Laparoscopically Limited Anatomic Liver Resections: A Single-Center Analysis for Oncologic Outcomes of the Conceptual Procedure.

BACKGROUND: Limited anatomic resections (LARs), such as segmentectomies, performed using a fully laparoscopic approach, have gained popularity for liver malignancies. However, the oncologic efficacy of laparoscopic LARs (Lap-LARs) needs further investigation. This cohort study evaluated the oncologic outcomes of Lap-LAR for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). METHODS: At a Japanese referral center, 112 patients underwent Lap-LAR using the Glissonean approach and indocyanine green (ICG) fluorescence navigation. Recurrence-free survival (RFS), overall survival (OS), time to interventional failure (TIF), and time to surgical failure (TSF) were assessed. RESULTS: Among the 112 patients (median age, 74 years [range, 66-80 years]; 80 men [71.4 %]), Lap-LAR showed promising results. The median operative time was 348 min (range, 280-460 min), and the median blood loss was 190 mL (range, 95.5-452.0 mL). The median error between the estimated and actual liver volumes was 2 % (1.2-4.8 %). Complications greater than Clavien-Dindo 3a were observed in 11.6 % of the patients. The 5-year RFS, OS, and TIF rates for HCC were 45.1 % ± 7.9 %, 73.1 % ± 6.7 %, and 74.2 % ± 6 .6 %, respectively. The 5-year RFS, OS, and TSF rates for CRLM were 36.8 % ± 8.7 %, 60.1 % ± 13.3 %, and 63.6 % ± 10.4 %, respectively. CONCLUSIONS: Lap-LAR showed favorable oncologic outcomes for HCC and CRLM. Its precise technique makes it a promising therapeutic option for liver malignancies. Further comparisons with conventional approaches are warranted.

Anatomic versus non-anatomic resection for early-stage intrahepatic cholangiocarcinoma: a propensity score matching and stabilized inverse probability of treatment weighting analysis.

BACKGROUND: Radical resection is still the most cost-effectiveness curative strategy for intrahepatic cholangiocarcinoma (ICC), but it remains controversial on the survival benefit of anatomic resection (AR). In this study, we sought to compare the oncologic outcomes between AR versus non-AR (NAR) as the primary treatment for early-stage ICC patients. METHODS: Data of ICC patients who underwent hepatectomy and staged at AJCC I were retrospectively collected from 12 hepatobiliary centers in China between Dec 2012 and Dec 2015. Propensity score matching (PSM) and stabilized inverse probability of treatment weighting (IPTW) analysis were performed to minimize the effect of potential confounders, and the perioperative and long-term outcomes between AR and NAR groups were compared. RESULTS: Two hundred seventy-eight ICC patients staged at AJCC I were eligible for this study, including 126 patients receiving AR and 152 patients receiving NAR. Compared to the NAR group, the AR group experienced more intraoperative blood loss before and after PSM or stabilized IPTW (all P > 0.05); AR group also experienced more intraoperative transfusion after stabilized IPTW (P > 0.05). In terms of disease-free survival (DFS) and overall survival (OS), no significant differences were observed between the two groups before and after PSM or stabilized IPTW (all P > 0.05). Multivariable Cox regression analyses found that AR was not an independent prognostic factor for either DFS or OS (all P > 0.05). Further analysis also showed that the survival benefit of AR was not found in any subgroup stratified by Child-Pugh grade (A or B), cirrhosis (presence or absence), tumor diameter (≤ 5 cm or > 5 cm) and pathological type (mass-forming or non-mass-forming) with all P > 0.05. CONCLUSION: Surgical approach does not influence the prognosis of patients with stage I primary ICC, and NAR might be acceptable and oncological safety.

Clinical outcomes of parenchymal-sparing versus anatomic resection for colorectal liver metastases: a systematic review and meta-analysis.

