Laparoscopic central hepatectomy: Feasibility and safety.

BACKGROUND: Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group. METHODS: A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures. RESULTS: 70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400 ml vs. 290 ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330 min vs. 360 min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6 days vs. 9 days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group. CONCLUSION: Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function.

Defining Global Benchmarks for Laparoscopic Liver Resections: An International Multicenter Study.

OBJECTIVE: To establish global benchmark outcomes indicators after laparoscopic liver resections (L-LR). BACKGROUND: There is limited published data to date on the best achievable outcomes after L-LR. METHODS: This is a post hoc analysis of a multicenter database of 11,983 patients undergoing L-LR in 45 international centers in 4 continents between 2015 and 2020. Three specific procedures: left lateral sectionectomy (LLS), left hepatectomy (LH), and right hepatectomy (RH) were selected to represent the 3 difficulty levels of L-LR. Fifteen outcome indicators were selected to establish benchmark cutoffs. RESULTS: There were 3519 L-LR (LLS, LH, RH) of which 1258 L-LR (40.6%) cases performed in 34 benchmark expert centers qualified as low-risk benchmark cases. These included 659 LLS (52.4%), 306 LH (24.3%), and 293 RH (23.3%). The benchmark outcomes established for operation time, open conversion rate, blood loss ≥500 mL, blood transfusion rate, postoperative morbidity, major morbidity, and 90-day mortality after LLS, LH, and RH were 209.5, 302, and 426 minutes; 2.1%, 13.4%, and 13.0%; 3.2%, 20%, and 47.1%; 0%, 7.1%, and 10.5%; 11.1%, 20%, and 50%; 0%, 7.1%, and 20%; and 0%, 0%, and 0%, respectively. CONCLUSIONS: This study established the first global benchmark outcomes for L-LR in a large-scale international patient cohort. It provides an up-to-date reference regarding the "best achievable" results for L-LR for which centers adopting L-LR can use as a comparison to enable an objective assessment of performance gaps and learning curves.

Utility of the Iwate difficulty scoring system for laparoscopic right posterior sectionectomy: do surgical outcomes differ for tumors in segments VI and VII?

INTRODUCTION: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. METHODS: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. RESULTS: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. CONCLUSION: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.

Efficacy and safety of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis: 3-year follow up results.

BACKGROUND/PURPOSE: Gastroparesis is a common but easily overlooked disease. Gastric peroral endoscopic myotomy (G-POEM) is one of the third-space endoscopy techniques to treat gastroparesis. In this study, we aimed to evaluate the efficacy and safety of G-POEM for patients with refractory gastroparesis. METHODS: Between December 2017 and 2020, we consecutively enrolled patients with gastroparesis who failed after the administration of several kinds of medication and repeated admission for nutritional support. All patients underwent gastric emptying scintigraphy and answered a questionnaire on Gastroparesis Cardinal Symptom Index (GCSI). Demographic data, endoscopic procedure, and post procedural outcome were analyzed. RESULTS: A total of 11 (9 women and 2 men) patients with refractory gastroparesis (nine with diabetes mellitus, one systemic lupus erythematosus, and one idiopathic) were enrolled. The mean (±standard deviation (SD)) procedure time was 61.82 (±18.99) min with technical and clinical success rates of 100% and 81.82%, respectively. A statistically significant improvement was observed in the clinical severity (mean GCSI score 36.00 vs. 14.73, p < 0.0001) and gastric emptying time (mean T1/2 341.92 vs. 65.92 min, p = 0.016) after G-POEM. Hospital stay was 7.18 (±4.49) days without mortality. Complications included 4 (36.36%) patients with self-limited postprocedural abdominal pain and 3 (27.27%) patients with intra-procedural pneumoperitoneum. During the mean follow-up period of 554.36 days, one (9.09%) patient had relapsed clinical symptoms after 6 months. CONCLUSION: G-POEM is an efficient and safe pylorus-directed endoscopic therapy for refractory gastroparesis with promising results.

Peroral endoscopic tumor resection (POET) with preserved mucosa technique for management of upper gastrointestinal tract subepithelial tumors.

BACKGROUND: Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal. METHODS: Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient's request were enrolled. Demographic, endoscopic and pathological data were analyzed retrospectively. RESULTS: Totally 18 esophageal (mean ± SD age, 55.23 ± 4.15 year-old, 38.89% female) and 30 gastric (52.65 ± 2.43 year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (± SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (± 7.89)/11.86 (± 5.67) and 12.57 (± 6.25)/12.35 (± 5.73) mm, 14.86 (± 6.15) and 38.21 (± 15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (± 0.21) and 4.17 (± 0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (± 4.12) months. CONCLUSIONS: POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20 mm. Long term data are warranted to validate these results.

