Introduction
The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the ...presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process.
Methods
Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients.
Results
Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%,
p
= 0.03), operation time (261 vs 238 min,
p
< 0.001), blood loss (607 vs 314 mls,
p
= 0.002), transfusion rate (22% vs 9%,
p
= 0.001), need for application of Pringles maneuver (51% vs 34%,
p
= 0.010), postoperative stay (6 vs 4.5 days,
p
= 0.004) and postoperative morbidity (26% vs 13%,
p
= 0.029).
Conclusion
The presence of liver cirrhosis affected both the intraoperative technical difficulty and postoperative outcomes of MILR and hence should be considered an important parameter to be included in future difficulty scoring systems for MILR.
Background
This study aims to determine the safety and efficacy of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma (rHCC).
Methods
Twenty patients underwent LRLR for ...rHCC between 2015 and 2017. The control groups consisted of 79 open RLR (ORLR) for rHCC and 185 LLR for primary HCC. We undertook propensity score-adjusted analyses (PSA) and 1:1 propensity score matching (PSM) for the comparison of LRLR versus ORLR. Comparison of LRLR versus LLR was done using multivariable regression models with adjustment for clinically relevant covariates.
Results
Twenty patients underwent LRLR with three open conversions (15%). Both PSA and 1:1-PSM demonstrated that LRLR was significantly associated with a shorter stay, superior disease-free survival (DFS) but longer operation time compared to ORLR. Comparison between LRLR versus LLR demonstrated that patients undergoing LRLR were significantly older, had smaller tumors, longer operation time and decreased frequency of Pringle’s maneuver applied. There was no difference in other key perioperative outcomes.
Conclusion
The results of this study demonstrate that in highly selected patients; LRLR for rHCC is feasible and safe. LRLR was associated with a shorter hospitalization but longer operation time compared to ORLR. Moreover, other than a longer operation time, LRLR was associated with similar perioperative outcomes compared to LLR for primary HCC.
Background
This study aims to compare the short‐ and long‐term outcomes of patients undergoing minimally invasive liver resection (MILR) versus open liver resection (OLR) for nonrecurrent ...hepatocellular carcinoma (HCC).
Methods
Review of 204 MILR and 755 OLR without previous LR performed between 2005 and 2018. 1:1 coarsened exact matching (CEM) and 1:1 propensity‐score matching (PSM) were performed.
Results
Overall, 190 MILR were well‐matched with 190 OLR by PSM and 86 MILR with 86 OLR by CEM according to patient baseline characteristics. After PSM and CEM, MILR was associated with a significantly longer operation time 230 min (interquartile range IQR, 145–330) vs. 160 min (IQR, 125–210), p < .001 215 min (IQR, 135–295) vs. 153.5 min (120–180), p < .001, shorter postoperative stay 4 days (IQR, 3–6) vs. 6 days (IQR, 5–8), p = .001) 4 days (IQR, 3–5) vs. 6 days (IQR, 5–7), p = .004 and lower postoperative morbidity 40 (21%) vs. 67 (35.5%), p = .003 16 (18.6%) vs. 27 (31.4%), p = .036 compared to OLR. MILR was also associated with a significantly longer median time to recurrence (70 vs. 40.3 months, p = .014) compared to OLR after PSM but not CEM. There was no significant difference in terms of overall survival and recurrence‐free survival.
Conclusion
MILR is associated with superior short‐term postoperative outcomes and with at least equivalent long‐term oncological outcomes compared to OLR for HCC.
Background
Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported ...experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience.
Methods
This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion.
Results
Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality.
Conclusion
The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.
Background
The role of minimally invasive major hepatectomy (MIMH) remains controversial and questions remain about its safety and reproducibility outside expert centres. This study examines the ...changing trends, safety and outcomes associated with the adoption of MIMH based on a contemporary single institution experience.
Methods
This study is a review of 120 consecutive patients who underwent MIMH between 2011 and 2018. To determine the evolution of MIMH, the study population was stratified into four equal groups of patients. Both conventional major hepatectomies (CMHs) (≥3 segments) and technical major hepatectomies (right anterior and posterior sectionectomies) were included.
