Outcomes of Robotic Living Donor Right Hepatectomy From 52 Consecutive Cases: Comparison With Open and Laparoscopy-assisted Donor Hepatectomy.

OBJECTIVE: To investigate the feasibility and safety of RLDRH. SUMMARY OF BACKGROUND DATA: Data for minimally invasive living-donor right hepatectomy, especially RLDRH, from a relatively large donor cohort that have not been reported yet. METHODS: From March 2016 to March 2019, 52 liver donors underwent RLDRH. The clinical and perioperative outcomes of RLDRH were compared with those of CODRH (n = 62) and LADRH (n = 118). Donor satisfaction with cosmetic results was compared between RLDRH and LADRH using a body image questionnaire. RESULTS: Although RLDRH was associated with longer operative time (minutes) (RLDRH, 493.6; CODRH, 404.4; LADRH, 355.9; P < 0.001), mean estimated blood loss (mL) was significantly lower (RLDRH, 109.8; CODRH, 287.1; LADRH, 265.5; P = 0.001). Postoperative complication rates were similar among the 3 groups (RLDRH, 23.1%; CODRH, 35.5%; LADRH, 28.0%; P = 0.420). Regarding donor satisfaction, body image and cosmetic appearance scores were significantly higher in RLDRH than in LADRH. After propensity score matching, RLDRH showed less estimated blood loss compared to those of CODRH (RLDRH, 114.7 mL; CODRH, 318.4 mL; P < 0.001), but complication rates were similar among the three groups (P = 0.748). CONCLUSIONS: RLDRH resulted in less blood loss compared with that of CODRH and similar postoperative complication rates to CODRH and LADRH. RLDRH provided better body image and cosmetic results compared with those of LADRH. RLDRH is feasible and safe when performed by surgeons experienced with both robotic and open hepatectomy.

Total laparoscopic versus robotic-assisted laparoscopic pancreaticoduodenectomy: which one is better?

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD) is a challenging procedure. Laparoscopic pancreaticoduodenectomy (LPD) is feasible and safe. Since the development of robotic platforms, the number of reports on robot-assisted pancreatic surgery has increased. We compared the technical feasibility and safety between LPD and robot-assisted LPD (RALPD). METHODS: From September 2012 to August 2020, 257 patients who underwent MIPD for periampullary tumors were enrolled. Of these, 207 underwent LPD and 50 underwent RALPD. We performed a 1:1 propensity score-matched (PSM) analysis and retrospectively analyzed the demographics and surgical outcomes. RESULTS: After PSM analysis, no difference was noted in demographics. Operation times and estimated blood loss were similar, as was the incidence of complications (p > 0.05). In subgroup analysis in patients with soft pancreas with pancreatic duct ≤ 2 mm, no significant between-group difference was noted regarding short-term surgical outcomes, including clinically relevant POPF (CR-POPF) (p > 0.05). In multivariable analysis, the only soft pancreatic texture was a predictive factor (HR 3.887, 95% confidence interval 1.121-13.480, p = 0.032). CONCLUSION: RALPD and LPD are safe and effective for MIPD and can compensate each other to achieve the goal of minimally invasive surgery.

Wrapping the pancreas with a polyglycolic acid sheet before stapling reduces the risk of fluid collection on the pancreatic stump after distal pancreatectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) and postoperative fluid collection (POFC) are common complications after distal pancreatectomy (DP). The previous method of reducing the risk of POPF was the application of a polyglycolic acid (PGA) sheet to the pancreatic stump after cutting the pancreas with a stapler (After-stapling); the new method involves wrapping the pancreatic resection line with a PGA sheet before stapling (Before-stapling). The study aimed to compare the incidence of POPF and POFC between two methods. METHODS: Data of patients who underwent open or laparoscopic DPs by a single surgeon from October 2010 to February 2020 in a tertiary referral hospital were retrospectively analyzed. POPF was defined according to the updated International Study Group of Pancreatic Fistula criteria. POFC was measured by postoperative computed tomography (CT). RESULTS: Altogether, 182 patients were enrolled (After-stapling group, n = 138; Before-stapling group, n = 44). Clinicopathologic and intraoperative findings between the two groups were similar. Clinically relevant POPF rates were similar between both groups (4.3% vs. 4.5%, p = 0.989). POFC was significantly lesser in the Before-stapling group on postoperative day 7 (p < 0.001). CONCLUSIONS: Wrapping the pancreas with PGA sheet before stapling was a simple and effective way to reduce POFC.

