Novel Techniques in the Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with cirrhosis preceding its development in most cases. Surgical resection remains the primary therapeutic option despite the recent emergence of locoregional therapies. Novel surgical techniques are being proposed to overcome the limitations of traditional anatomical open liver resection. Laparoscopic resection is a safe and effective alternative to open liver resection, especially for left lateral or peripheral segment tumors. It is associated with less postoperative morbidity, intraoperative blood loss, and medial hospital stay with no difference in oncological outcomes. Robotic-assisted liver resection overcomes the technically difficult resection of tumors located at the posterosuperior segments with similar outcomes to laparoscopic resection. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure allows resection in patients with HCC, and associated major vascular resection or small future liver remnant (FLR) with long-term results yet to be announced. For patients with small solitary tumors or poor liver function, nonanatomical liver resection is a feasible therapeutic option due to minimal postoperative morbidity and similar oncological results of anatomical resection

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Primary Hydatid Cysts of extremities: A Systematic review of the literature

Primary hydatid cysts (PHC) of extremities are uncommon, presenting in the majority of cases with atypical clinical features. Radical surgical excision remains the mainstay of treatment. The aim of our systematic review was to accumulate the existing data on PHC of extremities with special attention to the demographic, diagnostic and therapeutic aspects

Primary Hydatid Cysts of extremities: A Systematic review of the literature

Primary hydatid cysts (PHC) of extremities are uncommon, presenting in the majority of cases with atypical clinical features. Radical surgical excision remains the mainstay of treatment. The aim of our systematic review was to accumulate the existing data on PHC of extremities with special attention to the demographic, diagnostic and therapeutic aspects

Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature

Οι ελάχιστα επεμβατικές χειρουργικές τεχνικές υιοθετήθηκαν αρκετά αργότερα από την Ενδοκρινική Χειρουργική συγκριτικά με άλλες εξειδικεύσεις της Γενικής Χειρουργικής, λόγω των αξιοσημείωτων επιπλοκών που παρουσιάστηκαν εξαιτίας του μικρού χειρουργικού πεδίου και του υψηλού ρίσκου για κάκωση καίριων ανατομικών δομών, όπως είναι μεγάλα αγγεία του τραχήλου και νεύρα. Τα τελευταία χρόνια, τεχνολογικές βελτιώσεις ανέπτυξαν ρομποτικά συστήματα και τεχνικές και στην Ενδοκρινική χειρουργική. Πολυάριθμες δημοσιεύσεις στην σύγχρονη βιβλιογραφία έχουν περιγράψει την ασφάλεια και την επάρκεια των χειρουργικών αυτών προσπελάσεων, όπως για παράδειγμα της ρομποτικής θυρεοειδεκτομής και παραθυρεοειδεκτομής. Στην παρούσα συστηματική ανασκόπηση συμπεριλάβαμε 15 μελέτες, οι οποίες περιγράφουν την εφαρμογή ρομποτικά-υποβοηθούμενης παραθυρεοειδεικτομής για τραχηλικό αδένωμα παραθυρεοειδούς, σε ασθενείς είτε με πρωτοπαθή είτε με δευτεροπαθή υπερπαραθυρεοειδισμό. Δεν παρατηρήθηκαν αξιοσημείωτα αρνητικά βραχυπρόθεσμα μετεγχειρητικά αποτελέσματα, σε σχέση με μετεγχειρητικές επιπλοκές που αφορούν για παράδειγμα την παροδική ή μόνιμη κάκωση του παλίνδρομου λαρυγγικού νεύρου, τον μετεγχειρητικό υποπαραθυρεοειδισμό και την απώλεια αίματος. Το αισθητικό αποτέλεσμα ήτα αισθητά ανώτερο στην ρομποτική παραθυρεοειδεκτομή σε σχέση με την κλασσική παραθυρεοειδεκτομή. Τέλος, παρά το. Γεγονός ότι η ρομποτικά-υποβοηθούμενη παραθυρεοειδεκτομή είναι ασφαλής και επαρκής θεραπευτική μέθοδος για ασθενείς με πρωτοπαθή ήδευτεροπαθή υπερπαραθυρεοειδισμό, δεν υπάρχουν διαθέσιμες τυχαιοποιημένες κλινικές μελέτες που να εγκαθιστούν την συγκεκριμένη μοντέρνα τεχνική ως την τεχνική εκλογής για την θεραπεία αυτών των ασθενών.Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures like robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with Primary Hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials in order to establish this modern procedure as a gold-standard treatment strategy for these patients

The effects of ursodeoxycholic acid pretreatment in an experimental Setting of extended hepatectomy: a feasibility study

