Innovation for the Sake of Innovation? How Does Robotic Hepatectomy Compare to Laparoscopic or Open Resection for HCC—A Systematic Review and Meta-Analysis

The future of liver transplantation

Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.

Comparison of short-term outcomes between robotic and laparoscopic liver resection: a meta-analysis of propensity score-matched studies

OBJECTIVE

This meta-analysis aimed to compare short-term outcomes between robotic liver resection (RLR) and laparoscopic liver resection (LLR) using data collected from propensity score-matched studies.

METHODS

The PubMed, Cochrane Library, and Embase databases were searched to collect propensity score-matched studies comparing RLR and LLR. Relevant data were extracted and analyzed. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect models. Meta-regression analysis was performed for primary outcome measures. Subgroup analyses and sensitivity analyses were performed for outcomes exhibiting high heterogeneity. Quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation framework.

RESULTS

Twenty-two propensity score-matched studies were included to comprise 5272 patients (RLR group, 2422 cases; LLR group, 2850 cases). Intraoperative blood loss (SMD=-0.31 ml, 95% CI -0.48 to -0.14; P =0.0005), open conversion (OR=0.46, 95% CI 0.37-0.58; P <0.0001), and severe complications (OR=0.76, 95% CI 0.61-0.95; P =0.02) were significantly lower in the RLR group. Operation time, odds of use, and duration of Pringle maneuver, length of hospital stay, and odds of intraoperative blood transfusion, overall complications, R0 resection, reoperation, 30-day readmission, 30-day mortality, and 90-day mortality did not significantly differ between the groups. Further subgroup and sensitivity analyses suggested that the results were stable. Meta-regression analysis did not suggest a correlation between primary outcomes and study characteristics. The quality of evidence for the primary outcomes was medium or low, while that for the secondary outcomes was medium, low, or very low.

CONCLUSION

Although some short-term outcomes are similar between RLR and LLR, RLR is superior in terms of less blood loss and lower odds of open conversion and severe complications. In the future, RLR may become a safe and effective replacement for LLR.

Robotic versus laparoscopic liver resection for liver malignancy: a systematic review and meta-analysis of propensity score-matched studies

OBJECTIVE

How different surgical procedures, including the robotic-assisted liver resection (RLR) and laparoscopic liver resection (LLR), can affect the prognosis of patients with liver malignancies is unclear. Thus, in this study, we compared the effects of RLR and LLR on the surgical and oncological outcomes in patients with liver malignancies through propensity score-matched cohort studies.

METHODS

The PubMed, Embase, and Cochrane databases were searched using Medical Subject Headings terms and keywords from inception until May 31, 2023. The quality of the included studies was assessed using the Newcastle-Ottawa quality assessment scale. The mean difference with 95% confidence interval (95% CI) was used for analysis of continuous variables; the risk ratio with 95% CI was used for dichotomous variables; and the hazard ratio with 95% CI was used for survival-related variables. Meta-analysis was performed using a random-effects model.

RESULTS

Five high-quality cohort studies with 986 patients were included (370 and 616 cases for RLR and LLR, respectively). In terms of surgical outcomes, there were no significant differences in the operation time, conversion rate to open surgery, overall complication rate, major complication rate, and length of hospital stay between the RLR and LLR groups. In terms of oncological outcomes, there were no significant differences in the 5-year overall survival and disease-free survival between the two groups.

CONCLUSION

Surgical and oncological outcomes are comparable between RLR and LLR on patients with liver malignancies. Therefore, the benefits of applying RLR in patients with liver malignancies need to be further explored.

Hepatocellular Carcinoma from a Hepatologist's Perspective

Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, represents a growing health challenge worldwide. The incidence of HCC is rising, which, in turn, has led to a corresponding increase in the associated number of deaths. HCC will become the third leading cause of cancer-related deaths in the United States by 2030. HCC usually develops in the setting of chronic liver disease. Individuals at increased risk of HCC are recommended to undergo surveillance with ultrasound every 6 months along with serum α-fetoprotein testing. Computed tomography (CT) and magnetic resonance imaging (MRI) are considered alternatives based on specific patient factors. Lesions suspicious for HCC are recommended to undergo a diagnostic testing, which includes contrast-enhanced multiphase CT or MRI and liver biopsy when findings are indeterminate. The Barcelona Clinic Liver Cancer prognosis and treatment strategy is the most used assessment for patients with HCC ( Fig. 2 ). Curative therapies include resection, liver transplantation, and ablation. Locoregional therapies, such as transarterial chemoembolization and radioembolization, can be used for patients with intermediate-stage HCC. For patients with advanced-stage HCC, systemic therapy is often used. This review aims to provide an overview of HCC from a hepatologist's perspective, including epidemiology, screening, surveillance, diagnosis, and management.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection (RLR) has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system, however, controversies still exist. Based on the foundation of the previous consensus statement, this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice. The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine (EBM). Relevant literature was reviewed and analyzed by the evidence evaluation group. According to the WHO Handbook for Guideline Development, the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022, a total of 14 recommendations were generated. Among them were 8 recommendations formulated by the GRADE method, and the remaining 6 recommendations were formulated based on literature review and experts' opinion due to insufficient EBM results. This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

