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Chemotherapy is the mainstay treatment for liver metastasis from gastric cancer. However, some retrospective studies and meta-analyses have indicated the efficacy of hepatectomy, which is an aggressive treatment option. However, the optimal selection criteria for hepatectomy and the role of perioperative chemotherapy remain unclear. Therefore, a meta-analysis of studies on hepatectomy was performed to assess the impact of various factors on overall survival (OS). A systematic review was conducted in accordance with the PRISMA criteria using studies published until 2022. The primary outcome was the hazard ratio (HR) for OS. Comparisons were made between hepatectomy and nonhepatectomy, solitary and multiple metastases, synchronous and metachronous metastases, treatment with and without neoadjuvant chemotherapy, and treatment with and without adjuvant chemotherapy. A total of 50 studies involving 1966 patients who underwent hepatectomy were included in the analysis. The meta-analysis showed a 5-year OS rate of 25 %. A meta-analysis comparing hepatectomy with nonhepatectomy showed an HR of 0.2 for hepatectomy. A meta-analysis comparing solitary and multiple metastases showed a trend toward better OS in patients with solitary metastases (odds ratio [OR]: 0.35). A meta-analysis comparing synchronous and metachronous metastases showed favorable OS for patients with metachronous metastases (OR: 0.66). A meta-analysis comparing neoadjuvant chemotherapy with no neoadjuvant chemotherapy showed no difference in OS. In contrast, a meta-analysis comparing adjuvant chemotherapy with no adjuvant chemotherapy showed better OS for adjuvant chemotherapy (OR: 0.39). This retrospective study indicates that hepatectomy may benefit patients with liver metastases from gastric cancer, particularly those with solitary and metachronous metastases., Competing Interests: Declaration of competing interest M.T. has received research grants from Taiho Pharmaceutical Co. Ltd., Chugai Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Bristol Myers Squib Japan K.K., Yakult Honsha Co., Ltd., Takeda Pharmaceutical Co., Ltd., Eli Lilly Japan, Pfizer Japan Inc., Daiichi Sankyo Ltd., Johnson and Johnson K.K., Medtronic Japan Co., Ltd., Intuitive Japan Inc., and Olympus Co., Ltd., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background/aim: No studies have investigated the advantage of laparoscopic hepatectomy (LH) compared with open hepatectomy (OH) from a nutritional perspective. This study aimed to compare the postoperative nutritional status between LH and OH., Patients and Methods: A total of 186 patients who underwent partial hepatic resection for liver tumors were analyzed retrospectively. We compared perioperative variables between LH and OH. The nutritional status was assessed using serum albumin (Alb) and rapid turnover protein concentrations. We investigated risk factors for postoperative malnutrition using univariate and multivariate analyses., Results: The LH group, compared with the OH group, had a significantly shorter operative time (239 vs. 344 min, p<0.03), less intraoperative blood loss (100 vs. 343 g, p<0.01), and a shorter length of postoperative stay (8 vs. 11 days, p<0.01). Postoperative serum Alb and prealbumin concentrations in the LH group were significantly higher than those in the OH group (3.4 vs. 3.2 g/dl, p<0.01; 15.0 vs. 12.0 mg/dl, p=0.02, respectively). The multivariate analysis showed that OH (p=0.02) and hepatocellular carcinoma (p<0.01) were significant and independent risk factors for postoperative malnutrition., Conclusion: LH may be superior to OH in terms of the postoperative nutritional status, intraoperative blood loss, and length of postoperative stay., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-sided hepatectomy, with good results for liver hypertrophy and function. However, the histological and radiological findings of DHVE have not been thoroughly investigated., Methods: This study included 14 patients who underwent DHVE before right-sided major hepatectomy. DHVE was performed if the future liver remnant was < 35% or borderline, but with concomitant vascular resection. The liver function was assessed using the signal intensity on Gd-EOB-DTPA-MRI. A histological evaluation of the area of DHVE and portal vein embolization (PVE) were performed., Results: The median pre- and post-functional liver remnants were 363 ml and 498 ml, respectively (p < 0.001). The median growth rate was 