Robotic versus open hemihepatectomy: a propensity score-matched study

BACKGROUND

Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy.

METHODS

Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio.

RESULTS

After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P < 0.001) but the postoperative hospital stay was significantly shorter (median 5 days vs 6.5 days, P = 0.040) in the robotic group. When right and left hepatectomy were analyzed separately, the advantage of shorter hospital stay remained in left but not right hepatectomy. For patients with hepatocellular carcinoma, there was no difference between the two groups in 5-year overall and disease-free survival.

CONCLUSION

Compared with the open approach, robotic hemihepatectomy has longer operation time but shorter hospital stay. Thus, use of robot is feasible and effective in hemihepatectomy with the benefit of shorter hospital stay.

En bloc transdiaphragmatic lung resection for locally advanced hepatocellular carcinoma: a case report

A 56-year-old man presented with an 11-cm hepatocellular carcinoma (HCC) at segment 7 of liver. To induce left liver hypertrophy, a sequential transarterial chemoembolization (TACE) and portal vein embolization before right hepatectomy were adopted. However, the tumor further increased in size despite TACE and invaded through the diaphragm to the right lung base. Anterior approach right hepatectomy with en bloc wedge resection of the involved right lower lobe of lung by endovascular staplers via transdiaphragmatic approach was performed. The diaphragmatic defect was closed with Goretex mesh. Patient made an uneventful recovery. Pathology confirmed a 12.5 cm poorly differentiated HCC invading through diaphragm to lung. During follow-up, patient developed a 6 cm recurrence at left lung base 17 months after surgery for which he received sorafenib therapy. However, the lung mass further increased in size with new liver recurrence at segment 3 despite treatment. He succumbed 2 years and 3 months after surgery.

Robotic versus laparoscopic hepatectomy: application of the difficulty scoring system

BACKGROUND

The development of robotic system may help to relieve the difficulties encountered during laparoscopic hepatectomy. A difficulty scoring system (DSS) was developed to assess the difficulty of various laparoscopic liver resection procedures. The aim of this study is to explore if the DSS is applicable in robotic hepatectomy and to compare the outcomes of robotic hepatectomy and laparoscopic hepatectomy among different difficulty levels.

METHODS

Clinical data from all consecutive patients who underwent robotic and conventional laparoscopic hepatectomy at the Prince of Wales Hospital, Hong Kong, were prospectively collected and reviewed. The difficulty level of operations was graded using the DSS. Perioperative outcomes of robotic and conventional laparoscopic hepatectomy were compared at each difficulty level.

RESULTS

A total of 107 and 94 patients underwent robotic and laparoscopic hepatectomy during the study period, respectively. Among them, 16 and 2 patients were operated for recurrent pyogenic cholangitis, respectively, and were excluded because no mark for tumour location can be assigned. For robotic hepatectomy, a higher DSS was significantly correlated with higher minor complication rate (p = 0.001), more intraoperative blood loss (p = 0.002), longer operation time (p < 0.001) and longer post-operative hospital stay (p < 0.001). The mean DSS scores of robotic and laparoscopic hepatectomy were 4.5 and 3.6, respectively. (p = 0.004). For cases with low (DSS 1-3) and intermediate (DSS 4-6) difficulty level, there was no significant difference in operative blood loss, operation time and overall complications rate. Only 2 cases (2.2%) with high difficulty level were operated with laparoscopic approach while 20% of patients operated with robotic approach had DSS > 6.

CONCLUSIONS

DSS significantly correlated with surgical outcomes in patient who underwent robotic hepatectomy. Perioperative outcomes following robotic and conventional laparoscopic hepatectomy were similar in cases with low and intermediate difficulty. However, robotic system allowed minimally invasive approach in cases with higher difficulty level.

Laparoscopic Hepatectomy (with or without Robotic Assistance) versus Radiofrequency Ablation as a Minimally Invasive Treatment for Very Early-Stage or Early-Stage Hepatocellular Carcinoma

BACKGROUND

The advantages of radiofrequency ablation (RFA) over hepatectomy as a treatment for early-stage hepatocellular carcinoma (HCC) include reduced morbidity and more rapid recovery. Although minimally invasive surgery provides similar benefits, few studies have compared the long-term oncological outcomes of these techniques. This study aimed to compare the outcomes of minimally invasive hepatectomy (MIH) and RFA.

