Additional hepatic artery embolization after liver venous deprivation for right hepatectomy: A case report.

Post hepatectomy Liver Failure (PHLF) is a fatal complication, especially after major liver resection. Insufficient remnant liver volume is a common cause of postoperative liver failure. Many strategies have been applied to induce the remnant liver hypertrophy: Portal vein embolization (PVE), PVE combined with hepatic vein embolization (LVD), two staged liver resection, Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS). We present a case of a 39-year-old male patient who underwent LVD for preoperative liver hypertrophy. After LVD, the patient underwent additional artery embolization, and the patient's remaining liver volume increased by 63.2% in 7 weeks. The patient underwent a right hepatectomy and was discharged after 10 days, with no complications of postoperative liver failure. Simultaneous portal and hepatic vein embolization is a technique that has been applied recently because it can significantly promote the speed and extent of liver hypertrophy before major liver resection compared to portal vein embolization procedure alone. In this case, additional hepatic artery embolization may be an important factor lead to hypertrophy of the remnant liver, thereby shortening the waiting time for surgery and reducing the risk of tumor progression. Liver venous deprivation is safe and feasible to perform. Additional hepatic artery embolization may accelerate the hypertrophy of the remnant liver.

Heparin is an effective treatment for preventing liver failure after hepatectomy.

BACKGROUND: Posthepatectomy liver failure (PHLF) is one of the most important causes of death following liver resection. Heparin, an established anticoagulant, can protect liver function through a number of mechanisms, and thus, prevent liver failure. AIM: To look at the safety and efficacy of heparin in preventing hepatic dysfunction after hepatectomy. METHODS: The data was extracted from Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) v1. 4 pinpointed patients who had undergone hepatectomy for liver cancer, subdividing them into two cohorts: Those who were injected with heparin and those who were not. The statistical evaluations used were unpaired t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests to assess the effect of heparin administration on PHLF, duration of intensive care unit (ICU) stay, need for mechanical ventilation, use of continuous renal replacement therapy (CRRT), incidence of hypoxemia, development of acute kidney injury, and ICU mortality. Logistic regression was utilized to analyze the factors related to PHLF, with propensity score matching (PSM) aiming to balance the preoperative disparities between the two groups. RESULTS: In this study, 1388 patients who underwent liver cancer hepatectomy were analyzed. PSM yielded 213 matched pairs from the heparin-treated and control groups. Initial univariate analyses indicated that heparin potentially reduces the risk of PHLF in both matched and unmatched samples. Further analysis in the matched cohorts confirmed a significant association, with heparin reducing the risk of PHLF (odds ratio: 0.518; 95% confidence interval: 0.295-0.910; P = 0.022). Additionally, heparin treatment correlated with improved short-term postoperative outcomes such as reduced ICU stay durations, diminished requirements for respiratory support and CRRT, and lower incidences of hypoxemia and ICU mortality. CONCLUSION: Liver failure is an important hazard following hepatic surgery. During ICU care heparin administration has been proved to decrease the occurrence of hepatectomy induced liver failure. This indicates that heparin may provide a hopeful option for controlling PHLF.

Dense tumor-infiltrating lymphocytes (TILs) in liver metastasis from colorectal cancer are related to improved overall survival.

BACKGROUND AND OBJECTIVES: Tumor-infiltrating lymphocytes (TILs) represent a host-tumor interaction, frequently signifying an augmented immunological response. Nonetheless, implications with survival outcomes in patients with colorectal carcinoma liver metastasis (CRLM) warrant rigorous validation. The objective was to demonstrate the association between TILs and survival in patients with CRLM. METHOD: In a retrospective evaluation conducted in a single institution, we assessed all patients who underwent hepatectomy due to CRLM between 2014 and 2018. Comprehensive medical documentation reviews were executed. TILs were assessed by a liver pathologist, blinded to the clinical information, in all surgical slides. RESULTS: This retrospective cohort included 112 patients. Median overall survival (OS) was 58 months and disease-free survival (DFS) was 12 months for the entire cohort. Comparison between groups showed a median OS of 81 months in the dense TILs group and 40 months in the weak/absent group (p = 0.001), and DFS was 14 months versus 9 months (p = 0.041). Multivariable analysis showed that TILs were an independent predictor of OS (HR 1.95; p = 0.031). CONCLUSIONS: Dense TILs are a pivotal prognostic indicator, correlating with enhanced OS. Including TILs information in histopathological evaluations should refine the clinical decision-making process for this group of patients.

