Search Results (92)

Background: Acute kidney injury (AKI) frequently occurs following major liver resection, adversely affecting both short- and long-term outcomes. This study aimed to determine the incidence of AKI post-hepatectomy and identify relevant pre- and intraoperative risk factors. Our secondary objectives were to develop a predictive score for postoperative AKI and assess the associations between AKI, chronic kidney disease (CKD), and 1-year mortality. Methods: This was a retrospective study in a cancer referral center in Marseille, France, from 2018 to 2022. Results: Among 169 patients, 55 (32.5%) experienced AKI. Multivariate analysis revealed several independent risk factors for postoperative AKI, including age, body mass index, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, time to liver resection, intraoperative shock, and bile duct reconstruction. Neoadjuvant chemotherapy was protective. The AKIMEBO score was developed, with a threshold of ≥15.6, demonstrating a sensitivity of 89.5%, specificity of 76.4%, positive predictive value of 61.8%, and negative predictive value of 94.4%. AKI was associated with increased postoperative morbidity and one-year mortality following major hepatectomy. Conclusion: AKI is a common complication post-hepatectomy. Factors such as time to liver resection and intraoperative shock management present potential clinical intervention points. The AKIMEBO score can provide a valuable tool for postoperative risk stratification. Full article

Background/Objectives: Preoperative strategies for hepatocellular carcinoma (HCC) requiring major hepatectomy remain controversial, particularly in “borderline resectable” cases. This study aimed to evaluate the oncological benefit and perioperative safety of Yttrium-90 transarterial radioembolization (TARE) in patients undergoing right or extended right hepatectomy for HCC. Material and Methods: All consecutive patients who underwent right or extended right hepatectomy for HCC at a single tertiary center between January 2013 and December 2023 were retrospectively reviewed. Patients were grouped based on whether they received preoperative TARE or underwent upfront resection. Outcomes analyzed included perioperative morbidity and long-term oncological endpoints. Results: A total of 39 patients were included, of whom 18 received preoperative TARE and 21 underwent upfront surgery. Patients in the TARE group showed significantly greater tumor necrosis at pathology (70% vs. 10%, p = 0.002) and more frequent extended resections. Five-year cancer-specific survival (80.4% vs. 33.5%, p = 0.011), recurrence-free survival (33.8% vs. 14.0%, p = 0.047), and curative-intent disease-free survival (69.3% vs. 18.9%, p = 0.0037) were significantly higher in the TARE group. Overall survival showed a favorable trend. Intraoperative outcomes, postoperative morbidity, and 90-day mortality were comparable between groups. Conclusions: Preoperative TARE is a safe and effective neoadjuvant strategy in selected patients with HCC undergoing major hepatectomy. It may enhance long-term oncological outcomes without increasing surgical risk, supporting its potential role in the management of borderline resectable HCC. Full article

Background: Post-hepatectomy liver failure (PHLF) is the most worrisome complication after a major hepatectomy and is the leading cause of postoperative mortality. The most important predictor of PHLF is the future liver remnant (FLR), the volume of the liver that will remain after the hepatectomy, representing a major concern for hepatobiliary surgeons, radiologists, and patients. Therefore, an accurate preoperative assessment of the FLR and the prediction of PHLF are crucial to minimize risks and enhance patient outcomes. Recent radiomics and deep learning models show potential in predicting PHLF and the FLR by integrating imaging and clinical data. However, most studies lack external validation and methodological homogeneity and rely on small, single-center cohorts. This review outlines current CT-based approaches for surgical risk stratification and key limitations hindering clinical translation. Methods: A literature analysis was performed on the PubMed Dataset. We reviewed original articles using the subsequent keywords: [(Artificial intelligence OR radiomics OR machine learning OR deep learning OR neural network OR texture analysis) AND liver resection AND CT]. Results: Of 153 pertinent papers found, we underlined papers about the prediction of PHLF and about the FLR. Models were built according to machine learning (ML) and deep learning (DL) automatic algorithms. Conclusions: Radiomics models seem reliable and applicable to clinical practice in the preoperative prediction of PHLF and the FLR in patients undergoing major liver surgery. Further studies are required to achieve larger validation cohorts. Full article

