Indications of pro-inflammatory cytokines in laparoscopic and open liver resection for early-stage hepatocellular carcinoma

Background:Our clinical practice of laparoscopic liver resection(LLR)had achieved better short-term and long-term benefits for patients with hepatocellular carcinoma(HCC)over open liver resection(OLR),but the underlying mechanisms are not clear.This study was to find out whether systemic inflammation plays an important role.Methods:A total of 103 patients with early-stage HCC under liver resection were enrolled(LLR group,n=53;OLR group,n=50).The expression of 9 inflammatory cytokines in patients at preoperation,postoperative day 1(POD1)and POD7 was quantified by Luminex Multiplex assay.The relationships of the cytokines and the postoperative outcomes were compared between LLR and OLR.Results:Seven of the circulating cytokines were found to be significantly upregulated on POD1 after LLR or OLR compared to their preoperative levels.Compared to OLR,the POD1 levels of granulocytemacrophage colony-stimulating factor(GM-CSF),interleukin-6(IL-6),IL-8,and monocyte chemoattractant protein-1(MCP-1)in the LLR group were significantly lower.Higher POD1 levels of these cytokines were significantly correlated with longer operative time and higher volume of blood loss during operation.The levels of these cytokines were positively associated with postoperative liver injury,and the length of hospital stay.Importantly,a high level of IL-6 at POD1 was a risk factor for HCC recurrence and poor disease-free survival after liver resection.Conclusions:Significantly lower level of GM-CSF,IL-6,IL-8,and MCP-1 after liver resection represented a milder systemic inflammation which might be an important mechanism to offer better short-term and long-term outcomes in LLR over OLR.

Ex vivo liver resection and auto-transplantation as an alternative for the treatment of liver malignancies: Progress and challenges

Hepatectomy is still the major curative treatment for patients with liver malignancies.However,it is still a big challenge to remove the tumors in the central posterior area,especially if their location involves the retrohepatic inferior vena cava and hepatic veins.Ex vivo liver resection and auto-transplantation(ELRA),a hybrid technique of the traditional liver resection and transplantation,has brought new hope to these patients and therefore becomes a valid alternative to liver transplantation.Due to its technical difficulty,ELRA is still concentrated in a few hepatobiliary centers that have experienced surgeons in both liver resection and liver transplantation.The efficacy and safety of this technique has already been demonstrated in the treatment of benign liver diseases,especially in the advanced alveolar echinococcosis.Recently,the application of ELRA for liver malignances has gained more attention.However,standardization of clinical practice norms and international consensus are still lacking.The prognostic impact in these oncologic patients also needs further evaluation.In this review,we summarized the principles and recent progresses on ELRA.

Preoperative albumin-bilirubin score and liver resection percentage determine postoperative liver regeneration after partial hepatectomy

BACKGROUND The success of liver resection relies on the ability of the remnant liver to regenerate.Most of the knowledge regarding the pathophysiological basis of liver regeneration comes from rodent studies,and data on humans are scarce.Additionally,there is limited knowledge about the preoperative factors that influence postoperative regeneration.AIM To quantify postoperative remnant liver volume by the latest volumetric software and investigate perioperative factors that affect posthepatectomy liver regenera-tion.METHODS A total of 268 patients who received partial hepatectomy were enrolled.Patients were grouped into right hepatectomy/trisegmentectomy(RH/Tri),left hepa-tectomy(LH),segmentectomy(Seg),and subsegmentectomy/nonanatomical hepatectomy(Sub/Non)groups.The regeneration index(RI)and late rege-neration rate were defined as(postoperative liver volume)/[total functional liver volume(TFLV)]×100 and(RI at 6-months-RI at 3-months)/RI at 6-months,respectively.The lower 25th percentile of RI and the higher 25th percentile of late regeneration rate in each group were defined as“low regeneration”and“delayed regeneration”.“Restoration to the original size”was defined as regeneration of the liver volume by more than 90%of the TFLV at 12 months postsurgery.RESULTS The numbers of patients in the RH/Tri,LH,Seg,and Sub/Non groups were 41,53,99 and 75,respectively.The RI plateaued at 3 months in the LH,Seg,and Sub/Non groups,whereas the RI increased until 12 months in the RH/Tri group.According to our multivariate analysis,the preoperative albumin-bilirubin(ALBI)score was an independent factor for low regeneration at 3 months[odds ratio(OR)95%CI=2.80(1.17-6.69),P=0.02;per 1.0 up]and 12 months[OR=2.27(1.01-5.09),P=0.04;per 1.0 up].Multivariate analysis revealed that only liver resection percentage[OR=1.03(1.00-1.05),P=0.04]was associated with delayed regeneration.Furthermore,multivariate analysis demonstrated that the preoperative ALBI score[OR=2.63(1.00-1.05),P=0.02;per 1.0 up]and liver resection percentage[OR=1.02(1.00-1.05),P=0.04;per 1.0 up]were found to be independent risk factors associated with volume restoration failure.CONCLUSION Liver regeneration posthepatectomy was determined by the resection percentage and preoperative ALBI score.This knowledge helps surgeons decide the timing and type of rehepatectomy for recurrent cases.

