Minimally Invasive Stage 1 to Protect Against the Risk of Liver Failure: Results from the Hepatocellular Carcinoma Series of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Italian Registry

Cornerstones and divergencies in the implementation and use of liver hypertrophy techniques: results from a nationwide survey for the set-up of the prospective registry

BACKGROUND

The aim of this national survey on liver hypertrophy techniques was to track the trends of their use and implementation in Italy and to detect analogies and heterogeneities among centers.

METHODS

In December 2022, Italian centers with liver resection activity were specifically contacted and asked to fill an online questionnaire composed of 6 sections including a total of 51 questions.

RESULTS

46 Italian centers filled the questionnaire. The proportion of major/total number of liver resections was 27% and the use of hypertrophy techniques was required in 6,2% of cases. The most frequent reason of drop out was disease progression in 58.5% of cases. Most frequently used techniques were PVE and ALPPS with an increasing use of hepatic venous deprivation (HVD). Heterogeneous answers were provided regarding the cutoff values to indicate the need for hypertrophy techniques. Criteria to allocate a patient to different hypertrophy techniques are not standardized.

CONCLUSIONS

The use of hypertrophy techniques is deep-rooted in Italy, documenting the established value of their role in improving resectability rate. While an evolution of techniques is detectable, still significant heterogeneity is perceived in terms of cutoff values, indications and managing protocols.

Robotic ALPPS for primary and metastatic liver tumours: short-term outcomes versus open approach

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is one of the strategies available for patients initially unresectable. High risk of peri-operative morbidity and mortality limited its application and diffusion. We aimed to analyse short-term outcomes of robotic ALPPS versus open approach, to assess safety and reproducibility of this technique. A retrospective analysis of prospectively maintained databases at University of Modena and Reggio Emilia on patients that underwent ALPPS between January 2015 and September 2022 was conducted. The main aim of the study was to evaluate safety and feasibility of robotic approach, either full robotic or only first-stage robotic, compared to a control group of patients who underwent open ALPPS in the same Institution. 23 patients were included. Nine patients received a full open ALPPS (O-ALPPS), 7 received a full robotic ALPPS (R-ALPPS), and 7 underwent a robotic approach for stage 1, followed by an open approach for stage 2 (R + O-ALPPS). PHLF grade B-C after stage 1 was 0% in all groups, rising to 58% in the R + O-ALPPS group after stage 2 and remaining 0% in the R-ALPPS group. 86% of R-ALPPS cases were discharged from the hospital between stages 1 and 2, and median total in-hospital stay and ICU stay favoured full robotic approach as well. This contemporary study represents the largest series of robotic ALPPS, showing potential advantages from full robotic ALPPS over open approach, resulting in reduced hospital stay and complications and lower incidence of 90-day mortality.

Robotic Approach for Lymphadenectomy in Biliary Tumors: The Missing Ring Between the Benefits of Laparoscopic and Reproducibility of Open Approach?

OBJECTIVE

This study aimed to evaluate the oncological adequacy of lymphadenectomy (LND) for biliary tumors and surgical outcomes of resections performed using robotic, laparoscopic, and open approaches and to compare the techniques within a weighted propensity score analysis.

BACKGROUND

The need to perform formal LND is considered a limit for the applicability of minimally invasive liver surgery.

METHODS

Overall, 25 robotic resections with LND (2021-2022) from a single-center constituted the study group (Rob group), matched by inverse probability treatment weighting with 97 laparoscopic (Lap group) and 113 open (Open group) procedures to address the primary endpoint. A "per-period" analysis was performed comparing the characteristics and outcomes of the Rob group with the first 25 consecutive laparoscopic liver resections with associated LND (LapInit group).

RESULTS

Minimally invasive techniques performed equally well regarding the number of harvested nodes, blood transfusions, functional recovery, length of stay, and major morbidity and provided a short-term benefit to patients when compared with the open technique. A better performance of the robotic approach over laparoscopic approach (and both approaches over the open technique) was recorded for patients achieving LND with retrieval of >6 nodes. The open approach reduced both the operative time and time for LND, and robotic surgery performed better than laparoscopic surgery.

CONCLUSIONS

Minimally invasive techniques are excellent tools for the management of LND in patients with biliary tumors, showing feasibility, and oncological adequacy. Robotics could contribute to the large-scale diffusion of these procedures with a high profile of complexity.

Ten years of Italian mini-invasiveness: the I Go MILS registry as a tool of dissemination, characterization and networking

Purposes of this study are to evaluate the main changes that have occurred in the Italian MILS activity in the last decade in terms of indications, approaches and outcomes as reported in the national registry and to provide specific details on the main areas of development of MILS. Data from patients undergoing minimally invasive liver resections at centers included in the I Go MILS Registry from its start-up (November 2014) to March 2023 were analyzed for the purposes of this study. The registry is intention-to-treat and prospective. Global recruitment trends stratified by indication to surgery and type of approach were analysed. 7413 MILS procedures were performed across all centers (median number of procedures per center: 63). Years (2020-2023) displayed a significantly higher proportion of treated patients diagnosed with hepatocellular carcinoma (HCC) (38.2% vs. 28.9% and 33.9%, p < 0.001) and cholangiocarcinoma (6.7% vs. 6.5% and 4.2%, p < 0.001) compared to the preceding triennial periods. Additionally, technical complexity demonstrated an increased prominence in Years (2019-2023) with a significantly higher percentage of grade III cases compared to the earlier periods (39.3% vs. 21.7% and 25.6%, p < 0.001). Annual case trends focusing on laparoscopic and robotic techniques demonstrated a steadily increase in the use of these techniques for complex case mix of indications. Overall, attitude and attention to MILS approach has evolved, so that currently indications to hepatic mini-invasiveness have expanded and surgical technique has been refined: Areas mainly involved in increasing growth trends are hepatocellular carcinoma, possible applications of MILS in transplant setting, intrahepatic cholangiocarcinoma and robotic approach.

