Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-li...Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis.The aim of this review is to assess current indications,advantages and limits of laparoscopic surgery for HCC resections.We also discussed the possible evolution of this surgical approach in parallel with new technologies.展开更多
AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad. METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections(n = 101 major anatomical and n = 74 large atypical >...AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad. METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections(n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients(143 surgeries). Accompanying, 37 wedge resections(specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by waterjet. The median central venous pressure was 4 mmH g(range: 5-14). Data was collected prospectively. RESULTS The median age of patients was 60 years(range: 16-85). Preoperative chemotherapy was used in 70 cases(49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL(range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures(15%). The median weight of anatomically resected liver specimens was 525 g(range: 51-1850 g). One patient died postoperatively. Biliary leakages(n = 5) were treated conservatively. Temporary liver failure occurred in two patients.CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.展开更多
To evaluate safety and outcomes of a new technique for extreme hepatic resections with preservation of segment 4 only. METHODSThe new method of extreme liver resection consists of a two-stage hepatectomy. The first st...To evaluate safety and outcomes of a new technique for extreme hepatic resections with preservation of segment 4 only. METHODSThe new method of extreme liver resection consists of a two-stage hepatectomy. The first stage involves a right hepatectomy with middle hepatic vein preservation and induction of left lobe congestion; the second stage involves a left lobectomy. Thus, the remnant liver is represented by the segment 4 only (with or without segment 1, ± S1). Five patients underwent the new two-stage hepatectomy (congestion group). Data from volumetric assessment made before the second stage was compared with that of 10 matched patients (comparison group) that underwent a single-stage right hepatectomy with middle hepatic vein preservation. RESULTSThe two stages of the procedure were successfully carried out on all 5 patients. For the congestion group, the overall volume of the left hemiliver had increased 103% (mean increase from 438 mL to 890 mL) at 4 wk after the first stage of the procedure. Hypertrophy of the future liver remnant (i.e., segment 4 ± S1) was higher than that of segments 2 and 3 (144% vs 54%, respectively, P < 0.05). The median remnant liver volume-to-body weight ratio was 0.3 (range, 0.28-0.40) before the first stage and 0.8 (range, 0.45-0.97) before the second stage. For the comparison group, the rate of hypertrophy of the left liver after right hepatectomy with middle hepatic vein preservation was 116% ± 34%. Hypertrophy rates of segments 2 and 3 (123% ± 47%) and of segment 4 (108% ± 60%, P > 0.05) were proportional. The mean preoperative volume of segments 2 and 3 was 256 ± 64 cc and increased to 572 ± 257 cc after right hepatectomy. Mean preoperative volume of segment 4 increased from 211 ± 75 cc to 439 ± 180 cc after surgery. CONCLUSIONThe proposed method for extreme hepatectomy with preservation of segment 4 only represents a technique that could allow complete resection of multiple bilateral liver metastases.展开更多
Objective:The authors present outcomes of robotic liver resections in comparison with open technique questioning the need to have experience of laparoscopy for such procedures before transition to robotic assisted.Mat...Objective:The authors present outcomes of robotic liver resections in comparison with open technique questioning the need to have experience of laparoscopy for such procedures before transition to robotic assisted.Materials and methods:Retrospective review of liver resections done robotically from February 2015 to June 2017 compared to matched control cohort of open cases from January 2012 to December 2016.Results:Twenty-one patients in the study groupwere comparedwithmatched control of 42 open cases(1:2 ratio).The types of procedure were similar in both the groups.There were 4 left lateral hepatectomy,3 left hepatectomy,and 1 left hepatectomy with hepatico-jejunostomy,3 right hepatectomy,3 right posterior sectorectomy,4 bisegmentectomy and 4 mono-segmentectomy.There were 9 patients with primary liver cancer,2 each with livermetastasis and carcinoma gall bladder and 8 patients had benign liver disease.Mean blood losswas 370±311ml in the robotic group compared to 451±330ml in control group(p=0.06).Minor complications developed in 19.0%of robotic cases compared to 40.5%in open surgery,while major complications occurred in 4.7%of robotic cases compared to 7.1%of open cases.Mean hospital staywas 5.3±0.8 days for the robotic group and 7.7±4.2 days for open group(p=0.02).Local tumor recurrence occurred in 1 out of 13 resections done for malignancy in the robotic group and 7 out of 26 in the open group.Conclusion:This study highlights the utility of surgical robots for segmental and complex liver resections with equivalent outcomes and decreased length of hospital stay compared to open surgery without having experience of same with the laparoscopy.展开更多
Significant advances in surgical techniques and relevant medium-and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections.To support these outst...Significant advances in surgical techniques and relevant medium-and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections.To support these outstanding results and to reduce perioperative complications,anesthesiologists must address and master key perioperative issues(preoperative assessment,proactive intraoperative anesthesia strategies,and implementation of the Enhanced Recovery After Surgery approach).Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate.Among postoperative complications,posthepatectomy liver failure(PHLF)occurs in different grades of severity(A-C)and frequency(9%-30%),and it is the main cause of 90-d postoperative mortality.PHLF,recently redefined with pragmatic clinical criteria and perioperative scores,can be predicted,prevented,or anticipated.This review highlights:(1)The systemic consequences of surgical manipulations anesthesiologistsmust respond to or prevent,to positively impact PHLF(a proactive approach);and(2)the maximal intensivetreatment of PHLF,including artificial options,mainly based,so far,on Acute Liver Failure treatment(s),to buytime waiting for the recovery of the native liver or,when appropriate and in very selected cases,toward livertransplant.Such a clinical context requires a strong commitment to surgeons,anesthesiologists,and intensivists towork together,for a fruitful collaboration in a mandatory clinical continuum.展开更多
