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.

Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective?

Patients with locally advanced hepatocellular cancer(HCC)and portal vein tumor thrombosis(PVTT)have a dismal prognosis since limited treatment options are available for them.In recent years,effective systemic therapy,and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy,have given some hope to prolong survival in them.This review summarized recent evidence in literature regarding the possible role of liver resection(LR)and liver transplantation(LT)in patients with locally advanced HCC and PVTT with no extrahepatic disease.Downstaging therapies have helped make curative resection or LT a reality in selected patients.This review emphasizes on the key points to focus on when considering surgery in these patients,who are usually relegated to palliative systemic therapy alone.Meticulous patient selection based on tumor biology,documented downstaging based on imaging and decrease in tumor marker levels,and an adequate waiting period to demonstrate stable disease,may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.

Predicting short-term major postoperative complications in intestinal resection for Crohn’s disease:A machine learning-based study

BACKGROUND Due to the complexity and numerous comorbidities associated with Crohn’s disease(CD),the incidence of postoperative complications is high,significantly impacting the recovery and prognosis of patients.Consequently,additional stu-dies are required to precisely predict short-term major complications following intestinal resection(IR),aiding surgical decision-making and optimizing patient care.AIM To construct novel models based on machine learning(ML)to predict short-term major postoperative complications in patients with CD following IR.METHODS A retrospective analysis was performed on clinical data derived from a patient cohort that underwent IR for CD from January 2017 to December 2022.The study participants were randomly allocated to either a training cohort or a validation cohort.The logistic regression and random forest(RF)were applied to construct models in the training cohort,with model discrimination evaluated using the area under the curves(AUC).The validation cohort assessed the performance of the constructed models.RESULTS Out of the 259 patients encompassed in the study,5.0%encountered major postoperative complications(Clavien-Dindo≥III)within 30 d following IR for CD.The AUC for the logistic model was 0.916,significantly lower than the AUC of 0.965 for the RF model.The logistic model incorporated a preoperative CD activity index(CDAI)of≥220,a diminished preoperative serum albumin level,conversion to laparotomy surgery,and an extended operation time.A nomogram for the logistic model was plotted.Except for the surgical approach,the other three variables ranked among the top four important variables in the novel ML model.CONCLUSION Both the nomogram and RF exhibited good performance in predicting short-term major postoperative complic-ations in patients with CD,with the RF model showing more superiority.A preoperative CDAI of≥220,a di-minished preoperative serum albumin level,and an extended operation time might be the most crucial variables.The findings of this study can assist clinicians in identifying patients at a higher risk for complications and offering personalized perioperative management to enhance patient outcomes.

Double-nylon purse-string suture in closing postoperative wounds following endoscopic resection of large(≥3 cm)gastric submucosal tumors

BACKGROUND Endoscopic full-thickness resection(EFTR)of gastric submucosal tumors(SMTs)is safe and effective;however,postoperative wound management is equally important.Literature on suturing following EFTR for large(≥3 cm)SMTs is scarce and limited.AIM To evaluate the efficacy and clinical value of double-nylon purse-string suture in closing postoperative wounds following EFTR of large(≥3 cm)SMTs.METHODS We retrospectively analyzed the data of 85 patients with gastric SMTs in the fundus of the stomach or in the lesser curvature of the gastric body whose wounds were treated with double-nylon purse-string sutures after successful tumor resection at the Endoscopy Center of Renmin Hospital of Wuhan University.The operative,postoperative,and follow-up conditions of the patients were evaluated.RESULTS All tumors were completely resected using EFTR.36(42.35%)patients had tumors located in the fundus of the stomach,and 49(57.65%)had tumors located in the body of the stomach.All patients underwent suturing with double-nylon sutures after EFTR without laparoscopic assistance or further surgical treatment.Postoperative fever and stomach pain were reported in 13(15.29%)and 14(16.47%)patients,respectively.No serious adverse events occurred during the intraoperative or postoperative periods.A postoperative review of all patients revealed no residual or recurrent lesions.CONCLUSION Double-nylon purse-string sutures can be used to successfully close wounds that cannot be completely closed with a single nylon suture,especially for large(≥3 cm)EFTR wounds in SMTs.

