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Background: Pure laparoscopic donor hepatectomy (L-DH) has seen a rise in uptake in recent years following the popularization of minimally invasive modality for major hepatobiliary surgery. Our study aimed to determine the safety and compare the perioperative outcomes of L-DH with open donor hepatectomy (O-DH) and laparoscopic non donor hepatectomy (L-NDH) based on our single institution experience., Methods: Eighty of 113 laparoscopic hemi-hepatectomies performed between 2015 and 2022 met study inclusion criteria. Of these, 11 were L-DH. PSM in a 1:2 ratio of L-DH versus L-NDH and 1:1 ratio of L-DH versus O-DH were performed, identifying patients with similar baseline clinicopathological characteristics., Results: After 2:1 matching, the L-DH cohort were significantly younger (P < 0.001) and had lower ASA scores (P < 0.001) than the L-NDH cohort. L-DH was associated with a longer median operating time (P < 0.001) and shorter median postoperative stay (P < 0.001) than L-NDH. After 1:1 matching, there were no significant differences in baseline demographic between the L-DH and O-DH cohorts. L-DH was associated with lower median blood loss (P = 0.040) and shorter length of stay compared to O-DH (P = 0.004). There were no significant differences in recipient outcomes for both cohorts., Conclusion: L-DH can be adopted safely by surgeons experienced in L-NDH and ODH. It is associated with decreased blood loss and shorter length of stay compared to O-DH., (© 2023 Royal Australasian College of Surgeons.)

Background: Liver transplantation remains the optimal treatment for multifocal hepatocellular carcinoma (HCC). However, due to resource constrains, other therapeutic modalities such as liver resection (LR), are frequently utilized. LR, however, has to be balanced against potential morbidity and mortality along with the risks of early recurrence leading to futile surgery. In this study, we evaluated preoperative factors, including inflammatory indices, in predicting early (< 1 year) recurrence in patients who underwent LR for multifocal HCC., Methods: This was a post hoc analysis of 250 consecutive patients with multifocal HCC who underwent LR., Results: After exclusion of 10 patients with 30-day/in-hospital mortality, 240 were included of which 134 (55.8%) developed early recurrence. Hepatitis B/C aetiology, 3/ > more hepatic nodules and elevated alpha-fetoprotein (AFP) ≥ 200 ng/ml were significant independent preoperative predictors of early recurrence. The early recurrence rate was 72.1% when 2 out of 3 significant predictive factors were present. The conglomerate of all 3 factors predicted early recurrence of 100% with a statistically significant association between number of predictive factors and early recurrence (p < 0.001)., Conclusion: Better patient selection via the use of preoperative predictive factors of early recurrence such as hepatitis B/C aetiology, ≥ 3 nodules and elevated AFP ≥ 200 ng/ml may assist in identifying patients in whom LR is deemed futile and improve resource allocation., (© 2023. The Society for Surgery of the Alimentary Tract.)

Background: Results from the BIOLUX P-III registry have demonstrated favourable outcomes of Passeo-18 Lux™ (Biotronik®, Buelach, Switzerland) drug-coated balloon in treating obstructive infrainguinal peripheral artery disease, but it has not been established if Asians would benefit to the same extent as non-Asians., Methods: A subgroup analysis was performed on the 24-month data comparing the Asian cohort (AC) to non-Asian cohort (NAC)., Results: AC included 49 patients with 77 lesions. AC was significantly younger (65.6 vs 70.3 years, p < 0.05), had more diabetes (87.8% vs 45.3%, p < 0.05), and was more likely to present with CLTI (73.5% vs 35.3%, p < 0.001) compared to NAC. They had significantly longer mean target lesions (115 vs 86.9 mm, p = 0.006), and received significantly higher paclitaxel doses (10.7 vs 7.2 mg, p = 0.0005). Device, technical and procedural successes were 125/125(100%), 95/97(97.5%) and 45/49(91.8%), respectively. There was no significant difference in target lesion revascularization rates between groups (10.5% vs 12%, p = 0.91). However, the AC had more major adverse events (30.2% vs 16.1%, p = 0.001), amputations (26.3% vs 6.2%, p < 0.05) and mortality (37.9% vs 10.6%, p < 0.05) at 24 months., Conclusion: Passeo-18 Lux™ use was efficacious in Asians, but was associated with higher adverse events, amputations and mortality rates, likely attributable to poorer patient comorbidities and more extensive PAD.

