Outcomes of hepatectomy for hepatolithiasis based on 3-dimensional reconstruction technique

mm3DSNet: multi-scale and multi-feedforward self-attention 3D segmentation network for CT scans of hepatobiliary ducts

Image segmentation is a key step of the 3D reconstruction of the hepatobiliary duct tree, which is significant for preoperative planning. In this paper, a novel 3D U-Net variant is designed for CT image segmentation of hepatobiliary ducts from the abdominal CT scans, which is composed of a 3D encoder-decoder and a 3D multi-feedforward self-attention module (MFSAM). To well sufficient semantic and spatial features with high inference speed, the 3D ConvNeXt block is designed as the 3D extension of the 2D ConvNeXt. To improve the ability of semantic feature extraction, the MFSAM is designed to transfer the semantic and spatial features at different scales from the encoder to the decoder. Also, to balance the losses for the voxels and the edges of the hepatobiliary ducts, a boundary-aware overlap cross-entropy loss is proposed by combining the cross-entropy loss, the Dice loss, and the boundary loss. Experimental results indicate that the proposed method is superior to some existing deep networks as well as the radiologist without rich experience in terms of CT segmentation of hepatobiliary ducts, with a segmentation performance of 76.54% Dice and 6.56 HD.

Three-dimensional visualization technology for guiding one-step percutaneous transhepatic cholangioscopic lithotripsy for the treatment of complex hepatolithiasis

BACKGROUND

Biliary stone disease is a highly prevalent condition and a leading cause of hospitalization worldwide. Hepatolithiasis with associated strictures has high residual and recurrence rates after traditional multisession percutaneous transhepatic cholangioscopic lithotripsy (PTCSL).

AIM

To study one-step PTCSL using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique guided by three-dimensional (3D) visualization.

METHODS

This was a retrospective, single-center study analyzing, 140 patients who, between October 2016 and October 2023, underwent one-step PTCSL for hepatolithiasis. The patients were divided into two groups: The 3D-PTOBF group and the PTOBF group. Stone clearance on choledochoscopy, complications, and long-term clearance and recurrence rates were assessed.

RESULTS

Age, total bilirubin, direct bilirubin, Child-Pugh class, and stone location were similar between the 2 groups, but there was a significant difference in bile duct strictures, with biliary strictures more common in the 3D-PTOBF group (P = 0.001). The median follow-up time was 55.0 (55.0, 512.0) days. The immediate stone clearance ratio (88.6% vs 27.1%, P = 0.000) and stricture resolution ratio (97.1% vs 78.6%, P = 0.001) in the 3D-PTOBF group were significantly greater than those in the PTOBF group. Postoperative complication (8.6% vs 41.4%, P = 0.000) and stone recurrence rates (7.1% vs 38.6%, P = 0.000) were significantly lower in the 3D-PTOBF group.

CONCLUSION

Three-dimensional visualization helps make one-step PTCSL a safe, effective, and promising treatment for patients with complicated primary hepatolithiasis. The perioperative and long-term outcomes are satisfactory for patients with complicated primary hepatolithiasis. This minimally invasive method has the potential to be used as a substitute for hepatobiliary surgery.

Application of 3-dimensional visualization and image fusion technology in liver cancer with portal vein tumor thrombus surgery

Liver cancer with portal vein tumor thrombus (PVTT) is a frequent finding and is related to poor prognosis. Surgical resection provides a more promising prognosis in selected patients. The purpose of this study was to explore the application of 3D (3-dimensional) visualization and image fusion technology in liver cancer with PVTT surgery. 12 patients were treated with surgery between March 2019 and August 2022. The preoperative standard liver volume (SLV), estimated future liver remnant (FLR), FLR/SLV, 3D visualization models, PVTT classification, operation programs, surgical results, and prognosis were collected and analyzed. Twelve patients who had complete data of 3D visualization and underwent hemihepatectomy combined with portal vein tumor thrombectomy. The operation plan was formulated by 3D visualization and was highly consistent with the actual surgery. The SLV was 1208.33 ± 63.22 mL, FLR was 734.00 mL and FLR/SLV was 61.62 ± 19.38%. The accuracy of classification of PVTT by 3D visualization was 100%, Cheng type Ⅱa (4 cases), Ⅱb (2 cases), Ⅲa (4 cases), and Ⅲb (2 cases). The 3D visualization model was a perfect fusion with the intraoperative live scene and precise guidance for hepatectomy. No patient was suffering from postoperative liver failure and without procedure‑associated death. 6 patients died of tumor recurrence, and 2 patients died of other reasons. The 12-month cumulative survival rate was 25.9%. 3D visualization and image fusion technology could be used for precise assessment of FLR, classification of PVTT, surgery navigation, and which was helpful in improving the safety of hepatectomy.

Laparoscopic left hemihepatectomy using augmented reality navigation plus ICG fluorescence imaging for hepatolithiasis: a retrospective single-arm cohort study (with video)

BACKGROUND

Laparoscopic left hemihepatectomy (LLH) has been shown to be an effective and safe method for treating hepatolithiasis primarily affecting the left hemiliver. However, this procedure still presents challenges. Due to pathological changes in intrahepatic duct stones, safely dissecting the hilar vessels and determining precise resection boundaries remains difficult, even with fluorescent imaging. Our team proposed a new method of augmented reality navigation (ARN) combined with Indocyanine green (ICG) fluorescence imaging for LLH in hepatolithiasis cases. This study aimed to investigate the feasibility of this combined approach in the procedure.

METHODS

Between May 2021 and September 2023, 16 patients with hepatolithiasis who underwent LLH were included. All patients underwent preoperative 3D evaluation and were then guided using ARN and ICG fluorescence imaging during the procedure. Perioperative and short-term postoperative outcomes were assessed to evaluate the safety and efficacy of the method.

RESULTS

All 16 patients successfully underwent LLH. The mean operation time was 380.31 ± 92.17 min, with a mean estimated blood loss of 116.25 ± 64.49 ml. ARN successfully aided in guiding hilar vessel dissection in all patients. ICG fluorescence imaging successfully identified liver resection boundaries in 11 patients (68.8%). In the remaining 5 patients (31.3%) where fluorescence imaging failed, virtual liver segment projection (VLSP) successfully identified their resection boundaries. No major complications occurred in any patients. Immediate stone residual rate, stone recurrence rate, and stone extraction rate through the T-tube sinus tract were 12.5%, 6.3%, and 6.3%, respectively.

CONCLUSION

The combination of ARN and ICG fluorescence imaging enhances the safety and precision of LLH for hepatolithiasis. Moreover, ARN may serve as a safe and effective tool for identifying precise resection boundaries in cases where ICG fluorescence imaging fails.

Efficacy of hepatectomy for hepatolithiasis using 3D visualization combined with ICG fluorescence imaging: A retrospective cohort study

BACKGROUND

Hepatolithiasis is a complex condition that poses challenges and difficulties in surgical treatment. Three-dimensional visualization technology combined with fluorescence imaging (3DVT-FI) enables accurate preoperative assessment and real-time intraoperative navigation. However, the perioperative outcomes of 3DVT-FI in hepatolithiasis have not been reported. We aim to evaluate the efficacy of 3DVT-FI in the treatment of hepatolithiasis.

METHODS

A retrospective analysis was performed on 128 patients who underwent hepatectomy for hepatolithiasis at the Department of Hepatobiliary Surgery, Zhujiang Hospital, between January 2017 and December 2022. Among them, 50 patients underwent hepatectomy using 3DVT-FI (3DVT-FI group), while 78 patients underwent conventional hepatectomy without 3DVT-FI (CH group). The operative data, postoperative liver function indices, complication rates and stone residue were compared between the two groups.

RESULTS

There were no significant differences in preoperative baseline data between the two groups (p > 0.05). Compared with the CH group, the 3DVT-FI group exhibited lower intraoperative blood loss (140.00 ± 112.12 vs. 225.99 ± 186.50 mL, p = 0.001), and a lower intraoperative transfusion rate (8.0% vs. 23.1%, p = 0.027). The overall incidence of postoperative complications did not differ significantly (22.0% vs. 35.9%, p = 0.096). The 3DVT-FI group was associated with a lower immediate residual stone rate (16.0% vs. 34.6%, p = 0.021). There were no perioperative deaths in the 3DVT-FI group, while one perioperative death occurred in the CH group.

