Additional nodules detected using EOB-MRI in patients with resectable single hepatocellular carcinoma: an implication for active treatment strategy.

BACKGROUND/AIM: Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOBMRI) further enhances the identification of additional hepatic nodules compared with computed tomography (CT) alone; however, the optimal treatment for such additional nodules remains unclear. We investigated the long-term oncological effect of aggressive treatment strategies for additional lesions identified using EOB-MRI in patients with hepatocellular carcinoma (HCC). METHODS: Data from 522 patients diagnosed with solitary HCC using CT between January 2008 and December 2012 were retrospectively reviewed. Propensity score-matched (PSM) analysis was used to compare the oncologic outcomes between patients with solitary HCC and those with additional nodules on EOB-MRI after aggressive treatment (resection or radiofrequency ablation [RFA]). RESULTS: Among the 383 patients included, 59 had additional nodules identified using EOB-MRI. Compared with patients with solitary HCC, those with additional nodules on EOB-MRI had elevated total bilirubin, aspartate transaminase, and alanine transaminase; had a lower platelet count, higher MELD score, and highly associated with liver cirrhosis (P<0.05). Regarding long-term outcomes, 59 patients with solitary HCC and those with additional nodules after PSM were compared. Disease-free survival (DFS) and overall survival (OS) were comparable between the two groups (DFS, 60.4 vs. 44.3 months, P=0.071; OS, 82.8 vs. 84.8 months, P=0.986). CONCLUSION: The aggressive treatment approach, either resection or RFA, for patients with additional nodules identified on EOBMRI was associated with long-term survival comparable with that for solitary HCC. However, further studies are required to confirm these findings.

Major Laparoscopic Versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-Matched Analysis Based on Surgeons' Learning Curve.

BACKGROUND: Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis. METHODS: This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized. RESULTS: Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups. CONCLUSIONS: LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.

Oncologic safety of laparoscopic radical cholecystectomy in pT2 gallbladder cancer: A propensity score matching analysis compared to open approach.

The role of laparoscopic radical cholecystectomy (LRC) in the surgical management of T2 gallbladder carcinoma (GBC) is still controversial.The medical records of patients with T2 GBC treated with radical cholecystectomy were retrospectively reviewed. In this study, we compare the short- and long-term oncologic outcomes, using propensity score matching analysis, of patients with T2 GBC who underwent LRC and open radical cholecystectomy (ORC).Among 183 patients, 86 were selected by propensity score matching (LRC = 43 and ORC = 43). The ORC group underwent more extensive surgery (liver resections and extended lymph node dissections [ELND]) than the LRC group. The LRC group had less operative blood loss, shorter length of hospital stay, fewer complications, and had the earlier start of adjuvant chemotherapy. There was no significant difference between the laparoscopic and open surgery groups in terms of 5-year overall survival rate (64.6% vs 80.4%, P = .214) and disease-free survival rate (77.1% vs 82.2%, P = .641). A subgroup analyses showed that liver resection and ELND had no survival advantage compared to no liver resection and regional lymph node dissection, respectively.Our LRC approach is safe and effective, with long-term survival comparable to that of ORC.

What are the most important predictive factors for clinically relevant posthepatectomy liver failure after right hepatectomy for hepatocellular carcinoma?