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review

BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide.About 5%-10%of patients are diagnosed with locally advanced rectal cancer(LARC)on presentation.For LARC invading into other structures(i.e.T4b),multivisceral resection(MVR)and/or pelvic ex-enteration(PE)remains the only potential curative surgical treatment.MVR and/or PE is a major and complex surgery with high post-operative morbidity.Minimally invasive surgery(MIS)has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies,but there is little evi-dence on its use in MVR,especially so for robotic MVR.This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023.Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR,or stage 4 disease with resectable systemic metastases.Pa-tients who underwent curative MVR for locally recurrent rectal cancer,or me-tachronous rectal cancer were also included.Exclusion criteria were patients with systemic metastases with non-resectable disease.All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery.Complex sur-gery was defined based on technical difficulty of surgery(i.e.total PE,bladder-sparing prostatectomy,pelvic lymph node dissection or need for flap creation).Our primary outcomes were the margin status,and complication rates.Cate-gorical values were described as percentages and analysed by the chi-square test.Continuous variables were expressed as median(range)and analysed by Mann-Whitney U test.Cumulative overall survival(OS)and recurrence-free survival(RFS)were analysed using Kaplan-Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.RESULTS A total of 46 patients were included in this study[open MVR(oMVR):12(26.1%),miMVR:36(73.9%)].Patients’American Society of Anesthesiologists score,body mass index and co-morbidities were comparable between oMVR and miMVR.There is an increasing trend towards robotic MVR from 2015 to 2023.MiMVR was associated with lower estimated blood loss(EBL)(median 450 vs 1200 mL,P=0.008),major morbidity(14.7%vs 50.0%,P=0.014),post-operative intra-abdominal collections(11.8%vs 50.0%,P=0.006),post-operative ileus(32.4%vs 66.7%,P=0.04)and surgical site infection(11.8%vs 50.0%,P=0.006)compared with oMVR.Length of stay was also shorter for miMVR compared with oMVR(median 10 vs 30 d,P=0.001).Oncological outcomes-R0 resection,recurrence,OS and RFS were comparable between miMVR and oMVR.There was no 30-d mortality.More patients underwent robotic compared with laparoscopic MVR for complex cases(robotic 57.1%vs laparoscopic 7.7%,P=0.004).The operating time was longer for robotic compared with laparoscopic MVR[robotic:602(400-900)min,laparoscopic:Median 455(275-675)min,P<0.001].Incidence of R0 resection was similar(laparoscopic:84.6%vs robotic:76.2%,P=0.555).Overall complication rates,major morbidity rates and 30-d readmission rates were similar between la-paroscopic and robotic MVR.Interestingly,3-year OS(robotic 83.1%vs 58.6%,P=0.008)and RFS(robotic 72.9%vs 34.3%,P=0.002)was superior for robotic compared with laparoscopic MVR.CONCLUSION MiMVR had lower post-operative complications compared to oMVR.Robotic MVR was also safe,with acceptable post-operative complication rates.Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Impact of propofol and sevoflurane anesthesia on cognition and emotion in gastric cancer patients undergoing radical resection

BACKGROUND Propofol and sevoflurane are commonly used anesthetic agents for maintenance anesthesia during radical resection of gastric cancer.However,there is a debate concerning their differential effects on cognitive function,anxiety,and depression in patients undergoing this procedure.AIM To compare the effects of propofol and sevoflurane anesthesia on postoperative cognitive function,anxiety,depression,and organ function in patients undergoing radical resection of gastric cancer.METHODS A total of 80 patients were involved in this research.The subjects were divided into two groups:Propofol group and sevoflurane group.The evaluation scale for cognitive function was the Loewenstein occupational therapy cognitive assessment(LOTCA),and anxiety and depression were assessed with the aid of the self-rating anxiety scale(SAS)and self-rating depression scale(SDS).Hemodynamic indicators,oxidative stress levels,and pulmonary function were also measured.RESULTS The LOTCA score at 1 d after surgery was significantly lower in the propofol group than in the sevoflurane group.Additionally,the SAS and SDS scores of the sevoflurane group were significantly lower than those of the propofol group.The sevoflurane group showed greater stability in heart rate as well as the mean arterial pressure compared to the propofol group.Moreover,the sevoflurane group displayed better pulmonary function and less lung injury than the propofol group.CONCLUSION Both propofol and sevoflurane could be utilized as maintenance anesthesia during radical resection of gastric cancer.Propofol anesthesia has a minimal effect on patients'pulmonary function,consequently enhancing their postoperative recovery.Sevoflurane anesthesia causes less impairment on patients'cognitive function and mitigates negative emotions,leading to an improved postoperative mental state.Therefore,the selection of anesthetic agents should be based on the individual patient's specific circumstances.