48.6%, and there was no post-hepatectomy liver failure in the patients who underwent DHVE. The signal intensity ratio in the area of DHVE was lower than that in the areas of PVE and the remnant liver (p < 0.01). The degree of congestion and necrosis was greater in the area of DHVE than in the area of PVE alone (p < 0.01 and p = 0.04, respectively)., Conclusions: We observed good liver hypertrophy after DHVE and histological and radiological changes in the area of DHVE. Our findings provide a compelling rationale for further investigation of the mechanism of liver hypertrophy in DHVE., Competing Interests: Declarations. Conflict of interest: The authors declare no conflicts of interest in association with the present study. Ethical approval: This study protocol was approved by the ethics committee of Jikei University School of Medicine (No. 32-504). Patients were given the opportunity to opt out of this study through public announcements., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Owing to advances in the multidisciplinary treatment of hepatocellular carcinoma (HCC), a conceptualization and definition for borderline resectable (BR) HCC, which carries a high risk of recurrence, is warranted. In this study, we aimed to define BR-HCC using a prognosis-oriented approach., Study Design: The study included an original cohort of 221 patients and an independent validation cohort of 181 patients who had undergone primary hepatic resection for HCC. To define biological BR-HCC, we evaluated the risk factors for early recurrence beyond the Milan criteria within 1 year after hepatic resection using multivariable logistic regression models. Subsequently, we developed high-risk scores using the identified risk factors and defined BR-HCC. The utility of high-risk score was validated in the validation cohort., Results: In the original cohort (hepatitis B virus:hepatitis C virus = 20%:29%), recurrence beyond the Milan criteria within 1 year was observed in 28 patients (13%), with a 5-year survival rate of 25%. Multivariable analysis identified risk factors for recurrence beyond the Milan criteria within 1 year, including serum alpha-fetoprotein levels of 12 ng/mL or more (p = 0.02), tumor diameters less than 5 cm (p = 0.02), tumor number 3 or more (p = 0.001), and macrovascular invasion (p = 0.04). BR-HCC was defined as a tumor with 2 or more identified risk factors, and 42 patients (19%) were diagnosed with BR-HCC, with a 5-year survival rate of 51%. In the validation cohort, 45 (25%) patients had BR-HCC, with a 5-year survival rate of 42%., Conclusions: The prognosis-oriented definition of BR-HCC enabled us to identify patients who are susceptible to early unresectable recurrence and have poor survival after hepatic resection for HCC. For patients with BR-HCC, preoperative systemic therapy may be a viable option to improve postresection outcomes., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background/aim: With the aging of the population, there is a rising proportion of elderly patients undergoing liver resection. However, the safety and efficacy of laparoscopic liver resection (LLR) in the elderly have not yet been established. In this study, we compared the short-term results of LLR and open liver resection (OLR) in elderly patients using propensity score matched (PSM) analysis., Patients and Methods: The study comprised 237 elderly patients aged 65 years and older who had undergone liver resection between 2015 to 2021, excluding biliary and vascular reconstruction and simultaneous surgeries other than liver resection. We conducted PSM analysis for baseline characteristics (age, sex, BMI, ASA-PS, disease, procedure, tumor size, and number of tumors) to eliminate potential selection bias. We then compared short-term postoperative outcomes between LLR and OLR groups in patients selected by PSM analysis., Results: Applying PSM analysis, 90 cases each were selected for the LLR and OLR groups. The LLR group had a significantly lower complication rate (Clavien-Dindo: CD ≥II) (19% vs. 33%, p=0.03), especially bile leakage (CD ≥II) (0% vs. 6.7%, p=0.03) compared with those in the OLR group. In addition, a shorter operation time (244 min vs. 351 min, p<0.01), less blood loss (150 ml vs. 335 ml, p<0.01), and shorter hospital stay (8 days vs. 12 days, p<0.01) were observed in the LLR group. No operative or in-hospital deaths were observed in both groups., Conclusion: LLR can be safely performed in elderly patients and offers better short-term