Evolution of minimally invasive techniques and surgical outcomes of ALPPS in Italy: a comprehensive trend analysis over 10 years from a national prospective registry

BACKGROUND

Since 2012, Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has encountered several modifications of its original technique. The primary endpoint of this study was to analyze the trend of ALPPS in Italy over a 10-year period. The secondary endpoint was to evaluate factors affecting the risk of morbidity/mortality/post-hepatectomy liver failure (PHLF).

METHODS

Data of patients submitted to ALPPS between 2012 and 2021 were identified from the ALPPS Italian Registry and evaluation of time trends was performed.

RESULTS

From 2012 to 2021, a total of 268 ALPPS were performed within 17 centers. The number of ALPPS divided by the total number of liver resections performed by each center slightly declined (APC = - 2.0%, p = 0.111). Minimally invasive (MI) approach significantly increased over the years (APC = + 49.5%, p = 0.002). According to multivariable analysis, MI completion of stage 1 was protective against 90-day mortality (OR = 0.05, p = 0.040) as well as enrollment within high-volume centers for liver surgery (OR = 0.32, p = 0.009). Use of interstage hepatobiliary scintigraphy (HBS) and biliary tumors were independent predictors of PHLF.

CONCLUSIONS

This national study showed that use of ALPPS only slightly declined over the years with an increased use of MI techniques, leading to lower 90-day mortality. PHLF still remains an open issue.

Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes

Background: Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a recent strategy to improve resectability of extensive hepatic malignancies. Recent surgical advances, such as the application of technical variants and use of a mini-invasive approach (MI-ALPPS), have been proposed to improve clinical outcomes in terms of morbidity and mortality. Methods: A total of 119 MI-ALPPS cases from 6 series were identified and discussed to evaluate the feasibility of the procedure and short-term clinical outcomes. Results: Hepatocellular carcinoma were widely the most common indication for MI-ALPPS. The median estimated blood loss was 260 mL during Stage 1 and 1625 mL in Stage 2. The median length of the procedures was 230 min in Stage 1 and 184 in Stage 2. The median increase ratio of future liver remnant volume was 87.8%. The median major morbidity was 8.14% in Stage 1 and 23.39 in Stage 2. The mortality rate was 0.6%. Conclusions: MI-ALPPS appears to be a feasible and safe procedure, with potentially better short-term outcomes in terms of blood loss, morbidity, and mortality rate if compared with those of open series.

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure - First technical report

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Laparoscopic Surgery for Intrahepatic Cholangiocarcinoma: A Focus on Oncological Outcomes

Background: The aim of the present study was to analyze the long-term outcomes of laparoscopic and open surgery for intrahepatic cholangiocarcinoma (iCCA) in a series, collected in a tertiary referral center with a high annual volume of laparoscopic activity. Methods: Between January 2004 and June 2020, 446 liver resections (LR) were performed for iCCA: of these, 179 were performed by laparoscopic surgery (LS) and 267 with the open approach. The two groups were matched through a 1:1 propensity score using covariates representative of patient and disease characteristics. The study and control groups were compared, with specific attention given to oncological outcomes (rate of R0, depth of resection margins, overall and disease-free survival, rate, and site of recurrence). Results: The number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. The interval time between surgery and subsequent adjuvant treatments was significantly shorter in LS patients. No differences were shown even in the comparison between the LS and the open group in terms of median disease-free and overall survival. Moreover, the disease recurrence rate was comparable between the LS and the open groups (45.2% versus 56.7%), and the recurrence pattern was similar. Conclusions: The minimally invasive approach for iCCA was once again confirmed to be associated with advantages in terms of intraoperative and short-term outcomes, but was also proven to be oncologically non-inferior to the open counterpart. In the present study, overall and disease-free survival were found to be similar between the two approaches.

Total robotic ALPPS approach for hepatocellular carcinoma in cirrhotic liver

BACKGROUND

Hepatocellular carcinoma (HCC) is a common indication for associating liver partition with portal vein ligation for staged hepatectomy (ALPPS). Robotic liver resection has been done for HCC, but robotic ALPPS is a rare procedure.

METHODS

To present three cases of totally robotic ALPPS in cirrhotic patients with HCC.

RESULTS

Three cirrhotic male patients with HCC underwent ALPPS; the mean age was 54.3 years. MELD score was ≤9 and tumour size between 90 and 140 mm. The mean hypertrophy of the future liver remnant after the first stage was 77.5% and no postoperative liver failure was reported. Mean operative time of stage 1 was 7:30 h and of stage 2 was 4:37 h, without blood transfusion. The mean hospital stay for the first stage was 10 days and for the second stage was 9.3 days. No postoperative complication was recorded.

CONCLUSIONS

Robotic ALPPS in cirrhotic patients with HCC is safe and feasible.

The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness

BACKGROUND

The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided.

METHODS

Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach.

RESULTS

No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation.

CONCLUSIONS

The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.