Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Preoperative Endoscopic Ultrasound-Guided Hepaticogastrostomy for Definite Biliary Drainage in Hilar Cholangiocarcinoma Laparoscopic Resection: A Hybrid Minimal-Invasive Technique.

BACKGROUND AND STUDY AIMS: Laparoscopic approach of perihilar cholangiocarcinoma (PHC) is still challenging. We report the original use of a endoscopic hepaticogastrostomy (EHG) for definite biliary drainage in order to avoid biliary reconstruction. PATIENTS AND METHODS: A 70-year-old man presenting with jaundice was referred for resection of a Bismuth type IIIa PHC. Repeated endoscopic retrograde cholangiopancreatography failed to drain the future liver remnant, enabling only right anterior liver section drainage. EHG was performed three weeks before surgery. A hepatogastric anastomosis was created, placing a half-coated self-expanding endoprosthesis between biliary duct of segment 2 and the lesser gastric curvature. RESULTS: A laparoscopic right hepatectomy extended to segment 1, common bile duct, and hepatic pedicle lymphadenectomy was performed. The left hepatic duct was sectioned and ligated downstream to the biliary confluence of segment 2-3 and 4 allowing exclusive biliary flow through the EHG. The patient was disease free at 12 months, postoperative outcomes were uneventful except three readmissions for acute cholangitis due to prosthesis obstruction. CONCLUSIONS: EHG may be used as definite biliary drainage technique in laparoscopic PHC resection, at the expense of prosthesis obstruction and cholangitis.

Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis.

PURPOSE: The present study assessed the factors associated with the maintenance of a functional anastomosis in a large consecutive series of patients with anastomotic leakage (AL). METHODS: All consecutive patients presenting with AL after colorectal or coloanal anastomosis (2012-2019) were analyzed. The primary end point was a functional anastomosis without a stoma at 1 year. RESULTS: A total of 156 patients were included. AL was initially treated by antibiotics (38%), drainage (43%) or urgent surgery (19%). Initial treatment of AL was not adequate in 24.3%, and reintervention in the form of drainage or surgery was required. A total of 60.9% of patients had a functional anastomosis without a stoma 1 year after surgery. Factors associated with the risk of anastomotic failure at 1 year were diabetes (odds ratio [OR] = 4.24 [95% confidence interval {CI} 1.39-14.24] p = 0.014), neoadjuvant chemoradiotherapy (OR = 3.03 [95% CI 1.14-8.63] p = 0.03) and Grade B (OR = 6.49 [95% CI 2.23-21.74] p = 0.001) or C leak (OR = 35.35 [95% CI 9.36-168.21] p < 0.001). Among patients treated initially by drainage, side-to-end or J-pouch anastomoses were significantly associated with revision of the anastomosis compared to end-to-end (OR = 12.90, p = 0.04). CONCLUSION: After acute AL following coloanal or colorectal anastomosis, 60.9% of patients had a functional anastomosis without a stoma at the 1 year of follow-up. The type of treatment of AL influenced the risk of anastomotic failure.

Assessing textbook outcome after single large hepatocellular carcinoma resection.

BACKGROUND: This study aimed to investigate the impact and predictors of an ideal surgical care following SLHCC resection. METHODS: SLHCC patients who underwent LR in two tertiary hepatobiliary centers between 2000 and 2021 were retrieved from prospectively maintained databases. The quality of surgical care was measured by the textbook outcome (TO). Tumor burden was defined by the tumor burden score (TBS). Factors associated with TO were determined on multivariate analysis. The impact of TO on oncological outcomes was assessed using Cox regressions. RESULTS: Overall, 103 SLHCC patients were included. Laparoscopic approach was considered in 65 (63.1%) patients and 79 (76.7%) patients presented with moderate TBS. TO was achieved in 54 (52.4%) patients. Laparoscopic approach was independently associated with TO (OR 2.57; 95% CI 1.03-6.64; p = 0.045). Within 19 (6-38) months of median follow up, patients who achieved TO had better OS compared to non-TO patients (1-year OS: 91.7% vs. 66.9%; 5-year OS: 83.4% vs. 37.0%, p < 0.0001). On multivariate analysis, TO was independently associated with improved OS, especially in non-cirrhotic patients (HR 0.11; 95% CI 0.02-0.52, p = 0.005). CONCLUSIONS: TO achievement could be a relevant surrogate marker of improved oncological care following SLHCC resection in non-cirrhotic patients.

