Quantitative anatomy of the large variant right hepatic vein: A systematic three-dimensional analysis.

Anatomical variations of the right hepatic vein, especially large variant right hepatic veins (≥5 mm), have important clinical implications in liver transplantation and resection. This study aimed to evaluate anatomical variations of the right hepatic vein using quantitative three-dimensional visualization analysis. Computed tomography images of 650 patients were retrospectively analyzed, and three-dimensional visualization was applied using the derived data to analyze large variant right hepatic veins. The proportion of the large variant right hepatic vein was 16.92% (110/650). According to the location and number of the variant right hepatic veins, the configuration of the right hepatic venous system was divided into seven subtypes. The length of the retrohepatic inferior vena cava had a positive correlation with the diameter of the right hepatic vein (rs = 0.266, p = 0.001) and the variant right hepatic veins (rs = 0.211, p = 0.027). The diameter of the right hepatic vein was positively correlated with that of the middle hepatic vein (rs = 0.361, p < 0.001), while it was inversely correlated with that of the variant right hepatic veins (rs = -0.267, p = 0.005). The right hepatic vein diameter was positively correlated with the drainage volume (rs = 0.489, p < 0.001), while the correlation with the variant right hepatic veins drainage volume was negative (rs = -0.460, p < 0.001). The number of the variant right hepatic veins and their relative diameters were positively correlated (p < 0.001). The volume and percentage of the drainage area of the right hepatic vein decreased significantly as the number of the variant right hepatic vein increased (p < 0.001). The findings of this study concerning the variations of the hepatic venous system may be useful for the surgical planning of liver resection or transplantation.

Indocyanine green fluorescence image-guided laparoscopic anatomical S2/3 resection using the TICGL technique.

BACKGROUND: Segment 2/3 (S2/3) resection, which can preserve more residual liver parenchyma, is a feasible alternative to left lateral sectionectomy. However, it is still challenging to perform anatomical S2/3 resection safely and precisely, especially laparoscopically. This study was designed to evaluate the safety and accuracy of the temporary inflow control of the Glissonean pedicle (TICGL) technique combined with indocyanine green (ICG) fluorescence imaging in laparoscopic anatomical S2/3 resection. PATIENTS AND METHODS: A total of 12 patients recruited at Zhujiang Hospital of Southern Medical University from June 2021 to August 2022 were included in the study. All patients underwent ICG fluorescence imaging guided laparoscopic anatomical S2/3 resection. The TICGL technique was used to control the blood inflow of the target segment. The total time used to control the hepatic inflow of the target segment, the time of hemostasis, the amount of intraoperative blood loss, predicted resected liver volume (PRLV) and actual resected liver volume (ARLV) were used to evaluate the simplicity, safety, and accuracy of the TICGL technique combined ICG fluorescent imaging in guiding laparoscopic anatomical S2/3 resection. RESULTS: Of the 12 included patients, 7 underwent S2 resection and 5 underwent S3 resection. The operation time was 76.92 ± 11.95 min, the intraoperative blood loss was 15.42 ± 5.82 ml, and the time of hepatic blood inflow control was 7.42 ± 2.43 min. There was a strong correlation between PRLV and ARLV (r = 0.903, P < 0.05). CONCLUSION: The combination of the TICGL technique with ICG negative staining fluorescence imaging is a feasible approach for laparoscopic anatomical S2/3 resection.

Laparoscopic right hemi-hepatectomy plus total caudate lobectomy for perihilar cholangiocarcinoma via anterior approach with augmented reality navigation: a feasibility study.

BACKGROUND: Right hemi-hepatectomy plus total caudate lobectomy is the appropriate procedure for type IIIa or partial type II pCCA. However, the laparoscopic implementation of this procedure remains technically challenging, especially hilar vascular dissection and en bloc resection of the total caudate lobe. Augmented reality navigation can provide intraoperative navigation to enhance visualization of invisible hilar blood vessels and guide the parenchymal transection plane. METHODS: Eleven patients who underwent laparoscopic right hemi-hepatectomy plus total caudate lobectomy from January 2021 to January 2023 were enrolled in this study. Augmented reality navigation technology and the anterior approach were utilized in this operation. Routine operative and short-term postoperative outcomes were assessed to evaluate the feasibility of the novel navigation method in this operation. RESULTS: Right hemi-hepatectomy plus total caudate lobectomy was successfully performed in all 11 enrolled patients. Among the 11 patients, the mean operation time was 454.5 ± 25.0 min and the mean estimated blood loss was 209.1 ± 56.1 ml. Negative surgical margins were achieved in all patients. The postoperative course of all the patients was uneventful, and the mean length of postoperative hospital stay was 10.5 ± 1.2 days. CONCLUSION: Laparoscopic right hemi-hepatectomy plus total caudate lobectomy via the anterior approach may be feasible and safe for pCCA with the assistance of augmented reality navigation.

Augmented Reality Navigation Plus Indocyanine Green Fluorescence Imaging Can Accurately Guide Laparoscopic Anatomical Segment 8 Resection.

