Hepatocellular carcinoma(HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC(e.g., imaging studies and liver function test...Hepatocellular carcinoma(HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC(e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection(AR) was introduced in the 1980 s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.展开更多
Hepatocellular carcinoma(HCC)is the most frequent primary tumor of the liver and the sixth most common cancer worldwide with more than 800,000 cases per year(1).Potentially curative treatments such as liver transplant...Hepatocellular carcinoma(HCC)is the most frequent primary tumor of the liver and the sixth most common cancer worldwide with more than 800,000 cases per year(1).Potentially curative treatments such as liver transplantation(LT),liver resection(LR),and ablation(in selected cases)currently represent the best available options to offer long-term survival to patients(2).Given the worldwide scarcity of organs for transplantation,hepatic resection(open or minimally invasive),is frequently considered as the first option upon presentation.One of the most intriguing and longstanding debated issues among the hepatobiliary surgical community is the type of surgical resection that should be performed.Should we systematically pursue an anatomical resection(AR)or non-anatomical resection(NAR)for HCC?展开更多
BACKGROUND The long-term survival of patients with solitary hepatocellular carcinoma(HCC)following anatomical resection(AR)vs non-anatomical resection(NAR)is still controversial.It is necessary to investigate which ap...BACKGROUND The long-term survival of patients with solitary hepatocellular carcinoma(HCC)following anatomical resection(AR)vs non-anatomical resection(NAR)is still controversial.It is necessary to investigate which approach is better for patients with solitary HCC.AIM To compare perioperative and long-term survival outcomes of AR and NAR for solitary HCC.METHODS We performed a comprehensive literature search of PubMed,Medline(Ovid),Embase(Ovid),and Cochrane Library.Participants of any age and sex,who underwent liver resection,were considered following the following criteria:(1)Studies reporting AR vs NAR liver resection;(2)Studies focused on primary HCC with a solitary tumor;(3)Studies reporting the long-term survival outcomes(>5 years);and(4)Studies including patients without history of preoperative treatment.The main results were overall survival(OS)and disease-free survival(DFS).Perioperative outcomes were also compared.RESULTS A total of 14 studies,published between 2001 and 2020,were included in our meta-analysis,including 9444 patients who were mainly from China,Japan,and Korea.AR was performed on 4260(44.8%)patients.The synthetic results showed that the 5-year OS[odds ratio(OR):1.19;P<0.001]and DFS(OR:1.26;P<0.001)were significantly better in the AR group than in the NAR group.AR was associated with longer operating time[mean difference(MD):47.08;P<0.001],more blood loss(MD:169.29;P=0.001),and wider surgical margin(MD=1.35;P=0.04)compared to NAR.There was no obvious difference in blood transfusion ratio(OR:1.16;P=0.65)or postoperative complications(OR:1.24,P=0.18).CONCLUSION AR is superior to NAR in terms of long-term outcomes.Thus,AR can be recommended as a reasonable surgical option in patients with solitary HCC.展开更多
AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.
BACKGROUND Laparoscopic hepatectomy is a proven safe and technically feasible approach for liver tumor resection,but laparoscopic anatomical SVIII resection(LASVIIIR)remains rarely reported due to poor accessibility,d...BACKGROUND Laparoscopic hepatectomy is a proven safe and technically feasible approach for liver tumor resection,but laparoscopic anatomical SVIII resection(LASVIIIR)remains rarely reported due to poor accessibility,difficult exposure,and the deep-lying Glissonean pedicle.This study examined the safety,feasibility,and perio-perative outcomes of LASVIIIR via a middle hepatic fissure approach at our in-stitution.AIM To investigate the safety,feasibility,and perioperative outcomes of LASVIIIR via a middle hepatic fissure approach at our institution.METHODS From November 2017 to December 2022,all patients with a liver tumor who underwent LASVIIIR were enrolled.The perioperative outcomes and postope-rative complications were evaluated.RESULTS Thirty-four patients underwent LASVIIIR via a middle hepatic fissure approach from the side or cranio side and were included.The mean operation time was 164±54 minutes,and the intra-operative blood loss was 100 mL(range:20-1000 mL).The mean operative times were,respectively,152±50 minutes and 222±29 minutes(P=0.001)for the caudal side and cranial side approaches.In addition,the median blood loss volumes were 100 mL(range:20-300 mL)and 250 mL(range:20-1000 mL),respectively,for the caudal and cranial sides(P=0.064).Three patients treated using the cranial side approach experienced bile leakage,while 1 patient treated using the caudal side approach had subphrenic collection and underwent percutaneous drainage to successfully recover.There were no differences regarding postoperative hospital stays for the caudal and cranial side approaches[9(7-26)days vs 8(8-19)days](P=0.226).CONCLUSION LASVIIIR resection remains a challenging operation,but the middle hepatic fissure approach is a reasonable and easy-to-implement technique.展开更多
Various approaches to laparoscopic anatomic liver resection have been described.In this paper,the authors present a technique that utilizes the ventral avascular areas above the inferior vena cava.While many liver sur...Various approaches to laparoscopic anatomic liver resection have been described.In this paper,the authors present a technique that utilizes the ventral avascular areas above the inferior vena cava.While many liver surgeons partially adopt this elements of this method,few employ it to the full extent outlined here.Main-taining low central venous pressure during anesthesia is critical to this approach,as demonstrated by the operative images showing collapsed hepatic veins.This technique is particularly advantageous when the patient’s body mass index is low,the tumor is small(or large but deeply embedded within the liver parenchy-ma),and the overlying liver tissue is not excessively bulky or heavy.Nonetheless,following the conventional course along the Glissonean pedicle can be beneficial.The authors demonstrate notable skill in completing these procedures laparosco-pically.However,concerns over margin positivity and tumor recurrence remain,and follow up studies are needed to further validate the approach.展开更多