BACKGROUND Repeated application of the Pringle maneuver is a key obstacle to safe minimally invasive repeat liver resection(MISRLR).However,limited technical guidance is available.AIM To study the utility of newly dev...BACKGROUND Repeated application of the Pringle maneuver is a key obstacle to safe minimally invasive repeat liver resection(MISRLR).However,limited technical guidance is available.AIM To study the utility of newly developed Pringle taping method guided by liver surface in MISRLR.METHODS We retrospectively reviewed 72 cases of MISRLR performed by a single surgeon at two centers from August 2015 to July 2024.Beginning in October 2019,a liver surface-guided encirclement of hepatoduodenal ligament(LSEH)was used for repeat Pringle taping.Perioperative outcomes including Pringle taping success,operative time,blood loss,conversion rate,morbidity,and mortality were assessed.RESULTS Laparoscopic and robotic approaches were used in 63 patients and 9 patients,respectively.The median operative time,blood loss,and hospital stay were 331.5 minutes,70 mL,and 8 days,respectively.Open conversion occurred in two cases(2.8%)due to severe adhesions and right renal vein injury.Clavien-Dindo grade≥III complications occurred in 5.6%of cases with no mortality.Anti-adhesion barriers were used in 54 patients(75.0%).LSEH was attempted in 57 cases,improving Pringle taping success from 33.0%to 91.4%(P<0.001).LSEH succeeded in all patients with prior open liver resection(n=11).Among 6 patients in whom LSEH failed,3 patients(50.0%)had undergone a third liver resection,and 1 patient had a history of distal gastrectomy with choledochoduodenostomy.CONCLUSION The newly developed LSEH technique for Pringle taping in MISRLR was feasible,enhancing safety and reproducibility even in patients with a history of open liver resection.展开更多
BACKGROUND Laparoscopic liver resection(LLR)can be challenging due to the difficulty of establishing a retrohepatic tunnel under laparoscopy.Dissecting the third hepatic hilum before parenchymal transection often lead...BACKGROUND Laparoscopic liver resection(LLR)can be challenging due to the difficulty of establishing a retrohepatic tunnel under laparoscopy.Dissecting the third hepatic hilum before parenchymal transection often leads to significant liver mobilization,tumor compression,and bleeding from the short hepatic veins(SHVs).This study introduces a novel technique utilizing the ventral avascular area of the inferior vena cava(IVC),allowing SHVs to be addressed after parenchymal transection,thereby reducing surgical complexity and improving outcomes in in situ LLR.AIM To introduce and evaluate a novel LLR technique using the ventral avascular area of the IVC and compare its short-term outcomes with conventional methods.METHODS The clinical cohort data of patients with pathologically confirmed hepatocellular carcinoma or intrahepatic cholangiocarcinoma who underwent conventional LLR and novel LLR between July 2021 and July 2023 at the First Affiliated Hospital of Chongqing Medical University were retrospectively analyzed.In novel LLR,we initially separated the caudate lobe from the IVC using dissecting forceps along the ventral avascular area of the IVC.Then,we transected the parenchyma of the left and right caudate lobes from the caudal side to the cephalic side using the avascular area as a marker.Subsequently,we addressed the SHVs and finally dissected the root of the right hepatic vein or left hepatic vein.The short-term postoperative outcomes and oncological results of the two approaches were evaluated and compared.RESULTS A total of 256 patients were included,with 150(58.59%)undergoing conventional LLR and 106(41.41%)undergoing novel LLR.The novel technique resulted in significantly larger tumor resections(6.47±2.96 cm vs 4.01±2.33 cm,P<0.001),shorter operative times(199.57±60.37 minutes vs 262.33±83.90 minutes,P<0.001),less intraoperative blood loss(206.92±37.09 mL vs 363.34±131.27 mL,P<0.001),and greater resection volume(345.11±31.40 mL vs 264.38±31.98 mL,P<0.001)compared to conventional LLR.CONCLUSION This novel technique enhances liver resection outcomes by reducing intraoperative complications such as bleeding and tumor compression.It facilitates a safer,in situ removal of complex liver tumors,even in challenging anatomical locations.Compared to conventional methods,this technique offers significant advantages,including reduced operative time,blood loss,and improved overall surgical efficiency.展开更多
Extracorporeal liver surgery(ELS), also known as liver autotransplantation, is a hybrid(cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently b...Extracorporeal liver surgery(ELS), also known as liver autotransplantation, is a hybrid(cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently became more embraced and popularized among leading centers. ELS could be summarized into three major categories, namely, ex-situ liver resection and autotransplantation(ELRA), ante-situm liver resection and autotransplantation(ALRA) and auxiliary partial liver autotransplantation(APLA). The successful development of ELS during the past 37 years is definitely inseparable from continuous effort s done by Chinese surgeons and researchers. Especially, the precision liver surgery paradigm has allowed to transform ELS into a modularized, more simplified, and standardized surgery, to upgrade surgical skills, to improve peri-operative outcome and long-term survival, to increase the capability of surgeons to select more complex diseases and to expand the level of medical service to the population. This review highlights the Chinese contributions to the field of ELS, focusing thereby on features of different surgical types, technical innovations, disease selection and surgical indication, patient prognosis and future perspectives.展开更多
Currently,laparoscopic liver resections are routinely performed at an increasing number of centres and has extended to include major liver resections as well as more challenging segments of the liver.We believe that p...Currently,laparoscopic liver resections are routinely performed at an increasing number of centres and has extended to include major liver resections as well as more challenging segments of the liver.We believe that patient positioning and port placement is a critical yet under described component of successful laparoscopic liver resection to achieve optimal visualisation and allow for an ergonomic and safe dissection.In this article,we describe the advantages of various types of patient positioning as well as provide illustrations for an array of trocar configurations previously described in literature.Whilst there is no universally accepted standardization of port placement for various resection types,this descriptive article can serve as a guide for the various possibilities of port configurations that can be individually adapted by surgeons based on their preference as well as the patient’s physique and anatomy.展开更多
Transplantation of the left lateral section(LLS)of the liver is now an established practice for treating advanced diffuse and unresectable focal liver diseases in children,with variants of the LLS primarily used in in...Transplantation of the left lateral section(LLS)of the liver is now an established practice for treating advanced diffuse and unresectable focal liver diseases in children,with variants of the LLS primarily used in infants.However,the surgical challenge of matching the size of an adult donor's graft to the volume of a child's abdomen remains significant.This review explores historical developments,various approaches to measuring the required functional liver mass,and techniques to prevent complications associated with large-for-size grafts in infants.展开更多