outcomes., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Laparoscopic hepatic resection is currently used for ruptured hepatocellular carcinoma (HCC); however, it is technically challenging. We developed and implemented surgical strategies for emergency laparoscopic partial liver resection in selected patients with peripheral lesions who were hemodynamically stable and without severe liver dysfunction., Patients and Methods: The surgical techniques used were as follows. First, the Pringle maneuver was performed to control hepatic blood inflow (step 1). Next, strong hemostatic agents were applied at the rupture point of the tumor (step 2). The hanging tape was positioned along the dorsal side of the resection line to control the partial blood inflow and outflow of the tumor, as well as to expose the surgical plane (step 3). The liver parenchyma was dissected along the hanging tape (step 4). We performed emergency laparoscopic partial liver resection in three patients who were in a pre-shock status., Results: The tumors were located in segments 6 (cases 1 and 2) and 2 (case 3). The tumor diameters were 90, 62, and 80 mm. The Preoperative Child-Pugh scores were B7, B9, and B8. The hemostatic products performed well and controlled bleeding from the ruptured HCC. The hanging tape facilitated the dissection of the liver parenchyma. The operative time and intraoperative blood loss were 135 min and 400 ml, 266 min and 200 ml, and 191 min and 495 ml for cases 1, 2, and 3 respectively. There were no in-hospital deaths., Conclusion: Emergency laparoscopic partial liver resection could be an option for patients with ruptured HCC., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Aim: To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC)., Methods: This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model., Results: Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01)., Conclusions: OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA., Competing Interests: Declaration of competing interest The authors declare no Conflicts of Interest for this article., (Copyright © 2024. Published by Elsevier Ltd.)

Background: The conventional markers for hepatocellular carcinoma (HCC), α-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP), have several limitations; both have low sensitivity in patients with early-stage HCC; low sensitivity for AFP with HCC after eliminating hepatitis C virus (HCV); low specificity for DCP in patients with non-viral HCC, which is increasing worldwide; low specificity for AFP in patients with liver injury; and low specificity for DCP in patients treated with warfarin. To overcome these issues, the identification of novel biomarkers is an unmet need., Objective: This study aimed to assess the usefulness of serum protein kinase C delta (PKCδ) for detecting these HCCs., Methods: PKCδ levels were measured using a sandwich enzyme-linked immunosorbent assay in 363 chronic liver disease (CLD) patients with and without HCC., Results: In both viral and non-viral CLD, PKCδ can detect HCCs with high sensitivity and specificity, particularly in the very early stages. Notably, the value and sensitivity of PKCδ were not modified by HCV elimination status. Liver injury and warfarin administration, which are known to cause false-positive results for conventional markers, did not modify PKCδ levels., Conclusions: PKCδ is an enhanced biomarker for the diagnosis of HCC that compensates for the drawbacks of conventional markers.

Background/aim: The prognostic outcome of the controlling nutritional status (CONUT) score in patients with colorectal liver metastases (CRLM) who underwent hepatectomy has not been investigated. The aim of this study was to investigate the prognostic value of preoperative CONUT score and other systemic inflammation-related biomarkers in patients who underwent hepatectomy for CRLM., Patients and Methods: The subjects included 145 patients with CRLM who underwent hepatectomy and retrospectively investigated the association of preoperative CONUT score with disease-free survival (DFS), surgical failure-free survival (SFS), and overall survival (OS) using univariate and multivariate analyses., Results: In this study, the cut-off of the CONUT score was 4. In the univariate analysis, the high CONUT score was associated with worse SFS and OS (p=0.01, 0.01). The multivariate analysis showed significant and independent predictors of OS were lymph node metastases (p=0.03) and a high CONUT score (p=0.04). In patients with a high CONUT score, postoperative