Background
Clinical evaluation of the demarcation line separating ischemic from non-ischemic liver parenchyma may be challenging. Hyperspectral imaging (HSI) is a noninvasive imaging modality, which ...combines a camera with a spectroscope and allows quantitative imaging of tissue oxygenation. Our group developed a software to overlay HSI images onto the operative field, obtaining HSI-based enhanced reality (HYPER). The aim of the present study was to evaluate the accuracy of HYPER to identify the demarcation line after a left vascular inflow occlusion during an anatomical left hepatectomy.
Materials and methods
In the porcine model (
n
= 3), the left branches of the hepatic pedicle were ligated. Before and after vascular occlusion, HSI images based on tissue oxygenation (StO
2
), obtained through the Near-Infrared index (NIR index), were regularly acquired and superimposed onto RGB video. The demarcation line was marked on the liver surface with electrocautery according to HYPER. Local lactates were measured on blood samples from the liver surface in both ischemic and perfused segments using a strip-based device. At the same areas, confocal endomicroscopy was performed.
Results
After ligation, HSI demonstrated a significantly lower oxygenation (NIR index) in the left medial lobe (LML) (0.27% ± 0.21) when compared to the right medial lobe (RML) (58.60% ± 12.08;
p
= 0.0015). Capillary lactates were significantly higher (3.07 mmol/L ± 0.84 vs. 1.33 ± 0.71 mmol/L;
p
= 0.0356) in the LML versus RML, respectively. Concordantly, confocal videos demonstrated the absence of blood flow in the LML and normal perfusion in the RML.
Conclusions
HYPER has made it possible to correctly identify the demarcation line and quantify surface liver oxygenation. HYPER could be an intraoperative tool to guide perfusion-based demarcation line assessment and segmentation.
Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused ...technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.
Radiomics is an emerging field which extracts quantitative radiology data from medical images and explores their correlation with clinical outcomes in a non-invasive manner. This review aims to ...assess whether radiomics is a useful and reproducible method for clinical management of hepatocellular carcinoma (HCC) by reviewing the strengths and weaknesses of current radiomics literature pertaining specifically to HCC. From an initial set of 48 articles recovered through database searches, 23 articles were retained to be included in this review after full screening. Among these 23 studies, 7 used a radiomics approach in magnetic resonance imaging (MRI). Only two studies applied radiomics to positron emission tomography–computed tomography (PET–CT). In the remaining 14 articles, a radiomics analysis was performed on computed tomography (CT). Eight studies dealt with the relationship between biological signatures and imaging findings, and can be classified as radiogenomic studies. For each study included in our review, we computed a Radiomics Quality Score (RQS) as proposed by Lambin et al. We found that the RQS (mean ± standard deviation) was 8.35 ± 5.38 (out of a possible maximum value of 36). Although these scores are fairly low, and radiomics has not yet reached clinical utility in HCC, it is important to underscore the fact that these early studies pave the way for the radiomics field with a focus on HCC. Radiomics is still a very young field, and is far from being mature, but it remains a very promising technology for the future for developing adequate personalized treatment as a non-invasive approach, for complementing or replacing tumor biopsies, as well as for developing novel prognostic biomarkers in HCC patients.
Background Incomplete evaluation of venous invasion has led to conflicting results regarding the prognosis of patients undergoing pancreatectomy with a synchronous venous resection. This study ...evaluates the prognostic value associated with the presence and the depth of venous invasion in T3 pancreatic adenocarcinoma. Methods This study evaluated retrospectively 181 consecutive pancreatoduodenectomies performed for T3N0M0 and T3N1M0 pancreatic adenocarcinomas (stages IIA and IIB) from January 2006 to December 2014. Univariate and multivariate Cox analyses were performed to assess survival prognostic factors. Results Pancreatoduodenectomies with a segmental venous resection was performed on 91 patients, while 90 other patients had a standard pancreatoduodenectomies without venous resection. Pathologic venous invasion was detected in 68 (74%) of the 91 venous resection patients. Depth of venous invasion was into the adventitia ( n = 25), media ( n = 28), and intima ( n = 15). The overall survival rates at 1, 3, 5, and 10 years were 75%, 33%, 21%, and 6%, respectively. There were no differences in survival between patients undergoing standard pancreatoduodenectomies and pancreatoduodenectomies with venous resection (27 vs 22 months; P = .28) or between patients with and without venous invasion (20 vs 27 months; P = .08). In multivariate analysis, depth of venous invasion into the intima (hazard ratio, 2.25; 95% confidence interval, 1.16–4.34; P = .0001) and adjuvant chemotherapy (hazard ratio, 0.16; 95% confidence interval, 0.09–0.43; P ≤ .0001) were identified as independent prognostic factors of overall survival. Conclusion Depth of venous invasion into the intima indicates poor survival in pancreatic T3 adenocarcinoma. Preoperative identification of this factor could be helpful for better selection of patients for curative operation.
Background
In laparoscopic cholecystectomy (LC), achievement of the Critical View of Safety (CVS) is commonly advocated to prevent bile duct injuries (BDI). However, BDI rates remain stable, probably ...due to inconsistent application or a poor understanding of CVS as well as unreliable reporting. Objective video reporting could serve for quality auditing and help generate consistent datasets for deep learning models aimed at intraoperative assistance. In this study, we develop and test a method to report CVS using videos.
