Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes

A Prospective Analysis of the Effects of a Powder-Type Hemostatic Agent on the Short-Term Outcomes after Liver Resection

Background and Objectives: Postoperative bleeding is a significant cause of morbidity and mortality following liver resection. Therefore, it is crucial to minimize bleeding during liver resection and effectively manage it when it occurs. Arista® AH (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) is a microporous polysaccharide hemosphere (MPH), a new plant-derived polysaccharide powder hemostat that can be applied to the entire surgical field. This study prospectively assessed the effectiveness of Arista for bleeding control when applied intraoperatively to the liver resection surface. Materials and Methods: Data were collected at Seoul National University Bundang Hospital for patients who underwent liver resection owing to malignant hepatocellular carcinoma or benign liver diseases. We compared the outcomes between 45 patients managed with Arista® AH (data were prospectively collected between September 2022 and May 2023) and 156 patients managed without the use of Arista® AH (data were retrospectively collected between January 2021 and December 2021). Results: There were no significant differences in patient characteristics between the two groups. The estimated blood loss (EBL) was significantly lower in the Arista® AH group compared with the control group (495.56 ± 672.7 mL vs. 691.9 ± 777.5 mL, p = 0.049). The mean postoperative hospital stay was significantly shorter in the Arista® AH group (5.93 ± 1.88 days vs. 6.94 ± 4.17 days, p = 0.024). The time to Jackson-Pratt drain removal was also significantly shorter in the Arista® AH group (4.64 ± 1.31 days vs. 5.30 ± 2.87 days, p = 0.030). The patient subgroup was divided into four categories based on the type of resection and the presence or absence of cirrhosis. Within the subgroup of major resections in non-cirrhotic patients, the Arista® AH group demonstrated significantly better outcomes compared to the control group, showed lower EBL, reduced need for blood transfusions, decreased volume of drain fluid collected within 48 h, earlier removal of drains, and shorter hospital stays. In contrast, for the other subgroups such as minor resection (both non-cirrhotic and cirrhotic) and major resection with cirrhosis, the differences between the Arista® AH and control groups in various parameters like EBL, blood transfusion rates, drain fluid volume, time to drain removal, and duration of hospital stay were not statistically significant. Conclusions: Arista® AH significantly improved intraoperative blood management and postoperative recovery in patients undergoing liver resection, particularly in non-cirrhotic patients who underwent major resection

Comparative Study of Long-Term Outcomes of Laparoscopic Liver Resection versus Radiofrequency Ablation for Single Small Hepatocellular Carcinoma Located in Left Lateral Segments of the Liver

Background and Objectives: Laparoscopic liver resection (LLR) is now widely recognized as the primary surgical option for hepatocellular carcinomas (HCC) smaller than 3 cm located in the left lateral segment of the liver. Nevertheless, there is a scarcity of studies comparing laparoscopic liver resection with radiofrequency ablation (RFA) in these cases. Materials and Methods: We retrospectively compared the short- and long-term outcomes of Child–Pugh class A patients who underwent LLR (n = 36) or RFA (n = 40) for a newly diagnosed single small (≤3 cm) HCC located in the left lateral segment of the liver. Results: Overall survival (OS) was not significantly different between the LLR and RFA groups (94.4% vs. 80.0%, p = 0.075). However, disease-free survival (DFS) was better in the LLR group than in the RFA group (p p p = 0.031) and DFS (68.8% vs. 20.0%, p = 0.002) rates were greater in the LLR group. Conclusions: LLR showed superior OS and DFS compared to RFA in patients with a single small HCC situated in the left lateral segment of the liver. LLR can be considered for patients with an α-fetoprotein level of ≥20 ng/mL

Development and Validation of a Difficulty Scoring System for Laparoscopic Liver Resection to Treat Hepatolithiasis

Background and Objectives: A difficulty scoring system was previously developed to assess the difficulty of laparoscopic liver resection (LLR) for liver tumors; however, we need another system for hepatolithiasis. Therefore, we developed a novel difficulty scoring system (nDSS) and validated its use for predicting postoperative outcomes. Materials and Methods: This was a retrospective study. We used clinical data of 123 patients who underwent LLR for hepatolithiasis between 2003 and 2021. We analyzed the data to determine which indices were associated with operation time or estimated blood loss (EBL) to measure the surgical difficulty. We validated the nDSS in terms of its ability to predict postoperative outcomes, namely red blood cell (RBC) transfusion, postoperative hospital stay (POHS), and major complications defined as grade ≥IIIa according to the Clavien–Dindo classification (CDC). Results: The nDSS included five significant indices (range: 5–17; median: 8). The RBC transfusion rate (p p = 0.002), and major complication rate (p = 0.002) increased with increasing nDSS score. We compared the two groups of patients divided by the median nDSS (low: 5–7; high: 8–17). The operation time (210.7 vs. 240.7 min; p p p p = 0.001), and major complication rate (8.8% vs. 25.8%; p = 0.014) were greater in the high group. Conclusions: The nDSS can predict the surgical difficulty and outcomes of LLR for hepatolithiasis and may help select candidates for the procedure and surgical approach

Long-Term Outcomes of Laparoscopic Liver Resection for Centrally Located Hepatocellular Carcinoma

Background and Objectives: The feasibility of laparoscopic liver resection (LLR) for centrally located hepatocellular carcinoma (cHCC 1 cm of the hilum, major hepatic veins, and inferior vena cava) is still controversial. This study aims to evaluate the feasibility and safety of LLR for cHCC and compare the perioperative outcomes with those of open liver resection (OLR). Materials and Methods: This retrospective study included 110 patients who underwent LLR (n = 59) or open liver resection (OLR) (n = 51) for cHCC between January 2004 and September 2018. LLR group was divided into the following two subgroups according to the date of operation: Group 1 (n = 19) and Group 2 (n = 40), to account for the advancement in the laparoscopic techniques. Results: No mortality within 3 months was observed. There were no significant differences in operation time (285 vs. 280 min; p = 0.938) and postoperative complication rate (22.0% vs. 27.5%; p = 0.510) between both groups. However, intraoperative blood loss (500 vs. 700 mL; p &lt; 0.001), transfusion rate (10.2% vs. 31.4%; p = 0.006), and hospital stay (6 vs. 10 days; p &lt; 0.001) were significantly lower in the LLR group than in the OLR group. In the LLR group, Group 2, showed a shorter hospital stay than Group 1 (6 vs. 8 days; p = 0.006). There were improvements in the operation time (280 vs. 360 min; p = 0.036) and less intraoperative blood loss (455 vs. 500 mL; p = 0.075) in Group 2. Conclusions: We demonstrated that LLR can be safely performed in highly selected patients with cHCC