Current Status of Laparoscopic Hepatectomy

Modified extracorporeal traction with wires: a method for steering the liver for laparoscopic resection of hepatic tumors in segment 7 (with video)

BACKGROUND

Laparoscopic hepatectomy is a less traumatic, minimally invasive procedure that has been widely used to address liver tumors because of its association with a faster recovery and less bleeding. Although adequate exposure and transposition of the liver ensure a clear surgical field and a successful operation, tumors in S7 present a challenge in that surgeons experience difficulty in exposing such tumors and the operating space is small. We used a modified extracorporeal traction with wires method for use in minimally invasive hepatic resection surgery to improve visibility of the surgical field and therefore reduce the difficulty of surgery. The method involved adjusting the traction force appropriately for transposition of the liver.

METHODS

We reviewed data from 15 laparoscopic hepatic tumor resections performed between January and November 2024. In this paper, we describe the surgical and traction techniques used and evaluate the intraoperative and postoperative course.

RESULTS

The study population consisted of 9 males and 6 females, and the median mean age was 61.84 ± 11.08 years (Table 1). The median body mass index was 25.65 ± 3.14 kg/m2, the median tumor size was 3.78 ± 2.09 cm, the median operative time was 154.09 ± 31.97 min, the median intraoperative blood loss volume was 115.36 ± 51.26 ml, and the median hospitalization time was 10.33 ± 2.09 days.No serious intraoperative or postoperative complications occurred, and R0 resection was achieved in all cases. Morevoer, in all cases, the time to set up bandwire extracorporeal traction was less than 3 min.

CONCLUSION

The bandwire traction technique can provide a more stable surgical field, shorten the surgical time, and reduce the likelihood of surgical trauma. The technique allows safe transposition of the liver and plays an important role in minimally invasive resection of hepatic tumors, highlighting its suitability for widespread clinical applications.

A novel Pringle maneuver instrument for laparoscopic hepatectomy

Background

The Pringle maneuver is a classic and commonly used technique in hepatectomy for bleeding control. However, it is not convenient to perform Pringle maneuver in laparoscopic hepatectomy. This study aimed to investigate the value of a novel blocking forceps designed by our center for the Pringle maneuver in laparoscopic hepatectomy.

Methods

Data of patients with liver tumors who underwent laparoscopic hepatectomy between 2017 and 2022 were retrospectively collected. Patients who underwent an intraoperative Pringle maneuver were selected. Cases using the new blocking forceps comprised the new blocking forceps group (NBF group), while cases using the traditional method of binding the hepatoduodenal ligament comprised the traditional group (TRA group). The baseline and perioperative data of the two patient groups were compared and analyzed.

Results

A total of 253 cases were included in the analysis, including 169 in the TRA group and 84 in the NBF group. There were no statistically significant differences between the two groups in terms of preoperative examinations and other indicators. The NBF group had a significantly lower number of blocks, total blocking time, intraoperative bleeding, and transfusion ratio than the TRA group.

Conclusion

Our self-designed blocking forceps can safely and effectively complete the Pringle maneuver and are convenient to operate, which is conducive to the successful completion of the operation.

Impact of postoperative morbidity on the prognosis of patients with hepatocellular carcinoma after laparoscopic liver resection: a multicenter observational study

The long-term impact of postoperative morbidity following laparoscopic liver resection for hepatocellular carcinoma is unclear. This study aimed to investigate whether the prognosis of hepatocellular carcinoma patients were affected by postoperative morbidity after laparoscopic liver resection. Hepatocellular carcinoma patients who underwent curative-intent laparoscopic liver resection were included. Risk factors of 30-day morbidity were identified using logistic regression analysis. Early (≤ 2 years) and late (> 2 years) recurrence rates, overall survival, and time to recurrence were compared among patients with and without postoperative morbidity. Independent prognostic factors of overall survival and time to recurrence of these patients were investigated using Cox regression analysis. This study included 420 patients, 147 (35%) of whom experienced postoperative morbidity. Diabetes mellitus, cirrhosis, portal hypertension, Child-Pugh grade B, multiple tumors, poor tumor differentiation and intraoperative blood transfusion were risk factors of postoperative morbidity. Patients with postoperative morbidity had higher early and late recurrence rates than those without postoperative morbidity (38.8% vs. 22.4%, P = 0.001; 50% vs. 25.5%, P = 0.001). Postoperative morbidity was associated with decreased overall survival (median: 54.5 months vs. not reached, P < 0.001) and time to recurrence (median: 36.4 vs. 68.2 months; P < 0.001). Postoperative morbidity resulted in a 43% and 92% higher risk of long-term mortality (HR 1.43; 95% CI 1-2.03; P = 0.048) and recurrence (HR 1.92; 95% CI 1.41-2.62; P < 0.001). For hepatocellular carcinoma patients undergoing laparoscopic liver resection, long-term oncologic outcomes are adversely affected by postoperative morbidity. Therefore, it is of great importance for surgeons to prevent and manage postoperative morbidity.

Multicenter retrospective study on advancements in diagnosis and laparoscopic treatment of hepatic echinococcosis in Xinjiang China

