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Background Robotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP). Methods Between March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group. Results The two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group. Conclusion Apart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Hepatocellular carcinoma is one of the commonest cancer in the world. Despite curative resection, recurrence remains the largest challenge. Many risk factors were identified for predicting recurrence, including liver fibrosis and cirrhosis. Transient elastography (Fibroscan) is an accurate tool in measuring liver fibrosis. This study aimed to evaluate the use of preoperative liver stiffness measurement (LSM), with Fibroscan in predicting long-term recurrence of hepatocellular carcinoma (HCC) after curative resection.A prospective cohort study was conducted from February 2010 - June 2017 in Prince of Wales hospital. All consecutive patients with HCC undergone hepatectomy were included. Demographic factors, preoperative LSM, tumor characteristics and operative details were assessed. Primary outcome and secondary outcome were overall survival and disease free survival at 1 year, 3 year and 5 year respectively.A total of 401 cases were included. Patients with LSM ≥12kPa had significantly lower 5-year overall survival rate (75.1% vs 57.3%, p 0.001) and disease free survival rate (45.8% vs. 26.7%, p 0.001). On multivariate analysis, pre-operative creatinine and vascular invasion of tumor were significant factors in predicting early recurrence (p = 0.012 and p = 0.004). LSM ≥12kPa were the only significant factor in predicting late recurrence (p = 0.048).Pre-operative liver stiffness measurement could predict the late recurrence of hepatocellular carcinoma after curative resection.

PURPOSE To compare the survival outcomes of patients treated with transarterial ethanol ablation (TEA) with those treated with liver resection (LR) for solitary HCC less than 5 cm in diameter, in patients stratified according to liver function using ALBI grade. MATERIALS AND METHODS This retrospective study approved by the Institutional Committee included all treatment-naive patients with solitary HCC (≤ 5 cm) and Child-Pugh score 5, and who had received TEA (33 patients) or LR (192 patients) between 2004 and 2012. Treatment outcomes were compared between patients treated with TEA and LR after a period of at least 7 years of follow-up. Comparison was repeated for those patients with ALBI grade 2 or 3. RESULTS Both overall survival (OS, months) and recurrence-free survival (RFS months) were significantly longer in the LR group (OS: LR 129.7[119.5, 140], TEA 69.1[55.9, 82.3], P

Background Liver resection is an established treatment of choice for colorectal liver metastasis (CLM). However, the role of hepatectomy for non-colorectal liver metastasis (NCLM) is less clear. Patients and method From 2004 to 2017, 264 patients received curative hepatectomy for NCLM (n = 28) and CLM (n = 236). Propensity score (PS) matching was performed between two groups, with respect to the significant confounding factors. Short-term and long-term outcomes were compared between PS matched groups. Univariate analysis was performed to identify prognostic factors affecting overall and recurrence-free survival. Results After PS matching, there were 28 patients in NCLM group and 56 patients in CLM group. With a median follow-up of 34 months, there was no significant difference in 5-year overall survival rate between NCLM and CLM groups (62% vs. 39%) (P = 0.370). The 5-year recurrence-free survival rate was also comparable between NCLM and CLM groups (23% vs. 22%) (P = 0.707). Use of pre-operative systemic therapy (hazard ratio: 2.335, CI 1.157–4.712), multifocal tumors (hazard ratio: 1.777, CI 1.010–3.127), tumor size (hazard ratio: 1.135, CI 1.012–1.273), R1 resection (hazard ratio: 2.484, CI 1.194–5.169) and severe complications (hazard ratio: 6.507, CI 1.454–29.124), but not tumor type (NCLM vs. CLM), were associated with poor overall survival. Conclusion Hepatectomy for NCLM can achieve similar oncological outcomes in selected patients as those with CLM. Significant prognostic factors were identified associating with worse overall survival.

Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy. Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio. After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P

Background Microwave (MWA) and radiofrequency ablation are the commonly used local ablation for hepatocellular carcinoma (HCC). Studies comparing both techniques are scarce. The aim of this study was to compare the efficacy of MWA versus RFA as a treatment for HCC. Methods Patients with HCC who were suitable for local ablation were randomized into MWA or RFA. All patients were followed up regularly with contrast-enhanced computed tomography (CT) performed at 1, 3, 6 and 12 months after ablation. Both patients and the radiologists who interpreted the post-procedure CT scans were blinded to the treatment allocation. Treatment-related morbidity, overall and disease-free survivals were analyzed. Results A total of 93 patients were recruited. Among them, 47 and 46 patients were randomized to MWA and RFA respectively. Patients in two groups were comparable in baseline demographics and tumor characteristics. With a median follow-up of around 30 months, there were no significant difference in the treatment-related morbidity, overall and disease-free survivals. MWA had a significantly shorter overall ablation time when compared with RFA (12 min vs 24 min, p Conclusions MWA is no different to RFA with respect to completeness of ablation and survivals. It is, however, as safe and effective as RFA in treating small HCC.