Primary hepatic gastrointestinal stromal tumours (PHGISTs) are rare and frequently misdiagnosed due to their atypical presentation and uncertain origin. The purpose of this article is to present the case of a 79-year-old female patient with a gigantic PHGIST characterized by a predominantly cystic nature—an extremely rare presentation, as most cases of PHGIST are solid. Despite extensive imaging and exploratory laparotomy, the primary origin remained uncertain, leading to questioning about whether it was a true primary hepatic GIST or an atypical metastatic lesion. The initial therapeutic approach involved a surgical procedure aimed to confirm the diagnosis and achieve reductive tumourectomy. Following the surgery, the patient was administered imatinib with a favourable clinical response for four and a half years—an atypical pattern of resistance, as most patients typically develop therapeutic resistance within two to three years. A second surgical intervention was performed to address a cystic lesion localized in the left hepatic lobe, followed by an atypical segment III hepatectomy to achieve macroscopic resection. Subsequently, the patient received sunitinib for two and a half years, which resulted in temporary disease stabilization. However, the sunitinib treatment was associated with hypertension and leukopenia. The patient’s overall survival was 8 years, suggesting that individualized therapeutic strategies and close monitoring might be the key in such cases. Furthermore, this case confirms the role of surgical intervention even in advanced disease stages, with multiple major resections contributing significantly to prolonged survival. The interplay between surgical and oncologic therapies remains essential to guiding clinical decisions. Given the unusual cystic presentation, this case highlights the necessity to expand the pathological and molecular profiling of PHGISTs. Furthermore, the atypical timeline of resistance development and treatment-related toxicity emphasizes the importance of further research into the genetic and pharmacological determinants of PHGISTs. These findings advocate for the refinement of diagnostic, therapeutic, and surveillance protocols tailored to rare GIST subtypes. Full article

Background: Bile leakage remains a significant challenge following major liver resection, with potential for improvement depending on the transection technique used. In this study, we aimed to evaluate the effectiveness of our hybrid resection technique—utilizing both LigaSure and stapler devices—in reducing bile leakage after major liver resection compared to our conventional stapler-only technique. As a secondary aim, we compared overall morbidity, costs, and reimbursements. Method: Patients who underwent major hepatectomy without biliary reconstruction using either the hybrid or stapler technique between August 2014 and December 2021 were included in the study. Propensity score matching was performed using a one-to-two algorithm. Perioperative data, bile leakage rates, and cost and reimbursement information based on the diagnosis-related group (DRG) system were analyzed. Results: In total, data from 492 patients were evaluated (hybrid = 152; stapler = 340). After one-to-two propensity score matching, the operation time was significantly longer in the hybrid group (p = 0.005). A cost analysis showed no significant difference in total operative costs between the two techniques (p = 0.092). However, the hybrid group had a significantly lower rate of bile leakage (p = 0.002), as well as shorter intensive care unit (ICU) and overall hospital stays (p = 0.034 and p = 0.007, respectively). Consequently, ICU and ward costs were significantly lower in the hybrid group (p = 0.024 and p = 0.014, respectively) compared to the stapler group. The financial difference calculated as DRG reimbursement minus costs was two-fold higher in the hybrid group (p = 0.02). Conclusions: Although the hybrid technique resulted in a longer operating time, it proved superior to the stapler technique in reducing postoperative bile leakage and shortening ICU and hospital stays. Furthermore, the use of the hybrid technique was more cost efficient and resulted in a greater positive financial margin. Full article

Background/Objectives: Colorectal liver metastases (CRLMs) occur in 25–30% of colorectal cancer (CRC) patients, significantly impacting survival. While major liver resection (MLR) was traditionally preferred for oncologic clearance, parenchymal-sparing surgery (PSS) has emerged as a less invasive alternative. This study compares perioperative and long-term outcomes of PSS versus MLR in CRLM patients. Methods: We conducted a retrospective cohort study at the Regional Oncology Institute, Iasi, Romania, analyzing patients who underwent hepatic resection for CRLM between August 2013 and June 2024. Patients were categorized into PSS (n = 58) and MLR (n = 28) groups. Outcomes assessed included perioperative parameters, postoperative morbidity, overall survival (OS), and disease-free survival (DFS). Results: PSS was associated with a shorter operative time (235.2 vs. 302.6 min, p = 0.003), lower morbidity (18.9% vs. 57.1%, p = 0.001), and fewer major complications (Clavien–Dindo ≥ III, p = 0.005). ICU stay was significantly longer in MLR patients (p = 0.04). After propensity score matching (PSM), PSS was found to have lower morbidity compared to MLR (p = 0.023) with similar major morbidity (p = 0.473) and LOS (p = 0.579). Overall survival (31 vs. 37.1 months, p = 0.884) and disease-free survival (25.2 vs. 22.2 months, p = 0.519) were comparable between the groups before and after propensity score matching PSM (40.9 vs. 21.2 months, p = 0.741 and 24.3 vs. 13.8 months, p = 0.653). Conclusions: PSS achieves comparable oncologic outcomes to MLR while reducing postoperative morbidity and ICU stay. These findings support PSS as the preferred approach for CRLM, reserving MLR for select cases requiring extensive resection. Full article