Ex vivo liver resection and auto-transplantation and special systemic therapy in perihilar cholangiocarcinoma treatment

This editorial contains comments on the article“Systematic sequential therapy for ex vivo liver resection and autotransplantation:A case report and review of li-terature”in the recent issue of World Journal of Gastrointestinal Surgery.It points out the actuality and importance of the article and focuses primarily on the role and place of ex vivo liver resection and autotransplantation(ELRAT)and systemic therapy,underlying molecular mechanisms for targeted therapy in perihilar cho-langiocarcinoma(pCCA)management.pCCA is a tough malignancy with a high proportion of advanced disease at the time of diagnosis.The only curative option is radical surgery.Surgical excision and reconstruction become extremely com-plicated and not always could be performed even in localized disease.On the other hand,ELRAT takes its place among surgical options for carefully selected pCCA patients.In advanced disease,systemic therapy becomes a viable option to prolong survival.This editorial describes current possibilities in chemotherapy and reveals underlying mechanisms and projections in targeted therapy with ki-nase inhibitors and immunotherapy in both palliative and adjuvant settings.Fi-broblast grow factor and fibroblast grow factor receptor,human epidermal grow-th factor receptor 2,isocitrate dehydrogenase,and protein kinase cAMP activated catalytic subunit alpha(PRKACA)and beta(PRKACB)pathways have been ac-tively investigated in CCA in last years.Several agents were introduced and approved by the Food and Drug Administration.They all demonstrated mean-ingful activity in CCA patients with no global change in outcomes.That is why every successfully treated patient counts,especially those with advanced disease.In conclusion,pCCA is still hard to treat due to late diagnosis and extremely complicated surgical options.ELRAT also brings some hope,but it could be performed in very carefully selected patients.Advanced disease requires systemic anticancer treatment,which is supposed to be individualized according to the genetic and molecular features of cancer cells.Targeted therapy in combination with chemo-immunotherapy could be effective in susceptible patients.

Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer

Gallbladder cancer(GBC)is a rare disease with a poor prognosis.Simple cholecystectomy may be an adequate treatment only for very early disease(Tis,T1a),whereas reoperation is recommended for more advanced disease(T1b and T2).Radical cholecystectomy should have two fundamental objectives:To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes.However,recent studies have shown that compared with lymph node dissection alone,liver resection does not improve survival outcomes.The oncological roles of lymphadenectomy and liver resection is distinct.Therefore,for patients with incidental GBC without liver invasion,hepatic resection is not always mandatory.

Development of a novel difficulty scoring system for laparoscopic liver resection procedure in patients with intrahepatic duct stones