CONCLUSIONS

The 3DVT-FI may offer significant benefits in terms of surgical safety, reduced intraoperative bleeding and decreased stone residue during hepatectomy for hepatolithiasis.

Augmented reality-assisted navigation system contributes to better intraoperative and short-time outcomes of laparoscopic pancreaticoduodenectomy: a retrospective cohort study

BACKGROUND

Augmented reality (AR)-assisted navigation system are currently good techniques for hepatectomy; however, its application and efficacy for laparoscopic pancreatoduodenectomy have not been reported. This study sought to focus on and evaluate the advantages of laparoscopic pancreatoduodenectomy guided by the AR-assisted navigation system in intraoperative and short-time outcomes.

METHODS

Eighty-two patients who underwent laparoscopic pancreatoduodenectomy from January 2018 to May 2022 were enrolled and divided into the AR and non-AR groups. Clinical baseline features, operation time, intraoperative blood loss, blood transfusion rate, perioperative complications, and mortality were analyzed.

RESULTS

AR-guided laparoscopic pancreaticoduodenectomy was performed in the AR group ( n =41), whereas laparoscopic pancreatoduodenectomy was carried out routinely in the non-AR group ( n =41). There was no significant difference in baseline data between the two groups ( P >0.05); Although the operation time of the AR group was longer than that of the non-AR group (420.15±94.38 vs. 348.98±76.15, P <0.001), the AR group had a less intraoperative blood loss (219.51±167.03 vs. 312.20±195.51, P =0.023), lower blood transfusion rate (24.4 vs. 65.9%, P <0.001), lower occurrence rates of postoperative pancreatic fistula (12.2 vs. 46.3%, P =0.002) and bile leakage (0 vs. 14.6%, P =0.026), and shorter postoperative hospital stay (11.29±2.78 vs. 20.04±11.22, P <0.001) compared with the non-AR group.

CONCLUSION

AR-guided laparoscopic pancreatoduodenectomy has significant advantages in identifying important vascular structures, minimizing intraoperative damage, and reducing postoperative complications, suggesting that it is a safe, feasible method with a bright future in the clinical setting.

A Bibliometric Analysis of the Role of 3D Technology in Liver Cancer Resection

BACKGROUND

Liver cancer resection is an effective but complex way to treat liver cancer, and complex anatomy is one of the reasons for the difficulty of surgery. The use of 3D technology can help surgeons cope with this dilemma. This article intends to conduct a bibliometric analysis of the role of 3D technology in liver cancer resection.

METHODS

(TS = (3D) OR TS = (three-dimensional)) AND (TS = (((hepatic) OR (liver)) AND ((cancer) OR (tumor) OR (neoplasm)))) AND (TS = (excision) OR TS = (resection)) was used as a search strategy for data collection in the Web of Science (WoS) Core Collection. CiteSpace, Carrot2 and Microsoft Office Excel were used for data analysis.

RESULTS

Three hundred and eighty-eight relevant articles were obtained. Their annual and journal distribution maps were produced. Countries/regions and institutions collaboration, author collaboration, references co-citations and their clusters and keywords co-occurrences and their clusters were constructed. Carrot2 cluster analysis was performed.

CONCLUSIONS

There was an overall upward trend in the number of publications. China's contribution was greater, and the USA had greater influence. Southern Med Univ was the most influential institution. However, the cooperation between institutions still needs to be further strengthened. Surgical Endoscopy and Other Interventional Techniques was the most published journal. Couinaud C and Soyer P were the authors with the highest citations and centrality, respectively. "Liver planning software accurately predicts postoperative liver volume and measures early regeneration" was the most influential article. 3D printing, 3D CT and 3D reconstruction may be the mainstream of current research, and augmented reality (AR) may be a future hot spot.

The value of three-dimensional visualization techniques in hepatectomy for complicated hepatolithiasis: A propensity score matching study

OBJECTIVE

The present study aimed to investigate the safety, feasibility, and efficacy of three-dimensional visualization technique (3DVT)-guided hepatectomy in the treatment of complicated hepatolithiasis.

METHODS

The clinical and follow-up data of 279 patients with complicated hepatolithiasis were retrospectively analyzed. The patients were divided into a 3DVT group (group A, 66 cases) and a non-3DVT group (group B, 213 cases). After baseline data were balanced using propensity score matching (PSM), the clinical characteristics and follow-up data of the two groups were observed.

RESULTS

After 1:1 PSM, 58 patients in each group were successfully matched with each other. When the groups were compared, the surgical duration (p = 0.033) and intraoperative blood loss (p = 0.002) of group A were lower than those of group B. The immediate stone clearance rate (91.4% vs. 75.9%, p = 0.024) and quality of life outcome (p = 0.034) of group A were significantly higher than those of group B. Logistic regression analysis showed that history of two or more biliary tract operations (odds ratio [OR] = 6.544, 95% confidence interval [CI] = 1.193-35.890, p = 0.031), bilateral stone distribution (OR = 4.198, 95% CI = 1.186-14.854, p = 0.026), and Geng grade III or IV (OR = 12.262, 95% CI = 2.224-67.617, p = 0.004) were independent risk factors for poor outcomes in patients with complicated hepatolithiasis.

CONCLUSION

Compared to conventional imaging examinations, 3DVT can be used to guide and achieve accurate preoperative diagnosis of complicated hepatolithiasis and has good safety, feasibility, and efficacy.

A meta-analysis of the three-dimensional reconstruction visualization technology for hepatectomy

This meta-analysis was conducted to systematically evaluate the short-term efficacy and safety of the three-dimensional (3D) reconstruction visualization technology (3D-RVT) technique for hepatectomy. A systematic literature search was used to gather information on the 3D reconstruction visualization technology technique for hepatectomy from retrospective cohort studies and comparative studies. The retrieval period was up to March 2022. Publications and conference papers in English were manually searched and references in bibliographies traced. After evaluating the quality of selected studies, a meta-analysis was conducted using Review Manager 5.1 software. We included 12 studies comprising 2053 patients with liver disease. Our meta-results showed that 3D-RVT significantly shortened operation times [weighted mean differences (WMD) = -29.36; 95% confidence interval (CI): -55.20 to -3.51; P = 0.03], reduced intraoperative bleeding [WMD = -93.53; 95% CI: -152.32 to -34.73; P = 0.002], reduced blood transfusion volume [WMD = -66.06; 95% CI: -109.13 to -22.99; P = 0.003], and shortened hospital stays [WMD = -1.90; 95% CI: -3.05 to -0.74; P = 0.001]. Additionally, the technique reduced the use of hepatic inflow occlusion and avoided overall postoperative complications [odds ratio (OR) = 0.60; 95% CI: 0.46 to 0.79; P < 0.001]. 3D-RVT is safe and effective for liver surgery and provides safety assessments before anatomical hepatectomy.

The role of artificial intelligence in surgical simulation

Artificial Intelligence (AI) plays an integral role in enhancing the quality of surgical simulation, which is increasingly becoming a popular tool for enriching the training experience of a surgeon. This spans the spectrum from facilitating preoperative planning, to intraoperative visualisation and guidance, ultimately with the aim of improving patient safety. Although arguably still in its early stages of widespread clinical application, AI technology enables personal evaluation and provides personalised feedback in surgical training simulations. Several forms of surgical visualisation technologies currently in use for anatomical education and presurgical assessment rely on different AI algorithms. However, while it is promising to see clinical examples and technological reports attesting to the efficacy of AI-supported surgical simulators, barriers to wide-spread commercialisation of such devices and software remain complex and multifactorial. High implementation and production costs, scarcity of reports evidencing the superiority of such technology, and intrinsic technological limitations remain at the forefront. As AI technology is key to driving the future of surgical simulation, this paper will review the literature delineating its current state, challenges, and prospects. In addition, a consolidated list of FDA/CE approved AI-powered medical devices for surgical simulation is presented, in order to shed light on the existing gap between academic achievements and the universal commercialisation of AI-enabled simulators. We call for further clinical assessment of AI-supported surgical simulators to support novel regulatory body approved devices and usher surgery into a new era of surgical education.

