Robot-assisted minimally invasive liver surgery in elderly patients: A single-centre, propensity score- matched study.

BACKGROUND: The aim was to evaluate the short-term results of robot-assisted minimally invasive liver surgery(Robot-assisted liver surgery (RLS)) in elderly patients. METHODS: Between November 2019 and July 2022, RLS was performed on 100 consecutive patients. Patients were divided into a middle-aged group (Group1:＜75years) and an elderly group(Group2:≧75years). A propensity score matching(PSM) analysis with a ratio of 1:1 was performed. RESULTS: After PSM, there were 28 patients in each group. There were no significant differences in clinicopathologic characteristics, type of resection and intraoperative variables. Postoperative complications and length of hospital stay were comparable in Groups 1 and 2. In a comparison between minor and major hepatectomy in Group 2, there were no significant differences in any of the factors. CONCLUSIONS: The study showed that RLS for patients over 75years had similar short-term outcomes as for younger patients down to middle-aged, especially the risk of perioperative complications was comparable.

Learning curves in robot-assisted minimally invasive liver surgery at a high-volume center in Denmark: Report of the first 100 patients and review of literature.

BACKGROUND AND OBJECTIVE: Minimally invasive liver surgery is evolving worldwide, and robot-assisted liver surgery (RLS) can deliver obvious benefits for patients. However, so far no large case series have documented the learning curve for RLS. METHODS: We conducted a retrospective study for robotic liver surgery (RLS) from June 2019 to June 2022 where 100 patients underwent RLS by the same surgical team. Patients' variables, short-term follow-up, and the learning curve were analyzed. A review of the literature describing the learning curve in RLS was also conducted. RESULTS: Mean patient age was 63.1 years. The median operating time was 246 min and median estimated blood loss was 100 mL. Thirty-two patients underwent subsegmentectomy, 18 monosegmentectomies, 25 bisegmentectomies, and 25 major hepatectomies. One patient (1.0%) required conversion to open surgery. Five patients (5%) experienced postoperative major complications, and no mortalities occurred. Median length of hospital stay was 3 days. R0 resection was achieved in 93.4% of the malignant cases. The learning curve consisted of three stages; there were no significant differences in operative time, transfusion rate, or complication rate among the three groups. Postoperative complications were similar in each group despite an increase in surgical difficulty scores. The learning effect was highlighted by significantly shorter hospital stays in cohorts I, II, and III, respectively. The included systematic review suggested that the learning curve for RLS is similar to, or shorter, than that of laparoscopic liver surgery. CONCLUSIONS: In our experience, RLS has achieved good clinical results, albeit in the short term. Standardization of training leads to increasing proficiency in RLS with reduced blood loss and low complication rates even in more advanced liver resections. Our study suggests that a minimum of 30 low-to-moderate difficulty robotic procedures should be performed before proceeding to more difficult resections.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature.

BACKGROUND: Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature. METHODS: We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers. RESULTS: A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course. CONCLUSION: MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

Enhanced recovery after surgery is feasible and safe in liver transplantation: a cohort study.

BACKGROUND: The principles of enhanced recovery after surgery (ERAS) are being applied to still more advanced procedures. Liver transplantation offers a unique opportunity for a multimodal approach including donor care as well. Our objective was to determine if ERAS was applicable and safe in orthotopic liver transplantation (OLT). METHODS: A national single centre retrospective study showing the implementation of ERAS from 2013 to 2019 with the proceeding 2 years serving as baseline. The primary endpoints were mortality, length of stay (LOS) in the ward and intensive care unit stay. Secondary endpoints were complications estimated by Dindo-Clavien classification, comprehensive complication index (CCI®) and re-admissions. RESULTS: A total of 334 patients were included. LOS was significantly reduced from a median of 22.5 days at introduction to 14 days at 2019. Cold ischaemia time was reduced from a mean of 10.7 to 6.0 h and the use of blood products (erythrocytes, plasma and thrombocytes) from a median of 28 to 6 units. Complications were reduced in severity. Mortality and readmission rates were not affected. CONCLUSION: ERAS principles are safe and recommended in patients undergoing OLT resulting in reduced severity of complications and LOS without affecting re-admissions or mortality.

