Intraoperative ultrasonography and surgical strategy in hepatic resection: What difference does it make?

H. USG and magnetic resonance imaging in the preoperative and postoperative management of hepatic lesions: A prospective study

Hepatic lesions are common and require accurate diagnosis for effective management and treatment outcomes. This study compared the diagnostic efficacy and sensitivity of USG and MRI in preoperative and postoperative evaluations of hepatic lesions in 100 patients over 12 months. MRI demonstrated superior sensitivity, particularly for lesions smaller than 2 cm (p < 0.0001) and influenced surgical decision-making in 40% of cases by providing more accurate lesion characterization. Postoperative assessments with MRI were more effective in detecting residual or recurrent disease than USG (p = 0.002). These findings highlight MRI's critical role in surgical planning and comprehensive management of hepatic lesions.

Comparative analysis of the safety and feasibility of laparoscopic and open approaches for right anterior sectionectomy

Laparoscopic hepatectomy has minimally invasive advantages, but reports on laparoscopic right anterior sectionectomy (LRAS) are rare. Herein, we try to explore the benefits and drawbacks of LRAS by comparing it with open right anterior sectionectomy (ORAS). Between January 2015 and September 2023, 39 patients who underwent LRAS (n = 18) or ORAS (n = 21) were enrolled in the study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between the two groups. No significant differences in the preoperative data were observed between the two groups. The LRAS group had significantly lesser blood loss (P = 0.019), a shorter hospital stay (P = 0.045), and a higher rate of bile leak (P = 0.039) than the ORAS group. There was no significant difference in the operative time (P = 0.156), transfusion rate (P = 0.385), hospital expenses (P = 0.511), rate of other complications, postoperative white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels between the two groups (P > 0.05). Beside, there was no significant difference in disease-free survival (P = 0.351) or overall survival (P = 0.613) in patients with hepatocellular carcinoma between the two groups. LRAS is a safe and feasible surgical procedure. It may be preferred for lesions in the right anterior lobe of the liver.

Enhancing Surgical Guidance: Deep Learning-Based Liver Vessel Segmentation in Real-Time Ultrasound Video Frames

BACKGROUND/OBJECTIVES

In the field of surgical medicine, the planning and execution of liver resection procedures present formidable challenges, primarily attributable to the intricate and highly individualized nature of liver vascular anatomy. In the current surgical milieu, intraoperative ultrasonography (IOUS) has become indispensable; however, traditional 2D ultrasound imaging's interpretability is hindered by noise and speckle artifacts. Accurate identification of critical structures for preservation during hepatectomy requires advanced surgical skills.

METHODS

An AI-based model that can help detect and recognize vessels including the inferior vena cava (IVC); the right (RHV), middle (MHV), and left (LVH) hepatic veins; the portal vein (PV) and its major first and second order branches the left portal vein (LPV), right portal vein (RPV), and right anterior (RAPV) and posterior (RPPV) portal veins, for real-time IOUS navigation can be of immense value in liver surgery. This research aims to advance the capabilities of IOUS-guided interventions by applying an innovative AI-based approach named the "2D-weigthed U-Net model" for the segmentation of multiple blood vessels in real-time IOUS video frames.

RESULTS

Our proposed deep learning (DL) model achieved a mean Dice score of 0.92 for IVC, 0.90 for RHV, 0.89 for MHV, 0.86 for LHV, 0.95 for PV, 0.93 for LPV, 0.84 for RPV, 0.85 for RAPV, and 0.96 for RPPV.

CONCLUSION

In the future, this research will be extended for real-time multi-label segmentation of extended vasculature in the liver, followed by the translation of our model into the surgical suite.

Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study

BACKGROUND

The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery.

METHODS

In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs.

RESULTS

In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3).

CONCLUSIONS

The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

Artificial intelligence for identification of focal lesions in intraoperative liver ultrasonography

PURPOSE

Intraoperative ultrasonography (IOUS) of the liver is a crucial adjunct in every liver resection and may significantly impact intraoperative surgical decisions. However, IOUS is highly operator dependent and has a steep learning curve. We describe the design and assessment of an artificial intelligence (AI) system to identify focal liver lesions in IOUS.

METHODS

IOUS images were collected during liver resections performed between November 2020 and November 2021. The images were labeled by radiologists and surgeons as normal liver tissue versus images that contain liver lesions. A convolutional neural network (CNN) was trained and tested to classify images based on the labeling. Algorithm performance was tested in terms of area under the curves (AUCs), accuracy, sensitivity, specificity, F1 score, positive predictive value, and negative predictive value.

RESULTS

Overall, the dataset included 5043 IOUS images from 16 patients. Of these, 2576 were labeled as normal liver tissue and 2467 as containing focal liver lesions. Training and testing image sets were taken from different patients. Network performance area under the curve (AUC) was 80.2 ± 2.9%, and the overall classification accuracy was 74.6% ± 3.1%. For maximal sensitivity of 99%, the classification specificity is 36.4 ± 9.4%.

CONCLUSIONS

This study provides for the first time a proof of concept for the use of AI in IOUS and show that high accuracy can be achieved. Further studies using high volume data are warranted to increase accuracy and differentiate between lesion types.