Single Port Robotic Liver Resection: Metastasectomy for Recurrent Fibrolamellar Hepatocellular Carcinoma.

BACKGROUND: Robotic surgery has emerged as a promising approach for managing complex hepatic malignancies. This report presents a case of a single-port robotic liver resection for a patient with recurrent hepatocellular carcinoma (HCC) and metastases, focusing on the surgical technique and outcomes. METHOD: An 18-year-old female with a history of left hepatectomy for fibrolamellar HCC underwent robotic liver resection using the Da Vinci SP Surgical System. The procedure entailed excising a 30 mm tumor in liver segment 4 (Sg4) along with peritoneal metastases in the superior pole of the spleen and cardiophrenic lymph node metastasis. Surgical techniques comprised adhesiolysis, resection of the peritoneal nodule, Sg4 partial liver resection, and excision of the cardiophrenic lymph node. RESULTS: The operative time was 310 min, with a blood loss of 37 mL. The patient experienced an uneventful postoperative course and was discharged home after 8 days. Partial liver resection of Sg4 revealed a moderately differentiated HCC with negative resection margins. Additionally, excision of peritoneal metastases in the superior pole of the spleen and cardiophrenic lymph nodes, consistent with metastasis, was performed. Notably, the Da Vinci SP system's relocation function proved useful in this case, particularly in slender patients with multiple distant metastases. CONCLUSION: This case underscores the importance of technological advancements in robotic surgery. The Da Vinci SP system, with its advantageous features, shows promise in challenging clinical scenarios. Its ability to facilitate precise navigation and manipulation within the patient's restricted abdominal cavity contributed to the observed successful outcome.

Advantages of laparoscopic segmentectomy of the liver using ICG fluorescent navigation by the negative staining method: A comparison with open procedure.

Aim: Laparoscopic segmentectomy (LS) using indocyanine green (ICG) fluorescence navigation with negative staining method has potential for performing accurate and safe anatomical excision. This study aimed to evaluate the significance of LS using ICG fluorescence navigation compared with open segmentectomy (OS). Methods: Eighty-seven patients who underwent anatomical segmentectomies were evaluated for OS (n = 44) and LS (n = 43). The Glissonean pedicle approach was performed using either extra- or intrahepatic method, depending on the location of segment in LS. After clamping pedicle, negative staining method was performed. Liver transection was done along intersegmental plane visualizing by overlay mode of ICG camera. Surgical outcomes were compared between two groups. Correlation between predicted resecting liver volume (PRLV) calculated using volumetry and actual resected liver volume (ARLV) was assessed in two groups. Results: Patients who underwent LS showed better outcomes in operative time, blood loss, and length of hospital stay. There were significantly fewer Grade II and Grade III or higher postoperative complications in LS group. Both values of AST (p < 0.001) and ALT (p < 0.001) on postoperative day 1 were significantly lower in LS group than in OS group. PRLV and ARLV were more strongly correlated in LS (r = 0.896) than in OS (r = 0.773). The difference between PRLV and ARLV was significantly lower in LS group than in OS group (p = 0.022), and this trend was particularly noticeable in posterosuperior segment (p = 0.008) than in anterolateral segment (p = 0.811). Conclusion: LS using ICG navigation allows precise resection and may contribute to safer short-term outcomes than OS, particularly in posterosuperior segment.

Is operation time over the benchmark value a risk factor for worse short-term outcomes after laparoscopic liver resection?