With the advancement of precise hepatobiliary surgery concepts, the diagnostic and therapeutic approaches for hepatic echinococcosis have undergone significant transformations. However, whether these changes have correspondingly improved patient outcomes remains unclear. A retrospective analysis of these changes will provide crucial guidance for the prevention and treatment of hepatic echinococcosis. Clinical data from 6 hospitals in Xinjiang region of China from January 2009 to December 2023 were collected and systematically random sampling was conducted. The study was divided into the first stage (2009-2013), the second stage (2014-2018), and the third stage (2019-2023) with a 5-year time node to compare the changes in diagnosis and treatment mode and clinical features. There was no significant difference in the age of onset among patients across different phases (P = 0.759). The frequency of open cystectomy gradually decreased [302 (62.3%), 223 (53.0%), 165 (55.7%), P = 0.015], while the rate of total cystectomy increased steadily [82 (16.9%), 88 (20.9%), 94 (23.7%), P = 0.040]. The proportion of patients admitted due to screening also increased [367 (75.7%), 373 (88.6%), 364 (91.9%), P < 0.001]. Preoperative imaging techniques evolved from being singular to diversified. Postoperative recurrence rates declined over time [89 (18.4%), 53 (12.6%), 32 (8.1%), P < 0.001], as did the incidence of grade C bile leakage [88 (18.1%), 51 (12.1%), 20 (5.1%), P < 0.001]. However, the incidence of intraoperative bleeding ≥ 800 ml showed an upward trend [39 (8.0%), 53 (12.6%), 60 (15.2%), P = 0.004]. No significant differences were observed in clinical classification across different periods, but average hospitalization costs increased. The data across all groups indicated that herdsmen remain the most affected population, while the incidence among students gradually decreased. Over the past 15 years, both the diagnostic and therapeutic approaches and the prognosis of patients with hepatic echinococcosis in the Xinjiang region of China have improved. Laparoscopic total cystectomy is gradually becoming the preferred surgical approach for these patients, and early screening efforts have benefited an increasing number of patients.

Textbook outcome of laparoscopic hepatectomy in the context of precision surgery: A single center experience

OBJECTIVE

Laparoscopic hepatectomy (LH) has become a common surgery for the treatment of liver tumor. To evaluate the surgical quality of laparoscopic hepatectomy under the context of precision surgery with Textbook outcome (TO), a comprehensive and holistic assessment approach.

METHODS

A total of 1056 patients who underwent laparoscopic hepatectomy from May 2016 and December 2022 were enrolled in the study. All the patients were performed hepatectomy. The rate of TO and factors associated with achieving TO were examined.

RESULTS

Among the 1056 patients, 75 % patients achieved TO. The main reason limited patients achieving textbook outcomes was prolonged length of hospital stay (LOS). The univariate analysis indicated that age>65, ASA classification ≥3, liver cirrhosis, tumor size > 3 cm, tumor number ≥2, type of primary cancer, and IWATE DSS were significantly associated with non-achievement of TO. The multivariate analysis indicated that the ASA classification ≥3 and advanced difficulty level in IWATE DSS independent factors associated with achieving TO. Reaching TO can significantly prolong the postoperative recurrence time and overall survival time of hepatocellular carcinoma patients.

CONCLUSION

In the context of precision surgery, 75 % patients undergoing laparoscopic hepatectomy achieved a TO. Patients who achieved TO had significantly improved survival.

Correlation Between Illness Uncertainty in Caregivers of Patients with Liver Cancer, Their Coping Styles, and Quality of Life

Objective

This study explores the correlation between coping style, quality of life, and illness uncertainty in the family caregivers of patients with liver cancer.

Methods

Employing convenience sampling, 210 family caregivers of patients with liver cancer who met the admission criteria were selected from a grade A infectious disease hospital in Beijing between January and December 2022. A cross-sectional survey was conducted using the Simplified Coping Style Questionnaire, Caregiver Quality of Life, and the Mishel Uncertainty in Illness Scale for Family Members. This study analysed the correlations between coping styles, quality of life, and illness uncertainty in these caregivers.

Results

The study found that family caregivers of patients with liver cancer had average scores for illness uncertainty (83.44 ± 11.86), coping style (33.19 ± 9.79; both positive [23.02 ± 6.81] and negative [10.17 ± 5.05]), and quality of life (169.53 ± 32.46). A negative association was observed between illness uncertainty in these caregivers and positive coping style (r = -0.207, p = 0.003), physical status (r = -0.182, p = 0.008), psychological status (r = -0.200, p = 0.004), and social adaptation (r = -0.229, p = 0.001).

Conclusion

The study concludes that illness uncertainty in family caregivers of patients with liver cancer is at a moderate level. Furthermore, there is a notable correlation between illness uncertainty, coping style, and quality of life in these caregivers.

Current Status of Robotic Hepatobiliary and Pancreatic Surgery

Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

A multicenter case-controlled study on laparoscopic hepatectomy versus microwave ablation as first-line therapy for 3-5 cm hepatocellular carcinoma in patients aged 60 and older

BACKGROUND

There is currently a lack of convincing evidence for microwave ablation (MWA) and laparoscopic liver resection (LLR) for patients ≥60 years old with 3-5 cm hepatocellular carcinoma.

MATERIALS AND METHODS

Patients were divided into three cohorts based on restricted cubic spline analysis: 60-64, 65-72, and ≥73 years. Propensity score matching (PSM) was performed to balance the baseline variables in a 1:1 ratio. Overall survival (OS) and disease-free survival (DFS) were assessed, followed by a comparison of complications, hospitalization, and cost.

RESULTS

Among 672 patients, the median age was 66 (IQR 62-71) years. After PSM, two groups of 210 patients each were selected. During the 36.0 (20.4-52.4) month follow-up period, the 1-year, 3-year, and 5-year OS rates in the MWA group were 97.6, 80.9, and 65.3% and 95.5, 78.7, and 60.4% in the LLR group (HR 0.98, P =0.900). The corresponding DFS rates were 78.6, 49.6, and 37.5% and 82.8, 67.8, and 52.9% (HR 1.52, P =0.007). The 60-64 age cohort involved 176 patients, with no a significant difference in OS between the MWA and LLR groups (HR 1.25, P =0.370), MWA was associated with a higher recurrence rate (HR 1.94, P =0.004). A total of 146 patients were matched in the 65-72 age cohort, with no significant differences in OS and DFS between the two groups (OS (HR 1.04, P =0.900), DFS (HR 1.56, P =0.110)). In 76 patients aged ≥73 years after PSM, MWA provided better OS for patients (HR 0.27, P =0.015), and there were no significant differences in DFS between the two groups (HR 1.41, P =0.380). Taken together, for patients older than 65 years, the recurrence rate of MWA was comparable with LLR. Safety analysis indicated that LLR was associated with more postoperative bleeding ( P =0.032) and hypoproteinemia ( P =0.024).