Feasibility and outcomes of multiple simultaneous laparoscopic liver resections.

INTRODUCTION: Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). METHODS: All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. RESULTS: During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p = 0.124), mean operative time was significantly longer in Group C (p = 0.039). Blood loss amount (p = 0.396) and conversion rate (p = 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p = 0.078). Achievement of TO was not different between groups (p = 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33-3.98)). CONCLUSION: Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.

Quality of oncological resection criteria in minimally invasive esophagectomy.

BACKGROUND: Even though minimally invasive esophageal surgery (MIE) is spreading, questions remain regarding its oncological outcomes. The aim of this study was to assess the quality of oncological resection criteria in MIE. METHODS: All patients undergoing a two-way Ivor Lewis esophagectomy for esophageal or junctional cancer between 2010 and 2020 in a single tertiary upper gastrointestinal surgery ward were analyzed retrospectively. The following oncological criteria were analyzed: lymph node (LN) harvest and location, positive lymph node rate, margins, and R0 rates. They were compared between the MIE group (thoracoscopy + laparoscopy) and the hybrid group (H/O, thoracotomy + laparoscopy). RESULTS: Among the 240 patients included, 34 (14%) had MIE and 206 a hybrid esophagectomy. Main surgical indication was lower thoracic adenocarcinoma and the rate of neoadjuvant treatments administered (chemotherapy or chemoradiotherapy) was comparable between both groups (p = 1.0). LN harvest was significantly higher in the MIE group (31 ± 9 vs. 28 ± 9, p = 0.04) as well as thoracic LN harvest (14 ± 7 vs. 11 ± 5, p = 0.002). When analyzing patients according to T stage and response to neoadjuvant treatments, patients with T1 and T2 tumors and patients with a poor pathological response (TRG3, 4, 5) had a significantly higher LN harvest when undergoing a minimally invasive approach (p = 0.021 and p = 0.01, respectively). Positive LN rates (1.26 ± 3.63 in the MIE group vs. 1.60 ± 2.84 in the H/O group, p = 0.061), R0 rates (97% vs. 98.5%, p = 0.46) as well as proximal (p = 0.083), distal (p = 0.063), and lateral (p = 0.15) margins were comparable between both approaches. CONCLUSION: MIE seems oncologically safe and may even be better than the open approach in terms of LN harvest especially in patients with T1 and T2 tumors and in poor responders.

Factors of Early Recurrence After Resection for Intrahepatic Cholangiocarcinoma.

