness,surgical safety and minimal invasiveness.The main characteristics of precision surgery may be summarized as determinacy,predictability,controllability,integration,standardization and individualization.The strategy of precision hepatic surgery is to seek a balance of maximizing the removal of the target lesions,while maximizing the functional remnant liver and minimizing surgical invasiveness.The concept of precision surgery should be considered for wider application in liver surgery and other fields as a step toward the ultimate goal of perfect surgery. Key words: Precision liver surgery; Certainty; Multi-objective optimization

Practice and experiences in precision hepatectomy

With the wide application of liver transplantation techniques,rapid development of digital imaging medicine and continuous update of surgical implements,the theory of precision hepatectomy still keeps optimizing.Precision hepatectomy is not a surgical implement or surgical technique,but a concept of liver surgery emphasizing less bleeding,minimal invasion,fast recovery and long-term curative effect,which is updating and improving with the development of modern science.Much less intraoperative bleeding,shorter operation time,better postoperative recovery and long-term survival should be the chief pursuit and principle of precision hepatectomy. Key words: Precision liver surgery; Hepatectomy; Surgical concept

Effects of concept and techniques of precision liver surgery on the perioperative safety of patients undergoing major hepatectomy

Objective To evaluate the effects of concept and techniques of precision hepatic surgery on the perioperative safety of patients who received major hepatectomy.Methods The clinical data of 1250 patients with hepatic diseases who received major hepatectomy at the Chinese PLA General Hospital from January 1986 to January 2012 were retrospectively analyzed.All the patients were divided into 2 groups,459 patients who were admitted from January 1986 to December 2006 were in the traditional surgery group,and 791 patients who were admitted from January 2007 to January 2012 were in the precision surgery group.The perioperative conditions of the patients in the 2 groups were compared,and the risk factors of morbidity and mortality were analyzed.The patients were followed up via out-patient examination,mail or telephone till December 2012.The measurement data,non-normal data and count data were analyzed using independent sample t test,non-parametric MannWhitney U test and chi-square test,respectively.The univariate and multivariate analysis were done using the chisquare test and bivariate Logistic regression analysis,respectively.The survival rates were calculated by using the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The ratios of anatomical hepatectomy and unanatomical hepatectomy were 62.31％ (286/459) and 37.69％ (173/459) in the traditional surgery group,and 85.59％ (677/791) and 14.41％ (114/791) in the precision surgery group,with significant difference between the 2 groups (x2 =88.98,88.98,P ＜ 0.05).The ratios of right hemihepatectomy,left hemihepatectomy and extended left hemihepatectomy were 18.52％ (85/459),29.85％ (137/459) and 3.05％ (14/459)in the traditional surgery group,which were significantly lower than 28.45 ％ (225/791),37.67 ％ (298/791) and 6.32％ (50/791) in the precision surgery group (x2=15.35,7.84,6.40,P ＜ 0.05).The ratios of hepatic inflow occlusion with Pringle maneuver and selective inflow occlusion were 66.01％ (303/459) and 12.42％ (57/459)in the traditional surgery group,27.18％ (215/791) and 31.73％ (251/791) in the precision surgery group,with significant difference between the 2 groups (x2=180.49,58.35,P ＜ 0.05).The operation time,median volume of intraoperative blood loss,ratio of intraoperative blood transfusion,duration of postoperative hospital stay,morbidity and mortality were (291 ± 124)minutes,750 ml,62.75％ (288/459),(18± 14)days,26.36％ (121/459)and 3.49％ (16/459) in the traditional surgery group,and (337 ± 142) minutes,550 ml,35.40％ (280/791),(14±9) days,20.73％ (164/791) and 1.52％ (12/791) in the precision surgery group,with significant difference between the 2 groups (t =-5.74,Z =-2.01,x2 =87.62,t =5.90,x2 =5.23,5.14,P ＜ 0.05).The results of univariate analysis showed that age ＞ 60 years,hepatic cirrhosis,hepatic inflow occlusion,operation time ＞360 minutes,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,vessel reconstruction,preoperative total bilirubin ＞ 17.1 μmol/L,preoperative albumin ＜35 g/L were correlated with the morbidity (x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P ＜ 0.05) ; hepatic cirrhosis,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 × 109/L were correlated with the mortality (x2=4.21,22.31,12.68,32.25,P ＜ 0.05).The results of multivariate analysis showed that volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,hepatic inflow occlusion and preoperative albumin ＜ 35 g/L were the independent risk factors of morbidity (odds ratio =2.642,2.515,1.637,1.796,P ＜ 0.05) ; volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 x 109/L were the independent risk factors of mortality (odds ratio =1.325,1.682,3.742,P ＜ 0.05).A total of 345 patients in the traditional surgery group and 651 patients in the precision surgery group were followed up for 11-96 months.The 1-,3-,5-year survival rates of patients with primary liver cancer in the traditional surgery group were 83.5％,51.6％,42.0％,and the 1-,3-year survival rates of patients with primary liver cancer of the precision surgery group were 85.4％ and 63.8％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.96,P ＜ 0.05).The 1-,3-,5-year survival rates of patients with hilar cholangiocarcinoma of the traditional surgery group were 63.1％,31.4％ and 26.7％,and the 1-,3-year survival rates of patients with hilar cholangiocarcinoma of the precision surgery group were 71.3％ and 48.1％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.95,P ＜ 0.05).Conclusion Application of the concept and techniques of precision hepatic surgery significantly decreases the perioperative morbidity and mortality,increase the safety and improves the long-term efficacy of treatment. Key words: Liver diseases; precision liver surgery; Hepatectomy; Complication; Mortality

Modern concept and clinical practice of precise liver surgery

The principles of “precise liver surgery”include to absolutely clearing target lesions,ensuring structural integrity of residual liver,maximizing the volume of remnant liver,controlling bleed as well as minimizing hepatic parenchymal damage and surgical invasiveness.This theory serves the whole procedure of liver surgery for the optimal recovery of patients.The major strategies consist of accurate preoperative evaluation:rigorous surgical planning,refined surgical operation and meticulous perioperative care.The construction of “recise liver surgery” system requires the combination of modern technology and traditional surgery,and the breakthrough in the core theory and key techniques of liver surgery. Key words: Precise surgery; Surgical planning; Surgical procedures, operative

Treatment of primary liver cancer by precise liver surgery: an analysis of 53 cases

Treatment of primary liver cancer by precise liver surgery: an analysis of 53 cases