Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial

Efficiency and safety of laparoscopic left hemihepatectomy: A study of intrathecal vs extrathecal Glissonean pedicle techniques

BACKGROUND

Selective hemihepatic vascular occlusion is utilized in both right and left hemihepatectomies to preserve blood supply to the intact lobe, maintain hemodynamic stability, and mitigate surgical risks. While this technique encompasses both intrathecal and extrathecal Glissonean pedicle transection methods, there is a lack of systematic comparative reports on these two approaches.

AIM

To retrospectively analyze the clinical data of patients with hepatocellular carcinoma (HCC) undergoing laparoscopic anatomical hepatectomy in our hospital to explore the feasibility, safety, and short- and long-term efficacy of extrathecal and intrathecal Glissonean pedicle transection methods in laparoscopic left hemihepatectomy.

METHODS

A retrospective study was performed to analyze the clinical data of 49 HCC patients who underwent laparoscopic left hemihepatectomy from January 2019 to December 2022 in our hospital. These patients were divided into extrathecal Glissonean pedicle transection (EGP) group (n = 24) and intrathecal Glissonean pedicle transection (IGP) group (n = 25) according to the different approaches used for selective hemihepatic vascular occlusion. The perioperative indicators, liver function indexes, complications, and follow-up findings were compared between these two groups.

RESULTS

The surgeries were smooth in both groups, and no perioperative death was noted. The hepatic pedicle transection time and the operation time were (16.1 ± 2.3) minutes and (129.6 ± 19.0) minutes, respectively, in the EGP group, which were significantly shorter than those in the IGP group [(25.5 ± 2.4) minutes and (184.8 ± 26.0) minutes, respectively], both P < 0.01. There were no significant differences in intraoperative blood loss, time to anal exhaust, hospital stay, drain indwelling time, and postoperative liver function between the two groups (all P > 0.05). The incidence of postoperative complications showed no significant difference [16.67% (4/24) vs 16.0% (4/25), P > 0.05). All the 49 HCC patients were followed up after surgery (range: 11.2-53.3 months; median: 36.4 months). The overall survival rate and disease-free survival rate were not significantly different (both P > 0.05).

CONCLUSION

Both extrathecal and intrathecal Glissonean pedicle approaches are effective and safe hepatic inflow occlusion techniques in laparoscopic left hemihepatectomy for HCC. However, the extrathecal approach simplifies the hepatic pedicle transection, shortens the operation time, and increases the surgical efficiency, making it a more feasible technique.

Comparison of the benefits and risks of hemihepatic inflow occlusion: a systematic review and meta-analysis

Background

Application of hemihepatic inflow occlusion (HIO) and total hepatic inflow occlusion (TIO) are two common approaches for hepatectomy. However, their efficacy and safety remain controversial.

Methods

Randomized control trials (RCTs) published before 15t January 2023 were included by a systematic literature search, which compared the clinical outcomes between HIO and TIO. The primary outcome was the estimated blood loss (EBL). Three independent authors screened and extracted the data and resolved disagreements by consensus. The ROB2.0 tool was used for evaluating the risk of bias.

Results

A total of 1026 patients (511 TIO and 515 HIO) from 9 studies were analyzed in the meta-analyses. The EBL between TIO and HIO group was similar, while HIO was associated with a lower proportion of patients required transfusion (P=0.002), less units of blood transferred (P<0.001) and a lower overall complication rate (P=0.008). There were no significant differences between TIO and HIO in mortality (P=0.37), length of stay (P=0.97), bile leak rate (P=0.58), liver failure rate (P=0.96), reoperation rate (P=0.48), postoperative haemorrhage rate (P=0.93) and incidence of postoperative ascites (P=0.96). The operative time of HIO was usually no more than 15 min longer than that of TIO (P<0.001).

Conclusions

Comparing with the TIO, HIO increased the operative time and failed to further reduce the EBL in patients with liver surgery. However, despite the complexity of the operation, HIO was recommended due to the similar effect on the consumption of blood products and the postoperative complications.

Gut microbiota regulates hepatic ischemia-reperfusion injury-induced cognitive dysfunction via the HDAC2-ACSS2 axis in mice

AIMS

Hepatic ischemia-reperfusion injury (HIRI) resulting from hepatic inflow occlusion, which is a common procedure in liver surgery is inevitable. Previous research has confirmed that the cognitive dysfunction induced by HIRI is closely related to dysbiosis of the gut microbiota. This research aims to investigate the mechanisms underlying this complication.

METHODS

C57BL/6 mice underwent hepatic ischemia experimentally through the occlusion of the left hepatic artery and portal vein. To assess the HDAC2-ACSS2 axis, gut microbiota transplantation. Enzyme-linked immunosorbent assay and LC/MS short-chain fatty acid detection were utilized.

RESULTS

The findings indicated a notable decline in ACSS2 expression in the hippocampus of mice experiencing hepatic ischemia-reperfusion injury, emphasizing the compromised acetate metabolism in this particular area. Furthermore, the cognitive impairment phenotype and the dysregulation of the HDAC2-ACSS2 axis could also be transmitted to germ-free mice via fecal microbial transplantation. Enzyme-linked immunosorbent assay revealed reduced Acetyl-coenzyme A (acetyl-CoA) and Acetylated lysine levels in the hippocampus.