Introduction: Laparoscopic liver resection is a challenging surgical procedure that may require prolonged operation time, particularly during the learning curve. Operation time significantly decreases with increasing experience; however, prolonged operation time may significantly increase the risk of postoperative complications. Aim: To assess whether prolonged operation time over the benchmark value influences short-term postoperative outcomes after laparoscopic liver resection. Material and methods: A retrospective cohort study based on data from the National Polish Registry of Minimally Invasive Liver Surgery was performed. A total of 197 cases consisting of left lateral sectionectomy (LLS), left hemihepatectomy (LH), and right hemihepatectomy (RH) with established benchmark values for operation time were included. Data about potential confounders for prolonged operation time and worse short-term outcomes were exported. Results: Most cases (129; 65.5%) were performed during the learning curve, while the largest rate was observed in LLS (57; 78.1%). Median operation time exceeded the benchmark value in LLS (Me = 210 min) and LH (Me = 350 min), while in RH the benchmark value was exceeded in 39 (44.3%) cases. Textbook outcomes were achieved in 138 (70.1%) cases. Univariate analysis (OR = 1.11; 95% CI: 0.61-2.06; p = 0.720) and multivariate analysis (OR = 1.16; 95% CI: 0.50-2.68; p = 0.734) did not reveal a significant impact of prolonged surgery on failing to achieve a textbook outcome. Conclusions: Prolonging the time of laparoscopic liver resection does not significantly impair postoperative results. There is no reason related to the patients' safety to avoid prolonging the time of laparoscopic liver resection over the benchmark value.

Perioperative impact of liver cirrhosis on robotic liver resection for hepatocellular carcinoma: a retrospective cohort study.

BACKGROUND: The safety and efficacy of robotic liver resection (RLR) for patients with hepatocellular carcinoma (HCC) have been reported worldwide. However, the exact role of RLR in HCC patients with liver cirrhosis is not sufficiently determined. METHODS: We conducted a retrospective study on consecutive patients with cirrhosis or non-cirrhosis who received RLR for HCC from 2018 to 2023. Data on patients' demographics and perioperative outcomes were collected and analyzed. Propensity score matching (PSM) analysis was performed. Multivariate logistic regression analysis was performed to determine the risk factors of prolonged postoperative length of stay (LOS) and morbidity. RESULTS: Of the 571 patients included, 364 (64%) had cirrhosis. Among the cirrhotic patients, 48 (13%) were classified as Child-Pugh B. After PSM, the cirrhosis and non-cirrhosis group (n = 183) had similar operative time, estimated blood loss, postoperative blood transfusion, LOS, overall morbidity (p > 0.05). In addition, the intraoperative and postoperative outcomes were similar between the two groups in the subgroup analyses of patients with tumor size ≥ 5 cm, major hepatectomy, and high/expert IWATE difficulty grade. However, patients with Child-Pugh B cirrhosis had longer LOS and more overall morbidity than that of Child-Pugh A. Child-Pugh B cirrhosis, ASA score > 2, longer operative time, and multiple tumors were risk factors of prolonged LOS or morbidity in patients with cirrhosis. CONCLUSION: The presence of Child-Pugh A cirrhosis didn't significantly influence the difficulty and perioperative outcomes of RLR for selected patients with HCC. However, even in high-volume center, Child-Pugh B cirrhosis was a risk factor for poor postoperative outcomes.

Indocyanine Green Fluorescence-Guided Laparoscopic Anatomical Segmentectomy of Liver Segment 6: Surgical Strategy and Technical Details.

BACKGROUND: Because of the complex anatomy of the right posterior hepatic pedicle, there have been few reports on standardized laparoscopic portal territory staining-guided anatomical resection of liver segment 6 (LPTAR-S6). This study aimed to elucidate the indocyanine green (ICG) fluorescence staining methods for LPTAR-S6. PATIENTS AND METHODS: LPTAR-S6 can be performed using positive and negative fluorescence staining approaches. We implemented these two approaches for patients with hepatocellular carcinoma. Descriptions of the surgical strategy and technical details are presented. RESULTS: Two patients safely underwent LPTAR-S6 using a preoperative three-dimensional reconstruction plan. The intraoperative ICG fluorescence staining effect was satisfactory, and the anatomical landmarks were fully exposed. CONCLUSIONS: A detailed preoperative three-dimensional reconstruction plan, complete intraoperative application of real-time laparoscopic ultrasound guidance, and ICG fluorescence staining can result in accurate transection of the liver parenchyma during LPTAR-S6.

6,126 hepatectomies in 2022: current trend of outcome in Italy.

PURPOSE: Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume. METHODS: This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added. RESULTS: 6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively). CONCLUSIONS: High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.

