Does enhanced recovery after surgery programs improve clinical outcomes in liver cancer surgery?

Enhanced recovery after surgery(ERAS)programs have been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016 and the new recommendations in 2022.Liver surgery is usually performed in oncological patients(liver metastasis,hepatocellular carcinoma,cholangiocarcinoma,etc.),but the real impact of liver surgery ERAS programs in oncological outcomes is not clearly defined.Theoretical advantages of ERAS programs are:ERAS decreases postoperative complication rates and has been demonstrated a clear relationship between complications and oncological outcomes;a better and faster posto-perative recovery should let oncologic teams begin chemotherapeutic regimens on time;prehabilitation and nutrition actions before surgery should also improve the performance status of the patients receiving chemotherapy.So,ERAS could be another way to improve our oncological results.We will discuss the literature about liver surgery ERAS focusing on its oncological implications and future investigations projects.

Machine learning in liver surgery:Benefits and pitfalls

The application of machine learning(ML)algorithms in various fields of hepatology is an issue of interest.However,we must be cautious with the results.In this letter,based on a published ML prediction model for acute kidney injury after liver surgery,we discuss some limitations of ML models and how they may be addressed in the future.Although the future faces significant challenges,it also holds a great potential.

Alcohol associated liver disease and bariatric surgery:Current perspectives and future directions

Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity.However,bariatric sur-gery has also been linked to increased alcohol use with up to 30%of these patients developing alcohol use disorder(AUD).The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic,metabolic,and neurohumoral changes associated with post-surgical anatomy.These patients are at increased risk of alcohol associated liver disease and,in some cases,require liver trans-plantation.In this article,we provide a scoping review of epidemiology,patho-physiology,and clinical outcomes of alcohol-related health conditions after bariatric surgery.

Outcomes of liver transplantation as an oncologic surgery for different primary liver cancers:A real-world,population-based study

To the Editor:Although liver transplantation is likely used to treat individuals with end-stage liver disease because of non-neoplastic reasons,the adoption of liver transplantation in the management of primary liver cancer has been expanding in the past decades[1-3].Prior population-based studies for liver transplantation,in the cancer sphere,focused on delineating the outcomes of patients with hepatocellular carcinoma(HCC)treated with transplantation versus other locoregional treatments[4-6].

Safety and outcomes of hip and knee replacement surgery in liver transplant recipients

BACKGROUND Liver transplant(LT)is becoming increasingly common with improved life expectancy.Joint replacement is usually a safe procedure;however,its safety in LT recipients remains understudied.AIM To evaluate the mortality,outcome,and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery.METHODS Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database.RESULTS A total of 5046119 hip and knee replacement surgeries were identified.3219 patients had prior LT.Mean age of patients with no history of LT was 67.51[95%confidence interval(CI):67.44-67.58],while it was 64.05(95%CI:63.55-64.54)in patients with LT.Patients with history of LT were more likely to have prolonged length of hospital stay(17.1%vs 8.4%,P<0.001).The mortality rate for patients with no history of LT was 0.22%,while it was 0.24%for patients with LT(P=0.792).Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization:11.4%as compared to 6.2%in patients without history of LT(P<0.001).The mortality rate between both groups during readmission was not statistically different(1.9%vs 2%,P=0.871)respectively.CONCLUSION Hip and knee replacements in patients with history of LT are not associated with increased mortality;increased readmissions were more frequent in this cohort of patients.Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.

Liver transplantation as an alternative for the treatment of intrahepatic cholangiocarcinoma: Past, present, and future directions

Intrahepatic cholangiocarcinoma(iCCA)is a rare biliary tract cancer with high mortality rate.Complete resection of the iCCA lesion is the first choice of treatment,with good prognosis after margin-negative resection.Unfortunately,only 12%-40% of patients are eligible for resection at presentation due to cirrhosis,portal hypertension,or large tumor size.Liver transplantation(LT)offers margin-negative iCCA extirpation for patients with unresectable tumors.Initially,iCCA was a contraindication for LT until size-based selection criteria were introduced to identify patients with satisfied post-LT outcomes.Recent studies have shown that tumor biology-based selection can yield high post-LT survival in patients with locally advanced iCCA.Another selection criterion is the tumor response to neoadjuvant therapy.Patients with response to neoadjuvant therapy have better outcomes after LT compared with those without tumor response to neoadjuvant therapy.Another index that helps predict the treatment outcome is the biomarker.Improved survival outcomes have also opened the door for living donor LT for iCCA.Patients undergoing LT for iCCA now have statistically similar survival rates as patients undergoing resection.The combination of surgery and locoregional and systemic therapies improves the prognosis of iCCA patients.