complications due to infections were significantly more than in those with a low CONUT score (27% vs. 9%, p=0.04)., Conclusion: The CONUT score can be useful for predicting not only short-term but also long-term outcomes in patients with CRLM after hepatectomy., (Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Identifying the prognostic indicators that reflect the efficacy of preoperative chemotherapy is necessary. In this study, we investigated the prognostic indicators targeting the systemic inflammatory response for the administration of preoperative chemotherapy in patients with colorectal liver metastases., Methods: Data for 192 patients were retrospectively analyzed. The relationship between overall survival and clinicopathological variables, including biomarkers such as the prognostic nutritional index, was investigated in patients who underwent upfront surgery or preoperative chemotherapy., Results: In the upfront surgery group, extrahepatic lesion (p=0.01) and low prognostic nutritional index (p < 0.01) were significant prognostic indicators, whereas a decrease in the prognostic nutritional index (p=0.01) during preoperative chemotherapy were independent poor prognostic factors in the preoperative chemotherapy group. In particular, a decrease in the prognostic nutritional index was a significant prognostic marker in patients aged <75 years (p=0.04). In patients with a low prognostic nutritional index aged <75 years, preoperative chemotherapy significantly prolonged overall survival (p=0.02)., Conclusion: A decrease in the prognostic nutritional index during preoperative chemotherapy predicted overall survival of patients with colorectal liver metastases after hepatic resection, and preoperative chemotherapy may be effective for patients aged <75 years with a low prognostic nutritional index., Competing Interests: Declaration of competing interest Authors declare no Conflict of Interests for this article., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: In tumor adjacent to the hepatic vein, it is important to treat two tertiary Glissonean pedicles that straddle to the hepatic vein in order to remove the tumor with a negative margin. The anatomical resection of the smallest unit may be considered to be the resection of the double cone-unit (DCU) in small tumor adjacent to the vein., Patients and Methods: 127 patients who had undergone laparoscopic hepatectomy at the Jikei Medical University Hospital from 2020 through 2021. In 5 cases, Laparoscopic DCU resection was performed. If the CT image shows a hepatic vein near the tumor and the tumor is relatively small, less than 50 mm in size, DCU resection should be considered. After approaching the target Glissonean pedicles, the Bulldog Clamps were used to testing clamp it. After clamping it, the ICG was injected from peripheral veins. A few minutes later, the tumor-bearing portal territory could be identified as negative regions of fluorescence in the near infrared imaging system. The target hepatic vein, which runs between the two territories, was dissected where it transitions from the first to the second territory., Results: The median operative time in these 5 patients was 279 min, and the median volume of blood loss was 290 g. The average tumor size was 33 mm and the average surgical margin was 4.5 mm., Conclusion: In small tumor adjacent to the hepatic vein, the anatomical hepatectomy of the smallest unit may be the Double Cone-Unit resection., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: This study was performed to propose a strategy for repeat laparoscopic liver resection (RLLR) and investigate the preoperative predictive factors for RLLR difficulty., Methods: Data from 43 patients who underwent RLLR using various techniques at 2 participating hospitals from April 2020 to March 2022 were retrospectively reviewed. Surgical outcomes, short-term outcomes, and feasibility and safety of the proposed techniques were evaluated. The relationship between potential predictive factors for difficult RLLR and perioperative outcomes was evaluated. Difficulties associated with RLLR were analyzed separately in two surgical phases: the Pringle maneuver phase and the liver parenchymal transection phase., Results: The open conversion rate was 7%. The median surgical time and intraoperative blood loss were 235 min and 200 mL, respectively. The Pringle maneuver was successfully performed in 81% of patients using the laparoscopic Satinsky vascular clamp (LSVC). Clavien-Dindo class ≥III postoperative