Perioperative outcomes of robot-assisted pancreatoduodenectomy (PD) and totally laparoscopic PD after overcoming learning curves with comparison of oncologic outcomes between open PD and minimally invasive PD.

Backgrounds/Aims: Minimally invasive pancreatoduodenectomy (MIPD), such as totally laparoscopic pancreatoduodenectomy (TLPD) or robot-assisted pancreatoduodenectomy (RAPD), is increasingly performed worldwide. This study aimed to compare the perioperative outcomes of TLPD and RAPD, and compare the oncologic outcomes between MIPD and open pancreatoduodenectomy (OPD) for malignant disease. Methods: This retrospective study was conducted at two hospitals that followed similar oncological surgical principles, including the extent of resection. RAPD was performed at Seoul National University Hospital, and TLPD at Seoul National University Bundang Hospital. Patient demographics, perioperative outcomes, and oncological outcomes were analyzed. Propensity score matching (PSM) analysis was performed to compare oncologic outcomes between MIPD and OPD. Results: Between 2015 and 2020, 332 RAPD and 178 TLPD were performed. The rates of Clavian-Dindo grade ≥ 3 complications (19.3% vs. 20.2%, p = 0.816), clinically relevant postoperative pancreatic fistula (9.9% vs. 11.8%, p = 0.647), and open conversions (6.6% vs. 10.5%, p = 0.163) were comparable between the two groups. The mean operation time (341 minutes vs. 414 minutes, p < 0.001) and postoperative hospital stay were shorter in the RAPD group (11 days vs. 14 days, p = 0.034). After PSM, the 5-year overall survival rate was comparable between MIPD and OPD for overall malignant disease (58.4% vs. 55.5%, p = 0.180). Conclusions: Both RAPD and TLPD are safe and feasible, and MIPD has clinical outcomes that are comparable to those of OPD. Although RAPD exhibits some advantages, its perioperative outcomes are similar to those associated with TLPD. A surgical method may be selected based on the convenience of surgical movements, medical costs, and operator experience.

SARS-CoV-2 detection in COVID-19 patients' sample using Wooden quoit conformation structural aptamer (WQCSA)-Based electronic bio-sensing system.

The COVID-19 epidemic and its continuous spread pose a serious threat to public health. Coronavirus strains known as SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) variants have undergone genomic changes. The severity of the symptoms, the efficiency of vaccinations, and the transmission capacity of the virus can be impacted by these alterations. Point-of-care diagnostic assays can identify particular genetic or protein sequences that are exclusive to each variety. Currently, ultrafast, responsive, and accurate antibody detection faces several challenges. Here, we outline the fabrication, implementation, and sensing performance benchmarking of an ultrafast (5 s) and inexpensive (0.15 USD) assay with label-free sensing of SARS-CoV-2 S (Spike)/N (Nucleocapsid) protein and other variants in real patient samples. A label-free DNA aptameric capacitive bio-sensing device was used to detect SARS-CoV-2 variants. Our novel, cutting-edge bio-sensing device contains a Wooden quoits conformation structural aptamer (WQCSA)-based inter-digitated capacitor electronic (WQCSA-IDCE) system. WQCSA-aptamer was used as a switch-turn on response to achieve ultrasensitivity in the variable area of the SARS-CoV-2. The molecular beacon (MB) method was also used to measure the fluorescently colored SARS-CoV-2 S/N protein. These sensors can be used with several types of label-free DNA aptamers to act as rapid, affordable, and label-free biosensors for a variety of critical acute respiratory virus syndrome disorders.

Laparoscopic versus open liver resection for huge hepatocellular carcinoma (≥ than 10 cm): a retrospective analysis from a high-volume referral center.

BACKGROUND: There is still poor evidence about the safety and feasibility of laparoscopic liver resection (LLR) for huge (> 10 cm) hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long-term outcomes of LLR versus open liver resection (OLR) for patients with huge HCC from real-life data from consecutive patients. METHODS: Data regarding all consecutive patients undergoing liver resection for huge HCC were retrospectively collected from a Korean referral HPB center. Primary outcomes were the postoperative results, while secondary outcomes were the oncologic survivals. RESULTS: Sixty-three patients were included in the study: 46 undergoing OLR and 17 LLR. Regarding postoperative outcomes, there were no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications, and R1 resection rates. After a median follow-up of 48.4 (95% CI 8.9-86.8) months, there were no statistically significant differences in 3 years OS (59.3 ± 8.7 months vs. 85.2 ± 9.8 months) and 5 years OS (31.1 ± 9 months vs. 73.1 ± 14.1 months), after OLR and LLR, respectively (p = 0.10). Similarly, there was not a statistically significant difference in both 3 years DFS (23.5% ± 8.1 months vs. 51.6 ± months) and 5 years DFS (15.7 ± 7.1 months vs. 38.7 ± 15.3 months), respectively (p = 0.13), despite a potential clinically significant difference. CONCLUSION: LLR for huge HCC may be safe and effective in selected cases. Further studies with larger sample size and more appropriate design are needed to confirm these results.

