Background
Anatomical resection of segment 8 (s8) is a challenging procedure. S8 can be subdivided into two areas: ventral (s8v) and dorsal (s8d). In the last years, different approaches for ...performing laparoscopic resection of s8 or any of its subsegments have been described, i.e. the hilar extrafascial approach, transfissural approach for s8v, transparenchymal approach for s8d, and the intrahepatic Glissonean approach. We recently described the dorsal approach of the right hepatic vein (RHV) for anatomical segment 7 resection. This video report describes the approach to a dorsal s8 pedicle using the RHV dorsal approach.
Methods
A 50-year-old woman with a history of morbid obesity and sleep apnea was diagnosed after episodes of hematochezia sigmoid cancer and a 2-cm liver metastases in the s8d, according to vascular reconstruction (Cella Medical Solutions, Murcia, Spain). The surgical technique started with mobilization of the right liver until the root of the RHV was identified and exposed in a craniocaudal fashion and until the s8d Glissonean pedicle was identified and clamped. Indocyanine green counterstaining depicted an intersegmental plane between the s8d and segment 5 and s8v. Transection continued until the anterior fissural vein was exposed at its root, as a landmark of the medial plane.
Results
Operative time lasted 265 min. Transection was carried out using the intermittent Pringle maneuver over a period of 81 min. Estimated blood loss was 252 cc. There were no postoperative complications and the patient was discharged on postoperative day 2.
Conclusions
In some cases, the RHV dorsal approach can be used as the landmark for the s8d Glissonean pedicle, allowing anatomical resection of this particular area.
The aim of this study was to compare the perioperative outcomes of robotic liver surgery (RLS) and laparoscopic liver surgery (LLS) in various settings.
Clear advantages of RLS over LLS have rarely ...been demonstrated, and the associated costs of robotic surgery are generally higher than those of laparoscopic surgery. Therefore, the exact role of the robotic approach in minimally invasive liver surgery remains to be defined.
In this international retrospective cohort study, the outcomes of patients who underwent RLS and LLS for all indications between 2009 and 2021 in 34 hepatobiliary referral centers were compared. Subgroup analyses were performed to compare both approaches across several types of procedures: minor resections in the anterolateral (2, 3, 4b, 5, and 6) or posterosuperior segments (1, 4a, 7, 8), and major resections (≥3 contiguous segments). Propensity score matching (PSM) was used to mitigate the influence of selection bias. The primary outcome was textbook outcome in liver surgery (TOLS), previously defined as the absence of intraoperative incidents ≥grade 2, postoperative bile leak ≥grade B, severe morbidity, readmission, and 90-day or in-hospital mortality with the presence of an R0 resection margin in case of malignancy. The absence of a prolonged length of stay was added to define TOLS+.
Among the 10.075 included patients, 1.507 underwent RLS and 8.568 LLS. After PSM, both groups constituted 1.505 patients. RLS was associated with higher rates of TOLS (78.3% vs. 71.8%, P<0.001) and TOLS+ (55% vs. 50.4%, P=0.026), less Pringle usage (39.1% vs. 47.1%, P<0.001), blood loss (100 vs. 200 milliliters, P<0.001), transfusions (4.9% vs. 7.9%, P=0.003), conversions (2.7% vs 8.8%, P<0.001), overall morbidity (19.3% vs. 25.7%, P<0.001) and R0 resection margins (89.8% vs. 86%, P=0.015), but longer operative times (190 vs. 210 min, P=0.015). In the subgroups, RLS tended to have higher TOLS rates, compared to LLS, for minor resections in the posterosuperior segments (n=431 per group, 75.9% vs. 71.2%, P=0.184) and major resections (n=321 per group, 72.9% vs. 67.5%, P=0.086), although these differences did not reach statistical significance.
While both producing excellent outcomes, RLS might facilitate slightly higher TOLS rates than LLS.
ABSTRACT Background: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this ...tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. Aim: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. Methods: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. Results: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. Conclusion: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.
RESUMO Racional: O uso do protocolo Recuperação Otimizada Após Cirurgia (ERAS/ACERTO) com sucesso na cirurgia colorretal favoreceu a aplicação dele em outros órgãos; as ressecções hepáticas não foram excluídas dessa tendência. Alguns autores sugerem que a abordagem laparoscópica é elemento central para a obtenção de melhores resultados. Objetivo: Comparar as ressecções hepáticas laparoscópicas e abertas dentro de um ACERTO para avaliar se existem diferenças entre as duas técnicas. Métodos: Estudo descritivo comparando 80 ressecções hepáticas divididas em dois grupos, as realizadas por laparoscopia e aquelas por laparotomia. Foram analisados dados demográficos, referentes à hepatectomia e ao ACERTO. Resultados: Foram realizadas 47 ressecções por laparotomia e o restante por laparoscopia; houve apenas uma conversão para laparotomia no grupo da laparoscopia. Do total, 17 ressecções foram hepatectomias maiores e em 18 ressecções simultâneas. Não houve diferenças entre os procedimentos quanto ao tempo de internação e número de complicações. Houve maior adesão ao ACERTO (p=0,046) e deambulação mais rápida (p=0,001) na operação aberta. Conclusão: O procedimento, seja laparotômico ou laparoscópico nas ressecções hepáticas, não parece mostrar diferenças em uma avaliação ERAS/ACERTO.
Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg is not ...encouraged. Here, we reappraised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres.
This was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified.
In total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients at 3 months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively.
Patients with cirrhosis, HCC and HVPG ≥10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome.
Patients with cirrhosis, hepatocellular carcinoma, and clinically significant portal hypertension (defined as a hepatic venous pressure gradient ≥10 mmHg) can undergo resection with acceptable mortality, morbidity, liver decompensation rates, and a textbook outcome. These results can be achieved in selected patients with preserved liver function, good general status, and sufficient remnant liver volume.
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•Patients with HCC and CSPH can undergo resection, with mortality of 6% and severe morbidity of 27%.•Postoperative and persistent liver decompensation occurred in 35% and 10% of patients, respectively.•Textbook outcome was achieved in 34% of patients.•The laparoscopic approach was identified as a predictor of postoperative liver decompensation and textbook outcome.
Metabolic syndrome (MS) is a growing epidemic and a risk factor for the development of hepatocellular carcinoma (HCC). This study investigated the long-term outcomes of liver resection (LR) for HCC ...in patients with MS. Rates, timing, patterns, and treatment of recurrences were investigated, and cancer-specific survivals were assessed.
Between 2001 and 2021, data from 24 clinical centers were collected. Overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival were analyzed as well as recurrence patterns and treatment. The analysis was conducted using a competing-risk framework. The trajectory of the risk of recurrence over time was applied to a competing risk analysis. For post-recurrence survival, death resulting from tumor progression was the primary endpoint, whereas deaths with recurrence relating to other causes were considered as competing events.
In total, 813 patients were included in the study. Median OS was 81.4 months (range 28.1–157.0 months), and recurrence occurred in 48.3% of patients, with a median RFS of 39.8 months (range 15.7–174.7 months). Cause-specific hazard of recurrence showed a first peak 6 months (0.027), and a second peak 24 months (0.021) after surgery. The later the recurrence, the higher the chance of receiving curative intent approaches (p = 0.001). Size >5 cm, multiple tumors, microvascular invasion, and cirrhosis were independent predictors of recurrence showing a cause-specific hazard over time. RFS was associated with death for recurrence (hazard ratio: 0.985, 95% CI: 0.977–0.995; p = 0.002).
Patients with MS undergoing LR for HCC have good long-term survival. Recurrence occurs in 48% of patients with a double-peak incidence and time-specific hazards depending on tumor-related factors and underlying disease. The timing of recurrence significantly impacts survival. Surveillance after resection should be adjusted over time depending on risk factors.
Metabolic syndrome (MS) is a growing epidemic and a significant risk factor for the development of hepatocellular carcinoma (HCC). The present study demonstrated that patients who undergo surgical resection for HCC on MS have a good long-term survival and that recurrence occurs in almost half of the cases with a double peak incidence and time-specific hazards depending on tumor-related factors and underlying liver disease. Also, the timing of recurrence significantly impacts survival. Clinicians should therefore adjust follow-up after surgery accordingly, considering timing of recurrence and specific risk factors. Also, the results of the present study might help design future trials on the use of adjuvant therapy following resection.
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•Patients with MS undergoing LR for MS have good long-term survival.•Recurrence occurs in 48% of patients with a double-peak incidence.•Time-specific hazard of recurrence depends on tumor-related factors and underlying liver disease.•The timing of recurrence significantly impacts survival.
Metabolic syndrome (MS) is rapidly growing as risk factor for HCC. Liver resection for HCC in patients with MS is associated with increased postoperative risks. There are no data on factors ...associated with postoperative complications.
The aim was to identify risk factors and develop and validate a model for postoperative major morbidity after liver resection for HCC in patients with MS, using a large multicentric Western cohort.
The univariable logistic regression analysis was applied to select predictive factors for 90 days major morbidity. The model was built on the multivariable regression and presented as a nomogram. Performance was evaluated by internal validation through the bootstrap method. The predictive discrimination was assessed through the concordance index.
A total of 1087 patients were gathered from 24 centers between 2001 and 2021. Four hundred and eighty-four patients (45.2%) were obese. Most liver resections were performed using an open approach (59.1%), and 743 (68.3%) underwent minor hepatectomies. Three hundred and seventy-six patients (34.6%) developed postoperative complications, with 13.8% major morbidity and 2.9% mortality rates. Seven hundred and thirteen patients had complete data and were included in the prediction model. The model identified obesity, diabetes, ischemic heart disease, portal hypertension, open approach, major hepatectomy, and changes in the nontumoral parenchyma as risk factors for major morbidity. The model demonstrated an AUC of 72.8% (95% CI: 67.2%-78.2%) ( https://childb.shinyapps.io/NomogramMajorMorbidity90days/ ).
Patients undergoing liver resection for HCC and MS are at high risk of postoperative major complications and death. Careful patient selection, considering baseline characteristics, liver function, and type of surgery, is key to achieving optimal outcomes.