Current role of intraoperative ultrasonography in hepatectomy

Hepatectomy had a high mortality rate in the previous decade because of inadequate techniques, intraoperative blood loss, liver function reserve misdiagnoses, and accompanying postoperative complications. However, the development of several modalities, including intraoperative ultrasonography (IOUS), has made hepatectomy safer. IOUS can provide real-time information regarding the tumor position and vascular anatomy of the portal and hepatic veins. Systematic subsegmentectomy, which leads to improved patient outcomes, can be performed by IOUS in open and laparoscopic hepatectomy. Although three-dimensional (3D) computed tomography and gadoxetic acid-enhanced magnetic resonance imaging have been widely used, IOUS and contrast-enhanced IOUS are important modalities for risk analyses and making decisions regarding resectability and operative procedures because of the vital anatomical information provided and high sensitivity for liver tumors, including "disappearing" liver metastases. Intraoperative color Doppler ultrasonography can be used to delineate the vascular anatomy and evaluate the blood flow volume and velocity in hepatectomy patients and recipients of deceased- and living-donor liver transplantation after vessel reconstruction and liver positioning. For liver surgeons, IOUS is an essential technique to perform highly curative hepatectomy safely, although recent advances have also been made in virtual modalities, such as real-time virtual sonography with 3D visualization.

The actual management of colorectal liver metastases

Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.

Right Hemihepatectomy via an Anterior Approach for Hepatocellular Carcinoma in a Situs Inversus Totalis Patient

Situs inversus totalis (SIT) is a rare congenital condition in which the usual position of the organs is reversed from left to right as a mirror image of the normal situation. Due to the abnormal transposition, this represents a technical challenge for the surgeon. In the present study, right hemihepatectomy via the anterior approach was performed for a 68-year-old hepatocellular carcinoma (HCC) patient with SIT. SIT was diagnosed by chest X-ray and computed tomography. The tumors were located in segments VIII and VI of the liver, and there was no metastasis to the lymph nodes and distant organs. Hemihepatic vascular inflow occlusion was performed using the selective intra-Glissonian approach. The middle hepatic vein was preserved under the guidance with intraoperative ultrasonography. The present case suggests that right hemihepatectomy via the anterior approach may be a safe, feasible, and effective procedure for HCC patients with SIT.

Hepatic resection in children: highlighted and revisited steps

Background

Hepatectomy in children deserves exhaustive preoperative and intraoperative tools to define the anatomy, minimize blood loss, and confirm adequacy of liver tissue left. The aim of this study is to report our experience in surgical management of liver tumors.

Results

All liver resections performed in Ain-Shams University Hospital, by the same team, between July 2013 and June 2018 were retrospectively reviewed. Data related to basic demographics, indication for resection, methods of parenchymal resection, blood loss, hospital stay, morbidity, and mortality was collected. The study included 27 patients who underwent different types of hepatectomies. There was a male predominance. Age ranged from 6 months to 13 years. Weight ranged from 5.7 to 33.7 kg. Total operative time ranged from 68 to 322 min, while resection time ranged from 34 to 144 min. Blood loss ranged from 53 to 259 ml. Surgical morbidities included five patients with minor biliary leak, three patients had surgical site infection, and one patient had torsion of the remnant liver necessitating repositioning. Recurrence of the mass was faced in three patients with hepatoblastoma. There were two mortalities; one occurred as a sequela of massive intraoperative bleeding and the other took place due to postoperative hepatic insufficiency.

Conclusion

For a safe hepatectomy, thorough familiarity of the hepatic segmental anatomy together with the various techniques for parenchymal resection and vascular control is fundamental. Complications such as biliary leak and torsion of remnant can be easily avoided by simple measures.

Updates and Critical Insights on Glissonian Approach in Liver Surgery

Recent advances in surgical techniques have broadened the indications of surgical management of liver malignancies. Intraoperative bleeding is one of the known predictors of postoperative outcomes following liver surgery, signifying the importance of vascular control during liver resection. Furthermore, preservation of future liver remnant plays a critical role in prevention of post-hepatectomy liver failure as one of the main causes of postoperative morbidity and mortality. Glissonian approach liver resection offers an effective method for vascular inflow control while protecting future liver remnant from ischemia-reperfusion injury. Several studies have demonstrated the feasibility of Glisson's pedicle resection technique in modern liver surgery with an acceptable safety profile. Moreover, with increasing popularity of minimally invasive surgery, laparoscopic liver resection via Glissonian approach has been shown to be superior to standard laparoscopic hepatectomy. Herein, we systematically review the role of Glissonian approach hepatectomy in current practice of liver surgery, highlighting its advantages and disadvantaged over other methods of vascular control.

The First Case Report of Robotic Multivisceral Resection for Synchronous Liver Metastasis from Pancreatic Neuroendocrine Tumor: A Case Report and Literature Review

INTRODUCTION

Surgery for liver metastases in pancreatic neuroendocrine tumor (PNET) improves overall survival rate. We present the first case report for robotic multivisceral resection of distal pancreas, spleen, and left liver for metastatic PNET.

MATERIALS AND METHODS

We present a case of 52-year-old female diagnosed with PNET in the pancreatic neck metastatic to the liver, responding to somatostatin and bland embolization, who underwent surgical debulking using da Vinci robotic platform. Intraoperative Doppler ultrasound was used to define the vascular distribution and tumor extension. The parenchymal liver transection was performed with vessel sealer. The distal pancreas and the spleen were approached medial to lateral and resected in an en-bloc fashion. The left liver inflow, outflow, and splenic artery and vein were transected with vascular stapler device.

RESULTS

Da Vinci robot-assisted multivisceral resection has been performed with good postoperative outcome. Operative time was 369 minutes and the estimated blood loss was 100 mL. The patient had a short hospital stay with quick recovery and good outcome at 5 months follow-up after the surgery.

DISCUSSION

Liver metastases in PNETs are considered an adverse factor. Aggressive surgical management is a mainstay. The laparoscopic approach to pancreatic or hepatic surgery is difficult in inexperienced hands with steep learning curve. The recent robotic system seems to overcome many limitations. This is the first case of robotic multivisceral resection for synchronous liver metastasis from PNET. Concurrent primary tumor resection with hepatectomy offers potential curative intention.