Meta-analysis of intermittent Pringle manoeuvre versus no Pringle manoeuvre in elective liver surgery

Robotic Versus Laparoscopic Liver Resection in Various Settings: An International Multicenter Propensity Score Matched Study of 10.075 Patients

OBJECTIVE

To compare the perioperative outcomes of robotic liver surgery (RLS) and laparoscopic liver surgery (LLS) in various settings.

BACKGROUND

Clear advantages of RLS over LLS have rarely been demonstrated, and the associated costs of robotic surgery are generally higher than those of laparoscopic surgery. Therefore, the exact role of the robotic approach in minimally invasive liver surgery remains to be defined.

METHODS

In this international retrospective cohort study, the outcomes of patients who underwent RLS and LLS for all indications between 2009 and 2021 in 34 hepatobiliary referral centers were compared. Subgroup analyses were performed to compare both approaches across several types of procedures: (1) minor resections in the anterolateral (2, 3, 4b, 5, and 6) or (2) posterosuperior segments (1, 4a, 7, 8), and (3) major resections (≥3 contiguous segments). Propensity score matching was used to mitigate the influence of selection bias. The primary outcome was textbook outcome in liver surgery (TOLS), previously defined as the absence of intraoperative incidents ≥grade 2, postoperative bile leak ≥grade B, severe morbidity, readmission, and 90-day or in-hospital mortality with the presence of an R0 resection margin in case of malignancy. The absence of a prolonged length of stay was added to define TOLS+.

RESULTS

Among the 10.075 included patients, 1.507 underwent RLS and 8.568 LLS. After propensity score matching, both groups constituted 1.505 patients. RLS was associated with higher rates of TOLS (78.3% vs 71.8%, P < 0.001) and TOLS+ (55% vs 50.4%, P = 0.026), less Pringle usage (39.1% vs 47.1%, P < 0.001), blood loss (100 vs 200 milliliters, P < 0.001), transfusions (4.9% vs 7.9%, P = 0.003), conversions (2.7% vs 8.8%, P < 0.001), overall morbidity (19.3% vs 25.7%, P < 0.001), and microscopically irradical resection margins (10.1% vs. 13.8%, P = 0.015), and shorter operative times (190 vs 210 minutes, P = 0.015). In the subgroups, RLS tended to have higher TOLS rates, compared with LLS, for minor resections in the posterosuperior segments (n = 431 per group, 75.9% vs 71.2%, P = 0.184) and major resections (n = 321 per group, 72.9% vs 67.5%, P = 0.086), although these differences did not reach statistical significance.

CONCLUSIONS

While both produce excellent outcomes, RLS might facilitate slightly higher TOLS rates than LLS.

Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience

BACKGROUND

Blood loss is a major determinant of outcomes following hepatectomy. Robotic technology enables hepatobiliary surgeons to mimic open techniques for inflow control and parenchymal transection during major hepatectomy, increasing the ability to minimize blood loss and perform safe liver resections.

METHODS

Initial experience of 20 consecutive major robotic hepatectomies from November 2018 to July 2020 at two co-located institutions was reviewed. All cases were performed with extrahepatic inflow control and parenchymal transection with the laparoscopic cavitron ultrasonic surgical aspirator (CUSA), and a technical description is illustrated. Clinical characteristics, operative data, and surgical outcomes were retrospectively analyzed.

RESULTS

The median (range) patient age was 58 years (20-76) and the majority of 14 (70%) patients were ASA III-IV. There were 12 (60%) resections for malignancy and the median tumor size was 6.2 cm (1.2-14.6). Right or extended right hepatectomy was the most common procedure (12 or 60% of cases). There were 7 (35%) left or extended left hepatectomies and 1 (5%) central hepatectomy. The median operative time was 420 (177-622) minutes. Median estimated blood loss was 300 mL (25-800 mL). One (5%) case was converted to open. Two (10%) patients required blood transfusion. The median length of stay was 3 (1-6) days. Major complications included 1 (5%) Clavien-Dindo IIIa bile leak requiring percutaneous drainage placement. There was no 90-day mortality.

CONCLUSION

Advanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.

Meta-analysis of the effect of the pringle maneuver on long-term oncological outcomes following liver resection

Hepatic pedicle clamping reduces intraoperative blood loss and the need for transfusion, but its long-term effect on survival and recurrence remains controversial. The aim of this meta-analysis was to evaluate the effect of the Pringle maneuver (PM) on long-term oncological outcomes in patients with primary or metastatic liver malignancies who underwent liver resection. Literature was searched in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (via PubMed), and Web of Science databases. Survival was measured as the survival rate or as a continuous endpoint. Pooled estimates were represented as odds ratios (ORs) using the Mantel–Haenszel test with a random-effects model. The literature search retrieved 435 studies. One RCT and 18 NRS, including 7480 patients who underwent liver resection with the PM (4309 cases) or without the PM (3171 cases) were included. The PM did not decrease the 1-year overall survival rate (OR 0.86; 95% CI 0.67–1.09; P = 0.22) or the 3- and 5-year overall survival rates. The PM did not decrease the 1-year recurrence-free survival rate (OR 1.06; 95% CI 0.75–1.50; P = 0.75) or the 3- and 5-year recurrence-free survival rates. There is no evidence that the Pringle maneuver has a negative effect on recurrence-free or overall survival rates.

