Clinical and biological impact of conversion on outcomes of minimally invasive liver surgery: a multimodal analysis.

Minimally invasive liver surgery (MILS) offers several advantages over open liver surgery (OLS), but the underlying mechanisms remain unclear. This study compares inflammatory marker levels between OLS and MILS and examines the impact of conversion. Patients undergoing liver resection at San Raffaele Hospital (September 2022-May 2023) were prospectively enrolled.

Novel Benchmark for Robotic Liver Resection - Bridging Tradition with Innovation.

Objective: To establish benchmark cutoffs for robotic liver resection (R-LR), encompassing both major and minor resections, and to determine the impact of patient selection on outcomes.

Background: R-LR is a key advancement in minimally invasive liver surgery but lacks standardized benchmarks, especially for minor resections. While guidelines endorse R-LR, its role in optimizing outcomes remains unclear.

Liver transplantation for hepatocellular carcinoma following immunotherapy.

Purpose Of Review: To explore the emerging use of immune checkpoint inhibitors (ICIs) in hepatocellular carcinoma (HCC) patients eligible for liver transplantation (LT), particularly as bridging and downstaging therapies. This review also addresses the clinical challenges of integrating ICIs into transplant protocols, including graft rejection, immune-related toxicities, and gaps in evidence.

Recent Findings: ICIs have shown potential as bridging and downstaging therapies before LT, with multicentric studies reporting 75.

Laparoscopic versus open parenchymal preserving liver resections in the posterosuperior segments (ORANGE Segments): a multicentre, single-blind, randomised controlled trial.

Background: An increasing number of liver resections are performed laparoscopically, while laparoscopic resection of lesions in the posterosuperior segments is technically challenging. We aimed to assess the outcomes of laparoscopic and open parenchymal preserving resection of lesions in the posterosuperior segments in a randomised controlled trial.

Methods: In this multicentre, patient-blinded, superiority randomised controlled trial, patients requiring parenchymal preserving liver resection for tumours in segment 4a, 7, or 8 were enrolled at 17 centres and randomised 1:1 to laparoscopic or open surgery using a minimisation scheme stratifying for centre and lesion size.

Neoadjuvant atezolizumab plus bevacizumab prior liver transplantation for hepatocellular carcinoma.

Background & Aims: The combination of atezolizumab and bevacizumab offers a novel approach to immunomodulation, showing efficacy as a primary treatment in advanced hepatocellular carcinoma (HCC). Concerns about graft safety and rejection have limited its exploration in the neoadjuvant setting of liver transplantation (LT). In this study, we investigate the clinical efficacy and the safety profile of pre-transplant administration of atezolizumab and bevacizumab for HCC.

Predicting futile outcomes following deceased donor liver transplantation in non-HCC patients with MELD-Na score above 30: a retrospective international multicenter cohort study.

Introduction: In the current "sickest first" allocation policy for limited deceased liver grafts, identifying patients "too sick to transplant" before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with model for end-stage liver disease-sodium (MELD-Na) scores ≥30.

Methods: This international multicenter study was conducted as part of the International Society of Liver Surgeons.

Downstaging of hepatocellular carcinoma before liver transplantation: Results from a national multicenter prospective cohort study.

Background And Aims: Patients with HCC meeting United Network for Organ Sharing (UNOS)-downstaging (DS) criteria have excellent post-liver transplantation (LT) outcomes. Studies on HCC beyond UNOS-DS criteria ("All-Comers" [AC]) have been limited by small sample size and short follow-up time, prompting this analysis.

Approach And Results: Three hundred twenty-six patients meeting UNOS-DS and 190 meeting AC criteria from 9 LT centers across 5 UNOS regions were enrolled from 2015 to 2023 and prospectively followed.

Liver resection and transplantation in the era of checkpoint inhibitors.

Immune checkpoint inhibitors (ICIs) have revolutionised the treatment landscape for advanced hepatocellular carcinoma (HCC). The combination of atezolizumab and bevacizumab has demonstrated efficacy, establishing a new standard of care for advanced HCC. Neoadjuvant studies have shown promising results with high response rates, increasing research into ICIs' role.

Intention-to-treat outcomes of patients with hepatocellular carcinoma receiving immunotherapy before liver transplant: The multicenter VITALITY study.

Background & Aims: The use of immune checkpoint inhibitors (ICIs) in patients with advanced hepatocellular carcinoma (HCC) has become widespread with encouraging outcomes in the neoadjuvant setting. Safety and intention-to-treat (ITT) outcomes in the peri-transplant setting are currently based on small and heterogenous single-center reports.

Methods: This first multiregional US study (2016-2023) included 117 consecutive patients with HCC assessed for liver transplantation (LT) and treated preoperatively with ICIs.

The oncologic burden of residual disease in incidental gallbladder cancer: An elastic net regression model to profile high-risk features.

Introduction: Incidental Gallbladder Cancer (IGBC) following cholecystectomy constitutes a significant portion of gallbladder cancer diagnoses. Re-exploration is advocated to optimize disease clearance and enhance survival rates. The consistent association of residual disease (RD) with inferior oncologic outcomes prompts a critical examination of re-resection's role as a modifying factor in the natural history of IGBC.