BACKGROUND: The advantages of parenchymal-sparing resection (PSR) over anatomic resection (AR) of colorectal liver metastases (CRLM) remain controversial. Here, we aim to evaluate their safety and efficacy. METHODS: A systematic review and meta-analysis of short-term perioperative outcomes and long-term oncological outcomes for PSR and AR were performed by searching Pubmed, Embase, the Cochrane Library and Web of Science databases. RESULTS: Twenty-two studies were considered eligible (totally 7228 patients: AR, n = 3154 (43.6%) vs. PSR, n = 4074 (56.4%)). Overall survival (OS, HR = 1.08, 95% CI: 0.95-1.22, P = 0.245) and disease-free survival (DFS, HR = 1.09, 95% CI: 0.94-1.28, P = 0.259) were comparable between the two groups. There were no significant differences in 3-year OS, 5-year OS, 3-year DFS, 5-year DFS, 3-year liver recurrence-free survival (liver-RFS) and 5-year liver-RFS. In terms of perioperative outcome, patients undergoing AR surgery were associated with prolonged operation time (WMD = 51.48 min, 95% CI: 29.03-73.93, P < 0.001), higher amount of blood loss (WMD = 189.92 ml, 95% CI: 21.39-358.45, P = 0.027), increased intraoperative blood transfusion rate (RR = 2.24, 95% CI: 1.54-3.26, P < 0.001), prolonged hospital stay (WMD = 1.00 day, 95% CI: 0.34-1.67, P = 0.003), postoperative complications (RR = 2.28, 95% CI: 1.88-2.77, P < 0.001), and 90-day mortality (RR = 3.08, 95% CI: 1.88-5.03, P < 0.001). While PSR surgery was associated with positive resection margins (RR = 0.77, 95% CI: 0.61-0.97, P = 0.024), intrahepatic recurrence (RR = 0.90, 95% CI: 0.82-0.98, P = 0.021) and repeat hepatectomy (RR = 0.64, 95% CI: 0.55-0.76, P < 0.001). CONCLUSION: Considering relatively acceptable heterogeneity, PSR had better perioperative outcomes without compromising oncological long-term outcomes. However, these findings must be carefully interpreted, requiring more supporting evidence. TRIAL REGISTRATION: PROSPERO registration number: CRD42023445332.

Oncological outcomes of anatomic versus non-anatomic resections for small hepatocellular carcinoma: systematic review and meta-analysis of propensity-score matched studies.

BACKGROUND: Primary liver cancer is the second-most commonly occurring cancer and has resulted in numerous deaths worldwide. Hepatic resection is of two main types, i.e., anatomic resection (AR) and non-anatomic resection (NAR). The oncological outcomes of hepatocellular carcinoma (HCC) patients after AR and NAR are still considered controversial. Therefore, we aimed to compare the impact of AR and NAR on the oncological outcomes of HCC patients with tumor diameters ≤ 5 cm using the propensity score matching method and research-based evidence. METHOD: A systematic literature search was conducted. The main outcomes were disease-free survival (DFS), overall survival (OS), intrahepatic recurrence rate, and extrahepatic metastasis rate. Relative risk (RR) was calculated from forest plots and outcomes using random-effects model (REM). RESULT: AR significantly improved DFS at 1, 3. and 5 years after surgery, compared to NAR (RR = 1.09, 95% CI = 1.04-1.15, P = 0.0003; RR = 1.16, 95% CI = 1.07-1.27, P = 0.0005; RR = 1.29, 95% CI = 1.07-1.55, P = 0.008). However, both of the difference in DFS at 7 years and OS at 1 and 3 years after AR versus that after NAR were not statistically significant. Nevertheless, the long-term OS associated with AR (5, 7, and 10 years) was superior to that associated with NAR (RR = 1.12, 95% CI = 1.03-1.21, P = 0.01; RR = 1.19, 95% CI = 1.04-1.36, P = 0.01; RR = 1.18, 95% CI = 1.05-1.34, P = 0.008). The difference in the intrahepatic recurrence rate after AR versus that after NAR was not statistically significant, but the extrahepatic metastasis rate after AR was significantly lower than that observed after NAR (RR = 0.61, 95% CI = 0.40-0.94, P = 0.03). CONCLUSION: Therefore, AR should be the preferred surgical approach for HCC patients with tumor diameters ≤ 5 cm. TRIAL REGISTRATION: PROSPERO registration number CRD42022330596.

Single-port thoracoscopic anatomic resection for chronic inflammatory lung disease.