Three-dimensional visual technique based on CT lymphography data combined with methylene blue in endoscopic sentinel lymph node biopsy for breast cancer

BACKGROUND

The combined application of blue dye and radioisotopes is currently the primary mapping technique used for sentinel lymph node biopsy (SLNB) in breast cancer patients. However, radiocolloid techniques have not been widely adopted, especially in developing countries, given the strict restrictions on radioactive materials. Consequently, we carried out a retrospective study to evaluate the feasibility and accuracy of three-dimensional visualization technique (3DVT) based on computed tomography-lymphography (CT-LG) in endoscopic sentinel lymph node biopsy (ESLNB) for breast cancer.

METHODS

From September 2018 to June 2020, 389 patients who underwent surgical treatment of breast cancer in our department were included in this study. The CT-LG data of these patients were reconstructed into digital 3D models and imported into Smart Vision Works V1.0 to locate the sentinel lymph node (SLN) and for visual simulation surgery. ESLNB and endoscopic axillary lymph node dissection were carried out based on this new technique; the accuracy and clinical value of 3DVT in ESLNB were analyzed.

RESULTS

The reconstructed 3D models clearly displayed all the structures of breast and axilla, which favors the intraoperative detection of SLNs. The identification rate of biopsied SLNs was 100% (389/389). The accuracy, sensitivity, and false-negative rate were 93.83% (365/389), 93.43% (128/137), and 6.57% (9/137), respectively. Upper limb lymphedema occurred in one patient 3 months after surgery during the 12-month follow-up period.

CONCLUSIONS

Our 3DVT based on CT-LG data combined with methylene blue in ESLNB ensures a high identification rate of SLNs with low false-negative rates. It, therefore, has the potential to serve as a new method for SLN biopsy in breast cancer cases.

Diagnostic accuracy of 3D imaging combined with intra-operative ultrasound in the prediction of post-hepatectomy liver failure

Background

The risk of post-hepatectomy liver failure (PHLF) is difficult to predict preoperatively. Accurate preoperative assessment of residual liver volume is critical in PHLF. Three-dimensional (3D) imaging and intra-operative ultrasound (IOUS) offer significant advantages in calculating liver volume and have been widely used in hepatectomy risk assessment. Our research aimed to explore the accuracy of 3D imaging technique combining IOUS in predicting PHLF after hepatectomy.

Methods

We used a retrospective study design to analyze patients who underwent hepatectomy with 3D imaging combined with IOUS between 2017 and 2020. Utilizing 3D reconstruction, the patient's residual liver volumes (PRLVs) and ratio of PRLV to standard liver volume (SLV) were calculated preoperatively. Hepatectomy were performed and actual hepatectomy volume (AHV) were measured. Consistency between preoperative planned hepatectomy volume (PPHV) and AHV was quantified postoperatively by Bland-Altman analysis. Multiple logistic regression and receiver-operating characteristic (ROC) curves were utilized to discuss the predictive value of PRLV/SLV in PHLF.

Results

Among the 214 included patients, 58 (27.1%) had PHLF. Patients with PHLF had significantly higher residual rates of ICG-R15 (%) (P=0.000) and a lower PRLV/SLV ratio (P=0.000). Bland-Altman analysis showed that PPHV was consistent with AHV (P=0.301). Multivariate analysis confirmed that PRLV/SLV ratio >60% (OR, 0.178; 95% CI: 0.084-0.378; P<0.01) was a protective factor for PHLF. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75.8% (95% CI: 64.5.3-87.2%), 66.6% (95% CI: 59.1-74.1%), 45.8%, and 88.1%, respectively. The area under the ROC curve (AUC) was 73.7% (95% CI: 65.7-85.8%) and the diagnostic accuracy of PRLV/SLV for PHLF was moderate (P<0.001). These results were validated in the validation cohort perfectly. The primary cohort included 214 patients with a PHLF rate of 27.1% (n=58, 28 grade B and 13 grade C). The validation cohort included 135 patients with a PHLF rate of 35.6% (n=48, 24 grade B and 11 grade C).

Conclusions

The calculation of PRLV/SLV has predictive value in PHLF and can be exploited as a predictive factor. The 3D imaging technique combined with IOUS may be useful for PHLF risk assessment in hepatectomy patients.

Augmented reality navigation facilitates laparoscopic removal of foreign body in the pancreas that cause chronic complications

BACKGROUND

Foreign bodies that enter the pancreas and cause chronic complications cannot be removed by endoscopy. Surgical removal is necessary but also challenging. The development of augmented reality navigation has made it possible to accurate intraoperative navigation in laparoscopic surgery.

METHODS

A 37-year-old female had epigastric pain for 3 months and her abdominal CT showed a linear high-density shadow in her pancreas along with chronic pancreatitis. Three-dimensional models of the liver, pancreas, stomach, blood vessels, and foreign body were created based on CT images. Gastroptosis was found in the three-dimensional models, so surgical approach was adapted to open the hepatogastric ligament to reach the pancreas. After 2-3 s of video images were captured by 3D laparoscopy, a three-dimensional dense stereo-reconstruction method was used to obtain the surface model of pancreas, stomach, and blood vessels. The Globally Optimal Iterative Closest Point method was used to obtain a spatial transformation matrix between the preoperative CT image space and the intraoperative laparoscopic space. Under augmented reality navigation guidance, the position and location of the foreign body were displayed on the surface of the pancreas. Then intraoperative ultrasound was used for further verification and to quickly and easily confirm the surgical entrance. After minimal dissection and removal of the pancreatic parenchyma, the foreign body was removed completely.

RESULTS

The operation time was 60 min, the estimated blood loss was 10 ml. The foreign body was identified as a 3-cm-long fishbone. The patient recovered without complications and was discharged on the third postoperative day.

CONCLUSION

Because it enables direct visual navigation via simple operation, ARN facilitates the laparoscopic removal of foreign bodies in the pancreas with accurate and rapid positioning and minimal damage.

Clinical online nomogram for predicting prognosis in recurrent hepatolithiasis after biliary surgery: A multicenter, retrospective study

BACKGROUND

Methods for predicting the prognosis of patients undergoing surgery for recurrent hepatolithiasis after biliary surgery are currently lacking.

AIM

To establish a nomogram to predict the prognosis of patients with recurrent hepatolithiasis after biliary surgery.

METHODS

In this multicenter, retrospective study, data of consecutive patients in four large medical centers who underwent surgery for recurrent hepatolithiasis after biliary surgery were retrospectively analyzed. We constructed a nomogram to predict the prognosis of recurrent hepatolithiasis in a training cohort of 299 patients, following which we independently tested the nomogram in an external validation cohort of 142 patients. Finally, we used the concordance index (C-index), calibra-tion, area under curve, decision curve analysis, clinical impact curves, and visual fit indices to evaluate the accuracy of the nomogram.

RESULTS

Multiple previous surgeries [2 surgeries: Odds ratio (95% confidence interval), 1.451 (0.719-2.932); 3 surgeries: 4.573 (2.015-10.378); ≥ 4 surgeries: 5.741 (1.347-24.470)], bilateral hepatolithiasis [1.965 (1.039-3.717)], absence of immediate clearance [2.398 (1.304-4.409)], neutrophil-to-lymphocyte ratio ≥ 2.462 [1.915 (1.099-3.337)], and albumin-to-globulin ratio ≤ 1.5 [1.949 (1.056-3.595)] were found to be independent factors influencing the prognosis. The nomogram constructed on the basis of these variables showed good reliability in the training (C-index: 0.748) and validation (C-index: 0.743) cohorts. Compared with predictions using traditional classification models, those using our nomogram showed better agreement with actual observations in the calibration curve for the probability of endpoints and the receiver operating characteristic curve. Dichloroacetate and clinical impact curves showed a larger net benefit of the nomogram.

CONCLUSION

The nomogram developed in this study demonstrated superior performance and discriminative power compared to the three traditional classifications. It is easy to use, highly accurate, and shows excellent calibration.

Indications and Complications of Hepatic Resection Patients at Sher-I-Kashmir Institute of Medical Sciences: An Observational Study

Aim: This study aimed to determine the indications and demographic profile of hepatic resection at Sher-I-Kashmir Institute of Medical Sciences (SKIMS), the performed types of hepatic resection, as well as assess the details of the operation and perioperative complications of hepatic resection.