Robotic liver resection in Denmark: Report of the first 50 cases at Rigshospitalet Copenhagen.

While most centers around the globe still consider open hepatic resection as the standard, innovative centers step in light of future developments of the robotic platform forward and introduce a robotic liver program while skipping the laparoscopic approach for its technological flaws. This applies also for our Department of Surgery and Transplantation at Rigshospitalet, Copenhagen University Hospital in Denmark. We herewith present as-to our best knowledge-the first center in Scandinavia our experience with the initial 50 robotic liver resections.

Hydrogen Gas Ameliorates Hepatic Reperfusion Injury After Prolonged Cold Preservation in Isolated Perfused Rat Liver.

Hydrogen gas reduces ischemia and reperfusion injury (IRI) in the liver and other organs. However, the precise mechanism remains elusive. We investigated whether hydrogen gas ameliorated hepatic I/R injury after cold preservation. Rat liver was subjected to 48-h cold storage in University of Wisconsin solution. The graft was reperfused with oxygenated buffer with or without hydrogen at 37° for 90 min on an isolated perfusion apparatus, comprising the H2 (+) and H2 (-) groups, respectively. In the control group (CT), grafts were reperfused immediately without preservation. Graft function, injury, and circulatory status were assessed throughout the perfusion. Tissue samples at the end of perfusion were collected to determine histopathology, oxidative stress, and apoptosis. In the H2 (-) group, IRI was indicated by a higher aspartate aminotransferase (AST), alanine aminotransferase (ALT) leakage, portal resistance, 8-hydroxy-2-deoxyguanosine-positive cell rate, apoptotic index, and endothelial endothelin-1 expression, together with reduced bile production, oxygen consumption, and GSH/GSSG ratio (vs. CT). In the H2 (+) group, these harmful changes were significantly suppressed [vs. H2 (-)]. Hydrogen gas reduced hepatic reperfusion injury after prolonged cold preservation via the maintenance of portal flow, by protecting mitochondrial function during the early phase of reperfusion, and via the suppression of oxidative stress and inflammatory cascades thereafter.

Age is no longer a limit: two cases of hepatectomy in patients over 90 years old.

Hepatocellular carcinoma (HCC) is a common malignant tumor with poor prognosis. The age of patients affected by HCC is considered to be increasing, and several studies have reported significantly higher rates of morbidity and mortality after hepatectomy for HCC in elderly patients. However, other studies have reported that the short- and long-term outcomes of surgery for HCC in elderly patients are similar to those in younger patients. Whether the indications for hepatic resection in elderly patients resemble those in younger patients has thus been questioned. We describe two cases of patients over 90 years old who underwent major hepatectomy for HCC, representing the oldest patients in the world to have done so.

Successfully treated intra-abdominal abscess caused by fish bone with perforation of ascending colon: a case report.

Ingestion of a foreign body is not uncommon, but rarely results in perforation of the gastrointestinal tract. The most common sites of perforation are reportedly the narrowest parts of the bowel, and perforation of the right side of the colon is rare. We report herein the case of a 69-year-old man who presented with an 8-week history of right upper abdominal pain. Laboratory data revealed inflammation at the first hospital visit. Computed tomography revealed a hypodense lesion containing a hyperdense foreign body in the abdomen. Intra-abdominal abscess caused by foreign body perforation was diagnosed. After administering antibiotics for 2 weeks, surgery was performed. Symptoms had resulted from perforation of the ascending colon by a fish bone.

Management considerations for purported spontaneous regression of hepatocellular carcinoma: a case report.