Major Laparoscopic Versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-Matched Analysis Based on Surgeons' Learning Curve.

BACKGROUND: Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis. METHODS: This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized. RESULTS: Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups. CONCLUSIONS: LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.

Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method.

BACKGROUND: Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR. METHODS: A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded. RESULTS: A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities. CONCLUSION: Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients.

Stepwise development of laparoscopic liver resection skill using rubber traction technique.

BACKGROUND: To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes. METHODS: Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome. RESULTS: As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed. CONCLUSION: Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.

Prognostic significance of and risk prediction model for lymph node metastasis in resectable intrahepatic cholangiocarcinoma: do all require lymph node dissection?

BACKGROUND: Lymph node (LN) metastasis portends a worse prognosis following resection of intrahepatic cholangiocarcinoma (ICC); however, lymphadenectomy is not routinely performed, as its role remains controversial. Herein, we developed a risk model for LN metastasis by identifying its predictive factors and assessed a subset of patients who might not benefit from LN dissection (LND). METHODS: 210 patients who underwent curative-intent surgery for ICC were retrospectively reviewed. A preoperative risk model for LN metastasis was developed following identification of its preoperative predictive factors using the recursive partitioning method. RESULTS: In the multivariable analysis, CA 19-9 level of >120 U/mL, an enlarged LN on computed tomography, and a tumor location abutting the Glissonean pedicles were independent predictors of LN metastasis. The preoperative risk model classified the patients according to their risk: high, intermediate, and low risks at a rate of LN metastasis on final pathology of 60.9%, 35%, and 2.3%, respectively. In the subgroup analysis among the low-risk patients, performance of LND had no survival advantage over non-performance of LND. CONCLUSION: Routine LND for preoperatively diagnosed ICC should be recommended to patients at an intermediate and a high risk of developing LN metastasis but may be omitted for low-risk patients.

Comparison of Training Efficacy Between Custom-Made Skills Simulator (CMSS) and da Vinci Skills Simulators: A Randomized Control Study.

BACKGROUND: To compare the effectiveness of a custom-made skills simulator (CMSS) with the commercially available da Vinci® skills simulator (DVSS) that help improving surgical skills for effective and safe robotic surgical interventions. METHODS: A randomized control study was conducted to determine the performance of participants after undergoing robotic surgical training. Total 64 students who had no previous experience with robotic surgery enrolled this study. After 5 min-introduction of robotic surgical system, the participants got random-assignment into two groups to perform either CMSS-or DVSS-exercises. After 15 min-practicing the corresponding simulator, task-execution performance and individual questionnaires were compared between participants trained with the CMSS and those trained with the DVSS. RESULTS: Regardless of simulator the participants used, the system understanding and manipulation ability of the participants was found to be higher than after completing the simulation-based robotic surgical training (p < 0.05). However, there were no significant differences in terms of the required time to complete the tasks, and improvement of understanding the concept of robotic surgery, or surgical skill capacity between two groups (p > 0.05). CONCLUSIONS: The training effectiveness of CMSS was not significantly different to DVSS. It can be synergetic tool to DVSS for novice trainees of robotic surgery to get accustomed to the robotic surgical system and to improve their basic robotic surgical skills.

Robotic simultaneous resection for colorectal liver metastasis: feasibility for all types of liver resection.