Methods: This is a prospective, retrospective observational study. The retrospective study period was from January 2005 to August 2015 and the prospective study period was from 2015 till 2017. Prospective patients were clinically evaluated by medical history and clinical examination and also underwent various investigations. The patients were scored on Child-Pugh and American Society of Anesthesiology (ASA) scores for risk stratification and prepared for surgery, which included segmentectomy to major liver resection. The retrospective data were obtained from the Medical Records Department (MRD). Statistical analysis was done on SPSS software 25.0 version (Armonk, NY: IBM Corp.).

Results: This study included 122 patients with a male to female ratio of 1:1.59. The patients' age was between 1 and 73 years. The patients' most common complaint was right upper quadrant abdominal pain. The main established clinical diagnosis was oriental cholangiohepatitis (OCH) (36.9%) followed by carcinoma of gallbladder (CaGB) which accounted for 37 cases (30.4%). Liver metastases including solitary masses and multiple lesions were 10 cases (8.2%). Fifty-five patients underwent left lateral segmentectomy (45.1%) and mostly for OCH. Standard wedge resection was done in 30.7% of cases and for all cases of CaGB. The mean blood loss was 146.5 ml. A total of 37 patients had complications. Wound infection was the most common complication, occurring in 10 patients (8.2%).

Conclusion: Patients with hepatobiliary pathology, necessitating liver resection are now routinely admitted to the Department of Surgical Gastroenterology in SKIMS, Srinagar. Patients are carefully evaluated and operated with a confirmed definitive diagnosis. The overall surgical outcome does not differ from India's best centers.

The Application of Preoperative Three-Dimensional Reconstruction Visualization Digital Technology in the Surgical Treatment of Hepatic Echinococcosis in Tibet

Objective: The present study aims to explore the application value of three-dimensional (3D) reconstruction technology in the preoperative evaluation of patients with complicated hepatic echinococcosis in Tibet.

Methods: A total of 200 patients with complicated hepatic echinococcosis, admitted to our hospital between May 2019 and December 2020, who underwent radical hepatectomy, were enrolled in the present study. The patients were randomly divided into a preoperative computer tomography group and a preoperative 3D reconstruction group. According to the imaging results, a surgical plan was formulated. A comparison was made between the two groups of the coincidence rate of the surgical plan and intraoperative and postoperative complications.

Results: The patients with hepatic echinococcosis who underwent 3D visualization reconstruction before surgery had a high compliance rate with the surgical plans and the operating time, the number of cases with blood flow blockage, the blood flow blockage time, intraoperative hemorrhage, and postoperative biliary fistulas were significantly lower.

Conclusion: The application of preoperative 3D visualization reconstruction in patients with complicated hepatic echinococcosis in Tibet could effectively improve surgical safety.

Artificial intelligence in perioperative management of major gastrointestinal surgeries

Artificial intelligence (AI) demonstrated by machines is based on reinforcement learning and revolves around the usage of algorithms. The purpose of this review was to summarize concepts, the scope, applications, and limitations in major gastrointestinal surgery. This is a narrative review of the available literature on the key capabilities of AI to help anesthesiologists, surgeons, and other physicians to understand and critically evaluate ongoing and new AI applications in perioperative management. AI uses available databases called “big data” to formulate an algorithm. Analysis of other data based on these algorithms can help in early diagnosis, accurate risk assessment, intraoperative management, automated drug delivery, predicting anesthesia and surgical complications and postoperative outcomes and can thus lead to effective perioperative management as well as to reduce the cost of treatment. Perioperative physicians, anesthesiologists, and surgeons are well-positioned to help integrate AI into modern surgical practice. We all need to partner and collaborate with data scientists to collect and analyze data across all phases of perioperative care to provide clinical scenarios and context. Careful implementation and use of AI along with real-time human interpretation will revolutionize perioperative care, and is the way forward in future perioperative management of major surgery.

Role of artificial intelligence in hepatobiliary and pancreatic surgery

Over the past decade, enhanced preoperative imaging and visualization, improved delineation of the complex anatomical structures of the liver and pancreas, and intra-operative technological advances have helped deliver the liver and pancreatic surgery with increased safety and better postoperative outcomes. Artificial intelligence (AI) has a major role to play in 3D visualization, virtual simulation, augmented reality that helps in the training of surgeons and the future delivery of conventional, laparoscopic, and robotic hepatobiliary and pancreatic (HPB) surgery; artificial neural networks and machine learning has the potential to revolutionize individualized patient care during the preoperative imaging, and postoperative surveillance. In this paper, we reviewed the existing evidence and outlined the potential for applying AI in the perioperative care of patients undergoing HPB surgery.

Long-term efficacy and advantages of minimally invasive hepatectomy for hepatolithiasis: A protocol for systematic review and meta-analysis

BACKGROUND

Hepatolithiasis commonly occurs in the bile duct proximal to the confluence of the right and left hepatic ducts, regardless of the coexistence of gallstones in gallbladder or the common bile duct. Clinical research proves that minimally invasive surgery is effective in the treatment of hepatolithiasis. Although previous meta-analysis also shows that it could reduce intraoperative bleeding and blood transfusion, and shorten hospital stay time, there are few meta-analyses on its long-term efficacy. We conducted the meta-analysis and systematic review to systematically evaluate the long-term efficacy and advantages of minimally invasive hepatectomy in the treatment of hepatolithiasis.

METHODS

Articles of randomized controlled trials will be searched in the PubMed, Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, Chongqing VIP Chinese Science and Technology Periodical Database, Chinese Biological and Medical database, and Wanfang database until September, 2020. Literature extraction and risk of bias assessment will be completed by 2 reviewers independently. Statistical analysis will be conducted in RevMan 5.3.

RESULTS

This study will summarize the present evidence by exploring the long-term efficacy and advantages of minimally invasive hepatectomy in the treatment of hepatolithiasis CONCLUSIONS:: The findings of the study will help to determine potential long-term efficacy and advantages of minimally invasive hepatectomy in the treatment of hepatolithiasis.

ETHICS AND DISSEMINATION

The private information from individuals will not be published. This systematic review also will not involve endangering participant rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/H6WRV.

Three-dimensional versus two-dimensional video-assisted hepatectomy for liver disease: a meta-analysis of clinical data

Introduction

The benefit of three-dimensional (3D) visualization for liver disease is uncertain.

Aim

To evaluate the effectiveness and safety of 3D versus two-dimensional (2D) video-assisted hepatectomy for LD.

Material and methods

We searched PubMed, Embase, Cochrane Library, Medline, and Web of Science for studies addressing 3D versus 2D for 2D until 30 February 2020. Study-specific effect sizes and their 95% confidence intervals (CIs) were combined to calculate the pooled value using a fixed-effects or random-effects model.

Results

Nine studies with 808 patients were included. The 3D group had shorter operative time (mean difference (MD) = 34.39; 95% CI = 59.50, 9.28), experienced less intraoperative blood loss (MD = 106.55; 95% CI = 183.76, 29.34), and a smaller blood transfusion volume (MD = 88.25; 95% CI = 141.26, 35.24). The 3D group had a smaller difference between the predicted volume and the actual resected volume (MD = 103.25; 95% CI = 173.24, 33.26) and a lower rate of postoperative complications (odds ratio (OR) = 0.57; 95% CI: 0.35, 0.91).

Conclusions

During surgery, 3D video-assisted hepatectomy could effectively reduce operative time, intraoperative bleeding, and blood transfusion volume, and had a smaller difference between the predicted volume and the actual resected volume and a lower rate of postoperative complications. More high-quality randomized controlled trials are required to verify the reliability and validity of our conclusion.

Outcomes of reoperation for hepatolithiasis with 3D imaging individualized preoperative planning technique: a single-center experience

BACKGROUND

A detailed assessment of biliary tract anatomy is necessary for the successful reoperation for hepatolithiasis. This study aimed to evaluate the feasibility of preoperative individualized surgical planning with three-dimensional (3D) imaging technique for reoperation of hepatolithiasis.