BACKGROUND For intrahepatic duct(IHD)stones,laparoscopic liver resection(LLR)is currently a reliable treatment.However,the current LLR difficulty scoring system(DSS)is only available for patients with hepatocellular carcinoma.AIM To explore the development of a DSS for IHD stone patients with LLR and the validation of its reliability.METHODS We used clinical data from 80 patients who received LLR for IHD stones.Forty-six of these patients were used in multiple linear regression to construct a scoring system.Another 34 patients from different centers were used as external validation.The completeness of our DSS was then evaluated in patients with varying degrees of surgical difficulty based on documented surgical outcomes in the study group of patients.RESULTS The following five predictors were ultimately included and scored by calculating the weighted contribution of each factor to the prediction of operative time in the training cohort:Location of stones,number of stones≥3,stones located in the bile ducts of several grades,previous biliary surgery less than twice,distal bile duct atrophy.Subsequently,the data set was validated using a DSS developed from the variables.The following variables were identified as statistically significant in external validation:Operative time,blood loss,intraoperative transfusion,postoperative alanine aminotransferase,and Clavien-Dindo grading≥3.These variables demonstrated statistically significant differences in patients with three or more grades.CONCLUSION Patients with IHD stones have varying degrees of surgical difficulty,and the newly developed DSS can be validated with external data to effectively predict risks and complications after LLR surgery.

Major liver resections,perioperative issues and posthepatectomy liver failure:A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium-and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections.To support these outstanding results and to reduce perioperative complications,anesthesiologists must address and master key perioperative issues(preoperative assessment,proactive intraoperative anesthesia strategies,and implementation of the Enhanced Recovery After Surgery approach).Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate.Among postoperative complications,posthepatectomy liver failure(PHLF)occurs in different grades of severity(A-C)and frequency(9%-30%),and it is the main cause of 90-d postoperative mortality.PHLF,recently redefined with pragmatic clinical criteria and perioperative scores,can be predicted,prevented,or anticipated.This review highlights:(1)The systemic consequences of surgical manipulations anesthesiologistsmust respond to or prevent,to positively impact PHLF(a proactive approach);and(2)the maximal intensivetreatment of PHLF,including artificial options,mainly based,so far,on Acute Liver Failure treatment(s),to buytime waiting for the recovery of the native liver or,when appropriate and in very selected cases,toward livertransplant.Such a clinical context requires a strong commitment to surgeons,anesthesiologists,and intensivists towork together,for a fruitful collaboration in a mandatory clinical continuum.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection(RLR)has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system,however,controversies still exist.Based on the foundation of the previous consensus statement,this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice.The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine(EBM).Relevant literature was reviewed and analyzed by the evidence evaluation group.According to the WHO Handbook for Guideline Development,the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022,a total of 14 recommendations were generated.Among them were 8 recommendations formulated by the GRADE method,and the remaining 6 recommendations were formulated based on literature review and experts’opinion due to insufficient EBM results.This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

The effect of adjuvant transarterial chemoembolization for hepatocellular carcinoma after liver resection based on risk stratification

Background:There is currently no standard adjuvant treatment proven to prevent hepatocellular carcinoma(HCC)recurrence.Recent studies suggest that postoperative adjuvant transarterial chemoembolization(PA-TACE)is beneficial for patients at high risk of tumor recurrence.However,it is difficult to select the patients.The present study aimed to develop an easy-to-use score to identify these patients.Methods:A total of 4530 patients undergoing liver resection were recruited.Independent risk factors were identified by Cox regression model in the training cohort and the Primary liver cancer big data transarterial chemoembolization(PDTE)scoring system was established.Results:The scoring system was composed of ten risk factors including alpha-fetoprotein(AFP),albuminbilirubin(ALBI)grade,operative bleeding loss,resection margin,tumor capsular,satellite nodules,tumor size and number,and microvascular and macrovascular invasion.Using 5 points as risk stratification,the patients with PA-TACE had higher recurrence-free survival(RFS)compared with non-TACE in>5 points group(P<0.001),whereas PA-TACE patients had lower RFS compared with non-TACE in≤5 points group(P=0.013).In the training and validation cohorts,the C-indexes of PDTE scoring system were 0.714[standard errors(SE)=0.010]and 0.716(SE=0.018),respectively.Conclusions:The model is a simple tool to identify PA-TACE for HCC patients after liver resection with a favorable performance.Patients with>5 points may benefit from PA-TACE.