METHODS

Patients who underwent MIH or RFA for HCC between January 2005 and January 2015 were included in a propensity score matching analysis. Only patients who underwent minimally invasive procedures for small HCC were included. Baseline clinical and laboratory parameters were retrieved from the hospital database and analyzed.

RESULTS

Two hundred and twenty-five patients underwent MIH or RFA for HCC during the study period. Propensity score matching yielded 59 patient-pairs. The complication rates did not differ statistically between the 2 groups (p = 0.309). However, MIH provided significantly better overall (p = 0.005) and disease-free survival outcomes (p < 0.001) than RFA.

CONCLUSIONS

Compared with RFA, MIH provided better long-term survival outcomes in patients with early-stage HCC, with no increase in the incidence of complications. When feasible, MIH should be considered a first-line treatment for this patient population.

Enhanced recovery after surgery for liver resection

INTRODUCTION

Enhanced recovery after surgery (ERAS) reduces postoperative length of hospital stay and patient stress response to liver surgery. The aim of the present study was to evaluate the efficacy and feasibility of an ERAS programme for liver resection.

METHODS

A multidisciplinary ERAS protocol was implemented for both open and laparoscopic liver resection in a tertiary hospital in Hong Kong. The clinical outcomes of patients who underwent liver resection and underwent the ERAS perioperative programme were compared with those who received a conventional perioperative programme between September 2015 and July 2016. Propensity score matching analysis was used to minimise background differences.

RESULTS

A total of 20 patients who underwent liver resection were recruited to the ERAS programme. Their clinical outcomes were compared with another 20 patients who received hepatectomy under a conventional perioperative programme after propensity score matching. The ERAS programme was associated with a significantly shorter length of hospital stay (P=0.033) without an increase in complication rates in patients who underwent open liver resection. There was no such significant association in patients who underwent laparoscopic liver resection. No patients required readmission in this cohort.

CONCLUSIONS

The ERAS perioperative programme for liver resection is safe and feasible. It significantly shortened the hospital stay after open liver resection but not after laparoscopic liver resection.

Pattern of disease recurrence and its implications for postoperative surveillance after curative hepatectomy for hepatocellular carcinoma: experience from a single center

Background

Hepatectomy is a widely accepted curative treatment for hepatocellular carcinoma (HCC). However, the disease frequently recurs after a curative hepatectomy. The objective of this study is to provide a better understanding of the pattern of disease recurrence and the risk factors involved so as to improve the postoperative surveillance.

Methods

A retrospective study for all patients receiving hepatectomy for HCC between 2003 and 2014 was performed. Emphasis was made on the timing and pattern of recurrent disease, and type of treatment given.

Results

There were 506 patients in the study. Median follow-up was 43.7 months. The 1-, 3-, 5-, 10-year overall and disease free survival were 89.5%, 74.1%, 63.9%, 49.0% and 69.5%, 54.3%, 43.4%, 30.9% respectively. Recurrent disease occurred in 267 patients, 47.2% occurred within 9 months of hepatectomy and 80.1% recurred only in liver. Median survival was shorter for recurrence occurring within 9 months compared with those occurring between 10 months and 2 years postoperatively (36.2 vs. 65.7 months, P<0.01) whilst less curative treatment was offered for patients with early (within 9 months) intrahepatic alone recurrence (22.2% vs. 51.7%, P<0.01). Multivariate analysis revealed tumor size >3.5 cm and history of rupture were risk factors for recurrence within 9 months.

Conclusions

These findings suggest that recurrent diseases are common after curative hepatectomy for HCC and most recurrences occur in the remnant liver. Since almost half of recurrences occurred within first 9 months after hepatectomy, a more stringent postoperative surveillance with target imaging of liver in this period is needed. Early diagnosis of recurrent disease and curative retreatment hopefully can bring about a longer survival.

Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome

Introduction

Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong.

Materials & methods

Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed.

Results

There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non-operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non-operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis.

Conclusions

Non-operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.

Robotic Liver Resection For Primary Hepatolithiasis: Is It Beneficial?

BACKGROUND

Primary hepatolithiasis is a disease characterized by primary biliary ductal abnormality with stone formation predominantly within the intrahepatic bile ducts. Its management is difficult, but liver resection has emerged as a promising treatment option.

METHODS

Robotic liver resection (RLR) has been adopted in our center for the management of patients with hepatolithiasis. The operative and short-term outcomes of this cohort of patients were compared with a historical cohort of patients using open approach (OLR). A subgroup analysis was performed for left lateral sectionectomy.