Liver transplantation represents a complex surgical procedure and serves as a curative treatment for patients presenting an acute or chronic end-stage liver disease, or carefully selected liver malignancy. A significa...Liver transplantation represents a complex surgical procedure and serves as a curative treatment for patients presenting an acute or chronic end-stage liver disease, or carefully selected liver malignancy. A significant gap still exists between the number of available donor organs and potential recipients. The use of an otherwise-wasted resected liver lobe from patients with benign liver tumors is a new, albeit small, option to alleviate the allograft shortage. This review provides evidence that resected liver lobes may be used successfully in liver transplantation.展开更多
Liver-directed therapies such as resection,ablation,and embolization offer potentially curative options for patients with primary and metastatic liver tumors as part of multidisciplinary oncology care.However,these tr...Liver-directed therapies such as resection,ablation,and embolization offer potentially curative options for patients with primary and metastatic liver tumors as part of multidisciplinary oncology care.However,these treatments pose significant hepatic decompensation risks,particularly with underlying liver disease and chemotherapy-associated steatohepatitis.Accurate assessment of liver function and portal hypertension(PH)is critical for candidate selection.While Child-Pugh score and model for end-stage liver disease are commonly used,they have substantial limitations.Hepatic venous pressure gradient(HVPG)measurement remains the gold standard for assessing PH but is invasive and not widely available.Endoscopic ultrasound(EUS)guided portal pressure gradient(PPG)measurement has emerged as a promising minimally invasive alternative.EUSPPG demonstrates excellent technical success rates,safety profile,and correlation with HVPG in early studies.By providing direct portal pressure measurement,EUS-PPG offers several advantages over existing methods for prognostication and risk stratification prior to liver-directed therapies,particularly in detecting presinusoidal hypertension.Furthermore,it has potential applications in assessing response to neoadjuvant treatments and guiding adjuvant therapies.However,research is needed to validate its predictive performance and cost-effectiveness in larger prospective cohorts and to establish its accuracy compared to non-invasive assessment of liver function.展开更多
BACKGROUND Hepatocellular carcinoma(HCC)in segments VII and VIII poses technical challenges for both liver resection and radiofrequency ablation(RFA).Robotic-assisted techniques may enhance safety and precision,but co...BACKGROUND Hepatocellular carcinoma(HCC)in segments VII and VIII poses technical challenges for both liver resection and radiofrequency ablation(RFA).Robotic-assisted techniques may enhance safety and precision,but comparative evidence remains limited.AIM To compare the clinical outcomes of robotic liver resection(R-LR)and robotic intraoperative RFA(RIO-RFA)for HCC located in liver segments VII and VIII.METHODS We retrospectively analyzed 93 HCC patients in segments VII/VIII with de novo(n=57)or first recurrent(n=36).HCC who underwent R-LR or RIO-RFA between 2015 and 2024.Propensity score matching was performed to reduce selection bias.Primary outcomes were overall survival(OS)and recurrence-free survival(RFS).Kaplan-Meier curves,log-rank tests,and Cox regression were used to identify prognostic factors for OS and RFS.RESULTS In the de novo group,OS and RFS did not differ significantly between R-LR and RIO-RFA before or after propensity score matching.In contrast,the recurrent group showed significantly improved OS and RFS with R-LR(P=0.005 and P=0.012,respectively).Subgroup analyses revealed that low-risk de novo patients with smaller tumors achieved superior OS after R-LR,whereas carefully selected low-risk recurrent patients undergoing RIO-RFA(smaller tumors,absence of complications)achieved outcomes comparable to R-LR.Platelet count,tumor size,and postoperative complications constituted key prognostic factors.CONCLUSION For HCC in challenging liver segments VII and VIII,R-LR and RIO-RFA achieve comparable outcomes in de novo cases,whereas R-LR confers superior survival in recurrent disease.R-LR should be prioritized for small de novo HCCs and for recurrent disease overall;RIO-RFA may serve as an effective alternative in carefully selected lowrisk recurrent patients.Tumor size,platelet count,and postoperative complications are key prognostic indicators to guide individualized treatment.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
Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria....Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seq LDLT) after LR as a strategy for HCC patients with high-risk of recurrence.Methods:We analyzed data from 27 adult patients who underwent seq LDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS).Results:Among 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqL DLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqL DLT as a preemptive strategy. The median age was 53.5 years with 85%males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0%and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors> 5 cm(19%), and a total tumor diameter> 10 cm (7%).Conclusions:Seq LDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seq LDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.展开更多
BACKGROUND Tacrolimus is a key immunosuppressive agent used to prevent allograft rejection in kidney transplant recipients.Due to its narrow therapeutic index,careful monitoring is essential to avoid adverse effects,p...BACKGROUND Tacrolimus is a key immunosuppressive agent used to prevent allograft rejection in kidney transplant recipients.Due to its narrow therapeutic index,careful monitoring is essential to avoid adverse effects,particularly neurotoxicity and nephrotoxicity.Hepatic metabolism is an important part of tacrolimus pharmacokinetics.This case report highlights the impact of liver resection on tacrolimus pharmacokinetics in a kidney transplant recipient.CASE SUMMARY A 61-year-old male with end-stage kidney disease underwent a living-unrelated donor kidney transplant at age 46 and has maintained a stable tacrolimus regimen for 15 years.He was later diagnosed with hepatocellular carcinoma and underwent an open wedge liver resection.Despite stable preoperative tacrolimus levels,he developed acute kidney injury and neurotoxicity(manifested as new-onset tremors and headache)postoperatively.Tacrolimus levels rose from 3.4 ng/mL before surgery to 19.5 ng/mL postoperatively,despite no changes in dosage.This increase was most likely due to reduced liver mass and function following resection,in addition to ischemic injury of the remaining liver parenchyma,leading to impaired drug metabolism and acute toxicity.Liver function tests showed transient abnormalities postoperatively,with transaminase levels peaking at 30 times the normal range before gradually returning to normal,coinciding with the decline in tacrolimus levels.The patient’s symptoms and acute kidney injury improved as tacrolimus concentration returned to normal.CONCLUSION This is the first reported case of acute tacrolimus neurotoxicity and nephrotoxicity in a kidney transplant recipient following liver resection.It highlights the critical need for vigilant therapeutic drug monitoring of tacrolimus after liver surgery to prevent severe adverse effects.展开更多
