Debulking hepatectomy for colorectal liver metastasis: Analysis of risk factors for progression free survival.

BACKGROUND: The study explores the role of liver debulking surgery in cases of unresectable colorectal liver metastases (CRLM), challenging the traditional notion that surgery is not a valid option in such scenarios. MATERIALS AND METHODS: Patients with advanced but resectable disease who underwent surgery with a curative intent (Group I) and those with advanced incompletely resectable disease who underwent a "debulking" hepatectomy (Group II) were compared. RESULTS: There was no difference in the intra-operative and post-operative results between the two groups. The 3-year and 5-year OS rates were 69% and 47% for group 1 vs 64% and 35% for group 2 respectively (p = 0.14). The 3-year and 5-year PFS rates were 32% and 21% for group 1 vs 12% and 8% for group 2 respectively (p = 0.009). Independent predictors of PFS in the debulking group were bilobar metastases (HR = 2.70; p = 0.02); the presence of extrahepatic metastasis (HR = 2.65, p = 0.03) and the presence of more than 9 metastases (HR = 2.37; p = 0.04). Iterative liver surgery for CRLM was a significant protective factor (HR = 0.34, p = 0.04). CONCLUSION: An aggressive palliative surgical approach may offer a survival benefit for selected patients with unresectable CRLM, without increasing the morbidity. The decision for surgery should be made on a case-by-case basis.

Oncological Outcome After Laparoscopic 'No-touch' RAMPS Versus 'Touch' Left Pancreatectomy for Pancreatic Adenocarcinoma.

BACKGROUND/AIM: The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a "no-touch" technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aimed to evaluate the oncological outcomes of the laparoscopic "no touch" technique versus the "touch" technique. PATIENTS AND METHODS: From 2001 to 2020, we retrospectively analyzed 45 patients undergoing laparoscopic distal pancreatectomy (LDP) for PDAC in two centers. Factors associated with overall (OS), disease-free survival (DFS) and time to recurrence (TTR) were identified. RESULTS: The OS rates in the 'no-touch' and 'touch' groups were 95% vs. 78% (1-year OS); 50% vs. 50% (3-year OS), respectively (p=0.60). The DFS rates in the 'no-touch' and 'touch' groups were 72 % vs. 57% (1-year DFS); 32% vs. 28% (3-year DFS), respectively (p=0.11). The TTR rates in the 'no-touch' and 'touch' groups were 77% vs. 61% (1-year TTR); 54% vs. 30% (3-year TTR); 46% vs. 11% (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique [odds ratio (OR)=2.62, p=0.02] and lymphovascular emboli (OR=4.8; p=0.002). CONCLUSION: We advise the 'no-touch' technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the 'no-touch' technique in this setting although there could be oncological benefits.

Towards AI-driven longevity research: An overview.

While in the past technology has mostly been utilized to store information about the structural configuration of proteins and molecules for research and medical purposes, Artificial Intelligence is nowadays able to learn from the existing data how to predict and model properties and interactions, revealing important knowledge about complex biological processes, such as aging. Modern technologies, moreover, can rely on a broader set of information, including those derived from the next-generation sequencing (e.g., proteomics, lipidomics, and other omics), to understand the interactions between human body and the external environment. This is especially relevant as external factors have been shown to have a key role in aging. As the field of computational systems biology keeps improving and new biomarkers of aging are being developed, artificial intelligence promises to become a major ally of aging research.

Pure abdominal laparoscopic approach versus thoraco-abdominal laparoscopic approach: What is the best technique for liver resection in segment 7 and segment 8? An answer from the Institut Mutualiste Montsouris experience with short- and long-term outcome evaluation.

BACKGROUND: Lesions in segments 7 and 8 are a challenge during standard laparoscopic liver resection. The addition of transthoracic trocars could be useful in the standard abdominal approach for laparoscopic liver resection. We report our experience with a thoraco-abdominal laparoscopic combined approach for liver resection with the aim of comparing short- and long-term outcomes. METHODS: We reviewed 1,003 laparoscopic liver resections in a prospectively maintained, single-institution database. We compared patient outcomes intraoperatively and postoperatively. We analyzed the long-term outcomes of the colorectal liver metastasis subgroup. Propensity score matching 1:1 was performed based on the following variables: age, American Society of Anesthesiologists, body mass index, previous abdominal surgery, multiple or single liver resection, lesion >50 mm or <50 mm, presence of solitary or multiple lesions, T stage, and N stage. RESULTS: The standard abdominal approach was used in 110 laparoscopic liver resections, and the thoraco-abdominal laparoscopic combined approach was used in 62 laparoscopic liver resections. The thoraco-abdominal laparoscopic combined approach was associated with better intraoperative results (less blood loss and no need for conversion to open surgery). The R1s rate for segmentectomy 7 and 8 was lower in the thoraco-abdominal laparoscopic combined approach in the entire group and in the colorectal liver metastasis subgroup. In the colorectal liver metastasis subgroup, the 3- and 5-year overall survival was 90% and 80% in the thoraco-abdominal laparoscopic combined approach group and 76% and 52% in the standard abdominal approach group, respectively (P = .02). In univariate and multivariate analysis, the thoraco-abdominal laparoscopic combined approach was a significant factor that positively affected disease-free survival and overall survival. CONCLUSION: The thoraco-abdominal laparoscopic combined approach in laparoscopic liver resection in segments 7 and 8 is safe and feasible, and it has demonstrated better oncologic outcomes than the pure abdominal approach, especially in segmentectomy.

Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation.

BACKGROUND: The optimal in-hospital observation periods associated with minimal risks of complications and unplanned readmission after laparoscopic liver resection are unknown. The purpose of this study was to assess changes in the risks of postoperative complications over time. METHODS: Surgical complexity of laparoscopic liver resection was stratified into grades I (low complexity), II (intermediate), and III (high) using our 3-level complexity classification. The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication Clavien-Dindo grade ≥II (defined as treatment-requiring complications) were assessed. RESULTS: The cumulative incidence of treatment-requiring complications was higher in patients undergoing grade III resection than in patients undergoing grade I resection (32.3% vs 10.4%, P < .001) and grade II resection (32.3% vs 20.7%, P = .019). The conditional probability of postoperative complication stratified by our complexity classification decreased over time and was <10% for patients undergoing grade I resection on postoperative day 1, grade II resection on postoperative day 4, and grade III resection on postoperative day 10. CONCLUSION: The conditional cumulative incidence of treatment-requiring complications for patients undergoing laparoscopic liver resection is well stratified based on the 3-level complexity classification. Conditional complication risk analysis stratified by the 3 complexity grades may be useful for optimizing in-hospital observation after laparoscopic liver resection.

R1 Vascular or Parenchymal Margins: What Is the Impact after Resection of Intrahepatic Cholangiocarcinoma?

Background: to date, long-term outcomes of R1 vascular (R1vasc) and R1 parenchymal (R1par) resections in the setting of intrahepatic cholangiocarcinoma (iCCA) have been examined in only one study which did not find significant difference. Patients and Methods: we analyzed consecutive patients who underwent iCCA resection between 2000 and 2019 in two tertiary French medical centers. We report overall survival (OS) and disease-free-survival (DFS). Univariate and multivariate analyses were performed to determine associated factors. Results: 195 patients were analyzed. The number of R0, R1par and R1vasc patients was 128 (65.7%), 57 (29.2%) and 10 (5.1%), respectively. The 1- and 2-year OS rates in the R0, R1par and R1vasc groups were 83%, 87%, 57% and 69%, 75%, 45%, respectively (p = 0.30). The 1- and 2-year DFS rates in the R0, R1par and R1vasc groups were 58%, 50%, 30% and 43%, 28%, 10%, respectively (p = 0.019). Resection classification (HR 1.56; p = 0.003) was one of the independent predictors of DFS in multivariate analysis. Conclusions: the survival outcomes after R1par resection are intermediate to those after R0 or R1vasc resection. R1vasc resection should be avoided in patients with iCCA as it does not provide satisfactory oncological outcomes.

Number of hepatocellular carcinoma nodules in patients listed for liver transplantation within alpha-fetoprotein score: a new prognostic risk factor.

In France, the listing for liver transplantation (LT) for hepatocellular carcinoma (HCC) requires an AFP score ≤2. This study evaluates whether the number of nodules assessed immediately before LT has a prognostic value among patients already listed within AFP score. Among 143 recipients transplanted with an AFP score ≤2 between 2013 and 2017 in our center, the number of nodules was considered at listing on the waiting list and at last imaging before LT. We compared the overall survival (OS) and disease-free survival (DFS) post-LT of patients with ≤3 and >3 nodules (current classification), and aimed to propose a new criteria to exclude patients on list at high risk of recurrence. The 3-year OS of patients with ≤3 HCC vs. >3 HCC at listing was of 90.3% vs. 67.3%, respectively (P = 0.04). At last imaging, eight listed patients presented ≥5 HCC nodules and had a significantly lower OS than <5 nodules patients (5-year OS: 24.4% vs. 78.1%; P = 0.01). Although the current AFP score offers satisfactory outcomes, we highlight the poorer outcomes when ≥5 nodules persist or appear after listing. A modification of the AFP score is mandatory to consider exclusion of high-risk patients already listed for LT program.

Downstaging with Radioembolization or Chemotherapy for Initially Unresectable Intrahepatic Cholangiocarcinoma.

OBJECTIVE: The aim of this retrospective study was to compare the outcomes of patients resected for intrahepatic cholangiocarcinoma (ICC) with upfront surgery or after downstaging treatment. METHODS: All consecutive patients with ICC between January 1997 and November 2017 were included in a single-center database and retrospectively reviewed. Patients were divided into two groups: upfront resection or resection after downstaging using either chemotherapy alone or selective internal radiation therapy (SIRT) combined with chemotherapy. Survival rates of patients who underwent upfront surgery for ICC were compared with those of patients who underwent surgery after downstaging therapy. RESULTS: A total of 169 patients resected for ICC were included: 137 underwent upfront surgery and 32 received downstaging treatment because their tumor was initially unresectable (13 received chemotherapy, 19 received SIRT). Median OS was not different between the two groups: 32.3 months [95% confidence interval (CI) 23.9-40.7] with primary surgery versus 45.9 months (95% CI 32.3-59.4) with downstaging treatment (p = 0.54, log-rank test). In a multivariable Cox regression model, downstaging treatment was not associated with a better or worse prognosis; however, delivery of SIRT as a downstaging treatment was associated with a significant benefit in multivariable analysis (hazard ratio 0.34, 95% CI 0.14-0.84; p = 0.019). CONCLUSIONS: Overall survival of patients resected after downstaging treatment was not different compared with the OS of patients resected upfront. Patients should therefore again be discussed with the surgeon following medical treatment. SIRT may be an efficient neoadjuvant therapy in patients with resectable ICC, in order to improve surgical results.