CONCLUSIONS

MWA was comparable to LLR in patients aged 65 years and older. MWA could be an alternative for the oldest old or the ill patients who cannot afford LLR, while LLR is still the first option of treatments for early-stage 3-5 cm hepatocellular carcinoma in capable elderly's.

Comparing triple scope-combined bile duct exploration lithotripsy with laparoscopic hepatectomy for hepatolithiasis (with video)

BACKGROUND

To compare the efficacy of Three-scope combined (laparoscopic, rigid choledochoscopy and electronic choledochoscopy, TS) with laparoscopic hepatectomy (LH) for patients with hepatolithiasis (HL).

METHODS

Between January 2019 and January 2020, 118 consecutive patients with HL treated with TS (TS group, n = 57) or LH (LH group, n = 61) were analyzed in this study. Perioperative and long-term outcomes, including operative time, intraoperative blood loss, blood transfusion, postoperative bowel function recovery time, postoperative hospital stay, complication rate, stone removal rate, and stone recurrence rate, were compared and analyzed between the two groups.

RESULTS

Compared with the LH group, the TS group had significantly lower intraoperative blood loss and transfusions, significantly shorter operative time and hospital stay, and fewer complications (P < 0.05 for all). There was no significant difference in the final stone removal rate, stone recurrence rate and postoperative bowel function recovery time (P > 0.05 for all).

CONCLUSION

TS is a safe and effective treatment for HL and is superior to LH in terms of overall treatment outcome and complications.

Safety and effectiveness of indocyanine green fluorescence imaging-guided laparoscopic hepatectomy for hepatic tumor: a systematic review and meta-analysis

Introduction

Previous clinical investigations have reported inconsistent findings regarding the feasibility of utilizing indocyanine green fluorescence imaging (ICGFI) in laparoscopic liver tumor removal. This meta-analysis aims to comprehensively evaluate the safety and effectiveness of ICGFI in laparoscopic hepatectomy (LH).

Methods

A systematic search of pertinent clinical studies published before January 30th, 2023 was conducted in databases including PubMed, Embase, Cochrane, and Web of Science. The search strategy encompassed key terms such as "indocyanine green fluorescence," "ICG fluorescence," "laparoscopic hepatectomy," "hepatectomies," "liver Neoplasms," "hepatic cancer," and "liver tumor." Additionally, we scrutinized the reference lists of included articles to identify supplementary studies. we assessed the quality of the incorporated studies and extracted clinical data. Meta-analysis was performed using STATA v.17.0 software. Either a fixed-effects or a random-effects model was employed to compute combined effect sizes, accompanied by 95% confidence intervals (CIs), based on varying levels of heterogeneity.

Results

This meta-analysis encompassed eleven retrospective cohort studies, involving 959 patients in total. Our findings revealed that, in comparison to conventional laparoscopic hepatectomy, patients receiving ICGFI-guided LH exhibited a higher R0 resection rate (OR: 3.96, 95% CI: 1.28, 12.25, I2 = 0.00%, P = 0.778) and a diminished incidence of intraoperative blood transfusion (OR: 0.42, 95% CI: 0.22, 0.81, I 2 = 51.1%, P = 0.056). Additionally, they experienced shorter postoperative hospital stays (WMD: -1.07, 95% CI: -2.00, -0.14, I 2 = 85.1%, P = 0.000). No statistically significant differences emerged between patients receiving ICGFI-guided LH vs. those undergoing conventional LH in terms of minimal margin width and postoperative complications.

Conclusion

ICGFI-guided LH demonstrates marked superiority over conventional laparoscopic liver tumor resection in achieving R0 resection and reducing intraoperative blood transfusion rates. This technique appears to hold substantial promise. Nonetheless, further studies are needed to explore potential long-term benefits associated with patients undergoing ICGFI-guided LH.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD 42023398195.

Laparoscopic and open liver resection for hepatocellular carcinoma with type 2 diabetes mellitus: multicenter propensity score-matched study

PURPOSE

This study aimed at analyzing and comparing the perioperative results and long-term oncological outcomes of hepatocellular carcinoma (HCC) patients with type 2 diabetes mellitus (T2DM) treated with laparoscopic (LLR) versus open liver resection (OLR).

METHODS

Clinicopathological data of HCC patients with T2DM who underwent LLR or OLR as initial treatment from four medical centers were retrospectively reviewed. The survival outcomes of patients who underwent laparoscopic liver resection (LLR) were compared with those of patients who underwent open liver resection (OLR). Using the Kaplan-Meier method, survival curves for the two groups of patients were generated, and the log-rank test was used to compare survival differences. Propensity score matching (PSM) analysis was used to match patients of the LLR and OLR groups in a 1:1 ratio.

RESULTS

230 HCC patients with T2DM were enrolled, including 101 patients in the LLR group and 129 patients in the OLR group. After PSM, 90 patients were matched in each of the study group. Compared with the OLR group, the LLR group had less blood loss, a shorter hospitalization and fewer postoperative complications. The LLR group had a significantly better overall survival (OS) and recurrence-free survival (RFS) than the OLR group before and after PSM. Subgroup analysis demonstrated that HCC patients with T2DM had survival benefits from LLR regardless of the course of T2DM.

CONCLUSIONS

Laparoscopic liver resection for HCC patients with T2DM can be safely performed with favorable perioperative and long-term oncological outcomes at high-volume liver cancer centers, regardless of the course of T2DM.

Analysis of Clinical Outcomes After Robotic Hepatectomy Applying the Western-Model Southampton Laparoscopic Difficulty Scoring System. An Experience From a Tertiary US Hepatobiliary Center

BACKGROUND

Identification of resections with high risk of intraoperative complications is critical in guiding case selection for minimally invasive liver surgery. Several Japanese and European difficulty scoring systems have been proposed for laparoscopic liver surgery. However, the applicability of these systems for robotic liver resections has not been fully investigated. This study considers the Southampton system and examines its validity when applied to robotic hepatectomies.