Systematic sequential therapy for ex vivo liver resection and autotransplantation: A case report and review of literature

BACKGROUND Perihilar cholangiocarcinoma(pCCA)is a highly malignant tumor arising from the biliary tree.Radical surgery is the only treatment offering a chance of long-term survival.However,limited by the tumor’s anatomic location and peri-vascular invasion,most patients lose the chance for curative treatment.Therefore,more methods to increase the resectability of tumors as well as to improve outcomes are needed.CASE SUMMARY A 68-year-old female patient had a hepatic hilar mass without obvious symptoms.Laboratory results showed hepatitis B positivity.Magnetic resonance imaging indicated that the mass(maximum diameter:41 mm)invaded the left and right branches of the main portal vein,as well as the middle,left and right hepatic veins;enlarged lymph nodes were also detected in the hilum.The patient was diagnosed with pCCA,and the clinical stage was determined to be T4N1M0(stage IIIC).Considering the tumor’s anatomic location and vascular invasion,systematic conversion therapy followed by ex vivo liver resection and autotrans-plantation(ELRA)was determined as personalized treatment for this patient.Our original systemic sequential therapeutic strategy(lenvatinib and tislelizumab in combination with gemcitabine and cisplatin)was successfully adopted as conversion therapy because she achieved partial response after three cycles of treatment,without severe toxicity.ELRA,anastomotic reconstruction of the middle hepatic vein,right hepatic vein,root of portal vein,inferior vena cava and right hepatic artery,and lymph node dissection were performed at one month after systemic therapy.Pathological and immunohistochemical examination confirmed the diagnosis of pCCA with lymph node metastasis.Although the middle hepatic vein was partially obstructed four months later,hepatic vein stent implantation successfully addressed this problem.The patient has survived for 22 mo after the diagnosis,with no evidence of recurrence or metastasis.CONCLUSION An effective therapeutic strategy for conversion therapy greatly increases the feasibility and efficiency of ELRA.

Laparoscopic liver resection for hepatocellular carcinoma complicated with significant portal hypertension:A propensity score-matched survival analysis

Background: Significant portal hypertension(SPH) is a relative contraindication for patients with resectable hepatocellular carcinoma(HCC). However, increasing evidence indicates that liver resection is feasible for HCC patients with SPH. Methods: HCC patients with cirrhosis who underwent laparoscopic liver resection(LLR) in two centers from January 2013 to April 2018 were included. Surgical and survival outcomes were analyzed to explore potential prognostic factors. Propensity score matching(PSM) analysis was performed to minimize bias. Results: A total of 165 patients were divided into two groups based on the presence(SPH, n = 76) or absence(non-SPH, n = 89) of SPH. Patients in the SPH group had longer operative time, more blood loss, and more advanced TNM stage than patients in the non-SPH group( P < 0.05). However, there were no significant differences in the postoperative 90-day mortality rate( n = 0), overall postoperative complications(47.4% vs. 41.6%, P = 0.455), Clavien-Dindo classification( P = 0.347), conversion to open surgery(9.2% vs. 6.7%, P = 0.557), or length of hospitalization(16 vs. 15 days, P = 0.203) between the SPH and non-SPH groups before PSM. Similar results were obtained after PSM. The 1-, 3-, and 5-year overall survival(OS) and recurrence-free survival rates in the SPH group were not significantly different from those in the non-SPH group both before and after PSM(log-rank P > 0.05). After PSM, alpha-fetoprotein(AFP) ≥ 400 μg/L [hazard ratio(HR) = 4.71, 95% confidence interval(CI): 2.69-8.25], ascites(HR = 2.18, 95% CI: 1.30-3.66), American Society of Anesthesiologists(ASA) classification(Ⅲ vs. Ⅱ)(HR = 2.13, 95% CI: 1.11-4.07) and tumor diameter > 5 cm(HR = 3.91, 95% CI: 2.02-7.56) independently predicted worse OS. Conclusions: LLR for patients with HCC complicated with SPH appears feasible at the price of increasing operative time and blood loss. AFP, ascites, ASA classification and tumor diameter may predict the prognosis of HCC complicated with SPH after LLR.