Spontaneous regression of hepatocellular carcinoma (HCC) is an extraordinary phenomenon that occurs rarely. While more than 80 cases have been described, most have been established via radiological findings or examination of biopsy tissues rather than via pathological examination of a resected specimen. The present report describes a purported case of spontaneous regression of HCC as indicated by radiological examination. Subsequent immunostaining of surgically resected specimens revealed viable cancer cells, though only necrotic tissues were seen on hematoxylin and eosin staining. These data indicate that viable cancer cells may still be present even if imaging findings suggest spontaneous regression of HCC. Therefore, these patients should receive aggressive treatment similar to that used for patients with established HCC.

First report of hepatectomy without endotracheal general anesthesia.

BACKGROUND: Local anesthesia, including epidural anesthesia, has much merit over general anesthesia for the reduction of perioperative cardiac and respiratory complications. Liver operations commonly require general anesthesia. This is the first report of hepatectomy performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation. STUDY DESIGN: We devised the following protocol for hepatectomy under epidural anesthesia with conscious sedation: the patient receives 10 mg diazepam orally 1 hour before surgery, followed by 10 mg diazepam and 15 mg pentazocine intravenously just before surgery. An epidural catheter is inserted via the thoracic vertebra 7 to 9 interspaces. Intraoperatively, the patient receives a bolus of 7 mL 2% mepivacaine hydrochloride every 40 minutes through the epidural catheter. We conducted 4 left hepatectomies, 1 left lateral sectorectomy, and 5 partial hepatectomies under this protocol. We assessed the efficacy and safety of hepatectomy under epidural anesthesia with conscious sedation in terms of mortality rate, surgical time, amount of bleeding, and central venous pressure during the procedure. RESULTS: Every patient was managed without endotracheal intubation and laryngeal masks. There was no perioperative mortality. Median intraoperative blood loss was 453.0 mL (range 144.0 to 1292.0 mL) and median surgical time was 273.0 minutes (range 137.0 to 440.0 minutes). Median total amount of 2% mepivacaine hydrochloride used was 52.0 mL (range 23.0 to 95.0 mL). Central venous pressure values were significantly lower during the Pringle maneuver than at preclamp. CONCLUSIONS: The traditional belief is that liver resection should be performed under general anesthesia. We report the world's first series of liver resections for malignant tumors performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation.

Effectiveness of using ultrasonically activated scalpel in combination with radiofrequency dissecting sealer or irrigation bipolar for hepatic resection.

BACKGROUND/AIMS: Many kinds of transection devices have been developed but there are very few reports on the effectiveness of using ultrasonically activated scalpel with a hook blade in combination with a thermo-coagulating device for hepatectomy. METHODOLOGY: We studied 533 consecutive patients who underwent hepatectomy for primary disease and for living- related liver transplantation (LRLT) donors preformed using ultrasonically activated scalpel with a hook blade along with a saline-linked radiofrequency dissecting sealer (TL group, n=215) or bipolar cautery with a saline-irrigation system (IB group, n=318). Intraoperative blood loss, operative time, postoperative laboratory data collected over a week and the incidence of postoperative complications were analyzed in accordance with the pre-existing liver conditions. RESULTS: The median operative time required to perform partial hepatectomy and hemihepatectomy in liver tumor cases was found to be significantly shorter in the TL group than in the IB group. There was no significant difference in the amount of blood loss between the 2 groups. Postoperative laboratory data was favorable and the overall complication rate after hepatectomy was 9.01%. CONCLUSIONS: Ultrasonically activated scalpel with a hook blade used in combination with a thermo-coagulation device yielded favorable intra and postoperative outcomes.

Successful transplantation of rat hearts subjected to extended cold preservation with a novel preservation solution.