The Cross-Sectional Area Ratio of Right-to-Left Portal Vein Predicts the Effect of Preoperative Right Portal Vein Embolization.

Background and Objectives: Preoperative right portal vein embolization (RPVE) is often attempted before right hepatectomy for liver tumors to increase the future remnant liver volume (FRLV). Although many factors affecting FRLV have been discussed, few studies have focused on the ratio of the cross-sectional area of the right portal vein to that of the left portal vein (RPVA/LPVA). The aim of the present study was to evaluate the effect of RPVA/LPVA on predicting FRLV increase after RPVE. Materials and Methods: The data of 65 patients who had undergone RPVE to increase FRLV between 2004 and 2021 were investigated retrospectively. Using computed tomography scans, we measured the total liver volume (TLV), FRLV, the proportion of FRLV relative to TLV (FRLV%), the increase in FRLV% (ΔFRLV%), and RPVA/LPVA twice, immediately before and 2-3 weeks after RPVE; we analyzed the correlations among those variables, and determined prognostic factors for sufficient ΔFRLV%. Results: Fifty-four patients underwent hepatectomy. Based on the cut-off value of RPVA/LPVA, the patients were divided into low (RPVA/LPVA ≤ 1.20, N = 30) and high groups (RPVA/LPVA > 1.20, N = 35). The ΔFRLV% was significantly greater in the high group than in the low group (9.52% and 15.34%, respectively, p < 0.001). In a multivariable analysis, RPVA/LPVA (HR = 20.368, p < 0.001) was the most significant prognostic factor for sufficient ΔFRLV%. Conclusions: RPVE was more effective in patients with higher RPVA/LPVA, which is an easily accessible predictive factor for sufficient ΔFRLV%.

Harmonizing Definitions and Perspectives in Extreme Liver Surgery: A Delphi Experts Consensus.

OBJECTIVE: To propose to our community a common language about extreme liver surgery. BACKGROUND: The lack of a clear definition of extreme liver surgery prevents convincing comparisons of results among centers. METHODS: We used a two-round Delphi methodology to quantify consensus among liver surgery experts. For inclusion in the final recommendations, we established a consensus when the positive responses (agree and totally agree) exceeded 70%. The study steering group summarized and reported the recommendations. In general, a five-point Likert scale with a neutral central value was used, and in a few cases multiple choices. Results are displayed as numbers and percentages. RESULTS: A two-round Delphi study was completed by 38 expert surgeons in complex hepatobiliary surgery. The surgeon´s median age was 58 years old (52-63) and the median years of experience was 25 years (20-31). For the proposed definitions of total vascular occlusion, hepatic flow occlusion and inferior vein occlusion, the degree of agreement was 97%, 81% and 84%, respectively. In situ approach (64%) was the preferred, followed by ante situ (22%) and ex situ (14%). Autologous or cadaveric graft for hepatic artery or hepatic vein repair were the most recommended (89%). The use of veno-venous bypass or portocaval shunt revealed the divergence depending on the case. Overall, 75% of the experts agreed with the proposed definition for extreme liver surgery. CONCLUSION: Obtaining a consensus on the definition of extreme liver surgery is essential to guarantee the correct management of patients with highly complex hepatobiliary oncological disease. The management of candidates for extreme liver surgery involves comprehensive care ranging from adequate patient selection to the appropriate surgical strategy.

Cost-effectiveness of open versus laparoscopic pancreatectomy: A nationwide, population-based study.