Combined hepatocellular cholangiocarcinoma(cHCC-CCA)is a rare and ag-gressive primary liver malignancy characterized by features of both HCC and CCA.Preoperative diagnosis remains challenging because of overlapping i-...Combined hepatocellular cholangiocarcinoma(cHCC-CCA)is a rare and ag-gressive primary liver malignancy characterized by features of both HCC and CCA.Preoperative diagnosis remains challenging because of overlapping i-maging and histopathological features,which often lead to misclassification.Although liver resection is the primary curative therapy,the efficacy of liver transplantation(LT)remains controversial.Historically,LT has been considered contraindicated owing to the poor prognosis,high recurrence rate of cHCC-CCA,and the potential for organ wastage.Recent studies have suggested that LT may benefit carefully selected patients,particularly those with early-stage tumors or cirrhosis.However,there is no consensus on the criteria for LT in patients with cHCC-CCA.Lymphadenectomy and vascular resection strategies were discussed along with locoregional and systemic therapies.This review synthesized the current evidence on surgical strategies for cHCC-CCA,focusing on evolving LT criteria and outcomes.展开更多
Background:Hepatocellular carcinoma(HCC)is a common malignancy with high mortality.Liver resection(LR)is a curative treatment for early-stage HCC,but the prognosis of HCC patients after LR is unsatisfactory because of...Background:Hepatocellular carcinoma(HCC)is a common malignancy with high mortality.Liver resection(LR)is a curative treatment for early-stage HCC,but the prognosis of HCC patients after LR is unsatisfactory because of tumor recurrence.Prognostic prediction models with great performance are urgently needed.The present study aimed to establish a novel prognostic nomogram to predict tumor recurrence in HCC patients after LR.Methods:We retrospectively analyzed 726 HCC patients who underwent LR between October 2011 and December 2016.Patients were randomly divided into the training cohort(n=508)and the testing cohort(n=218).The protein expression of 14 biomarkers in tumor tissues was assessed by immunohistochemistry.The nomogram predicting recurrence-free survival(RFS)was established by a multivariate Cox regression analysis model and was evaluated by calibration curves,Kaplan-Meier survival curves,time-dependent areas under the receiver operating characteristic(ROC)curves(AUCs),and decision curve analyses in both the training and testing cohorts.Results:Alpha-fetoprotein[hazard ratio(HR)=1.013,P=0.002],portal vein tumor thrombosis(HR=1.833,P<0.001),ascites(HR=2.024,P=0.014),tumor diameter(HR=1.075,P<0.001),Ecadherin(HR=0.859,P=0.011),EMA(HR=1.196,P=0.022),and PCNA(HR=1.174,P=0.031)immunohistochemistry scores were found to be independent factors for RFS.The 1-year and 3-year AUCs of the nomogram for RFS were 0.813 and 0.739,respectively.The patients were divided into the high-risk group and the low-risk group by median value which was generated from the nomogram,and Kaplan-Meier analysis revealed that the high-risk group had a shorter RFS than the low-risk group in both the training(P<0.001)and testing cohorts(P<0.001).Conclusions:Our newly developed nomogram integrated clinicopathological data and key gene expression data,and was verified to have high accuracy in predicting the RFS of HCC patients after LR.This model could be used for early identification of patients at high-risk of postoperative recurrence.展开更多
In this article,we comment on the article by Wang et al published in the recent issue of the World Journal of Gastroenterology Surgery.Most prominent advancements in liver surgery in the last two decades are related t...In this article,we comment on the article by Wang et al published in the recent issue of the World Journal of Gastroenterology Surgery.Most prominent advancements in liver surgery in the last two decades are related to refinements in surgical technique(extraglissonean approach)and advancements in surgical technology(laparoscopy and robotics).In this article,authors present both these aspects:Laparoscopic segmentectomy using extraglissonean approach.Furthermore,they describe segmental resections of all 8 segments which is the main novelty that can be observed in the article.By now,extraglissonean approach was thoroughly described mainly in hepatectomies or lateral sectionectomies.Various“hilar gates”are defined which allows safe liver resection by ligating Glissonean pedicles first which is then followed by parenchymal resection.We here focus on past,present and future perspectives of extraglissonean approach and laparoscopic liver resections and comment the value of the presented article.展开更多
BACKGROUND Post-hepatectomy liver failure(PHLF),represents a serious complication after liver resection,significantly impacting the long-term outcomes for patients who undergo such surgeries.There exists a strong corr...BACKGROUND Post-hepatectomy liver failure(PHLF),represents a serious complication after liver resection,significantly impacting the long-term outcomes for patients who undergo such surgeries.There exists a strong correlation between intraoperative hemorrhage and transfusion requirements with the development of PHLF.Presently,a combination of hepatic portal occlusion techniques alongside con-trolled low central venous pressure(CLCVP)methodologies is extensively em-ployed to mitigate intraoperative bleeding.Nonetheless,limited studies have analyzed the risk factors for PHLF under CLCVP.AIM To develop and validate a nomogram that predicts the risk factors associated with the development of PHLF patients undergoing liver resection with CLCVP.METHODS We conducted a retrospective analysis of 285 patients who underwent hepatectomy for the first time and had no history of prior non-index abdominal surgeries,with hepatic inflow occlusion combined with CLCVP from January to December 2019 in Hunan Provincial People’s Hospital.Univariate and multivariate regression analyses were used to identify preoperative and intraoperative risk factors for PHLF.Eligible patients were randomly divided into training and validation groups in a 7:3 ratio,and a nomogram prediction model was constructed.RESULTS The incidence of PHLF in these patients was 22.46%.Multiple logistic analysis showed that preoperative serum albumin level,causes of liver resection(cancer or others),and cirrhosis were independent preoperative risk factors for PHLF(P<0.05)and that only post-blocking blood potassium concentration was an independent intraoperative risk factor for PHLF(P<0.05).Least absolute shrinkage and selection operator regression analysis revealed that preoperative serum albumin level,direct bilirubin level(DBIL),platelet count,causes of liver resection(cancer or others),and cirrhosis were significant predictors of PHLF.The nomogram risk prediction model based on preoperative serum albumin level,DBIL,platelet count,causes of liver resection(cancer or others),cirrhosis and post-blocking blood potassium concentration can better predict the occurrence of PHLF.CONCLUSION For patients undergoing liver resection with CLCVP,serum albumin level,DBIL,platelet count,causes of liver resection(cancer or others),and cirrhosis are independent preoperative risk factors for PHLF.展开更多
文摘Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis.The aim of this review is to assess current indications,advantages and limits of laparoscopic surgery for HCC resections.We also discussed the possible evolution of this surgical approach in parallel with new technologies.