Background: Despite the wide use of laparoscopy for liver resection, laparoscopic caudate lobe resections(L-CLR) remain technically challenging, only attempted by experts in the field. The primary objective of this study was to determine the safety and compare the perioperative outcomes of L-CLR with O-CLR based on our single institution experience in a 1:2 propensity score-matched controlled study based on our single institution experience., Methods: Between 2004 and 2020, 67 consecutive patients who underwent CLR at Singapore General Hospital were identified. Propensity score matching (PSM) of laparoscopic versus open caudate lobe resections(O-CLR) was performed in a 1:2 ratio with no replacements using nearest neighbour matching method., Results: L-CLR was associated with a significantly decreased median blood loss (150 mL versus 500 mL, P = 0.001) and a decreased median post-operative stay (3 days versus 7.5 days, P = <0.01) in the unmatched cohorts. After 1:2 propensity score matching, these results were again demonstrated with a significantly lower blood loss (150 mL versus 400 mL, P = 0.016) and a shorter postoperative stay (3 days versus 7 days, P = <0.01) in favour of L-CLR. 30-day readmission and major morbidity (Clavien-Dindo grade > 2) rates were all in favour of L-CLR as well but could not reach statistical significance., Conclusion: L-CLR can be safely performed by experienced surgeons. It is associated with decreased blood loss and shorter perioperative stay compared to O-CLR., (© 2022 Royal Australasian College of Surgeons.)

Purpose: Type III endoleak can be difficult to distinguish from Type I endoleak. Depending on the stent graft anatomy, the use of standard bifurcated endografts may not be technically feasible, and patients may have to be subject to an aorto-uni-iliac repair with femoral-femoral bypass or open surgery., Case Report: We report a case of an 86-year-old male who had a Type IIIb endoleak 20 years post EVAR which was characterized on angiography to be from a hole close to the bifurcation limb origin. The initial Talent (Medtronic, Santa Rosa, California) device had a 50 mm main body common trunk, which was not amenable to treatment with standard devices. He was successfully treated with a custom-made device with an inverted contralateral limb., Conclusions: Our case highlights the need for lifelong surveillance post EVAR as endoleak may present decades post initial EVAR. It also demonstrates that many Type III endoleak which were otherwise deemed unsuitable for treatment with standard devices may potentially be treatable with custom-made device (CMD). This solution preserves a percutaneous option in a now older person which avoids surgical bypass. Further studies are required to establish the durability of this treatment and survey for recurrence.

