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ObjectiveTo present surgical and oncological outcomes using a prospective and randomized trial (LapOpHuva, NCT02727179) comparing minimally invasive liver resection (LLR) versus open liver resection (OLR) in patients with colorectal liver metastases (CRLM).MethodsBetween February 2005 and March 2016, 204 selected patients with CRLM were randomized and 193 were included: LLR (n = 96) and OLR (n = 97). The primary endpoint was to compare postoperative morbidity. Other secondary endpoints were oncological outcomes, use of the Pringle maneuver, surgical time, blood losses, transfusions, hospital stay, mortality and OS, and disease-free survival (DFS) at 3, 5, and 7 years.ResultsLLR presented with lower global morbidity (11.5% vs. 23.7%, p = 0.025) but with similar severe complications. Long-term survival outcomes were similar in both groups. The cumulative 1-, 3-, 5-, 7-year OS for LLR and OLR were 92.5%, 71.5%, 49.3%, 35.6% versus 93.6%, 69.7%, 47.4%, 35.5%, respectively (log-rank = 0.047, p = 0.82). DFS for LLR and OLR was 72.7%, 33.5%, 22.7%, and 20.8% versus 61.6%, 27.2%, 23.9%, and 17.9%, respectively (log-rank = 1.427, p = 0.23). LLR involved more use of the Pringle maneuver (15.5% vs. 30.2%, p = 0.025) and a shorter hospital stay (4 vs. 6 days, p < 0.001). There were no differences regarding surgical time, blood losses, transfusion, and mortality.ConclusionsIn selected patients with CRLM, LLR presents similar oncological outcomes with the advantages of the short-term results associated with LLR.

ObjectivesImmunoscore evaluates the density of CD3+ and CD8+ T cells in both the tumor core and invasive margin. Pretreatment prediction of immunoscore in hepatocellular cancer (HCC) is important for precision immunotherapy. We aimed to develop a radiomics model based on gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced MRI for pretreatment prediction of immunoscore (0–2 vs. 3–4) in HCC.Materials and methodsThe study included 207 (training cohort: n = 150; validation cohort: n = 57) HCC patients with hepatectomy who underwent preoperative Gd-EOB-DTPA-enhanced MRI. The volumes of interest enclosing hepatic lesions including intratumoral and peritumoral regions were manually delineated in the hepatobiliary phase of MRI images, from which 1044 quantitative features were extracted and analyzed. Extremely randomized tree method was used to select radiomics features for building radiomics model. Predicting performance in immunoscore was compared among three models: (1) using only intratumoral radiomics features (intratumoral radiomics model); (2) using combined intratumoral and peritumoral radiomics features (combined radiomics model); (3) using clinical data and selected combined radiomics features (combined radiomics-based clinical model).ResultsThe combined radiomics model showed a better predicting performance in immunoscore than intratumoral radiomics model (AUC, 0.904 (95% CI 0.855–0.953) vs. 0.823 (95% CI 0.747–0.899)). The combined radiomics-based clinical model showed an improvement over the combined radiomics model in predicting immunoscore (AUC, 0·926 (95% CI 0·884–0·967) vs. 0·904 (95% CI 0·855–0·953)), although differences were not statistically significant. Results were confirmed in validation cohort and calibration curves showed good agreement.ConclusionThe MRI-based combined radiomics nomogram is effective in predicting immunoscore in HCC and may help making treatment decisions.Key Points• Radiomics obtained from Gd-EOB-DTPA-enhanced MRI help predicting immunoscore in hepatocellular carcinoma.• Combined intratumoral and peritumoral radiomics are superior to intratumoral radiomics only in predicting immunoscore.• We developed a combined clinical and radiomicsnomogram to predict immunoscore in hepatocellular carcinoma.