BACKGROUND: Laparoscopic anatomical Segment 8 (S8) resection is a highly challenging hepatectomy. Augmented reality navigation (ARN), which could be combined with indocyanine green (ICG) fluorescence imaging, has been applied in various complex liver resections and may also be applied in laparoscopic anatomical S8 resection. However, no study has explored how to apply ARN plus ICG fluorescence imaging (ARN-FI) in laparoscopic anatomical S8 resection, or explored its accuracy. PATIENTS AND METHODS: This study is a post hoc analysis that included 31 patients undergoing laparoscopic anatomical S8 resection from the clinical NaLLRFI trial, and the resected liver volume was measured in each patient. The perioperative parameters of safety and feasibility, as well as the accuracy analysis outcomes were compared. RESULTS: There were 16 patients in the ARN-FI group and 15 patients underwent conventional laparoscopic hepatectomy without ARN or fluorescence imaging (non-ARN-FI group). There was no significant difference in baseline characteristics between the two groups. Compared with the non-ARN-FI group, the ARN-FI group had lower intraoperative bleeding (median 125 vs. 300 mL, P = 0.003). No significant difference was observed in other postoperative short-term outcomes. Accuracy analysis indicated that the actual resected liver volume (ARLV) in the ARN-FI group was more accurate. CONCLUSIONS: ARN-FI was associated with less intraoperative bleeding and more accurate resection volume. These techniques may address existing challenges and provide rational guidance for laparoscopic anatomical S8 resection.

Indocyanine green fluorescence imaging to localize insulinoma and provide three-dimensional demarcation for laparoscopic enucleation: a retrospective single-arm cohort study.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is a new technology that can improve the real-time location of tumor edges and small nodules during surgery. However, no study has investigated its application in laparoscopic insulinoma enucleation. This study aimed to evaluate the feasibility and accuracy of this method for intraoperative localization of insulinomas and margin assessment during laparoscopic insulinoma enucleation. MATERIALS AND METHODS: Eight patients who underwent laparoscopic insulinoma enucleation from October 2016 to June 2022 were enrolled. Two methods of ICG administration, ICG dynamic perfusion and three-dimensional (3D) demarcation staining, were utilized in the laparoscopic insulinoma enucleation. Tumor-to-background ratio (TBR) and histopathologic analysis were used to evaluate the feasibility and accuracy of these novel navigation methods in laparoscopic insulinoma enucleation. RESULTS: All eight enrolled patients underwent both ICG dynamic perfusion and 3D demarcation staining. ICG dynamic perfusion images were available for six of them, among which five tumors could be recognized by TBR (largest TBR in each case 4.42±2.76), while the other could be distinguished by the disordered blood vessels in the tumor area. Seven out of eight specimens had successful 3D demarcation staining (TBR 7.62±2.62). All wound bed margins had negative frozen sections and final histopathologic diagnoses. CONCLUSIONS: ICG dynamic perfusion may be helpful in observing the abnormal vascular perfusion of tumors, providing similar functionality to intraoperative real-time angiography. ICG injection under the tumor pseudocapsule may be a useful method for acquiring real-time, 3D demarcation for the resection of insulinoma.

Augmented reality navigation facilitates laparoscopic removal of foreign body in the pancreas that cause chronic complications.

BACKGROUND: Foreign bodies that enter the pancreas and cause chronic complications cannot be removed by endoscopy. Surgical removal is necessary but also challenging. The development of augmented reality navigation has made it possible to accurate intraoperative navigation in laparoscopic surgery. METHODS: A 37-year-old female had epigastric pain for 3 months and her abdominal CT showed a linear high-density shadow in her pancreas along with chronic pancreatitis. Three-dimensional models of the liver, pancreas, stomach, blood vessels, and foreign body were created based on CT images. Gastroptosis was found in the three-dimensional models, so surgical approach was adapted to open the hepatogastric ligament to reach the pancreas. After 2-3 s of video images were captured by 3D laparoscopy, a three-dimensional dense stereo-reconstruction method was used to obtain the surface model of pancreas, stomach, and blood vessels. The Globally Optimal Iterative Closest Point method was used to obtain a spatial transformation matrix between the preoperative CT image space and the intraoperative laparoscopic space. Under augmented reality navigation guidance, the position and location of the foreign body were displayed on the surface of the pancreas. Then intraoperative ultrasound was used for further verification and to quickly and easily confirm the surgical entrance. After minimal dissection and removal of the pancreatic parenchyma, the foreign body was removed completely. RESULTS: The operation time was 60 min, the estimated blood loss was 10 ml. The foreign body was identified as a 3-cm-long fishbone. The patient recovered without complications and was discharged on the third postoperative day. CONCLUSION: Because it enables direct visual navigation via simple operation, ARN facilitates the laparoscopic removal of foreign bodies in the pancreas with accurate and rapid positioning and minimal damage.