METHODS

This was a retrospective matched case-control study. From January 2011 to December 2018, 56 patients receiving reoperation according to the individualized preoperative plan based on 3D imaging at our center were included (group A). Meanwhile, 54 patients receiving traditional imaging guided reoperation matched by age, gender and distribution of hepatobiliary stones to each case were selected as controls (group B). The perioperative and long-term follow-up outcomes were compared between the two groups.

RESULTS

There was no significant difference in demographic characteristics between groups. Compared with group B, the group A had a significantly shorter operation time (245.7±56.2 min vs. 305.2±79.9 min, P<0.001), a significantly higher surgical plan implementation rate (SPIR, 92.9% vs. 66.7%, P=0.001) and a lower incidence-of severe complications (Clavien-Dindo grade>II, 1.8% vs. 14.8%, P=0.015). The incidences of initial residual stone (7.1% vs. 44.4%, P<0.001) and repeated cholangitis (3.6% vs. 33.3%, P<0.001) were significantly lower in group A than in group B. After postoperative choledochoscopic lithotripsy, the incidence of final residual stones was significantly lower in group A than in group B. (1.8% vs. 20.4%, P=0.002).

CONCLUSIONS

The preoperative 3D imaging assisted surgical planning is feasible and safe for reoperation of hepatolithiasis which can effectively improve surgical plan implementation rate and reduce the incidence of postoperative complications as compared with conventional surgical planning.

Consensus recommendations of three-dimensional visualization for diagnosis and management of liver diseases

Three-dimensional (3D) visualization involves feature extraction and 3D reconstruction of CT images using a computer processing technology. It is a tool for displaying, describing, and interpreting 3D anatomy and morphological features of organs, thus providing intuitive, stereoscopic, and accurate methods for clinical decision-making. It has played an increasingly significant role in the diagnosis and management of liver diseases. Over the last decade, it has been proven safe and effective to use 3D simulation software for pre-hepatectomy assessment, virtual hepatectomy, and measurement of liver volumes in blood flow areas of the portal vein; meanwhile, the use of 3D models in combination with hydrodynamic analysis has become a novel non-invasive method for diagnosis and detection of portal hypertension. We herein describe the progress of research on 3D visualization, its workflow, current situation, challenges, opportunities, and its capacity to improve clinical decision-making, emphasizing its utility for patients with liver diseases. Current advances in modern imaging technologies have promised a further increase in diagnostic efficacy of liver diseases. For example, complex internal anatomy of the liver and detailed morphological features of liver lesions can be reflected from CT-based 3D models. A meta-analysis reported that the application of 3D visualization technology in the diagnosis and management of primary hepatocellular carcinoma has significant or extremely significant differences over the control group in terms of intraoperative blood loss, postoperative complications, recovery of postoperative liver function, operation time, hospitalization time, and tumor recurrence on short-term follow-up. However, the acquisition of high-quality CT images and the use of these images for 3D visualization processing lack a unified standard, quality control system, and homogeneity, which might hinder the evaluation of application efficacy in different clinical centers, causing enormous inconvenience to clinical practice and scientific research. Therefore, rigorous operating guidelines and quality control systems need to be established for 3D visualization of liver to develop it to become a mature technology. Herein, we provide recommendations for the research on diagnosis and management of 3D visualization in liver diseases to meet this urgent need in this research field.

[Three-dimensional reconstruction of human kidney based on UroMedix-3D system and its application in kidney surgery]

OBJECTIVE

To explore the feasibility of rapid and accurate three-dimensional (3D) image reconstruction using Uromedix-3D software for urological surgery.

METHODS

The original renal thin-slice enhancement CT data were obtained from patients with kidney lesions treated in our hospital between December, 2015 and October, 2018. The self-developed Uromedix- 3D system was used to reconstruct the normal kidney structures, blood vessels, collecting systems and the lesions. The spatial anatomic relationships of the structures were measured and digitized for surgical planning.

RESULTS

3D reconstruction of the kidneys was performed in a total of 173 cases, and the mean time for reconstruction was 31.24±2.012 min. Of these cases, 147 (84.9%) had renal tumors, and 2 had renal tumors with tumor thrombus. In addition to renal tumors, the Uromedix-3D system was also used for reconstructing other lesions including UPJO, kidney stones and retroperitoneal masses. Renal artery reconstruction was performed in 170 cases, which allowed observation of the precise terminal branches (up to 7th grade arterial branch) of the artery; 109 (64%) cases showed the 5th grade arterial branch or above. Renal artery variations were detected in 37 cases, including accessory renal artery (24 cases) and multiple renal arteries (13 cases). The renal veins were reconstructed in 164 cases, and second grade or above (up to the 4th grade) vein branches were observed in 138 (84%) cases.

CONCLUSIONS

Uromedix-3D system can accurately and efficiently reconstruct the 3D structure of human kidneys and the renal lesions based on enhanced CT data. The reconstructed 3D model allows objective assessment of the spatial anatomical relationship of the lesions to provide assistance in surgical planning.

Digital and intelligent liver surgery in the new era: Prospects and dilemmas

Despite tremendous advances in traditional imaging technology over the past few decades, the intraoperative identification of lesions is still based on naked eye observation or pre-operative image evaluation. However, these two-dimensional image data cannot objectively reflect the complex anatomical structure of the liver and the detailed morphological features of the lesion, which directly limits the clinical application value of these imaging data in surgery in that it cannot improve the curative efficacy of surgery and the prognosis of the patient. This traditional mode of diagnosis and treatment has been changed by digital medical imaging technology in the new era with its significant function of accurate and efficient diagnosis of diseases, selection of reasonable treatment schemes, improvement of radical resection rate and reduction of surgical risk. In this paper, we reviewed the latest application of digital intelligent diagnosis and treatment technology related to liver surgery in the hope that it may help to achieve accurate treatment of liver surgery diseases.

Effective preoperative abdominal incision planning on a patient with a history of repeated abdominal operations using a three-dimensional reconstruction technique: a case report

This case report describes the use of a three-dimensional reconstruction technique to plan the abdominal incision in order to avoid incision-related complications in a 53-year-old female patient who had had a cystic mass in the liver for 16 years and had undergone four previous surgeries. The patient presented with a recurrent cyst. The surgical team used three-dimensional reconstruction to model the liver mass, the area of abdominal wall weakness due to previous surgeries, bowel adhesions, skeletal structure and whole abdominal contour. The models were superimposed upon each other to reveal the relationship between the various features so that the optimum incision point could be selected so as to avoid the area of abdominal wall weakness, bowel adhesions and vital organs. The actual surgical incision was made based on the three-dimensional reconstruction models and the surgeon was able to avoid the area of abdominal wall weakness and bowel adhesions as planned. No incisional hernia and wound infection were observed postoperatively and the incision healed well. The three-dimensional reconstruction technique for preoperative surgical incision planning on patients with a history of multiple abdominal surgeries can minimize incision-related complications and achieve good therapeutic results.

Accuracy of actual resected liver volume in anatomical liver resections guided by 3-dimensional parenchymal staining using fusion indocyanine green fluorescence imaging

BACKGROUND

The aim of this study was to assess the accuracy of actual resected liver volume (ARLV) in anatomical liver resections (ALRs) guided by 3-dimensional parenchymal staining using fusion indocyanine green fluorescence imaging (IGFI).

METHODS

Patients eligible for hepatic resection were enrolled in the current study from January 2016 to November 2017. All patients underwent surgery planning based on Medical Image Three-Dimensional Visualization System (MI-3DVS) before the operation, in which predicted resected liver volumes (PRLVs) were calculated. Under 3-dimensional guidance by fusion IGFI, ALRs were performed and ARLVs were measured. Simple linear regression, intra-class correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the relationship and agreement between PRLV and ARLV.

RESULTS

Of the 27 patients who achieved valid demarcation by fusion IGFI, 12 (44.4%) received hemihepatectomy, while 10 (37.0%) and five (18.5%) underwent sectionectomy and segmentectomy, respectively. The relationship and agreement between PRLV (481.37 ± 189.47 cm³) and ARLV (450.57 ± 205.19 cm³) were then evaluated. The simple regression equation obtained was PRLV = 0.874 × ARLV + 87.75 (R = 0.946; P = 0.000). Meanwhile, ARLV (ICC = 0.943) achieved an excellent agreement with PRLV ( P < 0.001); 25 of 27 dots were in the range of 95% confidence interval in Bland-Altman analysis.