METHODS

We undertook a retrospective review of 372 patients who underwent robotic hepatectomies for various indications between 2013 and 2022. Of these patients, 63 operations were classified as low risk, 91 as moderate risk, 198 as high risk and 20 as extremely high risk based on Southampton criteria. Patient outcomes were compared by utilizing an ANOVA of repeated measures. Data are presented as median (mean ± SD).

RESULTS

The Southampton difficulty scoring system was a strong predictor of intraoperative variables including tumor size, operative duration, estimated blood loss (EBL), and incidence of major vs minor resection (all P < .0001). In contrast, the Southampton system was a weaker predictor of postoperative outcomes including 30-day mortality (P = .15), length of stay (P = .13), and readmissions within 30 days (P = .38).

CONCLUSION

The Southampton difficulty scoring system is a valid system for classifying robotic liver resections and is a strong predictor of intraoperative outcomes. However, the system was found to be a weaker predictor of postoperative outcomes. This finding may suggest the need for proposal of a new difficulty scoring system for robotic hepatectomies.

Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection

BACKGROUND

The Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections.

METHODS

We conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD).

RESULTS

Of the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission.

CONCLUSION

The IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.

Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation

In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.

Minimally invasive vs. open segmental resection of the splenic flexure for cancer: a nationwide study of the Italian Society of Surgical Oncology-Colorectal Cancer Network (SICO-CNN)

BACKGROUND

Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes.

METHODS

This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed ≧12, and proximal and distal free resection margins length ≧ 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate.

RESULTS

A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray's tests p = 0.004, respectively), while recurrences were comparable (Gray's tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI - 4.7% to ∞). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference - 0.3%; 1-sided 95%CI - 5.0% to ∞).

CONCLUSIONS

Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection.

Extrahepatic approach for taping the common trunk of the middle and left hepatic veins or the left hepatic vein alone in laparoscopic hepatectomy (with videos)

BACKGROUND

Outflow control is difficult, and techniques required for effectively handling intraoperative hemorrhage during laparoscopic hepatectomy have not previously been adequately reported.

METHODS

Sixteen patients underwent surgery, of which 15 underwent laparoscopic left hepatectomy and one underwent laparoscopic partial hepatectomy of the caudate lobe. Encircling and taping of the common trunk of the middle (MHV) and left hepatic veins (LHV) was performed in 12 patients, and that of the LHV alone in four patients. Surgical techniques based on anatomical landmarks and histological findings are presented with videos. Histological confirmation of the anatomical landmarks for these procedures was performed in fresh cadavers to understand the anatomical structures and layers involved.

RESULTS

The median procedure duration was 15 (6-25) minutes. All procedures were performed safely with no major bleeding. Histological findings showed fibrous connective tissue between the tunica adventitia of the inferior vena cava (IVC) and the Laennec's capsule of the liver. The layer of dissection was along the tunica adventitia of the IVC.

CONCLUSIONS

The surgical techniques for encircling and taping of the common trunk of the MHV and LHV and the LHV alone based on anatomical landmarks were feasible and could allow for efficient outflow control in laparoscopic hepatectomy.

The Role of the Spleen in Portal Hypertension

As liver disease progresses, intrahepatic vascular resistance increases (backward flow theory of portal hypertension) and collateral veins develop. Adequate portal hypertension is required to maintain portal flow into the liver through an increase in blood flow into the portal venous system (forward flow theory of portal hypertension). The splenic artery resistance index is significantly and selectively elevated in cirrhotic patients. In portal hypertension, a local hyperdynamic state occurs around the spleen. Splenomegaly is associated with a poor prognosis in cirrhosis and is caused by spleen congestion and by enlargement and hyperactivation of splenic lymphoid tissue. Hypersplenism can lead to thrombocytopenia caused by increased sequestering and breakdown of platelets in the spleen. The close relationship between the spleen and liver is reflected in the concept of the hepatosplenic axis. The spleen is a regulatory organ that maintains portal flow into the liver and is the key organ in the forward flow theory of portal hypertension. This review summarizes the literature on the role of the spleen in portal hypertension.

Robotic versus laparoscopic major hepatectomy for hepatocellular carcinoma: short-term outcomes from a single institution

BACKGROUND

Currently, an increasing number of robotic major hepatectomies for hepatocellular carcinoma (HCC) are being performed. Despite the advantages of robotic surgery over laparoscopic procedures, studies comparing robotic with laparoscopic major hepatectomy in terms of short-term results remain scarce. This study was performed to compare robotic major hepatectomy and laparoscopic major hepatectomy in terms of their intraoperative and postoperative results.

METHODS

Data regarding demographics and intraoperative and postoperative results of 131 patients undergoing robotic or laparoscopic major hepatectomy between January 2017 and March 2022 were retrieved from their medical records and compared between the two types of surgery.

RESULTS

Between January 2017 and March 2022, 44 robotic major hepatectomies and 87 laparoscopic major hepatectomies were performed at the Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital. Patients undergoing robotic major hepatectomy were not significantly different from those undergoing laparoscopic major hepatectomy in terms of age (P = 0.397), sex (P = 0.624), body mass index (BMI) (P = 0.118), alpha-fetoprotein (AFP) (P = 0.09), tumor size (P = 0.176), cirrhosis (P = 0.384), fatty liver (P = 0.162), preoperative antiviral treatment (P = 0.934), hepatitis B virus (HBV) DNA (P = 0.646) and operation type (P = 0.054). Robotic major hepatectomy was associated with a longer operation time (median: 255.5 versus 206.8 min; P < 0.001) and less estimated blood loss (median: 118.9 versus 197.0 ml; P = 0.002) than laparoscopic major hepatectomy. However, robotic major hepatectomy was not significantly different from laparoscopic major hepatectomy regarding length of postoperative hospital stay (P = 0.849), open conversion (P = 0.077), ICU stay (P = 0.866), postoperative massive abdominal bleeding (P = 1.00), portal vein thrombosis (P = 1.00), abdominal infection (P = 1.00), pulmonary infection (P = 1.00), pulmonary embolism (P = 1.00), cardiac complications (P = 1.00), liver failure (P = 1.00), kidney failure (P = 1.00), biliary leak (P = 1.00), positive resection margin (P = 1.00), 30-day mortality (P = 1.00) and 90-day mortality (P = 1.00).