To the Editor:Liver resection,particularly anatomical hepatectomy,has become a vital surgical approach for managing a range of liver diseases[1].Owing to its deep anatomical position,the caudate lobe is frequently imp...To the Editor:Liver resection,particularly anatomical hepatectomy,has become a vital surgical approach for managing a range of liver diseases[1].Owing to its deep anatomical position,the caudate lobe is frequently implicated in hepatobiliary diseases,necessitating precise evaluation and targeted treatment during anatomical liver resection[2,3].The caudate lobe's vascular anatomy is complex:the left portal vein branch(G1L,LPb)primarily supplies the Spiegel lobe,the bifurcation branch(G1F,HBb)feeds the paracaval region or caudate process,and the right posterior portal branch(G1C,RPb)serves the caudate process[4,5].展开更多
BACKGROUND Portal vein thrombosis(PVT)after liver resection is rare but can lead to lifethreatening liver failure.This prospective study evaluated patients using contrastenhanced computed tomography(E-CT)on the first ...BACKGROUND Portal vein thrombosis(PVT)after liver resection is rare but can lead to lifethreatening liver failure.This prospective study evaluated patients using contrastenhanced computed tomography(E-CT)on the first day after liver resection for early PVT detection and management.AIM To evaluate patients by E-CT on the first day after liver resection for early PVT detection and immediate management.METHODS Patients who underwent liver resection for primary liver cancer from January 2015 were enrolled.E-CT was performed on the first day after surgery in patients undergoing anatomical resection,multiple resections,or with postoperative bile leakage in the high-risk group for PVT.When PVT was detected,anticoagulant therapy including heparin,warfarin,and edoxaban was administered.E-CT was performed monthly until PVT resolved.RESULTS The overall incidence of PVT was 1.57%(8/508).E-CT was performed on the first day after surgery in 235 consecutive high-risk patients(165 anatomical resections,74 multiple resections,and 28 bile leakages),with a PVT incidence of 3.4%(8/235).Symptomatic PVT was not observed in the excluded cohort.Multivariate analyses revealed that sectionectomy was the only independent predictor of PVT[odds ratio(OR)=12.20;95%confidence interval(CI):2.22-115.97;P=0.003].PVT was found in the umbilical portion of 75.0%(6/8)of patients,and sectionectomy on the left side showed the highest risk of PVT(OR=14.10;95%CI:3.17-62.71;P<0.0001).CONCLUSION Sectionectomy on the left side should be chosen with caution as it showed the highest risk of PVT.E-CT followed by anticoagulant therapy was effective in managing early-phase PVT for 2 mo without adverse events.展开更多
BACKGROUND The long-term effect of anatomic resection(AR)is better than that of nonanatomic resection(NAR).At present,there is no study on microvascular invasion(MVI)and liver resection types.AIM To explore whether AR...BACKGROUND The long-term effect of anatomic resection(AR)is better than that of nonanatomic resection(NAR).At present,there is no study on microvascular invasion(MVI)and liver resection types.AIM To explore whether AR improves long-term survival in patients with hepatocellular carcinoma(HCC)by removing the peritumoral MVI.METHODS A total of 217 patients diagnosed with HCC were enrolled in the study.The surgical margin was routinely measured.According to the stratification of different tumor diameters,patients were divided into the following groups:≤2 cm group,2-5 cm group,and>5 cm group.RESULTS In the 2-5 cm diameter group,the overall survival(OS)of MVI positive patients was significantly better than that of MVI negative patients(P=0.031).For the MVI positive patients,there was a statistically significant difference between AR and NAR(P=0.027).AR leads to a wider surgical margin than NAR(2.0±2.3 cm vs 0.7±0.5 cm,P<0.001).In the groups with tumor diameters<2 cm,both AR and NAR can obtain a wide surgical margin,and the surgical margins of AR are wider than that of NAR(3.5±5.8 cm vs 1.6±0.5 cm,P=0.048).In the groups with tumor diameters>5 cm,both AR and NAR fail to obtain wide surgical margin(0.6±1.0 cm vs 0.7±0.4 cm,P=0.491).CONCLUSION For patients with a tumor diameter of 2-5 cm,AR can achieve the removal of peritumoral MVI by obtaining a wide incision margin,reduce postoperative recurrence,and improve prognosis.展开更多
Laennec's capsule is a dense fibrous membrane that has recently been confirmed to exist across the entire liver surface,Glissonean pedicles,and major hepatic veins,forming a continuous fibrous system.Minimally inv...Laennec's capsule is a dense fibrous membrane that has recently been confirmed to exist across the entire liver surface,Glissonean pedicles,and major hepatic veins,forming a continuous fibrous system.Minimally invasive anatomical liver resection based on Laennec's capsule-guided dissection leverages natural avascular planes to enable safe and efficient resection.This approach significantly reduces intraoperative bleeding,improves sur-gical precision and R0 resection rates,and contributes to better long-term survival in patients.This review discusses the anatomical concept of Laennec's capsule and its clinical application in minimally invasive anatomical liver resection.It outlines the advantages,limitations,and strategic use of various preoperative navigation techniques;analyses the indications for intrafascial/extrafascial Glissonean approaches and the technical aspects of their selection;analyses outer/inner dissection of Laennec's capsule around the hepatic veins according to the type of tumour;and proposes technical refinements based on outflow control and precision surgery.Finally,it explores the debate about the origins of Laennec's capsule and suggests directions for future bastardization and research.This review aims to provide hepatobiliary surgeons with a comprehensive reference based on recent technical advances and application strategies for Laennec's capsule-based anatomical liver resection.展开更多
To the Editor:Laparoscopic liver resection(LLR)is widely used as a standard procedure for liver malignancies and benign diseases.Consensus guidelines stated that LLR may be feasible and safe in experienced centers.Evi...To the Editor:Laparoscopic liver resection(LLR)is widely used as a standard procedure for liver malignancies and benign diseases.Consensus guidelines stated that LLR may be feasible and safe in experienced centers.Evidence has shown that LLR is less invasive and has bet-ter patient prognosis than conventional procedures[1].However,laparoscopic anatomic liver resection(LALR)such as segment 8(S8)resection is still challenging due to difficulties in segmental mapping and surgical techniques[2,3].Liver S8 is in a deep-seated area surrounded by the ribs and the diaphragm,and closely con-nected to the right and middle hepatic veins and inferior vena cava.Furthermore,the Glissonean pedicle of segment 8(G8)is lo-cated deep in the liver parenchyma,lacking anatomical landmarks,and making forceps manipulation difficult.Therefore,LALR-S8 has been described as the most challenging procedure[4].展开更多