Introduction: The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR., Methods: We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR., Results: A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris [IMM], and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS., Conclusion: The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: The aim of this study was to evaluate the efficacy of acellular dermal matrix (ADM) use in reducing Frey syndrome (FS) rates in patients postparotidectomy., Study Design: We performed a systematic review and meta-analysis of existing literature comparing rates of FS with and without ADM use., Results: Eight studies were shortlisted for qualitative study, of which 7 compared rates of FS with and without the use of ADM. A total of 211 patients underwent parotidectomy with the use of ADM. Of these, mean patient age was 44.7 (SD ± 7.2); 89 of 159 were pleomorphic adenoma (55.9%), 29 of 159 with histological diagoses stated were Warthin's tumor (18.2%), and 159 of 211 were other histologic diagnoses (25.7%). Subjective and objective incidence rates for FS were 23 of 211 (10.9%) and 7 of 211 (3.3%), respectively. Patients in whom ADM barriers were used had significantly lower rates of subjective and objective FS (relative risk = 0.22; 95% confidence interval, 0.09-0.57; P = .002; and relative risk = 0.07; 95% confidence interval, 0.07-0.33; P < .001), respectively, compared to patients with no ADM., Conclusion: The use of ADM was associated with lower FS rates compared to no ADM and should be considered in routine use to prevent this condition., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The Venablock© Venous Closure System (Invamed, Ankara, Turkey) is a novel cyanoacrylate-based non-thermal non-tumescent embolization device to block refluxing truncal veins for chronic venous insufficiency and varicose veins. The aim was to prospectively evaluate the safety and 6 months efficacy of Venablock© for the treatment of primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetency in a multi-ethnic cohort from Singapore. Methods: This was a single arm, single investigator prospective study of 29 patients (39 limbs, 39 truncal veins) recruited over a 5-month period (August 2019 to February 2020), who were treated with the Venablock© device at a tertiary vascular unit in Singapore. Patients with symptomatic varicose veins (C2–6) and had truncal reflux > 0.5 second on venous Duplex ultrasound were included. Follow-up occurred at 2 weeks, 3 and 6 months with dedicated quality of life questionnaires and a targeted Duplex ultrasound performed to check for continued venous occlusion. Result: Mean age was 61.4 (±11.0) years and mean BMI was 26.2 (±5.7) kg/m2. 11/29 (37.9%) were males. Most common CEAP class treated was 2 (12/29, 41.3%). Mean diameter of treated GSV was 5.7 (±2.0) mm, 4.8 (±1.7) mm and 4.2 (±1.3) mm for the proximal, mid and distal above knee segments respectively. Mean time from access puncture to sheath removal was 23.4 (±10.0) mins. Vein occlusion at 2 weeks, 3 and 6 months was 39/39 (100%), 39/39 (100%) and 36/37 (97.2%) respectively. 5/29 (17.2%) developed puncture site infections, of which 3/29 (7.7%) required formal surgical drainage. 3/29 (7.7%) developed phlebitis. At 6 months, revised Venous Clinical Severity Score improved from 5.2 (±3.5) to 2.1 (±2.9; p <.001); EuroQol-5 Dimension score, from 7.4 (±2.1) to 5.7 (±1.4; p <.001); Aberdeen Varicose Vein Questionnaire score, from 18.1 (±15.5) to 7.9 (±8.9; p =.007); and Chronic Venous Insufficiency Questionnaire, from 18.6 (±16.2) to 4.5 (±6.3; p <.001). Conclusion: Venablock© is a safe and efficacious option of treating truncal venous insufficiency in a multi-ethnic Asian cohort from Singapore in the short term. There is a significant improvement in QoL. Longer follow-up is required to assess the durability of this technique, in particular the higher puncture site infection rates observed compared to other glue-based therapies. [ABSTRACT FROM AUTHOR]

Sirolimus-coated balloons (SCB) have demonstrated much promise as an alternative drug eluting device to the existing paclitaxel coated balloon platforms for the treatment of peripheral arterial disease (PAD). They have been well tested pre-clinically and have demonstrated anti-restenotic effects as well as clinical safety in its use for treatment of coronary artery disease. The existing approved SCBs have thus far demonstrated good short-term patency (12-months) and did not exhibit any major adverse events or device related shortcomings in its use for treatment of PAD. There are several studies ongoing which aim to further investigate the efficacy of existing SCBs and establish a direct comparison of its outcomes compared with plain balloon angioplasty. Also, SCB utility to salvage failing arteriovenous fistulas for haemodialysis patients has also been explored. We review the current progress made in the establishment of SCB in the treatment of PAD as well as highlight ongoing studies investigating the role of SCB in various settings., (© 2022. The Author(s).)

Background: The majority of evidence with regards to minimally invasive liver resection (MILR) favors its application in minor hepatectomies. We conducted a propensity score-matched (PSM) analysis to determine its feasibility and safety in major hepatectomies (MIMH) for liver malignancies., Methods: Retrospective review of 130 patients who underwent MIMH and 490 patients who underwent open major hepatectomy (OMH) for malignant pathologies was performed. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Perioperative outcomes were then compared. Major hepatectomies included traditional major (>3 segments) and technical major hepatectomies (right anterior and right posterior sectionectomies)., Results: Both cohorts were well-matched for baseline characteristics after PSM. Of 130 MIMH cases, there were 12 conversions to open. Comparison of perioperative outcomes demonstrated a significant association of MIMH with longer operation time and more frequent application of Pringle's maneuver (PM), but decreased postoperative stay. These results were consistent on a subgroup analysis that only included patients undergoing traditional major hepatectomies. A second subgroup analysis restricted to cirrhotic patients demonstrated that while perioperative outcomes were equivalent, MIMH was similarly associated with a longer operative time. Subset analyses of resections performed after 2015 demonstrated that MIMH was additionally associated with a lower postoperative morbidity compared to OMH., Conclusion: Comparison of perioperative and short-term oncological outcomes between MIMH and OMH for malignancies demonstrated that MIMH is feasible and safe. It is associated with a shorter hospital stay at the expense of a longer operation time compared to OMH., (© 2021. The Society for Surgery of the Alimentary Tract.)