CONCLUSIONS

Robotic major hepatectomy was as effective as laparoscopic surgery in terms of intraoperative and postoperative results but took longer and could more efficiently control intraoperative blood loss.

Perioperative and long-term survival outcomes of laparoscopic versus laparotomic hepatectomy for BCLC stages 0-A hepatocellular carcinoma patients associated with or without microvascular invasion: a multicenter, propensity score matching analysis

PURPOSE

To analyze the long-term oncological outcomes of Barcelona Clinic Liver Cancer (BCLC) stages 0-A hepatocellular carcinoma (HCC) patients associated with or without microvascular invasion (MVI) treated with laparoscopic versus laparotomic liver resection.

METHODS

Clinicopathological data of HCC patients with BCLC stages 0-A from four medical centers were retrospectively reviewed. The survival outcomes of patients who underwent laparoscopic hepatectomy were compared with those who underwent laparotomic hepatectomy. Subgroup analyses in terms of MVI were further performed to explore the effect of surgical approaches on the long-term survival outcomes. Propensity score matching (PSM) analysis was used to match patients between the laparoscopic and laparotomic resection groups in a 1:1 ratio.

RESULTS

495 HCC patients at BCLC stages 0-A were enrolled, including 243 in the laparoscopic resection group and 252 in the laparotomic resection group. Laparoscopic resection group had a shorter operation time, less blood loss, a lower frequency of blood transfusion and postoperative complication rates. The laparoscopic resection group had a significantly better overall survival (OS) and recurrence-free survival (RFS) than the laparotomic resection group before and after PSM. Subgroup analysis demonstrated that OS and RFS of patients without MVI were remarkably better in the laparoscopic resection group compared with the laparotomic resection group. However, no significant differences in OS and RFS between the two groups were found in patients with MVI after PSM.

CONCLUSIONS

Pure laparoscopic hepatectomy for patients with BCLC stages 0-A HCC can be performed safely with favorable perioperative and long-term oncological outcomes at high-volume liver cancer centers, regardless of the presence of MVI.

Short-Term and Long-Term Curative Effect of Partial Hepatectomy on Ruptured Hemorrhage of Primary Liver Cancer after TAE

Objective

To observe the short-term and long-term curative effects of partial hepatectomy on ruptured hemorrhage of primary liver cancer after transcatheter arterial embolization (TAE).

Methods

A total of 150 patients with primary liver cancer treated in the hospital were enrolled as research objects between February 2018 and February 2021, including 75 cases undergoing TAE in the TAE group and the other 75 cases undergoing elective partial hepatectomy after TAE in the combination group. The surgical related indexes (leaving bed time, discharge time, success rate of hemostasis, lesion clearance rate), mean arterial pressure (MAP), heart rate (HR), hemoglobin, and liver function indexes (serum alpha-fetoprotein (AFP), albumin (ALB), total bilirubin (TBIL)) before and after treatment, postoperative complications, survival rate, and recurrence rate at 1 year after surgery between the two groups were compared.

Results

Compared with the TAE group, hospitalization time was shorter (P < 0.05), the success rate of hemostasis and lesions clearance rate were higher in the combination group (P < 0.05). After surgery, levels of HR and serum AFP were significantly decreased, while levels of MAP, hemoglobin, serum ALB, and TBIL were significantly increased in both groups. The levels of HR and serum AFP in the combination group were lower than those in the TAE group, while levels of MAP, hemoglobin, serum ALB, and TBIL were higher than those in the TAE group (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P < 0.05). Compared with the TAE group, the recurrence rate was lower, and the survival rate was higher in the combination group at 1 year after surgery (P < 0.05).

Conclusion

Partial hepatectomy can effectively improve hemostatic effect and liver function in ruptured hemorrhage of primary liver cancer after TAE, increase survival rate, and reduce postoperative recurrence rate.

Current indications of ex-situ liver resection: A systematic review

BACKGROUND

Ex situ liver resection and autotransplantation, a surgical technique introduced for managing advanced and unresectable malignant tumors, never became a popular surgical procedure, due mainly to the high incidence of adverse events and postoperative recurrences. This study aims to assess the clinical outcomes of ex situ liver resection and autotransplantation in the currently available literature.

METHODS

The PubMed electronic database was used to retrieve studies that meet the inclusion criteria for the topic.

RESULTS

Twenty-nine studies were included. The mean (range) 90-day mortality rate was 11.6% (0%-50%) and the mean overall survival was 55.8% (12.5%-100.0%). R0 resection was achieved in 100% of cases. In the overall study sample, the maximum tumor size was found to be positively correlated with the 90-day mortality rate (P = .047) and negatively correlated with the overall survival (P = .048). The mean number of total resected segments appeared to be positively correlated with the length of hospital stay (P = .039). In the malignant tumor sample, there was a significant relationship between the maximum tumor size and postoperative liver failure, 90-day mortality rate (P = .027 and P = .034, respectively), and between the mean length of anhepatic phase and mean length of hospital stay (P = .0092).

CONCLUSION

The ex situ liver resection and autotransplantation appears to be a valuable option in selected patients with conventionally unresectable hepatic tumors and normal liver function. However, it was not possible to provide clear and unequivocal recommendations about this procedure. To rectify this, an international database to help surgeons in their decision-making process ought to be established.

