Comments on:Perioperative von Willebrand factor dynamics are associated with liver regeneration and predict outcome after liver resection

Recentlythearticle"PerioperativevonWillebrandfactordynamics are associated with liver regeneration and predict outcome afterliver resection" was published in Hepatology[1].Prof.Starlinger et al. aimed to assess the association of von Willebrand factor (vWF) levels and clinical outcome in patients with liver cancers post-liverresection(LR).Basedonthemechanismthatplatelets accumulation in the liver may promote liver regeneration after partial LR in mice, they found the vWF-dependent pattern of platelets accumulationduringliverregenerationinpatientsaftersurgery.

Risk of early hepatocellular carcinoma recurrence following liver resection: arbitrary specification or possible target to improve outcome?

Data from the literature favour liver transplantation(LT)as best curative-intent treatment in patients with early-stage hepatocellular carcinoma(HCC)arising from cirrhosis,as this approach targets both malignancy and the underlying cancerogenic pathomorphology.By strictly adhering to well-defined morphometric tumor burden limits,such as the Milan criteria,excellent recurrence-free survival(RFS)rates beyond 70%at 5 years may be achieved after LT.However,growing donor liver shortage has significantly increased waiting times and thereby risk of tumor-related dropout from the waiting list,ultimately resulting in inferior survival probability.In recent years,this critical situation further aggravated by growing evidence that beyond Milan patients may also benefit from LT,when being successfully downstaged by neoadjuvant locoregional interventions like transarterial chemoembolization(TACE)or radiofrequency ablation(RFA)(1).Therefore,even though being associated with an extraordinary risk of HCC recurrence accounting for 50%to 70%,upfront liver resection(LR)still represents the preferred surgical procedure in patients with resectable tumor stage,especially in those who do not suffer from severe portal hypertension.

Long-and short-term outcomes for resectable gallbladder carcinoma patients treated with curative-intent laparoscopic versus open resection:a multicenter propensity score-matched comparative study

Background:Gallbladder cancer(GBC)was once considered a contraindication for laparoscopic surgery,but it is becoming more common to use laparoscopic surgery for GBC treatment.The aim of this study was to analyze the long-and short-term outcomes of patients with more advanced T-staged GBC treated with curative intent as defined by the National Comprehensive Cancer Network(NCCN)after laparoscopic resection(LR)versus open resection(OR).Methods:A multicenter database was used to select consecutive GBC patients treated with curative-intent resection as defined by the NCCN between 2016 and 2020.The patients were divided into the LR group and the OR group.Propensity score matching(PSM)was used to eliminate selection bias.The endpoints were overall survival(OS),progression-free survival(PFS),and short-term outcomes.Risk factors that were independently associated with OS and PFS were identified.Results:Of 626 GBC patients treated with curative-intent resection,after PSM,51 patients were in the LR group and 153 patients were in the OR group.The LR group had more patients who were suitable to receive adjuvant chemotherapy(AC),a longer operation time,more harvested lymph nodes,and a lower overall morbidity rate.The rates of OS and PFS were not significantly different between the two groups.AC was independently associated with better OS and PFS.Conclusions:The overall morbidity of GBC patients after LR was lower,but the long-term outcomes between LR and OR were not significantly different.The GBC patients treated with LR were more likely to receive AC,and the use of AC after curative-intent resection of GBC helped achieve better long-term survival outcomes.

Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria:a meta-analysis of 18,421 patients

Background:Outcomes after liver resection(LR)and liver transplantation(LT)for hepatocellular carcinoma(HCC)are heterogenous and may vary by region,over time periods and disease burden.We aimed to compare overall survival(OS)and disease-free survival(DFS)between LT versus LR for HCC within the Milan criteria.Methods:Two authors independently searched Medline and Embase databases for studies comparing survival after LT and LR for patients with HCC meeting the Milan criteria.Meta-analyses and meta-regression were conducted using random-effects models.Results:We screened 2,278 studies and included 35 studies with 18,421 patients.LR was associated with poorer OS[hazard ratio(HR)=1.44;95%confidence interval(CI):1.14-1.81;P<0.01]and DFS(HR=2.71;95%CI:2.23-3.28;P<0.01)compared to LT,with similar findings among intention-to-treat(ITT)studies.In uninodular disease,OS in LR was comparable to LT(P=0.13)but DFS remained poorer(HR=2.95;95%CI:2.30-3.79;P<0.01).By region,LR had poorer OS versus LT in North America and Europe(P≤0.01),but not Asia(P=0.25).LR had inferior survival versus LT in studies completed before 2010(P=0.01),but not after 2010(P=0.12).Cohorts that underwent enhanced surveillance had comparable OS after LT and LR(P=0.33),but cohorts undergoing usual surveillance had worse OS after LR(HR=1.95;95%CI:1.24-3.07;P<0.01).Conclusions:Mortality after LR for HCC is nearly 50%higher compared to LT.Survival between LR and LT were similar in uninodular disease.The risk of recurrence after LR is threefold that of LT.