BACKGROUND: A laparoscopic approach is increasingly being utilized in simultaneous colorectal and liver resection (SCLR) for colorectal cancer with liver metastasis. However, this approach is technically challenging and hence has not been widely adopted. Robotic surgical systems could potentially overcome this problem. We aim to describe the feasibility and outcomes of robotic SCLR for colorectal carcinoma with liver metastasis. METHODS: The medical records of 12 patients who underwent robotic SCLR for colorectal cancer with liver metastasis between January 2008 and September 2018 were reviewed retrospectively. RESULTS: The mean age was 59 years (range, 37-77 years). The liver resections were comprised of two right hepatectomies, one left hepatectomy, one left lateral sectionectomy, one segmentectomy of S3 and wedge resection (segment 7), one caudate lobectomy, one associated liver partition and portal vein ligation for staged hepatectomy, and five wedge resections involving segments 4, 5, 6, 7, or 8. The colorectal procedures involved seven low-anterior resections, two anterior resections, two right hemicolectomies, and one left hemicolectomy. The mean operative time was 449 min (range, 135-682 min) with a mean estimated blood loss of 274.3 mL (range, 40-780 mL). The mean length of hospital stay was 12 days (range, 5-28 days). No patients required conversion to laparotomy. Liver resection-related complications were two liver abscesses (Clavien-Dindo classification, one grade II and one grade III) and one case of ascites (grade I), whereas colorectal resection-related complications included one anastomosis leak (grade III) and one superficial wound infection (grade II). There were no deaths reported within 30 days of the procedure. With a mean follow-up duration of 31.5 ± 26.1 months, the overall survival and disease-free survival values were 75.2 and 47.1 months, respectively. CONCLUSION: Robotic SCLR for colorectal neoplasm with liver metastasis can be performed safely even in cases requiring major liver resections, especially in a specialized center with a well-trained team.

Surgical approach to solid pseudopapillary neoplasms of the proximal pancreas: minimally invasive vs. open.

BACKGROUND: Solid pseudopapillary neoplasms (SPN) of the pancreas are rare pancreatic neoplasms where complete resection is the cornerstone in management. It has been demonstrated in previous studies that minimally invasive surgical approaches are effective management options in treating SPNs of the distal pancreas. The purpose of this study is to evaluate the feasibility of minimally invasive surgery in treating SPNs of the uncinate, head, and neck of the pancreas. METHODS: Data from 2005 to 2017 at Severance Hospital of the Yonsei University Health systems in Seoul, South Korea, were retrospectively collected for 25 patients who were diagnosed with SPN of the uncinate, head, and neck of the pancreas and who underwent curative resection. Three groups of patients were considered, depending on the year of surgery, in order to determine trends in the surgical management of SPN. The patients were also divided into two groups corresponding to the type of operation done (minimally invasive surgery vs. open surgery). Perioperative patient data, including age, gender, body mass index (BMI), tumor size, and operation done, were compared and analyzed statistically. Long-term nutritional effects were measured using the Controlling Nutritional Status (CONUT) scoring system. RESULTS: There were no statistically significant differences in age, gender, BMI, symptomatic presentation, operation type, tumor size, and tumor stage between the three time periods. In comparing between minimally invasive and open surgery, there were no statistically significant differences in age, gender, symptomatic presentation, BMI, tumor size, preoperative stage, type of operation, operation time, pancreatic duct size, post-operative pancreatic fistula (POPF) grade, death associated with disease, recurrence, pathological parameters, and change in CONUT score. There was a significant difference in tumor size (4.5 ± 1.8 vs. 2.6 ± 1.0 cm, p = 0.004), blood loss (664.2 ± 512.4 vs. 277.7 ± 250.8 mL, p = 0.024), need to transfuse (33% vs. 0%, p = 0.023), hospital length of stay (27.4 ± 15.3 vs. 11.5 ± 5.3 days, p = 0.002), and complication rate (75% vs. 30.8%, p = 0.027) between the two groups. CONCLUSIONS: In appropriately selected patients with SPNs of the uncinate, head, and neck of the pancreas, a minimally invasive surgical approach offers at least equal oncologic and nutritional outcomes, while demonstrating decreased complications and decreased hospital length of stay compared with that of an open surgical approach.

Is ICG-enhanced image able to help predicting pancreatic fistula in laparoscopic pancreaticoduodenectomy?