Since prolonged cold preservation of the heart deteriorates the outcome of heart transplantation, a more protective preservation solution is required. We therefore developed a new solution, named Dsol, and examined whether Dsol, in comparison to UW, could better inhibit myocardial injury resulting from prolonged cold preservation. Syngeneic heterotopic heart transplantation in Lewis rats was performed after cold preservation with UW or Dsol for 24 or 36 h. In addition to graft survival, myocardial injury, ATP content, and Ca(2+) -dependent proteases activity were assessed in the 24-h preservation group. The cytosolic Ca(2+) concentration of H9c2 cardiomyocytes after 24-h cold preservation was assessed. Dsol significantly improved 7-day graft survival after 36-h preservation. After 24-h preservation, Dsol was associated with significantly faster recovery of ATP content and less activation of calpain and caspase-3 after reperfusion. Dsol diminished graft injury significantly, as revealed by the lower levels of infarction, apoptosis, serum LDH and AST release, and graft fibrosis at 7-day. Dsol significantly inhibited Ca(2+) overload during cold preservation. Dsol inhibited myocardial injury and improved graft survival by suppressing Ca(2+) overload during the preservation and the activation of Ca(2+) -dependent proteases. Dsol is therefore considered a better alternative to UW to ameliorate the outcome of heart transplantation.

Preoperative percutaneous transhepatic portal vein embolization with ethanol injection.

OBJECTIVE: The purpose of this article is to evaluate the feasibility and efficacy of preoperative percutaneous transhepatic portal vein embolization with ethanol injection. MATERIALS AND METHODS: We retrospectively evaluated 143 patients who underwent percutaneous transhepatic portal vein embolization. Hypertrophy of the future liver remnant was assessed by comparing the volumetric data obtained from CT image data before and after percutaneous transhepatic portal vein embolization. The evaluation of effectiveness was based on changes in the absolute volume of the future liver remnant and the ratio of the future liver remnant to the total estimated liver volume. RESULTS: Ten of 143 patients (7.0%) underwent additional embolization because of recanalization and insufficient hypertrophy of the future liver remnant. The mean increase in the ratio of the future liver remnant was 33.6% (p < 0.0001), and the mean ratio of future liver remnant to total estimated liver volume increased from 34.9% to 45.7% (p < 0.0001). Although most of the patients complained of pain after ethanol injection, they were gradually relieved of pain in a few minutes by conservative treatment. Fever (38-39°C) was reported after 47 of 151 (31.1%) percutaneous transhepatic portal vein embolization sessions and was resolved within a few days. Transient elevation of the liver transaminases was observed after the procedures and resolved within about a week. Major complications occurred in nine of 151 (6%) percutaneous transhepatic portal vein embolization sessions, but no patients developed hepatic insufficiency or severe complications precluding successful resection. One hundred twenty patients underwent hepatic resection, and two patients developed hepatic failure after surgery. CONCLUSION: Preoperative percutaneous transhepatic portal vein embolization with ethanol is a feasible and effective procedure to obtain hypertrophy of the future liver remnant for preventing hepatic failure after hepatectomy.

Ectopic gastric pancreatic cancer: report of a case.

It is very rare for ectopic pancreas to become cancerous. We herein report on a case of ectopic pancreatic cancer developed in the stomach. A neoplastic lesion was detected in the pyloric part in an upper GIS of a 76-year-old female, requiring biopsy, but because it was classified as Group I, it was observed temporarily. Following blood collection after approximately 2 years, the CA19-9 increased from 177.5 to 279.5, so a GIS was again performed. Although the pyloric part of the stomach became more stenosed than before, it was still considered Group I disease based on biopsy findings. When EUS was performed, the tumor appeared as a submucosal tumor, and was thus suspected as GIST. In an abdominal CT, a neoplastic lesion with a clear boundary was observed in the pylorus, as was an enlarged lymph node in the hepatoduodenal ligament. Therefore malignancy could not be ruled out, and a gastrectomy on the pylorus side, lymph node dissection (D2), and cholecystectomy were performed. The tumor was a submucosal tumor covered by a coherent mucosa. According to histopathological findings, it was diagnosed as ectopic pancreatic cancer developed in the ectopic pancreas (Heinrich type II), consisting of acinar tissue and capillary tubes. Thus ectopic pancreas should be considered in the differential diagnosis of gastric submucosal tumors. Regarding surgery for ectopic pancreas, it is considered necessary to establish a treatment policy by making an immediate pathological diagnosis with sufficient consideration of the possibility of malignancy.