Laparoscopic liver resection for liver metastasis of leiomyosarcoma of the thigh: a case report

Background

Although there is no established treatment strategy for liver metastasis of leiomyosarcoma, liver resection has been reported to be effective in some cases. However, almost all liver resections performed for liver metastasis of primary leiomyosarcoma are reported to be open resections, and there are few reports of liver resection performed by laparoscopy. Here, we report a case of laparoscopic liver resection for liver metastasis of a leiomyosarcoma in the right thigh.

Case presentation

An 80-year-old man was diagnosed with leiomyosarcoma of the right thigh with liver metastasis. The primary tumor was first resected, and he was discharged on the 25th postoperative day. Four months after primary tumor resection, a laparoscopic right posterior sectionectomy was performed. There were no postoperative complications, and the patient was discharged on the 11th postoperative day with a histopathological diagnosis of liver metastasis of leiomyosarcoma and negative resection margins. Currently, 9 months have passed since the resection of the primary tumor, and 5 months have passed since the laparoscopic liver resection; there is no recurrence.

Conclusions

The liver metastasis of leiomyosarcoma was successfully removed, with good short-term outcomes after the laparoscopic liver resection. Laparoscopic liver resection seems to be effective for liver metastasis of leiomyosarcoma, which is characterized by a high recurrence rate after surgery. However, more case studies may be necessary to examine the effectiveness and long-term results of laparoscopic liver resection for the treatment of liver metastasis of leiomyosarcoma.

Comparison between subtraction and dynamic MRI in assessing treatment response following radiofrequency ablation in patients with hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is one of the most prevalent cancers worldwide, and if left untreated, one of the most lethal. Ablative therapies including radiofrequency ablation (RFA) play increasingly important role for patients with liver tumors who are not surgical candidates. Monitoring treatment response following ablation is crucial in oncologic imaging. Dynamic contrast-enhanced MRI can assess changes in tumor vascularity and perfusion while subtraction imaging is useful in differentiating residual tumor from post-ablation parenchymal changes. The aim of this study is to compare the role of subtraction MRI and conventional dynamic MRI in assessing treatment response following RFA in patients with HCC.

Results

The study included 48 patients with 62 HCC lesions who underwent RFA from May to October 2020, followed by MRI evaluation with 1-month interval. Two readers with experience in hepatic imaging interpreted the dynamic and subtraction dynamic MRI. The hepatic focal lesions were classified into “well-ablated” and “residual” groups according to MRI findings, and the agreement between the two readers was evaluated. Using dynamic MRI, the first reader reported 38 well-ablated lesions, and the second reader agreed in 34 of them (89.5%). Residual disease was reported by the first reader in 22 lesions and the second reader disagreed in 10 of them (45.5%) where complete ablation was reported. Thirty-eight out 44 well-ablated lesions (86.4%) showed high signal intensity on non-enhanced T1 images, and 28 lesion (63.6%) showed intermediate T2 signal. All the mis-matched readings occurred in lesions with a high signal intensity in pre-contrast T1 images. Moderate agreement between the two readers was found with Kappa value of 0.467. Significant additive value of subtraction technique to dynamic MRI was detected with a P value of 0.009. No major complications recorded except for a single case of major portal vein branch occlusion.

Conclusion

MRI is a powerful imaging tool in assessing tumor viability and complications after RFA in patients with HCC. Dynamic MRI study is the gold standard in detecting recurrent lesions while subtraction technique is crucial in differentiating between arterial enhancement due to residual disease and normal hyperintense T1 signal of the ablation zone.

6-Phosphogluconolactonase Promotes Hepatocellular Carcinogenesis by Activating Pentose Phosphate Pathway

Hepatocellular carcinoma (HCC) has a poor prognosis due to the rapid disease progression and early metastasis. The metabolism program determines the proliferation and metastasis of HCC; however, the metabolic approach to treat HCC remains uncovered. Here, by analyzing the liver cell single-cell sequencing data from HCC patients and healthy individuals, we found that 6-phosphogluconolactonase (PGLS), a cytosolic enzyme in the oxidative phase of the pentose phosphate pathway (PPP), expressing cells are associated with undifferentiated HCC subtypes. The Cancer Genome Atlas database showed that high PGLS expression was correlated with the poor prognosis in HCC patients. Knockdown or pharmaceutical inhibition of PGLS impaired the proliferation, migration, and invasion capacities of HCC cell lines, Hep3b and Huh7. Mechanistically, PGLS inhibition repressed the PPP, resulting in increased reactive oxygen species level that decreased proliferation and metastasis and increased apoptosis in HCC cells. Overall, our study showed that PGLS is a potential therapeutic target for HCC treatment through impacting the metabolic program in HCC cells.

Laparoscopic liver resection for colorectal liver metastases - short- and long-term outcomes: A systematic review

BACKGROUND

For well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.

AIM

To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.

METHODS

A systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords "colorectal liver metastases", "laparoscopy", "liver resection", "prognostic factors", "outcomes" and "survival". Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.

RESULTS

Out of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures. The obtained results accounted for minor LLR, as well as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.

CONCLUSION

In experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.

The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown.

METHODS

This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI.

RESULTS

The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004).

CONCLUSIONS

Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.

Comparison of Thiel preserved, fresh human, and animal liver tissue in terms of mechanical properties

BACKGROUND

In medical training and research fresh human tissue is often replaced by preserved human or fresh animal tissue, due to availability and ethical reasons. Newer preservation approaches, such as the Thiel method, promise more realistic mechanical properties than conventional formaldehyde fixation. Concerning animal substitute material, porcine and bovine tissue is often chosen, as it is easily obtainable and certain similarity to human tissue is assumed. However, it has not been thoroughly investigated how Thiel preservation changes non-linear and viscoelastic behaviour of soft organ tissues. Furthermore, differences in these properties between animal tissue and human tissue have not been previously corroborated.

METHODS

We conducted ramp and relaxation tensile tests on fresh human and Thiel preserved hepatic tissue, extracting strain-specific elastic moduli, and viscoelastic properties. The results for fresh human liver were then compared to corresponding results for Thiel preserved liver, as well as previously published results for porcine and bovine liver.