Introduction Liver regeneration is an exceptionally complex process, orchestrated by a multitude of growth factors and cytokines. Tumor necrosis factor-alpha (TNF-a) and interleukin-6 (Il-6) have a pivotal role in the initiation of the regenerative response. Ursodeoxycholic acid (UDCA) exhibits a liver protective effect that enhances liver growth after injury. The aim of the present study is to evaluate the effect of UDCA in the circulating levels of TNF-a and Il-6 in rats undergoing extended 80% hepatectomy. Materials and methods Twenty-two male Sprague Dawley rats were randomly assigned in an experimental (UDCA group) and a control group. Mice in the UDCA-group received oral pretreatment of UDCA for two weeks preoperatively at a dosage of 25 mg/kg/day. An 80% hepatic resection was performed in both groups by resecting the middle, inferior right, and left lateral liver lobes. The experiment ended 48 hours postoperatively. Results UDCA pretreatment significantly depressed circulating levels of both TNF-a and Il-6 after the conclusion of the experiment as compared to the control group (p=0.001 and p=0.01, respectively). Furthermore, TNF-a levels were significantly reduced before the institution of liver injury (p=0.02). Mice in the UDCA-group exhibited better liver growth as demonstrated by significantly increased Ki-67 and mitotic rate (p=0.04 and p=0.02, respectively). Finally, the liver regeneration rate (LRR) was significantly elevated in the experimental group (UDCA group, 54.5% vs control group, 35.8%; p=0.002) signifying enhanced liver growth kinetics. Conclusion UDCA reduces the expression of TNF-a and Il-6 during the priming phase of liver regeneration. An 80% hepatectomy model of acute liver failure exhibited enhanced liver regeneration in the experimental group, plausibly due to the immunomodulatory effects of UDCA.Εισαγωγή: Η αναγέννηση του ήπατος είναι μια εξαιρετικά περίπλοκη διαδικασία, χαρακτηριζόμενη από ένα πλήθος αυξητικών παραγόντων και κυτταροκινών. Ο παράγοντας νέκρωσης όγκου-άλφα (TNF-α) και η ιντερλευκίνη-6 (Il-6) έχουν καθοριστικό ρόλο στην έναρξη της αναγεννητικής απόκρισης. Το ουρσοδεοξυχολικό οξύ (UDCA) εμφανίζει ηπατική προστασία που ενισχύει την ανάπτυξη του ήπατος μετά από τραυματισμό. Ο στόχος της παρούσας μελέτης είναι να αξιολογήσει την επίδραση της UDCA στα κυκλοφορούντα επίπεδα TNF-α και Il-6 σε αρουραίους που υποβάλλονται σε εκτεταμένη ηπατεκτομή. Υλικά και μέθοδοι: 22 αρσενικοί αρουραίοι Sprague Dawley διαχωρίστηκαν σε δύο ομάδες: Ομάδα ελέγχου και Ομάδα UDCA. Η Ομάδα UDCA έλαβε από του στόματος προθεραπεία με UDCA για δύο εβδομάδες προεγχειρητικά σε δόση 25 mg / kg / ημέρα. Πραγματοποιήθηκε 80% ηπατεκτομή και στις δύο ομάδες με εκτομή του μεσαίου, του άνω δεξιού πλάγιου και αριστερού πλάγιου λοβού του ήπατος. Το πείραμα έληξε 48 ώρες μετεγχειρητικά.Αποτελέσματα: Η προθεραπεία με UDCA μείωσε σημαντικά τα επίπεδα ς τόσο του TNF-α όσο και της IL-6 μετά το πέρας του πειράματος σε σύγκριση με την ομάδα ελέγχου (p = 0,001 και p = 0,01, αντίστοιχα). Επιπλέον, τα επίπεδα του TNF-α μειώθηκαν σημαντικά πριν από την έναρξη της ηπατεκτομής (p = 0,02) Η Ομάδα UDCA εμφάνισε μεγαλύτερη ανάπτυξη ηπατικού παρεγχύματος, όπως αποδεικνύεται από σημαντικά αυξημένο Ki-67 και αριθμό μιτώσεων (p = 0,04 και p = 0,02, αντίστοιχα). Τέλος, ο ρυθμός αναγέννησης του ήπατος (LRR) ήταν σημαντικά αυξημένος στην πειραματική ομάδα (ομάδα UDCA, 54,5% έναντι της ομάδας ελέγχου, 35,8% · ρ = 0,002).Συμπέρασμα: Το UDCA μειώνει την έκφραση των TNF-α και Il-6 κατά τη διάρκεια της φάσης έναρξης της αναγέννησης του ήπατος. Ένα μοντέλο ηπατεκτομής 80% οξείας ηπατικής ανεπάρκειας παρουσίασε ενισχυμένη αναγέννηση του ήπατος στην πειραματική ομάδα, εύλογα λόγω των ανοσορρυθμιστικών επιδράσεων του UDCA

Η επίδραση του ουρσοδεοξυχολικού οξέος στα επίπεδα του TNF-α και της IL-6 στην ηπατική αναγέννηση σε πειραματικό μοντέλο ηπατεκτομής σε επίμυες