The rationale of the performance of anatomic resection(AR)of the liver in case of hepatocellular carcinoma(HCC)is the removal of portal pedicle feeding the tumor because of the tumor’s tendency to invade the portal v...The rationale of the performance of anatomic resection(AR)of the liver in case of hepatocellular carcinoma(HCC)is the removal of portal pedicle feeding the tumor because of the tumor’s tendency to invade the portal veins(1).This technical approach is expected to be effective from an oncological perspective for a disease such as HCC,which is associated with a high rate of intrahepatic recurrence(2,3).In the eighties,Makuuchi et al.proposed the systematic subsegmentectomy(4)reporting excellent results(5),and later some other authors reported new techniques to identify the portal territory of a given HCC and perform a true AR of the liver(5-7).展开更多
AIM To establish the surgical flow for anatomic isolated caudate lobe resection. METHODS The study was approved by the ethics committee of the Second Affiliated Hospital Zhejiang University School of Medicine(SAHZU). ...AIM To establish the surgical flow for anatomic isolated caudate lobe resection. METHODS The study was approved by the ethics committee of the Second Affiliated Hospital Zhejiang University School of Medicine(SAHZU). From April 2004 to July 2014, 20 patients were enrolled who underwent anatomic isolated caudate lobectomy at SAHZU. Clinical and postoperative pathological data were analyzed. RESULTS Of the total 20 cases, 4 received isolated complete caudate lobectomy(20%) and 16 received isolated partial caudate lobectomy(80%). There were 4 caseswith the left approach(4/20, 20%), 6 cases with the right approach(6/20, 30%), 7 cases with the bilateral combined approach(7/20, 35%), 3 cases with the anterior approach(3/20, 15%), and the hanging maneuver was also combined in 2 cases. The median tumor size was 5.5 cm(2-12 cm). The median intraoperative blood loss was 600 m L(200-5700 m L). The median intra-operative blood transfusion volume was 250 m L(0-2400 m L). The median operation time was 255 min(110-510 min). The median post-operative hospital stay was 14 d(7-30 d). The 1-and 3-year survival rates for malignant tumor were 88.9% and 49.4%, respectively. CONCLUSION Caudate lobectomy was a challenging procedure. It was demonstrated that anatomic isolated caudate lobectomy can be done safely and effectively.展开更多
BACKGROUND Laparoscopic anatomical liver resection has become more challenging because some subsegmental Glissonean pedicles are hard to dissect.Here,we introduce how to dissect every(sub)segmental Glissonean pedicle ...BACKGROUND Laparoscopic anatomical liver resection has become more challenging because some subsegmental Glissonean pedicles are hard to dissect.Here,we introduce how to dissect every(sub)segmental Glissonean pedicle from the first porta hepatis and perform standardized(sub)segmentectomy[from segment 1(S1)to S8].AIM To summarize our methods of laparoscopic anatomical segmental and subseg-mental liver resection.METHODS The Glisson sheath and liver capsule were separated along the Laennec mem-brane.The Glissonean pedicle could be isolated and transected with little or no parenchymal damage through this extra-Glissonean dissection approach.The basin of the(sub)segment was determined by the ischemia demarcation line or indocyanine green staining.The hepatic vein or intersegmental vein was also used to guide the plane of parenchymal transection.RESULTS All segmental or subsegmental pedicles or even the pedicle of the cone unit could be dissected along the Laennec membrane using our novel technique through the first porta hepatis.The dorsal branches of S8,the branches of S4a and the paracaval portion branches(b/c vein)of the caudate lobe were the most difficult to dissect.CONCLUSION The novel techniques of liver segmental and subsegmental pedicle anatomy is feasible for laparoscopic liver resection and can help accurately guide(sub)segmentectomy from S1 to S8.展开更多
Anatomical resection(AR)has been reported to achieve better long-term outcomes than non-anatomical resection for the treatment of hepatocellular carcinoma(HCC).The surgical feasibility and oncological significance of ...Anatomical resection(AR)has been reported to achieve better long-term outcomes than non-anatomical resection for the treatment of hepatocellular carcinoma(HCC).The surgical feasibility and oncological significance of laparoscopic AR(LAR),especially“subsegment resection”,“cone unit resection”,and repeat LAR for HCC,remain unproven.We present a 67-year-old patient with alcoholic liver cirrhosis and HCC who underwent full LAR three times,focusing on the technical aspects of the Glissonean approach.Repeating LAR for recurrent HCC could be a safe and feasible procedure.However,HCC recurred in the neighboring segment twice,even though pathological vascular invasion and marginal remnants were not confirmed.We should investigate the oncological significance and advancements in subsegmentectomy and cone unit resection,in the future.展开更多
Background:Laparoscopic liver resection(LLR)has been considered to be safe and feasible.However,few studies focused on the comparison between the anatomic and nonanatomic LLR.Therefore,the purpose of this study was to...Background:Laparoscopic liver resection(LLR)has been considered to be safe and feasible.However,few studies focused on the comparison between the anatomic and nonanatomic LLR.Therefore,the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR,especially the area of liver parenchymal transection and blood loss per unit area.Methods:In this study,surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected.Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter.All procedures were conducted by a single surgeon.Results:During nearly 5 years,84 patients with malignant liver tumor received a pure LLR procedure were included.Among them,34 patients received anatomic LLR and 50 received nonanatomic LLR,respectively.Patients of the two groups were similar in terms of demographic features and tumor characteristics,despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group(4.77±2.57 vs.2.87±2.10 cm,P=0.001).Patients who underwent anatomic resection had longer operation time(364.09±131.22 vs.252.00±135.21 min,P〈0.001)but less blood loss per unit area(7.85±7.17 vs.14.17±10.43 ml/cm2,P=0.018).Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR.No mortality occurred during the hospital stay and 30 days alter the operation.Moreover,there was no difference in the incidence of postoperative complications.The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups.Conclusions:Both anatomic and nonanatomic pure LLR are safe and feasible.Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery'.Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.展开更多