CONCLUSIONS

In the study, these findings validated the consistency between PRLV calculated by MI-3DVS and ARLV guided by fusion IGFI, which proved that IGFI can accurately guide anatomical hepatectomy. Generally, fusion IGFI can provide a valid, feasible and accurate demarcation line, which can confer precision to hepatic resection.

Application of 3D visualization and 3D printing technology on ERCP for patients with hilar cholangiocarcinoma

Endoscopic retrograde cholangiopancreatography (ERCP) is an important treatment for inoperable hilar cholangiocarcinoma (HCC). The aim of the present study as to evaluate the clinical value of three-dimensional visualization (3DV) and 3D printing (3DP) technologies for ERCP in patients with HCC. The clinical data of 15 patients with HCC admitted for ERCP were analyzed retrospectively, including 9 males and 6 females. Thin-sliced data of computed tomography and magnetic resonance cholangiopancreatography (MRCP) were acquired and imported into Mimics Innovation Suite v17.0 software for 3D reconstruction. Standard Template Library files were exported for 3D printing. The target bile duct and Bismuth-Corlette (BC) classification were selected and performed respectively with the aid of Mimics Innovation Suite v17.0 software. The results were compared with the selected ones in ERCP. 3DV and 3DP models were successfully constructed for all patients, which presented the tumor, bile duct and the spatial relationship between them from multiple perspectives. The ERCP of all patients in the present study were performed successfully. The target bile duct screened by them had a high concordance rate of 86.7% with that in ERCP. The diagnostic accuracy of BC type results by 3DV and 3DP models was 93.3%. 3DV and 3DP technologies can accurately show the tumor and its associations with the surrounding bile duct, and it can be used to guide ERCP in HCC patients and improve the success rate of the operation.

Impact of Three-Dimensional Surgical Simulation on Pancreatic Surgery

Background/Aims

Anatomical variations are frequently encountered during hepato-biliary-pancreatic surgeries, requiring surgeons to have a precise understanding of the surgical anatomy in order to perform a safe surgery. We evaluated the impact of novel three-dimensional (3D) surgical simulation on pancreatic surgeries to enhance surgical residents' understanding.

Methodology

Between January 2013 and May 2014, 61 preoperative 3D surgical simulations were performed. The consistency (0-10, with 10 representing 100% consistency) among the 15 surgical residents' anatomical drawings from multidetector computed tomography images and the simulated 3D images by SYNAPSE VINCENT® was assessed. We divided the surgical residents into two groups - first- to fifth-year postgraduate doctors (group A) and sixth- to tenth-year postgraduate doctors (group B) - and compared the self-assessment scores between these two groups.

Results

In terms of the self-assessment scores, a statistically significant difference was observed between the two groups (p < 0.001).

Conclusions

In this study, 3D surgical simulation was useful for preoperative assessments prior to pancreatic surgery, especially in younger postgraduate surgeons.

The Safety and Feasibility of Three-Dimensional Visualization Technology Assisted Right Posterior Lobe Allied with Part of V and VIII Sectionectomy for Right Hepatic Malignancy Therapy

BACKGROUND

Hepatectomy is the optimal method for liver cancer; the virtual liver resection based on three-dimensional visualization technology (3-DVT) could provide better preoperative strategy for surgeon. We aim to introduce right posterior lobe allied with part of V and VIII sectionectomy assisted by 3-DVT as a promising treatment for massive or multiple right hepatic malignancies to retain maximum residual liver volume on the basis of R0 resection.

METHODS

Among 126 consecutive patients who underwent hepatectomy, 9 (7%) underwent right posterior lobe allied with part of V and VIII sectionectomy. 21 (17%) underwent right hemihepatectomy (RH). The virtual RH was performed with 3-DVT, which provided better observation of spatial position relationship between tumor and vessels, and the more accurate estimation of the remnant liver volume. If remnant liver volume was <40%, right posterior lobe allied with part of V and VIII sectionectomy should be undergone. Then, the precut line ought to be planned on the basis of protecting the portal branch of subsegment 5 and 8. The postoperative outcome of patients was compared before and after propensity score matching.

RESULTS

Nine patients meeting the eligibility criteria received right posterior lobe allied with part of V and VIII sectionectomy. The variables, including the overall mean operation time, blood transfusion, operation length, liver function, and postoperative complications, were similar between two groups before and after propensity matching. The postoperative first, third, fifth, and seventh days mean value of aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), and total bilirubin had no significant difference compared with preoperative value. One patient in each group had recurrence six months after surgery.

CONCLUSION

Right posterior lobe allied with part of V and VIII sectionectomy based on 3-DVT is safe and feasible surgery way, and can be a very promising method in massive or multiple right hepatic malignancy therapy.

Simple resection of the lesion bile duct branch for treatment of regional hepatic bile duct stones

To evaluate the effectiveness and safety of simple resections of bile duct branch lesions for the treatment of regional hepatic bile duct stones.A retrospective analysis of the clinical data from patients in our hospital from November 2008 to November 2015, who only underwent a simple resection of the lesion bile duct branch. The patients' clinical characteristics, surgical features, postoperative complications, stone clear rate, residual stone rate, and recurrence stone rate were analyzed.This study of 32 patients included 13 males and 19 females with intrahepatic bile duct stones confined to the right hepatic bile duct branch. The intraoperative blood loss, operation time, and postoperative hospital stay were 478.0 ± 86.5, 210.7 ± 6.6, and 10.8 ± 3.5, respectively. Postoperative complications occurred in 6 patients (18.8%), all of whom recovered with conservative management. There were no deaths during hospitalization. The intraoperative stone clearance rate was 95.8%. Three patients had a recurrence of stones at a mean of 22 months of follow-up (range, 4-36 months).Simple resection of bile duct branch lesions is safe and feasible for patients who have regional hepatic bile duct stones limited to the right hepatic bile duct branches.

Surgical management of hepatolithiasis: A minireview

Hepatolithiasis is highly prevalent in Asia but rare in Western countries. However, the incidence of hepatolithiasis may be increasing in Western countries due to the increased rate of immigration from areas where hepatolithiasis is prevalent. There are many non-surgical treatments for hepatolithiasis, but surgical management remains the best curative treatment for some cases of hepatolithiasis. Surgical treatments can remove biliary stones and relieve stricture of the bile ducts. This review describes the indications for and the outcomes of surgical treatment of hepatolithiasis, including liver resection and liver transplantation.

Postoperative liver volume was accurately predicted by a medical image three dimensional visualization system in hepatectomy for liver cancer

BACKGROUND

Liver cancer is the second most common cause of cancer death worldwide. The hepatectomy is the most effective and the only potentially curative treatment for patients with resectable neoplasm. Precisely preoperative assessment of remnant liver volume is essential in preventing postoperative liver failure. The aim of our study is to report our experience of using a medical image three dimensional (3D) visualization system (MI-3DVS), which was developed by our team, in assisting hepatectomy for patients with liver cancer.

METHODS

Between January 2010 and June 2016, 69 patients with liver cancer underwent hepatic resection based on the MI-3DVS were enrolled in this study. All patients underwent CT scan 5 days before the surgery and within 5 days after resection. CT images were reconstructed with the MI-3DVS to assist to perform hepatectomy. Simple linear regression, intra-class correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the relationship and agreement between actual excisional liver volume (AELV) and predicted excisional liver volume (PELV).

RESULTS

Among 69 patients in this study, 62(89.85%) of them were diagnosed with hepatocellular carcinoma by histopathologic examination, and 41(59.42%) underwent major hepatectomy. The average AELV was 330.13 cm³ and the average PELV was 287.67 cm³. The simple regression equation is AELV = 1.016 × PELV+30.39(r = 0.966; p < 0.0003). PELV (ICC = 0.964) achieved an excellent agreement with AELV with statistical significance (p < 0.001). 65 of 69 dots are in the range of 95% confidence interval in Bland-Altman analyses.

CONCLUSIONS

The MI-3DVS has advantages of simple usage and convenient hold. It is accurate in assessment of postoperative liver volume and improve safety in liver resection.