Radiofrequency ablation is an inferior option to liver resection for solitary hepatocellular carcinoma≤5 cm without cirrhosis:A population-based study with stratification by tumor size

Background:About 10%-20%of all individuals who develop hepatocellular carcinoma(HCC)do not have cirrhosis.Comparisons are rarely reported regarding the effectiveness of radiofrequency ablation(RFA)and liver resection(LR)in survival of HCC without cirrhosis and stratification by tumor size≤5 cm.Methods:We used the Surveillance,Epidemiology,and End Results(SEER)database and identified 1505 patients with a solitary HCC tumor≤5 cm who underwent RFA or LR during 2004-2015.Patients were classified into non-cirrhosis and cirrhosis groups and each group was categorized into three subgroups,according to tumor size(≤30 mm,31-40 mm,41-50 mm).Results:In patients without cirrhosis,LR showed better 5-year HCC cancer-specific survival than RFA in all tumor size subgroups(≤30 mm:82.51%vs.56.42%;31-40 mm:71.31%vs.46.83%;41-50 mm:74.7%vs.37.5%;all P<0.05).Compared with RFA,LR was an independent protective factor for HCC cancer-specific survival in multivariate Cox analysis[≤30 mm:hazard ratio(HR)=0.533,95%confidence interval(CI):0.313-0.908;31-40 mm:HR=0.439,95%CI:0.201-0.957;41-50 mm:HR=0.382;95%CI:0.159-0.916;all P<0.05].In patients with cirrhosis,for both tumor size≤30 mm and 31-40 mm groups,there were no significant survival differences between RFA and LR in multivariate analysis(all P>0.05).However,in those with tumor size 41-50 mm,LR showed significantly better 5-year HCC cancer-specific survival than RFA in both univariate(54.72%vs.23.06%;P<0.001)and multivariate analyses(HR=0.297;95%CI:0.136-0.648;P=0.002).Conclusions:RFA is an inferior treatment option to LR for patients without cirrhosis who have a solitary HCC tumor≤5 cm.

Global scientific production of robotic liver resection from 2003 to 2022:A bibliometric analysis

Objective:With the widespread application of robotic liver surgery,the body of literature related to robotic liver resection is growing.However,there is a lack of understanding of the publication activities surrounding robotic liver resection research.This bibliometric study aimed to detect the global publication distributions of robotic liver resection research over the past 20 years.Methods:Articles on robotic liver resection published from January 1,2003 to August 31,2022 were extracted from the Web of Science Core Collection database.The publication language was restricted to English.Literature distribution analyses were performed at the country/region,institution,author,and journal levels.In addition,each author's productivity was assessed with Lotka's law.Academic influence was assessed by local citation score and global citation score.The keywords evolution was also analyzed.R software and HistCite were applied for the analyses.Results:A total of 685 articles were identified,with 4107 local citations and 9458 global citations.These articles were published in 156 journals and written by 2449 authors from 785 institutions in 49 countries/regions.The cumulative publication number of the last 5 years accounted for 66.3%(454/685)of the total publication number.The USA played a leading role in the publication output(212,30.9%),followed by Italy(120,17.5%)and China(104,15.2%).The three countries also had the most citations.Yonsei University from South Korea had the highest publication number(30,4.4%).The Asian Journal of Surgery published the most articles(51,7.4%),and Surgical Endoscopy and Other Interventional Techniques had the most local citations(575)and global citations(1115).Sucandy published 44 articles,ranking first in productivity.Choi had many more citations than other scholars,with 465 local citations and 1253 global citations.Lotka's law reflected that the majority of the authors(1783,72.8%)wrote one document.The top 5 most prominent keywords were“surgery”,“hepatocellular-carcinoma”,“outcomes”,“hepatectomy”,and“experience”.Conclusion:The number of publications on robotic liver resection research has been rapidly increasing over the last 20 years.The most prolific countries/regions and institutions also had strong academic influence.The articles,institutions and authors with high citations mainly came from USA,China,South Korea,Italy,and Singapore.The research hotspots shifted from survival to complications,mortality,and augmented reality.