To compare minimally invasive (MILR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with metabolic syndrome (MS).
Liver resections for HCC on MS are associated with ...high perioperative morbidity and mortality. No data on the minimally invasive approach in this setting exist.
A multicenter study involving 24 institutions was conducted. Propensity scores were calculated, and inverse probability weighting was used to weight comparisons. Short- and long-term outcomes were investigated.
996 patients were included, 580 in OLR and 416 in MILR. After weighting, groups were well matched. Blood loss was similar between groups (OLR 275.9±3.1 vs. MILR 226±4.0, P=0.146). There were no significant differences in 90-day morbidity (38.9% vs. 31.9% OLRs and MILRs, P=0.08) and mortality (2.4% vs. 2.2% OLRs and MILRs, P=0.84). MILRs were associated with lower rates of major complications (9.3% vs. 15.3%, P=0.015), post hepatectomy liver failure (0.6% vs. 4.3%, P=0.008) and bile leaks (2.2% vs. 6.4%, P=0.003); ascites was significantly lower at postoperative day 1 (2.7% vs. 8.1%, P=0.002) and day 3 (3.1% vs. 11.4%, P<0.001); hospital stay was significantly shorter (5.8±1.9 vs. 7.5±1.7, P<0.001). There was no significant difference in overall survival and disease-free survival.
MILR for HCC on MS is associated with equivalent perioperative and oncological outcomes to OLRs. Fewer major complications, post hepatectomy liver failures, ascites and bile leaks can be obtained, with shorter hospital stay. The combination of lower short-term severe morbidity and equivalent oncologic outcomes favor MILR for MS when feasible.
INTRODUCTIONSARS-CoV-2 pandemic has caused an important impact in our country and elective surgery has been postponed in most cases. There's not known information about the decreasing and impact on ...surgery. Mortality of surgical patients with SARS-CoV-2 infection is estimated to be around 20%.METHODSWe conducted prospective data recruitment of people inpatient in our Digestive and General Surgery section of Girona's University Hospital Dr. Josep Trueta from 03/14 to 05/11. Our objective is to analyze the impact that SARS-CoV-2 pandemic over elective and urgent surgery.RESULTSDuring the peak occupation of our center Intensive Care Unit (303.8%) there was a reduction on elective (93.8%) and urgent (72.7%) surgery. Mortality of patients with SARS-CoV-2 infection who underwent surgery (n=10) is estimated to be a 10%. An 80% of these patients suffer complications (sever complications in 30%).CONCLUSIONSThe actual study shows a global reduction of the surgical activity (elective and urgent) during de SARS-CoV-2 pandemic. Global mortality of patients with SARS-CoV-2 infection are low, but the severe complications have been over the usual.
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SARS-CoV-2 pandemic has caused an important impact in our country and elective surgery has been postponed in most cases. There is not known information about the decreasing and impact ...on surgery. Mortality of surgical patients with SARS-CoV-2 infection is estimated to be around 20%.
We conducted prospective data recruitment of people inpatient in our Digestive and General Surgery section of Girona's University Hospital Dr. Josep Trueta from 03/14 to 05/11. Our objective is to analyze the impact that SARS-CoV-2 pandemic over elective and urgent surgery.
During the peak occupation of our center Intensive Care Unit (303.8%) there was a reduction on elective (93.8%) and urgent (72.7%) surgery. Mortality of patients with SARS-CoV-2 infection who underwent surgery (n=10) is estimated to be a 10%. An 80% of these patients suffer complications (sever complications in 30%).
The actual study shows a global reduction of the surgical activity (elective and urgent) during de SARS-CoV-2 pandemic. Global mortality of patients with SARS-CoV-2 infection are low, but the severe complications have been over the usual.
La pandemia por SARS-CoV-2 ha causado un importante impacto en nuestro medio, con la necesidad de demorar la cirugía programada y urgente. Las cifras referentes a la disminución de la actividad quirúrgica y el impacto del periodo aún no se conocen con exactitud. Se estima una mortalidad de hasta un 20% en los pacientes operados con infección peroperatoria por SARS-CoV-2.
Del 14/03 al 11/05 del 2020 se han recogido los datos de los pacientes ingresados en el servicio de Cirugía General y Digestiva del Hospital Universitari Dr. Josep Trueta de Girona, para analizar el impacto de la pandemia sobre la cirugía electiva y urgente.
Durante el periodo de ocupación pico de la Unidad de Medicina Intensiva de nuestro centro (con un máximo de 303,8%), la cirugía electiva y la urgente se redujeron un 93,8% y un 72,7%, respectivamente. La mortalidad de los pacientes operados con infección por SARS-CoV-2 en nuestro estudio (n=10) fue del 10%; las complicaciones fueron del 80% (siendo graves un 30%).
El presente estudio muestra una reducción global de la actividad quirúrgica tanto electiva como urgente durante la pandemia. La mortalidad global de los pacientes operados con infección por SARS-CoV-2 ha sido baja, pero la tasa de complicaciones graves ha sido superior a la global.
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