Background:An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision.We discovered a triangular zone during the laparoscopic right liver surgery and termed this...Background:An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision.We discovered a triangular zone during the laparoscopic right liver surgery and termed this zone the APR triangle.The purpose of this study was to determine the probability of the existence of the APR triangle and elucidate its various forms.Methods:Analyzed three-dimensional image reconstructions of 66 individuals who underwent liver surgery and calculated the statistics for various types of APR triangles under various grouping settings.Results:The APR triangle was present in the majority of cases,with right hepatic vein trunk type in 68%and right hepatic vein branch type in 21%,respectively.The angle between the right anterior and right posterior hepatic pedicles(AP&PP)was at most between 45 and 90°(74%).There was a 35%chance that at least one of the AP&PP was longer than 2 cm,and a 39%chance that both were.The right posterior pedicle first branch would appear at the bifurcation of AP&PP in 13%only.Conclusions:The APR triangle is objectively present and may represent a practical zone for performing laparoscopic right hepatic anatomical resection more simply and safely.展开更多
A 73-year-old woman with liver cirrhosis caused by hepatitis C virus(HCV)underwent treatment of three hepatocellular carcinomas(HCCs)in liver segment 4,following three previous laparoscopic liver resections(LLRs)over ...A 73-year-old woman with liver cirrhosis caused by hepatitis C virus(HCV)underwent treatment of three hepatocellular carcinomas(HCCs)in liver segment 4,following three previous laparoscopic liver resections(LLRs)over 73 months.Contrast-enhanced computed tomography showed three 0.5-1.2 cm HCCs deep within the portal territories of subsegments 4a and 4b.The patient underwent laparoscopic resection of 4a and 4b,with the preservation of the portal branch to 4c,after minimal adhesiolysis around segment 4.The operation lasted 284 min,there was 50 mL of intra-operative bleeding and her recovery was uneventful.She was well,had experienced no recurrence and was HCV-negative,after taking oral anti-HCV therapy,21 months later.LLR is associated with fewer adhesions after surgery and requires less adhesiolysis,because the laparoscope and forceps can be used in the small spaces between adhesions.The present patient underwent four LLRs over 6 years without severe deterioration of liver functional reserve.LLR is a useful localized therapy,which can be performed repeatedly and may prolong the survival of patients with multicentric metachronous HCCs.展开更多
Aim:Robotic liver resection(RLR)is a new platform for minimally invasive hepatobiliary surgery.Minimally invasive surgery can confer benefits to patients with hepatocellular carcinoma(HCC),which is mostly associated w...Aim:Robotic liver resection(RLR)is a new platform for minimally invasive hepatobiliary surgery.Minimally invasive surgery can confer benefits to patients with hepatocellular carcinoma(HCC),which is mostly associated with underlying chronic liver disease.Despite the inherent functional merits of robotics for surgical techniques,the clinical advantages of hepatectomy are not well defined.Therefore,we reviewed the short-term and longterm surgical results of 57 HCC cases in 46 patients who underwent RLR at our institution.Methods:We evaluated the feasibility and safety of robotic anatomic liver resection for HCC by comparing the results of the anatomic resection(AR)group(n=23)and non-anatomic resection(NAR)group(n=34).Results:Overall(n=57),the liver-specific console time was 487 min,blood loss was 194 g,and there was one open conversion(2%).Postoperative data showed acceptable hepatic functional recovery,with a major complication rate of 11%and no 90-day mortality.Compared to NAR,AR was associated with longer operative and console times,more blood loss,and worse postoperative liver function,thus reflecting the greater extent and complexity of hepatectomies for more advanced-stage tumors than NAR.Nonetheless,major complication rate,mortality rate,length of hospital stay,and R0 resection rate were comparable between groups.Long-term results were comparable to those of previously reported hepatectomies for HCC and were similar between groups.Conclusion:RLR including AR may be a safe and feasible form of hepatectomy for select patients with HCC.展开更多
Hepatocellular carcinoma(HCC)is one of the leading causes of cancer-related death not only in the United States but in the world.One of the curative treatment options for early-stage HCC is surgical resection,which ca...Hepatocellular carcinoma(HCC)is one of the leading causes of cancer-related death not only in the United States but in the world.One of the curative treatment options for early-stage HCC is surgical resection,which can be divided into two approaches:anatomic and nonanatomic.The theoretical advantage of anatomic liver resection is excising the entire primary tumor along with adjacent liver parenchyma containing micrometastases that reside in the surrounding portal tributaries.However,the superiority of anatomic vs.nonanatomic liver resection in patients with HCC is controversial.While this is a feasible strategy for patients with preserved liver function,it may not be ideal for patients with cirrhosis,who rely on parenchymal-sparing or nonanatomic approaches to maximize their future liver remnant and prevent post-operative liver failure.This review identifies and critically analyzes the evidence for anatomic vs.nonanatomic liver resection for HCC.展开更多
文摘Hepatocellular carcinoma(HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC(e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection(AR) was introduced in the 1980 s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.