Background/Objectives: Ropivacaine is primarily metabolized by the liver. High doses of ropivacaine, combined with altered pharmacokinetics due to hepatectomy, raise concerns about potential drug toxicity. We investigated the impact of LMH (laparoscopic major hepatectomy) on the pharmacokinetics of high-dose ropivacaine. Methods: Ten patients undergoing LMH received a BD-TAP (bilateral dual transversus abdominis plane) block with a high dose of ropivacaine (3 mg·kg⁻¹ in 60 mL). Plasma concentrations of total and free ropivacaine and AAG (alpha-1 acid glycoprotein) levels were measured. Liver volumes were calculated using three-dimensional liver reconstruction technology. Results: The peak total ropivacaine concentration occurred 45 min after the block, reaching 2031.5 (876.0) ng·mL⁻¹, with a tendency to exceed the toxicity threshold in patients with a CFLV (cut functional liver volume) exceeding 199.24 mL or a CFLV/TFLV (total functional liver volume) ratio surpassing 18.61%. The peak free ropivacaine concentration, 111.5 (31.3) ng·mL⁻¹, was observed 90 min after the block, potentially exceeding the toxicity threshold when CFLV exceeded 452.33 mL or the CFLV/TFLV ratio was greater than 42.16%. Plasma AAG levels increased approximately 1.5 times within 24 h, from 1519.7 (422.6) μg·mL⁻¹ preoperatively to 2253.6 (460.4) μg·mL⁻¹ postoperatively, effectively reducing the toxicity risk associated with free ropivacaine. Conclusions: Preoperative administration of high-dose ropivacaine can be safely utilized in patients undergoing major hepatectomy. The increased plasma AAG concentration due to surgical stress reduces free ropivacaine levels, enhancing patient tolerance to the drug. The CFLV and CFLV/TFLV ratio may be supplementary indicators for predicting ropivacaine toxicity. Full article

Background/Objectives: There is still no consensus as to whether patients with upfront resectable synchronous colorectal liver metastases (sCRLM) should receive neoadjuvant treatment prior to liver surgery. Two randomized controlled trials have assessed the role of peri-operative chemotherapy in sCRLM; neither have shown a survival benefit in the neoadjuvant group. The aim of this population-based study was to examine overall survival in patients treated with neoadjuvant chemotherapy and hepatectomy compared to patients who had upfront surgery. Methods: This is a retrospective observational study between 2009 and 2017 containing data extracted from two Swedish national registries. Descriptive statistics and Cox regression analyses were employed. Results: In total, 2072 patients with sCRLM were treated with liver surgery between 2009 and 2017. A majority (n = 1238, 60%) were treated with neoadjuvant chemotherapy, and 834 patients (40%) had upfront surgery. Patients in the upfront surgery group were older (median age 70 compared to 65 years, p ≤ 0.001). Median overall survival in the upfront surgery group was 26 months (95% CI 23–29 months) compared to 57 months (95% CI 42–48 months) in the neoadjuvant group, log rank p ≤ 0.001. In the multivariable Cox regression analysis, age ≥ 70 years (HR 1.46, 95% CI 1.25–1.70), T category of primary cancer (HR 1.41, 95% CI 1.09–1.84), lymphatic spread of primary cancer (HR 1.68, 95% CI 1.41–1.99), and number of liver metastases (six or more metastases resulted in HR 2.05, 95% CI 1.38–3.01) negatively influenced overall survival. By contrast, adjuvant therapy was protective (HR 0.80, 95% CI 0–69–0.94), whereas neoadjuvant treatment compared to upfront surgery did not influence overall survival (HR 1.04, 95% CI 0.86–1.26). Conclusions: Neoadjuvant treatment in sCRLM did not confer a survival benefit compared to upfront surgery. Full article