BACKGROUND: Two-thirds of patients undergoing liver resection for intrahepatic cholangiocarcinoma experience recurrence after surgery. Our aim was to identify factors associated with early recurrence after resection for intrahepatic cholangiocarcinoma. METHODS: Patients with intrahepatic cholangiocarcinoma undergoing curative intent resection (complete resection and lymphadenectomy) were included in two centers between 2005 and 2021 and were divided into three groups: early recurrence (< 12 months after resection), delayed recurrence (> 12 months), and no recurrence. Patients experiencing early (< 90 days) postoperative mortality were excluded. RESULTS: Among 120 included patients, 44 (36.7%) experienced early recurrence, 24 (20.0%) experienced delayed recurrence, and 52 (43.3%) did not experience recurrence after a median follow-up of 59 months (IQR: 26-113). The median recurrence-free survival was 16 months (95% CI: 9.6-22.4). Median overall survival was 55 months (95% CI: 45.7-64.3), while it was 25 months for patients with early recurrence (p < 0.001). Patients with early recurrence had significantly larger tumors (59.1% of tumors > 70 mm in early vs. 58.3% in delayed vs. 26.9% in no recurrence group, p = 0.002), multiple lesions (65.9% vs. 29.2% vs. 11.5%, p < 0.001), and positive lymph nodes (N +) (38.6% vs. 37.5% vs. 11.5%, p = 0.005). In multivariable analysis, presence of multiple lesions (OR: 9.324; 95% CI: 3.051-28.489; p < 0.001) and positive lymph nodes (OR: 3.307. 95% CI: 1.001-11.011. p = 0.05) were associated with early recurrence. CONCLUSION: Early recurrence after curative resection of intrahepatic cholangiocarcinoma is frequent and is associated with the presence of multiple lesions and positive lymph nodes, raising the question of surgery's futility in this context.

Prognostic role of infracentimetric colorectal liver metastases.

BACKGROUND: The number of lesions and the size of the largest (CRLMmax) have been widely investigated as prognostic factors in patients with colorectal liver metastases (CRLM). The aim of the present study was to assess whether, in patients undergoing curative liver resection, the presence of infracentimetric lesions could affect recurrence-free survival (RFS) and overall survival (OS). METHODS: Patients who underwent a liver resection for CRLM between 2001 and 2019 were included. The size of CRLM was measured on the surgical specimen. The best cut-off of the smallest lesion (CRLMmin) associated with RFS was determined through the time-dependent ROC analysis. A multivariate Cox regression analysis was carried out. RESULTS: Overall, 227 patients were included. Median follow-up time was 50 months [IQR 26-84]. Recurrence occurred for 151 (66.5%) patients (liver recurrence in 67.5%, while exclusive extra-hepatic recurrence in 32.5%). The best cut-off for CRLMmin associated with RFS was 9 mm, with 12- and 24-month td-AUC 0.56 and 0.52 respectively. CRLMmin ≤ 9 mm was found to be an independent prognostic factor that impairs RFS at multivariate analysis (HR 1.534 (1.02-2.32), p = 0.042). In particular, CRLMmin ≤ 9 mm was correlated with impaired hepatic RFS (HR 1.860 (1.15-3.01), p = 0.011), but not extra-hepatic RFS. CONCLUSIONS: Infracentimetric metastases (≤ 9 mm) are an independent prognostic factor that impairs hepatic RFS. This result suggests the potential benefit of neoadjuvant chemotherapy (CT) also in selected patients with initially resectable lesions, in case of CRLM ≤ 9 mm on preoperative imaging.

Predictive ability of preoperative CT scan for the intraoperative difficulty and postoperative outcomes of laparoscopic liver resection.

BACKGROUND: The surgical difficulty and postoperative outcomes of laparoscopic liver resection (LLR) are related to the size of the cut liver surface. This study assessed whether the estimated parenchymal transection surface area could predict intraoperative difficulty and postoperative outcomes. METHODS: LLRs performed between 2008 and 2018, for whom a preoperative CT scan was available for 3D review, were included in the study. The area of scheduled parenchymal transection was measured on the preoperative CT scan and cut-off values that could predict intraoperative difficulty were analyzed. RESULTS: 152 patients who underwent left lateral sectionectomy (n = 27, median estimated area 30.1 cm2 [range 16.6-65.9]), left/right hepatectomy (n = 17 and n = 70, 76.8 cm2 [range 43.9-150.9] and 72.2 cm2 [range 39.4-124.9], respectively), right posterior sectionectomy (n = 7, 113.3 cm2 [range 102.1-136.3]), central hepatectomy (n = 11, 109.1 cm2 [range 66.1-186.1]) and extended left/right hepatectomy (n = 6 and n = 14, 115.3 cm2 [range 92.9-128.9] and 50.7 cm2 [range 13.3-74.9], respectively) were included. An estimated parenchymal transection surface area ≥ 100 cm2 was associated with significant increase in operative time (AUC 0.81, 95% CI [0.70, 0.93], p < 0.001) and estimated blood loss (AUC 0.92, 95% CI [0.86, 0.97], p < 0.001), as well as a higher conversion rate (22.2% vs. 4.0%, p < 0.001). Overall (p = 0.017) and major morbidity (p = 0.003), biliary leakage (p < 0.001) and pulmonary complications (p < 0.001) were significantly higher in patients with an estimated parenchymal transection surface area ≥ 100 cm2. CONCLUSIONS: An estimated parenchymal transection surface area ≥ 100 cm2 is a relevant indicator of surgical difficulty and postoperative complications in LLR.