文摘AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad. METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections(n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients(143 surgeries). Accompanying, 37 wedge resections(specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by waterjet. The median central venous pressure was 4 mmH g(range: 5-14). Data was collected prospectively. RESULTS The median age of patients was 60 years(range: 16-85). Preoperative chemotherapy was used in 70 cases(49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL(range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures(15%). The median weight of anatomically resected liver specimens was 525 g(range: 51-1850 g). One patient died postoperatively. Biliary leakages(n = 5) were treated conservatively. Temporary liver failure occurred in two patients.CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.
文摘To evaluate safety and outcomes of a new technique for extreme hepatic resections with preservation of segment 4 only. METHODSThe new method of extreme liver resection consists of a two-stage hepatectomy. The first stage involves a right hepatectomy with middle hepatic vein preservation and induction of left lobe congestion; the second stage involves a left lobectomy. Thus, the remnant liver is represented by the segment 4 only (with or without segment 1, ± S1). Five patients underwent the new two-stage hepatectomy (congestion group). Data from volumetric assessment made before the second stage was compared with that of 10 matched patients (comparison group) that underwent a single-stage right hepatectomy with middle hepatic vein preservation. RESULTSThe two stages of the procedure were successfully carried out on all 5 patients. For the congestion group, the overall volume of the left hemiliver had increased 103% (mean increase from 438 mL to 890 mL) at 4 wk after the first stage of the procedure. Hypertrophy of the future liver remnant (i.e., segment 4 ± S1) was higher than that of segments 2 and 3 (144% vs 54%, respectively, P < 0.05). The median remnant liver volume-to-body weight ratio was 0.3 (range, 0.28-0.40) before the first stage and 0.8 (range, 0.45-0.97) before the second stage. For the comparison group, the rate of hypertrophy of the left liver after right hepatectomy with middle hepatic vein preservation was 116% ± 34%. Hypertrophy rates of segments 2 and 3 (123% ± 47%) and of segment 4 (108% ± 60%, P > 0.05) were proportional. The mean preoperative volume of segments 2 and 3 was 256 ± 64 cc and increased to 572 ± 257 cc after right hepatectomy. Mean preoperative volume of segment 4 increased from 211 ± 75 cc to 439 ± 180 cc after surgery. CONCLUSIONThe proposed method for extreme hepatectomy with preservation of segment 4 only represents a technique that could allow complete resection of multiple bilateral liver metastases.
文摘Objective:The authors present outcomes of robotic liver resections in comparison with open technique questioning the need to have experience of laparoscopy for such procedures before transition to robotic assisted.Materials and methods:Retrospective review of liver resections done robotically from February 2015 to June 2017 compared to matched control cohort of open cases from January 2012 to December 2016.Results:Twenty-one patients in the study groupwere comparedwithmatched control of 42 open cases(1:2 ratio).The types of procedure were similar in both the groups.There were 4 left lateral hepatectomy,3 left hepatectomy,and 1 left hepatectomy with hepatico-jejunostomy,3 right hepatectomy,3 right posterior sectorectomy,4 bisegmentectomy and 4 mono-segmentectomy.There were 9 patients with primary liver cancer,2 each with livermetastasis and carcinoma gall bladder and 8 patients had benign liver disease.Mean blood losswas 370±311ml in the robotic group compared to 451±330ml in control group(p=0.06).Minor complications developed in 19.0%of robotic cases compared to 40.5%in open surgery,while major complications occurred in 4.7%of robotic cases compared to 7.1%of open cases.Mean hospital staywas 5.3±0.8 days for the robotic group and 7.7±4.2 days for open group(p=0.02).Local tumor recurrence occurred in 1 out of 13 resections done for malignancy in the robotic group and 7 out of 26 in the open group.Conclusion:This study highlights the utility of surgical robots for segmental and complex liver resections with equivalent outcomes and decreased length of hospital stay compared to open surgery without having experience of same with the laparoscopy.
文摘Significant advances in surgical techniques and relevant medium-and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections.To support these outstanding results and to reduce perioperative complications,anesthesiologists must address and master key perioperative issues(preoperative assessment,proactive intraoperative anesthesia strategies,and implementation of the Enhanced Recovery After Surgery approach).Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate.Among postoperative complications,posthepatectomy liver failure(PHLF)occurs in different grades of severity(A-C)and frequency(9%-30%),and it is the main cause of 90-d postoperative mortality.PHLF,recently redefined with pragmatic clinical criteria and perioperative scores,can be predicted,prevented,or anticipated.This review highlights:(1)The systemic consequences of surgical manipulations anesthesiologistsmust respond to or prevent,to positively impact PHLF(a proactive approach);and(2)the maximal intensivetreatment of PHLF,including artificial options,mainly based,so far,on Acute Liver Failure treatment(s),to buytime waiting for the recovery of the native liver or,when appropriate and in very selected cases,toward livertransplant.Such a clinical context requires a strong commitment to surgeons,anesthesiologists,and intensivists towork together,for a fruitful collaboration in a mandatory clinical continuum.