Highlights • Hepatocellular carcinoma invading to gastrointestinal tract can present as bleeding. • Invasion to gastrointestinal tract by hepatocellular carcinoma is relatively rare. • Long term survival can be achieved by en bloc resection even if hepatocellular carcinoma invades into nearby organs., Introduction Upper gastrointestinal bleeding (UGIB) in patients suffering from hepatocellular carcinoma (HCC) is usually due to oesophageal or gastric varices secondary to portal hypertension. Very rarely, HCC can directly invade into the stomach or duodenum resulting in UGIB. Presentation of case A 62-year-old man presented to the emergency department for haematemesis and tarry stool. He was a hepatitis B carrier and had received open radiofrequency ablation and wedge resection for HCC previously. Urgent endoscopy and contrast computed tomography confirmed recurrent HCC invading into the duodenum. The patient received radical resection and remained disease free for 7 years after the operation. Discussion Direct invasion into gastrointestinal tract by HCC is rare. Different modalities of treatment have been reported in the literature with variable success. En-bloc resection should be considered if surgically feasible in order to achieve good haemostasis and possible long term survival. Conclusion Upper gastrointestinal bleeding is a rare presentation of hepatocellular carcinoma and long term survival can be achieved by curative surgery.

Both Inflammation and health-related quality of life (HRQoL) are independent prognosticators in HCC patients. We hypothesized that inflammation can cause impairment in HRQoL and investigated the correlation between inflammatory status and HRQoL in HCC patients. Clinical, laboratory and HRQoL (using EORTC QLQ-C30, QLQ-HCC18, C30 and HCC18 index-scores) data were prospectively collected from HCC patients at diagnosis. Correlation analyses were performed between HRQoL and inflammation-based markers including C-reactive protein (CRP), CRP/albumin ratio (CRP/alb), Glasgow Prognostic Score (GPS), Inflammation-Based Index (IBI) and Prognostic Index (PI). Among 445 HCC patients, higher inflammatory states were significantly correlated with worse HRQoL. For CRP and CRP/alb ratio, the HRQoL factors with higher correlations included C30 and HCC18 index-scores, certain QLQ-C30 domains and items (‘physical functioning’, ‘role functioning’, ‘fatigue’, ‘pain’, ‘appetite loss’) and QLQ-HCC18 items (‘fatigue’, ‘body image’, ‘nutrition’ and ‘abdominal swelling’), where the Pearson’s correlation coefficients were up to 0.416. Multivariate analyses indicated that worse HRQoL factors were significantly correlated with worse scores in GPS, IBI and PI. In HCC patients, inflammatory status correlates with HRQoL at presentation. In particular, relatively stronger correlations with CRP-based markers have been observed in HRQoL scales that assess constitutional symptoms (QLQ-C30 ‘physical functioning’, ‘role functioning’, ‘fatigue’, ‘appetite loss’ and QLQ-HCC18 ‘fatigue’ and ‘nutrition’) and tumor burden (QLQ-C30 ‘pain’ and QLQ-HCC18 ‘abdominal swelling’ and ‘body image’). Future studies are warranted to evaluate whether intervention that reduces inflammation could improve HRQoL in HCC patients.

Purpose Health-related quality of life (HRQoL) is a significant prognostic factor for overall survival in hepatocellular carcinoma (HCC) patients, and this is independent of stage and liver function. Inflammation plays a significant role in HCC development and progression. It was hypothesized that the inflammatory status of HCC patients may affect their HRQoL. The relationship between HRQoL and inflammatory status was explored using indicators IL-8 level and modified inflammation-based index (mIBI, based on IL-8, C-reactive protein, and albumin). Methods From 2007-2011, HCC patients were enrolled prospectively. Baseline HRQoL assessment utilized the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-HCC18; clinical and laboratory data were collected at diagnosis. Two summary indices, C30 and HCC18 index-scores, were calculated. Correlation analyses were performed between HRQoL and inflammatory markers. Results In the 445 patients studied, significant correlations were found between IL-8 levels and EORTC QLQ-C30, QLQ-HCC18, C30, and HCC18 index-scores. The strongest correlated factors were those reflective of constitutional symptoms, namely QLQ-C30 "appetite loss" (with Pearson's correlation coefficient, r=0.322, P

Background: The advantages of radiofrequency ablation (RFA) over hepatectomy as a treatment for early-stage hepatocellular carcinoma (HCC) include reduced morbidity and more rapid recovery. Although minimally invasive surgery provides similar benefits, few studies have compared the long-term oncological outcomes of these techniques. This study aimed to compare the outcomes of minimally invasive hepatectomy (MIH) and RFA. Methods: Patients who underwent MIH or RFA for HCC between January 2005 and January 2015 were included in a propensity score matching analysis. Only patients who underwent minimally invasive procedures for small HCC were included. Baseline clinical and laboratory parameters were retrieved from the hospital database and analyzed. Results: Two hundred and twenty-five patients underwent MIH or RFA for HCC during the study period. Propensity score matching yielded 59 patient-pairs. The complication rates did not differ statistically between the 2 groups (p = 0.309). However, MIH provided significantly better overall (p = 0.005) and disease-free survival outcomes (p < 0.001) than RFA. Conclusions: Compared with RFA, MIH provided better long-term survival outcomes in patients with early-stage HCC, with no increase in the incidence of complications. When feasible, MIH should be considered a first-line treatment for this patient population.

Tumor invasion into the inferior vena cava (IVC) and hepatic vein (HV) is challenging in cancer surgery with curative intent. Appropriate techniques for venous reconstruction are essential. We have described in detail a novel technique of fashioning an interposition tube graft using the falciform ligament to reconstruct the IVC and HV. The falciform ligament maintains all the benefits of an autologous tissue graft, with the added advantage of its flexibility in customizing graft dimensions. Its use in IVC and HV reconstruction has rarely been reported. The short-term outcomes with this tube graft are promising.