Analysis of economic impact of laparoscopic liver resection according to surgical difficulty.

INTRODUCTION: The advantages of laparoscopic liver resection (LLR) are well known, but their financial costs are poorly evaluated. The aim of this study was to analyze the economic impact of surgical difficulty on LLR costs, and to identify clinical factors that most affect global charges. METHODS: All patients who underwent LLR from 2014 to 2018 in a single French center were included. The IMM classification was used to stratify surgical difficulty, from group I through group III. The costing method was done combining top-down and bottom-up approaches. A multivariate analysis was performed in order to identify clinical factors that most affect global charges. RESULTS: Two hundred seventy patients were included (Group I: n = 136 (50%), Group II: n = 60 (22%), Group III: n = 74 (28%)). Total expenses significantly increased (p < 0.001) from Group I to Group III, but there was no difference regarding financial income (p = 0.133). Technical platform expenses significantly increased (p < 0.001) from Group I to Group III and represented the main expense among all costs with a total of 4 930 ± 2 601€. Among technical platform expenses, the anesthesia platform represented the main expense. In multivariate analysis, the four clinical factors that affected global charges in the whole study population were operating time (p < 0.001), length of stay (p < 0.001), admission in ICU (p < 0.001) and the occurrence of major complication (p < 0.05). An admission in ICU was the clinical factor that affected most global charges, as an ICU stay had a 39.1% increase effect on global charges in the whole study population. CONCLUSION: LLR is a cost-effective procedure. The more complex is the LLR, the higher is the hospital cost. An admission in ICU was the clinical factor that most affected global charges.

What is the Best Therapeutic Strategy for Metachronous Resectable Colorectal Liver Metastases After Adjuvant Oxaliplatin-Based Chemotherapy? A Multidisciplinary Inter-Group Survey.

BACKGROUND: To report the current clinical practice of French physicians for metachronous resectable liver metastasis (LM) occurring after a FOLFOX adjuvant chemotherapy for primary cancer. METHODS: Twenty four clinical situations were proposed to a panel of experts via 4 learned societies. Clinical situations varied according time of recurrence (early between 6 and 12 month or > 12 month), extension of LM (limited ≤ 2 or extended > 2 lesions), presence of a neuropathy or not, and of a RAS or BRAF mutation. RESULTS: A total of 157 physicians participated in this study. A consensus was reached in 17 (71%) clinical situations. For an early limited recurrence, whatever presence of neuropathy, the preferred therapeutic approach (45%) was upfront surgery. For an early extended recurrence, whatever presence of neuropathy, there was a consensus (64%) for a preoperative chemotherapy by FOLFIRI + biologic agent. For a late recurrence without neuropathy, there was a consensus (50%) for a preoperative FOLFOX chemotherapy, whatever the extension of LM. For a late recurrence with neuropathy, upfront surgery was chosen (52%) for limited LM, and preoperative chemotherapy by FOLFIRI + biologic agent (73%) for extended LM. No response was influenced by the RAS mutation status. There was a strong consensus for intensified preoperative chemotherapy in all clinical situations for BRAF-mutated LM. CONCLUSIONS: This national survey provides an overview of the practice patterns in the treatment of LM occurring after adjuvant FOLFOX for primary. It could be a basis to establish expert's recommendations for the clinical practice.