Complex inferior vena cava reconstruction during ex vivo liver resection and autotransplantation:A case report

BACKGROUND Ex vivo liver resection and autotransplantation(ELRA)is an essential approach for treating patients with end-stage hepatic alveolar echinococcosis(AE),and its surgical indications involve severe invasion of important hepatic vessels,which makes in vivo resection impossible.Revascularization is a major step in the process of ELRA,which is extremely challenging when the invaded vessels have huge defects.CASE SUMMARY Herein,we have reported the case of a 26-year-old patient with hepatic AE in an autologous liver graft who underwent complex inferior vena cava(IVC)reconstruction using disease-free IVC,autologous portal vein fragments,and umbilical vein within the ligamentum teres hepatis.The patient showed good surgical recovery without vascular-related complications during the long-term follow-up.CONCLUSION We reviewed three studies that have reported complex revascularization of the IVC.This case report and systematic review showed that the use of autologous perihepatic vessels prevents donor-area trauma,immune rejection,and other adverse reactions.When the blood vessel is severely invaded and a single vascular material cannot repair and reconstruct the defect,ELRA may provide a safe and feasible surgical approach,which has good prospects for clinical application.

Prognostic role of serum carcinoembryonic antigen in patients receiving liver resection for colorectal cancer liver metastasis:A meta-analysis

BACKGROUND Carcinoembryonic antigen(CEA)is a broad-spectrum tumor marker for differential diagnosis,monitoring,and response assessment of a variety of malignancies.AIM To evaluate whether serum CEA could predict the prognosis in patients with colorectal cancer liver metastasis(CRCLM)before and after liver resection(LR).METHODS PubMed,Embase,Cochrane,and Web of Science were systematically searched to retrieve literature,with a search cut-off date of February 27,2023.Articles were strictly screened for inclusion according to pre-specified inclusion and exclusion criteria.Data were pooled and analyzed using Stata 16.0.RESULTS This meta-analysis included 36 studies involving a total of 11143 CRCLM patients.The results showed that a high pre-LR serum CEA level was correlated with poor overall survival(OS)[hazard ratio(HR)=1.61,95%confidence interval(CI):1.49-1.75,P<0.001]and recurrence-free survival(HR=1.27,95%CI:1.11-1.45,P<0.001)in CRCLM patients.A high post-LR serum CEA level predicted poor OS(HR=2.66,95%CI:2.10-3.38,P<0.001).A comparison by treatment modality,analysis modality,patient source,and cutoff-value showed that overall,high preoperative and postoperative serum CEA levels remained correlated with a poor prognosis.CONCLUSION This study concluded that high pre-LR and post-LR serum CEA levels were significantly correlated with a poor prognosis in CRCLM patients.

Liver Resection for Spontaneous Rupture of Primary Hepatocellular Carcinoma

Objective To study the effect of liver resection for spontaneous rupture of primary hepatocellulal carcinoma (PHCC). Methods The clinical data of 12 patients with ruptured PHCC treated by liver resection in Xiangya Hospital since 1970 were analyzed retrospectively. Results There were 10 males and 2 females with mean age of 42 (ranged 22–65) years in this series. Of the 12 patients, 11 underwent emergent hepatectomy and one 2-stage hepatectomy, including left segmental liver resection in 6 patients, left median lobectomy in 1, left hemihepatectomy in 1, partial right hepatectomy in 2, and tumor resection in 2. There was no operative death in 11 patients with liver function in grade A of Child-Paugh classification, but 1 patient with grade B liver function died of liver failure after operation. The operative mortality was 8.3%. In 11 survived patients, the postoperative median survival time was 16.5 months. The 1?, 3?, 5-year survival rate was 72.7%, 18.2%, 9.1% respectively; among them one patient has been alive free of the tumor for 25 years and 9 months. Conclusion Liver resection is the best treatment for ruptured PHCC when possible, which can result in long survival time. Key words liver resection - spontaneous ruptare - primary hepatocellular carcinoma