文摘Hepatocellular carcinoma(HCC)is the most frequent primary tumor of the liver and the sixth most common cancer worldwide with more than 800,000 cases per year(1).Potentially curative treatments such as liver transplantation(LT),liver resection(LR),and ablation(in selected cases)currently represent the best available options to offer long-term survival to patients(2).Given the worldwide scarcity of organs for transplantation,hepatic resection(open or minimally invasive),is frequently considered as the first option upon presentation.One of the most intriguing and longstanding debated issues among the hepatobiliary surgical community is the type of surgical resection that should be performed.Should we systematically pursue an anatomical resection(AR)or non-anatomical resection(NAR)for HCC?
基金Supported by National Key Technologies RD Program,No.2018YFC1106803National Natural Science Foundation of China,No.81872004,No.81770615,and No.81672882Science and Technology Support Program of Sichuan Province,No.2019YFQ0001 and No.2017SZ0003。
文摘BACKGROUND The long-term survival of patients with solitary hepatocellular carcinoma(HCC)following anatomical resection(AR)vs non-anatomical resection(NAR)is still controversial.It is necessary to investigate which approach is better for patients with solitary HCC.AIM To compare perioperative and long-term survival outcomes of AR and NAR for solitary HCC.METHODS We performed a comprehensive literature search of PubMed,Medline(Ovid),Embase(Ovid),and Cochrane Library.Participants of any age and sex,who underwent liver resection,were considered following the following criteria:(1)Studies reporting AR vs NAR liver resection;(2)Studies focused on primary HCC with a solitary tumor;(3)Studies reporting the long-term survival outcomes(>5 years);and(4)Studies including patients without history of preoperative treatment.The main results were overall survival(OS)and disease-free survival(DFS).Perioperative outcomes were also compared.RESULTS A total of 14 studies,published between 2001 and 2020,were included in our meta-analysis,including 9444 patients who were mainly from China,Japan,and Korea.AR was performed on 4260(44.8%)patients.The synthetic results showed that the 5-year OS[odds ratio(OR):1.19;P<0.001]and DFS(OR:1.26;P<0.001)were significantly better in the AR group than in the NAR group.AR was associated with longer operating time[mean difference(MD):47.08;P<0.001],more blood loss(MD:169.29;P=0.001),and wider surgical margin(MD=1.35;P=0.04)compared to NAR.There was no obvious difference in blood transfusion ratio(OR:1.16;P=0.65)or postoperative complications(OR:1.24,P=0.18).CONCLUSION AR is superior to NAR in terms of long-term outcomes.Thus,AR can be recommended as a reasonable surgical option in patients with solitary HCC.
基金Supported by A Grant-in-Aid for Scientific Research from the Ministry of Education,Culture,Sports,Science,and Technology,No.23591993a Grant from the Yuasa Memorial Foundation
文摘AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.
基金Supported by Guangdong Provincial Science and Technology Plan Project,No.2022A0505050065Guangdong Natural Science Foundation,No.2022A1515011632.
文摘BACKGROUND Laparoscopic hepatectomy is a proven safe and technically feasible approach for liver tumor resection,but laparoscopic anatomical SVIII resection(LASVIIIR)remains rarely reported due to poor accessibility,difficult exposure,and the deep-lying Glissonean pedicle.This study examined the safety,feasibility,and perio-perative outcomes of LASVIIIR via a middle hepatic fissure approach at our in-stitution.AIM To investigate the safety,feasibility,and perioperative outcomes of LASVIIIR via a middle hepatic fissure approach at our institution.METHODS From November 2017 to December 2022,all patients with a liver tumor who underwent LASVIIIR were enrolled.The perioperative outcomes and postope-rative complications were evaluated.RESULTS Thirty-four patients underwent LASVIIIR via a middle hepatic fissure approach from the side or cranio side and were included.The mean operation time was 164±54 minutes,and the intra-operative blood loss was 100 mL(range:20-1000 mL).The mean operative times were,respectively,152±50 minutes and 222±29 minutes(P=0.001)for the caudal side and cranial side approaches.In addition,the median blood loss volumes were 100 mL(range:20-300 mL)and 250 mL(range:20-1000 mL),respectively,for the caudal and cranial sides(P=0.064).Three patients treated using the cranial side approach experienced bile leakage,while 1 patient treated using the caudal side approach had subphrenic collection and underwent percutaneous drainage to successfully recover.There were no differences regarding postoperative hospital stays for the caudal and cranial side approaches[9(7-26)days vs 8(8-19)days](P=0.226).CONCLUSION LASVIIIR resection remains a challenging operation,but the middle hepatic fissure approach is a reasonable and easy-to-implement technique.