Method
LC videos performed at our institution were retrieved and the video segments starting 60 s prior to the division of cystic structures were edited. Two independent reviewers assessed CVS using an adaptation of the doublet view 6-point scale and a novel binary method in which each criterion is considered either achieved or not. Feasibility to assess CVS in the edited video clips and inter-rater agreements were evaluated.
Results
CVS was attempted in 78 out of the 100 LC videos retrieved. CVS was assessable in 100% of the 60-s video clips. After mediation, CVS was achieved in 32/78(41.03%). Kappa scores of inter-rater agreements using the doublet view versus the binary assessment were as follows: 0.54 versus 0.75 for CVS achievement, 0.45 versus 0.62 for the dissection of the hepatocystic triangle, 0.36 versus 0.77 for the exposure of the lower part of the cystic plate, and 0.48 versus 0.79 for the 2 structures connected to the gallbladder.
Conclusions
The present study is the first to formalize a reproducible method for objective video reporting of CVS in LC. Minute-long video clips provide information on CVS and binary assessment yields a higher inter-rater agreement than previously used methods. These results offer an easy-to-implement strategy for objective video reporting of CVS, which could be used for quality auditing, scientific communication, and development of deep learning models for intraoperative guidance.
Chronic HBV infection is a major cause of liver disease and cancer worldwide. Approaches for cure are lacking, and the knowledge of virus-host interactions is still limited. Here, we perform a ...genome-wide gain-of-function screen using a poorly permissive hepatoma cell line to uncover host factors enhancing HBV infection. Validation studies in primary human hepatocytes identified CDKN2C as an important host factor for HBV replication. CDKN2C is overexpressed in highly permissive cells and HBV-infected patients. Mechanistic studies show a role for CDKN2C in inducing cell cycle G1 arrest through inhibition of CDK4/6 associated with the upregulation of HBV transcription enhancers. A correlation between CDKN2C expression and disease progression in HBV-infected patients suggests a role in HBV-induced liver disease. Taken together, we identify a previously undiscovered clinically relevant HBV host factor, allowing the development of improved infectious model systems for drug discovery and the study of the HBV life cycle.
Purpose
The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head ...of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included.
Methods
A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines.
Results
After an initial selection of 141 titles, 9 articles were included in the study (
n
= 10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports.
Conclusion
Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.
Background
Laparoscopic repeat liver resection (LRLR) still represents a challenge for surgeons especially in case with previous open liver surgery. The aim of the study is to perform a systematic ...review of the current literature to investigate the feasibility of LRLR after open liver resection (OLR) for liver diseases.
Methods
A computerized search was performed for all English language studies evaluating LRLR. A meta-analysis was performed to evaluate the short-term outcomes in comparative studies between LRLR with previous laparoscopic liver resection (LLR) and OLR.
Results
From the initial 55 manuscripts, 8 studies including 3 comparative studies between LRLR after OLR and LLR were investigated. There was a total of 108 patients. Considering initial surgery, the extent of initial liver resection was major liver resection in 20% of patients in whom it was reported. In all the patients, the most frequent primary histology was hepatocellular carcinoma, followed by colorectal liver metastasis. A half of reported patients had severe adhesions at the time of LRLR. The median operative time for LRLR was ranged from 120 to 413 min and the median blood loss ranged from 100 to 400 mL. There were 11% of the patients conversions to open surgery, hand-assisted laparoscopic surgery, or tumor ablation. The overall postoperative morbidity was 15% of all the patients, and there was no postoperative mortality. The median postoperative hospital stay was ranged from 3.5 to 10 days. The meta-analysis shows that LRLR after OLR is associated with a longer operative time and a more important blood loss compared to LRLR after LLR. However, no difference between LRLR after OLR and LLR was shown as far as hospital stay and morbidity rate are concerned.
Conclusions
LRLR after OLR has been described in eight articles with favorable short-term outcomes in highly selected patients.
Background
Considering the increase in overall life expectancy and the rising incidence of hepatocellular carcinoma (HCC), more elderly patients are considered for hepatic resection. Traditionally, ...major hepatectomy has not been proposed to the elderly due to severe comorbidities. Indeed, only a few case series are reported in the literature. The present study aimed to compare short-term and long-term outcomes between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH) in elderly patients with HCC using propensity score matching (PSM).
Methods
We performed a multicentric retrospective study including 184 consecutive cases of HCC major liver resection in patients aged ≥ 70 years in _8 European Hospital Centers. Patients were divided into LMH and OMH groups, and perioperative and long-term outcomes were compared between the 2 groups.
Results
After propensity score matching, 122 patients were enrolled, 38 in the LMH group and 84 in the OMH group. Postoperative overall complications were lower in the LMH than in the OMH group (18 vs. 46%,
p
< 0.001). Hospital stay was shorter in the LMH group than in the OMH group (5 vs. 7 days,
p
= 0.01). Mortality at 90 days was comparable between the two groups. There were no significant differences between the two groups in terms of overall survival (OS) and disease-free survival (DFS) at 1, 3, and 5 years.
Conclusion
LMH for HCC is associated with appropriate short-term outcomes in patients aged ≥ 70 years as compared to OMH. LMH is safe and feasible in elderly patients with HCC.
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