Background/Objectives: Indocyanine green (ICG) fluorescence imaging is widely utilized for visualizing hepatic tumors, hepatic segmentation, and biliary anatomy, improving the safety and curability of cancer surgery. However, its application for perfusion assessment in hepatobiliary and pancreatic (HBP) surgery has been less explored. Methods: This study evaluated outcomes of patients undergoing HBP surgery with vascular reconstruction from April 2022 to August 2024. During surgery, ICG (1.25–5 mg/body) was administered intravenously to assess the need and quality of vascular reconstruction via fluorescence imaging. Results: Among 30 patients undergoing hepatectomies and/or pancreatectomies, ICG fluorescence imaging was used in 16 cases (53%) to evaluate organ and vascular perfusion. In two hepatectomy cases with consideration of reconstruction of the middle hepatic veins, sufficient fluorescence intensities in drainage areas led to the avoidance of middle hepatic vein reconstruction. In 14 cases requiring vascular reconstruction, fluorescence imaging visualized smooth blood flow through anastomotic sites in 11 cases, while insufficient signals were observed in 3 cases. Despite this, re-do anastomoses were not indicated because the fluorescence signals in the targeted organs were adequate. Postoperative contrast-enhanced computed tomography confirmed satisfactory blood perfusion in all cases. Conclusions: Real-time blood flow assessment using ICG fluorescence imaging provides valuable information for intraoperative decision-making in HBP surgeries that require vascular reconstruction of major vessels, such as hepatic arteries, veins, and the portal system. Full article

Background: Liver resection is the standard treatment for resectable hepatocellular carcinoma (HCC). The advent of robotic surgery has extended its application in liver surgery, reducing post-operative complications without compromising oncological safety. This study is a retrospective series with the aim of analyzing the preoperative patient’s and tumor’s characteristics and evaluating intraoperative and post-operative data in terms of hospital stay, complications, and oncological radicality. Methods: Data were collected from a multicenter retrospective database that includes 1070 consecutive robotic liver resections (RLRs) performed in nine European hospital centers from 2011 to 2023. Of the entire series, 343 liver resections were performed for HCC. Results: A total of 247 patients (72.3%) had mono-focal lesions. Major hepatectomies and anatomical resections have been perfomed in 87% and 55% of patients, respectively. All 17 conversions (4.95%) were to the open approach. The operative mean time was 239.56 min and the estimated blood loss was 229.45 mL. The overall post-operative complication rate was 22.74%, but severe complications occurred in 4.08% of patients and one of them (0.29%) was reoperated on. The mean hospital stay was 5.82 days with a mean ICU stay of 0.9 days. Twenty-six resections (7.6%) were R1 parenchymal. Forty-six patients (4.08%) were readmitted to the hospital within 90 days after discharge and seventy-eight patients (22.74%) had disease recurrence. Total deaths included 36 (10.5%) patients with a 90-day mortality of 0.9%. Conclusions: Robotic liver resection for HCC is feasible and safe when performed in experienced centers by surgeons who have completed the learning curve. Full article

Background: Post-hepatectomy liver failure (PHLF) is a serious complication following hepatic resection for Klatskin tumors, significantly affecting patient prognosis. Identifying reliable preoperative and early postoperative predictors of PHLF can help optimize patient outcomes and guide surgical planning. Method: We conducted a retrospective review of 34 patients who underwent hemi-hepatectomy for extrahepatic cholangiocarcinoma at Kosin University Gospel Hospital between April 2019 and April 2024, and at Chonnam National University Hwasun Hospital between September 2017 and April 2024. Demographics, laboratory data, and volumetric measurements including spleen volume, were analyzed to assess their roles in predicting PHLF. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate the predictive value of these factors. Results: Elevated preoperative glucose levels and reduced future liver remnant to spleen ratio (FLR/SV) were significantly associated with an increased risk of PHLF. Additionally, elevated postoperative day 1 total bilirubin (POD 1 TB) was identified as a key postoperative predictor of PHLF. Multivariable analysis confirmed the significance of these factors, with FLR/SV, preoperative glucose, and POD 1 TB demonstrating good discriminative ability in ROC analysis, with AUC values of 0.779, 0.782, and 0.786 respectively. Conclusion: Preoperative glucose control, evaluation of FLR/SV, and early postoperative monitoring of TB are useful for improving outcomes in patients undergoing major hepatectomy for Klatskin tumors. Full article