文摘BACKGROUND Repeated application of the Pringle maneuver is a key obstacle to safe minimally invasive repeat liver resection(MISRLR).However,limited technical guidance is available.AIM To study the utility of newly developed Pringle taping method guided by liver surface in MISRLR.METHODS We retrospectively reviewed 72 cases of MISRLR performed by a single surgeon at two centers from August 2015 to July 2024.Beginning in October 2019,a liver surface-guided encirclement of hepatoduodenal ligament(LSEH)was used for repeat Pringle taping.Perioperative outcomes including Pringle taping success,operative time,blood loss,conversion rate,morbidity,and mortality were assessed.RESULTS Laparoscopic and robotic approaches were used in 63 patients and 9 patients,respectively.The median operative time,blood loss,and hospital stay were 331.5 minutes,70 mL,and 8 days,respectively.Open conversion occurred in two cases(2.8%)due to severe adhesions and right renal vein injury.Clavien-Dindo grade≥III complications occurred in 5.6%of cases with no mortality.Anti-adhesion barriers were used in 54 patients(75.0%).LSEH was attempted in 57 cases,improving Pringle taping success from 33.0%to 91.4%(P<0.001).LSEH succeeded in all patients with prior open liver resection(n=11).Among 6 patients in whom LSEH failed,3 patients(50.0%)had undergone a third liver resection,and 1 patient had a history of distal gastrectomy with choledochoduodenostomy.CONCLUSION The newly developed LSEH technique for Pringle taping in MISRLR was feasible,enhancing safety and reproducibility even in patients with a history of open liver resection.
基金Supported by the General Project of the Natural Science Foundation of Chongqing,No.cstc2021jcyj-msxmX0604.
文摘BACKGROUND Laparoscopic liver resection(LLR)can be challenging due to the difficulty of establishing a retrohepatic tunnel under laparoscopy.Dissecting the third hepatic hilum before parenchymal transection often leads to significant liver mobilization,tumor compression,and bleeding from the short hepatic veins(SHVs).This study introduces a novel technique utilizing the ventral avascular area of the inferior vena cava(IVC),allowing SHVs to be addressed after parenchymal transection,thereby reducing surgical complexity and improving outcomes in in situ LLR.AIM To introduce and evaluate a novel LLR technique using the ventral avascular area of the IVC and compare its short-term outcomes with conventional methods.METHODS The clinical cohort data of patients with pathologically confirmed hepatocellular carcinoma or intrahepatic cholangiocarcinoma who underwent conventional LLR and novel LLR between July 2021 and July 2023 at the First Affiliated Hospital of Chongqing Medical University were retrospectively analyzed.In novel LLR,we initially separated the caudate lobe from the IVC using dissecting forceps along the ventral avascular area of the IVC.Then,we transected the parenchyma of the left and right caudate lobes from the caudal side to the cephalic side using the avascular area as a marker.Subsequently,we addressed the SHVs and finally dissected the root of the right hepatic vein or left hepatic vein.The short-term postoperative outcomes and oncological results of the two approaches were evaluated and compared.RESULTS A total of 256 patients were included,with 150(58.59%)undergoing conventional LLR and 106(41.41%)undergoing novel LLR.The novel technique resulted in significantly larger tumor resections(6.47±2.96 cm vs 4.01±2.33 cm,P<0.001),shorter operative times(199.57±60.37 minutes vs 262.33±83.90 minutes,P<0.001),less intraoperative blood loss(206.92±37.09 mL vs 363.34±131.27 mL,P<0.001),and greater resection volume(345.11±31.40 mL vs 264.38±31.98 mL,P<0.001)compared to conventional LLR.CONCLUSION This novel technique enhances liver resection outcomes by reducing intraoperative complications such as bleeding and tumor compression.It facilitates a safer,in situ removal of complex liver tumors,even in challenging anatomical locations.Compared to conventional methods,this technique offers significant advantages,including reduced operative time,blood loss,and improved overall surgical efficiency.
基金supported by grants from the Beijing Hospitals Authority Youth Program (12022B4010)BTCH Young Talent En-lightenment Program (2024QMRC24)CAMS Innovation Fund for Medical Sciences (2019-I2M-5–056)。
文摘Extracorporeal liver surgery(ELS), also known as liver autotransplantation, is a hybrid(cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently became more embraced and popularized among leading centers. ELS could be summarized into three major categories, namely, ex-situ liver resection and autotransplantation(ELRA), ante-situm liver resection and autotransplantation(ALRA) and auxiliary partial liver autotransplantation(APLA). The successful development of ELS during the past 37 years is definitely inseparable from continuous effort s done by Chinese surgeons and researchers. Especially, the precision liver surgery paradigm has allowed to transform ELS into a modularized, more simplified, and standardized surgery, to upgrade surgical skills, to improve peri-operative outcome and long-term survival, to increase the capability of surgeons to select more complex diseases and to expand the level of medical service to the population. This review highlights the Chinese contributions to the field of ELS, focusing thereby on features of different surgical types, technical innovations, disease selection and surgical indication, patient prognosis and future perspectives.
文摘Currently,laparoscopic liver resections are routinely performed at an increasing number of centres and has extended to include major liver resections as well as more challenging segments of the liver.We believe that patient positioning and port placement is a critical yet under described component of successful laparoscopic liver resection to achieve optimal visualisation and allow for an ergonomic and safe dissection.In this article,we describe the advantages of various types of patient positioning as well as provide illustrations for an array of trocar configurations previously described in literature.Whilst there is no universally accepted standardization of port placement for various resection types,this descriptive article can serve as a guide for the various possibilities of port configurations that can be individually adapted by surgeons based on their preference as well as the patient’s physique and anatomy.
文摘Transplantation of the left lateral section(LLS)of the liver is now an established practice for treating advanced diffuse and unresectable focal liver diseases in children,with variants of the LLS primarily used in infants.However,the surgical challenge of matching the size of an adult donor's graft to the volume of a child's abdomen remains significant.This review explores historical developments,various approaches to measuring the required functional liver mass,and techniques to prevent complications associated with large-for-size grafts in infants.