Primary breast carcinomas often present as ill-defined, infiltrative lesions which may contain calcifications, whereas metastatic cancers from non-mammary sites are often more well-circumscribed, sharply demarcated from the adjacent breast tissue and are usually not associated with calcifications, although there are exceptions. We report an atypical case of a lady with lung adenocarcinoma with pleural involvement, who presented with diffuse breast swelling with calcifications on imaging from metastatic lung adenocarcinoma, the first of its kind in the literature. We postulate that the pathophysiology of this was due to lymphatic spread of the tumour from the pleura resulting in retrograde lymphovascular congestion of the breast, resulting in swelling and dystrophic calcification.

Background: The management of HCC differs depending on the extent of disease. Surgery may be offered in selected cases of T4 disease as defined by AJCC 8th. However, outcome data post partial hepatectomy (PH) for T4 disease is scarce. We sought to evaluate the outcomes of patients post resection of T4 HCC and assess preoperative predictive factors of early recurrence., Methods: We performed a retrospective review of 235 consecutive patients who underwent resection for T4 HCC from 2001 to 2018 at our institution., Results: Median overall survival was 35.9 months (95% CI 25.7-46.0). 109 patients (49.5%) developed recurrence, of which 94 patients (42.7%) experienced early recurrence within 12 months. Median time to recurrence was 38.1 months. Multivariate analysis demonstrated that vascular invasion were significant independent preoperative predictor of early recurrence post resection. Patients who experienced early recurrence had a significantly shorter median overall survival 14.3 months (95% CI 25.7-46.0) compared to those who did not (55.5 months, 95% CI 40.6-70.8, p = .000)., Conclusion: Selected patients with T4 HCC may benefit from PH. Macrovascular invasion was associated with early recurrence within 12 months., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The utility of minimally-invasive liver resection (MILR) for deep centrally located tumours (CLT) remains controversial. We aimed to review our institution's experience and outcomes with minimally invasive central hepatectomy (CH) and right anterior sectionectomy (RAS) for CLT in a propensity score-matched (PSM) analysis., Methods: Retrospective review of a prospectively maintained surgical database revealed 23 patients who underwent MILR (6 CH, 17 RAS) and 53 patients who underwent open liver resection (OLR; 24 CH, 29 RAS) for CLT. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Peri-operative outcomes were then compared., Results: There was one laparoscopic-assisted, one robot-assisted and two laparoscopic-converted-open procedures in the MILR cohort. Across the unmatched cohort, there was only one mortality (MILR) and five patients with major morbidity (all OLR). MILR was associated with a longer operating time (P < 0.001), but shorter post-operative hospital stay (P = 0.002) and decreased morbidity (P = 0.018) in the unmatched cohort. Examination of peri-operative outcomes after PSM revealed that MILR was similarly associated with a longer operating time (P = 0.001) and shortened post-operative hospital stay (P = 0.043). OLR was associated with a significantly reduced application of Pringle manoeuvre (P = 0.004). There were no significant differences between MILR and OLR with regards to blood loss, blood transfusions, morbidity and margin status in the PSM analysis., Conclusion: MILR for CLT is safe and feasible when performed by experienced surgeons. It is associated with shorter hospital stays but at the expense of longer operation times and more frequent application of Pringle manoeuver., (© 2021 Royal Australasian College of Surgeons.)