Although hepatectomy is a curative treatment modality for hepatocellular carcinoma (HCC), the associated 10-year long-term actual survival are rarely reported. This study aims to develop and validate a predictive nomogram for 10-year actual survivors with HCC.From 2004 to 2009, 753 patients with curative hepatectomy for HCC (development set, n = 325; validation set, n = 428) were included. In development set, comparison of clinic-pathological data was made between patients surviving ≥10 years and those surviving10 years. Good independent prognostic factors identified by multivariate analysis were involved in a nomogram development, which was validated internally and externally using validation set.On multivariate analysis, five independent good prognostic factors for 10-year survival were identified, including young age (OR = 0.943), good ASA status (≤2) (OR = 2.794), higher albumin level (OR = 1.116), solitary tumor (OR = 2.531) and absence of microvascular invasion (OR = 3.367). A novel nomogram was constructed with C-index of 0.801 (95% CI 0.762-0.864). A cut-off point of 167.5 had a sensitivity of 0.794 and specificity of 0.730. Internal validation using bootstrap sampling and external validation using validation set revealed C-index of 0.792 (95% CI, 0.741-0.853) and 0.761 (95% CI, 0.718-0.817).A novel nomogram for 10-year HCC survivor using age, ASA status, preoperative albumin, tumor number and presence of microvascular tumor invasion was developed and validated with high accuracy.

A 56-year-old man presented with an 11-cm hepatocellular carcinoma (HCC) at segment 7 of liver. To induce left liver hypertrophy, a sequential transarterial chemoembolization (TACE) and portal vein embolization before right hepatectomy were adopted. However, the tumor further increased in size despite TACE and invaded through the diaphragm to the right lung base. Anterior approach right hepatectomy with en bloc wedge resection of the involved right lower lobe of lung by endovascular staplers via transdiaphragmatic approach was performed. The diaphragmatic defect was closed with Goretex mesh. Patient made an uneventful recovery. Pathology confirmed a 12.5 cm poorly differentiated HCC invading through diaphragm to lung. During follow-up, patient developed a 6 cm recurrence at left lung base 17 months after surgery for which he received sorafenib therapy. However, the lung mass further increased in size with new liver recurrence at segment 3 despite treatment. He succumbed 2 years and 3 months after surgery.

A big advancement in endoscopic management for biliary stone diseases was seen in the past three decades.

Background Studies comparing microwave ablation (MWA) and liver resection are lacking. This study evaluates the survival of patients with hepatocellular carcinoma (HCC) treated with liver resection or MWA and the role of Albumin-Bilirubin (ALBI) score in patient selection for treatments. Methods This is a retrospective analysis of patients who received curative liver resection or MWA for HCC. Propensity score matching was used at a 1:1 ratio. The value of ALBI grade for patient selection was evaluated. Overall and disease-free survival were compared between two groups. Results Of the 442 patients underwent MWA or liver resection for HCC during the study period, 63 patients received MWA and 379 patients received liver resection. Propensity scoring matching analysis resulted in 63 matched pairs for further analysis. Subgroup analysis according to the ALBI grade was performed. Liver resection offered better overall and disease-free survivals in patients with ALBI grade 1. MWA provided a significantly better overall survival (p = 0.025) and a trend towards better disease-free survival (p = 0.39) in patients with ALBI grade 2 or 3. Conclusions Liver resection offered superior disease-free survival to MWA in patients with HCC. The ALBI grade could identify patients with worse liver function who might gain survival advantage from MWA.

Background: Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC. Summary: The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need. Key Message: The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

Summary Background Both microwave ablation (MWA) and radiofrequency ablation (RFA) are commonly employed local ablation techniques for malignant liver tumors. However, comparative data on long-term results between these two techniques is scarce in the literature. Methods This is a retrospective comparative study between MWA and RFA for hepatocellular carcinoma (HCC) using surgical approach. Results The MWA group consisted of 26 patients while the RFA group consisted of 47 case-matched patients. The two groups were comparable, except patients were older and their platelet count was lower in the MWA group. The median follow-up period was 47.5 months in MWA group and 52.9 months in RFA group ( p = 0.322). There was no difference in 5-year overall survival (MWA 73.1%, RFA 46.3%, p = 0.082) and 5-year disease free survival (MWA 13.8%, RFA 14.6%, p = 0.736). When a subgroup analysis of tumors ≥ 3.5 cm was performed, there were 16 patients in the MWA group and 21 patients in the RFA group, the 5-year overall and disease-free survival were MWA 75.0%, RFA 28.6% ( p = 0.022) and MWA 25.0%, RFA 4.8% ( p = 0.207), respectively. Conclusion MWA is comparable to RFA for HCC in terms of long-term outcomes. For tumors ≥ 3.5 cm, MWA is associated with a better overall 5-year survival.

Aim To achieve better outcomes, non-operative management (NOM) and damage control surgery (DCS) are now recommended for traumatic liver injury. This study aims to review the outcomes of patients suffering from liver trauma and to determine the factors affecting the outcomes, with emphasis on NOM and DCS. Patients and Methods This was a retrospective cohort study for liver trauma patients from a single centre. The outcomes were compared between two equal consecutive periods: period A (year 2001–2007) and period B (year 2008–2014). Results There were 116 patients with a mean age of 38.1 years and male predominance (61.2%). Around 57% of patients suffered from grade III or above liver injury. The mean Injury Severity Score (ISS) was 32.3. The 90-day mortality was 20.7%. In period B, the 90-day mortality was significantly lowered (6/56 vs. 18/60, P = 0.010) with less liver operation (13/56 vs. 26/60, P = 0.022) and more hepatic angiography+/−embolization (7/56 vs. 0/60, P = 0.005). The proportion of DCS was similar but more hepatectomies were performed in period B (4/13 vs. 0/26, P = 0.009). Multivariate analysis revealed ISS grade, age and sex were predictors for 90-day mortality. Conclusions A reduced mortality was seen in traumatic liver injury accomplished by increased NOM but not DCS.