ObjectiveEvaluation of the benefits of a virtual reality (VR) environment with a head-mounted display (HMD) for decision-making in liver surgery.BackgroundTraining in liver surgery involves appraising radiologic images and considering the patient’s clinical information. Accurate assessment of 2D-tomography images is complex and requires considerable experience, and often the images are divorced from the clinical information. We present a comprehensive and interactive tool for visualizing operation planning data in a VR environment using a head-mounted-display and compare it to 3D visualization and 2D-tomography.MethodsNinety medical students were randomized into three groups (1:1:1 ratio). All participants analyzed three liver surgery patient cases with increasing difficulty. The cases were analyzed using 2D-tomography data (group “2D”), a 3D visualization on a 2D display (group “3D”) or within a VR environment (group “VR”). The VR environment was displayed using the “Oculus Rift ™” HMD technology. Participants answered 11 questions on anatomy, tumor involvement and surgical decision-making and 18 evaluative questions (Likert scale).ResultsSum of correct answers were significantly higher in the 3D (7.1 ± 1.4, p < 0.001) and VR (7.1 ± 1.4, p < 0.001) groups than the 2D group (5.4 ± 1.4) while there was no difference between 3D and VR (p = 0.987). Times to answer in the 3D (6:44 ± 02:22 min, p < 0.001) and VR (6:24 ± 02:43 min, p < 0.001) groups were significantly faster than the 2D group (09:13 ± 03:10 min) while there was no difference between 3D and VR (p = 0.419). The VR environment was evaluated as most useful for identification of anatomic anomalies, risk and target structures and for the transfer of anatomical and pathological information to the intraoperative situation in the questionnaire.ConclusionsA VR environment with 3D visualization using a HMD is useful as a surgical training tool to accurately and quickly determine liver anatomy and tumor involvement in surgery.

Introduction Surgical process models (SPM) are simplified representations of operations and their visualization by surgical workflow management systems (SWMS), and offer a solution to enhance communication and workflow. Methods A 1:1 randomized controlled trial was conducted. A SPM consisting of six surgical steps was defined to represent the surgical procedure. The primary outcome, termed “deviation” measured the difference between actual and planned surgery duration. Secondary outcomes included stress levels of the operating team and complications. Analyses employed Welch t-tests and linear regression models. Results 18 procedures were performed with a SWMS and 18 without. The deviation showed no significant difference between the intervention and control group. Stress levels (TLX score) of the team remained largely unaffected. Duration of operation steps defined by SPM allows a classification of all liver procedures into three phases: The Start Phase (low IQR of operation time), the Main Phase (high IQR of operation time) and the End Phase (low IQR of operation time). Conclusion This study presents a novel SPM for open liver resections visualized by a SWMS. No significant reduction of deviations from planned operation time was observed with system use. Stress levels of the operation team were not influenced by the SWMS.

Background Low pneumoperitoneum pressure (LPP) lowers the incidence of CO 2 embolisms in minimally invasive liver resections (MILR), while higher pneumoperitoneum pressure (HPP) reduces intraoperative blood loss. This contradiction necessitates careful pressure management especially in major liver resections where intraoperative blood loss greatly impacts postoperative outcome. Methods In this randomized non-inferiority trial, adults undergoing elective MILR for any indication will be recruited in alignment with inclusion and exclusion criteria. After given informed consent, eligible patients will be randomized to either low (≤10 mmHg) or high (≥14 mmHg) pneumoperitoneum pressure during parenchymal transection. Blood, peritoneal biopsies, and liver tissue will be sampled to evaluate intraoperative tissue damage. Sample size ( n  = 66 patients per group) is calculated based on the current literature. The primary study endpoint is intraoperative blood loss during the parenchymal transection phase. Secondary endpoints include CO 2 embolisms, intraoperative tissue damage, operation time, morbidity, mortality, and duration of hospitalization. Discussion Minimizing intraoperative blood loss in MILR is a clinically relevant problem, which greatly impacts the procedure’s safety and influences the patient’s morbidity and mortality. HPP, exerting counter pressure to the vascular pressure, serves for bleeding control in MILR. The risk of CO 2 embolism, arising from the combination of high intra-abdominal pressure and low central venous pressure, favors the use of LPP. The proposed trial aims to assess the non-inferiority of LPP compared to HPP during the parenchymal transection phase of MILR. Trial registration ClinicalTrials.gov NCT06770803. First Submitted: 2024-12-30, First Submitted that Met QC Criteria: 2025-01-07, First Posted: 2025-01-13.