BACKGROUND: It is challenging to proceed thoracoscopic anatomic resection when encountering severe pleural adhesion or calcified peribronchial lymphadenopathy. Compared with multiple-port video-assisted thoracoscopic surgery (MP-VATS), how to overcome these challenges in single-port (SP-) VATS is still an intractable problem. In the present study, we reported the surgical results of chronic inflammatory lung disease and shared some useful SP-VATS techniques. METHODS: We retrospectively assessed the surgical results of chronic inflammatory lung disease, primarily bronchiectasis, and mycobacterial infection, at our institution between 2010 and 2018. The patients who underwent SP-VATS anatomic resection were compared with those who underwent MP-VATS procedures. We analyzed the baseline characteristics, perioperative data, and postoperative outcomes, and illustrated four special techniques depending on the situation: flexible hook electrocautery, hilum-first technique, application of Satinsky vascular clamp, and staged closure of bronchial stump method. RESULTS: We classified 170 consecutive patients undergoing thoracoscopic anatomic resection into SP and MP groups, which had significant between-group differences in operation time and overall complication rate (P = 0.037 and 0.018, respectively). Compared to the MP-VATS group, the operation time of SP-VATS was shorter, and the conversion rate of SP-VATS was relatively lower (3.1% vs. 10.5%, P = 0.135). The most common complication was prolonged air leakage (SP-VATS, 10.8%; MP-VATS, 2.9%, P = 0.045). CONCLUSIONS: For chronic inflammatory lung disease, certain surgical techniques render SP-VATS anatomic resection feasible and safe with a lower conversion rate.

[Segmentectomy in patients with primary pulmonary malignancies]. / Segmentéktomiia pri pervichnykh zlokachestvennykh opukholiakh legkikh.

OBJECTIVE: To analyze immediate and long-term results of anatomical resections for lung cancer with subsequent comparison of the results of segmentectomy and lobectomy in patients with peripheral NSCLC stage IA1-2. MATERIAL AND METHODS: There were 52 sublobular anatomical resections of the lung for peripheral non-small cell carcinoma and carcinoid T1a-bN0M0, IA1-2 stage. 3D-CT reconstruction with separation of bronchial and vascular structures was used to schedule complex segmentectomy. We retrospectively analyzed 200 patients with cT1a-bN0M0 peripheral non-small cell lung cancer (NSCLC) and tumor dimension ≤2 cm who underwent lobectomy (n=148) and segmentectomy (n=52). Mortality, morbidity and overall 5-year survival were compared in two propensity score matched groups (46 pairs, segmentectomy vs. lobectomy). RESULTS: There was no mortality in both groups. Morbidity was similar after segmentectomy and lobectomy (8.69 and 6.52%; p=0.32). 3D-CT with separation of bronchial and vascular structures enabled surgeons to perform atypical segmentectomies and VATS procedures more often (from 13.5 to 31.3%; p>0.05 and from 11.5 to 50.0%; p<0.05). Five-year survival was 82 and 86% (p=0.652) after segmentectomy and lobectomy, respectively. CONCLUSION: Postoperative results and long-term outcome after segmentectomy and lobectomy are comparable in patients with NSCLC cT1a-bN0M0, stage IA1-2. Segmentectomy is advisable surgery in patients with low pulmonary capacity and severe comorbidities.

Complete removal of the tumor-bearing portal territory decreases local tumor recurrence and improves disease-specific survival of patients with hepatocellular carcinoma.

BACKGROUND & AIMS: Anatomic resection (AR) of the tumor-bearing portal territory has been reported to be associated with a decreased recurrence of hepatocellular carcinoma (HCC). However, because of the heterogeneity of the study populations, its oncologic advantage remains controversial. The objective of the present study was to determine the clinical advantage of AR for primary HCC, based on the data from a large prospective cohort treated under a constant surgical policy. METHODS: In 209 Child-Pugh class A patients with primary, solitary HCC measuring ⩽5.0cm in diameter, which was resectable either by AR or limited resection (non-AR), the overall survival (OS) and disease-free survival (DFS) were compared with patients in whom complete AR was achieved and those who eventually ended up with non-AR after adjustment for the propensity scores to select AR. Advantages of AR in disease-specific survival and local recurrence were also evaluated by competing-risks regression to clarify the true oncologic impact of AR. RESULTS: The AR group showed better DFS than the non-AR group (HR, 0.67; 95% CI, 0.45-0.99; p=0.046), while no significant difference was observed in OS (hazard ratio [HR], 0.82; 95% CI, 0.46-1.48; p=0.511). Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.12; 95% CI, 0.05-0.30; p<0.001) and improves disease-specific survival (HR, 0.50; 95% CI, 0.28-0.90; p=0.020), while the other cause of death was highly influenced by patient age (>65years) (HR, 7.51; 95% CI, 2.16-26.04; p=0.002) and not associated with AR. CONCLUSION: Complete removal of tumor-bearing portal territory decreases the risk of local recurrence and death from HCC.