Background: At present, the majority of outcome studies of survival of hepatocellular carcinoma (HCC) post-liver resection (post-LR) present actuarial survival data, which often results in overestimation of survival. We sought to evaluate the actual 10-year survival post-LR for HCC and identify variables that are associated with long-term survival., Methods: We performed a retrospective review of 600 consecutive patients who underwent primary LR for HCC from 2000 to 2010 at our institution. Twenty-eight patients (4.7%) with 90-day mortality and 125 patients who were lost to follow-up within 10 years were excluded leaving 447 patients who met the study criteria., Results: There were 140 actual 10-year survivors of which 57 (40.7%) had a recurrence within 10 years. The actual 10-year overall survival (OS) rate of the 447 patients was 31.5% and the actual 10-year recurrence-free survival (RFS) was 18.6%. Multivariate analyses demonstrated that only age >65 years (OR, 0.29; p < .001) (OR, 0.973; p = .041) and presence of cirrhosis (OR. 0.37; p = .005) (OR, 0.31; p = .001) were independent factors negatively associated with actual 10-year OS and actual 10-year RFS, respectively., Conclusion: Approximately one-third of patients will survive over 10 years after LR for HCC. Amongst these 10-year survivors, 41% had developed recurrent cancer within 10-years of follow-up., (© 2020 Wiley Periodicals LLC.)

Ischaemic diabetic heel ulcers are difficult to treat and prognosis is often guarded. The aim was to document our outcome of treating heel ulcers following revascularization in a predominantly diabetic Asian cohort presenting with chronic limb threatening ischaemia from Singapore. Retrospective cohort study (n = 66, 66 limbs) over a 5-year period. Data were collected from hospital electronic health records. Outcomes included time to healing, amputation free survival (AFS), and mortality. Minimum follow-up period was 6 months. Multivariate regression analysis was performed to look for factors associated with poor outcome. Mean age was 67.4 ± 8.8 years. 62/66 (93.9%) were diabetics. Mean wound size at presentation was 3.6 ± 2.3 cm. Mean Wound, Ischaemia, Foot Infection (WIFI) score was 5 ± 1.6. 12/66 (18%) patients had a patent posterior tibial artery pre-operatively. Straight line flow was restored in only 31/66 (46.9) patients but 47/66 (71.2%) had successful limb salvage. Median time to wound healing was 90.0 (IQR 60-180) days. A median of 1 (IQR 0-2) wound debridement was required. Patients who underwent negative pressure dressing (23/66; 34.8%) required a median of 26 (IQR 13-33) cycles to achieve healing. Amputation free survival (AFS) was 72% and 68% at 6- and 12-months, respectively. Mortality rate was 16.7% and 19.7% at 6- and 12-months, respectively. Low albumin level and initial Rutherford class were independent predictors of worse 6-month AFS. Outcomes of heel ulcers post revascularisation may not be as poor as previously described. Persistent attention to wound care with multidisciplinary effort is needed for optimal healing., (© 2020 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: As the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions., Methods: An enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed., Results: There were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised., Conclusion: In healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments., Background: Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature., Methods: This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias., Results: A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset., Conclusions: RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The clinical diagnosis and treatment of dilation of the cholangiopancreatic duct in patients with ambiguous ampullary disease, termed unexplained dilation of the cholangiopancreatic duct (UDCD), is commonly difficult. This study aimed to evaluate the applicability of transduodenal ampullectomy (TDA) for the diagnosis and treatment of UDCD. Methods: We first proposed a surgical exploration procedure based on the TDA and applied it in a representative UDCD patient. We retrospectively analyzed the pathological diagnosis and prognosis of 14 patients at our hospital and 189 patients reported in existing studies who were treated with TDA between January 2010 and December 2022. Results: TDA can be used to radically explore the ampullary region and harvest adequate pathological tissue, which is helpful for identifying the cause of UDCD. The diagnostic rate of intraoperative frozen pathology was greater than that of preoperative endoscopic biopsy (78.41% vs. 65.94%, P = 0.044). The postoperative complication rate was 27.07%, with a mortality rate of 0.00%. The 5-year survival rate was 68.31% in patients with adenocarcinoma, 85.99% in patients with adenoma with HGD/pTis, and 100% in patients with benign lesions, and these had a statistically significant difference (P = 0.021). Conclusions: TDA-based surgical exploration can be used as a safe and effective transitional procedure in the treatment of UDCD. [ABSTRACT FROM AUTHOR]

Introduction: Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions., Methods: Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors., Results: Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH., Conclusions: Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures., (© 2023. Society of Surgical Oncology.)