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.

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.

Achieving laparoscopic anatomic resection for hepatocellular carcinoma by fluorescence guided positive staining of hepatic cone unit

Laparoscopic anatomical liver resection has been increasingly reported worldwide,but how to demarcate the resection planes is technically challenging[1].Positive staining technique with intraoperative indocyanine green(ICG)-fluorescence imaging has been introduced as an effective tool for real-time intraoperative guidance[2].Liver anatomy is complex.Generally,liver is composed of 9 segments,each is composed of two to three subsegments,and each subsegment contains several hepatic cone units.A hepatic cone unit is dominated by a tertiary or quaternary hepatic pedicles[3].

Laparoscopic anatomical liver resection of segment 7 using a sandwich approach to the right hepatic vein (with video)

Full laparoscopic liver resection has been performed widely since it was introduced in the early 1990s.It has been expanded from initial for partial resection of the anterolateral segments to non-restriction of area of the liver[1–3].Anatomical liver resec-tion is considered to have potential superiority than non-anatomic resection in terms of tumor prognosis,thus it is more often rec-ommended in the treatment of hepatocellular carcinoma[4,5].Recently,laparoscopic segmental liver resection according to the Couinaud classification has been widely performed due to its ad-vantages in minimal invasiveness and tumor prognosis.

Transurethral resection of bladder tumor: A systematic review of simulator-based training courses and curricula

Objective:Transurethral resection of bladder tumor is one of the most common everyday urological procedures.This kind of surgery demands a set of skills that need training and experience.In this review,we aimed to investigate the current literature to find out if simulators,phantoms,and other training models could be used as a tool for teaching urologists.Methods:A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews.Fifteen out of 932 studies met our inclusion criteria and are presented in the current review.Results:The UroTrainer(Karl Storz GmbH,Tuttlingen,Germany),a virtual reality training simulator,achieved positive feedback and an excellent face and construct validity by the participants.The inspection of bladder mucosa,blood loss,tumor resection,and procedural time was improved after the training,especially for inexperienced urologists and medical students.The construct validity of UroSim®(VirtaMed,Zurich,Switzerland)was established.SIMBLA simulator(Samed GmbH,Dresden,Germany)was found to be a realistic and useful tool by experts and urologists with intermediate experience.The test objective competency model based on SIMBLA simulator could be used for evaluating urologists.The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it.The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity,and 60%of participants would like to use the simulators in the future.The 5-day multimodal training curriculum“Boot Camp”in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project.Conclusion:Simulators and courses or curricula based on a simulator training could be a valuable learning tool for any surgeon,and there is no doubt that they should be a part of every urologist's technical education.

Distal margin distance in radical resection of locally advanced rectal cancer after neoadjuvant therapy

Colorectal cancer has a high incidence and mortality rate in China, with the majority of cases being middle and low rectal cancer. Surgical intervention is currently the main treatment modality for locally advanced rectal cancer, with the common goal of improving oncological outcomes while preserving function. The controversy regarding the circumferential resection margin distance in rectal cancer surgery has been resolved. With the promotion of neoadjuvant therapy concepts and advancements in technology, treatment strategies have become more diverse.Following tumor downstaging, there is an increasing trend towards extending the safe distance of distal rectal margin. This provides more opportunities for patients with low rectal cancer to preserve their anal function.However, there is currently no consensus on the specific distance of distal resection margin.

Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria

BACKGROUND The majority of esophageal subepithelial lesions originating from the muscularis propria(SEL-MPs)are benign in nature,although a subset may exhibit malignant characteristics.Conventional endoscopic resection techniques are time-consuming and lack efficacy for small SEL-MPs.AIM To evaluate the efficacy and safety of ligation-assisted endoscopic submucosal resection(ESMR-L)following unroofing technique for small esophageal SEL-MPs.METHODS From January 2021 to September 2023,17 patients diagnosed with esophageal SEL-MPs underwent ESMR-L following unroofing technique at the endoscopy center of Shenzhen People’s Hospital.Details of clinicopathological characteristics and clinical outcomes were collected and analyzed.RESULTS The mean age of the patients was 50.12±12.65 years.The mean size of the tumors was 7.47±2.83 mm and all cases achieved en bloc resection successfully.The average operation time was 12.2 minutes without any complications.Histopathology identified 2 Lesions(11.8%)as gastrointestinal stromal tumors at very low risk,12 Lesions(70.6%)as leiomyoma and 3 Lesions(17.6%)as smooth muscle proliferation.No recurrence was found during the mean follow-up duration of 14.18±9.62 months.CONCLUSION ESMR-L following roofing technique is an effective and safe technique for management of esophageal SEL-MPs smaller than 20 mm,but it cannot ensure en bloc resection and may require further treatment.