PURPOSE: The risk of posthepatectomy liver failure (PHLF) after right hepatectomy remains substantial. Additional parameters such as computed tomography volumetry, liver stiffness measurement by FibroScan, indocyanine green retention rate at 15 minutes, and platelet count used to properly assess future liver remnant volume quality and quantity are of the utmost importance. Thus, we compared the usefulness of these modalities for predicting PHLF among patients with hepatocellular carcinoma after right hepatectomy. METHODS: We retrospectively reviewed patients who underwent right hepatectomy for hepatocellular carcinoma between 2007 and 2013. PHLF was determined according to International Study Group of Liver Surgery consensus definition and severity grading. Grades B and C were defined as clinically relevant posthepatectomy liver failure (CRPHLF). The results were internally validated using a cohort of 97 patients. RESULTS: Among the 90 included patients, 15 (16.7%) had CRPHLF. Multivariate analysis confirmed that platelet count < 140 (109/L) (hazard ratio [HR], 24.231; 95% confidence interval [CI], 3.623-161.693; P = 0.001) and remnant liver volume-to-body weight (RVL/BW) ratio < 0.55 (HR, 25.600; 95% CI, 4.185-156.590; P < 0.001) were independent predictors of CRPHLF. Among the 12 patients with a platelet count < 140 (109/L) and RLV/BW ratio < 0.55, 9 (75%) had CRPHLF. Likewise, 5 of 38 (13.2%) with only one risk factor developed CRPHL versus 1 of 40 (2.5%) with no risk factors. These findings were confirmed by the validation cohort. CONCLUSION: RLV/BW ratio and platelet count are more important than the conventional RLV/TFLV, indocyanine green retention rate at 15 minutes, and liver stiffness measurement in the preoperative risk assessment for CRPHLF.

Prognostic significance of and risk prediction model for lymph node metastasis in resectable intrahepatic cholangiocarcinoma: do all require lymph node dissection?

BACKGROUND: Lymph node (LN) metastasis portends a worse prognosis following resection of intrahepatic cholangiocarcinoma (ICC); however, lymphadenectomy is not routinely performed, as its role remains controversial. Herein, we developed a risk model for LN metastasis by identifying its predictive factors and assessed a subset of patients who might not benefit from LN dissection (LND). METHODS: 210 patients who underwent curative-intent surgery for ICC were retrospectively reviewed. A preoperative risk model for LN metastasis was developed following identification of its preoperative predictive factors using the recursive partitioning method. RESULTS: In the multivariable analysis, CA 19-9 level of >120 U/mL, an enlarged LN on computed tomography, and a tumor location abutting the Glissonean pedicles were independent predictors of LN metastasis. The preoperative risk model classified the patients according to their risk: high, intermediate, and low risks at a rate of LN metastasis on final pathology of 60.9%, 35%, and 2.3%, respectively. In the subgroup analysis among the low-risk patients, performance of LND had no survival advantage over non-performance of LND. CONCLUSION: Routine LND for preoperatively diagnosed ICC should be recommended to patients at an intermediate and a high risk of developing LN metastasis but may be omitted for low-risk patients.

Clinical implication of tumor site in terms of node metastasis for intrahepatic cholangiocarcinoma.

BACKGROUND: The clinical implication of lymph node (LN) dissection of intrahepatic cholangiocarcinoma (ICCA) is still controversial, and LN metastasis (LNM) based on tumor site has not been confirmed yet. METHODS: Patients who underwent curative-intent surgery at 10 tertiary referral centers were identified and divided into peripheral (PP) and near second confluence level tumor (NC) groups on the basis of the distance from the second confluence and oncological outcomes were compared. RESULTS: Of 179 patients, 121 patients with LND were divided into the NC (n = 89) and PP groups (n = 32) on the basis of 4.5 cm from the second confluence. NC group showed higher LNM rate than PP group (46.1 vs 21.9%, p = 0.016) and NC was a risk factor for LNM (odds ratio: 4.367; 95% confidence interval: 1.234-15.453, p = 0.022). The 5-year overall survival (OS) rate (38.0% vs. 27.8%, p = 0.777) and recurrence-free survival (RFS) rates (22.8% vs. 25.8%, p = 0.742) showed no differences between the PP and NC groups. In the NC group, N1 patients showed worse 5-year OS (12.7% vs 39.0%, p = 0.004) and RFS (8.8% vs 28.6%, p = 0.004) than the N0 patients. In the PP group, discordant results in 5-year OS (48.9% vs. 50.0%, p = 0.462) and RFS (41.3% vs. 0%, p = 0.056) were found between the N0 and N1 patients. CONCLUSION: The NC group was an independent risk factor for LNM and LNM worsened prognosis in NC group for ICCA. In the PP group, LND should not be omitted because of high LNM rate and insufficient oncologic evidence.