Analysis of risk factors for hyperbilirubinemia occurring after hepatectomy.

BACKGROUND: To further improve the outcomes of liver resection, it is important to identify and prevent the causes of the hyperbilirubinemia occurring after hepatectomy and postoperative liver failure. METHODS: Between 2004 and 2009, 591 consecutive patients underwent a hepatectomy at our center. Twenty-two patients who developed hyperbilirubinemia (postoperative total bilirubin over 5 mg/dL) after hepatectomy were classified as Hi-Bi group and another 569 whose total bilirubin did not increase beyond 5 mg/dL were classified as non-Hi-Bi group. RESULTS: A preoperative prothrombin test of less than 80% and a blood loss of more than 1000 mL were identified as independent risk factors for the Hi-Bi group by multivariate analysis. The hyperbilirubinemia of 16 cases improved, while that of 6 cases was prolonged. One of these patients died of liver failure without responding to treatment. The mortality rate for postoperative liver failure in this study was 0.16% (1/591). CONCLUSION: It is important to reduce the length of surgery and intraoperative blood loss to prevent hyperbilirubinemia after hepatectomy. Additionally, decision-making using our algorithm and full examination of the accurate evaluation results, including those for prothrombin time, residual liver function and liver damage, can help reduce the development of hyperbilirubinemia.

[A successful case of S-1 chemotherapy for bilateral pulmonary recurrence of hepatocellular carcinoma long after hepatectomy].

The treatment for hepatocellular carcinoma with distant metastasis remains unclear. We experienced a successful case of S-1 chemotherapy for bilateral pulmonary recurrence of hepatocellular carcinoma following hepatectomy after gaining chemoresistance through pretreatment. A 62-year-old man underwent extended right hepatectomy for hepatocellular carcinoma occupying the whole right lobe. CT scan 15 months after hepatectomy revealed bilateral multiple pulmonary recurrence. Pharmacokinetic modulation chemotherapy (PMC) was performed after treatment of UFT, and stable disease status for 24 months was achieved. Pulmonary metastatic lesions gradually became larger, so oral administration of 100 mg per day of S-1 was followed by stable disease status for 9 months. The present case suggests that S-1 chemotherapy may be useful for hepatocellular carcinoma with distant metastasis.

[A study of cirrhotic patients with hepatocellular carcinoma and huge splenomegaly who received treatment for hepatocellular carcinoma with concomitant splenectomy].

Treatment for hepatocellular carcinoma (HCC) with advanced cirrhosis, especially with hypersplenic thrombocytopenia, will be very difficult. Then we evaluated usefulness of concomitant splenectomy with treatment for patients with HCC, severe cirrhosis and huge splenomegaly. The preoperative mean platelet (Plt) count was 4.6 × 10(4)/µL and the mean longest diameter of spleen on CT was 143.0 mm. The mean Plt count on postoperative days 14 and 28 was 23.1 × 10(4)/µL (p=0.005) and 16.1 × 10(4)/µL (p=0.01), respectively and improved significantly compared with preoperative one. A white blood cell count and serum albumin also improved significantly on postoperative days 14 and 28, respectively. Treatment for recurrent HCC after splenectomy was preformed 2.4 times per patient (transarterial chemoembolization 13 times and radiofrequency ablation 4 times/7 patients). Now 5 patients are alive and the mean survival period was 17.3 months (range 8-38 months). It maybe said that concomitant splenectomy for cirrhotic patients with HCC and huge splenomegaly who need to receive a treatment for HCC was useful in our study, because those patients could receive a treatment for recurrent HCC repeatedly, and that probably contributes to the improvement of prognosis.