基金supported by grants from the National Natural Science Foundation of China (82150 0 04)the National Municipal Key Clinical Specialtythe Clinical Research Project for Major Diseases in Municipal Hospitals (SHDC2020CR1022B)。
文摘Liver transplantation represents a complex surgical procedure and serves as a curative treatment for patients presenting an acute or chronic end-stage liver disease, or carefully selected liver malignancy. A significant gap still exists between the number of available donor organs and potential recipients. The use of an otherwise-wasted resected liver lobe from patients with benign liver tumors is a new, albeit small, option to alleviate the allograft shortage. This review provides evidence that resected liver lobes may be used successfully in liver transplantation.
文摘Liver-directed therapies such as resection,ablation,and embolization offer potentially curative options for patients with primary and metastatic liver tumors as part of multidisciplinary oncology care.However,these treatments pose significant hepatic decompensation risks,particularly with underlying liver disease and chemotherapy-associated steatohepatitis.Accurate assessment of liver function and portal hypertension(PH)is critical for candidate selection.While Child-Pugh score and model for end-stage liver disease are commonly used,they have substantial limitations.Hepatic venous pressure gradient(HVPG)measurement remains the gold standard for assessing PH but is invasive and not widely available.Endoscopic ultrasound(EUS)guided portal pressure gradient(PPG)measurement has emerged as a promising minimally invasive alternative.EUSPPG demonstrates excellent technical success rates,safety profile,and correlation with HVPG in early studies.By providing direct portal pressure measurement,EUS-PPG offers several advantages over existing methods for prognostication and risk stratification prior to liver-directed therapies,particularly in detecting presinusoidal hypertension.Furthermore,it has potential applications in assessing response to neoadjuvant treatments and guiding adjuvant therapies.However,research is needed to validate its predictive performance and cost-effectiveness in larger prospective cohorts and to establish its accuracy compared to non-invasive assessment of liver function.
基金Supported by Feng Chia University/Chung Shan Medical University,No.FCU/CSMU 112-001Taiwan National Science and Technology Council,No.NSTC 114-2221-E-035-036.
文摘BACKGROUND Hepatocellular carcinoma(HCC)in segments VII and VIII poses technical challenges for both liver resection and radiofrequency ablation(RFA).Robotic-assisted techniques may enhance safety and precision,but comparative evidence remains limited.AIM To compare the clinical outcomes of robotic liver resection(R-LR)and robotic intraoperative RFA(RIO-RFA)for HCC located in liver segments VII and VIII.METHODS We retrospectively analyzed 93 HCC patients in segments VII/VIII with de novo(n=57)or first recurrent(n=36).HCC who underwent R-LR or RIO-RFA between 2015 and 2024.Propensity score matching was performed to reduce selection bias.Primary outcomes were overall survival(OS)and recurrence-free survival(RFS).Kaplan-Meier curves,log-rank tests,and Cox regression were used to identify prognostic factors for OS and RFS.RESULTS In the de novo group,OS and RFS did not differ significantly between R-LR and RIO-RFA before or after propensity score matching.In contrast,the recurrent group showed significantly improved OS and RFS with R-LR(P=0.005 and P=0.012,respectively).Subgroup analyses revealed that low-risk de novo patients with smaller tumors achieved superior OS after R-LR,whereas carefully selected low-risk recurrent patients undergoing RIO-RFA(smaller tumors,absence of complications)achieved outcomes comparable to R-LR.Platelet count,tumor size,and postoperative complications constituted key prognostic factors.CONCLUSION For HCC in challenging liver segments VII and VIII,R-LR and RIO-RFA achieve comparable outcomes in de novo cases,whereas R-LR confers superior survival in recurrent disease.R-LR should be prioritized for small de novo HCCs and for recurrent disease overall;RIO-RFA may serve as an effective alternative in carefully selected lowrisk recurrent patients.Tumor size,platelet count,and postoperative complications are key prognostic indicators to guide individualized treatment.
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.
文摘Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seq LDLT) after LR as a strategy for HCC patients with high-risk of recurrence.Methods:We analyzed data from 27 adult patients who underwent seq LDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS).Results:Among 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqL DLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqL DLT as a preemptive strategy. The median age was 53.5 years with 85%males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0%and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors> 5 cm(19%), and a total tumor diameter> 10 cm (7%).Conclusions:Seq LDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seq LDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.
文摘BACKGROUND Tacrolimus is a key immunosuppressive agent used to prevent allograft rejection in kidney transplant recipients.Due to its narrow therapeutic index,careful monitoring is essential to avoid adverse effects,particularly neurotoxicity and nephrotoxicity.Hepatic metabolism is an important part of tacrolimus pharmacokinetics.This case report highlights the impact of liver resection on tacrolimus pharmacokinetics in a kidney transplant recipient.CASE SUMMARY A 61-year-old male with end-stage kidney disease underwent a living-unrelated donor kidney transplant at age 46 and has maintained a stable tacrolimus regimen for 15 years.He was later diagnosed with hepatocellular carcinoma and underwent an open wedge liver resection.Despite stable preoperative tacrolimus levels,he developed acute kidney injury and neurotoxicity(manifested as new-onset tremors and headache)postoperatively.Tacrolimus levels rose from 3.4 ng/mL before surgery to 19.5 ng/mL postoperatively,despite no changes in dosage.This increase was most likely due to reduced liver mass and function following resection,in addition to ischemic injury of the remaining liver parenchyma,leading to impaired drug metabolism and acute toxicity.Liver function tests showed transient abnormalities postoperatively,with transaminase levels peaking at 30 times the normal range before gradually returning to normal,coinciding with the decline in tacrolimus levels.The patient’s symptoms and acute kidney injury improved as tacrolimus concentration returned to normal.CONCLUSION This is the first reported case of acute tacrolimus neurotoxicity and nephrotoxicity in a kidney transplant recipient following liver resection.It highlights the critical need for vigilant therapeutic drug monitoring of tacrolimus after liver surgery to prevent severe adverse effects.
基金Supported by High-level Research Projects of China-Japan Friendship Hospital,No.2022-NHLHCRF-LX-03-0301 and No.2023-NHLHCRF-LXYZ-01.