Liver transplantation as an alternative for the treatment of perihilar cholangiocarcinoma: A critical review

Background:Perihilar cholangiocarcinoma(phCCC)is a dismal malignancy.There is no consensus regard-ing the best treatment for patients with unresectable phCCC.The present review aimed to gather the current pieces of evidence for liver transplantation and liver resection as a treatment for phCCC and to build better guidance for clinical practice.Data sources:The search was conducted in PubMed,Embase,Cochrane,and LILACS.The related references were searched manually.Inclusion criteria were:reports in English or Portuguese literature that a)patients with confirmed diagnosis of phCCC;b)patients treated with a curative intent;c)patients with the outcomes of liver resection and liver transplantation.Case reports,reviews,letters,editorials,conference abstracts and papers with full-text unavailability were excluded from the analysis.Results:Most of the current literature is based on observational retrospective studies with low grades of evidence.Liver resection has better long-term outcomes than systemic chemotherapy or palliation ther-apy and liver transplantation is a good alternative for selected patients with unresectable phCCC.All candidates for resection or transplantation should be medically fit and free of intrahepatic or extrahep-atic diseases.As a general rule,patients presenting with a tumor having a longitudinal size>3 cm or extending below the cystic duct,lymph node disease,confirmed extrahepatic dissemination;intraoper-atively diagnosed metastatic disease;a history of other malignancies within the last five years,and did not complete chemoradiation regimen and were medically unfit should not be considered for transplan-tation.Some of these criteria should be individually assessed.Liver transplantation or resection should only be considered in highly experienced hepatobiliary centers,and any decision-making must be based on a multidisciplinary evaluation.Conclusions:phCCC is a complex condition with high morbidity.Surgical therapies,including hepatec-tomy and liver transplantation,are the best option for better long-term disease-free survival.

Awake robotic liver surgery:A case report

BACKGROUND In recent years,minimally invasive liver resection has become a standard of care for liver tumors.Considering the need to treat increasingly fragile patients,general anesthesia is sometimes avoided due to respiratory complications.Therefore,surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach.Epidural anesthesia has been shown to reduce respiratory complications,especially in elderly patients with pre-existing lung disease.CASE SUMMARY A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma.The patient was suffering from hypertension,diabetes and chronic obstructive pulmonary disease.The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%.We planned a combined spinal–epidural anesthesia with conscious sedation to avoid general anesthesia.No modification of the standard surgical technique was necessary.Hemodynamics were stable and bleeding was minimal.The postoperative course was uneventful.CONCLUSION Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

Impact of bariatric surgery on glucose and lipid metabolism and liver and kidney function in food-induced obese diabetic rats

BACKGROUND Obesity usually causes diabetes mellitus(DM)and is a serious danger to human health.Type 2 DM(T2DM)mostly occurs along with obesity.Foodborne obesityinduced DM is caused by an excessive long-term diet and surplus energy.Bariatric surgery can improve the symptoms of T2DM in some obese patients.But different types of bariatric surgery may have different effects.AIM To investigate the effect of bariatric surgery on glucose and lipid metabolism and liver and kidney function in rats.METHODS Male Sprague-Dawley rats aged 6-8 wk underwent Roux-en-Y gastric bypass surgery(RYGB),sleeve gastrectomy(SG),or gastric banding(GB).Glucose and insulin tolerance tests,analyses of biochemical parameters,histological examination,western blot,and quantitative real-time polymerase chain reaction were conducted.RESULTS In comparison to the sham operation group,the RYGB,SG,and GB groups had decreased body weight and food intake,reduced glucose intolerance and insulin insensitivity,downregulated biochemical parameters,alleviated morphological changes in the liver and kidneys,and decreased levels of protein kinase Cβ/P66shc.The effect in the RYGB group was better than that in the SG and GB groups.CONCLUSION These results suggest that RYGB,SG and GB may be helpful for the treatment of foodborne obesity-induced DM.

