Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors.Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis. As long as it is performed in an experienced center could be used as a first choice technique versus PVE or could be used as a rescue technique in case of PVE failure.
Objective: To compare the outcomes between robotic major hepatectomy (R-MH) and laparoscopic major hepatectomy (L-MH). Background: Robotic techniques may overcome the limitations of laparoscopic liver resection. However, it is unknown whether R-MH is superior to L-MH. Methods: This is a post hoc analysis of a multicenter database of patients undergoing R-MH or L-MH at 59 international centers from 2008 to 2021. Data on patient demographics, center experience volume, perioperative outcomes, and tumor characteristics were collected and analyzed. Both 1:1 propensity-score matched (PSM) and coarsened-exact matched (CEM) analyses were performed to minimize selection bias between both groups Results: A total of 4822 cases met the study criteria, of which 892 underwent R-MH and 3930 underwent L-MH. Both 1:1 PSM (841 R-MH vs. 841 L-MH) and CEM (237 R-MH vs. 356 L-MH) were performed. R-MH was associated with significantly less blood loss {PSM:200.0 [interquartile range (IQR):100.
Objective: To compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments. Background: Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in existing literature. Methods: This is a post hoc analysis of a multicenter database of 5,446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumour features and perioperative characteristics were collected and analysed. Propensity score matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias. Results: A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%) and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate (10 of 449 [2.2%] vs. 54 of 898 [6.0%]; P=0.002), less blood loss (100 mL [IQR; 50-200] days vs. 150 mL [IQR; 50-350]; P<0.001) and a shorter operative time (188 min [IQR; 140-270] vs. 222 min [IQR; 158-300]; P<0.001). These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis - lower open conversion rate (1 of 136 [0.7%] vs. 17 of 272 [6.2%]; P=0.009), less blood loss (100 mL [IQR; 48-200] vs. 160 mL [IQR; 50-400]; P<0.001) and shorter operative time (190 min [IQR; 141-258] vs. 230 min [IQR; 160-312]; P=0.003). Post-operative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset. Conclusion: RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss and open conversion rate when compared to LLLR.
Background Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. Methods This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. Results We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0–85.3%, 95% confidence interval [CI]) and 71.7% (63.8–78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. Discussion Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.
Aim: To explore potential sex differences in outcomes and regenerative parameters post major hepatectomies. Background: Although controversial, sex differences in liver regeneration have been reported for animals. Whether sex disparity exists in human liver regeneration is unknown. Methods: Data from consecutive hepatectomy patients (55 females, 67 males) and from the international ALPPS (Associating-Liver-Partition-and-Portal-vein-ligation-for-Staged-hepatectomy, a two stage hepatectomy) registry (449 females, 729 males) were analyzed. Endpoints were severe morbidity (≥3b Clavien-Dindo grades), Model for End-stage Liver Disease (MELD) scores, and ALPPS interstage intervals. For validation and mechanistic insight, female-male ALPSS mouse models were established. t, χ2, or Mann-Whitney tests were used for comparisons. Univariate/multivariate analyses were performed with sensitivity inclusion. Results: Following major hepatectomy (Hx), males had more severe complications (P=0.03) and higher liver dysfunction (MELD) P=0.0001) than females. Multivariate analysis established male sex as a predictor of complications after ALPPS stage 1 (odds ratio=1.78; 95% confidence interval: 1.126–2.89; P=0.01), and of enhanced liver dysfunction after stage 2 (odds ratio=1.93; 95% confidence interval: 1.01–3.69; P=0.045). Female patients displayed shorter interstage intervals (<2 weeks, 64% females versus 56% males, P=0.01), however, not in postmenopausal subgroups. In mice, females regenerated faster than males after ALPPS stage 1, an effect that was lost upon estrogen antagonism. Conclusions: Poorer outcomes after major surgery in males and shorter ALPPS interstage intervals in females not necessarily suggest a superior regenerative capacity of female liver. The loss of interstage advantages in postmenopausal women and the mouse experiments point to estrogen as the driver behind these sex disparities. Estrogen’s benefits call for an assessment in postmenopausal women, and perhaps men, undergoing major liver surgery.
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