Repetitively hypoxic preconditioning attenuates ischemia/reperfusion-induced liver dysfunction through upregulation of hypoxia-induced factor-1 alpha-dependent mitochondrial Bcl-xl in rat.

Repetitive hypoxic preconditioning (HP) enforces protective effects to subsequently severe hypoxic/ischemic stress. We hypothesized that HP may provide protection against ischemia/reperfusion (I/R) injury in rat livers via hypoxia-induced factor-1 alpha (HIF-1α)/reactive oxygen species (ROS)-dependent defensive mechanisms. Female Wistar rats were exposed to hypoxia (15 h/day) in a hypobaric hypoxic chamber (5500 m) for HP induction, whereas the others were kept in sea level. These rats were subjected to 45 min of hepatic ischemia by portal vein occlusion followed by 6 h of reperfusion. We evaluated HIF-1α in nuclear extracts, MnSOD, CuZnSOD, catalase, Bad/Bcl-xL/caspase 3/poly-(ADP-ribose)-polymerase (PARP), mitochondrial Bcl-xL, and cytosolic cytochrome C expression with Western blot and nitroblue tetrazolium/3-nitrotyrosine stain. Kupffer cell infiltration and terminal deoxynucleotidyl transferase-mediated nick-end labeling method apoptosis were determined by immunocytochemistry. The ROS value from liver surface and bile was detected by an ultrasensitive chemiluminescence-amplification method. Hepatic function was assessed with plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. HP increased nuclear translocation of HIF-1α and enhanced Bcl-xL, MnSOD, CuZnSOD, and catalase protein expression in a time-dependent manner. The response of HP enhanced hepatic HIF-1α, and Bcl-xL expression was abrogated by a HIF-1α inhibitor YC-1. Hepatic I/R increased ROS levels, myeloperoxidase activity, Kupffer cell infiltration, ALT and AST levels associated with the enhancement of cytosolic Bad translocation to mitochondria, release of cytochrome C to cytosol, and activation of caspase 3/PARP-mediated apoptosis. HP significantly ameliorated hepatic I/R-enhanced oxidative stress, apoptosis, and mitochondrial and hepatic dysfunction. In summary, HP enhances HIF-1α/ROS-dependent cascades to upregulate mitochondrial Bcl-xL protein expression and to confer protection against I/R injury in the livers.

Rhodium-catalyzed cyclization of acceptor-substituted biphenyl α-diazoketones: a study of the substitution effect on chemoselectivity.

A range of biphenyl α-diazoketones containing various electron-withdrawing groups (EWG = COCH3, CN, CO2Et, COPh, SO2CH3, SO2Ph) on diazo carbon has been investigated for rhodium(ii)-catalyzed intramolecular cyclization. Among which, the α-acetyl, carboxylate and cyano substituted substrates show markedly different selectivity between aromatic substitution and aromatic cycloaddition processes, affording phenanthrol and/or benz[α]azulenone products in varying ratios. The selectivity is mainly directed by α-substitutions, and is also possibly influenced by the substituents on the biphenyl ring. Moreover, high chemoselectivity for aromatic substitution over cycloaddition is observed for the α-benzoyl and sulfonyl substituted substrates. But in addition to phenanthrols, these reactions produce aromatic ketones and/or 1,2-diketones as unprecedented products obtained from diazo precursors. Mechanistic rationales are given in the report.

Survey Results of the Expert Meeting on Laparoscopic Living Donor Hepatectomy and Literature Review.

BACKGROUND: Because laparoscopic donor surgery has been successful in pediatric living donor liver transplantation, its application is expanding to right hepatectomy. However, there is no consensus on the indications for laparoscopic donor hepatectomy or on the details of the surgical technique. OBJECTIVE: To evaluate the current status of laparoscopic donor hepatectomy and to summarize the expert opinion on it. METHODS: Before the expert meeting on September 8, 2016, in Seoul, Korea, a survey was undertaken from expert liver surgeons from around the world. RESULTS: Fifteen of 17 (88.2%) surgeons responded to the survey. The selection criteria for laparoscopic donor surgery are stricter than for open surgery in terms of the anatomy, remnant liver volume, and recipient's condition. There is no consensus on the instruments or equipment used. A literature review of laparoscopic donor hepatectomy showed that the use of this method is increasing and the short-term outcomes are similar to those of open surgery. CONCLUSIONS: This survey and literature review show that laparoscopic donor hepatectomy is performed by experienced surgeons in selected cases, and that its incidence is increasing worldwide.