RESULTS

Between September 2010 and April 2015, 15 RLRs were performed on patients with primary hepatolithiasis. The historical cohort consisted of 42 OLRs with operation done between January 2005 and January 2014. No differences were found in patient demographics, disease characteristics, or types of resection. No operative deaths occurred, and no difference was seen in complication rates. RLR had significantly less blood loss (100 vs. 235 ml; p = 0.011) and shorter hospital stays (6 vs. 8 days; p = 0.003). After a median follow-up of 19.4 months for RLRs and 79.2 months for OLRs (p < 0.001), there were no differences in residual stone rate, recurrent stone rate, or rate of recurrent cholangitis. Subgroup analysis of lateral sectionectomy (10 RLRs vs. 27 OLRs) revealed similar outcomes, i.e., less blood loss and shorter hospital stays in RLR.

CONCLUSIONS

Robotic liver resection reduces blood loss and shortens hospital stays compared with OLR. A longer follow-up is needed to assess the long-term outcomes of RLR regarding prevention of recurrent stones and cholangitis.

Albumin-bilirubin grade predicts the outcomes of liver resection versus radiofrequency ablation for very early/early stage of hepatocellular carcinoma

BACKGROUND AND PURPOSE

Whether liver resection or ablation should be the first-line treatment for very early/early hepatocellular carcinoma (HCC) in patients who are candidates for both remains controversial. The aim of this study was to determine if the newly-developed Albumin-Bilirubin (ALBI) grade might help in treatment selections and to evaluate the survival of patients treated with liver resection and radiofrequency ablation (RFA).

METHODS

Patients with BCLC stage 0/A HCC who were treated with curative liver resection and RFA from 2003 to 2013 were included. Baseline clinical and laboratory parameters were retrieved and reviewed from the hospital database. Liver function and its impact on survival was assessed by the ALBI score. Overall and disease-free survivals were compared between the two groups.

RESULTS

488 patients underwent liver resection (n = 318) and RFA (n = 170) for BCLC stage 0/A HCC during the study period. Liver resection offered superior survival to RFA in patients with BCLC stage 0/A HCC in the whole cohort. After propensity score matching, liver resection offered superior overall survival and disease-free survival to RFA in patients with ALBI grade 1 (P = 0.0002 and P < 0.0001 respectively). In contrast, there were no significant differences in overall survival and disease-free survival between liver resection and RFA in patients with ALBI grade 2 (P = 0.7119 and 0.3266, respectively).

CONCLUSIONS

Liver resection offered superior survival to RFA in patients with BCLC stage 0/A HCC. The ALBI grade could identify those patients with worse liver function who did not gain any survival advantage from curative liver resection.

Liver stiffness measurement predicts high-grade post-hepatectomy liver failure: A prospective cohort study

BACKGROUND AND AIM

Liver stiffness measurement using transient elastography appears to be an excellent tool for detection of liver fibrosis and cirrhosis with high accuracy. The aim of this study is to evaluate the efficacy of preoperative liver stiffness measurement in predicting post-hepatectomy liver failure.

METHODS

A prospective cohort study of all consecutive patients undergoing hepatectomy for hepatocellular carcinoma from February 2010 to August 2014 was studied. All patients received detailed preoperative assessments including liver stiffness measurement. The primary outcome was post-hepatectomy liver failure according to the International Study Group of Liver Surgery definition.

RESULTS

A total of 255 patients were included. Liver stiffness measurement showed significant correlation with grade B or C post-hepatectomy liver failure. (P = 0.003) Using the cutoff at 12 kPa, liver stiffness measurement had a sensitivity of 52.4% and specificity of 73.3% in predication of high-grade (grade B or C) post-hepatectomy liver failure. Liver stiffness measurement > 12 kPa was also an independent prognostic factor for both high-grade post-hepatectomy liver failure and major postoperative complications by multivariate analysis. The diagnostic accuracy was better in patients without right lobe tumor with an area under the receiver operating characteristic of 0.83 compared with an area under the receiver operating characteristic of only 0.62 in patients with right lobe tumor.

CONCLUSIONS

Liver stiffness measurement using Fibroscan is good to predict high-grade post-hepatectomy liver failure especially in patients without right lobe tumor.

CT features of mediastinal lymphangiohemangioma associated with superior vena cava ectasia: A case report

We present a case of mediastinal mesenchymal tumor in a 53-year-old woman with a 1-month history of chest tightness. A histological diagnosis of lymphangiohemangioma was obtained by excisional biopsy. CT findings are reported with emphasis on its association with intratumoral superior vena cava ectasia.