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM:To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection(LLR) and open liver resection(OLR) for hepatocellular carcinoma(HCC).METHODS:PubMed(Medline),EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012.Two authors independently assessed the trials for inclusion and extracted the data.Meta-analysis was performed using Review Manager Version 5.0 software(The Cochrane Collaboration,Oxford,United Kingdom).Pooled odds ratios(OR) or weighted mean differences(WMD) with 95%CI were calculated using either fixed effects(Mantel-Haenszel method) or random effects models(DerSimonian and Laird method).Evaluated endpoints were operative outcomes(operation time,intraoperative blood loss,blood transfusion requirement),postoperative outcomes(liver failure,cirrhotic decompensation/ascites,bile leakage,postoperative bleeding,pulmonary complications,intraabdominal abscess,mortality,hospital stay and oncologic outcomes(positive resection margins and tumor recurrence).RESULTS:Fifteen eligible non-randomized studies were identified,out of which,9 high-quality studies involving 550 patients were included,with 234 patients in the LLR group and 316 patients in the OLR group.LLR was associated with significantly lower intraoperative blood loss,based on six studies with 333 patients [WMD:-129.48 mL;95%CI:-224.76-(-34.21) mL;P = 0.008].Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups.The LLR group had lower blood transfusion requirement(OR:0.49;95%CI:0.26-0.91;P = 0.02).While analyzing hospital stay,six studies with 333 patients were included.Patients in the LLR group were found to have shorter hospital stay [WMD:-3.19 d;95%CI:-4.09-(-2.28) d;P < 0.00001] than their OLR counterpart.Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups.The LLR group appeared to have a lower incidence of postoperative ascites(OR:0.32;95%CI:0.16-0.61;P = 0.0006) as compared with OLR patients.Similarly,fewer patients had liver failure in the LLR group than in the OLR group(OR:0.15;95%CI:0.02-0.95;P =0.04).However,no significant differences were found between the two approaches with regards to operation time [WMD:4.69 min;95%CI:-22.62-32 min;P = 0.74],bile leakage(OR:0.55;95%CI:0.10-3.12;P = 0.50),postoperative bleeding(OR:0.54;95%CI:0.20-1.45;P = 0.22),pulmonary complications(OR:0.43;95%CI:0.18-1.04;P = 0.06),intra-abdominal abscesses(OR:0.21;95%CI:0.01-4.53;P = 0.32),mortality(OR:0.46;95%CI:0.14-1.51;P = 0.20),presence of positive resection margins(OR:0.59;95%CI:0.21-1.62;P = 0.31) and tumor recurrence(OR:0.95;95%CI:0.62-1.46;P = 0.81).CONCLUSION:LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence.However,further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Laparoscopic liver resections for hepatocellular carcinoma:Current role and limitations

Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis.The aim of this review is to assess current indications,advantages and limits of laparoscopic surgery for HCC resections.We also discussed the possible evolution of this surgical approach in parallel with new technologies.

Comprehensive application of modern technologies in precise liver resection

BACKGROUND: Liver surgery has gone through the phases of wedge liver resection, regular resection of hepatic lobes, irregular and local resection, extracorporeal hepatectomy, hemi-extracorporeal hepatectomy and Da Vinci surgical system-assisted hepatectomy. Taking advantage of modern technologies, liver surgery is stepping into an age of precise liver resection. This review aimed to analyze the comprehensive application of modern technologies in precise liver resection. DATA SOURCE: PubMed search was carried out for English-language articles relevant to precise liver resection, liver anatomy, hepatic blood inflow blockage, parenchyma transection, and down-staging treatment. RESULTS: The 3D image system can imitate the liver operation procedures, conduct risk assessment, help to identify the operation feasibility and confirm the operation scheme. In addition, some techniques including puncture and injection of methylene blue into the target Glisson sheath help to precisely determine the resection. Alternative methods such as Pringle maneuver are helpful for hepatic blood inflow blockage in precise liver resection. Moreover, the use of exquisite equipment for liver parenchyma transection, such as cavitron ultrasonic surgical aspirator, ultrasonic scalpel, Ligasure and Tissue Link is also helpful to reduce hemorrhage in liver resection, or even operate exsanguinous liver resection without blocking hepatic blood flow. Furthermore, various down-staging therapies including transcatheter arterial chemoembolization and radio-frequency ablation were appropriate for unresectable cancer, which reverse the advanced tumor back to early phase by local or systemic treatment so that hepatectomy or liver transplantation is possible.CONCLUSIONS: Modern technologies mentioned in this paper are the key tool for achieving precise liver resection and can effectively lead to maximum preservation of anatomical structural integrity and functions of the remnant liver. In addition, large randomized trials are needed to evaluate the usefulness of these technologies in patients with hepatocellular carcinoma who have undergone precise liver resection.

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.