The Magic Touch sirolimus-coated balloon (SCB) was recently introduced in Europe and features robust clinical technology different from other devices on the market. This device is able to deliver a sufficient sirolimus dose to the target segment to reduce neointimal proliferation with very little exposure downstream and no apparent adverse effects at sustained high drug concentrations. The SCB represents a promising novelty within the drug-coated balloon arena due to its mid-term efficacy and safety in the treatment of coronary artery disease, especially in de novo and small-vessel coronary lesions. The purpose of this article is to provide an up-to-date overview of the currently available animal and clinical trial results, as well as to highlight ongoing trials on the Magic Touch SCB. Tweetable Abstract Among modern drug-coated balloons, Magic Touch features Nanolutè technology, which allows effective and rapid sirolimus release and retention for 8–12 weeks. Previous and ongoing trials are showing good clinical performance with sustained safety. Graphical Abstract In the EASTBOURNE section of the graphical abstract, the statistical data, including numbers and percentages, were taken from the EASTBOURNE trial [1] to create the graphs. Article Highlights Background The development of drug-coated balloons (DCBs) has improved the management of coronary artery disease (CAD), the leading cause of death worldwide. The Magic Touch Sirolimus DCB was recently introduced in Europe and features Nanolutè technology to deliver sirolimus to the vessel wall, ensuring that it is sustained for the duration required to achieve therapeutic effects. The objective of this review is to provide an up-to-date overview and summary of the most recent animal and clinical trial data on the Magic Touch sirolimus DCB, as well as to highlight ongoing investigations analyzing the role of this sirolimus-coated balloon (SCB) in various clinical settings. Pre-clinical & clinical data of Magic Touch SCB This article demonstrates that the SCB is a promising novelty within the DCB arena due to its mid-term efficacy and safety in the treatment of CAD, particularly in de novo and small-vessel coronary lesions, at least from the Magic Touch perspective, as the other two SCBs on the market lack clinical evidence. In addition, preclinical studies have demonstrated that this device is capable of delivering sirolimus to the target segment in a sufficient amount to reduce neointima proliferation in a vascular model with minimal exposure to downstream organs, with no apparent adverse effects when sustained high drug concentrations in the target vessel are maintained. Conclusion In conclusion, SCBs represent a new option in the treatment of CAD, especially in patients with in-stent restenosis, de novo artery disease, and small coronary arteries, in addition to a few well-known and effective paclitaxel-coated balloons. Currently, ongoing trials will have to clarify the performance of this device compared with drug-eluting stents. [ABSTRACT FROM AUTHOR]

The liver requires careful handling intra‐operatively owing to its vital functions and complexity. Traditional open hepatectomy, while standard, is invasive and requires long recovery periods. Laparoscopic hepatectomy is a less invasive option, with its own challenges. The rise of robotic surgery, such as the da Vinci® system, improves precision and control, addressing the limitations of conventional methods, but brings new concerns, such as costs and training. This review focuses on the latest advancements in robotic hepatectomy from 2022/23 articles, delving into topics like "robotic surgery in liver transplantation," "robotic hepatectomy for hilar cholangiocarcinoma," "robotic vascular reconstruction following hepatectomy," "robotic repeat hepatectomy," and "prospective trials in robotic hepatectomy." To retrieve articles, a focused literature search was conducted using PubMed for articles from 2022/23 with a 5‐year filter, excluding reviews. Initially, abstracts were screened, and relevant articles on robotic surgery were examined in full for inclusion in this review. Although all the above items are cutting‐edge, and many of the references are necessarily at the level of case reports, recent articles are still accompanied by surgical videos, which are useful to readers, especially surgeons who are considering imitating the procedures. In summary, we examined the recent advancements in robotic liver resection. The inclusion of videos that present new techniques aids in knowledge transfer. We anticipate the continued growth of this field of research. [ABSTRACT FROM AUTHOR]

