Robotic liver resection for hepatocellular carcinoma: analysis of surgical margins and clinical outcomes from a western tertiary hepatobiliary center

Establishment and Validation of Diagnostic Model of Microvascular Invasion in Solitary Hepatocellular Carcinoma

BACKGROUND

The microvascular invasion (MVI) score evaluates the presence of MVI in patients with hepatocellular carcinoma (HCC) by integrating multiple factors associated with MVI. We aimed to establish a MVI scoring system for HCC based on the clinical characteristics and serum biomarkers of patients with HCC.

METHODS

A total of 1027 patients with HCC hospitalized at Shandong Provincial Hospital from January 2016 to August 2021 were included and randomly divided into the development group and validation group at a ratio of 3:1. Univariable and multivariable logistic regression analyses were conducted to identify independent risk factors for MVI in HCC patients. Based on these independent risk factors, the preoperative MVI scoring system (diagnostic model) for HCC was established and verified. The receiver operating characteristic (ROC) curves, calibration curves and decision curve analyses (DCA) were employed to evaluate the discrimination and clinical application of the diagnostic model.

RESULTS

Independent risk factors for MVI of HCC involved Hepatitis B virus infection (HBV), large tumor diameter, higher logarithm of Alpha-fetoprotein (Log AFP), higher logarithm of AFP-L3% (Log AFP-L3%), higher logarithm of protein induced by vitamin K absence or antagonist-II (Log PIVKA-II) and higher logarithm of Carbohydrate antigen 125 (Log CA125). The diagnostic model incorporating these six independent risk factors was finally established. The areas under the ROC curve (AUC) assessed by the nomogram in the development cohort and validation cohort were 0.806 (95% CI, 0.773-0.839) and 0.818 (95% CI, 0.763-0.874) respectively. The calibration curve revealed that the results predicted by our diagnostic model for MVI in HCC were highly consistent with the postoperative pathological outcomes. The DCA further indicated promising clinical application of the diagnostic model.

CONCLUSION

An effective preoperative diagnostic model for MVI of HCC based on readily available tumor markers and clinical characteristics has been established, which is both clinically significant and easy to implement for diagnosing MVI.

The role of the AST-to-platelet ratio index (APRI) score on outcomes following robotic minor, technically major, & major hepatectomy for liver tumors

Predictive capability of aspartate transaminase-to-platelet ratio index (APRI) in assessing liver fibrosis/cirrhosis. This study aims to evaluate the correlation between APRI scores and perioperative outcomes following robotic hepatectomy. Data of 530 consecutive patients undergoing robotic hepatectomy were analyzed. Patients were classified based on an APRI score threshold of 0.7 and extent of resection. Data are presented as median (mean ± SD). Of 530 patients, 166 (31%) underwent major resection. Expectedly, major resections were associated with higher expert-level operations based on IWATE system. While having statistically similar APRI scores, patients undergoing major resection had larger tumor size (p = 0.003), longer operative duration (p < 0.0001), and higher blood loss (p = 0.0002). Patients undergoing minor/technically major resections, 100 (27%) patients had an elevated APRI, which was associated with higher MELD score (p = 0.0001), Child-Pugh score (p = 0.0001), cirrhosis (p < 0.0001), and neoplastic diseases (p < 0.0001). Patients undergoing major resections, 48 (29%) had elevated APRI, which was also associated with higher Child-Pugh Score (p < 0.0001), cirrhosis (p = 0.0008), and neoplastic diseases (p = 0.001). Elevated APRI levels were indicative of cirrhosis and higher MELD score; however, outcomes following robotic major hepatectomy remain unaffected by the index.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Tampa difficulty score: a scoring system for difficulty of robotic pancreaticoduodenectomy

Robotic platforms are increasingly utilized in surgery, offering unique technical advantages, though there is a scarcity of difficulty scoring systems (DSS) for these procedures. DSS aids in understanding operative complexities and enhancing preoperative planning. With IRB approval, data were collected on 200 consecutive adult patients who underwent robotic pancreaticoduodenectomy at a high-volume institution from 2019 to 2022. Linear regression was employed on clinical variables to analyze operative time and estimated blood loss as markers of surgical complexity. Weighted scoring system was developed using significant linear coefficient values, and an ANOVA analysis created the difficulty-level grouping system. Significant variables affecting operative time and/or EBL included: history of alcoholism, preoperative endoscopic intervention, tumor size, nodal disease on preoperative imaging, pancreatic duct dilation. These factors created the DSS ranging from 0 to 33. Group 1 (0-8, n = 9), Group 2 (9-20, n = 145), Group 3 (21-26, n = 37), and Group 4 (27-33, n = 9) showed significant differences in age, history of alcoholism, preoperative jaundice, tumor size, nodal disease, and operative metrics. Our novel DSS for robotic pancreaticoduodenectomy effectively predicts intraoperative challenges and aids in preoperative planning. Future steps include validating the system internally and externally.

