Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

Controlled low central venous pressure maintenance level during laparoscopic hepatectomy negatively associated with PHLF incidence: a retrospective propensity score matching study

BACKGROUND

Posthepatectomy liver failure (PHLF), the most serious complication after hepatectomy, may evoke multisystemic complications and even mortality. Despite numerous studies demonstrated the safety and efficacy of controlled low central venous pressure (CLCVP), the optimal central venous pressure (CVP) maintenance level during CLCVP and its relationship with PHLF remain controversial. Therefore, the present study aimed to evaluate the association between the lowest CVP maintenance level during CLCVP and PHLF.

METHODS

755 patients who underwent laparoscopic hepatectomy at Sun Yat-Sen Memorial Hospital between January 2017 and March 2021 were recruited. Univariate and multivariate analyses were performed to determine the effect of the lowest CVP maintenance level on PHLF. After implementing propensity score matching (PSM) to equalize demographic confounders, univariate comparisons and subgroup analyses were conducted to investigate the impact of the lowest CVP maintenance level on PHLF in patients who underwent CLCVP.

RESULTS

Univariate and multivariate analyses identified intraoperative lowest CVP maintenance level < 2 mmHg as an independent risk factor for PHLF (P = 0.041; OR, 0.520; 95% CI 0.277 to 0.974). Following 1:1 PSM in individuals who received CLCVP, the lowest CVP maintenance level < 2 mmHg was associated with heightened PHLF incidence (P = 0.048) and elevated intraoperative lactate level (P = 0.011). Subgroup analyses revealed that the above effect of the lowest CVP maintenance level occurred mainly in elderly individuals or those with prolonged portal blockade.

CONCLUSION

During laparoscopic hepatectomy, excessively low CVP maintenance level should be avoided to decrease the risk of tissue malperfusion and PHLF, especially in elderly or prolonged portal blockade patients.

Robotic sectionectomy versus robotic hemihepatectomy for anatomic liver resection: a comparative analysis of perioperative outcomes

Sectionectomy is a parenchma-sparing alternative to (extended) right or left hemihepatectomy. However, the effectiveness and safety of robotic sectionectomy (RS) versus robotic (extended) hemihepatectomy (RH) for the treatment of liver tumors remains unclear. We reviewed our prospective database for consecutive patients who had undergone robotic hepatectomies between March 2021 and July 2023 and included all patients with RS and RH. Demographic data, perioperative outcomes and long-term outcomes were analyzed and compared between both groups. Thirty patients met our inclusion criteria, of whom 16 patients underwent RS as opposed to 14 patients who underwent RH. Baseline characteristics were comparable between the study groups. The duration of Pringle maneuver was significantly longer in the RS group, while the remaining operative details were comparable. There were no significant differences in posthepatectomy outcomes between the study groups. All patients had negative resection margins. RS is a safe and effective parenchyma-sparing treatment modality.

Robotic or laparoscopic repeat hepatectomy after open hepatectomy: a cohort study

BACKGROUND

Repeat hepatectomies are technically complex procedures. The evidence of robotic or laparoscopic (= minimally invasive) repeat hepatectomies (MIRH) after previous open hepatectomy is poor. Therefore, we compared postoperative outcomes of MIRH vs open repeat hepatectomies (ORH) in patients with liver tumors after previous open liver resections.

METHODS

Consecutive patients who underwent repeat hepatectomies after open liver resections were identified from a prospective database between April 2018 and May 2023. Postoperative complications were graded in line with the Clavien-Dindo classification. We stratified patients by intention to treat into MIRH or ORH and compared outcomes. Logistic regression analysis was performed to define variables associated with the utilization of a minimally invasive approach.

RESULTS

Among 46 patients included, 20 (43%) underwent MIRH and 26 (57%) ORH. Twenty-seven patients had advanced or expert repeat hepatectomies (59%) according to the IWATE criteria. Baseline characteristics were comparable between the study groups. The use of a minimally invasive approach was not dependent on preoperative or intraoperative variables. All patients had negative resection margins on final histology. MIRH was associated with less blood loss (450 ml, IQR (interquartile range): 200-600 vs 600 ml, IQR: 400-1500 ml, P = 0.032), and shorter length of stay (5 days, IQR: 4-7 vs 7 days, IQR: 5-9 days, P = 0.041). Postoperative complications were similar between the groups (P = 0.298).

CONCLUSIONS

MIRH is feasible after previous open hepatectomy and a safe alternative approach to ORH. (German Clinical Trials Register ID: DRKS00032183).

Stereotactic Body Radiation Therapy versus Surgical Resection for Stage I/II Hepatocellular Carcinoma

SBRT is an emerging locoregional treatment modality for hepatocellular carcinoma (HCC). Although local tumor control rates seem encouraging, large-scale survival data comparing SBRT to surgical resection are lacking. We identified patients with stage I/II HCC from the National Cancer Database amenable for potential surgical resection. Patients undergoing hepatectomy were matched by propensity score (1:2) with patients who underwent SBRT as primary treatment. A total of 3787 (91%) and 366 (9%) patients underwent surgical resection or SBRT between 2004 and 2015, respectively. After propensity matching, the 5-year overall survival was 24% (95% CI 19-30%) in the SBRT group versus 48% (95% CI 43-53%) in the surgery group (p < 0.001). The association of surgery with overall survival was consistent in all subgroups. In patients treated with SBRT, a biologic effective dose (BED) of ≥100 Gy (31%, 95% CI 22%-40%) compared with BED < 100 Gy (13%, 95% CI 8-22%) was associated with a higher 5-year overall survival rate (hazard ratio of mortality of 0.58, 95% CI 0.43-0.77; p < 0.001). Surgical resection may be associated with prolonged overall survival compared with SBRT in patients with stage I/II HCC.

Minimally invasive mesohepatectomy for centrally located liver lesions-a case series

BACKGROUND

Resection of centrally located liver lesions remains a technically demanding procedure. To date, there are limited data on the effectiveness and safety of minimally invasive mesohepatectomy for benign and malignant lesions. It was therefore the objective of this study to evaluate the perioperative outcomes of minimally invasive mesohepatectomy for liver tumors at a tertiary care hospital.

METHODS

Consecutive patients who underwent a minimally invasive anatomic mesohepatectomy using a Glissonean pedicle approach from April 2018 to November 2021 were identified from a prospective database. Demographics, operative details, and postoperative outcomes were analyzed using descriptive statistics for continuous and categorical variables.

RESULTS

A total of ten patients were included, of whom five patients had hepatocellular carcinoma, one patient had cholangiocarcinoma, three patients had colorectal liver metastases, and one patient had a hydatid cyst. Two and eight patients underwent robotic-assisted and laparoscopic resections, respectively. The median operative time was 393 min (interquartile range (IQR) 298-573 min). Conversion to laparotomy was required in one case. The median lesion size was 60 mm and all cases had negative resection margins on final histopathological analysis. The median total blood loss was 550 ml (IQR 413-850 ml). One patient had a grade III complication. The median length of stay was 7 days (IQR 5-12 days). Time-to-functional recovery was achieved after a median of 2 days (IQR 1-4 days). There were no readmissions within 90 days after surgery.

CONCLUSION

Minimally invasive mesohepatectomy is a feasible and safe approach in selected patients with benign and malignant liver lesions.