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program., Methods: Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method., Results: In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning., Conclusion: This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections., Competing Interests: Declarations. Conflict of interest: Victor López-López, Ignacio Sánchez-Esquer, Christoph Kuemmerli, Roberto Brusadin, Asunción López-Conesa, Álvaro Navarro, Patricia Pastor, Leonid Omar Carrión Retuerto, María Iniesta and Ricardo Robles-Campos have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group., Methods: A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures., Results: 70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400 ml vs. 290 ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330 min vs. 360 min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6 days vs. 9 days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group., Conclusion: Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Sectionectomy is a parenchma-sparing alternative to (extended) right or left hemihepatectomy. However, the effectiveness and safety of robotic sectionectomy (RS) versus robotic (extended) hemihepatectomy (RH) for the treatment of liver tumors remains unclear. We reviewed our prospective database for consecutive patients who had undergone robotic hepatectomies between March 2021 and July 2023 and included all patients with RS and RH. Demographic data, perioperative outcomes and long-term outcomes were analyzed and compared between both groups. Thirty patients met our inclusion criteria, of whom 16 patients underwent RS as opposed to 14 patients who underwent RH. Baseline characteristics were comparable between the study groups. The duration of Pringle maneuver was significantly longer in the RS group, while the remaining operative details were comparable. There were no significant differences in posthepatectomy outcomes between the study groups. All patients had negative resection margins. RS is a safe and effective parenchyma-sparing treatment modality. [ABSTRACT FROM AUTHOR]

Background: Three-dimensional (3D) chromatin architecture frequently altered in cancer. However, its changes during the pathogenesis of hepatocellular carcinoma (HCC) remained elusive. Methods: Hi-C and RNA-seq were applied to study the 3D chromatin landscapes and gene expression of HCC and ANHT. Hi-C Pro was used to generate genome-wide raw interaction matrices, which were normalized via iterative correction (ICE). Moreover, the chromosomes were divided into different compartments according to the first principal component (E1). Furthermore, topologically associated domains (TADs) were visualized via WashU Epigenome Browser. Furthermore, differential expression analysis of ANHT and HCC was performed using the DESeq2 R package. Additionally, dysregulated genes associated with 3D genome architecture altered were confirmed using TCGA, qRT-PCR, immunohistochemistry (IHC), etc. Results: First, the intrachromosomal interactions of chr1, chr2, chr5, and chr11 were significantly different, and the interchromosomal interactions of chr4–chr10, chr13–chr21, chr15–chr22, and chr16–chr19 are remarkably different between ANHT and HCC, which resulted in the up-regulation of TP53I3 and ZNF738 and the down-regulation of APOC3 and APOA5 in HCC. Second, 49 compartment regions on 18 chromosomes have significantly switched (A–B or B–A) during HCC tumorigenesis, contributing to up-regulation of RAP2A. Finally, a tumor-specific TAD boundary located on chr5: 6271000–6478000 and enhancer hijacking were identified in HCC tissues, potentially associated with the elevated expression of MED10, whose expression were associated with poor prognosis of HCC patients. Conclusion: This study demonstrates the crucial role of chromosomal structure variation in HCC oncogenesis and potential novel biomarkers of HCC, laying a foundation for cancer precision medicine development. [ABSTRACT FROM AUTHOR]