Toxicity of targeted anticancer treatments on the liver in myeloproliferative neoplasms

The liver has a central role in metabolism,therefore,it is susceptible to harmful effects of ingested medications(drugs,herbs,and nutritional supplements).Druginduced liver injury(DILI)comprises a range of unexpected reactions that occur after exposure to various classes of medication.Even though most cases consist of mild,temporary elevations in liver enzyme markers,DILI can also manifest as acute liver failure in some patients and can be associated with mortality.Herein,we briefly review available data on DILI induced by targeted anticancer agents in managing classical myeloproliferative neoplasms:Chronic myeloid leukemia,polycythemia vera,essential thrombocythemia,and myelofibrosis.

Liver Abscesses in General Surgery at CsRef CI in Bamako Mali

Liver abscesses correspond to a newly formed cavity created by necrosis of the liver parenchyma induced by the pathogen. The aim of the present work was to study liver abscesses;determine the frequency;describe the clinical and paraclinical aspects, therapeutic and evolutionary modalities;determine the follow-up of treatment in order to assess the cost of treatment in the Reference Health Center of Commune I of Bamako in Mali. This prospective study, involving 30 cases of liver abscess, took place over a period of 24 months from January 2015 to December 2016 in the general surgery department of the Cs Ref of commune I. The liver abscess is very often the consequence of amoebiasis which is rampant in the underprivileged population and it remains topical in surgical practice in Mali. Our hospital frequency was 0.081% with an average age of 34.40 years and extremes of 16 and 61 years;a sex ratio of 2.3 in favor of men. The main clinical signs were fever (56.7%), hepatalgia (73.3%) and hepatomegaly (26.7%). Hepatic collections objectified on abdominal ultrasound were located in the right lobe in 70% of cases and unique in 62%. Amebic serology carried out in 100% was negative in 20%;10% of cases had undergone surgical treatment. The consequences were simple for all our patients. The average cost of care, approximately 100,000 FCFA, was significantly higher than the minimum wage (28,460 FCFA) in Mali.

Health-related quality of life of pediatric living donor liver transplantation donors who undergone donation surgery for 10 years

Objective:To investigate the quality of life(QOL)of living donor liver transplantation(LDLT)donors.Methods:The Euro Qol 5-dimensional questionnaire(EQ-5D)was used to measure the QOL of donors.Results:One donor repor ted“a little problem”of mobility(MO),and 2 donors(9.1%)repor ted“a little problem”of usual activities(UA).Moreover,there were 8 donors(36.4%)and 7 donors(31.8%)declaring“a little problem”of pain/discomfor t(PD)and anxiety/depression(AD),respectively.And both dimensions have a donor repor ting“moderate problem.”The mean visual analog scale(VAS)was 83.1±12.4.Conclusions:Donors can gain a stable and preferable QOL after donation in both the shor t and long terms.ED-5D application in the field of liver transplant could be an effective choice in QOL studies.

Recent advances in computerized imaging and its vital roles in liverdisease diagnosis, preoperative planning, and interventional liversurgery: A review

The earliest and most accurate detection of the pathological manifestations of hepatic diseases ensures effective treatments and thus positive prognostic outcomes.In clinical settings,screening and determining the extent of a pathology are prominent factors in preparing remedial agents and administering approp-riate therapeutic procedures.Moreover,in a patient undergoing liver resection,a realistic preoperative simulation of the subject-specific anatomy and physiology also plays a vital part in conducting initial assessments,making surgical decisions during the procedure,and anticipating postoperative results.Conventionally,various medical imaging modalities,e.g.,computed tomography,magnetic resonance imaging,and positron emission tomography,have been employed to assist in these tasks.In fact,several standardized procedures,such as lesion detection and liver segmentation,are also incorporated into prominent commercial software packages.Thus far,most integrated software as a medical device typically involves tedious interactions from the physician,such as manual delineation and empirical adjustments,as per a given patient.With the rapid progress in digital health approaches,especially medical image analysis,a wide range of computer algorithms have been proposed to facilitate those procedures.They include pattern recognition of a liver,its periphery,and lesion,as well as pre-and postoperative simulations.Prior to clinical adoption,however,software must conform to regulatory requirements set by the governing agency,for instance,valid clinical association and analytical and clinical validation.Therefore,this paper provides a detailed account and discussion of the state-of-the-art methods for liver image analyses,visualization,and simulation in the literature.Emphasis is placed upon their concepts,algorithmic classifications,merits,limitations,clinical considerations,and future research trends.