A Contemporary Review of Robotic Resection for Hepatocellular Carcinoma

Background: Robotic hepatectomy represents an appealing treatment modality for resectable hepatocellular carcinoma (HCC). A contemporary review of robotic hepatectomy compared to laparoscopic/open hepatectomy is necessary. Methods: We performed a literature review to identify studies between 2018-2024 comparing robotic to laparoscopic/open hepatectomy for HCC with measurable outcomes. Results: A total of 10 studies were identified, including 943 patients undergoing robotic hepatectomy compared to 1678 patients undergoing laparoscopic/open hepatectomy. Generally, while similar short/long-term survival was noted across all resection modalities, robotic hepatectomy was associated with longer operative time, shorter length of stay, and less post-operative complications. An additional 4 studies were evaluated in the context of HCC, reviewing the prognostic value of robotic hepatectomy margins, robotic hepatectomy in the context of metabolic syndrome, "huge" (>10 cm) HCCs, and robotic hepatectomy vs. microwave ablation. Conclusions: Robotic hepatectomy is a safe alternative to laparoscopic/open hepatectomy for HCC that provides similar oncological/long-term outcomes, while potentially decreasing post-operative complications and length of stay.

Internal validation of the Tampa Robotic Difficulty Scoring System: real-time assessment of the novel robotic scoring system in predicting clinical outcomes after hepatectomy

INTRODUCTION

As the robotic approach in hepatectomy gains prominence, the need to establish a robotic-specific difficulty scoring system (DSS) is evident. The Tampa Difficulty Score was conceived to bridge this gap, offering a novel and dedicated robotic DSS aimed at improving preoperative surgical planning and predicting potential clinical challenges in robotic hepatectomies. In this study, we internally validated the recently published Tampa DSS by applying the scoring system to our most recent cohort of patients.

METHODS

The Tampa Difficulty Score was applied to 170 recent patients who underwent robotic hepatectomy in our center. Patients were classified into: Group 1 (score 1-8, n = 23), Group 2 (score 9-24, n = 120), Group 3 (score 25-32, n = 20), and Group 4 (score 33-49, n = 7). Key variables for each of the groups were analyzed and compared. Statistical significance was accepted at p ≤ 0.05.

RESULTS

Notable correlations were found between the Tampa Difficulty Score and key clinical parameters such as operative duration (p < 0.0001), estimated blood loss (p < 0.0001), and percentage of major resection (p = 0.00007), affirming the score's predictive capacity for operative technical complexity. The Tampa Difficulty Score also correlated with major complications (Clavien-Dindo ≥ III) (p < 0.0001), length of stay (p = 0.011), and 30-day readmission (p = 0.046) after robotic hepatectomy.

CONCLUSIONS

The Tampa Difficulty Score, through the internal validation process, has confirmed its effectiveness in predicting intra- and postoperative outcomes in patients undergoing robotic hepatectomy. The predictive capacity of this system is useful in preoperative surgical planning and risk categorization. External validation is necessary to further explore the accuracy of this robotic DSS.

A decade of experience with 530 minimally invasive robotic hepatectomies from a single tertiary hepatobiliary center: analysis of short-term outcomes and oncologic survival

BACKGROUND

This research is the first study in the United States to document more than a decade of experience with 530 patients who underwent robotic hepatectomy at a single high-volume institution.

METHODS

With institutional review board approval, a prospectively collected database of consecutive patients who underwent robotic hepatectomy from 2012 to January 2024 was reviewed. Data are presented as median (mean ± SD).