Results
There were 70 CMHs and 50 technical major hepatectomies. Seven MIMHs were laparoscopic‐assisted and 113 (94.2%) were totally laparoscopic/robotic. There were 10 (8.3%) open conversions. Comparison across the four groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher American Society of Anesthesiologists score patients, increasing frequency of CMH performed, increasing frequency of multifocal tumours resected, decreasing use of laparoscopic‐assisted approach and decrease in blood loss.
Conclusion
MIMH can be adopted safely today with a low open conversion rate. Over time with increasing experience, we performed MIMH with increasing frequency in higher risk patients and in patients with multifocal tumours but with a decrease in median estimated blood loss.
Minimally invasive major hepatectomy can be adopted safely today with a low open conversion rate. Over time with increasing experience, we performed minimally invasive major hepatectomy with increasing frequency in higher risk patients and in patients with multifocal tumors but with a decrease in median estimated blood loss.
Background
Pure laparoscopic donor hepatectomy (L‐DH) has seen a rise in uptake in recent years following the popularization of minimally invasive modality for major hepatobiliary surgery. Our study ...aimed to determine the safety and compare the perioperative outcomes of L‐DH with open donor hepatectomy (O‐DH) and laparoscopic non donor hepatectomy (L‐NDH) based on our single institution experience.
Methods
Eighty of 113 laparoscopic hemi‐hepatectomies performed between 2015 and 2022 met study inclusion criteria. Of these, 11 were L‐DH. PSM in a 1:2 ratio of L‐DH versus L‐NDH and 1:1 ratio of L‐DH versus O‐DH were performed, identifying patients with similar baseline clinicopathological characteristics.
Results
After 2:1 matching, the L‐DH cohort were significantly younger (P < 0.001) and had lower ASA scores (P < 0.001) than the L‐NDH cohort. L‐DH was associated with a longer median operating time (P < 0.001) and shorter median postoperative stay (P < 0.001) than L‐NDH. After 1:1 matching, there were no significant differences in baseline demographic between the L‐DH and O‐DH cohorts. L‐DH was associated with lower median blood loss (P = 0.040) and shorter length of stay compared to O‐DH (P = 0.004). There were no significant differences in recipient outcomes for both cohorts.
Conclusion
L‐DH can be adopted safely by surgeons experienced in L‐NDH and ODH. It is associated with decreased blood loss and shorter length of stay compared to O‐DH.
Laparoscopic donor hepatectomy has seen a rise in uptake due to reduced donor morbidity and improved cosmesis. Our study compared outcomes of laparoscopic donor hepatectomy with laparoscopic non‐donor hepatectomy and open donor hepatectomy, and found that there were no difference in donor morbidity and recipient outcomes, with the laparoscopic donor hepatectomy cohort experiencing reduced blood loss and shorter length of stay compared to the open donor hepatectomy cohort. We conclude that laparoscopic donor hepatectomy may be adopted safely by surgeons experienced in laparoscopic non‐donor hepatectomy and open donor hepatectomy.
Display omitted
•Liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis should be considered after careful patient selection.•Patient characteristics, tumor pattern, liver function ...and surgical approach should be considered as selection criteria.•Nomograms to predict surgical risks and survival may help in treatment allocation.
Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival.
Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed.
A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm3, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed.
Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes.
Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.
The clinical relevance of immune landscape intratumoural heterogeneity (immune-ITH) and its role in tumour evolution remain largely unexplored. Here, we uncover significant spatial and phenotypic ...immune-ITH from multiple tumour sectors and decipher its relationship with tumour evolution and disease progression in hepatocellular carcinomas (HCC). Immune-ITH is associated with tumour transcriptomic-ITH, mutational burden and distinct immune microenvironments. Tumours with low immune-ITH experience higher immunoselective pressure and escape via loss of heterozygosity in human leukocyte antigens and immunoediting. Instead, the tumours with high immune-ITH evolve to a more immunosuppressive/exhausted microenvironment. This gradient of immune pressure along with immune-ITH represents a hallmark of tumour evolution, which is closely linked to the transcriptome-immune networks contributing to disease progression and immune inactivation. Remarkably, high immune-ITH and its transcriptomic signature are predictive for worse clinical outcome in HCC patients. This in-depth investigation of ITH provides evidence on tumour-immune co-evolution along HCC progression.
PDF