Non-anatomical liver resection for hepatocellular carcinoma:the SegSubTe classification to overcome the problem of heterogeneity

Background:The superiority of anatomical resection(AR)vs.non-anatomical resection(NAR)in the surgical management of hepatocellular carcinoma(HCC)is debated.ARs are well-defined procedures,whereas the lack of NAR standardization results in heterogeneous outcomes.This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor.Methods:A single-center retrospective analysis of pre-and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted.The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section(segmental,subsegmental or terminal next to the tumor)of vascular pedicles feeding the HCCs;then,the population was divided in“SegSubTe-IN”or“SegSubTe-OUT”groups,and the tumor recurrence and survival were analyzed.Results:Ninety-seven patients who underwent NAR were included;76%were SegSubTe-IN and 24%were SegSubTe-OUT.Total disease recurrence,local recurrence and cut-edge recurrence in the SegSubTe-IN vs.SegSubTe-OUT groups were 50%vs.83%(P=0.006),20%vs.52%(P=0.003)and 16%vs.39%(P=0.020),respectively.SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis.One-,three-,and five-year disease-free survival rates in the SegSubTe-IN vs.SegSubTe-OUT groups were 81%,58%and 35%vs.46%,21%and 11%,respectively(P<0.001).Conclusions:The SegSubTe classification is a useful tool to stratify and standardize NAR for HCC,aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

Solid pseudopapillary tumor of the pancreas:A systematic review of clinical,surgical and oncological characteristics of 1384 patients underwent pancreatic surgery

Background:Pancreatic solid pseudopapillary tumors(SPTs)are rare clinical entity,with low malignancy and still unclear pathogenesis.They account for less than 2%of exocrine pancreatic neoplasms.This study aimed to perform a systematic review of the main clinical,surgical and oncological characteristics of pancreatic SPTs.Data sources:MEDLINE/PubMed,Web of Science and Scopus databases were systematically searched for the main clinical,surgical and oncological characteristics of pancreatic SPTs up to April 2021,in accordance with the preferred reporting items for systematic reviews and meta-analyses(PRISMA)standards.Primary endpoints were to analyze treatments and oncological outcomes.Results:A total of 823 studies were recorded,86 studies underwent full-text reviews and 28 met inclusion criteria.Overall,1384 patients underwent pancreatic surgery.Mean age was 30 years and 1181 patients(85.3%)were female.The most common clinical presentation was non-specific abdominal pain(52.6%of cases).Mean overall survival was 98.1%.Mean recurrence rate was 2.8%.Mean follow-up was 4.2 years.Conclusions:Pancreatic SPTs are rare,and predominantly affect young women with unclear pathogenesis.Radical resection is the gold standard of treatment achieving good oncological impact and a favorable prognosis in a yearly life-long follow-up.

Carcinoembryonic antigen in the diagnosis,treatment,and follow-up of focal liver lesions

In this editorial review,we comment on the article published in the recent issue of the World Journal of Gastrointestinal Surgery.Carcinoembryonic antigen(CEA)is a fetal glycoprotein and can be secreted in very small amounts from healthy adults after birth.CEA is widely used not only for diagnostic tumor markers but also importantly for the management of some gastrointestinal tumors.The most common clinical use is surveillance for the monitoring of colorectal carcinoma.However,CEA can become elevated in several malign or benign characterized pathologies.Serum CEA level may vary depending on the location of the lesion,whether it metastasizes or not,and its histopathological characteristics.It has been determined that cases with high preoperative CEA have a more aggressive course and the risk of metastasis to the lymph tissue and liver increases.In this editorial review,we focused on evaluating the role of CEA in clinical practice with a holistic approach,including the diagnostic and prognostic significance of CEA in patients with focal liver lesions,the role of CEA in follow-up after definitive surgery,and also hepatic resection for metastasis,and the management of all patients with raised CEA.