Expert Panel Statement on Laparoscopic Living Donor Hepatectomy.

BACKGROUND: With improvements in living donor liver transplantation (LDLT) techniques and the increased experience of surgeons in laparoscopic major liver resection, laparoscopic donor hepatectomy is performed increasingly. Therefore, expert opinion on this procedure is required. OBJECTIVE: The study aimed to report the current status and summarize the expert opinion on laparoscopic donor hepatectomy. METHODS: An expert consensus meeting was held on September 8, 2016, in Seoul, Korea. RESULTS: Laparoscopic donor left lateral sectionectomy could be considered the standard practice in pediatric LDLT. In adult LDLT, laparoscopy-assisted donor hepatectomy or left hepatectomy is potentially the next need, requiring more evidence for becoming standard practice. Laparoscopic donor right hepatectomy is still in the developmental stage, and more supporting evidence is required. Waving the cost consideration, the robotic approach could be a valid alternative for the suitable approaches of laparoscopy. CONCLUSIONS: Laparoscopic donor hepatectomy is increasing its role in both pediatric and adult LDLT. However, for major donor hepatectomy, more evidence is needed.

Catechins Blunt the Effects of oxLDL and its Primary Metabolite Phosphatidylcholine Hydroperoxide on Endothelial Dysfunction Through Inhibition of Oxidative Stress and Restoration of eNOS in Rats.

BACKGROUND/AIMS: We explored the effects of catechins (decaffeinated green tea extracts containing (-)-epicatechin, (-)-epigallocatechin, (-)-epicatechin gallate and (-)-epigallocatechin gallate) on atherosclerosis risk factors, oxidized low-density lipoprotein (oxLDL) and its primary metabolite, phosphatidylcholine hydroperoxide (PCOOH) induced oxidative injury in cultured endothelial cell line and rats. METHODS: We used endothelial cell line and male Wistar rats to determine the effect of catechins on oxLDL or PCOOH induced oxidative injury including apoptosis, H2O2 level, vascular responses and urinary 8-isoprostane and nitrite/nitrate concentration. Plasma catechins concentration was determined by a CoulArray HPLC. Responses of aortic and renal vasoconstriction were evaluated by a transonic meter and a full-field laser perfusion imager. RESULTS: PCOOH administration significantly increased H2O2 amounts and cell apoptosis and decreased endothelial nitric oxide synthase (eNOS) expression in the cultured endothelial cells. Catechins pretreatment significantly reduced PCOOH-elevated H2O2 amounts, endothelial cell apoptosis and partly recovered eNOS expression. Intravenous administration of oxLDL, PCOOH or H2O2, not native LDL, significantly decreased renal and aortic blood flow associated with enhanced ICAM-1 expression and 4-hydroxynoneal (4-HNE) accumulation, and decreased eNOS expression in the male Wistrar rats. One hour after oral intake of green tea extracts, 4 peaks of catechins were found in the rat plasma. The increased plasma catechins significantly inhibited oxLDL-, PCOOH- or H2O2-induced renal and aortic vasoconstriction, decreased urinary 8-isoprostane levels, renal ICAM-1 expression and 4-HNE accumulation, and restored nitrite/nitrate amounts and eNOS activity. CONCLUSIONS: Our data suggests that catechins pretreatment decrease PCOOH-induced endothelial apoptosis and arterial vasoconstriction through the action of H2O2 inhibition and eNOS restoration.

Graft calcification caused by a torsion of the hepatic vein after a living-related donor liver transplantation.

 The torsion of vessels after liver transplantation rarely occurs. Likewise, calcification of a liver graft has seldom been reported. This report details a case which had torsion of the left hepatic vein on the seventh day after living-related donor liver transplantation. The torsion was reduced soon after re-exploration; however, congestion with partial necrosis of the graft occurred. On the follow-up imaging studies, some resolution of necrosis and graft regeneration were found, yet geographic calcification of the liver graft appeared.The patient died of pneumonia after 13 weeks, post-operation. The avoidance such torsion of vessels is necessary and important.

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka.

The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.

De novo cancer avoidance after renal transplantation: A case-control study on low-dose sirolimus combined with a calcineurin inhibitor.