complications were observed in 12% of patients without mortality. An analysis of the risk factors for predicting difficult RLLR showed that a history of open liver resection was an independent risk factor for difficulty in the Pringle maneuver phase., Conclusion: We present a feasible and safe approach to address RLLR difficulty, especially difficulty with the Pringle maneuver using an LSVC, which is extremely useful in RLLR. The Pringle maneuver is more challenging in patients with a history of open liver resection., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The 5-5-500 rule has been proposed to increase the candidates of liver transplantation for patients with hepatocellular carcinoma with reasonable recurrence rates. However, the clinical significance of the 5-5-500 rule in patients who underwent hepatic resection for hepatocellular carcinoma has not been fully investigated., Patients and Methods: The study comprised 206 patients who had undergone primary hepatic resection for hepatocellular carcinoma between 2008 and 2018. We retrospectively investigated prognostic significance of the 5-5-500 rule and disease-free, as well as overall, survival and further prognostic stratification using inflammatory-based biomarkers., Results: 132 patients (64%) were classified within the 5-5-500 rule, while 74 patients (36%) were classified outside the 5-5-500 rule. Among the patients outside the 5-5-500 rule, 62 patients had tumors greater than 5 cm, and 23 patients showed serum AFP levels greater than 500 ng/ml. In the multivariate analysis, being female (p<0.01), HBs-Ag positive (p<0.01), having an ICG R15 ≥15% (p=0.03), and being outside the 5-5-500 rule (p=0.01) were independent and significant predictors of disease-free survival, while being HBs-Ag positive (p=0.04), having poor tumor differentiation (p=0.03), and residing outside the 5-5-500 rule (p=0.01) were independent and negative predictors of overall survival. Elevated CRP-to-albumin ratio was associated with poor overall survival in the patients outside the 5-5-500 rule, but not in patients within the 5-5-500 rule (p=0.17)., Conclusion: The 5-5-500 rule can be a prognostic factor in patients with hepatocellular carcinoma after hepatic resection. CRP-to-albumin ratio might be useful to stratify the outcomes in patients outside the 5-5-500 rule., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Sorafenib was previously the only targeted therapy for hepatocellular carcinoma (HCC). However, pharmaceutical therapy for HCC has undergone remarkable advances in recent years. Herein, we report cases of unresectable advanced HCC responding to pharmaceutical therapy resulting in improved prognosis through surgical intervention., Patients and Methods: Five patients with intermediate and advanced stage HCC treated with lenvatinib followed by hepatectomy between October 2019 and September 2022 were retrospectively reviewed. Patient characteristics, tumor factors, and treatment factors were compared., Results: The median patient age was 66 (60-79) years, and all patients (100%) were male. The median follow-up period was 10.4 months. All five patients received lenvatinib treatment for more than 2 months before surgery. Three patients achieved partial responses and 2 patients had stable disease with modified RESIST in response to lenvatinib. Three patients had a partial pathological response (50% or more tumor necrosis). Four patients underwent R0 resection and 3 cases had no recurrence., Conclusion: Lenvatinib might be useful for intermediate and advanced HCC and long-term survival may be obtained by combining lenvatinib therapy with surgery., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Frailty, represented by sarcopenia and osteopenia, has been associated with worse survival after hepatectomy in patients with hepatocellular carcinoma. Recently, the concept and term "osteosarcopenia" have been proposed, which has been associated with worse outcome in several malignancies., Methods: This study included 227 patients who underwent elective hepatic resection for hepatocellular carcinoma. Osteopenia was evaluated with computed tomographic measurement of pixel density in the midvertebral core of the 11th thoracic vertebra. The skeletal muscle index (SMI) was evaluated with psoas muscle areas at the third lumbar vertebra. Osteosarcopenia was defined as the concomitant occurrence of osteopenia and low SMI. We retrospectively investigated the relationship between osteosarcopenia and disease-free and overall