文摘Various approaches to laparoscopic anatomic liver resection have been described.In this paper,the authors present a technique that utilizes the ventral avascular areas above the inferior vena cava.While many liver surgeons partially adopt this elements of this method,few employ it to the full extent outlined here.Main-taining low central venous pressure during anesthesia is critical to this approach,as demonstrated by the operative images showing collapsed hepatic veins.This technique is particularly advantageous when the patient’s body mass index is low,the tumor is small(or large but deeply embedded within the liver parenchy-ma),and the overlying liver tissue is not excessively bulky or heavy.Nonetheless,following the conventional course along the Glissonean pedicle can be beneficial.The authors demonstrate notable skill in completing these procedures laparosco-pically.However,concerns over margin positivity and tumor recurrence remain,and follow up studies are needed to further validate the approach.
基金supported by the grants from the Natural Science Foundation of China(82173129 and 82203330)China Post-doctoral Science Foundation(2022M711589)+1 种基金Distinguished Youth Project of Nanjing Drum Tower HospitalNanjing Health Science and Technology Development Project(YKK22065)。
文摘To the Editor:Liver resection,particularly anatomical hepatectomy,has become a vital surgical approach for managing a range of liver diseases[1].Owing to its deep anatomical position,the caudate lobe is frequently implicated in hepatobiliary diseases,necessitating precise evaluation and targeted treatment during anatomical liver resection[2,3].The caudate lobe's vascular anatomy is complex:the left portal vein branch(G1L,LPb)primarily supplies the Spiegel lobe,the bifurcation branch(G1F,HBb)feeds the paracaval region or caudate process,and the right posterior portal branch(G1C,RPb)serves the caudate process[4,5].
文摘BACKGROUND Portal vein thrombosis(PVT)after liver resection is rare but can lead to lifethreatening liver failure.This prospective study evaluated patients using contrastenhanced computed tomography(E-CT)on the first day after liver resection for early PVT detection and management.AIM To evaluate patients by E-CT on the first day after liver resection for early PVT detection and immediate management.METHODS Patients who underwent liver resection for primary liver cancer from January 2015 were enrolled.E-CT was performed on the first day after surgery in patients undergoing anatomical resection,multiple resections,or with postoperative bile leakage in the high-risk group for PVT.When PVT was detected,anticoagulant therapy including heparin,warfarin,and edoxaban was administered.E-CT was performed monthly until PVT resolved.RESULTS The overall incidence of PVT was 1.57%(8/508).E-CT was performed on the first day after surgery in 235 consecutive high-risk patients(165 anatomical resections,74 multiple resections,and 28 bile leakages),with a PVT incidence of 3.4%(8/235).Symptomatic PVT was not observed in the excluded cohort.Multivariate analyses revealed that sectionectomy was the only independent predictor of PVT[odds ratio(OR)=12.20;95%confidence interval(CI):2.22-115.97;P=0.003].PVT was found in the umbilical portion of 75.0%(6/8)of patients,and sectionectomy on the left side showed the highest risk of PVT(OR=14.10;95%CI:3.17-62.71;P<0.0001).CONCLUSION Sectionectomy on the left side should be chosen with caution as it showed the highest risk of PVT.E-CT followed by anticoagulant therapy was effective in managing early-phase PVT for 2 mo without adverse events.
基金The National Key Research and Development Program of China,No.2016YFC0106004.
文摘BACKGROUND The long-term effect of anatomic resection(AR)is better than that of nonanatomic resection(NAR).At present,there is no study on microvascular invasion(MVI)and liver resection types.AIM To explore whether AR improves long-term survival in patients with hepatocellular carcinoma(HCC)by removing the peritumoral MVI.METHODS A total of 217 patients diagnosed with HCC were enrolled in the study.The surgical margin was routinely measured.According to the stratification of different tumor diameters,patients were divided into the following groups:≤2 cm group,2-5 cm group,and>5 cm group.RESULTS In the 2-5 cm diameter group,the overall survival(OS)of MVI positive patients was significantly better than that of MVI negative patients(P=0.031).For the MVI positive patients,there was a statistically significant difference between AR and NAR(P=0.027).AR leads to a wider surgical margin than NAR(2.0±2.3 cm vs 0.7±0.5 cm,P<0.001).In the groups with tumor diameters<2 cm,both AR and NAR can obtain a wide surgical margin,and the surgical margins of AR are wider than that of NAR(3.5±5.8 cm vs 1.6±0.5 cm,P=0.048).In the groups with tumor diameters>5 cm,both AR and NAR fail to obtain wide surgical margin(0.6±1.0 cm vs 0.7±0.4 cm,P=0.491).CONCLUSION For patients with a tumor diameter of 2-5 cm,AR can achieve the removal of peritumoral MVI by obtaining a wide incision margin,reduce postoperative recurrence,and improve prognosis.
基金funded by the Nantong Natural Science Founda-tion(JC2024078)the Scientific Research Project of Jiangsu Society of Traditional Chinese Medicine(ZXFZ2024100)the Hubei Chen Xiaoping Science and Technology Development Foundation Project(CXPJJH123009-079).