Laparoscopic pancreaticoduodenectomy (PD) has been reported to be technically feasible and safe. Successful pancreatico-enteric anastomosis in particular is important for safe PD. Intraoperative perfusion of the remnant pancreas can be evaluated with ICG technology and be applied in pancreatic reconstruction in PD. A 68-year old female patient with distal common bile duct cancer underwent laparoscopic pylorus-preserving pancreaticoduodenectomy. After pancreaticojejunostomy (PJ), we checked perfusion of the anastomosis line using an ICG imaging system and noticed a perfusion defect at the anterior wall. The patient developed a grade A postoperative pancreatic fistula, but was discharged without major sequelae. Even though pancreatic perfusion after laparoscopic PJ appeared adequate based on white light, hypo-perfusion was noted under infrared light. Our experience suggests that ICG technology may be more sensitive than white light for detecting pancreatic perfusion in pancreatic anastomoses. However, the clinical implications of this require further investigation.

Different biological behaviors in left-sided pancreatic cancer according to Yonsei criteria: Proposal of a modified Yonsei criteria score.

BACKGROUND/OBJECTIVES: Our institutional experience has demonstrated that bloodless and margin-negative resection is the most potent prognostic factor in treating left-sided pancreatic cancer and we developed selection guideline. The Yonsei criteria (YC) is selection criteria for oncologically safe and effective resection of left-sided pancreatic cancer by a minimally invasive approach. In this study, we investigated whether left-sided pancreatic cancer with YC can be more individualized to predict long-term survival by using clinically and pathologically detectable parameters. METHODS: From January 2000 to December 2015, 105 patients underwent distal pancreatectomy for left-sided pancreatic cancer. The medical records of the patients were retrospectively reviewed. RESULTS: Among clinically and pathologically detectable parameters to predict tumor conditions, radiologically determined tumor size (p = 0.080) and SUVmax (p = 0.086) were identified as predictors of early tumor recurrence with marginal significance. Among them, 20% of the patients with YC were identified as having the most favoring tumor condition, with an modified YC score of 3. The patient group with the lowest mYC score was found to have a very long disease-free survival time, with a mean of 108 months, which was statistically different from those with other mYC scores (mYC score = 4, mean 47.1 months [95% CI: 27.8-69.5] vs. mYC score = 5, mean 36.7 months [95% CI: 12.7-60.7], vs. mYC score = 6, mean 10.7 months [95% CI: 3.9-17.4]). CONCLUSIONS: Modified Yonsei criteria score can predict long-term survival in resected left-sided pancreatic cancer. And patients within YC with a mYC score = 3 could have a favorable survival outcome.

Minimally invasive pancreatoduodenectomy with combined venous vascular resection: A comparative analysis with open approach.

Backgrounds/Aims: This study aimed to compare the minimally invasive pancreatoduodenectomy with venous vascular resection (MI-PDVR) and open pancreatoduodenectomy with venous vascular resection (O-PDVR) for periampullary cancer. Methods: Data of 124 patients who underwent PDVR (45 MI-PDVR, 79 O-PDVR) between January 1, 2016, and December 31, 2023, was retrospectively reviewed. Results: MI-PDVR is significantly better than O-PDVR in terms of perioperative outcomes (median operation time [452.69 minutes vs. 543.91 minutes; p = 0.004], estimated blood loss [410.44 mL vs. 747.59 mL; p < 0.01], intraoperative transfusion rate [2 cases vs. 18 cases; p = 0.01], and hospital stay [18.16 days vs. 23.91 days; p = 0.008]). The complications until the discharge day showed no significant difference between the two groups (Clavien-Dindo < 3, 84.4% vs. 82.3%; Clavien-Dindo ≥ 3, 15.6% vs. 17.7%; p = 0.809). In terms of long-term oncological outcomes, there was no statistical difference in overall survival (OS, 51.55 months [95% CI: 35.95-67.14] vs. median 49.92 months [95% CI: 40.97-58.87]; p = 0.340) and disease-free survival (DFS, median 35.06 months [95% CI: 21.47-48.65] vs. median 38.77 months [95% CI: 29.80-47.75]; p = 0.585), between the two groups. Long-term oncological outcomes for subgroup analysis focusing on pancreatic ductal adenocarcinoma also showed no statistical differences in OS (40.86 months [95% CI: 34.45-47.27] vs. 48.48 months [95% CI: 38.16-58.59]; p = 0.270) and DFS (24.42 months [95% CI: 17.03-31.85] vs. 34.35 months, [95% CI: 25.44-43.27]; p = 0.740). Conclusions: MI-PDVR can provide better perioperative outcomes than O-PDVR, and has similar oncological impact.