Background and Aim Liver stiffness measurement using transient elastography appears to be an excellent tool for detection of liver fibrosis and cirrhosis with high accuracy. The aim of this study is to evaluate the efficacy of preoperative liver stiffness measurement in predicting post-hepatectomy liver failure. Methods A prospective cohort study of all consecutive patients undergoing hepatectomy for hepatocellular carcinoma from February 2010 to August 2014 was studied. All patients received detailed preoperative assessments including liver stiffness measurement. The primary outcome was post-hepatectomy liver failure according to the International Study Group of Liver Surgery definition. Results A total of 255 patients were included. Liver stiffness measurement showed significant correlation with grade B or C post-hepatectomy liver failure. (P = 0.003) Using the cutoff at 12 kPa, liver stiffness measurement had a sensitivity of 52.4% and specificity of 73.3% in predication of high-grade (grade B or C) post-hepatectomy liver failure. Liver stiffness measurement > 12 kPa was also an independent prognostic factor for both high-grade post-hepatectomy liver failure and major postoperative complications by multivariate analysis. The diagnostic accuracy was better in patients without right lobe tumor with an area under the receiver operating characteristic of 0.83 compared with an area under the receiver operating characteristic of only 0.62 in patients with right lobe tumor. Conclusions Liver stiffness measurement using Fibroscan is good to predict high-grade post-hepatectomy liver failure especially in patients without right lobe tumor.

The objective was to evaluate the local treatment efficacy of transarterial ethanol ablation (TEA) as compared to radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC). This was a retrospective study between January 2005 and April 2017, in which the treatment outcomes of all patients who received either percutaneous TEA or RFA for HCC tumors of size ≤ 3 cm, of Child–Pugh grade A or B, received no prior treatment other than surgical resection, were compared. For TEA, a mixture of absolute ethanol and ethiodized oil at a proportion of 1:2 by volume was administered superselectively into the tumor via a microcatheter placed at the feeding arteries. The TEA group and the RFA group consisted of 68 consecutive patients (88 treated target tumors) and 129 consecutive patients (129 tumors), respectively. Technical success was achieved in all the target tumors in both groups. Grade 3 complication (CIRSE Classification) of prolonged fever occurred in 3 cases with multi-focal and large tumors in the TEA group. There was no statistically significant difference in complete response rate between the TEA group (84/88 or 95.5%) and the RFA group (188/195 or 96.4%) (p = 0.7). Time to progression in the TEA group [median 11.9 months, interquartile range (IQR) 5.6–18 months] was not statistically different from that in the RFA group (median 9.5 months, IQR 3.5–18.7 months) (p = 0.773). TEA could be an effective alternative of RFA for the local treatment of small HCC; it is especially valuable for tumors of unfavorable location.

Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16–30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16–30 min. NCT00730743 and NCT01759901 (http://www.clinicaltrials.gov).

Recovery after traditional open liver resection is greatly hindered by a big upper abdominal incision. This is especially true when the scale of parenchymal liver resection is relatively small, such as wedge resection or left lateral sectionectomy. In such scenarios, the access trauma outweighs the surgical trauma. On the other hand, when the surgical trauma is large, such as major hepatectomy or extended liver resection, the surgical trauma rather than the access trauma determines the postoperative recovery. Thus, minimal access surgery or minimally invasive surgery has come up as a fantastic way to minimize the access trauma and help to speed up recovery and shorten hospital stay (1).

Introduction Duplication of gallbladder is a rare congenital condition. We describe a patient who underwent robotic cholecystectomy for duplicated gallbladder with symptomatic gallstones. Conclusion Surgeons performing cholecystectomies must be aware of duplicated gallbladders and robotic cholecystectomy is a feasible option for such patients.

Introduction Enhanced recovery after surgery (ERAS) reduces postoperative length of hospital stay and patient stress response to liver surgery. The aim of the present study was to evaluate the efficacy and feasibility of an ERAS programme for liver resection. Methods A multidisciplinary ERAS protocol was implemented for both open and laparoscopic liver resection in a tertiary hospital in Hong Kong. The clinical outcomes of patients who underwent liver resection and underwent the ERAS perioperative programme were compared with those who received a conventional perioperative programme between September 2015 and July 2016. Propensity score matching analysis was used to minimise background differences. Results A total of 20 patients who underwent liver resection were recruited to the ERAS programme. Their clinical outcomes were compared with another 20 patients who received hepatectomy under a conventional perioperative programme after propensity score matching. The ERAS programme was associated with a significantly shorter length of hospital stay (P=0.033) without an increase in complication rates in patients who underwent open liver resection. There was no such significant association in patients who underwent laparoscopic liver resection. No patients required readmission in this cohort. Conclusions The ERAS perioperative programme for liver resection is safe and feasible. It significantly shortened the hospital stay after open liver resection but not after laparoscopic liver resection.