文摘Laennec's capsule is a dense fibrous membrane that has recently been confirmed to exist across the entire liver surface,Glissonean pedicles,and major hepatic veins,forming a continuous fibrous system.Minimally invasive anatomical liver resection based on Laennec's capsule-guided dissection leverages natural avascular planes to enable safe and efficient resection.This approach significantly reduces intraoperative bleeding,improves sur-gical precision and R0 resection rates,and contributes to better long-term survival in patients.This review discusses the anatomical concept of Laennec's capsule and its clinical application in minimally invasive anatomical liver resection.It outlines the advantages,limitations,and strategic use of various preoperative navigation techniques;analyses the indications for intrafascial/extrafascial Glissonean approaches and the technical aspects of their selection;analyses outer/inner dissection of Laennec's capsule around the hepatic veins according to the type of tumour;and proposes technical refinements based on outflow control and precision surgery.Finally,it explores the debate about the origins of Laennec's capsule and suggests directions for future bastardization and research.This review aims to provide hepatobiliary surgeons with a comprehensive reference based on recent technical advances and application strategies for Laennec's capsule-based anatomical liver resection.
文摘To the Editor:Laparoscopic liver resection(LLR)is widely used as a standard procedure for liver malignancies and benign diseases.Consensus guidelines stated that LLR may be feasible and safe in experienced centers.Evidence has shown that LLR is less invasive and has bet-ter patient prognosis than conventional procedures[1].However,laparoscopic anatomic liver resection(LALR)such as segment 8(S8)resection is still challenging due to difficulties in segmental mapping and surgical techniques[2,3].Liver S8 is in a deep-seated area surrounded by the ribs and the diaphragm,and closely con-nected to the right and middle hepatic veins and inferior vena cava.Furthermore,the Glissonean pedicle of segment 8(G8)is lo-cated deep in the liver parenchyma,lacking anatomical landmarks,and making forceps manipulation difficult.Therefore,LALR-S8 has been described as the most challenging procedure[4].
文摘The rationale of the performance of anatomic resection(AR)of the liver in case of hepatocellular carcinoma(HCC)is the removal of portal pedicle feeding the tumor because of the tumor’s tendency to invade the portal veins(1).This technical approach is expected to be effective from an oncological perspective for a disease such as HCC,which is associated with a high rate of intrahepatic recurrence(2,3).In the eighties,Makuuchi et al.proposed the systematic subsegmentectomy(4)reporting excellent results(5),and later some other authors reported new techniques to identify the portal territory of a given HCC and perform a true AR of the liver(5-7).
基金Supported by the National Natural Science Foundation of China,No.81570559 and No.812726732014 Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents
文摘AIM To establish the surgical flow for anatomic isolated caudate lobe resection. METHODS The study was approved by the ethics committee of the Second Affiliated Hospital Zhejiang University School of Medicine(SAHZU). From April 2004 to July 2014, 20 patients were enrolled who underwent anatomic isolated caudate lobectomy at SAHZU. Clinical and postoperative pathological data were analyzed. RESULTS Of the total 20 cases, 4 received isolated complete caudate lobectomy(20%) and 16 received isolated partial caudate lobectomy(80%). There were 4 caseswith the left approach(4/20, 20%), 6 cases with the right approach(6/20, 30%), 7 cases with the bilateral combined approach(7/20, 35%), 3 cases with the anterior approach(3/20, 15%), and the hanging maneuver was also combined in 2 cases. The median tumor size was 5.5 cm(2-12 cm). The median intraoperative blood loss was 600 m L(200-5700 m L). The median intra-operative blood transfusion volume was 250 m L(0-2400 m L). The median operation time was 255 min(110-510 min). The median post-operative hospital stay was 14 d(7-30 d). The 1-and 3-year survival rates for malignant tumor were 88.9% and 49.4%, respectively. CONCLUSION Caudate lobectomy was a challenging procedure. It was demonstrated that anatomic isolated caudate lobectomy can be done safely and effectively.
基金Supported by General Project of Natural Science Foundation of Chongqing,No.cstc2021jcyj-msxmX0604Chongqing Doctoral“Through Train”Research Program,No.CSTB2022BSXM-JCX0045.
文摘BACKGROUND Laparoscopic anatomical liver resection has become more challenging because some subsegmental Glissonean pedicles are hard to dissect.Here,we introduce how to dissect every(sub)segmental Glissonean pedicle from the first porta hepatis and perform standardized(sub)segmentectomy[from segment 1(S1)to S8].AIM To summarize our methods of laparoscopic anatomical segmental and subseg-mental liver resection.METHODS The Glisson sheath and liver capsule were separated along the Laennec mem-brane.The Glissonean pedicle could be isolated and transected with little or no parenchymal damage through this extra-Glissonean dissection approach.The basin of the(sub)segment was determined by the ischemia demarcation line or indocyanine green staining.The hepatic vein or intersegmental vein was also used to guide the plane of parenchymal transection.RESULTS All segmental or subsegmental pedicles or even the pedicle of the cone unit could be dissected along the Laennec membrane using our novel technique through the first porta hepatis.The dorsal branches of S8,the branches of S4a and the paracaval portion branches(b/c vein)of the caudate lobe were the most difficult to dissect.CONCLUSION The novel techniques of liver segmental and subsegmental pedicle anatomy is feasible for laparoscopic liver resection and can help accurately guide(sub)segmentectomy from S1 to S8.
文摘Anatomical resection(AR)has been reported to achieve better long-term outcomes than non-anatomical resection for the treatment of hepatocellular carcinoma(HCC).The surgical feasibility and oncological significance of laparoscopic AR(LAR),especially“subsegment resection”,“cone unit resection”,and repeat LAR for HCC,remain unproven.We present a 67-year-old patient with alcoholic liver cirrhosis and HCC who underwent full LAR three times,focusing on the technical aspects of the Glissonean approach.Repeating LAR for recurrent HCC could be a safe and feasible procedure.However,HCC recurred in the neighboring segment twice,even though pathological vascular invasion and marginal remnants were not confirmed.We should investigate the oncological significance and advancements in subsegmentectomy and cone unit resection,in the future.