Comparison of liver volumetry on contrast-enhanced CT images: one semiautomatic and two automatic approaches

This study was to evaluate the accuracy, consistency, and efficiency of three liver volumetry methods- one interactive method, an in-house-developed 3D medical Image Analysis (3DMIA) system, one automatic active shape model (ASM)-based segmentation, and one automatic probabilistic atlas (PA)-guided segmentation method on clinical contrast-enhanced CT images. Forty-two datasets, including 27 normal liver and 15 space-occupying liver lesion patients, were retrospectively included in this study. The three methods - one semiautomatic 3DMIA, one automatic ASM-based, and one automatic PA-based liver volumetry - achieved an accuracy with VD (volume difference) of -1.69%, -2.75%, and 3.06% in the normal group, respectively, and with VD of -3.20%, -3.35%, and 4.14% in the space-occupying lesion group, respectively. However, the three methods achieved an efficiency of 27.63 mins, 1.26 mins, 1.18 mins on average, respectively, compared with the manual volumetry, which took 43.98 mins. The high intraclass correlation coefficient between the three methods and the manual method indicated an excel-lent agreement on liver volumetry. Significant differences in segmentation time were observed between the three methods (3DMIA, ASM, and PA) and the manual volumetry (p < 0.001), as well as between the automatic volumetries (ASM and PA) and the semiautomatic volumetry (3DMIA) (p < 0.001). The semiautomatic interactive 3DMIA, automatic ASM-based, and automatic PA-based liver volum-etry agreed well with manual gold standard in both the normal liver group and the space-occupying lesion group. The ASM- and PA-based automatic segmentation have better efficiency in clinical use.

A Comparison between Three-Dimensional Visualization Guided Hepatectomy and Ultrasonography Guided Radiofrequency Ablation in the Treatment of Small Hepatocellular Carcinoma within the Milan Criteria

Background. Treatment selection for small hepatocellular carcinoma (sHCC) is controversial. We aimed to compare the outcomes of medical imaging three-dimensional visualization system (MI-3DVS) guided surgical resection (SR) and ultrasonography guided radiofrequency ablation (RFA) for sHCC. Methods. In total, 194 patients who underwent SR or RFA in our hospital between January 2006 and May 2010 were retrospectively enrolled. Overall survival (OS), recurrence-free survival (RFS), and postoperative complications were compared. Cox regression was used to estimate the benefits of MI-3DVS-guided SR on OS and RFS. Results. Ninety-two patients underwent SR and 102 underwent RFA. The SR group experienced more complications (41.3% versus 19.6%) and longer hospital stay (18.04 ± 7.11 versus 13.06 ± 5.59) (both p < 0.05). The 1-, 2-, 3-, 4-, and 5-year OS was 96.7%, 95.7%, 93.5%, 83.5%, and 61.1% in the SR group and 95.0%, 88.1%, 72.7%, 56.9%, and 39.5% in the RFA group. Corresponding RFS was 95.7%, 94.6%, 84.7%, 59.8%, and 40.2% in SR group and 91.2%, 80.3%, 60.5%, 32.3%, and 22.3% in RFA group. The 5-year OS and RFS were higher in SR group (both p < 0.001). Interestingly, there was no significance in OS and RFS among subgroups aged >60 years. Independent predictors of OS and RFS, respectively, were intervention (HR, 2.769 and 1.933), tumor number (HR, 5.128 and 3.903), and serum alpha-fetoprotein (AFP) (HR, 1.871 and 1.474) (all p < 0.05). Conclusions. MI-3DVS based hepatectomy should be considered primary treatment while RFA can be treated as alternative therapy for older patients. Intervention, tumor number, and AFP are independent predictors for both survival and recurrence.

Negative short-term impact of intraoperative biliary lavage in patients with hepatolithiasis

AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis.

METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis.

RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays (6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees (RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood (13.3% vs 25.8%, P = 0.001) and bile (23.6% vs 40.7%, P = 0.001) samples, and increased usage of advanced antibiotics (26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever (> 37.5 °C, 81.4% vs 91.1%, P = 0.001) and hyperthermia (> 38.5°C，39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group.

CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.

Individualized preoperative planning using three-dimensional modeling for Bismuth and Corlette type III hilar cholangiocarcinoma

Background

A detailed evaluation of blood supply anatomy, especially the biliary anatomy at the hepatic hilus, is essential to ensure a complete and curative resection for Bismuth and Corlette type III hilar cholangiocarcinoma. The study aimed to investigate the impact of individualized preoperative planning using 3D modeling on surgical treatment for type III hilar cholangiocarcinoma.

Methods

This was a retrospective study of patients with type III hilar cholangiocarcinoma (n = 47) who underwent surgery at the Hepatobiliary Surgery Department of Zhujiang Hospital between March 2007 and January 2015. All patients had undergone preoperative computed tomography (CT) examination, and 3D images were reconstructed. Preoperative surgery simulation was performed, and the simulation was applied in the subsequent surgery. Clinical, surgical, and pathological characteristics were compared between patients undergoing preoperative planning (n = 25) and those who did not (n = 22). Complications were examined.

Results

Surgical time and blood loss were significantly smaller in patients with 3D reconstruction compared to those without. The number of bile duct orifices was correctly estimated in 14/25 (56.0 %) patients with preoperative planning. The width of the hepatic surgical margin could be measured for 18 hepatic ducts, and 17 (68.0 %) of them were pathologically diagnosed as margin-negative.

Conclusions

This technique has the advantages of precise visualization of the anatomic structures and 3D assessment of biliary branches and vessels, allowing improved operative planning for the treatment of hilar cholangiocarcinoma.

Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma for hepatolithiasis

AIM: To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS) and risk factors for recurrence in hepatolithiasis.

METHODS: From March 1993 to December 2012, 202 consecutive patients with hepatolithiasis underwent OSPCHS at our department. The Oddi sphincter preserved procedure consisted of common hepatic duct exploration, stone extraction, hilar bile duct plasty, establishment of subcutaneous stoma to the bile duct. Patients with recurrent stones can undergo stone extraction and/or biliary drainage via the subcutaneous stoma which can be incised under local anesthesia. The long-term results were reviewed. Cox regression model was employed to analyze the risk factors for stone recurrence.

RESULTS: Ninety-seven (48.0%) OSPCHS patients underwent hepatic resection concomitantly. The rate of surgical complications was 10.4%. There was no perioperative death. The immediate stone clearance rate was 72.8%. Postoperative cholangioscopic lithotomy raised the clearance rate to 97.0%. With a median follow-up period of 78.5 mo (range: 2-233 mo), 24.8% of patients had recurrent stones, 2.5% had late development of cholangiocarcinoma, and the mortality rate was 5.4%. Removal of recurrent stones and/or drainage of inflammatory bile via subcutaneous stoma were conducted in 44 (21.8%) patients. The clearance rate of recurrent stones was 84.0% after subsequent choledochoscopic lithotripsy via subcutaneous stoma. Cox regression analysis showed that residual stone was an independent prognostic factor for stone recurrence.

CONCLUSION: In selected patients with hepatolithiasis, OSPCHS achieves excellent long-term outcomes, and residual stone is an independent prognostic factor for stone recurrence.

Application of 3D reconstruction for surgical treatment of hepatic alveolar echinococcosis

AIM: To evaluate the reliability and accuracy of three-dimensional (3D) reconstruction for liver resection in patients with hepatic alveolar echinococcosis (HAE).

METHODS: One-hundred and six consecutive patients with HAE underwent hepatectomy at our hospital between May 2011 and January 2015. Fifty-nine patients underwent preoperative 3D reconstruction and “virtual” 3D liver resection before surgery (Group A). Another 47 patients used conventional imaging methods for preoperative assessment (Group B). Outcomes of hepatectomy were compared between the two groups.

RESULTS: There was no significant difference in preoperative data between the two groups. Compared with patients in Group B, those in Group A had a significantly shorter operation time (227.1 ± 51.4 vs 304.6 ± 88.1 min; P < 0.05), less intraoperative blood loss (308.1 ± 135.4 vs 458.1 ± 175.4 mL; P < 0.05), and lower requirement for intraoperative blood transfusion (186.4 ± 169.6 vs 289.4 ± 199.2 mL; P < 0.05). Estimated resection liver volumes in both groups had good correlation with actual graft weight (Group A: r = 0.978; Group B: r = 0.960). There was a significant higher serum level of albumin in Group A (26.3 ± 5.9 vs 22.6 ± 4.3 g/L, P < 0.05). Other postoperative laboratory parameters (serum levels of aminotransferase and bilirubin; prothrombin time) and duration of postoperative hospital stay were similar. Sixteen complications occurred in Group A and 19 in Group B. All patients were followed for 3-46 (mean, 17.3) mo. There was no recurrence of lesions in Group A, but two recurrences in Group B. There were three deaths: two from cerebrovascular accident, and one from car accident.