Stepwise development of laparoscopic liver resection skill using rubber traction technique.

BACKGROUND: To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes. METHODS: Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome. RESULTS: As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed. CONCLUSION: Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.

Robotic simultaneous resection for colorectal liver metastasis: feasibility for all types of liver resection.

BACKGROUND: A laparoscopic approach is increasingly being utilized in simultaneous colorectal and liver resection (SCLR) for colorectal cancer with liver metastasis. However, this approach is technically challenging and hence has not been widely adopted. Robotic surgical systems could potentially overcome this problem. We aim to describe the feasibility and outcomes of robotic SCLR for colorectal carcinoma with liver metastasis. METHODS: The medical records of 12 patients who underwent robotic SCLR for colorectal cancer with liver metastasis between January 2008 and September 2018 were reviewed retrospectively. RESULTS: The mean age was 59 years (range, 37-77 years). The liver resections were comprised of two right hepatectomies, one left hepatectomy, one left lateral sectionectomy, one segmentectomy of S3 and wedge resection (segment 7), one caudate lobectomy, one associated liver partition and portal vein ligation for staged hepatectomy, and five wedge resections involving segments 4, 5, 6, 7, or 8. The colorectal procedures involved seven low-anterior resections, two anterior resections, two right hemicolectomies, and one left hemicolectomy. The mean operative time was 449 min (range, 135-682 min) with a mean estimated blood loss of 274.3 mL (range, 40-780 mL). The mean length of hospital stay was 12 days (range, 5-28 days). No patients required conversion to laparotomy. Liver resection-related complications were two liver abscesses (Clavien-Dindo classification, one grade II and one grade III) and one case of ascites (grade I), whereas colorectal resection-related complications included one anastomosis leak (grade III) and one superficial wound infection (grade II). There were no deaths reported within 30 days of the procedure. With a mean follow-up duration of 31.5 ± 26.1 months, the overall survival and disease-free survival values were 75.2 and 47.1 months, respectively. CONCLUSION: Robotic SCLR for colorectal neoplasm with liver metastasis can be performed safely even in cases requiring major liver resections, especially in a specialized center with a well-trained team.

Right anterior section graft for living-donor liver transplantation: A case report.

RATIONALE: In living-donor liver transplantation (LDLT), the right lobe graft is commonly utilized to prevent small-for-size syndrome, despite the considerable donor morbidity. Conversely, the feasibility of the left lobe graft and the right posterior section graft in smaller-sized recipients is now commonly employed with comparable outcomes to right lobe grafts. The efficacy of the right anterior section graft has rarely been reported. PATIENT CONCERNS: A 56-year-old man, a heavy alcoholic beverage drinker for 20 years, presented in the emergency department with massive ascites and lethargy. He was previously admitted twice due to bleeding esophageal varices. DIAGNOSIS: He was diagnosed with hepatic encephalopathy coma due to alcoholic liver cirrhosis. The Child-Turcotte-Pugh score was 11 (class C), and the Model for End-stage Liver Disease score was 21.62. INTERVENTION: A LDTL was offered to the patient as the best treatment option available. The patient's 26-year-old son was found to be the only donor-compatible candidate for the LDTL.Preoperatively, the right lobe of the donor occupied 76.2% of the total liver volume exposing the donor to a small residual liver volume. The right posterior section and left lobe volumes were insufficient, providing a graft-to-recipient weight ratio of 0.42% and 0.38%, respectively. However, the right anterior section could fulfill an acceptable GRWR of 0.83%. Thus, a living donor right anterior sectionectomy was performed. OUTCOMES: Clinical signs and symptoms and liver function improved following anterior section graft transplantation without complications. LESSON: The procurement of anterior section graft is technically feasible in selected patients, especially in high-volume liver centers.

Pitfalls for laparoscopic pancreaticoduodenectomy: Need for a stepwise approach.