Pain relief provided by the transversus abdominis plane (TAP) block in individuals who have undergone living liver donation during the postoperative period has been demonstrated in previous studies. The external oblique intercostal plane (EOI) block is a recently introduced technique designed to provide analgesia for the anterolateral region of the upper abdominal wall. This study aims to evaluate and compare the efficacy of the external oblique intercostal plane (EOI) block and the subcostal TAP block in individuals who have undergone living liver donation. Patients were randomly assigned to one of two groups: EOI block group and subcostal TAP block group. In both groups, bilateral blocks were performed using a total of 40 ml of 0.25 % bupivacaine at the end of surgery and prior to extubation. Postoperatively, all patients were connected to an intravenous patient-controlled analgesia (PCA) device containing morphine. The primary outcome of the study was intravenous morphine consumption during the first 24 h postoperatively. The median [interquartile range] morphine consumption at 24 h postoperatively was similar between EOI block and subcostal TAP block groups (23.5 [19.5 to 27.5] vs 26 [24 to 28], respectively). There were no significant differences in terms of numerical rating scale (NRS) scores at rest and during movement at 2, 6, 12 and 24 h. No block-related complications were observed in any patients. The results of the study showed that there were no statistically significant differences in 24-h morphine consumption or pain scores at rest and during movement between the subcostal TAP and EOI block groups in living liver donors undergoing right hepatectomy. Either technique may be preferred depending on the clinician's experience and institutional practice. Trial registration. Clinicaltrials.gov identifier: NCT05890079 [Display omitted] •Effective postoperative pain management is crucial for optimal recovery and outcomes in liver donors.•Interfascial plane blocks provide effective and opioid-sparing analgesia after abdominal surgery.•This study compared the analgesic efficacy of EOI and subcostal TAP blocks in donor hepatectomy.•EOI and subcostal TAP blocks showed similar 24-h morphine consumption and pain scores in living liver donors.

Postoperative delirium was reported to be associated with increased postoperative mortality after liver resection. Therefore, it is crucial to prevent postoperative delirium in such cases. Ramelteon, an agonist of melatonin receptor has been suggested to be useful for preventing delirium. The aim of this study was to examine whether ramelteon is effective at preventing delirium after elective liver resection. The cases of patients who underwent liver resection at Nara Medical University (Nara, Japan) between January 2014 and August 2018 were analyzed. During the period from January 2017 to August 2018, ramelteon was prospectively administered to patients who underwent liver resection [8 mg/day on the day before surgery and on postoperative days 1 to 3] (ramelteon group), whereas ramelteon was not administered during the period from January 2014 to December 2016 (control group). The perioperative outcomes of the two groups were compared. There were 120 patients in the ramelteon group and 186 patients in the control group. No significant intergroup differences in background factors, including age, gender, and preoperative serological laboratory data, were detected. The incidence of postoperative delirium was significantly lower in the ramelteon group (5.8% vs. 15.1%, P = 0.035). Multivariate analysis revealed that being aged ≥75 (P = 0.002), being male (P = 0.020), cardiovascular disease (P = 0.023), blood loss ≥1000ml (P = 0.001) and the absence of ramelteon treatment (P = 0.046) were independent risk factors for postoperative delirium. The administration of ramelteon might reduce the risk of postoperative delirium after elective liver resection.