Clinical efficacy and pathological outcomes of transanal endoscopic intersphincteric resection for low rectal cancer

BACKGROUND Transanal endoscopic intersphincteric resection(ISR)surgery currently lacks sufficient clinical research and reporting.AIM To investigate the clinical effectiveness of transanal endoscopic ISR,in order to promote the clinical application and development of this technique.METHODS This study utilized a retrospective case series design.Clinical and pathological data of patients with lower rectal cancer who underwent transanal endoscopic ISR at the First Affiliated Hospital of Xiamen University between May 2018 and May 2023 were included.All patients underwent transanal endoscopic ISR as the surgical approach.We conducted this study to determine the perioperative recovery status,postoperative complications,and pathological specimen charac-teristics of this group of patients.RESULTS This study included 45 eligible patients,with no perioperative mortalities.The overall incidence of early complications was 22.22%,with a rate of 4.44%for Clavien-Dindo grade≥III events.Two patients(4.4%)developed anastomotic leakage after surgery,including one case of grade A and one case of grade B.Postoperative pathological examination confirmed negative circumferential resection margins and distal resection margins in all patients.The mean distance between the tumor lower margin and distal resection margin was found to be 2.30±0.62 cm.The transanal endoscopic ISR procedure consistently yielded high quality pathological specimens.CONCLUSION Transanal endoscopic ISR is safe,feasible,and provides a clear anatomical view.It is associated with a low incidence of postoperative complications and favorable pathological outcomes,making it worth further research and application.

Clinical characteristics of patients with early gastric prematurity cancer and analysis of complications by endoscopic resection

BACKGROUND Gastric cancer,a prevalent malignancy,poses a severe threat to the health of residents in China.Timely intervention in early stages can extend patients’survival.AIM To analyze clinical characteristics of patients with early gastric cancer and efficacy and risk of complications associated with endoscopic resection.METHODS This study included 175 patients with early gastric cancer treated at our hospital,with no restrictions on sex or age.General data,pathological information,and endoscopic biopsy results were obtained.The clinical characteristics of early gastric cancer were analyzed,and endoscopic resection was performed.Postoperative efficacy and incidence of complications were monitored.Statistical analysis was performed using SPSS 26.0 and GraphPad Prism 8.0 software.RESULTS A total of 175 patients with early gastric cancer were included,with 75.43%(n=132)males and 24.57%(n=43)females.38.29%(n=67)and 35.43%(n=62)of patients had a history of smoking and alcohol consumption,respectively.Comorbidities included diabetes(8.57%,n=15),coronary heart disease(10.29%,n=18),and hypertension(43.43%,n=76),which was highly prevalent.A history of abdominal surgery and family history of digestive system cancer accounted for 21.14%and 17.14%,respectively.The most common lesion location was the antral part of the stomach(52.00%,n=91),followed by the gastric angle,body,and fundus.The pathological types were predominantly high-grade intraepithelial neoplasia(28.00%,n=49)and well-differentiated adenocarcinoma(26.86%,n=47),followed by moderately differentiated adenocarcinoma,high-moderately differentiated adenocarcinoma,and moderate-lowly differentiated adenocarcinoma.89.14%of the patients had intestinal metaplasia and 85.14%had atrophy.After endoscopic resection,re-examination revealed that 13 patients had cancer cells at the tissue margin,with a positive margin rate of 7.43%.Postoperative complications included no cases of gastrointestinal obstruction,but incisional infection(2.86%,n=5),gastric perforation(1.14%,n=2),and gastric bleeding(4%,n=7)were present,with an overall incidence of 8.00%.CONCLUSION Analysis of the clinical characteristics indicated that early gastric cancer is more prevalent in males with a history of hypertension,with lesions most commonly occurring in the antral region of the stomach.The pathological types are often high-grade intraepithelial neoplasia and well-differentiated adenocarcinoma,with over 85%of patients having comorbid intestinal metaplasia and atrophy.Despite endoscopic resection,a positive margin rate persisted,indicating a probability of residual cancer at the margins.Postoperative complications,such as gastrointestinal obstruction,incisional infection,gastric perforation,and gastric bleeding can occur and require timely symptomatic treatment.