Decision making process in simultaneous laparoscopic resection of colorectal cancer and liver metastases. Review of literature

Purpose:

The benefits of laparoscopic approaches to treat colorectal cancer (CRC) and colorectal liver metastases (CRLM) separately are well established. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged. The objective of this review with practical reports is to discuss technical aspects required for patient selection to perform simultaneous laparoscopic approaches for CRC and CRLM.

Methods:

Literature review of oncological factors associated with patient selection for surgical treatment of CRLM and the use of laparoscopy in those cases, and report of technical aspects for simultaneous CRC and CRLM approaches.

Results:

Simultaneous laparoscopic resection has been successful in many series of selected patients, although it seems to be safer to perform minor and major liver resection with non-extended colorectal resections, and to avoid two high-risk procedures at the same time.

Conclusions:

Simultaneous CRC and CRLM resections seem to be safe when patients are carefully selected, also considering the risk of recurrence concerning oncologic outcomes. The pre-planning of simultaneous resection is mandatory to plan trocar positioning, procedure sequencing, and patient position.

Progress in hepatectomy for hepatocellular carcinoma and peri-operation management

The global incidence of liver cancer continues to grow. Liver cancer, especially hepatocellular carcinoma, has high recurrence and mortality rates. Here, we review the past decade's diagnostic, therapeutic, and management strategies for hepatocellular carcinoma, and summarize new patient management approaches, including enhanced recovery after surgery, targeted therapy, and immunotherapy. We compare traditional and innovative management methods, which comprise developments in precision medicine, and consider their limitations. Ongoing innovation and technological advances enable surgeons to gain deeper understandings of the multidimensionality of hepatocellular carcinoma, thereby promoting the continuous development of precision therapy.

Intermittent Pringle maneuver may be beneficial for radiofrequency ablations in situations with tumor-vessel proximity

Background

Radiofrequency ablation (RFA) represents a treatment option for non-resectable liver malignancies. Larger ablations can be achieved with a temporary hepatic inflow occlusion (Pringle maneuver - PM). However, a PM can induce dehydration and carbonization of the target tissue. The objective of this study was to evaluate the impact of an intermittent PM on the ablation size.

Methods

Twenty-five multipolar RFAs were performed in porcine livers ex vivo. A perfused glass tube was used to simulate a natural vessel. The following five test series (each n=5) were conducted: (1) continuous PM, (2-4) intermittent PM, and (5) no PM. Ablations were cut into half. Ablation area, minimal radius, and maximal radius were compared.

Results

No change in complete ablation size could be measured between the test series (p>0.05). A small rim of native liver tissue was observed around the glass tube in the test series without PM. A significant increase of ablation area could be measured on the margin of the ablations with an intermittent PM, starting without hepatic inflow occlusion (p<0.05).

Conclusion

An intermittent PM did not lead to smaller ablations compared to a continuous or no PM ex vivo. Furthermore, an intermittent PM can increase the ablation area when initial hepatic inflow is succeeded by a PM.

A systematic surgical procedure: The '7+3' approach to laparoscopic right partial hepatectomy [deep segment (S) VI, S VII or S VIII] in 52 patients with liver tumors

Laparoscopic right partial hepatectomy (LRPH), located in the deep segment (S) VI, S VII or S VIII, is a complicated procedure, due to its poor operative field and high risk of bleeding. The present study aimed to summarize our experience of LRPH and to share our systematic surgical procedure, the ‘7+3’ approach. This approach includes seven key points and three main instruments. A total of 81 cases were included, which were divided into 2 groups [LRPH, n=52; open hepatectomy (OH), n=29]. The demographic profile, intraoperative parameters and postoperative parameters were obtained and analyzed. Blood loss (245.38±268.37 ml) in the LRPH group was not significantly more than in the OH group (230.93±257.62 ml; P=0.936). The durations of surgery, liver parenchyma transection and portal triad clamping were also not significantly more than those in the OH group (145.52±48.29 vs. 129.83±35.04 min; P=0.149 for surgery; 28.52±10.16 vs. 23.97±10.44 min; P=0.059 for liver parenchyma transection; 20.62±9.61 vs. 17.31±10.12 min; P=0.149 for portal triad clamping). However, the number of postoperative hospital days in the LRPH group was smaller (10.67 in LRPH vs. 12.07 in OH; P=0.025). The present study demonstrated the satisfactory surgical outcomes and economic benefits of the systematic ‘7+3’ surgical technique for LRPH. Further studies in larger cohorts and other centers are required to confirm its feasibility and superiority.