RESULTS

Of the 530 robotic hepatectomies, 231 (44.0%) were minor resections, 133 (25.0%) were technically major resections, and 166 (31.0%) were major resections. The patients were aged 63.0 (61.0 ± 14.7) years with a body mass index of 28.0 (29.0 ± 7.9) kg/m2. Cirrhosis was present in 80 patients (19.0%), with an American Society of Anesthesiologists score of 3.0 (3.0 ± 0.5) and a Model for End-Stage Liver Disease score of 7.0 (8.0 ± 3.0). Of note, 280 patients (53.0%) had previous abdominal operations, and 44 patients (8%) had previous liver resections. The operative time was 233.0 (260.0 ± 130.7) minutes, and the estimated blood loss was 100.0 (165.0 ± 205.0) mL. Moreover, 353 patients (66%) had hepatectomies for neoplastic disease, and 500 patients (95%) had an R0 resection margin. The tumor size was 4.0 (5.0 ± 3.6) cm. The total 90-day postoperative complications were 45 (8%), of which 21 (4%) were classified as major complications (Clavien-Dindo score of >III). The length of stay was 3.0 (4.0 ± 3.7) days, and the 30-day readmission rate was 86 (16%). The overall survival rates at 1, 3, and 5 years were 82%, 65%, and 59% for colorectal liver metastases, 84%, 68%, and 60% for hepatocellular carcinoma, and 79%, 61%, and 50% for intrahepatic cholangiocarcinoma, respectively.

CONCLUSION

After a decade of application and optimization at a high-volume institution, the robotic approach has been demonstrated to be a safe and effective approach to liver resection.

Tampa Difficulty Score: a novel scoring system for difficulty of robotic hepatectomy

BACKGROUND

Difficulty scoring system (DSS) has been established for laparoscopic hepatectomy and serves as useful tools to predict difficulty and guide preoperative planning. Despite increased adoption of robotics and its unique technical characteristics compared with laparoscopy, no DSS currently exists for robotic hepatectomy. We aimed to introduce a new DSS for robotic hepatectomy.

METHODS

A total of 328 patients undergoing a robotic hepatectomy were identified. After removing the first 24 major and 30 minor hepatectomies using cumulative-sum analysis, 274 patients were included in this study. Relevant clinical variables underwent linear regression using operative time and/or estimated blood loss (EBL) as markers for operative difficulty. Score distribution was analyzed to develop a difficulty-level grouping system.

RESULTS

Of the 274 patients, neoadjuvant chemotherapy; tumor location, size, and type; the extent of parenchymal resection; the need for portal lymphadenectomy; and the need for biliary resection with hepaticojejunostomy were significantly associated with operative time and/or EBL. They were used to develop the difficulty scores from 1 to 49. Grouping system results were group 1 (less demanding/beginner), 1 to 8 (n = 39); group 2 (intermediate), 9 to 24 (n = 208); group 3 (more demanding/advanced), 25 to 32 (n = 17); and group 4 (most demanding/expert), 33 to 49 (n = 10). When stratified by group, age, previous abdominal operation, Child-Pugh score, operative duration, EBL, major resection, 30-day mortality, 90-day mortality, and length of stay were significantly different among the groups.

CONCLUSION

In addition to established variables in laparoscopic systems, new factors such as the need for portal lymphadenectomy and biliary resection specific to the robotic approach have been identified in this new robotic DSS. Internal and external validations are the next steps in maturing this robotic DSS.

Comparative Analysis of NSQIP National Outcomes and Projected Outcomes versus Our Institutional Outcomes for Robotic Gastrectomy: The Future of Gastric Resection

BACKGROUND

The robotic approach has vast applications in surgery; however, the utility of robotic gastrectomy has yet to be clearly defined. This study aimed to compare outcomes following robotic gastrectomy at our institution to the national patient-specific predicted outcomes data provided by the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP).

METHODS

We prospectively studied 73 patients who underwent robotic gastrectomy under our care. ACS NSQIP outcomes after gastrectomy and predicted outcomes for our patients were compared with our actual outcomes utilizing students t test and chi-square analysis, where applicable. Data are presented as median (mean ± SD).

RESULTS

Patients were 65 (66 ± 10.7) years old with a BMI of 26 (28 ± 6.5) kg/m2. 35 patients had gastric adenocarcinomas and 22 had gastrointestinal stromal tumors Operative duration was 245 (250 ± 114.7) minutes, estimated blood loss was 50 (83 ± 91.6) mL, and there were no conversions to 'open'. 1% of patients experienced superficial surgical site infections compared to the NSQIP predicted rate of 10% (P < .05). Length of stay (LOS) was 5 (6 ± 4.2) days vs NSQIP's predicted LOS of 8 (8 ± 3.2) days (P < .05). Three patients died during their postoperative hospital course (4%), due to multi-system organ failure and cardiac arrest. 1-year, 3-year, and 5-year estimated survival for patients with gastric adenocarcinoma was 76%, 63%, and 63%, respectively.

DISCUSSION

Robotic gastrectomy yields salutary patient outcomes and optimal survival for varying gastric diseases, particularly gastric adenocarcinoma. Our patients experienced shorter hospital stays and reduced complications relative to patients in NSQIP and predicted outcome for our patients. Gastrectomy undertaken robotically is the future of gastric resection.