Role of gut-liver axis and glucagon-like peptide-1 receptor agonists in the treatment of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease(MAFLD)is a hepatic manifestation of the metabolic syndrome.It is one of the most common liver diseases worldwide and shows increasing prevalence rates in most countries.MAFLD is a progressive disease with the most severe cases presenting as advanced fibrosis or cirrhosis with an increased risk of hepatocellular carcinoma.Gut microbiota play a significant role in the pathogenesis and progression of MAFLD by disrupting the gut-liver axis.The mechanisms involved in maintaining gut-liver axis homeostasis are complex.One critical aspect involves preserving an appropriate intestinal barrier permeability and levels of intestinal lumen metabolites to ensure gutliver axis functionality.An increase in intestinal barrier permeability induces metabolic endotoxemia that leads to steatohepatitis.Moreover,alterations in the absorption of various metabolites can affect liver metabolism and induce liver steatosis and fibrosis.Glucagon-like peptide-1 receptor agonists(GLP-1 RAs)are a class of drugs developed for the treatment of type 2 diabetes mellitus.They are also commonly used to combat obesity and have been proven to be effective in reversing hepatic steatosis.The mechanisms reported to be involved in this effect include an improved regulation of glycemia,reduced lipid synthesis,β-oxidation of free fatty acids,and induction of autophagy in hepatic cells.Recently,multiple peptide receptor agonists have been introduced and are expected to increase the effectiveness of the treatment.A modulation of gut microbiota has also been observed with the use of these drugs that may contribute to the amelioration of MAFLD.This review presents the current understanding of the role of the gutliver axis in the development of MAFLD and use of members of the GLP-1 RA family as pleiotropic agents in the treatment of MAFLD.

Molecular targets and mechanisms of different aberrant alternative splicing in metastatic liver cancer

Metastasis remains a major challenge in the successful management of malignant diseases.The liver is a major site of metastatic disease and a leading cause of death from gastrointestinal malignancies such as colon,stomach,and pancreatic cancers,as well as melanoma,breast cancer,and sarcoma.As an important factor that influences the development of metastatic liver cancer,alternative splicing drives the diversity of RNA transcripts and protein subtypes,which may provide potential to broaden the target space.In particular,the dysfunction of splicing factors and abnormal expression of splicing variants are associated with the occurrence,progression,aggressiveness,and drug resistance of cancers caused by the selective splicing of specific genes.This review is the first to provide a detailed summary of the normal splicing process and alterations that occur during metastatic liver cancer.It will cover the role of alternative splicing in the mechanisms of metastatic liver cancer by examining splicing factor changes,abnormal splicing,and the contribution of hypoxia to these changes during metastasis.

Hepatic grooves:An observational study at laparoscopic surgery

BACKGROUND In traditional descriptions,the upper surface of the liver is smooth and convex,but deep depressions are variants that are present in 5%-40%of patients.We sought to determine the relationship between surface depressions and the diaphragm.AIM To use exploratory laparoscopy to determine the relationship between surface depressions and the diaphragm.METHODS An observational study was performed in all patients undergoing laparoscopic upper gastro-intestinal operations between January 1,2023 and January 20,2024.A thirty-degree laparoscope was used to inspect the liver and diaphragm.When surface depressions were present,we recorded patient demographics,presence of diaphragmatic bands,rib protrusions and/or any other source of compression during inspection.RESULTS Of 394 patients,343 had normal surface anatomy,and 51(12.9%)had prominent surface depressions on the liver.There was no significant relationship between the presence of surface depressions and gender nor the presence of rib projections.However,there was significant association between the presence of surface depressions and diaphragmatic muscular bands(P<0.001).CONCLUSION With these data,the diaphragmatic-band theory has gained increased importance over other theories for surface depressions.Further studies are warranted using cross sectional imaging to confirm relationships with intersectional planes as well as beta-catenin assays in the affected liver parenchyma.

Progress in research of liver surgery in China

INTRODUCTIONLiver surgery,was started in the late 1950s in Chinaand has developed rapidly in the past 40 years.The study on the diagnosis and treatment of primaryliver cancer in China underwent four stages:①Inthe 1950s,the anatomical study of the liver lay asolid foundation for liver resection.①In