BACKGROUND: Laparoscopic pancreatic resection is comparable to open pancreatic resection; however, cost-effectiveness analyses of laparoscopic pancreatic resection are scarce. The authors performed a population-based study investigating the cost-effectiveness of laparoscopic pancreatic resection versus open pancreatic resection. METHODS: Data from 9,256 patients who received pancreaticoduodenectomy (66.8%) and distal pancreatectomy (33.2%) from 2016 to 2018 were retrieved from the Korean National Health Insurance Service. Events after pancreatectomy were categorized as no complication, complication, and death. Probabilities of each event and average cost during index admission and 1 year were utilized to calculate incremental cost-effectiveness ratio, the cost difference between two interventions divided by quality-adjusted life year. Quality-adjusted life year, a function of length and quality of life, was measured with utility values determined by researching literature. RESULTS: Laparoscopic pancreatic resection was performed in 12.4% of pancreaticoduodenectomies and 53.4% of distal pancreatectomies. For pancreaticoduodenectomy, laparoscopic pancreatic resection was associated with an increase of 0.0022 quality-adjusted life years for index admission and 0.0023 quality-adjusted life years for 1 year compared with open pancreatic resection. The incremental cost was $321 for index admission and -$1,414 for 1 year, leading to an incremental cost-effectiveness ratio of $147,429 per quality-adjusted life year gained for index admission and -$614,965 per quality-adjusted life year gained for 1 year. For distal pancreatectomy, laparoscopic pancreatic resection improved 0.0131 quality-adjusted life years for index admission and 0.0285 quality-adjusted life years for index admission. The incremental cost was -$1,240 for index admission and -$5,875 for 1 year, leading to an incremental cost-effectiveness ratio of -$94,519 per quality-adjusted life year gained for index admission and -$206,351 for 1 year. CONCLUSION: laparoscopic pancreatic resection was a cost-effective alternative to open pancreatic resection for pancreaticoduodenectomy and distal pancreatectomy, except for the higher cost of index admission for pancreaticoduodenectomy.

Microscopic tumor mapping of post-neoadjuvant therapy pancreatic cancer specimens to predict post-surgical recurrence: A prospective cohort study.

BACKGROUND: Although various pathological grading systems are available for evaluating the response of pancreatic ductal adenocarcinoma (PDAC) to neoadjuvant therapy (NAT), their prognostic value has not been thoroughly validated. This study examined whether microscopic tumor mapping of post-NAT specimens could predict tumor recurrence. METHODS: This prospective study enrolled 52 patients who underwent pancreaticoduodenectomy after NAT for PDAC between 2019 and 2021. Microscopic mapping was performed to identify residual tumor loci within the tumor bed using 4 mm2 pixels. Patients were divided into small extent (SE; n = 26) and large extent (LE; n = 26) groups using a cutoff value of 226 mm2. The diagnostic performance for predicting tumor recurrence was evaluated using receiver operating characteristic (ROC) curves. RESULTS: Carbohydrate antigen 19-9 levels were normalised after NAT in more patients in the SE group (SE 21 [80.8%] vs. LE 13 [50.0%]; P = 0.041). Tumor size (P < 0.001), T stage (P < 0.001), positive lymph node yield (P = 0.024), and perineural invasion rate (P = 0.018) were significantly greater in the LE group. The 3-year disease-free survival rate was significantly lower in the LE group (SE 83.3% vs. LE 50.0%, P = 0.004). The area under the ROC curve for mapping extent was 0.743, which was greater than that of the other tumor response scoring systems. CONCLUSIONS: Microscopic tumor mapping of the residual tumor in post-NAT specimens is a significant predictor of post-surgical recurrence, and offers better prognostic performance than the current grading systems.

Achieving Textbook Outcomes after Laparoscopic Resection in Posterosuperior Segments of the Liver: The Impact of the Learning Curve.

Achieving textbook outcomes (TOs) improves the short-term and long-term performance of a hospital. Our objective was to assess TOs in the laparoscopic liver resection (LLR) of tumors in the PS (posterosuperior) section of the liver and identify the impact of the learning curve. We conducted a retrospective cohort study analyzing patients who underwent LLR for lesions located in the PS segments. Patients were divided into a TO and no-TO group. TOs were defined as negative margins, no transfusion, no readmission, no major complications, no 30-day mortality, and a length of stay ≤ 50th percentile. Patients' outcomes were assessed in two study periods before and after 2015. TOs were achieved in 47.6% (n = 117). In multivariable analysis, obesity (p = 0.001), shorter operation time (p < 0.001), less blood loss (p < 0.001), normal albumin (p = 0.003), and minor resection (p = 0.046) were significantly associated with achieving TOs. Although the 5-year recurrence-free survival rate (p = 0.096) was not significantly different, the 5-year overall survival rate was significantly greater in the TO group (p = 0.001). Body mass index > 25 kg/m2 (p = 0.020), age > 65 years (p = 0.049), and achievement of TOs (p = 0.024) were independently associated with survival. The proportion of patients who achieved a TO was higher after 2015 than before 2015 (52.3% vs. 36.1%; p = 0.022). TOs are important markers not only for assessing hospital and surgeon performance but also as predictors of overall survival. As the number of surgeons who achieve the learning curve increases, the number of patients with TOs will gradually increase with a subsequent improvement in overall survival.