Hepatic compartment syndrome, a rare complication after any liver insult or liver transplantation: Three case reports and literature review.

Hepatic compartment syndrome (HCS) is a rare but life-threatening entity that consists of a decreased portal flow due to intraparenchymal hypertension secondary to subcapsular liver hematoma. Lethal liver failure can be observed. We report three cases, and review the literature. A 54-year-old male was admitted for extensive hepatic subcapsular hematoma after blunt abdominal trauma. Initially, he underwent embolization of the hepatic artery's right branch, after which he presented clinical deterioration, major cytolysis (310 times the upper limit of normal [ULN]), and liver failure with a prothrombin time (PT) at 31.0%. A 56-year-old male underwent liver transplantation for acute alcoholic hepatitis. On postoperative day 2, he presented a hemorrhagic shock associated with deterioration of liver function (cytolysis 21 ULN, PT 39.0%) due to extensive hepatic subcapsular hematoma. A 59-year-old male presented a hepatic subcapsular hematoma five days after a cholecystectomy, revealed by abdominal pain with liver dysfunction (cytolysis 10 ULN, PT 63.0%). All patients ultimately underwent urgent surgery for liver capsule excision, hematoma evacuation, and liver packing, if needed. The international literature was screened for this entity. These three patients' outcomes were favorable, and all were alive at postoperative day 90. The literature review found 15 reported cases. HCS can occur after any direct or indirect liver trauma. Surgical decompression is the main treatment, and there is probably no place for arterial embolization, which may increase the risk of liver necrosis. A 13.3% mortality rate is reported. HCS is a rare complication of subcapsular liver hematoma that compresses the liver parenchyma, and leads to liver failure. Urgent surgical decompression is needed.

[Prophylactic surgery for hepatic and biliary tumors]. / Chirurgie prophylactique des tumeurs du foie et des voies biliaires.

Benign tumors of the liver and biliary tract are rare entities, and some of them require surgical management to prevent their malignant transformation. Tumors from the biliary tract with malignant potential are treated either by hepatic resection, for mucinous cystic neoplasm and ciliated hepatic foregut cysts, or by biliary resections, for biliary papillary neoplasm and type I and IV choledochal cysts. The pathologies requiring prophylactic cholecystectomy are polyps larger than 10 mm, porcelain gallbladder and pancreaticobiliary maljunction. Finally, hepatocellular adenoma over 5cm, occurring in male patients, or exon 3 mutated beta-catenin, should lead to prophylactic resection by hepatic segmentectomy. This article describes these different pathologies and their management.

Factors of oncological failure in two stage hepatectomy for colorectal liver metastases.

BACKGROUND: Two-stage hepatectomy (TSH) has increased the chance of surgical resections for bilobar colorectal liver metastases (CRLM). Nevertheless, drop-out between stages and early recurrence rates raise the question of surgical futility in some situations. This study aimed to identify factors of TSH oncological failure. METHODS: Patients with bilobar CRLM eligible for TSH in three tertiary centers between 2010 and 2021 were included, and divided in Failure and Success groups. Oncological failure was defined as failure of the second stage hepatectomy for tumor progression or recurrence within 6 months after resection. RESULTS: Among 95 patients, 18 (18.9%) had hepatic progression between the two stages, and 7 (7.4%) failed to complete the second stage hepatectomy. After TSH, 31 (32.6%) patients experienced early recurrence. Overall, 38 (40.0%) patients experienced oncological failure (Failure group). The Failure group had lower median DFS (3 vs. 32 months, p < 0.001) and median OS (29 vs. 70 months, p = 0.045) than the Success group. On multivariable analysis, progression between the two stages in the future liver remnant (OR = 15.0 (3.22-113.0), p = 0.002), and maximal tumor size ≥40 mm in the future liver remnant (OR = 13.1 (2.12-117.0), p = 0.009) were independent factors of oncological failure. CONCLUSION: Recurrence between the two stages and maximal tumor size ≥40 mm in the future liver remnant were associated with TSH failure for patients with bilobar CRLM.