Robotic extrahepatic Glissonean pedicle approach for anatomic liver resection in the right liver: techniques and perioperative outcomes.

BACKGROUND: The Glissonean pedicle approach is one of the most popular methods of anatomic liver surgery. Liver surgeons have attempted to reproduce this method laparoscopically. In this study, we introduce our technique of the extrahepatic Glissonean approach for anatomic liver resections, using a robotic system, and report on short-term perioperative outcomes. METHODS: From December 2008 to July 2014, 10 patients underwent robotic anatomic liver resection in the right liver. The procedure is as follows: (1) mobilization of the liver and isolation and clamping of a selected Glissonean pedicle; (2) transection of the liver parenchyma using a rubber band retraction technique; (3) division of the Glissonean pedicle after full exposure, followed by completion of parenchymal transection. RESULTS: The median age of the patients was 52.50 (range 28-59) years, and seven were male. All patients had hepatocellular carcinoma. The types of resections performed were as follows: segmentectomy 6 (n = 1), segmentectomy of 4b + 5 ventral segments (n = 2), right posterior sectionectomy (n = 3), extended right hepatectomy (n = 1), extended right posterior sectionectomy (n = 2), and central bisectionectomy (n = 1). Only one case was converted to open surgery due to severe tumor adhesions on the diaphragm. The median operative time was 555 min (range 413-848), and the median estimated blood loss was 225 ml (range 30-700), with no perioperative transfusions. The overall complication rate was 70 % (grade I, 5; grade II, 1; grade III, 1; grade IV, 0). The median length of hospital stay postsurgery was 7 days (range 6-11). CONCLUSION: Robotic surgery allowed for successful anatomic liver resections via an extrahepatic Glissonean pedicle approach in the right liver and can be safely performed in selected patients.

Development and clinical usefulness of the liver hanging maneuver in various anatomical hepatectomy procedures.

PURPOSE: To assess the clinical application and usefulness of the liver hanging maneuver (LHM), proposed by Belghiti, for major hepatectomy, including its (1) historical development, (2) usefulness and application and (3) advantages and disadvantages, by reviewing the English literature published during the period 2001-2014. RESULTS: In major hepatic transection via the anterior approach, the deep area of transection around the vena cava is critical with regard to bleeding during right hemi-hepatectomy. Belghiti and other investigators identified avascular spaces that are devoid of short hepatic veins at the front of the vena cava and behind the liver. Forceps can be inserted into this space easily and then maneuvered to lift the liver using hanging tape. This procedure, termed LHM significantly reduces intraoperative blood loss and the transection time during right hemi-hepatectomy. LHM has been used in various anatomical hepatectomy procedures worldwide, including laparoscopic hepatectomy. The use of LHM markedly improves the amount of intraoperative blood loss, operative time and postoperative outcome. CONCLUSIONS: We conclude that the application of LHM is an important development in the field of liver surgery, although a further evaluation of its true impact on clinical outcomes is necessary.

When to anatomically excise a benign lung tumor-correspondence regarding the article: "large mesenchymal cystic and chondroid pulmonary hamartoma mimicking lung cancer: case report".

The decision of whether to perform a large anatomic resection for a lung mass that is not definitely malignant comes often forward in the everyday practice of the thoracic surgeon. The general characteristics of the tumor as well as of the patient and the instinct and experience of the surgeon are the ones that dictate the final choice. Such a decision was made in the case of a large pulmonary hamartoma where a right middle lobectomy was performed with the postoperative course justifying the surgeons' choice.