Laparoscopic anatomic vs. nonanatomic liver resection for large hepatocellular carcinoma (≥5 cm) in the right lobe.

OBJECTIVE: To determine the impacts and outcomes of laparoscopic anatomic liver resection (LAR) and laparoscopic nonanatomic resection (LNAR) in patients with large hepatocellular carcinoma (HCC) in the right lobe of the liver. BACKGROUND: There are few comparative studies of LAR and LNAR for large HCC. METHOD: Three hundred thirty-seven patients underwent liver resection for large HCC (≥5 cm) at Seoul National University Bundang Hospital, Seoul, Korea, between January 2004 and December 2022. After the exclusion of patients treated with open hepatic resection and those who had left-lobe or bilobar tumors, 94 patients were ultimately included. Patients were divided into LAR group (61 patients) and LNAR group (33 patients). After propensity score matching (PSM) with 1:1 matching, 31 patients were included in each group. The outcomes in the two groups were compared. RESULTS: LAR group had longer operative time than LNAR group (333.7 ± 113.7 vs 210 ± 117.6 min, respectively, P < 0.001), wider safety margin (1.4 ± 1.5 vs 0.7 ± 0.7 cm, respectively, P = 0.015), and lower incidence of recurrence (25.8% vs. 54.8%, respectively, P = 0.021). CONCLUSION: LAR required longer operative time, achieved wider safety margin, and had lower incidence of recurrence than LNAR.

Clinical outcomes of minimally invasive (laparoscopic and robotic) versus open extended cholecystectomy: A multicenter propensity score matched study.

BACKGROUND: This multicenter study aimed to compare the clinical outcomes of minimally invasive extended cholecystectomy (MI-EC) versus open EC (O-EC) for patients with gallbladder cancer (GBC). METHODS: Patients who underwent EC (cholecystectomy, wedge resection of the liver bed, and regional lymphadenectomy) for GBC between 2010 and 2020 in three centers were included in the study. The clinicopathological data were compared after propensity score matching. Additional subgroup analysis on laparoscopic and robotic EC (L-EC and R-EC) was performed. RESULTS: A total of 377 patients were included: 308 for O-EC and 69 for MI-EC, respectively. The MI-EC group had a longer operative time (188.9 vs. 238.1 min, p < .001) and shorter hospital stay (9.0 vs. 7.2 days, p = .007), although no differences were found in operative blood loss, complication rate and survival outcome. In subgroup analysis, L-EC patients had a longer operative time (264.4 vs. 202.0 min, p = .001), compared to R-EC patients with comparable perioperative and survival outcomes. CONCLUSION: Although patients with MI-EC had a longer operation time and higher medical costs, the advantages were enhanced recovery with comparable short- and long-term outcomes. The operation time was less for R-EC patients than for L-EC patients, though the high cost still remains. The surgery type for EC can be selected according to the patient's condition, social status and surgeon's preference.

Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis.

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.

A Prospective Analysis of the Effects of a Powder-Type Hemostatic Agent on the Short-Term Outcomes after Liver Resection.