This Phase I/II randomized, controlled, multicenter study aimed to evaluate the safety and efficacy of sFilm-FS compared to Tachosil® in patients undergoing elective liver surgery requiring hemostasis at the liver surface. sFilm-FS is a new fibrin sealant patch, coating on a biodegradable tri-block polymeric film. The trial included 33 patients randomized 1:1 to receive sFilm-FS or Tachosil®. While most patients underwent liver resection, a subset underwent other hepatic surgical interventions. Safety was the primary outcome, including treatment-emergent adverse events, coagulopathies, and intraoperative blood loss. Efficacy was assessed as secondary endpoints by the time to hemostasis and hemostasis at 2, 3, 5, 7, and 10 ​min from product application. Hemostasis was defined as the absence of bleeding at the target bleeding site within 10 ​min. Both treatments were well tolerated, with no significant differences in adverse events. All patients achieved hemostasis within 10 ​min. The median time to hemostasis was 2 ​min for sFilm-FS and 3 ​min for Tachosil®. sFilm-FS is a promising, well tolerated, fibrin sealant patch, offering the potential for a superior Fibrin Sealant patch that could improve surgical outcomes. Further studies are recommended to validate these findings in larger populations. •SFilm-FS achieved faster median hemostasis (2 ​min) vs. Tachosil (3 ​min) in liver resection.•No anti-fibrinogen antibody response detected in sFilm-FS patients during 6-month follow-up.•SFilm-FS is semi-transparent, enabling clear visibility of the target bleeding site.•SFilm-FS demonstrated suitability for minimal invasive surgery due to its thin, flexible structure.•SFilm-FS contains significantly lower fibrinogen levels, reducing production costs and immunogenicity risk.

Objective(s) The technical complexity of laparoscopic liver resection (LLR) poses unique challenges distinct from open surgery. An objective scoring system was developed that preoperatively quantifies the difficulty of LRR to help guide surgeon decision-making regarding the feasibility and safety of minimally invasive approaches. The aim of this multiinstitutional study was to externally validate this scoring system. Methods Patients who underwent LLR at two institutions were reviewed. LLR difficulty score (LDS) was calculated based on patient, tumor, and anatomic characteristics by two independent, blinded hepatobiliary surgeons. Surrogates of case complexity (e.g., conversion rate, operative time) were used for validation of this index. Results From 2006 to 2016, 444 LLR were scored as low ( n  = 94), intermediate ( n  = 98), and high difficulty ( n  = 152) with respective conversion rates of 5.3%, 15.7%, and 25%. Cases of higher LDS correlated with larger mean blood loss (203 ml vs. 331 ml vs. 635 ml). Mean operative and Pringle maneuver used were associated with increasing LDS (155 min vs. 202 min vs. 315 min and 14.4% vs. 29.7% vs. 45.1% respectively). These operative surrogates of difficulty correlated significantly with the LDS (all p  < 0.0001). Conclusions This comprehensive external validation of the LDS is robust and applicable in diverse patient populations. This LDS serves as a useful objective predictor of technical difficulty for LLR to help surgeons in selecting patients according to their individual operative experience and is valuable for preoperative risk estimation and stratification in randomized trials.

This study compared the analgesic effect of single-shot erector spinae plane block (ESPB) or posterior quadratus lumborum block (QLB) versus systemic analgesia alone after laparoscopic major liver resection. This randomized controlled trial was conducted at a single referral center between August 2022 and January 2024. 114 patients undergoing laparoscopic major liver resection were randomized to one of three groups: control, ESPB, or QLB (1:1:1). The control group received systemic analgesia without regional anesthesia, whereas both ESPB and QLB groups received an additional regional anesthesia using 40 mL of 0.5 % ropivacaine. The primary outcome was cumulative opioid consumption within 24 h post-surgery. Secondary outcomes included cumulative opioid consumption, pain intensity, and recovery parameters during 72 h post-surgery. Cumulative opioid consumption (median [IQR]) within 24 h post-surgery was not significantly different among the groups (control, 35 mg [25, 53]; ESPB, 32 mg [21, 44]; QLB, 29 mg [22, 40]; adjP > 0.99). Cumulative opioid consumption at 1 and 48 h also did not significantly differ among the three groups (adjP = 0.336 and 0.732) but was significantly lower at 72 h post-surgery (adjP = 0.032). Pain at rest during the postanesthesia care unit (PACU) stay and at 48 h post-surgery was lower in ESPB and QLB versus control, while pain when coughing in both block groups was reduced only during the PACU stay. Neither ESPB nor posterior QLB resulted in a significant decrease in cumulative opioid consumption within 24 h after laparoscopic major liver resection. •ESPB and QLB failed to lower opioid consumption within 24 h after liver resection.•ESPB and QLB may support multimodal analgesia for acute pain after liver resection.•No block-related complications occurred in ESPB or QLB despite reduced liver volume.