Additional nodules detected using EOB-MRI in patients with resectable single hepatocellular carcinoma: an implication for active treatment strategy.

BACKGROUND/AIM: Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOBMRI) further enhances the identification of additional hepatic nodules compared with computed tomography (CT) alone; however, the optimal treatment for such additional nodules remains unclear. We investigated the long-term oncological effect of aggressive treatment strategies for additional lesions identified using EOB-MRI in patients with hepatocellular carcinoma (HCC). METHODS: Data from 522 patients diagnosed with solitary HCC using CT between January 2008 and December 2012 were retrospectively reviewed. Propensity score-matched (PSM) analysis was used to compare the oncologic outcomes between patients with solitary HCC and those with additional nodules on EOB-MRI after aggressive treatment (resection or radiofrequency ablation [RFA]). RESULTS: Among the 383 patients included, 59 had additional nodules identified using EOB-MRI. Compared with patients with solitary HCC, those with additional nodules on EOB-MRI had elevated total bilirubin, aspartate transaminase, and alanine transaminase; had a lower platelet count, higher MELD score, and highly associated with liver cirrhosis (P<0.05). Regarding long-term outcomes, 59 patients with solitary HCC and those with additional nodules after PSM were compared. Disease-free survival (DFS) and overall survival (OS) were comparable between the two groups (DFS, 60.4 vs. 44.3 months, P=0.071; OS, 82.8 vs. 84.8 months, P=0.986). CONCLUSION: The aggressive treatment approach, either resection or RFA, for patients with additional nodules identified on EOBMRI was associated with long-term survival comparable with that for solitary HCC. However, further studies are required to confirm these findings.

ArtiSential® laparoscopic cholecystectomy versus single-fulcrum laparoscopic cholecystectomy: Which minimally invasive surgery is better?

Backgrounds/Aims: In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential® LC with those of single-fulcrum LC. Methods: This retrospective study compared ArtiSential® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain. Results: A total of 88 and 63 patients underwent ArtiSential® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01). Conclusions: ArtiSential® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential® LC is considered the better option for patients, compared to single-fulcrum LC.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study.

Background: SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods. Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018. Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®. Conclusions: SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Current Status of Therapeutic Choice and Feasibility for Patients with Hepatocellular Carcinoma Aged ≥ 70 Years: A Nationwide Cancer Registry Analysis.

BACKGROUND: The opportunities for examining elderly patients with hepatocellular carcinoma (HCC) have increased. We investigated the treatment of HCC for elderly patients and the overall survival associated with each treatment modality. METHODS: From January 2003 to December 2005 (n=578, period I) and January 2008 to December 2014 (n=2428, period II), the National Cancer Center and Korean Liver Cancer Association collected clinical data of 3006 patients with HCC aged ≥70 years old at 54 medical centers in Korea. We analyzed the treatment modalities and overall survival for patients with HCC aged ≥70 years. RESULTS: The mean age, Child-Pugh score, and model for end-stage liver disease score and proportion of male patients were not different between period I and period II (74 years, 6.6, 10.4 and 70.1% vs 76 years, 6.2, 9.9 and 67.3%). TNM stage II and BCLC stage A were most commonly noted in periods I and II (44.3% and 49.1% vs 40.4% and 40.2%). Transarterial therapy was the most commonly used treatment modality according to age in both periods. Surgical resection was associated with significant superior overall survival compared to local ablation and transarterial therapy (p<0.001). After propensity score matching between surgical resection and transarterial therapy in period II, surgical resection was associated with more favorable overall survival outcomes (median: 39 months vs 86 months, p<0.001). CONCLUSION: Transarterial therapy was the most commonly used treatment modality for patients with HCC aged ≥70 years. However, surgical resection led to significantly higher overall survival rates compared to other treatment modalities.