CONCLUSION: 3D reconstruction provides comprehensive and precise anatomical information for the liver. It also improves the chance of success and reduces the risk of hepatectomy in HAE.

Application of a Three-Dimensional Reconstruction Technique in Liver Autotransplantation for End-Stage Hepatic Alveolar Echinococcosis

BACKGROUND

The purpose of this study was to determine the clinical value of three-dimensional (3D) computer reconstruction technology in pre-operative assessment and surgical planning for liver autotransplantation in patients with end-stage hepatic alveolar echinococcosis (HAE).

STUDY DESIGN

Fifteen end-stage HAE patients received surgical treatment in our hospital between May 2011 and July 2014. 3D reconstruction and virtual surgeries were performed on diseased livers using a 3D reconstruction system for liver (IQQA-Liver). The feasibility and safety of liver autotransplantation were assessed for successful implementation of surgery. The results were compared with intraoperative conditions and computed tomography (CT) to verify the accuracy of pre-operative evaluation.

RESULTS

Fifteen patients underwent liver resections and liver autotransplantation using surgical strategies consistent with pre-operative surgical planning in 3D reconstruction. Furthermore, there was no significant difference between whole-liver volume (2848.26 ± 798.41 vs. 2598.70 ± 822.45 cm(3), t = -4.635, P > 0.05) and lesion volume (1159.09 ± 789.47 vs. 1213.14 ± 813.76 cm(3), t = -1.959, P > 0.05) measured by 3D and traditional two-dimensional (2D) manual tracing from CT. The remaining liver volumes calculated by 3D and 2D CT were 810.47 ± 214.05 and 892.00 ± 262.36 cm(3) (t = -3.275, P > 0.05), with an average error rate of 6.2 and 16.5%, respectively. The pre-operative remaining liver volumes estimated by the two methods were positively correlated with the actual weight (783.67 ± 217.74 g) after the surgery (r three-dimensional = 0.976, r multislice CT = 0.883, P < 0.01).

CONCLUSIONS

An individualized liver reconstruction technique can provide comprehensive anatomic information on livers of patients with end-stage HAE. Pre-operative virtual surgery can effectively improve the success rate of liver autotransplantation and reduce the risks of surgery.

Three-dimensional imaging identified the accessory bile duct in a patient with cholangiocarcinoma

The development of diagnostic imaging technology, such as multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP), has made it possible to obtain detailed images of the bile duct. Recent reports have indicated that a 3-dimensional (3D) reconstructed imaging system would be useful for understanding the liver anatomy before surgery. We have investigated a novel method that fuses MDCT and MRCP images. This novel system easily made it possible to detect the anatomical relationship between the vessels and bile duct in the portal hepatis. In this report, we describe a very rare case of extrahepatic cholangiocarcinoma associated with an accessory bile duct from the caudate lobe connecting with the intrapancreatic bile duct. We were unable to preoperatively detect this accessory bile duct using MDCT and MRCP. However, prior to the second operation, we were able to clearly visualise the injured accessory bile duct using our novel 3D imaging modality. In this report, we suggest that this imaging technique can be considered a novel and useful modality for understanding the anatomy of the portal hepatis, including the hilar bile duct.

Preliminary study of a new pathological evolution-based clinical hepatolithiasis classification

AIM: To investigate clinical features, treatment strategies and outcomes of patients with hepatolithiasis (HL) undergoing surgical treatment, using a new clinical classification.

METHODS: Sixty-eight HL patients were hospitalized and treated surgically from August 2011 to December 2012 and they were classified into four HL types according to pathological evolution of the disease. These four HL types included type I primary type (defined as no previous biliary tract surgery), type II inflammatory type (with previous biliary tract surgery and cholangitis), type III mass-forming type (HL complicated by hepatic mass-forming lesion), and type IV terminal type (with secondary biliary cirrhosis and resultant portal hypertension). The perioperative data including general information, imaging data, postoperative complications, and immediate and final stone clearance rate were obtained and analyzed.

RESULTS: In all 68 patients, the proportion of HL type I-IV was 50% (34/68), 36.8% (25/68), 10.3% (7/68) and 2.8% (2/68), respectively. Abdominal pain was the main clinical manifestation in type I (88.2%), fever was predominant in type II (52.0%), the malignancy rate in type III was high (71.4%), and portal hypertension and spleen enlargement were common in type IV (2/2, 100.0%). Liver resection rate for types I-III was 79.4%, 72.0% and 71.4%, respectively. The overall incidence of postoperative complications was 23.5% (16/68). There were no perioperative deaths. The average length of hospital stay was 12.7 ± 7.3 d. Immediate and final stone clearance rate was 73.5% (50/68) and 89.7% (61/68), respectively. Fifty-nine of 68 patients (86.8%) were followed- up for > 1 year after surgery, and 96.6% of these patients (57/59) had a good quality of life according to a criterion recommended for postoperative evaluation of quality of life.

CONCLUSION: The pathological evolution-based clinical classification of HL has a role in optimizing treatment strategy, and patients can benefit from this classification when it is used properly.

Impact of three-dimensional reconstruction technique in the operation planning of centrally located hepatocellular carcinoma

BACKGROUND

The aim of this retrospective study was to compare the outcomes of operations based on 3-dimensional (3D) operation planning with non 3D-assisted operations in the treatment of centrally located hepatocellular carcinoma.

STUDY DESIGN

From April 2008 to March 2014, 116 patients with centrally located hepatocellular carcinoma received surgical treatment in our department. Among these cases, a total of 60 patients received resection with operation planning based on 3D reconstructions (group A); the remaining 56 received treatment with the aid of traditional imaging (group B). Three-dimensional surgical planning, including the classification system for centrally located hepatocellular carcinoma, was elaborated in the study.

RESULTS

Compared with group B, group A was linked to shorter operation time (294.5 ± 61.9 minutes vs 324.3 ± 83.1 minutes; p = 0.028) and lower rate of hepatic inflow occlusion (51.7% vs 71.4%; p = 0.029). No differences were found in surgical methods, intraoperative blood transfusion, and intraoperative blood loss. The groups were similar in their rates of complications, except that group B was more liable to have Clavien Grade III to V complications (3.3% vs 14.3%; p = 0.048). In addition, a significant difference in ascites was found across the 2 cohorts (2 in group A and 8 in group B; p = 0.048), and the 2 groups also differed significantly in total bilirubin (23.2 ± 16.1 g/L vs 31.1 ± 24.1 g/L; p = 0.032) and albumin (29.3 ± 5.2 g/L vs 27.8 ± 7.9 g/L; p = 0.033).

CONCLUSIONS

Compared with non 3D-assisted operations, the operation planning based on 3D reconstruction is a more effective and reasonable method in the treatment of centrally located hepatocellular carcinoma. In addition, the classification system may facilitate the 3D operation planning.

Three-dimensional imaging identified the accessory bile duct in a patient with cholangiocarcinoma

The development of diagnostic imaging technology, such as multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP), has made it possible to obtain detailed images of the bile duct. Recent reports have indicated that a 3-dimensional (3D) reconstructed imaging system would be useful for understanding the liver anatomy before surgery. We have investigated a novel method that fuses MDCT and MRCP images. This novel system easily made it possible to detect the anatomical relationship between the vessels and bile duct in the portal hepatis. In this report, we describe a very rare case of extrahepatic cholangiocarcinoma associated with an accessory bile duct from the caudate lobe connecting with the intrapancreatic bile duct. We were unable to preoperatively detect this accessory bile duct using MDCT and MRCP. However, prior to the second operation, we were able to clearly visualise the injured accessory bile duct using our novel 3D imaging modality. In this report, we suggest that this imaging technique can be considered a novel and useful modality for understanding the anatomy of the portal hepatis, including the hilar bile duct.