Because of today's advancements in surgical techniques and perioperative management skills, surgeons are beginning to explore the usefulness of the laparoscopic approach in managing periampullary tumors. However, as a result of its innate complexity and associated high surgery-related complications, its applicability to the general surgical community remains controversial. To date, only retrospective data from high-volume centers support the safety and feasibility of laparoscopic pancreaticoduodenectomy (Lap PD) for the treatment of benign conditions and malignant periampullary tumors. In addition, various surgical techniques in terms of port placement, dissection, and reconstruction have evolved in different centers depending on the preferred method commonly used by the surgeon through accumulated experience. In our center, we used a stepwise approach and standardized our surgical technique to overcome this technically demanding procedure. A collaborative implementation of video review and analysis, practice training and simulation, operating room didactics, and strict adherence to our stepwise approach in Lap PD, might potentially improve the surgical skills of young hepatobiliary surgeons and possibly overcome the volume-based learning curve of Lap PD.

Laparoscopic radical cholecystectomy with common bile duct resection for T2 gallbladder cancer.

The oncologic safety and feasibility of laparoscopic radical cholecystectomy for a preoperatively suspected gallbladder cancer is continually being challenged even in an era of minimally invasive surgery. A seventy-four-year-old woman was presented in the outpatient department with a history of fever, abdominal pain, and vomiting. CT scan showed an irregular wall thickening of the body to the cystic duct of the gallbladder and portocaval lymph node. In addition, EUS revealed no subserosal invasion of the tumor. PET scan showed an intense FDG uptake of in the gallbladder and in the portocaval lymph node. The laparoscopic radical cholecystectomy was performed with 6 trocars. The procedure included simple cholecystectomy, hepatoduodenal and aortocaval lymphadenectomy, and common bile duct resection. The hepaticojejunal anastomosis was constructed laparoscopically, while the jejunal continuity was established via an extracorporeal anastomosis. The patient was discharged on the 7th postoperative day with no complications and adjuvant chemotherapy was started on the 14th day after surgery. Based on our experienced, laparoscopic radical cholecystectomy with combined common bile duct resection is technically safe and feasible.

Glucose to Lymphocyte Ratio as a Prognostic Marker in Patients With Resected pT2 Gallbladder Cancer.

BACKGROUND: We designed a clinical application of glucose to lymphocyte ratio (GLR) as it might be a sensitive parameter to determine the glucose metabolism and behavior of the cancer (i.e., its aggressiveness), and the immunologic status of a patient with cancer. Thus, we investigated the association of GLR with the overall survival (OS) and disease-free survival (DFS) of patients with T2 gallbladder (GB) cancer after curative-intent surgery. METHODS: The medical records of patients with T2 GB cancer who underwent surgery were retrospectively reviewed. The clinicopathologic characteristics, preoperative complete blood counts, fasting blood glucose, albumin, cholesterol, and follow-up information were collected. RESULTS: A total of 197 patients were included in the study. In multivariate analysis, high GLR (>69.3) was associated with poor OS (HR = 15.249, 95% CI: 4.090-56.849, P = 0.0001) along with R1 status (HR = 1.755, 95% CI: 0.033-0.910, P = 0.033), >3 metastatic lymph nodes (HR = 2.809, 95% CI: 1.403-5.625; P = 0.004), and lymphovascular invasion (HR = 8.041, 95% CI: 2.881-22.442; P = 0.0001). Moreover, high GLR (HR = 3.666, 95% CI: 1.145-11.737, P = 0.029), adjuvant chemotherapy (HR = 6.306, 95% CI: 1.921-20.699; P = 0.002), lymphovascular invasion (HR = 5.464, 95% CI: 1.783-16.746; P = 0.003), and high-grade tumor (HR = 2.143, 95% CI: 1.042-4.407; P = 0.038) were independently associated with DFS. CONCLUSIONS: Preoperative GLR is an independent predictor of OS and DFS in T2 GB cancer. Further studies are required to validate these findings.