Εισαγωγή: Η αναγέννηση του ήπατος είναι μια εξαιρετικά περίπλοκη διαδικασία, χαρακτηριζόμενη από ένα πλήθος αυξητικών παραγόντων και κυτταροκινών. Ο παράγοντας νέκρωσης όγκου-άλφα (TNF-α) και η ιντερλευκίνη-6 (Il-6) έχουν καθοριστικό ρόλο στην έναρξη της αναγεννητικής απόκρισης. Το ουρσοδεοξυχολικό οξύ (UDCA) εμφανίζει ηπατική προστασία που ενισχύει την ανάπτυξη του ήπατος μετά από τραυματισμό. Ο στόχος της παρούσας μελέτης είναι να αξιολογήσει την επίδραση της UDCA στα κυκλοφορούντα επίπεδα TNF-α και Il-6 σε αρουραίους που υποβάλλονται σε εκτεταμένη ηπατεκτομή. Υλικά και μέθοδοι: 22 αρσενικοί αρουραίοι Sprague Dawley διαχωρίστηκαν σε δύο ομάδες: Ομάδα ελέγχου και Ομάδα UDCA. Η Ομάδα UDCA έλαβε από του στόματος προθεραπεία με UDCA για δύο εβδομάδες προεγχειρητικά σε δόση 25 mg / kg / ημέρα. Πραγματοποιήθηκε 80% ηπατεκτομή και στις δύο ομάδες με εκτομή του μεσαίου, του άνω δεξιού πλάγιου και αριστερού πλάγιου λοβού του ήπατος. Το πείραμα έληξε 48 ώρες μετεγχειρητικά. Αποτελέσματα: Η προθεραπεία με UDCA μείωσε σημαντικά τα επίπεδα ς τόσο του TNF-α όσο και της IL-6 μετά το πέρας του πειράματος σε σύγκριση με την ομάδα ελέγχου (p = 0,001 και p = 0,01, αντίστοιχα). Επιπλέον, τα επίπεδα του TNF-α μειώθηκαν σημαντικά πριν από την έναρξη της ηπατεκτομής (p = 0,02) Η Ομάδα UDCA εμφάνισε μεγαλύτερη ανάπτυξη ηπατικού παρεγχύματος, όπως αποδεικνύεται από σημαντικά αυξημένο Ki-67 και αριθμό μιτώσεων (p = 0,04 και p = 0,02, αντίστοιχα). Τέλος, ο ρυθμός αναγέννησης του ήπατος (LRR) ήταν σημαντικά αυξημένος στην πειραματική ομάδα (ομάδα UDCA, 54,5% έναντι της ομάδας ελέγχου, 35,8% · ρ = 0,002). Συμπέρασμα: Το UDCA μειώνει την έκφραση των TNF-α και Il-6 κατά τη διάρκεια της φάσης έναρξης της αναγέννησης του ήπατος. Ένα μοντέλο ηπατεκτομής 80% οξείας ηπατικής ανεπάρκειας παρουσίασε ενισχυμένη αναγέννηση του ήπατος στην πειραματική ομάδα, εύλογα λόγω των ανοσορρυθμιστικών επιδράσεων του UDCA.Introduction Liver regeneration is an exceptionally complex process, orchestrated by a multitude of growth factors and cytokines. Tumor necrosis factor-alpha (TNF-a) and interleukin-6 (Il-6) have a pivotal role in the initiation of the regenerative response. Ursodeoxycholic acid (UDCA) exhibits a liver protective effect that enhances liver growth after injury. The aim of the present study is to evaluate the effect of UDCA in the circulating levels of TNF-a and Il-6 in rats undergoing extended 80% hepatectomy. Materials and methods Twenty-two male Sprague Dawley rats were randomly assigned in an experimental (UDCA group) and a control group. Mice in the UDCA-group received oral pretreatment of UDCA for two weeks preoperatively at a dosage of 25 mg/kg/day. An 80% hepatic resection was performed in both groups by resecting the middle, inferior right, and left lateral liver lobes. The experiment ended 48 hours postoperatively. Results UDCA pretreatment significantly depressed circulating levels of both TNF-a and Il-6 after the conclusion of the experiment as compared to the control group (p=0.001 and p=0.01, respectively). Furthermore, TNF-a levels were significantly reduced before the institution of liver injury (p=0.02). Mice in the UDCA-group exhibited better liver growth as demonstrated by significantly increased Ki-67 and mitotic rate (p=0.04 and p=0.02, respectively). Finally, the liver regeneration rate (LRR) was significantly elevated in the experimental group (UDCA group, 54.5% vs control group, 35.8%; p=0.002) signifying enhanced liver growth kinetics. Conclusion UDCA reduces the expression of TNF-a and Il-6 during the priming phase of liver regeneration. An 80% hepatectomy model of acute liver failure exhibited enhanced liver regeneration in the experimental group, plausibly due to the immunomodulatory effects of UDCA