Aim Studies comparing the efficacy of radiofrequency ablation (RFA) in terms of overall survival, disease-free survival and local recurrence in recurrent hepatocellular carcinoma (HCC) are limited. We carried out the present study to compare the survival of recurrent HCC after RFA with that of first-occurrence HCC. Patients and Methods A total of 170 patients with HCC smaller than 5 cm who received RFA in a tertiary academic hospital were recruited. Clinical data were prospectively collected, reviewed and compared between recurrent and first-occurrence HCC groups. Patients who received RFA for post-ablation recurrent HCC were excluded. Results There was no significant difference in the complication, incomplete ablation, recurrence and survival rates between the recurrent HCC and the first-occurrence HCC groups. The tumour size in the recurrent HCC group was significantly smaller than that in the first-occurrence group (1.8 vs 2.5 cm), and the recurrent HCC group had a significantly higher proportion of Child's A cirrhosis. Conclusions When detected and treated early, the overall survival of recurrent HCC treated RFA was comparable to that of first-occurrence HCC. The advantages of RFA, especially when percutaneous route is feasible, over hepatectomy should be extended to recurrent HCC in suitable cases.

Gallbladder adenomyomatosis (GA) is increasingly encountered in clinical practice due to increasing use of imagings especially ultrasound (US). Clinicians need to know what is the implication of this condition and its proper management. GA is a degenerative and proliferative disease characterized by excessive epithelial proliferation associated with hypertrophy of muscularis propria. This leads to outpouchings of mucosa into or beyond the muscle layer forming intramural diverticula recognized as Rokitansky-Aschoff sinuses (RAS). Three types of GA are recognised: fundal, segmental and diffuse type. In fundal GA, there is focal thickening involving the GB fundus. In segmental GA, there is circumferential overgrowth of the GB wall that leads to formation of compartments. In diffuse GA, there is disseminated thickening and irregularity of the mucosa and muscularis. The pathogenesis of GA is unknown. It commonly occurs in middle age with equal sex distribution. Diagnosis of GA is by imagings showing thickened gallbladder wall containing cysts. Characteristic features are “comet-tail” artefacts and “twinkling” artefacts on US, “pearl-necklace sign” on magnetic resonance imaging (MRI) and “rosary sign” on computed tomography (CT). Cholecystectomy should be offered for symptomatic GA of any type. For asymptomatic GA, cholecystectomy may be considered for segmental type for its increased risk of malignancy and for diffuse type for its difficult visualization of any coexisting malignancy. Asymptomatic fundal GA can be safely observed with US. How frequent and how long should a fundal GA be monitored with US remains unknown. In case of diagnostic doubt, cholecystectomy should always be offered to avoid overlooked malignancy.

Analysis for actual mid-term (≥5 years) and long-term (≥10 years) survivors with hepatocellular carcinoma (HCC) following curative hepatectomy are rarely reported in the literature.This retrospective study aims to study the mid- and long-term survival outcome and associated prognostic factors following curative hepatectomy for HCC in a tertiary referral center.The clinical data of 325 patients who underwent curative hepatectomy for HCC were reviewed. They were stratified into 3 groups for comparison (Group 1, overall survival

Background: Hepatectomy is a widely accepted curative treatment for hepatocellular carcinoma (HCC). However, the disease frequently recurs after a curative hepatectomy. The objective of this study is to provide a better understanding of the pattern of disease recurrence and the risk factors involved so as to improve the postoperative surveillance. Methods: A retrospective study for all patients receiving hepatectomy for HCC between 2003 and 2014 was performed. Emphasis was made on the timing and pattern of recurrent disease, and type of treatment given. Results: There were 506 patients in the study. Median follow-up was 43.7 months. The 1-, 3-, 5-, 10-year overall and disease free survival were 89.5%, 74.1%, 63.9%, 49.0% and 69.5%, 54.3%, 43.4%, 30.9% respectively. Recurrent disease occurred in 267 patients, 47.2% occurred within 9 months of hepatectomy and 80.1% recurred only in liver. Median survival was shorter for recurrence occurring within 9 months compared with those occurring between 10 months and 2 years postoperatively (36.2 versus 65.7 months, P vs . 51.7%, P 3.5 cm and history of rupture were risk factors for recurrence within 9 months. Conclusions: These findings suggest that recurrent diseases are common after curative hepatectomy for HCC and most recurrences occur in the remnant liver. Since almost half of recurrences occurred within first 9 months after hepatectomy, a more stringent postoperative surveillance with target imaging of liver in this period is needed. Early diagnosis of recurrent disease and curative retreatment hopefully can bring about a longer survival.

A 51-year-old man who was a hepatitis B carrier presented with ruptured hepatocellular carcinoma (HCC). Hepatic arterial embolization was performed for control of bleeding which was followed by staged open left lateral sectionectomy for tumor removal. Pathology confirmed a 3.5 cm ruptured subcapsular HCC in a cirrhotic liver with clear resection margin. However, the alpha-fetoprotein (AFP) increased from 14 to 72 µg/L after 7 months. A 1.7 × 0.8 cm nodule at left subdiaphragmatic region abutting on the spleen but no intrahepatic lesion was seen on computed tomography (CT). Dual tracer positron emission tomography suggested the nodule was a HCC seeding with no other recurrent tumor noted. Robotic exploration was offered to patient with the possibility of splenectomy. During operation, the nodule was adherent to the diaphragm with no splenic involvement. The lesion was locally excised. The diaphragmatic defect was closed with non-absorbable suture. Recovery was uneventful and the patient was discharged on postoperative day 4. Pathology confirmed HCC cells infiltrating to skeletal muscle and fibrous tissue. The resection margin was clear. Post-operatively AFP normalised. Serial abdominal CT and ultrasound revealed no evidence of recurrent disease. Patient had a disease-free survival of 47 months after excision of tumor seeding.