Liver resection versus intensity-modulated radiation therapy for treatment of hepatocellular carcinoma with hepatic vein tumor thrombus:a propensity score matching analysis

Background:The presence of hepatic vein tumor thrombus(HVTT)is a major determinant of survival outcomes in hepatocellular carcinoma(HCC)patients.This study compared survival outcomes between liver resection(LR)and intensity-modulated radiation therapy(IMRT)in HCC patients with HVTT.Methods:Data from patients who underwent LR or IMRT for HCC with HVTT at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed.Their survival outcomes were compared before and after propensity score matching(PSM).Results:Three hundred and seven HCC patients with HVTT who underwent either LR(n=140)or IMRT(n=167)were enrolled.PSM matched 82 pairs of patients.The overall survival(OS)and recurrence-free survival(RFS)rates were significantly higher for patients in the LR group than those in the IMRT group.On subgroup analysis,significantly better survival outcomes were obtained after LR than IMRT in patients with peripheral type of HVTT(pHVTT)and major type of HVTT(mHVTT).However,similar survival outcomes were obtained after LR and IMRT when the HVTT had developed into inferior vena cava tumor thrombus(IVCTT).Conclusions:LR resulted in significantly better survival outcomes in HCC patients with HVTT when compared to IMRT.Once the HVTT had developed IVCTT,LR and IMRT resulted in similarly bad survival outcomes.

Obesity and its influence on liver dysfunction,morbidity and mortality after liver resection

Background:Obesity and associated steatosis is an increasing health problem worldwide.Its influence on post-hepatectomy liver failure(PHLF)and after liver resection(LR)is still unclear.Methods:Patients who underwent LR were investigated and divided into three groups[normal weight:body mass index(BMI)18.5-24.9 kg/m2,overweight:BMI 25.0-29.9 kg/m2,obese:BMI≥30 kg/m2]in this retrospective study.Primary aim of this study was to assess the influence of BMI and nonalcoholic steatohepatitis(NASH)on PHLF and morbidity.Results:Of 888 included patients,361(40.7%)had normal weight,360(40.5%)were overweight,167(18.8%)were obese.Median age was 62.5 years(IQR,54-69 years).The primary indication for LR was colorectal liver metastases(CLM)(n=366,41.2%).NASH was present in 58(16.1%)of normal weight,84(23.3%)of overweight and 69(41.3%)of obese patients(P<0.001).PHLF occurred in 16.3%in normal weight,15.3%in overweight and 11.4%in obese patients(P=0.32).NASH was not associated with PHLF.There was no association between patients’weight and the occurrence of postoperative complications(P=0.45).At multivariable analysis,solely major LR[odds ratio(OR):2.7,95%confidence interval(CI):1.83-4.04;P<0.001]remained a significant predictor for PHLF.Conclusions:Postoperative complications and PHLF are comparable in normal weight,overweight and obese patients and LRs using modern techniques can be safely performed in these patients.

Liver transplantation:would it be the best and last chance of cure for hepatocellular carcinoma with major venous invasion?

Background:Hepatocellular carcinoma(HCC)with portal vein tumour thrombus(PVTT)signifies advanced disease,whether LT confers any survival superiority over resection remains uncertain.Methods:A propensity score matched(PSM)analysis of liver transplantation(LT)and liver resection(LR)for HCC with PVTT was performed.Results:A consecutive series of 88 patients who received either LT(10 DDLTs and 3 LDLTs)or LR(n=75)respectively were recruited.Before PSM,the LT group has a higher MELD score(17.3 vs.7.8,P<0.001),lower serum AFP levels(96 vs.2,164 ng/mL,P=0.017)and smaller tumour size(4 vs.10 cm,P<0.001).The 5-year overall survival for LT and LR were 55.4%and 15.9%respectively(P=0.007).After matching for serum AFP levels and tumour size,1-,3-and 5-year overall survival for LT were 81 ng/mL,3.9 cm,80%,70%and 70%and the corresponding rates for LR were 1,417 ng/mL,5.3 cm,51.8%,19,6%and 9.8%(P value=0.12,0.27 and 0.009 respectively).Conclusions:LT is associated with significantly better oncological outcomes in HCC patients with PVTT involving the lobar or segmental level.A modest expansion of selection criteria to include small HCC with segmental PVTT should be considered.