Background and Objectives: Postoperative bleeding is a significant cause of morbidity and mortality following liver resection. Therefore, it is crucial to minimize bleeding during liver resection and effectively manage it when it occurs. Arista® AH (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) is a microporous polysaccharide hemosphere (MPH), a new plant-derived polysaccharide powder hemostat that can be applied to the entire surgical field. This study prospectively assessed the effectiveness of Arista for bleeding control when applied intraoperatively to the liver resection surface. Materials and Methods: Data were collected at Seoul National University Bundang Hospital for patients who underwent liver resection owing to malignant hepatocellular carcinoma or benign liver diseases. We compared the outcomes between 45 patients managed with Arista® AH (data were prospectively collected between September 2022 and May 2023) and 156 patients managed without the use of Arista® AH (data were retrospectively collected between January 2021 and December 2021). Results: There were no significant differences in patient characteristics between the two groups. The estimated blood loss (EBL) was significantly lower in the Arista® AH group compared with the control group (495.56 ± 672.7 mL vs. 691.9 ± 777.5 mL, p = 0.049). The mean postoperative hospital stay was significantly shorter in the Arista® AH group (5.93 ± 1.88 days vs. 6.94 ± 4.17 days, p = 0.024). The time to Jackson-Pratt drain removal was also significantly shorter in the Arista® AH group (4.64 ± 1.31 days vs. 5.30 ± 2.87 days, p = 0.030). The patient subgroup was divided into four categories based on the type of resection and the presence or absence of cirrhosis. Within the subgroup of major resections in non-cirrhotic patients, the Arista® AH group demonstrated significantly better outcomes compared to the control group, showed lower EBL, reduced need for blood transfusions, decreased volume of drain fluid collected within 48 h, earlier removal of drains, and shorter hospital stays. In contrast, for the other subgroups such as minor resection (both non-cirrhotic and cirrhotic) and major resection with cirrhosis, the differences between the Arista® AH and control groups in various parameters like EBL, blood transfusion rates, drain fluid volume, time to drain removal, and duration of hospital stay were not statistically significant. Conclusions: Arista® AH significantly improved intraoperative blood management and postoperative recovery in patients undergoing liver resection, particularly in non-cirrhotic patients who underwent major resection.

International consensus guidelines on robotic pancreatic surgery in 2023.

Background: With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS. Methods: World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline. Results: After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence. Conclusions: The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

Multiregional analysis of combined hepatocellular-cholangiocarcinoma reveals histologic diversity and molecular clonality.

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare type of liver tumour that exhibits both hepatocytic and biliary differentiation within the same tumour. The histology and genomic alterations of recurrent/metastatic cHCC-CC are poorly understood. We selected six patients with cHCC-CC whose recurrent or metastatic tumours were histologically confirmed. Four patients with classic cHCC-CCs and two with intermediate cell carcinomas (ICs) were included. The clinicopathological features were evaluated, and next-generation sequencing was performed in 17 multiregional and longitudinal tumour samples. The histology of recurrent/metastatic lesions of classic cHCC-CCs was variable: hepatocellular carcinoma (HCC) was observed in one (25.0%) patient, cHCC-CC in one (25.0%) patient, and cholangiocarcinoma (CC) in two (50.0%) patients. Among 13 samples from four classic cHCC-CC patients, the most frequent pathological variants were TP53 (46.2%), TERT promoter (38.5%), ARID1A mutations (23.1%), and MET amplification (30.8%). In the sequencing analysis of each HCC and CC component, three (75.0%) of the four classic cHCC-CCs shared pathogenic variants. A large proportion of mutations, both pathogenic and those of undetermined significance, were shared by each HCC and CC component. Regarding ICs, the ATM mutation was detected in one patient. In conclusion, the histology of recurrent/metastatic cHCC-CCs was heterogeneous. Genomic profiling of classic cHCC-CCs revealed similar genomic alterations to those of HCC. Considerable overlapping genomic alterations in each HCC and CC component were observed, suggesting a monoclonal origin. Genetic alterations in ICs were different from those in either HCC or CC, suggesting the distinct nature of this tumour.

Laparoscopic versus open liver resection for multiple hepatocellular carcinoma within and beyond the Milan criteria: An Eastern-Western propensity score-matched analysis.

BACKGROUND: There is still little knowledge about the outcomes of laparoscopic liver resection (LLR) for multiple hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC within and beyond the Milan criteria, and in both BCLC-A and -B stage. METHODS: Data regarding all consecutive patients undergoing liver resection for multiple HCC were retrospectively collected from Asian (South Korean) and European (Italian) referral HPB centers. The cases were propensity-score matched for age, BMI, center, extent of the resection, postero-superior location of the lesion, underlying liver condition, BCLB staging and the Milan criteria. RESULTS: A total of 203 patients were included in the study: 27% of patients had undergone hemi-hepatectomy, 26.6% atypical resections, 20.6% sectionectomy and 16.2% segmentectomy. After PSM two cohorts of 57 patients were obtained, with no significant differences in all preoperative characteristics. The length of hospital stay was significantly lower after LLR (median 7 vs. 9 days, p < .01), with no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications and R1 resection rates. After a median follow-up of 61 (±7) months, there were no significant differences between OLR and LLR in both median OS (69 vs. 59 months, p = .74, respectively) and median DFS (12 vs. 10 months, p = .48, respectively). CONCLUSION: LLR for multiple HCC can be safe and effective in selected cases and is able to shorten median hospital stay without affecting perioperative and long-term oncological outcomes.