Complete anatomic segmentectomy shows improved oncologic outcomes compared to incomplete anatomic segmentectomy.

OBJECTIVES: To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures (incomplete anatomic segmentectomy). METHODS: We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence. RESULTS: Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy. CONCLUSIONS: This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.

Impact of preoperative radiation on survival of patients with T3N0 >7-cm non-small cell lung cancers treated with anatomic resection using the Surveillance, Epidemiology, and End Results database.

BACKGROUND: Very large non-small cell lung cancers (NSCLC) remain a therapeutic challenge. The objective of this study was to evaluate the effect of surgery in the presence and absence of neoadjuvant radiation (NRT) on survival of patients with T3N0 >7-cm NSCLCs. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients undergoing lobectomy or pneumonectomy for T3N0 NSCLC tumors >7 cm from 1999-2008. Patients were categorized into groups based on type of surgery performed and whether NRT was used. Five-year overall (OS) and lung cancer-specific survival (LCSS) were estimated by the Kaplan-Meier method and comparisons made using log-rank tests and Cox regression models. RESULTS: There were 1301 patients evaluated, including 1232 undergoing primary surgical therapy (PST) and 69 receiving NRT. NRT was not associated with improvements in 5-y OS (48% versus 41%, P = 0.062) or LCSS (59% versus 52%, P = 0.116) compared with PST. Lobectomies were associated with better 5-y OS (43% versus 33%; P = 0.006) and LCSS (54% versus 43%, P = 0.005) compared with pneumonectomies. On multivariate analysis, NRT did not produce any significant advantage in OS (P = 0.242) and LCSS (P = 0.208). Pneumonectomies were associated with significantly worse OS (hazard ratio, 1.32; P = 0.007) and LCSS (hazard ratio, 1.38; P = 0.005) when compared with lobectomies. CONCLUSIONS: NRT, which most likely was a combination of chemotherapy and radiation, was not associated with improvements in OS or LCSS in patients with T3N0 >7-cm NSCLC compared with PST. When feasible, lobectomy appears more beneficial than pneumonectomy in terms of long-term survival for very large tumors.

Intraoperative Catastrophes during Robotic Lung Resection: A Single-Center Experience and Review of the Literature.

BACKGROUND: Robotic surgery is increasingly used in the treatment of lung disease. Intraoperative catastrophes, despite their low incidence, are currently a critical aspect of this approach. This study aims to identify the incidence and management of catastrophic events in patients who underwent robotic anatomical pulmonary resection; (2) Methods: Data from all patients who underwent robotic anatomical pulmonary resection from 2014 to 2021 for lung disease were collected and analyzed. Catastrophic intraoperative events are defined as events that demanded emergency management for life-threatening bleeding, with or without undocking and thoracotomy; (3) Results: Catastrophic events occurred in seven (1.4%) procedures; all of them consisted of vascular damage during lobectomy. Most of the catastrophic events occurred during left upper lobectomies (57%). Patients in this group had a higher ASA class and a higher pathological stage compared to the control group; (4) Conclusions: Intraoperative catastrophes are unpredictable events which also occur in experienced surgical teams. Given the widespread use of robotic surgery, it is essential to develop well-defined crisis management strategies to better manage catastrophic events in robotic thoracic surgery and improve clinical outcomes.

Impact of anatomic resection on long-term survival in patients with hepatocellular carcinoma with T1-T2 disease or microscopic vascular invasion.

BACKGROUND: This study aimed to clarify potential candidates for anatomic resection (AR) among patients with pathological T1-T2 (pT1-T2) hepatocellular carcinoma (HCC) and to determine whether AR is effective for HCC with microscopic vascular invasion (MVI). METHODS: We retrospectively analyzed 288 patients with pT1a (n = 50), pT1b (n = 134) or pT2 (n = 104) HCC who underwent curative-intent resection between 1990 and 2010. Surgical outcomes were compared between patients who underwent AR (n = 189) and those who underwent nonanatomic resection (NAR; n = 99) according to pT category and MVI status. RESULTS: Patients who underwent AR were more likely to have good hepatic functional reserve and an aggressive primary tumor than those who underwent NAR. When patients were stratified according to pT category, AR had a more favorable impact on survival than NAR only in patients with pT2 HCC in univariate (5-year survival, 51.5% vs. 34.6%; p = 0.010) and multivariate analysis (hazard ratio 0.505; p = 0.014). However, AR had no impact on survival in patients with pT1a or pT1b HCC. In patients with MVI (n = 57), AR achieved better survival than NAR (5-year survival, 52.0% vs. 16.7%; p = 0.019) and was an independent prognostic factor (hazard ratio 0.335; p = 0.020). In patients without MVI (n = 231), there was no significant difference in survival between the two groups (p = 0.221). CONCLUSION: AR was identified as an independent factor in improved survival in patients with pT2 HCC or HCC with MVI.