Whether liver resection or ablation should be the first-line treatment for very early/early hepatocellular carcinoma (HCC) in patients who are candidates for both remains controversial. The aim of this study was to determine if the newly-developed Albumin-Bilirubin (ALBI) grade might help in treatment selections and to evaluate the survival of patients treated with liver resection and radiofrequency ablation (RFA).Patients with BCLC stage 0/A HCC who were treated with curative liver resection and RFA from 2003 to 2013 were included. Baseline clinical and laboratory parameters were retrieved and reviewed from the hospital database. Liver function and its impact on survival was assessed by the ALBI score. Overall and disease-free survivals were compared between the two groups.488 patients underwent liver resection (n = 318) and RFA (n = 170) for BCLC stage 0/A HCC during the study period. Liver resection offered superior survival to RFA in patients with BCLC stage 0/A HCC in the whole cohort. After propensity score matching, liver resection offered superior overall survival and disease-free survival to RFA in patients with ALBI grade 1 (P = 0.0002 and P 0.0001 respectively). In contrast, there were no significant differences in overall survival and disease-free survival between liver resection and RFA in patients with ALBI grade 2 (P = 0.7119 and 0.3266, respectively).Liver resection offered superior survival to RFA in patients with BCLC stage 0/A HCC. The ALBI grade could identify those patients with worse liver function who did not gain any survival advantage from curative liver resection.

Background Both laparoscopic and robotic hepatectomy have been adopted in our centre for selected patients with benign or malignant liver diseases. This article reports the perioperative outcomes of these two approaches and tries to determine any difference between them. Methods A retrospective review of prospectively collected data was performed for all patients who underwent laparoscopic hepatectomy (LH) and robotic hepatectomy (RH) in our institute. The perioperative results were reported and compared. In order to standardise the type of liver resection performed, a subgroup analysis was made for laparoscopic left lateral sectionectomy (LS) and robotic left lateral sectionectomy (RS). Results Sixty-six LH and 70 RH were performed between November 2003 and January 2015. The two groups were comparable in demographic data and disease characteristics except more patient with recurrent pyogenic cholangitis (RPC) occurred in RH group. More major hepatectomies were performed in RH (20.0% versus 3.0%, P = 0.002). There was no mortality. No difference was noted in morbidity (LH 4.5%, RH 11.4%), conversion rate (LH 12.1%, RH 5.7%), median blood loss (both 100 mL) and median length of post-operative hospital stay (both 5 days) but operative time was longer in RH (251.5 min versus 215 min, P = 0.008). There were 29 LS and 38 RS, no difference was noted in all perioperative outcomes between the two groups. Conclusion Both laparoscopic and robotic hepatectomy are safe and their perioperative outcomes are comparable and favourable.

Purpose To evaluate the feasibility, safety, and treatment effectiveness of ablative chemoembolization (ACE) in the treatment of hepatocellular carcinoma (HCC) and compare with a similar patient cohort who underwent conventional transarterial chemoembolization (cTACE). Materials and Methods This was a prospective phase I nonrandomized study conducted between March 2013 and October 2016 in accordance to the Declaration of Helsinki and Declaration Good Clinical Practice with written informed consent. There were 36 men and eight women (median age, 64 years [interquartile range, 58-74] and 74.5 years [interquartile range, 70-80], respectively). The primary end points were treatment safety and tumor response. The secondary end points were time to progression, progression-free survival, conversion to partial hepatectomy, and viable HCC within the tumor specimen. The end points of the study group (n = 22) were compared with those of a case-matched control group (n = 22) of patients who underwent conventional cTACE during the same period by using a Pearson χ

The aim of the present study was to review the current evidence in the management of the pancreatic stump after pancreaticoduodenectomy (PD). A literature search was conducted using the following key words: PD, Whipple's operation, pancreaticojejunostomy (PJ), pancreaticogastrostomy (PG), dunking, duct to mucosa (DTM) and pancreatic stent. Emphasis was made on randomized, controlled trials and meta-analyses. Simple ligation or occlusion of the pancreatic duct was abandoned due to a high complication rate. Most surgeons fashioned a PJ or PG to restore drainage of pancreatic juice. Dunking and DTM were the two major ways to construct anastomosis. The superiority of the binding technique still needs to be proved. However, Blumgart's modified DTM technique achieved a favourable outcome in some non-randomized trials. Pancreatic fistula was not decreased by internal stent, but an external stent might be helpful. No single type or technique of pancreaticoenteric anastomosis is able to demonstrate significant superiority to others. Similar controversy also occurs in the use of pancreatic stent. For the successful management of the pancreatic stump, no matter which type of anastomosis is employed, a meticulous surgical technique with optimization of blood supply to the anastomosis cannot be overemphasized.