Evolution of laparoscopic liver resection in the last two decades: lessons from 2000 cases at a referral Korean center.

BACKGROUND AND AIMS: Laparoscopic liver resection (LLR) has evolved to become the standard surgical approach in many referral centers worldwide. The aim of this study was to analyze how LLR evolved at a single high-volume referral center since its introduction, more than two decades ago. METHODS: Data from all consecutive LLR between January 2003 and September 2022 at the Seoul National University Bundang Hospital were analyzed. Perioperative outcomes were compared between three time periods, with major technological innovations considered as landmarks: before introduction of laparoscopic-US and CUSA (2003-2006), before (2006-2015) and after (2015-2022) introduction of high-definition scope. RESULTS: During the analyzed time periods the number of technically challenging procedures increased from 39.2 to 61.1% (p < 0.001). The most recent period showed shorter median operation time (from 267.5' to 175', p < 0.001), lower median estimated blood loss (EBL) (from 500 to 300 ml, p < 0.001), lower intraoperative transfusions (from 33.8 to 9.3%, p < 0.001), shorter median postoperative hospital stay (from 12 to 6 days, p < 0.001). The time period, a technical major resection and an underlying liver cirrhosis were found to be the associated with longer operation time (p < 0.001) in the multivariable linear regression analysis, while tumor size, technically major surgeries and liver cirrhosis were associated with higher EBL (p < 0.001). CONCLUSION: During the last two decades, the indications for patients undergoing LLR have expanded significantly, including more and more challenging procedures and frail patients. Despite such challenges, perioperative outcomes improved, although technically major procedures, cirrhotic patients and huge tumors have still to be considered challenging situations.

Robotic and laparoscopic right lobe living donation compared to the open approach: A multicenter study on 1194 donor hepatectomies.

Due to the success of minimally invasive liver surgery, laparoscopic and robotic minimally invasive donor hepatectomies (MIDH) are increasingly performed worldwide. We conducted a retrospective, multicentre, propensity score-matched analysis on right lobe MIDH by comparing the robotic, laparoscopic, and open approaches to assess the feasibility, safety, and early outcomes of MIDHs. From January 2016 until December 2020, 1194 donors underwent a right donor hepatectomy performed with a robotic (n = 92), laparoscopic (n = 306), and open approach (n = 796) at 6 high-volume centers. Donor and recipients were matched for different variables using propensity score matching (1:1:2). Donor outcomes were recorded, and postoperative pain was measured through a visual analog scale. Recipients' outcomes were also analyzed. Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery, respectively. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time (493 ± 96 min) compared to laparoscopic and open procedures (347 ± 120 and 358 ± 95 min; p < 0.001) but were associated with reduced donor blood losses ( p < 0.001). No differences were observed in overall and major complications (≥ IIIa). Robotic hepatectomy donors had significantly less pain compared to the 2 other groups ( p < 0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. No differences were observed in terms of postoperative complications, and recipients' survival was similar ( p =0.455). In very few high-volume centers, robotic right lobe procurement has shown to be a safe procedure. Despite an increased operative and the first warm ischemia times, this approach is associated with reduced intraoperative blood losses and pain compared to the laparoscopic and open approaches. Further data are needed to confirm it as a valuable option for the laparoscopic approach in MIDH.

Analysis of Recent Improvement of Survival Outcomes in Patients with Pancreatic Cancer Who Underwent Upfront Surgery.