Adaptative damping assistance in bimanual laparoscopic surgery.

PURPOSE: Laparoscopic surgery has demonstrated various advantages for the patients' care, but also presents some difficulties for the surgeons, such as kinematic restrictions. Robotic comanipulation, in which control of instruments is shared between the robot and the surgeon, can provide adaptative damping assistance which allows stabilisation of movements. The objective of the present study was to determine the contribution of this assistance on a bimanual laparoscopic task. METHODS: Adaptative damping was studied on Peg Transfer task, performed by eighteen surgery-naive subjects. This exercise was repeated seven times without (Classic repetitions) and seven times with comanipulated robots (Robot repetitions), in a randomised order. We measured task performance, using Peg Transfer score; gesture performance, using hand oscillations and travelled distance; eye-tracking movements as an indicator of emergence of expertise. Participants' perceived workload was assessed by NASA TLX questionnaire, and difference in impression between the two conditions by UEQ questionnaire. RESULTS: Adaptative damping improved gesture performance (oscillations F(1,17) = 23.473, p < 0.001, η2 = 0.580), with a statistically significant simple effect on the tool oscillation for both non-dominant (p < 0.001) and dominant hands (p = 0.005), without influencing task performance (mean Peg Transfer score t(17) = 0.920, p = 0.382, d = 0.29), but deteriorating eye-tracking movements associated with emergence of expertise (mean fixation rate per second F(1,17) = 6.318, p = 0.022, η2 = 0.271), at the cost of a high perceived workload (NASA TLX score 59.78/100). CONCLUSION: Assistance by adaptative damping applied by comanipulated robots improved gesture performance during a laparoscopic bimanual task, without impacting task's performance without allowing the emergence of comportments associated with an expertise, and at the cost of a high perceived workload. Further research should investigate this assistance on more precise and clinical tasks performed by professionals.

Current status and perspectives in the surgical and oncological management of intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor after hepatocellular carcinoma (HCC). Management depends on their resectability at the time of diagnosis. Two types can be distinguished by imaging: resectable ICCs amenable to surgery and locally advanced and/or metastatic ICCs, that are treated by chemotherapy, radiotherapy or loco-regional treatment (radioembolization, chemoembolization, intra-arterial chemotherapy and thermoablation). Over the last decade, the management strategy for these tumors has been modified by the appearance of loco-regional treatments as well as the introduction of immunotherapy that have shown their efficacy in the control of ICC. The aim of this review is to describe the current status of treatments for ICCs, as well as the different therapeutic strategies being assessed.

Intra-operative indocyanine green fluorescence imaging in hepatobiliary surgery: a narrative review of the literature as a useful guide for the surgeon.

INTRODUCTION: In hepatobiliary surgery, intra-operative indocyanine green (ICG) fluorescence imaging use started in the late 2000s with Japanese surgical teams and is now gaining popularity among surgeons all over the world to improve accuracy and safety of surgical procedures. However, even if ICG fluorescence has been shown to be a safe imaging modality, only a few clinical efficacity studies have been performed and no guidance has been established. This narrative review aims at assessing the potential applications of ICG fluorescence imaging in hepatobiliary surgery. METHODS: We screened the available international literature to identify the most used applications of ICG fluorescence imaging in hepatobiliary surgery. RESULTS: Three main fields were identified: biliary duct visualization, hepatic segments' delimitation, and liver tumor detection. Comments, application protocols, prospects, and limitations of each technique were described. DISCUSSION: These results could guide hepatobiliary surgeons in their use of ICG fluorescence imaging; nevertheless, further prospective studies are needed to assess the sensitivity and specificity of this modality.

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases.

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.