Mirizzi syndrome, known as extrinsic bile compression syndrome, is a rare complication of cholecystitis and chronic cholelithiasis, secondary to the obliteration of the infundibulum of the gallbladder or cystic duct caused by the impact of one or more calculations in these anatomical structures, which leads to compression of the adjacent bile duct, resulting in partial or complete obstruction of the common hepatic duct, triggering liver dysfunction. Our aim is to identify and describe the current epidemiology, diagnostic methods, and treatment of Mirizzi syndrome. A literature search was performed using different databases, including Medline, Cochrane, Embase, Medscape, PubMed, using keywords: Mirizzi syndrome, epidemiology, markers, pathophysiology, clinical presentation, diagnosis, and treatment. Selected original articles, review articles or case reports from 1997 to 2015 were collected, written in English or Spanish. The endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate diagnostic method. The traditional treatment has been surgery and involves an incision at the bottom of the gallbladder and calculus removal. If fistulas are observed, it is performed a partial cholecystectomy; otherwise, a cholecystocholedochoduodenostomy is an alternative. Endoscopic treatment includes biliary drainage and stone extraction. Many surgeons claim that laparoscopic cholecystectomy is contraindicated in Mirizzi syndrome because of the presence of inflammatory tissue and adhesions in the Calot’s triangle. If dissection is attempt, it can cause unnecessary injury to the bile duct. However, other surgeons consider the laparoscopic approach is feasible, although technically challenging. Currently, laparoscopic cholecystectomy for this condition is considered controversial and technically challenging; however, it has shown that with the right skills and equipment, it is a safe and feasible way to treat some cases of Mirizzi syndrome type I and II.

Liver fibrosis and cirrhosis are well-known risk factors for morbidity after hepatectomy. Liver stiffness measurement (LSM) using transient elastography is a new method for detection of hepatic fibrosis and cirrhosis with high accuracy. Whether LSM can predict posthepatectomy outcomes has not been studied.This was a prospective cohort study in which consecutive patients underwent hepatectomy for various indications from February 2010 to July 2011. All patients received detailed preoperative assessments including LSM and indocyanine green (ICG) clearance test. The primary outcome was major postoperative complication.One hundred five patients with a mean age of 59 years were included; 75 (71.4%) had chronic viral hepatitis and 76 (72.4%) had hepatocellular carcinoma. Thirty-four patients (32.4%) received major hepatectomy. The median ICG retention rate at 15 minutes was 4.2 (0.1%-32%) and the median LSM was 9.4 (3.3-75 kPa). For posthepatectomy outcomes, only LSM but not ICG showed significant correlation with major postoperative complications on receiver operating characteristic curves, with area under the curve of 0.79 (P0.001). Using the calculated cutoff at 12.0 kPa, LSM had sensitivity of 85.7% and specificity of 71.8% in the prediction of major postoperative complications. It was also an independent prognostic factor for major postoperative complications by multivariate analysis. The operative blood loss and transfusion rate were also significantly higher in patients with LSM12.0 kPa.High LSM (12.0 kPa) predicted worse posthepatectomy outcomes. Preoperative LSM was better than ICG test in the prediction of major postoperative complications. It was a useful preoperative investigation for risk stratification before hepatectomy.

Primary hepatolithiasis is a disease characterized by primary biliary ductal abnormality with stone formation predominantly within the intrahepatic bile ducts. Its management is difficult, but liver resection has emerged as a promising treatment option. Robotic liver resection (RLR) has been adopted in our center for the management of patients with hepatolithiasis. The operative and short-term outcomes of this cohort of patients were compared with a historical cohort of patients using open approach (OLR). A subgroup analysis was performed for left lateral sectionectomy. Between September 2010 and April 2015, 15 RLRs were performed on patients with primary hepatolithiasis. The historical cohort consisted of 42 OLRs with operation done between January 2005 and January 2014. No differences were found in patient demographics, disease characteristics, or types of resection. No operative deaths occurred, and no difference was seen in complication rates. RLR had significantly less blood loss (100 vs. 235 ml; p = 0.011) and shorter hospital stays (6 vs. 8 days; p = 0.003). After a median follow-up of 19.4 months for RLRs and 79.2 months for OLRs (p

Backgrounds and purpose To determine the predictors for recurrence in patients receiving curative hepatectomy for hepatocellular carcinoma (HCC). Methods From January 2001 to July 2007, all patients having hepatectomy for first occurrence HCC with curative intent were identified from a prospectively collected database. Prognostic factors for recurrence and survival after resection were analyzed. Results A total of 235 patients were included. With a median follow-up of 50.2 (0.07–125.1) months, the recurrence rate was 57.0%. The 1-, 3-, and 5-year overall survival rates were 83.9%, 66.0%, and 58.1% respectively. Multivariate analysis demonstrated that multi-focal lesions (HR: 2.93, P P = 0.002) and history of tumor rupture (HR: 2.84, P = 0.003) were independent risk factors for recurrence of HCC after hepatectomy. Conclusions Predictors for HCC recurrence can be identified before operation. These important parameters should be considered before and after contemplating curative resection for HCC patients and for risk stratification in future clinical trials for neoadjuvant or post-resection adjuvant therapy. The possible use of neoadjuvant or adjuvant treatment to improve survival should be addressed by further trials.

