Background
A recent study analysing the experience of fellowship‐trained early adopting surgeons during stage 3 of the IDEAL paradigm demonstrated that the learning curve (LC) of minimally invasive ...hepatectomy (MIH) can be shortened compared to the long steep LC of pioneering surgeons. In this study, we aimed to critically appraise the contemporary learning experience with MIH of a ‘self‐taught’ early adopter during stage 3 of the IDEAL paradigm.
Methods
A review of the first 200 patients who underwent MIH over an 88‐month period since 2011 by a single surgeon who had no prior training in MIH was conducted. The cohort was divided into four groups of 50 patients. Risk‐adjusted cumulative sum analysis of the LC was performed.
Results
Two hundred patients underwent MIH and there were 13 (6.5%) open conversions. There were 55 (27.5%) major resections and 94 (47.0%) were graded as high/expert difficulty according to the Iwate criteria. Fifty‐one (25.5%) patients had cirrhosis and 98 (49%) had previous abdominal surgery including 28 (14%) with previous liver resections. There were five (2.5%) major (Grade 3b–5) morbidities, zero 30‐day mortality and one (0.5%) 90‐day mortality. Comparison across the four groups demonstrated a significant trend towards increased adoption of total MIH, increased multifocal tumours, increased performance of major hepatectomies and decreased blood loss. Risk‐adjusted cumulative sum analysis demonstrated that the LC in terms of blood loss, blood transfusion rate, open conversion rate, operation time and post‐operative length of stay to be 65 cases. The LC for MIH of Iwate low/intermediate difficulty and of Iwate high/expert difficulty were 35 and 30 cases, respectively.
Conclusion
MIH of all difficulty levels is feasible and can be safely adopted today even by surgeons with no prior formal training. The LC of the ‘self‐taught’ early adopter is about 65 cases.
Minimally invasive hepatectomy of all difficulty levels is feasible and can be safely adopted today even by surgeons with no prior formal training. The learning curve of the ‘self‐taught’ early adopter is about 65 cases.
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
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
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.
The aim of this systematic review is to assess the role of 18-fluorodeoxyglucose positron emission tomography in the preoperative evaluation of intraductal papillary mucinous neoplasms and cystic ...lesions of the pancreas.
A computerized PubMed search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies evaluating positron emission tomography in the preoperative evaluation of pancreatic cystic lesions.
A total of 14 studies evaluated the role of 18-fluorodeoxyglucose positron emission tomography/positron emission tomography-computed tomography, 9 of which evaluated only intraductal papillary mucinous neoplasms and 5 evaluated all pancreatic cystic lesions, including intraductal papillary mucinous neoplasms. Pooled analysis was carried out for studies evaluating intraductal papillary mucinous neoplasms only and studies evaluating all cystic lesions. Imaging with 18-fluorodeoxyblucose positron emission tomography had a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 90%, 91%, 85%, 95%, and 91% in identifying malignancy (defined as either invasive and/or high-grade dysplasia) in intraductal papillary mucinous neoplasms and a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 85%, 81%, 79%, 86%, and 88% in identifying malignancy in other cystic lesions. Pooled analysis reported the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of Sendai consensus guidelines (SCG) criteria as 69%, 69%, 68%, 55%, and 58%. The Fukuoka consensus guidelines (FCG) only had sensitivity, specificity, and accuracy reported as 61%, 52%, and 52%, respectively.
The 18-fluorodeoxyblucose positron emission tomography had a high degree of accuracy of detecting malignancy in intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Comparison of the utility of positron emission tomography with the Fukuoka consensus guidelines and the Sendai consensus guidelines suggest that positron emission tomography is superior to present guidelines in detecting malignant intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Further studies in larger patient cohorts may be required to corroborate these findings and to determine the place of positron emission tomography in the management of intraductal papillary mucinous neoplasm and cystic lesions of the pancreas.
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.
Background
At present, the majority of outcome studies of survival of hepatocellular carcinoma (HCC) post‐liver resection (post‐LR) present actuarial survival data, which often results in ...overestimation of survival. We sought to evaluate the actual 10‐year survival post‐LR for HCC and identify variables that are associated with long‐term survival.
Methods
We performed a retrospective review of 600 consecutive patients who underwent primary LR for HCC from 2000 to 2010 at our institution. Twenty‐eight patients (4.7%) with 90‐day mortality and 125 patients who were lost to follow‐up within 10 years were excluded leaving 447 patients who met the study criteria.
Results
There were 140 actual 10‐year survivors of which 57 (40.7%) had a recurrence within 10 years. The actual 10‐year overall survival (OS) rate of the 447 patients was 31.5% and the actual 10‐year recurrence‐free survival (RFS) was 18.6%. Multivariate analyses demonstrated that only age >65 years (OR, 0.29; p < .001) (OR, 0.973; p = .041) and presence of cirrhosis (OR. 0.37; p = .005) (OR, 0.31; p = .001) were independent factors negatively associated with actual 10‐year OS and actual 10‐year RFS, respectively.
Conclusion
Approximately one‐third of patients will survive over 10 years after LR for HCC. Amongst these 10‐year survivors, 41% had developed recurrent cancer within 10‐years of follow‐up.
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