Current Management of Carcinoid Tumor: When Is a Wedge Enough?

Bronchopulmonary carcinoid tumors are rare, well-differentiated neuroendocrine neoplasms. They can be categorized as typical or atypical lesions and are low-to-intermediate-grade, respectively. The cornerstone of therapy for carcinoid tumors is surgical resection and current consensus guidelines recommend anatomic resection for stage I to IIIA disease. The renewed interest in sublobar resections for the treatment of lung malignancies has sparked debate over the degree of resection necessary for these indolent lesions. Segmentectomy provides an oncologic resection while preserving as much lung parenchyma as possible, and is a reasonable approach to apply to small, undifferentiated, or typical carcinoid lesions.

Initial experience with robotic liver resection: Audit of 120 consecutive cases at a single center and comparison with open and laparoscopic approaches.

BACKGROUND/PURPOSE: Surgical outcomes and utility of robotic liver resection (RLR) are undefined. METHODS: We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n = 58) and anatomic (AR, n = 62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n = 103) were compared to those of open (OLR, n = 495) or laparoscopic (LLR, n = 451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR. RESULTS: Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR. CONCLUSIONS: RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.

Study of the Intersegmental Veins Between S5 and S8 Based on 3D Reconstruction.

BACKGROUND: Anatomic resection (AR) is a surgical method for treating hepatocellular carcinoma, and identifying intersegmental planes between segments 5 (S5) and 8 (S8) remains challenging. This study aims to find reliable intersegmental veins (IVs) between them as anatomical landmarks using 3D reconstruction analysis. METHODS: We retrospectively evaluated 57 patients who underwent multidetector-row CT scans from September 2021 to January 2023. The portal vein watershed of S5 and S8 and hepatic veins were reconstructed using 3D reconstruction analysis software. We counted and analyzed the IVs running within the intersegmental plane between S5 and S8, examined their features, and analyzed the location of the junctions between IVs and middle hepatic veins (MHVs). RESULTS: Among the 57 patients, 43 patients (75.4%) had IVs between S5 and S8. Most patients (81.4%) had a single IV joining the MHV, while 13.9% had two IVs, one joining the MHV and the other joining the right hepatic vein (RHV). The majority of IV-MHV junctions were found in the lower part of the MHVs. The most clearly identifiable junctions between the IVs and MHVs occurred slightly below the midpoint of the horizontal planes of the second hepatic portal and the center of the gallbladder bed. CONCLUSION: Our study identified IVs between S5 and S8 in the liver as potential anatomical landmarks during AR for hepatocellular carcinoma surgery. We found three types of IVs and provided insights on how to locate their junctions with MHVs for easier surgical navigation. However, individual anatomical variations must be considered, and preoperative 3D reconstruction and personalized surgical planning are crucial for success. More research with larger sample sizes is needed to validate our findings and establish the clinical significance of these IVs as landmarks for AR.

Landmarks to identify segmental borders of the liver: A review prepared for PAM-HBP expert consensus meeting 2021.