BACKGROUND/PURPOSE: Full-dose sirolimus (SRL) therapy without a calcineurin inhibitor (CNI) reduces the incidence of malignancy after renal transplantation, but with significant side effects. We hypothesized that de novo therapy with low-dose SRL combined with a CNI could still prevent cancer in renal transplant recipients. METHODS: A retrospective case-control study was performed to assess the cancer incidence among renal transplant patients who had undergone surgery in our transplant centers between January 2000 and June 2012. Patients who received low-dose SRL and a CNI (SRL group, n = 189) were compared with patients receiving conventional CNI-based therapy in the same hospitals (Conventional group, n = 271). RESULTS: The 5-year graft and patient survival rates were comparable between the two groups. Seven patients in the SRL group and 24 patients in the Conventional group developed malignancies during mean follow-up periods of 68.2 ± 37.5 months and 81.7 ± 51.4 months, respectively. The cancer incidence at 5 years was significantly lower in the SRL group (1.9%), than that in the Conventional group (6.7%; p = 0.04). By multivariate analyses, SRL therapy (p = 0.04), male sex (p = 0.04), and younger age (p = 0.01) were significantly associated with a lower risk of malignancy after kidney transplantation. CONCLUSION: De novo therapy with low-dose SRL combined with a CNI was associated with reduced risk of post-transplant cancer in renal transplant recipients. De novo cancer prevention using a low-dose proliferation signal inhibitor such as SRL could be effective for renal transplant recipients.

Effect of Adenoviral Catalase Gene Transfer on Renal Ischemia/Reperfusion Injury in Rats.

Ischemia/reperfusion (I/R) may through overt H2O2-induced pathophysiologic mechanisms lead to renal dysfunction. We explore whether catalase (CAT) protein overexpression by adenoviral CAT gene (Adv-CAT) transfection may improve ischemia/reperfusion-induced renal dysfunction. We augmented renal CAT expression by intrarenal arterial Adv-CAT administration with renal venous clamping in avertin-anesthetized female Wistar rats. After Adv-CAT transfection, we examined the CAT expression, location and effects on blood urea nitrogen (BUN) and urinary tubular injury biomarkers by biochemical assays, microcirculation by a laser perfusion imager, renal H2O2 amount by a chemiluminescent analyzer and molecular mechanisms including cytosolic cytochrome C leakage, apoptosis, autophagy and phospho- Akt (p-Akt)/phospho-endothelial nitric oxide (p-eNOS)/nitric oxide (NO) signaling by western blotting, immunohistochemistry and immunofluorescence. Adv-CAT enhanced 2.6-fold renal CAT protein expression primarily located in the proximal and distal tubules and renal vessels. Ischemia/reperfusion increased cytosolic cytochrome C leakage, renal H2O2-dependent level, autophagic Beclin-1/Atg5-Atg12/LC3 II expression, apoptotic Bax/Bcl-2/caspase 3/poly-(ADP-ribose)-polymerase fragments (PARP) expression and terminal deoxynucleotidyl transferasemediated nick-end labeling (TUNEL) stains and BUN and urinary glutathione S-transferase (GST) levels leading to proximal tubular injury. Ischemia/reperfusion also decreased renal microvascular blood flow associated with the inhibited renal expression of p-Akt and p-eNOS and NO production. Adv-CAT significantly improved the reduction in renal microvascular blood flow, reduced ischemia/reperfusion-enhanced oxidative stress, Beclin-1/Atg5-Atg12/LC3 II-meidated autophagy, Bax/Bcl-2/caspase 3/PARP-mediated apoptotic signaling, TUNEL stains, urinary GST level, and restored the p-Akt/p-eNOS/NO signaling in the kidney. Treatment of phosphatidylinositol 3-kinase inhibitors, wortmannin and LY294002, deleted Adv-CAT-induced p-Akt/p-eNOS/NO protective signaling. In conclusion, our results suggest Adv-CAT gene transfer counteracts H2O2-induced ischemia/reperfusion injury through preserving p-Akt/p-eNOS/NO pathway in the rat kidney.

Increased age and the volume of intraoperative fluid administered predict urinary retention after elective inguinal herniorrhaphy.