[Effects of pharmacokinetic modulation chemotherapy (PMC) using oral UFT and venous 5-FU infusion as adjuvant chemotherapy for intrahepatic cholangiocellular carcinoma].

UNLABELLED: Intrahepatic cholangiocellular carcinoma after curative surgery was treated with pharmacokinetic modulation chemotherapy (PMC) as adjuvant chemotherapy. METHOD: PMC consists of medication with UFT and intravenous infusion of 5-FU. The dose of UFT is 300 mg/day and the infusion of 5-FU is performed with 500 mg/body once a week for one year. RESULTS: Twelve cases were treated with PMC (A-group) and eight cases were without PMC (B-group). The mean number of 5- FU infusions in all cases was 33.2 (6-48). The median survival time (MST) of A-group was 78.9 months, and of B-group was 74.3 months. Five-year cumulative survival rates of A-and B-group were 59.4%, 59%,and disease free survival rates were 37.5%, 25%,respectively. There was no significance between two groups. CONCLUSION: PMC as adjuvant chemotherapy for intrahepatic cholangiocellular carcinoma was not so effective in comparison with cases without adjuvant chemotherapy.

[Preoperative chemoradiotherapy for advanced lower rectal carcinoma].

Preoperative chemoradiotherapy in combination with radiation of 30 Gy and chemotherapy with oral uracil-tegafur for 14 patients with advanced lower rectal carcinoma was performed. Tumors were located at RaRb in 5 cases, RbRa in 2, Rb in 3, and RbP in 4 with a mean diameter of 3.8 cm. Preoperative lymphnodes were diagnosed as cN0 in 8 cases, cN1(metastases of perirectal nodes)in 4, cN1(perirectal and along superior rectal artery nodes)in 1, and cN3(perirectal and lateral nodes)in 1. Efficacy for primary carcinomas was evaluated as Partial Response in 9 cases, Stable Disease in 5 and perirectal nodes were down-sized in 4 without down-sizing of either along superior rectal artery nodes or lateral nodes. Margins of primary carcinomas to anal verge were prolonged in 7 cases with a mean prolongation of 0.81 cm. Autonomic nerve-preserving resections with lymphadenectomy of perirectal and along superior rectal artery nodes were performed. Histopathologically efficacy for primary tumors was diagnosed to as not effective in 9 cases, partially effective in 5, and all lymphnodes were combined with necroses and fibrosis. Preoperative chemoradiotherapy is safe for preserving autonomic nerves and serves to preserve the sphincter. A forthcoming study with more appropriate radiation, chemotherapy and lymphadenectomy is being considered.

An endoscopic sphincterotomy of the minor papilla in the management of symptomatic pancreas divisum.

BACKGROUND/AIMS: The efficacy of endoscopic treatment in pancreas divisum remains controversial. This study evaluated the results of an endoscopic sphincterotomy of the minor papilla and temporary transpapillary pancreatic stenting in patients with pancreas divisum. METHODOLOGY: Pancreas divisum was diagnosed in four patients between 1994 and 2004. All patients demonstrated episodes of recurrent upper abdominal and back pain were with a median follow-up period of 14.5 months. One patient was treated by a sphincterotomy of the minor papilla alone, while three others also underwent transpapillary pancreatic stent insertion for seven days. RESULTS: A Sphincterotomy of the minor papilla could be successfully achieved in all patients. There was no instance of bleeding, perforation or sepsis after the procedure. The postoperative serum amylase level in the patients without stent insertion (1352 IU/L) was higher than that the patients with stents (mean level 515 IU/L, range 358 to 680). The dilatated dorsal pancreatic ducts were found to improve after a sphincterotomy in all patients. None of the patients had any further episodes of pancreatitis. In addition, all patients demonstrated a considerable improvement in their upper abdominal or back pain symptoms, which did not require either analgesic medication or hospitalization. CONCLUSIONS: An endoscopic sphincterotomy and temporary transpapillary pancreatic stenting were therefore suggested to be a beneficial treatment modality for patients with pancreas divisum.