文摘Background:Laparoscopic liver resection(LLR)has been considered to be safe and feasible.However,few studies focused on the comparison between the anatomic and nonanatomic LLR.Therefore,the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR,especially the area of liver parenchymal transection and blood loss per unit area.Methods:In this study,surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected.Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter.All procedures were conducted by a single surgeon.Results:During nearly 5 years,84 patients with malignant liver tumor received a pure LLR procedure were included.Among them,34 patients received anatomic LLR and 50 received nonanatomic LLR,respectively.Patients of the two groups were similar in terms of demographic features and tumor characteristics,despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group(4.77±2.57 vs.2.87±2.10 cm,P=0.001).Patients who underwent anatomic resection had longer operation time(364.09±131.22 vs.252.00±135.21 min,P〈0.001)but less blood loss per unit area(7.85±7.17 vs.14.17±10.43 ml/cm2,P=0.018).Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR.No mortality occurred during the hospital stay and 30 days alter the operation.Moreover,there was no difference in the incidence of postoperative complications.The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups.Conclusions:Both anatomic and nonanatomic pure LLR are safe and feasible.Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery'.Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.
基金The authors express sincere thanks to the Natural Science Foundation of Guangdong Province of China(No.2021A1515010222)the National Natural Science Foundation of China(No.81800560)for funding this work.
文摘Background:An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision.We discovered a triangular zone during the laparoscopic right liver surgery and termed this zone the APR triangle.The purpose of this study was to determine the probability of the existence of the APR triangle and elucidate its various forms.Methods:Analyzed three-dimensional image reconstructions of 66 individuals who underwent liver surgery and calculated the statistics for various types of APR triangles under various grouping settings.Results:The APR triangle was present in the majority of cases,with right hepatic vein trunk type in 68%and right hepatic vein branch type in 21%,respectively.The angle between the right anterior and right posterior hepatic pedicles(AP&PP)was at most between 45 and 90°(74%).There was a 35%chance that at least one of the AP&PP was longer than 2 cm,and a 39%chance that both were.The right posterior pedicle first branch would appear at the bifurcation of AP&PP in 13%only.Conclusions:The APR triangle is objectively present and may represent a practical zone for performing laparoscopic right hepatic anatomical resection more simply and safely.
文摘A 73-year-old woman with liver cirrhosis caused by hepatitis C virus(HCV)underwent treatment of three hepatocellular carcinomas(HCCs)in liver segment 4,following three previous laparoscopic liver resections(LLRs)over 73 months.Contrast-enhanced computed tomography showed three 0.5-1.2 cm HCCs deep within the portal territories of subsegments 4a and 4b.The patient underwent laparoscopic resection of 4a and 4b,with the preservation of the portal branch to 4c,after minimal adhesiolysis around segment 4.The operation lasted 284 min,there was 50 mL of intra-operative bleeding and her recovery was uneventful.She was well,had experienced no recurrence and was HCV-negative,after taking oral anti-HCV therapy,21 months later.LLR is associated with fewer adhesions after surgery and requires less adhesiolysis,because the laparoscope and forceps can be used in the small spaces between adhesions.The present patient underwent four LLRs over 6 years without severe deterioration of liver functional reserve.LLR is a useful localized therapy,which can be performed repeatedly and may prolong the survival of patients with multicentric metachronous HCCs.
文摘Aim:Robotic liver resection(RLR)is a new platform for minimally invasive hepatobiliary surgery.Minimally invasive surgery can confer benefits to patients with hepatocellular carcinoma(HCC),which is mostly associated with underlying chronic liver disease.Despite the inherent functional merits of robotics for surgical techniques,the clinical advantages of hepatectomy are not well defined.Therefore,we reviewed the short-term and longterm surgical results of 57 HCC cases in 46 patients who underwent RLR at our institution.Methods:We evaluated the feasibility and safety of robotic anatomic liver resection for HCC by comparing the results of the anatomic resection(AR)group(n=23)and non-anatomic resection(NAR)group(n=34).Results:Overall(n=57),the liver-specific console time was 487 min,blood loss was 194 g,and there was one open conversion(2%).Postoperative data showed acceptable hepatic functional recovery,with a major complication rate of 11%and no 90-day mortality.Compared to NAR,AR was associated with longer operative and console times,more blood loss,and worse postoperative liver function,thus reflecting the greater extent and complexity of hepatectomies for more advanced-stage tumors than NAR.Nonetheless,major complication rate,mortality rate,length of hospital stay,and R0 resection rate were comparable between groups.Long-term results were comparable to those of previously reported hepatectomies for HCC and were similar between groups.Conclusion:RLR including AR may be a safe and feasible form of hepatectomy for select patients with HCC.
文摘Hepatocellular carcinoma(HCC)is one of the leading causes of cancer-related death not only in the United States but in the world.One of the curative treatment options for early-stage HCC is surgical resection,which can be divided into two approaches:anatomic and nonanatomic.The theoretical advantage of anatomic liver resection is excising the entire primary tumor along with adjacent liver parenchyma containing micrometastases that reside in the surrounding portal tributaries.However,the superiority of anatomic vs.nonanatomic liver resection in patients with HCC is controversial.While this is a feasible strategy for patients with preserved liver function,it may not be ideal for patients with cirrhosis,who rely on parenchymal-sparing or nonanatomic approaches to maximize their future liver remnant and prevent post-operative liver failure.This review identifies and critically analyzes the evidence for anatomic vs.nonanatomic liver resection for HCC.