BACKGROUND: Inguinal hernia repair (IHR) is a common surgical procedure worldwide. Although IHR can be performed by the minimally invasive method, which accelerates recovery, postoperative urinary retention (POUR) remains a common complication that significantly impacts patients. Thus, it is essential to identify the risk factors associated with POUR to diminish its negative impact. METHODS: We conducted a single-center retrospective review of elective IHR from 2018 to 2021. POUR was defined as the postoperative use of straight catheter or placement of an indwelling catheter to relieve the symptoms. Adjusted multivariate regression analysis was performed to address the associations of clinicodemographic, surgical, and intraoperative factors with POUR. RESULTS: A total of 946 subjects were included in the analysis after excluding cases of emergent surgery, recurrent hernia, or concomitant operations. The median age was 68.4 years, and 92.0% of the patients were male. Twenty-three (2.4%) patients developed POUR. In univariate analysis, POUR in comparison with non-POUR was significantly associated with increased age (72.2 versus 68.3 years, P = 0.012), a greater volume of intraoperative fluid administered (500 versus 400 ml, P = 0.040), and the diagnosis with benign prostate hypertrophy (34.8% versus 16.9%, P = 0.025). In the multivariate model, both increased age (odds ratio [OR] 1.04, 95% CI 1.01-1.08; P = 0.049) and a greater volume of intraoperative fluid administered (OR 1.12 per 100-mL increase, 95% CI 1.01-1.27; P = 0.047) were significantly associated with the occurrence of POUR. CONCLUSIONS: We found that increased age and a greater volume of intraoperative fluid administered were significantly associated with the occurrence of POUR. Limiting the administration of intraoperative fluid may prevent POUR. From the perspective of practical implications, specific guidelines or clinical pathways should be implemented for fluid management and patient assessment.

Precise mapping of hilar cholangiocarcinoma with a skip lesion by SpyGlass cholangioscopy: A case report.

BACKGROUND: Cholangiocarcinoma (CC) is a very aggressive cancer with a poor prognosis. As surgery is the only curative therapy, preoperative evaluation of the tumor extent is essential for surgical planning. Although high-quality image modalities such as computed tomography and magnetic resonance imaging have been used extensively in preoperative evaluation, the accuracy is low. To obtain precise localization of tumor spread arising from the hilar region preoperatively, the development of an acceptable imaging modality is still an unmet need. CASE SUMMARY: A 52-year-old female presented to our emergency department with jaundice, abdominal pain, and fever. Initially, she was treated for cholangitis. Endoscopic retrograde cholangiopancreatography with the cholangiogram showed long segment filling defect in the common hepatic duct with dilatation of bilateral intrahepatic ducts. Transpapillary biopsy was performed, and the pathology suggested intraductal papillary neoplasm with high-grade dysplasia. After treatment of cholangitis, contrasted-enhanced computed tomography revealed a hilar lesion with undetermined Bismuth-Corlette classification. SpyGlass cholangioscopy showed that the lesion involved the confluence of the common hepatic duct with one skip lesion in the posterior branch of the right intrahepatic duct, which was not detected by previous image modalities. The surgical plan was modified from extended left hepatectomy to extended right hepatectomy. The final diagnosis was hilar CC, pT2aN0M0. The patient has remained disease-free for more than 3 years. CONCLUSION: SpyGlass cholangioscopy may have a role in precision localization of hilar CC to provide surgeons with more information before the operation.

Systematic review and meta-analysis of difficulty scoring systems for laparoscopic and robotic liver resections.

INTRODUCTION: The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR. METHODS: We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR. RESULTS: A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris [IMM], and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS. CONCLUSION: The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases.

Background: The use of laparoscopic (LLR) and robotic liver resections (RLR) has been safely performed in many institutions for liver tumours. A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours ≥10 cm. Methods: This was a retrospective review of 971 patients who underwent LLR and RLR for huge (≥10 cm) tumors at 42 international centers between 2002-2020. Results: One hundred RLR and 699 LLR which met study criteria were included. The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching (PSM) (73 vs. 219). Before PSM, LLR was associated with significantly increased frequency of previous abdominal surgery, malignant pathology, liver cirrhosis and increased median blood. After PSM, RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time (242 vs. 290 min, P=0.286), transfusion rate rate (19.2% vs. 16.9%, P=0.652), median blood loss (200 vs. 300 mL, P=0.694), open conversion rate (8.2% vs. 11.0%, P=0.519), morbidity (28.8% vs. 21.9%, P=0.221), major morbidity (4.1% vs. 9.6%, P=0.152), mortality and postoperative length of stay (6 vs. 6 days, P=0.435). Conclusions: RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes. There was no significant difference in perioperative outcomes after RLR or LLR.