Background/Objectives: In the field of surgical medicine, the planning and execution of liver resection procedures present formidable challenges, primarily attributable to the intricate and highly individualized nature of liver vascular anatomy. In the current surgical milieu, intraoperative ultrasonography (IOUS) has become indispensable; however, traditional 2D ultrasound imaging’s interpretability is hindered by noise and speckle artifacts. Accurate identification of critical structures for preservation during hepatectomy requires advanced surgical skills. Methods: An AI-based model that can help detect and recognize vessels including the inferior vena cava (IVC); the right (RHV), middle (MHV), and left (LVH) hepatic veins; the portal vein (PV) and its major first and second order branches the left portal vein (LPV), right portal vein (RPV), and right anterior (RAPV) and posterior (RPPV) portal veins, for real-time IOUS navigation can be of immense value in liver surgery. This research aims to advance the capabilities of IOUS-guided interventions by applying an innovative AI-based approach named the “2D-weigthed U-Net model” for the segmentation of multiple blood vessels in real-time IOUS video frames. Results: Our proposed deep learning (DL) model achieved a mean Dice score of 0.92 for IVC, 0.90 for RHV, 0.89 for MHV, 0.86 for LHV, 0.95 for PV, 0.93 for LPV, 0.84 for RPV, 0.85 for RAPV, and 0.96 for RPPV. Conclusion: In the future, this research will be extended for real-time multi-label segmentation of extended vasculature in the liver, followed by the translation of our model into the surgical suite. Full article

Backgorund: Textbook outcome (TO) is a composite measure that reflects the most desirable surgical results as a single indicator. The aim of this study was to assess the achievement of TO at a hepatopancreatobiliary (HPB) surgery unit in a Spanish tertiary hospital. Methods: We performed a retrospective observational study of all consecutive patients who underwent HPB surgery over a 4-year period. Morbidity according to the Clavien-Dindo classification at 30 days, hospital stay, risk of morbidity and mortality according to the POSSUM, and mortality and readmissions at 90 days were recorded. TO was considered when a patient presented no major complications (≥IIIA), no mortality, no readmission, and no prolonged length of stay (≤75th). Results: 283 patients were included. Morbidity >IIIA was reported in 21.6%, and 5.7% died; the median postoperative stay was 4 days. TO was achieved in 56.2% of patients. Comparing patients who presented TO with those who did not, significant differences were recorded for the type of procedure and the expected risk of morbidity and mortality calculated according to the POSSUM scale. There were significant differences between patients with major resections (TO rates: major hepatectomy (46.3%) and major pancreatectomy (52.5%)) and those with minor resections (TO rates minor hepatectomy (67.7%) and minor pancreatectomy (40.4%)). Conclusions: TO is a useful management tool for assessing postoperative results. Full article

Background/Objectives: Liver retransplantation (reLT) is the only option for pediatric patients experiencing graft loss. Despite recent advancements in surgical techniques and perioperative management, it remains a high-risk procedure. Our aim is to describe our experience in pediatric reLT, focusing on the technical aspects and surgical challenges. Methods: We systematically analyzed surgical reports from pediatric reLT performed at our center between 2006 and 2023 to identify recurrent intraoperative findings and specific surgical techniques. We focused on challenges encountered during different phases of reLT, including hepatectomy, vascular, and biliary reconstruction. Additionally, we compared patient and graft survival rates among different groups. Results: During the study period, 23 children underwent 25 reLT procedures at our center. Major surgical challenges included complex hepatectomy and vascular reconstructions, necessitating tailored approaches. Our analysis shows that patient and graft survival were significantly lower for reLT compared to primary transplantation (p = 0.002). Early reLT had a significantly lower graft survival compared to late reLT (p = 0.002), although patient survival was comparable (p = 0.278). Patient and graft survival rates were comparable between the first and second reLT (p = 0.300, p = 0.597). Patient survival tended to be higher after living-donor liver transplantation (LDLT) compared to deceased-donor liver transplantation (DDLT), although the difference was not statistically significant (p = 0.511). Conclusions: Pediatric reLT involves significant technical challenges and lower survival rates. Advances in perioperative management are crucial for improving outcomes. Further research is needed to optimize surgical strategies and evaluate the long-term benefits of LDLT in pediatric reLT. Full article

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery—the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient—is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function. Full article