文摘Combined hepatocellular cholangiocarcinoma(cHCC-CCA)is a rare and ag-gressive primary liver malignancy characterized by features of both HCC and CCA.Preoperative diagnosis remains challenging because of overlapping i-maging and histopathological features,which often lead to misclassification.Although liver resection is the primary curative therapy,the efficacy of liver transplantation(LT)remains controversial.Historically,LT has been considered contraindicated owing to the poor prognosis,high recurrence rate of cHCC-CCA,and the potential for organ wastage.Recent studies have suggested that LT may benefit carefully selected patients,particularly those with early-stage tumors or cirrhosis.However,there is no consensus on the criteria for LT in patients with cHCC-CCA.Lymphadenectomy and vascular resection strategies were discussed along with locoregional and systemic therapies.This review synthesized the current evidence on surgical strategies for cHCC-CCA,focusing on evolving LT criteria and outcomes.
基金supported by a grant from the Exploration Project of Zhejiang Provincial Natural Science Foundation of China(LQ22H160031)。
文摘Background:Hepatocellular carcinoma(HCC)is a common malignancy with high mortality.Liver resection(LR)is a curative treatment for early-stage HCC,but the prognosis of HCC patients after LR is unsatisfactory because of tumor recurrence.Prognostic prediction models with great performance are urgently needed.The present study aimed to establish a novel prognostic nomogram to predict tumor recurrence in HCC patients after LR.Methods:We retrospectively analyzed 726 HCC patients who underwent LR between October 2011 and December 2016.Patients were randomly divided into the training cohort(n=508)and the testing cohort(n=218).The protein expression of 14 biomarkers in tumor tissues was assessed by immunohistochemistry.The nomogram predicting recurrence-free survival(RFS)was established by a multivariate Cox regression analysis model and was evaluated by calibration curves,Kaplan-Meier survival curves,time-dependent areas under the receiver operating characteristic(ROC)curves(AUCs),and decision curve analyses in both the training and testing cohorts.Results:Alpha-fetoprotein[hazard ratio(HR)=1.013,P=0.002],portal vein tumor thrombosis(HR=1.833,P<0.001),ascites(HR=2.024,P=0.014),tumor diameter(HR=1.075,P<0.001),Ecadherin(HR=0.859,P=0.011),EMA(HR=1.196,P=0.022),and PCNA(HR=1.174,P=0.031)immunohistochemistry scores were found to be independent factors for RFS.The 1-year and 3-year AUCs of the nomogram for RFS were 0.813 and 0.739,respectively.The patients were divided into the high-risk group and the low-risk group by median value which was generated from the nomogram,and Kaplan-Meier analysis revealed that the high-risk group had a shorter RFS than the low-risk group in both the training(P<0.001)and testing cohorts(P<0.001).Conclusions:Our newly developed nomogram integrated clinicopathological data and key gene expression data,and was verified to have high accuracy in predicting the RFS of HCC patients after LR.This model could be used for early identification of patients at high-risk of postoperative recurrence.
文摘In this article,we comment on the article by Wang et al published in the recent issue of the World Journal of Gastroenterology Surgery.Most prominent advancements in liver surgery in the last two decades are related to refinements in surgical technique(extraglissonean approach)and advancements in surgical technology(laparoscopy and robotics).In this article,authors present both these aspects:Laparoscopic segmentectomy using extraglissonean approach.Furthermore,they describe segmental resections of all 8 segments which is the main novelty that can be observed in the article.By now,extraglissonean approach was thoroughly described mainly in hepatectomies or lateral sectionectomies.Various“hilar gates”are defined which allows safe liver resection by ligating Glissonean pedicles first which is then followed by parenchymal resection.We here focus on past,present and future perspectives of extraglissonean approach and laparoscopic liver resections and comment the value of the presented article.
基金Supported by the Natural Science Foundation of Hunan Province,No.2018JJ3291the Scientific Research Project of the Hunan Provincial Health Commission,No.202104111288.
文摘BACKGROUND Post-hepatectomy liver failure(PHLF),represents a serious complication after liver resection,significantly impacting the long-term outcomes for patients who undergo such surgeries.There exists a strong correlation between intraoperative hemorrhage and transfusion requirements with the development of PHLF.Presently,a combination of hepatic portal occlusion techniques alongside con-trolled low central venous pressure(CLCVP)methodologies is extensively em-ployed to mitigate intraoperative bleeding.Nonetheless,limited studies have analyzed the risk factors for PHLF under CLCVP.AIM To develop and validate a nomogram that predicts the risk factors associated with the development of PHLF patients undergoing liver resection with CLCVP.METHODS We conducted a retrospective analysis of 285 patients who underwent hepatectomy for the first time and had no history of prior non-index abdominal surgeries,with hepatic inflow occlusion combined with CLCVP from January to December 2019 in Hunan Provincial People’s Hospital.Univariate and multivariate regression analyses were used to identify preoperative and intraoperative risk factors for PHLF.Eligible patients were randomly divided into training and validation groups in a 7:3 ratio,and a nomogram prediction model was constructed.RESULTS The incidence of PHLF in these patients was 22.46%.Multiple logistic analysis showed that preoperative serum albumin level,causes of liver resection(cancer or others),and cirrhosis were independent preoperative risk factors for PHLF(P<0.05)and that only post-blocking blood potassium concentration was an independent intraoperative risk factor for PHLF(P<0.05).Least absolute shrinkage and selection operator regression analysis revealed that preoperative serum albumin level,direct bilirubin level(DBIL),platelet count,causes of liver resection(cancer or others),and cirrhosis were significant predictors of PHLF.The nomogram risk prediction model based on preoperative serum albumin level,DBIL,platelet count,causes of liver resection(cancer or others),cirrhosis and post-blocking blood potassium concentration can better predict the occurrence of PHLF.CONCLUSION For patients undergoing liver resection with CLCVP,serum albumin level,DBIL,platelet count,causes of liver resection(cancer or others),and cirrhosis are independent preoperative risk factors for PHLF.