RESULTS

Our results showed that Thiel preservation seems to be associated with increased stiffness as well as decreased viscoelastic damping behaviour. Porcine liver was stiffer than human liver with similar viscoelastic properties. Bovine liver exhibited similar stiffness as human liver, however lower viscoelastic damping.

CONCLUSIONS

The differences between human and animal liver tissue, concerning their mechanical properties, can be explained by their characteristic histology. Changes in mechanical properties due to Thiel preservation might stem from altered protein cross-linking and dehydration. The results illustrate that appropriate materials for medical training systems must be selected based on which mechanical properties are relevant for the respective application.

Management of portal hypertension based on portal hemodynamics

Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.

Prediction of portal vein thrombosis after hepatectomy for hepatocellular carcinoma

PURPOSE

Portal vein thrombosis (PVT) following hepatectomy is potentially life-threatening. We aimed to evaluate the incidence of PVT after hepatectomy for hepatocellular carcinoma and identify coagulation and fibrinolytic factors that could predict early-stage postoperative PVT.

METHODS

A retrospective analysis was conducted on 65 hepatocellular carcinoma patients who underwent radical hepatectomy. The risk factors for postoperative PVT were identified based on univariate and multivariate analyses, and the levels of coagulation and fibrinolytic factors were measured during the perioperative period.

RESULTS

The incidence of PVT after hepatectomy was 20.0%. The patients were divided into two groups: those with PVT (n=13; PVT group) and those without PVT (n=52; no-PVT group). The frequency of the use of the Pringle maneuver during surgery was higher in the PVT group than in the no-PVT group, and the postoperative/preoperative ratios of thrombin-antithrombin III complex (TAT) and of D-dimer were significantly higher in the PVT group.

CONCLUSION

A high incidence of PVT was found in hepatocellular carcinoma patients after hepatectomy. The frequency of the Pringle maneuver is a potential risk factor for postoperative PVT, and the postoperative/preoperative TAT and D-dimer ratios may be used as early predictors of PVT after hepatectomy for hepatocellular carcinoma.

The effect of pre-operative autologous blood donation on bone marrow hematopoietic functions in rabbits after hepatectomy

BACKGROUND

Pre-operative autologous blood donation (PABD) is one of the most widely distributed autologous blood donation means, which has positive effect on erythropoiesis. However, whether PABD can stimulate the bone marrow hematopoiesis after hepatectomy have not been reported.

METHODS

Totally 80 New Zealand rabbits were randomly divided into 4 groups that included control group, surgery group, hemodilutional autotransfusion (HA) group and PABD group. Automatic reticulocyte examination was performed to detect the content of reticulocyte and immature reticulocyte fractions (IRF). Flow cytometric analysis was employed to monitor the level of CD34+ cells and the cell cycle status. Southern blotting was conducted to determine the telomere length of CD34+ cells.

RESULTS

The content of high fluorescence reticulocytes (HFR) and IRF was decreased at 6 h and 24 h after autotransfusion. However, the level of CD34+ cells was upregulated after PABD. Cell cycle status analysis revealed that majority of the CD34+ cells in HA and PABD group were maintained in G0/G1 phase. The telomere length in HA and PABD group was shorten than that of control group and surgery group.

CONCLUSION

PABD could promote the bone marrow hematopoietic functions in rabbits after hepatectomy via stimulating proliferation of CD34+ cells and shortening the telomere length of CD34+ cells, but the content of HFR was not increased immediately because of the stuck of CD34+ cells in G0/G1 phase.

Massage of the Hepatoduodenal Ligament Recovers Portal Vein Flow Immediately After the Pringle Maneuver in Hepatectomy

BACKGROUND

The Pringle maneuver is often used in liver surgery to minimize bleeding during liver transection. Many authors have demonstrated that intermittent use of the Pringle maneuver is safe and effective when performed appropriately. However, some studies have reported that the Pringle maneuver is a significant risk factor for portal vein thrombosis. In this study, we evaluated the effectiveness of portal vein flow after the Pringle maneuver and the impact that massaging the hepatoduodenal ligament after the Pringle maneuver has on portal vein flow.

MATERIALS AND METHODS

Patients treated with the Pringle maneuver for hepatectomies performed to treat hepatic disease at our hospital between August 2014 and March 2019 were included in the study (N = 101). We divided these patients into two groups, a massage group and nonmassage group. We measured portal vein blood flow with ultrasonography before and after clamping of the hepatoduodenal ligament. We also evaluated laboratory data after the hepatectomy.

RESULTS

Portal vein flow was significantly lower after the Pringle maneuver than before clamping of the hepatoduodenal ligament. The portal vein flow after the Pringle maneuver was improved following massage of the hepatoduodenal ligament. After hepatectomy, serum prothrombin time was significantly higher and serum C-reactive protein was significantly lower in the massage group than in the nonmassage group.

CONCLUSION

Massaging the hepatoduodenal ligament after the Pringle maneuver is recommended in order to quickly recover portal vein flow during hepatectomy and to improve coagulability.

Laparoscopic left hemihepatectomy in small dogs: an easy and effective new technique

The present report describes a novel approach to and presents the surgical results for laparoscopic hepatectomy of the left lobes in small dogs. A purely laparoscopic four-port approach was used in seven beagles. The left triangular ligament was cut first, then the base of the left medial lobe (LMB) was ligated with silk thread using a needle, and the liver parenchyma of the LMB approximately 0.5 cm above the ligation site was removed with LigaSure. The left lateral lobe (LLB) was removed in the same manner. Blood was collected on postoperative days 1, 3, 7, and 14 for laboratory testing. Left hepatic lobe resection was successfully completed in all dogs, with an average operation time of 102.53 ± 9.07 min and an average blood loss of 32.10 ± 6.43 ml. Serious postoperative complications were not observed. The white blood cell (WBC) count and alkaline phosphatase (ALP) level were significantly increased in experimental dogs 1 day after surgery (P< 0.05); aspartate transferase (AST) and alanine transaminase (ALT) were significantly different before and after surgery (P< 0.01); and all the indicators were basically normal seven days after the operation. Exploratory laparoscopy at 28 days revealed adhesion of the surface of the liver section to the omentum or the gastric wall, but there were no other abnormal findings. The combined application of liver pedicle ligation and LigaSure for liver lobectomy provides a simple and effective method for generating liver lobectomy models for research on liver disease and regeneration and a feasible laparoscopic liver lobectomy operation scheme for small dogs (10–15 kg).