Background The intermittent Pringle manoeuvre (IPM) is commonly applied during liver resection. Few randomized trials have addressed its effectiveness in reducing blood loss and the results have been conflicting. The present study investigated the hypothesis that IPM could reduce blood loss during liver resection by 50 per cent. Methods Between May 2008 and April 2011, patients who underwent elective open hepatectomy were randomized into an IPM or no Pringle manoeuvre (NPM) group and stratified according to the presence or absence of cirrhosis. Data on demographics, type of hepatectomy, operative blood loss, duration of operation, mortality, morbidity and postoperative liver function were recorded and analysed. The primary endpoint was operative blood loss. Results There were 63 patients in each group. Median (range) operative blood loss was 370 (50–3600) ml in the IPM group versus 335 (40–3160) ml in the NPM group (P = 1·000). There were no differences in blood loss in different phases of the operation, blood loss per area of liver transected or blood transfusion rate, nor in total duration of operation or liver transection time. Postoperative serum alanine aminotransferase levels were higher in the IPM group (P < 0·001). There were more postoperative complications in the IPM group (41 versus 24 per cent; P = 0·036). Conclusion The IPM did not reduce blood loss, but was associated with raised levels of postoperative liver parenchymal enzymes and more complications. Registration number: NCT00730743 (http://www.clinicaltrials.gov).

BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is an emerging technique used in cholecystectomy. Nevertheless, studies on the difference in postoperative pain between SILC and conventional laparoscopic cholecystectomy are lacking in the literature. PATIENT AND METHODS From August 2009 to July 2010, 20 consecutive patients who underwent SILC (SILC group) were compared with a prospective cohort of 20 patients who underwent conventional 4-port laparoscopic cholecystectomy (LC group) during the same period. Standard postoperative analgesic protocol was applied to all patients. Pain scores were registered before operation and one day after operation using visual analog scale. Satisfactory score was self-assessed by all patients one month after surgery using visual analog scale. RESULTS There was no significant difference in the baseline characteristics, preoperative pain score, and intraoperative opioid usage between the 2 groups. The postoperative pain score was significantly lower in the SILC group (2.9±1.6 in SILC group vs. 4.8±1.5 in LC group, P

Objective: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. This article reviews the latest evidence for the timing of laparoscopic cholecystectomy in the management of acute cholecystitis. Methodology: Trials comparing early laparoscopic cholecystectomy (ELC; carried out within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (DLC; carried out at least 6 weeks after symptoms settled) for acute cholecystitis were identified from Ovid Medline, Cochrane Library and PubMed database. Only meta-analyses and randomized clinical trials were reviewed. Results: A total of seven prospective randomized trials including 670 patients and four meta-analyses were reviewed. ELC was superior to DLC in terms of a shorter hospital stay without any significant difference in perioperative mortality and morbidity. Conclusions: Current evidence supports ELC as the preferred treatment strategy for acute cholecystitis. It allows a shorter hospital stay, but shares similar operative morbidity, mortality and conversion rate as DLC.

Aim: To review the evidence in using inflow occlusion during liver resection. Other strategies to minimize the untoward effects of inflow occlusion will also be discussed. Methods: Randomized trials evaluating the use of inflow occlusion in hepatectomy and strategies to minimize its associated adverse effects were reviewed in this article. Recent experience showing comparable operative outcomes without the use of portal clamping was also described. Results: Results from randomized trials and meta-analyses were not conclusive on the benefits of routine inflow occlusion during liver resection. Intermittent inflow occlusion and ischaemic preconditioning had been found to be effective in reducing ischaemic–reperfusion injury to remnant liver. With refined operative techniques and better instruments, routine inflow occlusion in liver resection can now be safely avoided. Conclusion: Vascular inflow occlusion is an important armamentarium during liver resection, but it should not be used indiscriminately. With refined techniques and better instruments, hepatectomy can be performed safely without the need for routine inflow occlusion.

Laparoscopic hepatectomy (LH) is established as a safe and feasible treatment option for liver tumors. However, whether the adoption of laparoscopic approach for malignant tumors, such as hepatocellular carcinoma (HCC), will compromise the long-term result is still unknown. This study was designed to evaluate the long-term results of LH compared with a cohort of case-matched open hepatectomy (OH). Thirty-three patients who underwent LH for HCC in our institution between June 2004 and March 2010 were recruited. A group of 50 patients who underwent OH for HCC during the same period was identified by matching to magnitude of operation, size of tumor, site of tumor, and the absence of concomitant local ablation or major procedure. The perioperative outcomes, disease recurrence, and survival of the two groups of patients were determined and compared. LH resulted in less operative complications (6.1% vs. 24%, P = 0.033) and shorter median hospital stay (5 vs. 7 days, P

Aliment Pharmacol Ther 2011; 33: 1104–1112 Summary Background The role of anti-viral therapy in prevention of hepatocellular carcinoma (HCC) recurrence is to be defined. Aim To investigate the role of anti-viral therapy in prevention of tumour recurrence after curative treatment of hepatitis B virus (HBV)-related HCC. Methods A systematic electronic search on keywords including HCC and different anti-viral therapies was performed through eight electronic databases, including Medline, EMBASE and Cochrane Databases. The primary outcome was HCC recurrence after curative treatment of HBV-related HCC. The secondary outcomes were mortality related to HCC, mortality related to liver failure and the overall mortality. Results Nine cohort studies were included with a total number of 551 patients: 204 patients with anti-viral treatment group and 347 patients without anti-viral treatment (control group). There was significant difference in the incidence of HCC recurrence in favour of the anti-viral treatment group (55% vs. 58%; odds risk (OR) = 0.59, 95% CI 0.35–0.97, P = 0.04). The risk of HCC was reduced by 41% in the anti-viral treatment group. There were also significant differences in favour of anti-viral treatment group in terms of liver-related mortality (0% vs. 8%; OR = 0.13, 95% CI 0.02–0.69, P = 0.02) and overall mortality (38% vs. 42%; OR = 0.27, 95% CI 0.14–0.50, P