Identification of a Four Cancer Stem Cell-Related Gene Signature and Establishment of a Prognostic Nomogram Predicting Overall Survival of Pancreatic Adenocarcinoma.

BACKGROUND: Cancer stem cells (CSCs) are now being considered as the initial component in the development of pancreatic adenocarcinoma (PAAD). Our aim was to develop a CSCrelated signature to assess the prognosis of PAAD patients for the optimization of treatment. METHODS: Differentially expressed genes (DEGs) between pancreatic tumor and normal tissue in the Cancer Genome Atlas (TCGA) were screened out, and the weighted gene correlation network analysis (WGCNA) was employed to identify the CSC-related gene sets. Then, univariate, Lasso Cox regression analyses and multivariate Cox regression were applied to construct a prognostic signature using the CSC-related genes. Its prognostic performance was validated in TCGA and ICGC cohorts. Furthermore, Univariate and multivariate Cox regression analyses were used to identify independent prognostic factors in PAAD, and a prognostic nomogram was established. RESULTS: The Kaplan-Meier analysis, ROC curve and C-index indicated the good performance of the CSC-related signature at predicting overall survival (OS). Univariate Cox regression and multivariate Cox regression revealed that the CSC-related signature was an independent prognostic factor in PAAD. The nomogram was superior to the risk model and AJCC stage in predicting OS. In terms of mutation and tumor immunity, patients in the high-risk group had higher tumor mutation burden (TMB) scores than patients in the low-risk group, and the immune score and the ESTIMATE score were significantly lower in the high-risk group. Moreover, according to the results of principal component analysis (PCA) and Gene Set Enrichment Analysis (GSEA), the low-risk and high-risk groups displayed different stemness statuses based on the risk model. CONCLUSION: Our study identified four CSC-related gene signatures and established a prognostic nomogram that reliably predicts OS in PAAD. The findings may support new ideas for screening therapeutic targets to inhibit stem characteristics and the development of PAAD.

Laparoscopic in Situ Anatomical Mesohepatectomy for Solitary Massive HCC Using Combined Intrafascial and Extrafascial Approaches With Indocyanine Green Navigation (with Video).

BACKGROUND: Laparoscopic anatomic mesohepatectomy for patients with hepatocellular carcinoma (HCC) remains technically challenging, especially for those with a massive tumor larger than 10 cm. METHODS: In this study, a 65-year-old man with a 13 × 10-cm2 solitary liver tumor located at segments 4, 5, and 8 underwent laparoscopic mesohepatectomy. To reduce the possibility of releasing cancer cells from the primary tumor, the in situ resection strategy for tumor removal was implemented. The intrafascial approach was used to dissect the right Glissonean pedicle, to transect the right anterior hepatic artery, and to ligate the right anterior portal vein. The extrafascial and transfissural approach was performed along the umbilical fissure to transect the Glissonean pedicle of segment 4. Indocyanine green (ICG) then was applied using "reverse staining" to visualize the resection extent and the right posterior hepatic duct (RPHD). During parenchymal resection, the right anterior Glissonean pedicle was adequately exposed and transected via the extrafascial approach above the plane of the RPHD. Finally, the right coronary ligament was dissected, and the tumor was removed. RESULTS: The operation was completed in 360 min, with a blood loss of 200 mL. The histopathologic diagnosis indicated a moderately differentiated HCC. The patient was discharged on postoperative day 8 without any complications. CONCLUSION: Laparoscopic in situ anatomic mesohepatectomy using combined intra- and extrafascial approaches with ICG navigation may be feasible for patients with a centrally located solitary massive HCC.

Comprehensive analysis of an immune-related ceRNA network in identifying a novel lncRNA signature as a prognostic biomarker for hepatocellular carcinoma.

The function of competitive endogenous RNA (ceRNA) network in the immune regulation of hepatocellular carcinoma (HCC) is unclear. Our study aimed to construct an immune-related ceRNA network and develop an immune-related long noncoding RNA (lncRNA) signature to assess the prognosis of HCC patients and to optimize the treatment methods. We firstly constructed a ceRNA regulatory network for HCC using differentially expressed lncRNAs, mRNAs and microRNAs (miRNAs) from the Cancer Genome Atlas. A signature was constructed by 11 immune-related prognostic lncRNAs from the ceRNA network. The survival analysis and receiver operating characteristic analysis validated the reliability of the signature. Multivariate Cox regression analysis revealed that the signature could act an independent prognostic indicator. This signature also showed high association with immune cell infiltration and immune check blockades. LINC00491 was identified as the hub lncRNA in the signature. In vitro and in vivo evidence demonstrated that silencing of LINC00491 significantly inhibited HCC growth. Finally, 59 lncRNAs, 21 miRNAs, and 26 mRNAs were obtained to build the immune-related ceRNA network for HCC. In conclusion, our novel immune-related lncRNA prognostic signature and the immune-related ceRNA network might provide in-depth insights into tumor-immune interaction of HCC and promote better individual treatment strategies in HCC patients.