Inhibitor for protein disulfide-isomerase family A member 3 enhances the antiproliferative effect of inhibitor for mechanistic target of rapamycin in liver cancer: An in vitro study on combination treatment with everolimus and 16F16

mTOR is involved in the proliferation of liver cancer. However, the clinical benefit of treatment with mTOR inhibitors for liver cancer is controversial. Protein disulfide isomerase A member 3 (PDIA3) is a chaperone protein, and it supports the assembly of mTOR complex 1 (mTORC1) and stabilizes signaling. Inhibition of PDIA3 function by a small molecule known as 16F16 may destabilize mTORC1 and enhance the effect of the mTOR inhibitor everolimus (Ev). The aim of the present study was to elucidate the usefulness of combination treatment with Ev and 16F16 in liver cancer using cultured Li-7 and HuH-6 cells. The proliferation of cultured cells was examined following treatment with 0.01 µM Ev, 2 µM 16F16 or both. The expression levels and phosphorylation of S6 kinase (S6K) and 4E-binding protein 1 (4E-BP1) were examined by western blotting. Li-7 was susceptible to Ev, and proliferation was reduced to 69.5±7.2% by Ev compared with that of untreated cells. Proliferation was reduced to 90.2±10.8% by 16F16 but to 62.3±12.2% by combination treatment with Ev and 16F16. HuH-6 cells were resistant to Ev, and proliferation was reduced to 86.7±6.1% by Ev and 86.6±4.8% by 16F16. However, combination treatment suppressed proliferation to 57.7±4.0%. Phosphorylation of S6K was reduced by Ev in both Li-7 and HuH-6 cells. Phosphorylation of 4E-BP1 was reduced by combination treatment in both Li-7 and HuH-6 cells. Immunoprecipitation assays demonstrated that PDIA3 formed a complex with 4E-BP1 but not with S6K. The small molecule 16F16 increased susceptibility to Ev in cultured liver cancer cells, which are resistant to Ev. The inhibition was associated with reduction of 4E-BP1 phosphorylation, which formed a complex with PDIA3. Combination treatment with Ev and 16F16 could be a novel therapeutic strategy for liver cancer.

Hyperelastic and viscoelastic characterization of hepatic tissue under uniaxial tension in time and frequency domain

In order to create accurate anatomical models for medical training and research, mechanical properties of biological tissues need to be studied. However, non-linear and viscoelastic behaviour of most soft biological tissues complicates the evaluation of their mechanical properties. In the current study, a method for measuring hyperelasticity and viscoelasticity of bovine and porcine hepatic parenchyma in tension is presented. First, non-linear stress-stretch curves resulting from ramp loading and unloading, were interpreted based on a hyperelastic framework, using a Veronda-Westmann strain energy function. Strain-specific elastic moduli, such as initial stiffness E_I, were thereupon defined in certain parts of the stress-stretch curves. Furthermore, dissipated and stored energy density were calculated. Next, the viscoelastic nature of liver tissue was examined with two different methods: stress relaxation and dynamic cyclic testing. Both tests yielded dissipated and stored energy density, as well as loss tangent (tanδ), storage modulus (E^'), and loss modulus (E^''). In tension, stress relaxation was experimentally more convenient than dynamic cyclic testing. Thus we considered whether relaxation could be used for approximating the results of the cyclic tests. Regarding the resulting elastic moduli, initial stiffness was similar for porcine and bovine liver (E_I∼30kPa), while porcine liver was stiffer for higher strains. Comparing stress relaxation with dynamic cyclic testing, tanδ of porcine and bovine liver was the same for both methods (tanδ=0.05-0.25 at 1 Hz). Storage and loss moduli matched well for bovine, but not as well for porcine tissue. In conclusion, the utilized Veronda-Westmann model was appropriate for representing the hyperelasticity of liver tissue seen in ramp tests. Concerning viscoelasticity, both chosen testing methods - stress relaxation and dynamic cyclic testing - yielded comparable results for E^', E^'', and tanδ, as long as elasticity non-linearities were heeded. The here presented method provides novel insight into the tensile viscoelastic properties of hepatic tissue, and provides guidelines for convenient evaluation of soft tissue mechanical properties.

Factors affecting tumor responders and predictive biomarkers of toxicities in cancer patients treated with immune checkpoint inhibitors

Cancer immunotherapy has brought a great revolution in the treatment of advanced human cancer. Immune checkpoint inhibitors (ICIs) that target cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and the programmed cell death protein 1 pathway (PD-1/PD-L1) have been widely administrated in the past years and demonstrated promising in a variety of malignancies. While some patients show benefit from ICIs, others do not respond or even develop resistance to these therapies. Among the responders, the treatments are consequently accompanied with immune-related adverse effects (irAEs), which are diverse in their effected organs, degree of severity and timing. Some of the toxicities are fatal and result in discontinuance of immunotherapy. The toxicity profile from anti-CTLA-4 to anti-PD-1/PD-L1 immunotherapies is distinct from those caused by conventional anticancer therapies, though their presentation may be similar. In order to better help clinicians recognize, monitor and manage irAEs in a growing population of cancer patients who are receiving ICI therapy, this article summarizes the FDA approved ICIs and focuses on (1) existing toxic evidence related to ICIs, (2) occurrence of irAEs, (3) factors influencing tumor responders treated with ICIs, (4) predictive biomarkers of irAEs, and (5) new potential mechanisms of resistance to ICI therapy.