Impact of Lymph Node Dissection for Patients With Clinically Node-Negative Intrahepatic Cholangiocarcinoma: A Multicenter Cohort Study.

Background: Lymph node status is a prominent prognostic factor for intrahepatic cholangiocarcinoma (ICC). However, the prognostic value of performing lymph node dissection (LND) in patients with clinical node-negative ICC remains controversial. The aim of this study was to evaluate the clinical value of LND on long-term outcomes in this subgroup of patients. Methods: We retrospectively analyzed patients who underwent radical liver resection for clinically node-negative ICC from three tertiary hepatobiliary centers. The propensity score matching analysis at 1:1 ratio based on clinicopathological data was conducted between patients with and without LND. Recurrence-free survival (RFS) and overall survival (OS) were compared in the matched cohort. Results: Among 303 patients who underwent radical liver resection for ICC, 48 patients with clinically positive nodes were excluded, and a total of 159 clinically node-negative ICC patients were finally eligible for the study, with 102 in the LND group and 57 in the non-LND group. After propensity score matching, two well-balanced groups of 51 patients each were analyzed. No significant difference of median RFS (12.0 vs. 10.0 months, P = 0.37) and median OS (22.0 vs. 26.0 months, P = 0.47) was observed between the LND and non-LND group. Also, LND was not identified as one of the independent risks for survival. Among 51 patients who received LND, 11 patients were with positive lymph nodes (lymph node metastasis (LNM) (+)) and presented significantly worse outcomes than those with LND (-). On the other hand, postoperative adjuvant therapy was the independent risk factor for both RFS (hazard ratio (HR): 0.623, 95% confidence interval (CI): 0.393 - 0.987, P = 0.044) and OS (HR: 0.585, 95% CI: 0.359 - 0.952, P = 0.031). Furthermore, postoperative adjuvant therapy was associated with prolonged survivals of non-LND patients (P = 0.02 for RFS and P = 0.03 for OS). Conclusions: Based on the data, we found that LND did not significantly improve the prognosis of patients with clinically node-negative ICC. Postoperative adjuvant therapy was associated with prolonged survival of ICC patients, especially in non-LND individuals.

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases.

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

The Effects of Sarcopenia on Overall Survival and Postoperative Complications of Patients Undergoing Hepatic Resection for Primary or Metastatic Liver Cancer: A Systematic Review and Meta-Analysis.

Background: Colorectal cancer is the third most common cancer worldwide, and 20-30% of patients will develop liver metastases (CRLM) during their lifetime. Hepatocellular carcinoma (HCC) is also one of the most common cancers worldwide with increasing incidence. Hepatic resection represents the most effective treatment approach for both CRLM and HCC. Recently, sarcopenia has gained popularity as a prognostic index in order to assess the perioperative risk of hepatectomies. The aim of this study is to assess the effects of sarcopenia on the overall survival (OS), complication rates and mortality of patients undergoing liver resections for HCC or CRLM. Methods: A systematic literature search was performed for studies including patients undergoing hepatectomy for HCC or CRLM, and a meta-analysis of the data was performed. Results: Sarcopenic patients had a significantly lower 5-year OS compared to non-sarcopenic patients (43.8% vs. 63.6%, respectively; p < 0.01) and a significantly higher complication rate (35.4% vs. 23.1%, respectively; p = 0.002). Finally, no statistical correlation was found in mortality between sarcopenic and non-sarcopenic patients (p > 0.1). Conclusions: Sarcopenia was significantly associated with decreased 5-year OS and increased morbidity, but no difference was found with regard to postoperative mortality.

Von Willebrand Factor Antigen Improves Risk Stratification for Patients with a Diagnosis of Resectable Hepatocellular Carcinoma.