Background: The influence of prolonged intermittent Pringle maneuver (IPM) on post-hepatectomy liver failure (PHLF) remains unclear. We evaluated the impact of the prolonged IPM on PHLF in patients undergoing open and laparoscopic hepatectomy. Methods: We retrospectively included 546 patients who underwent hepatectomy using IPM. The patients were divided into open (n = 294) and laparoscopic (n = 252) groups. Odds ratios for PHLF occurrence were estimated in each group according to cumulative Pringle time (CPT). The cut-off value was set at CPT of 120 min. Risk factors for PHLF were evaluated in the open and laparoscopic groups. Additionally, we analyzed the post-operative outcomes in the open and laparoscopic groups with CPT ≥ 120 min and performed propensity score matching analysis based on PFLF-associated factors. Results: In the open group, the risk of PHLF increased as CPT increased, particularly after 120 min. However, in the laparoscopic group, PHLF did not occur at less than 60 min, and the risk of PHLF was not significantly different at more than 60 min. Multivariate analysis identified CPT ≥ 120 min as an independent risk factor for PHLF in the open group (p < 0.001), but not in the laparoscopic group. Propensity score matching analysis showed that the PHLF rate was significantly lower in the laparoscopic group with CPT ≥ 120 min (p = 0.027). The post-operative transaminase levels were significantly lower in the laparoscopic group with CPT ≥ 120 min. Conclusions: Laparoscopic hepatectomy may cause less PHLF with prolonged IPM compared with open hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment. Methods: A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology. Results: Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination. Conclusion: These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic liver surgery has advanced significantly, offering benefits, such as reduced intraoperative complications and quicker recovery. However, complex laparoscopic hepatectomy (CLH) is technically demanding, requiring skilled surgeons. This study aims to share technical aspects, insightful tips, and outcomes of CLH at our center, focusing on the safety and learning curve., Methods: We reviewed all patients undergoing liver resection at our center from July 2017 to December 2023, focusing on those who underwent CLH. Of 135 laparoscopic liver resections, 63 (46.7%) were CLH. The learning curve of CLH was also assessed through linear and piecewise regression analyses considering the operation time and intraoperative blood loss., Results: Postoperative complications occurred only in 4.8% of patients, with a 90-day mortality rate of 3.2%. The mean operation time and blood loss significantly decreased after the first 20 operations, marking the learning curve's optimal cut-off. Significant improvements in R0 resection (p = 0.024) and 90-day mortality (p = 0.035) were noted beyond the learning curve threshold., Conclusion: CLH is a safe and effective approach, with a relatively short learning curve of 20 operations. Future large-scale studies should further investigate the impact of surgical experience on CLH outcomes to establish guidelines for training programs., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To investigate the effects of iodine-125 seed brachytherapy (ISB) on the overall survival (OS) of patients with heterochronous pulmonary metastasis (HPM) secondary to hepatocellular carcinoma (HCC). Materials and Methods: The clinical and imaging data of 123 patients with HPM secondary to HCC treated at a single center from July 2012 to July 2020 were analyzed retrospectively. The patients were divided into ISB and non-ISB groups based on ISB treatment. Propensity score matching yielded 46 pairs of patients. A total of 191 lesions were treated, and the data were evaluated for 6 months after ISB. The OS rates of the two groups were compared using the Kaplan--Meier method. Independent prognostic factors were determined using a Cox proportional hazards regression model. Results: The percentages of lung lesions in complete remission, partial remission, disease stable, and disease progression stages were 49.2%, 32.8%, 9.6%, and 8.4%, respectively. The disease control rate was 91.6%. The median follow-up time from the initial diagnosis was 47 months and 33 months for the ISB and non-ISB groups, respectively. Patients in the ISB group had a longer OS than those in the non-ISB group (1-year: 95.7% vs. 80.3%; 3-year: 62.9% vs. 45.7%; 5-year: 37% vs. 20.9%; P < 0.05). Multivariate analysis demonstrated that ISB treatment, tumor differentiation, vascular invasion, and Child -- Pugh score were independent prognostic factors for survival. Conclusion: ISB improves local control and OS rates of HPM secondary to HCC; thus, it is an effective and feasible option for patients with HPM secondary to HCC. [ABSTRACT FROM AUTHOR]

Background: Left lateral sectionectomy (LLS) is one of the most commonly performed minimally invasive liver resections. While laparoscopic (L)-LLS is a well-established technique, over traditional open resection, it remains controversial if robotic (R)-LLS provides any advantages of L-LLS. Methods: A post hoc analysis of 997 patients from 21 international centres undergoing L-LLS or R-LLS from 2006 to 2020 was conducted. A total of 886 cases (214 R-LLS, 672 L-LLS) met study criteria. 1:1 and 1:2 propensity score matched (PSM) comparison was performed between R-LLS & L-LLS. Further subset analysis by Iwate difficulty was also performed. Outcomes measured include operating time, blood loss, open conversion, readmission rates, morbidity and mortality. Results: Comparison between R-LLS and L-LLS after PSM 1:2 demonstrated statistically significantly lower open conversion rate in R-LLS than L-LLS (0.6% versus 5%, p = 0.009) and median blood loss was also statistically significantly lower in R-LLS at 50 (80) versus 100 (170) in L-LLS (p = 0.011) after PSM 1:1 although there was no difference in the blood transfusion rate. Pringle manoeuvre was also found to be used more frequently in R-LLS, with 53(24.8%) cases versus to 84(12.5%) L-LLS cases (p < 0.001). There was no significant difference in the other key perioperative outcomes such as operating time, length of stay, postoperative morbidity, major morbidity and 90-day mortality between both groups. Conclusion: R-LLS was associated with similar key perioperative outcomes compared to L-LLS. It was also associated with significantly lower blood loss and open conversion rates compared to L-LLS. [ABSTRACT FROM AUTHOR]