Simultaneous multi-frequency topological edge modes between one-dimensional photonic crystals

We show theoretically that, in the limit of weak dispersion, one-dimensional binary centrosymmetric photonic crystals can support topological edge modes in all photonic bandgaps. By analyzing their bulk band topology, these "harmonic" topological edge modes can be designed in a way that they exist at all photonic bandgaps opened at the center of the Brillouin zone, at all gaps opened at the zone boundaries, or both. The results may suggest a new approach to achieve robust multi-frequency coupled modes for applications in nonlinear photonics, such as frequency upconversion.

Laparoscopic and robotic hepatectomy: experience from a single centre

BACKGROUND

Both laparoscopic and robotic hepatectomy have been adopted in our centre for selected patients with benign or malignant liver diseases. This article reports the perioperative outcomes of these two approaches and tries to determine any difference between them.

METHODS

A retrospective review of prospectively collected data was performed for all patients who underwent laparoscopic hepatectomy (LH) and robotic hepatectomy (RH) in our institute. The perioperative results were reported and compared. In order to standardise the type of liver resection performed, a subgroup analysis was made for laparoscopic left lateral sectionectomy (LS) and robotic left lateral sectionectomy (RS).

RESULTS

Sixty-six LH and 70 RH were performed between November 2003 and January 2015. The two groups were comparable in demographic data and disease characteristics except more patient with recurrent pyogenic cholangitis (RPC) occurred in RH group. More major hepatectomies were performed in RH (20.0% versus 3.0%, P = 0.002). There was no mortality. No difference was noted in morbidity (LH 4.5%, RH 11.4%), conversion rate (LH 12.1%, RH 5.7%), median blood loss (both 100 mL) and median length of post-operative hospital stay (both 5 days) but operative time was longer in RH (251.5 min versus 215 min, P = 0.008). There were 29 LS and 38 RS, no difference was noted in all perioperative outcomes between the two groups.

CONCLUSION

Both laparoscopic and robotic hepatectomy are safe and their perioperative outcomes are comparable and favourable.

Antiviral therapy improves post-hepatectomy survival in patients with hepatitis B virus-related hepatocellular carcinoma: a prospective-retrospective study

BACKGROUND

The effect of antiviral therapy on the post-hepatectomy long-term survival in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains uncertain.

AIM

To evaluate the effect of antiviral therapy on post-hepatectomy survival and recurrence in patients with HBV-related HCC.

METHODS

This was a prospective-retrospective study of a total of 404 patients who underwent hepatectomy for HBV-related HCC in a tertiary academic hospital. Data on patient and tumour characteristics, tumour recurrence, treatment for recurrence and survival were compared between antiviral and no antiviral groups.

RESULTS

Patient's and tumour characteristics were comparable between the two groups, except a higher proportion of patients with cirrhosis in the antiviral group. With a mean follow-up time of 52.4 months, antiviral group had a better 5-year overall survival (66.7% vs. 56.0%, P = 0.001) while there was no significant difference in the 5-year disease-free survival (44.7% vs. 38.1%, P = 0.166). Use of antiviral therapy was associated with better liver function reserve at the time of recurrence and a greater proportion of patients could receive curative treatment for recurrence (38.5% vs. 24.3%, P = 0.041). There was no significant different in the hazard ratios of patients who started antiviral therapy before or after operation (P = 0.054).

CONCLUSIONS

Use of antiviral therapy improves the long-term post-hepatectomy survival in patients with HBV-related HCC. With a better liver function reserve at the time of recurrence, a greater proportion of patients in antiviral group could receive curative treatment for recurrence.

An uncommon cause of Cushing's syndrome in a 70-year-old man

Cushing's syndrome due to exogenous steroids is common, as about 1% of the general populations use exogenous steroids for various indications. Although endogenous Cushing's syndrome due to ectopic adrenocorticotropic hormone from a pancreatic neuroendocrine tumour is rare, a correct and early diagnosis is important. The diagnosis and management require high clinical acumen and collaboration between different specialists. We report a case of ectopic adrenocorticotropic hormone Cushing's syndrome due to pancreatic neuroendocrine tumour with liver metastasis. Early recognition by endocrinologists with timely surgical resection followed by referral to oncologists led to a favourable outcome for the patient up to 12 months after initial presentation.