BACKGROUND: Posthepatectomy liver failure (PHLF), complications of portal hypertension, and disease recurrence determine the outcome for hepatocellular carcinoma (HCC) patients undergoing liver resection. This study aimed to evaluate the von Willebrand factor antigen (vWF-Ag) as a non-invasive test for clinically significant portal hypertension (CSPH) and a predictive biomarker for time to recurrence (TTR) and overall survival (OS). METHODS: The study recruited 72 HCC patients with detailed preoperative workup from a prospective trial (NCT02118545) and followed for complications, TTR, and OS. Additionally, 163 compensated patients with resectable HCC were recruited to evaluate vWF-Ag cutoffs for ruling out or ruling in CSPH. Finally, vWF-Ag cutoffs were prospectively evaluated in an external validation cohort of 34 HCC patients undergoing liver resection. RESULTS: In receiver operating characteristic (ROC) analyses, vWF-Ag (area under the curve [AUC], 0.828) was similarly predictive of PHLF as indocyanine green clearance (disappearance rate: AUC, 0.880; retention rate: AUC, 0.894), whereas computation of future liver remnant was inferior (AUC, 0.756). Cox-regression showed an association of vWF-Ag with TTR (per 10%: hazard ratio [HR], 1.056; 95% confidence interval [CI] 1.017-1.097) and OS (per 10%: HR, 1.067; 95% CI 1.022-1.113). In the analyses, VWF-Ag yielded an AUC of 0.824 for diagnosing CSPH, with a vWF-Ag of 182% or lower ruling out and higher than 291% ruling in CSPH. Therefore, a highest-risk group (> 291%, 9.7% of patients) with a 57.1% incidence of PHLF was identified, whereas no patient with a vWF-Ag of 182% or lower (52.7%) experienced PHLF. The predictive value of vWF-Ag for PHLF and OS was externally validated. CONCLUSION: For patients with resectable HCC, VWF-Ag allows for simplified preoperative risk stratification. Patients with vWF-Ag levels higher than 291% might be considered for alternative treatments, whereas vWF-Ag levels of 182% or lower identify patients best suited for surgery.

Retrospective Analysis of Postoperative Nonhepatic Outcomes Following Major Liver Resection.

Background Liver surgery is a major and challenging procedure for the surgeon, the anesthetist, and the patient. The objective of this study was to evaluate the postoperative nonhepatic complications of patients undergoing liver resection surgery with perioperative factors. Methods We retrospectively analyzed 79 patients who underwent liver resection surgeries at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan, from July 2015 to December 2022. Results The mean age at the time of surgery was 53 years (range: 3-77 years), and the mean BMI was 26.43 (range: 15.72-38.0 kg/m2). Of the total patients, 44.3 % (n = 35) had no comorbidities, 26.6% (n=21) had one comorbidity, and 29.1% (n=23) had two or more comorbidities. Patients in whom the blood loss was more than 375 ml required postoperative oxygen inhalation with a significant relative risk of 2.6 (p=0.0392) and an odds ratio of 3.5 (p=0.0327). Similarly, patients who had a surgery time of more than five hours stayed in the hospital for more than seven days, with a statistically significant relative risk of 2.7 (p=0.0003) and odds ratio of 7.64 (p=0.0001). The duration of surgery was also linked with the possibility of requiring respiratory support, with a relative risk of 5.0 (p=0.0134) and odds ratio of 5.73 (p=0.1190). Conclusion Patients in our cohort who had a prolonged duration of surgery received an increased amount of fluids, and a large volume of blood loss was associated with prolonged stay in the ICU (>2 days), hospital admission (>7 days), ICU readmission, and increased incidence of cardiorespiratory, neurological, and renal disturbances postoperatively.

Analgesic effects of ultrasound-guided preoperative posterior Quadratus Lumborum block in laparoscopic hepatectomy: A prospective double-blinded randomized controlled trial.

STUDY OBJECTIVE: To determine if single-injection bilateral posterior quadratus lumborum block (QLB) with ropivacaine would improve postoperative analgesia in the first 24 h after laparoscopic hepatectomy, compared with 0.9% saline. DESIGN: Prospective, double blinded, randomized controlled trial. SETTING: A single tertiary care center from November 2021 and January 2023. PATIENTS: A total of 94 patients scheduled to undergo laparoscopic hepatectomy due to hepatocellular carcinoma. INTERVENTIONS: Ninety-four patients were randomized into a QLB group (receiving 20 mL of 0.375% ropivacaine on each side, 150 mg in total) or a control group (receiving 20 mL of 0.9% saline on each side). MEASUREMENTS: The primary outcome was the cumulative opioid consumption during the initial 24-h post-surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters. MAIN RESULTS: The mean cumulative opioid consumption during the initial 24-h post-surgery was 30.8 ± 22.4 mg in the QLB group (n = 46) and 34.0 ± 19.4 mg in the control group (n = 46, mean differences: -3.3 mg, 95% confidence interval, -11.9 to 5.4, p = 0.457). The mean resting pain score at 1 h post-surgery was significantly lower in the QLB group than in the control group (5 [4-6.25] vs. 7 [4.75-8], p = 0.035). No significant intergroup differences were observed in the resting or coughing pain scores at other time points or in other secondary outcomes. CONCLUSIONS: Preoperative bilateral posterior QLB did not reduce cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy.