Indocyanine green (ICG)-guided robotic resection for liver adenoma: combined technologies for precision surgery.

HCA resection is crucial to prevent bleeding and malignant transformation. The aim of this study was to enhance the precision of tumor resection in hepatocellular adenoma (HCA) through the combination of intraoperative ultrasound (IOUS) and indocyanine green (ICG) fluorescence imaging. ICG was intravenously injected 24 h before surgery, enabling positive staining of HCA nodules.

Achievement of textbook outcome after hepatectomy combined with thermal ablation for colorectal liver metastases.

Background: Hepatic resection combined with intraoperative ablation has been described as a technical solution potentially widening the resectability rate of patients with colorectal liver metastases (CRLM). Nevertheless, the perioperative and oncological benefit provided by this combined approach remains unclear. We hypothesized that textbook outcome (TO), which is a composite measure achieved for patients for whom some desired health indicators are met, may help to refine the indications of this approach.

Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA).

Background: Surgery for intrahepatic cholangiocarcinoma (iCCA) is jeopardized by significant risk of early recurrence (≤ 6 months). The aim of the present study is to analyze the oncological benefit provided by laparoscopic over open approach for iCCA in patients with high risk of very early recurrence (VER).

Materials And Methods: A total of 532 liver resections (LR) were performed for iCCA [265 by minimally invasive surgery (MIS) and 267 with open approach, matched through a 1:1 propensity score] and stratified using the postoperative prediction model of VER.

Immunotherapy for transplantation of hepatocellular carcinoma: the next frontier in adjunctive therapy.

Purpose Of Review: The increasing success of liver transplantation in hepatocellular carcinoma (HCC) drives an ever-evolving search for innovative strategies to broaden eligible patients' pools. Recent advances in immuno-oncology have turned the spotlight on immune checkpoint inhibitors (ICIs). This review offers an updated overview of ICIs in liver transplantation for HCC, exploring neoadjuvant and adjuvant approaches and addressing unanswered questions on safety, patients' selection, and response predictors.

Mechanism and Effect of HNF4α Decrease in a Rat Model of Cirrhosis and Liver Failure.

Background & Aims: HNF4α, a master regulator of liver development and the mature hepatocyte phenotype, is down-regulated in chronic and inflammatory liver disease. We used contemporary transcriptomics and epigenomics to study the cause and effects of this down-regulation and characterized a multicellular etiology.

Methods: Progressive changes in the rat carbon tetrachloride model were studied by deep RNA sequencing and genome-wide chromatin immunoprecipitation sequencing analysis of transcription factor (TF) binding and chromatin modification.

Defining and predicting textbook outcomes for perihilar cholangiocarcinoma: analysis of factors improving achievement of desired postoperative outcomes.

Background: Definition of textbook outcome (TO), defined as a single indicator combining the most advantageous short-term outcomes, is still lacking for perihilar cholangiocarcinoma (PHC). The primary endpoint of the present study is to analyze the rate of achievement of a disease-specific TO for PHC within a high volume tertiary referral centre. Secondary endpoints are to identify predictive factors of TO-achievement and to analyze the impact of achieving TO on long-term results.

Comparing Liver Venous Deprivation and Portal Vein Embolization for Perihilar Cholangiocarcinoma: Is It Time to Shift the Focus to Hepatic Functional Reserve Rather than Hypertrophy?

: Among liver hypertrophy technics, liver venous deprivation (LVD) has been recently introduced as an effective procedure to combine simultaneous portal inflow and hepatic outflow abrogation, raising growing clinical interest. The aim of this study is to investigate the role of LVD for preoperative optimization of future liver remnant (FLR) in perihilar cholangiocarcinoma (PHC), especially when compared with portal vein embolization (PVE). : Between January 2013 and July 2022, all patients diagnosed with PHC and scheduled for preoperative optimization of FTR, through radiological hypertrophy techniques, prior to liver resection, were included.

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy.

Background: The aim of the present study is to evaluate the possible advantages of the Robo-Lap (parenchymal transection by laparoscopic ultrasonic dissector and robotic bipolar forceps and scissors) compared with pure robotic technique (parenchymal transection by use of robotic bipolar forceps and scissors) in major anatomical liver resections with specific focus on intraoperative outcomes.

Methods: Major liver resections performed by robotic approach between February 1, 2021 and March 31, 2023 were stratified into two groups according to the approach used to address the phase of liver transection; Pure Robotic Group (n = 21) versus Robo-Lap Group (n = 48). The two groups were compared in terms of intra- and postoperative outcomes and in terms of rate of achievement of intraoperative textbook outcomes.

A "cui prodest" evaluation on the development of a minimally invasive liver surgery program: a differential benefit analysis of open and laparoscopic approach for left and right hemihepatectomies.

Background: The correlation between technical feasibility and short-term clinical advantage provided by laparoscopic over open technique for major hepatectomies is unclear. This monocentric retrospective study investigates the possible differences in the benefit provided by minimally invasive approach between left and right hepatectomy, deepening the concept of differential benefit in the setting of anatomical major resections.

Methods: All hemihepatectomies performed from January 2004 to December 2021 were identified in the institutional database.

Results from the european survey on preoperative management and optimization protocols for PeriHilar cholangiocarcinoma.

Background: Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe.

Methods: 61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management.