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.

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.

Endoscopic submucosal dissection and endoscopic mucosal resection for esophageal and gastric lesions:A comparison of procedures

Objective Esophageal and gastric lesions are effectively managed with minimally invasive upper endoscopic procedures such as endoscopic mucosa resection(EMR)and endoscopic submucosal dissection(ESD),offering patients alternatives to invasive interventions.While ESD is well established in Eastern Asia,its adoption in Denmark for superficial esophageal cancer is recent.This study presents real-world data on the feasibility,safety,and hospitalization duration associated with ESD and EMR for esophageal and gastric lesions.Methods A retrospective analysis was conducted on patients who underwent ESD or EMR at a specialized center in Denmark from October 2016 to June 2022.Data on treatment,indication,lesion location,hospitalization duration,procedure duration,specimen size,complications,recurrence,and one-year overall survival were collected.Statistical comparisons utilized the Mann-Whitney U test,independent sample median test,and chi-squared test.Results The study included 130 patients(144 procedures):72 underwent ESD and 58 underwent EMR.Compared with EMR,ESD resulted in greater percentages of en bloc and R0 resections(98.8%vs.64.1%,p<0.001;and 83.9%vs.23.8%,p<0.001),greater complication rates(28.7%vs.3.1%,p<0.001)and longer procedure times(119.5 min vs.37.0 min,p<0.001).The ESD procedure time significantly decreased over time(p=0.01).The local recurrence rates were 14.5%for ESD and 23.8%for EMR(p=0.767).The one-year overall survival rates were similar between the groups(95.8%vs.94.8%,p=0.553).Conclusion Both ESD and EMR are safe and viable for treating esophageal and gastric lesions.ESD offers advantages but requires more time and skill.These findings support the literature,emphasizing the importance of considering patient-specific factors and surgeon proficiency in selecting the appropriate procedure.

Robotic vs laparoscopic abdominoperineal resection for rectal cancer:A propensity score matching cohort study and metaanalysis

BACKGROUND Robotic surgery(RS)is gaining popularity;however,evidence for abdominoperineal resection(APR)of rectal cancer(RC)is scarce.AIM To compare the efficacy of RS and laparoscopic surgery(LS)in APR for RC.METHODS We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022.Data regarding short-term surgical outcomes were compared between the two groups.To reduce the effect of potential confounding factors,propensity score matching was used,with a 1:1 ratio between the RS and LS groups.A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery.RESULTS Of 133 patients,after propensity score matching,there were 42 patients in each group.The postoperative complication rate was significantly lower in the RS group(17/42,40.5%)than in the LS group(27/42,64.3%)(P=0.029).There wasno significant difference in operative time(P=0.564),intraoperative transfusion(P=0.314),reoperation rate(P=0.314),lymph nodes harvested(P=0.309),or circumferential resection margin(CRM)positive rate(P=0.314)between the two groups.The meta-analysis showed patients in the RS group had fewer positive CRMs(P=0.04),lesser estimated blood loss(P<0.00001),shorter postoperative hospital stays(P=0.02),and fewer postoperative complications(P=0.002)than patients in the LS group.CONCLUSION Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer

BACKGROUND The abdominal perineal resection(APR),historically referred to as Mile’s proce-dure,stands as a time-honored surgical intervention for rectal cancer manage-ment.Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer,including those with ultralow rectal cancer.Despite these improvements,APR maintains its irreplaceable role in the clinical landscape,particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles.Optimal perineal exposure stands as a pivotal phase in APR,given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient’s subse-quent long-term prognosis.AIM To evaluate the value of Lone-Star retractor(LSR)perineal exposure method in the treatment for laparoscopic APR of rectal cancer.METHODS We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023,including 20 patients who underwent the APR procedure with a LSR perineal exposure method(LSR group)and 18 patients who underwent the APR procedure with a conventional perineal exposure method(control group).In the LSR group,following incision of the skin and subcutaneous tissue,the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field.RESULTS A total of 38 patients underwent laparoscopic APR,none of whom were found to have distant metastasis upon intraoperative exploration.Perineal blood loss,the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group.A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group(P<0.05).The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group(P<0.05).No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up.CONCLUSION The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications,shorten the postoperative hospital stay,improve postoperative pain,and allow one surgeon to perform the perineal operation.