Current Management of Neuroendocrine Tumour Liver Metastases.

PURPOSE OF REVIEW: This article aims to illustrate the current state of investigations and management of liver metastases in patients with Neuroendocrine Neoplasms. Neuroendocrine tumours (NETs) are rising in incidence globally and have become the second most prevalent gastrointestinal malignancy in UK and USA. Frequently, patients have metastatic disease at time of presentation. The liver is the most common site of metastases for gastro-enteropancreatic NETs. Characterisation of liver metastases with imaging is important to ensure disease is not under-staged. RECENT FINDINGS: Magnetic resonance imaging and positron emission tomography are now becoming standard of care for imaging liver metastases. There is an increasing armamentarium of therapies available for management of NETs and loco-regional therapy for liver metastases. The data supporting surgical and loco-regional therapy is reviewed with focus on role of liver transplantation. It is important to use appropriate imaging and classification of NET liver metastases. It is key that decisions regarding approach to treatment is undertaken in a multidisciplinary team and that individualised approaches are considered for management of patients with metastatic NETs.

Mac-2 binding protein glycosylation isomer as a novel predictor of early recurrence after resection for hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) frequently recurs after radical resection, resulting in a poor prognosis. This study assessed the prognostic value of Mac-2 binding protein glycosylation isomer (M2BPGi) for early recurrence (ER) in patients with HCC. METHODS: Patients who underwent radical resection for HCC between 2015 and 2021. HCC recurrence within one year after curative resection was defined as ER. RESULTS: The 150 patients were divided into two groups: non-ER (116, 77.3%) and ER (34, 22.7%). The ER group had a lower overall survival rate (p < 0.0001) and significantly higher levels of M2BPGi (1.06 vs. 2.74 COI, p < 0.0001) than the non-ER group. High M2BPGi levels (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.31-2.41, p < 0.0001) and a large tumor size (OR 1.31, 95% CI, 1.05-1.63; p = 0.0184) were identified as independent predictors of ER. M2BPGi was the best predictor of ER according to a receiver operating characteristic (ROC) analysis (area under the ROC curve 0.82, p < 0.0001). CONCLUSIONS: M2BPGi can predict ER after surgery and is useful for risk stratification in patients with HCC.

Surgical Considerations in Portal Hypertension.

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

Surgical management of a 25-cm giant hepatic haemangioma: First case report from Bangladesh with literature review.

INTRODUCTION AND IMPORTANCE: Giant hepatic haemangioma (GHH) is defined as a hepatic haemangioma (HH) of >10 cm in diameter. Its association with thrombocytopenia and consumption coagulopathy is quite rare. CASE PRESENTATION: Here, we present a case of a 39-year-old man with a rapidly enlarging 25-cm GHH arising from the entire left hemiliver. Laboratory findings suggested pancytopenia but normal liver and renal functions. He was diagnosed with Kasabach-Merritt syndrome (KMS). After three units of aphaeretic platelet transfusion, the patient underwent left hepatectomy. Postoperative recovery was uneventful, and his regular follow-up revealed no recurrence even after two years. CLINICAL DISCUSSION: HH predominantly affects females, but males can also be affected, as seen in this case. With observation, it can grow over time, particularly in patients under 50 years of age. Surgical management should be considered when HH causes symptoms or is larger than 10 cm. The evolving understanding of GHH and the critical role of surgery are important, particularly when they complicate haematological or coagulation profiles and lead to thrombocytopenia. CONCLUSION: Our case report highlights the significance of surgical intervention in GHH, and a disease-free outcome can be expected for patients with this condition in the future. To our knowledge, this is the first such case report from Bangladesh.

Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.