Background/Aims: : Recently, patients with pancreatic cancer (PC) who underwent resection have exhibited improved survival outcomes, but comprehensive analysis is limited. We analyzed the trends of contributing factors. Methods: : Data of patients with resected PC were retrospectively collected from the Korean Health Insurance Review and Assessment Service (HIRA) database and separately at our institution. Cox regression analysis was conducted with the data from our institution a survival prediction score was calculated using the ß coefficients. Results: : Comparison between the periods 2013-2015 (n=3,255) and 2016-2018 (n=3,698) revealed a difference in the median overall survival (25.9 months vs not reached, p<0.001) when analyzed with the HIRA database which was similar to our single-center data (2013-2015 [n=119] vs 2016-2018 [n=148], 20.9 months vs 32.2 months, p=0.003). Multivariable analyses revealed six factors significantly associated with better OS, and the scores were as follows: age >70 years, 1; elevated carbohydrate antigen 19-9 at diagnosis, 1; R1 resection, 1; stage N1 and N2, 1 and 3, respectively; no adjuvant treatment, 2; FOLFIRINOX or gemcitabine plus nab-paclitaxel after recurrence, 4; and other chemotherapy or supportive care only after recurrence, 5. The rate of R0 resection (69.7% vs 80.4%), use of adjuvant treatment (63.0% vs 74.3%), and utilization of FOLFIRINOX or gemcitabine plus nab-paclitaxel (25.2% vs 47.3%) as palliative chemotherapeutic regimen, all increased between the two time periods, resulting in decreased total survival prediction score (mean: 7.32 vs 6.18, p=0.004). Conclusions: : Strict selection of surgical candidates, more use of adjuvant treatment, and adoption of the latest combination regimens for palliative chemotherapy after recurrence were identified as factors of recent improvement.

Laparoscopic anatomical versus non-anatomical liver resection for hepatocellular carcinoma in the posterosuperior segments: a propensity score matched analysis.

Background: Since laparoscopic anatomical resection (LAR) for tumors, especially located in the posterosuperior (PS) segments of the liver remains difficult, laparoscopic non-anatomical resection (LNAR) are generally preferred. To compare the clinical outcomes between LAR and LNAR for hepatocellular carcinoma (HCC) located in the PS segments. Methods: We retrospectively reviewed the data for 1,029 patients who underwent hepatectomy for HCC between 2004 and 2019. Of 167 patients who underwent laparoscopic hepatectomy for HCC in PS segments, 64 underwent LNAR and 103 underwent LAR. Patients were matched one-to-one using propensity score matching (46:46). Results: LNAR was associated with significantly shorter operation time (P=0.001), lower estimated blood loss (P=0.001), lower transfusion rate (P=0.006) and shorter hospital stay (P=0.012) than LAR. The respective 1- ,3-, and 5-year overall survival rates (LAR: 95.3%, 87.1%, and 77.8%; LNAR: 96.7%, 91.6%, and 85.0%; P=0.262) and recurrence-free survival rates (LAR: 75.7%, 70.3%, and 68.9%; LNAR: 81.8%, 58.3%, and 55.3%; P=0.879) were similar. The intrahepatic recurrence rate was significantly higher in LNAR group than in LAR group (78.6% vs. 57.1%, P=0.023), but the post-recurrence treatments differed significantly between the two groups (P=0.016); the re-resection rate was much greater in the LNAR group (45.0% vs. 0%) group. The respective 1-, 3-, and 5-year post-recurrence survival rates were similar in the LAR and LNAR groups (P=0.212). After recurrence, survival in re-resection group was significantly greater than not (P=0.026). Conclusions: LNAR is safe and feasible for HCC located in PS segments, and provided acceptable oncologic outcomes that are comparable to those of LAR. LNAR can be considered for patient with tumor located in PS segment when LAR is not feasible.

Intra-arterial lipo-prostaglandin E1 infusion for arterial spasm in liver transplantation: A case report.

BACKGROUND: Hepatic artery obstruction is a critical consideration in graft outcomes after living donor liver transplantation. We report a case of diffuse arterial vasospasm that developed immediately after anastomosis and was managed with an intra-arterial infusion of lipo-prostaglandin E1 (PGE1). CASE SUMMARY: A 57-year-old male with hepatitis B virus-related liver cirrhosis and hepatocellular carcinoma underwent ABO-incompatible living donor liver transplant. The grafted hepatic artery was first anastomosed to the recipient's right hepatic artery stump. However, the arterial pulse immediately weakened. Although a new anastomosis was performed using the right gastroepiploic artery, the patient's arterial pulse rate remained poor. We attempted angiographic intervention immediately after the operation; it showed diffuse arterial vasospasms like 'beads on a string'. We attempted continuous infusion of lipo-PGE1 overnight via an intra-arterial catheter. The next day, arterial flow improved without any spasms or strictures. The patient had no additional arterial complications or related sequelae at the time of writing, 1-year post-liver transplantation. CONCLUSION: Angiographic evaluation is helpful in cases of repetitive arterial obstruction, and intra-arterial infusion of lipo-PGE1 may be effective in treating diffuse arterial spasms.