Robotic major liver resections: Surgical outcomes compared with open major liver resections.

BACKGROUNDS/AIMS: Laparoscopic major liver resections are still considered innovative procedures despite the recent development of laparoscopic liver surgery. Robotic surgery has been introduced as an innovative system for laparoscopic surgery. In this study, we investigated surgical outcomes after major liver resections using robotic systems. METHODS: From January 2009 to October 2018, 70 patients underwent robotic major liver resections, which included conventional major liver resections and right sectionectomy. The short-term and long-term outcomes were compared with 252 open major resections performed during the same period. RESULTS: Operative time was longer in the robotic group (472 min vs. 349 min, p<0.001). However, estimated blood loss was lower in the robotic group compared with the open resection group (269 ml vs. 548 ml, p=0.009). The overall postoperative complication rate of the robotic group was lower than that of the open resection group (31.4% vs. 58.3%, p<0.001), but the major complication rate was similar between the two groups. Hospital stay was shorter in the robotic group (9.5 days vs. 15.1 days, p=0.006). Among patients with HCC, cholangiocarcinoma, and colorectal liver metastasis, there was no difference in overall and disease-free survival between the two groups. After propensity score matching in 37 patients with HCC for each group, the robotic group still showed a shorter hospital stay and comparable long-term outcomes. CONCLUSIONS: Robotic major liver resections provided improved perioperative outcomes and comparable long-term oncologic outcome compared with open resections. Therefore, robotic surgery should be considered one of the options for minimally invasive major liver resections.

Laparoscopic pancreaticoduodenectomy in pancreatic ductal adenocarcinoma.

Laparoscopic pancreatoduodenectomy (LPD) in pancreatic cancer is primarily criticized for its technical and oncological safety. Although solid evidence has not yet been established, many institutions are performing LPD for pancreatic cancer patients, with continuous efforts to ensure oncologic safety. In this video, we demonstrated a case of standard LPD combined with vascular resection in pancreatic cancer.

Clinical Pattern of Preoperative Positron Emission Tomography/Computed Tomography (PET/CT) Can Predict the Aggressive Behavior of Resected Solid Pseudopapillary Neoplasm of the Pancreas.

Predicting the aggressiveness of solid pseudopapillary neoplasms (SPNs) remains an important goal. The present study aimed to identify perioperative factors that can predict patients who will develop clinically aggressive SPN. Records of individuals with pathologically confirmed SPN from 2006 to 2017 were obtained from the patient registry database of Yonsei University, Severance Hospital. For this study, aggressive behavior was defined as SPN that had recurred, metastasized, or involved adjacent organs. A total of 98 patients diagnosed with SPNs were analyzed retrospectively. Of these, 10 were reported to have SPNs with aggressive characteristics. We found that age (≥40 years; p = 0.039), symptomatic presentation (p = 0.001), tumor size (>10 cm; p < 0.001), positron emission tomography/computed tomography (PET/CT) classification (p < 0.001), and lymphovascular invasion (p = 0.003) were significantly correlated with aggressive behavior of SPNs. Multivariate analysis showed that PET/CT configuration (p = 0.002) (exp(ß)111.353 (95% confidence interval (CI): 5.960-2081), age ≥40 years (p = 0.015) (exp(ß) 23.242 (95% CI: 1.854-291.4)), and lymphovascular invasion (p = 0.021) (exp(ß) 22.511 (95% CI: 1.595-317.6)) were the only independent factors associated with aggressive SPN. Our data suggest that age ≥40 years, PET/CT Type III configuration, and lymphovascular invasion are independent factors associated with aggressive SPN. This information can help clinicians develop individualized management and surveillance plans to manage patients more effectively.