BACKGROUND: In preparation for the upcoming consensus meeting in Tokyo in 2021, this systematic review aimed to analyze the current available evidence regarding surgical anatomy of the liver, focusing on useful landmarks, strategies and technical tools to perform precise anatomic liver resection (ALR). METHODS: A systematic review was conducted on MEDLINE/PubMed for English articles and on Ichushi database for Japanese articles until September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS: A total of 3169 manuscripts were obtained, 1993 in English and 1176 in Japanese literature. Subsequently, 63 English and 20 Japanese articles were selected and reviewed. The quality assessment of comparative series and case series was revealed to be usually low; only six articles were qualified as high quality. Forty-two articles focused on analyzing intersegmental/sectional planes and their relationship with specific hepatic landmark veins. In 12 articles, the authors aimed to investigate liver surface anatomic structures, while 36 articles aimed to study technological tools and contrast agents for surgical segmentation during ALR. Although Couinaud's classification has remained the cornerstone in daily diagnostic/surgical practices, it does not always portray the realistic liver segmentation and there has been no standardization on which a single strategy should be followed to perform precise ALR. CONCLUSIONS: A global consensus should be pursued in order to establish clear guidelines and proper recommendations to perform ALR in the era of minimally invasive surgery.

Anatomic resection versus radiofrequency ablation with an ablative margin ≥ 1.0 cm for solitary small hepatocellular carcinoma measuring ≤ 3 cm: Comparison of long-term outcomes using propensity score matching analysis.

PURPOSE: To compare the long-term outcomes of anatomic resection (AR) and radiofrequency ablation (RFA) with an ablative margin (AM) of ≥ 1.0 cm as first-line treatment for solitary hepatocellular carcinoma measuring ≤ 3 cm. METHODS: Two hundred and fifty-one patients who underwent AR (n = 156) or RFA (ablative margin ≥ 1.0 cm, n = 95) at any of 6 tertiary hospitals from 2009 to 2018 were enrolled. Propensity score matched analysis (PSM) were used to compare overall survival (OS), recurrence-free survival (RFS), and perioperative outcomes. Univariate and multivariate analyses were performed to identify prognostic factors associated with RFS and OS. RESULTS: PSM created 67 patient-pairs. After 96 months of follow-up, RFA with an ablative margin ≥ 1.0 cm and AR showed comparable 1-year, 3-year, 5-year, and 8-year OS rates before (P = 0.580) and after (P = 0.640) PSM. However, RFS was better at 1, 3, 5, and 8 years after AR before (P = 0.0036) and after (P = 0.017) PSM. The operation time and postoperative hospital stay were significantly longer in the AR group than in the RFA group before and after PSM (P < 0.05). Multivariate analysis identified age and type of treatment to be independent prognostic factors for RFS and age and hepatitis C to be associated with OS. CONCLUSIONS: Long-term OS was not significantly different between AR and RFA with an AM ≥ 1.0 cm in patients with a solitary hepatocellular carcinoma measuring ≤ 3 cm; but, RFS appeared to be better after AR than after RFA. However, RFA was associated with fewer perioperative complications and a shorter postoperative hospital stay.

The efficacy of anatomic resection for hepatocellular carcinoma within Milan criteria: A retrospective single-institution case-matched study.

INTRODUCTION: Still now, the efficacy of anatomic resection (AR) for hepatocellular carcinoma (HCC) is controversial. The aim of this study is to examine it in our cohort and detect an optimal indicator for AR. METHODS: The present study included 656 patients with primary HCC within Milan criteria who underwent hepatectomy from 2000 to 2019. Our cohort was divided into AR (n = 378) and non-anatomic resection (NAR) (n = 278) groups, and 1:1 propensity score matching (PSM) was performed to minimize the effect of potential confounders. Recurrence-free survival (RFS), overall survival (OS), and a preoperative indicator for AR were examined. RESULTS: 210 patients from each group were well-matched, and preoperative confounding factors were balanced between the two groups. There was no significant difference in RFS and OS between the two groups before (RFS; HR = 0.89 P = 0.25, OS; HR = 1.08 P = 0.64) and after PSM (RFS; HR = 0.93 P = 0.60, OS; HR = 1.07 P = 0.75). Subgroup analysis showed that the survival improvement effect of AR was observed in cases with a fucosylated fraction of alfa-fetoprotein (AFP-L3) > 10% and poorly differentiation (P for interaction <0.05). Moreover, the logistic regression analysis showed that preoperative AFP-L3 > 10% was an independent predictor for poorly differentiation (OR = 2.58, P = 0.03). CONCLUSION: The efficacy of AR for patients with primary HCC within Milan criteria was not shown. But it was suggested that AFP-L3 > 10% might be a preoperative indicator of AR for HCC within Milan criteria.