CONCLUSION

These findings suggest that acetate metabolism is impaired in the hippocampus of HIRI-induced cognitive impairment mice and related to dysbiosis, leading to compromised histone acetylation.

Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: protocol for a randomized controlled trial

BACKGROUND

Our previous randomized controlled trial (RCT) have demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma (HCC) patients. But prolonging the hepatic inflow blocking time will inevitably aggravate the ischemia-reperfusion injury (IRI) caused by systemic response. This RCT aims to evaluate the effect of administration of dexamethasone versus placebo before clamping the hilar pedicle on postoperative liver function, inflammatory response, and perioperative outcomes among HCC patients undergoing liver resection with 25-min hepatic inflow occlusion.

METHODS AND ANALYSIS

This will be a randomized, dual-arm, parallel-group, double-blinded trial. All eligible and consecutive patients are coming from a regional medical center who are diagnosed with HCC and underwent radical R0/R1 resection. All participates are randomly allocated in dexamethasone group or placebo group. All surgeons, anesthesiologists, and outcome assessors will be blinded to allocation status. Primary endpoints are transaminase-based postoperative hepatic injury on seven consecutive days after surgery and assessed by their peak values as well as area under the curve (AUC) of the postoperative course of aminotransferases. Secondary endpoints are postoperative total bilirubin (TBil), coagulation function, inflammatory cytokines and their respective peaks, intraoperative blood loss, postoperative hospital stay, morbidity, and mortality. The above parameters will be compared using the corresponding statistical approach. Subgroup analysis will be performed according to the liver cirrhosis and major hepatectomy.

DISCUSSION

Based on our previous study, we will explore further the effect of glucocorticoid administration on attenuating the surgical stress response in order to follow securely 25-min hepatic inflow occlusion. Therefore, the trial protocol is reasonable and the results of the trial may be clinically significant.

TRIAL REGISTRATION

This trial was registered on 3 December 2022, in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR2200066381. The protocol version is V1.0 (20221104).

Current Trends in Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Surgical management, including hepatic resection, liver transplantation, and ablation, offers the greatest potential for a curative approach. This review aims to discuss recent advancements in HCC surgery and identify unresolved issues in the field. Treatment selection relies on the BCLC staging system, with surgical therapies primarily recommended for early-stage disease. Recent studies have shown that patients previously considered unresectable, such as those with portal vein tumor thrombus and uncomplicated portal hypertension, may benefit from hepatic resection. Minimally invasive surgery and improved visualization techniques are also explored, alongside new techniques for optimizing future liver remnant, ex vivo resection, and advancements in hemorrhage control. Liver transplantation criteria, particularly the long-standing Milan criteria, are critically examined. Alternative criteria proposed and tested in specific regions are presented. In the context of organ shortage, bridging therapy plays a critical role in preventing tumor progression and maintaining patients eligible for transplantation. Lastly, we explore emerging ablation modalities, comparing them with the current standard, radiofrequency ablation. In conclusion, this comprehensive review provides insights into recent trends and future prospects in the surgical management of HCC, highlighting areas that require further investigation.

Exosomes from adipose-derived mesenchymal stem cells can attenuate liver injury caused by minimally invasive hemihepatectomy combined with ischemia-reperfusion in minipigs by modulating the endoplasmic reticulum stress response

AIMS

Hepatic ischemia-reperfusion injury (IRI) impairs postoperative recovery of liver function after liver resection or transplantation. It is crucial to minimize liver injury during surgery in order to improve patient survival and quality of life. The aim of this study was to explore the therapeutic efficacy of exosomes from adipose-derived mesenchymal stem cells (ADSCs-exo) against hepatectomy combined with IRI injury and compare that with the effect of adipose-derived mesenchymal stem cells (ADSCs).

MAIN METHOD

Minimally invasive hemihepatectomy combined with hepatic IRI was established in minipigs. A single dose of ADSCs-exo, ADSCs or PBS was injected through the portal vein. The histopathological features and function of the liver, and the oxidative stress levels, endoplasmic reticulum (ER) ultrastructure and ER stress (ERS) response were analyzed pre- and postoperatively.

KEY FINDINGS

ADSCs-exo alleviated the histopathological injuries and ultrastructural changes in the ER, and significantly improved ALP, TP and CAT levels. Furthermore, ADSCs-exo treatment also downregulated ERS-related factors such as GRP78, ATF6, IRE1α/XBP1, PERK/eIF2α/ATF4, JNK and CHOP. The therapeutic effects of ADSCs-exo and ADSCs were similar.

SIGNIFICANCE

Intravenous administration of a single dose of ADSCs-exo is a novel cell-free therapeutic approach to improve surgery-related liver injury. Our findings provide evidence of the paracrine effect of ADSCs and an experimental basis for treating liver injury with ADSCs-exo instead of ADSCs.