Short and long-term outcomes after minimally invasive liver resection for single small hepatocellular carcinoma: An analysis of 714 patients from the IGoMILS (Italian group of minimally invasive liver surgery) registry

BACKGROUND

Widespread use of minimally invasive liver surgery (MILS) contributed to the reduction of surgical risk of liver resection for hepatocellular carcinoma (HCC). Aim of this study was to analyze outcomes of MILS for single ≤3 cm HCC.

METHODS

Patients who underwent MILS for single ≤3 cm HCC (November 2014 - December 2019) were identified from the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) Registry.

RESULTS

Of 714 patients included, 641 (93.0%) were Child-Pugh A; 65.7% were limited resections and 2.2% major resections, with a conversion rate of 5.2%. Ninety-day mortality rate was 0.3%. Overall morbidity rate was 22.4% (3.8% major complications). Mean postoperative stay was 5 days. Robotic resection showed longer operative time (p = 0.004) and a higher overall morbidity rate (p < 0.001), with similar major complications (p = 0.431). Child-Pugh B patients showed worse mortality (p = 0.017) and overall morbidity (p = 0.021), and longer postoperative stay (p = 0.005). Five-year overall survival was 79.5%; cirrhosis, satellite micronodules, and microvascular invasion were independently associated with survival.

CONCLUSIONS

MILS for ≤3 cm HCC was associated with low morbidity and mortality rates, showing high safety, and supporting the increasing indications for surgical resection in these patients.

Perioperative outcomes of robot-assisted versus laparoscopic liver resection for cavernous hemangioma: a propensity score matching study

BACKGROUND

Minimally invasive techniques have increasingly been adopted for liver resection. This study aimed to compare the perioperative outcomes of robot-assisted liver resection (RALR) with laparoscopic liver resection (LLR) for liver cavernous hemangioma and to evaluate the treatment feasibility and safety.

METHODS

A retrospective study of prospectively collected data was conducted on consecutive patients who underwent RALR (n = 43) and LLR (n = 244) for liver cavernous hemangioma between February 2015 and June 2021 at our institution. Patient demographics, tumor characteristics, and intraoperative and postoperative outcomes were analyzed and compared using propensity score matching.

RESULTS

The postoperative hospital stay was significantly shorter (P = 0.016) in the RALR group. There were no significant differences between the two groups in overall operative time, intraoperative blood loss, blood transfusion rates, conversion to open surgery or complication rates. There was no perioperative mortality. Multivariate analysis showed that hemangiomas located in posterosuperior liver segments and those in close proximity to major vascular structures were independent predictors of increased intraoperative blood loss (P = 0.013 and P = 0.001, respectively). For patients with hemangioma in close proximity to major vascular structures, there were no significant differences in perioperative outcomes between the two groups, with the exception that intraoperative blood loss in the RALR group was significantly less than that in the LLR group (350 ml vs. 450 ml, P = 0.044).

CONCLUSIONS

Both RALR and LLR were safe and feasible for treating liver hemangioma in well-selected patients. For patients with liver hemangioma in close proximity to major vascular structures, RALR was better than conventional laparoscopic surgery in reducing intraoperative blood loss.

The Triple-S framework: ensuring scalable, sustainable, and serviceable practices in educational technology

Educational institutions are increasingly investing into digital delivery, acquiring new devices, and employing novel software and services. The rising costs associated with maintenance, in combination with increasing redundancy of older technologies, presents multiple challenges. While lesson content itself may not have changed, the educational landscape constantly evolves, where tertiary institutions are incorporating new modes of content delivery, hybrid-style learning, and interactive technologies. Investments into digital expansions must be taken with caution, particularly prior to the procurement of technology, with a need for the proposed interventions' scalability, sustainability, and serviceability to be considered. This article presents the Triple-S framework for educators, administrators, and educational institutions, and outlines examples of its application within curricula. The paper synthesises research evidence to provide the foundation underlying the key principles of the Triple-S framework, presenting a useful model to use when evaluating digital interventions. Utilising the framework for decisions regarding the acquisition of educational technology, devices, software, applications, and online resources can assist in the assurance of viable and  appropriate investments.

Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis

Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.