survival., Results: Osteosarcopenia was identified in 27 (12%) of the patients. Multivariate analysis showed that osteosarcopenia (P < .001), C-reactive protein-to-albumin ratio ≥0.02 (P = .002), and stage ≥III (P ≤ .001) were independent predictors of disease-free survival, while osteosarcopenia (P < .001), Child-Pugh grade B (P = .002), C-reactive protein-to-albumin ratio ≥0.02 (P = .001), low SMI (P ≤ .001), and stage ≥III (P ≤ .001) were independent predictors of overall survival., Conclusion: Preoperative osteosarcopenia may be a prognostic factor in patients with hepatocellular carcinoma after hepatic resection. Our results suggests that the preoperative maintenance of skeletal muscle and bone density may potentially improve prognosis., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Aim: The C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index is a novel inflammation-based biomarker. We aimed to investigate whether the CALLY can predict the prognosis in patients with colorectal liver metastases (CRLM) after hepatic resection., Methods: We included 183 patients with CRLM who underwent hepatectomy. The CALLY index was defined as (albumin × lymphocytes)/(CRP × 10 4 ). We investigated the association of the CALLY index with overall survival by univariate and multivariate analyses., Results: In total, 101 (55%) patients had a low CALLY index (<4). In the univariate analysis, overall survival was significantly worse in patients with lymph node metastases (p = 0.02), extrahepatic lesions (p < 0.01), and a low CALLY index (p < 0.01). In the multivariate analysis, independent and significant predictors of overall survival were lymph node metastases (p = 0.04), extrahepatic lesions (p = 0.03), and a low CALLY index (p = 0.03). Patients with a low CALLY index had significantly more postoperative complications than those with a high CALLY index (29% vs. 11%, p < 0.01)., Conclusion: The CALLY index may be an independent and significant indicator of outcomes in patients who underwent liver resection for CRLM., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background & Aims: TRIM27 is stabilized by binding to USP7 and mediates tumour progression in several cancers; however, the roles of TRIM27-USP7 complex on STAT3 activation in HCC are unknown., Methods: Regulations and functions of TRIM27 for activating STAT3 in HCC were assessed using 207 HCC samples or HCC cells., Results: TRIM27 expression was increased in some cases of HCC. High TRIM27 expression was an independent predictor for poor prognosis in HCC after surgery. It was correlated with the expression of EpCAM, vimentin, MMP-9, and activation of STAT3 in HCC. TRIM27 expression was correlated with USP7 expression, and HCC with high TRIM27 expression together with high USP7 expression showed enhanced STAT3 activation, resulting in poorer prognosis. p-JAK1 expression was correlated with STAT3 activation in HCC with high TRIM27 expression. In vitro, USP7 knockdown decreased TRIM27 expression, suggesting that USP7 was essential for TRIM27 stabilization. Knocking down of TRIM27 or USP7 suppressed STAT3 activation and overexpression of TRIM27 accelerated STAT3 activation; therefore, the formation of TRIM27-USP7 complex was needed for STAT3 activation, which led to aggressive tumour proliferation and invasion by enhancing EMT and CSC-like property. Binding of JAK1 to TRIM27-USP7 complex was confirmed in vitro. Deletion of TRIM27-USP7 complex by USP7 inhibitor significantly inhibited tumour cell invasion by suppressing STAT3 activation., Conclusions: TRIM27 is stabilized by binding to USP7 and is related to aggressive tumour progression in HCC via STAT3 activation, resulting in poor prognosis after operation. Therefore, TRIM27-USP7 complex is a useful prognostic predictor and a promising therapeutic target for HCC., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Preoperative systematic inflammatory response, represented by neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), and C-reactive protein-albumin ratio (CAR), has been associated with long-term outcomes in patients with hepatocellular carcinoma (HCC). However, the impact of sustained systematic inflammatory response after resection remains unclear., Methods: This study comprised 210 patients who had undergone primary hepatic resection for HCC between 2008 and 2018. Preoperative and postoperative NLR, LMR, and CAR were evaluated, and patients were then classified into three groups according to the status of each marker: persistently high inflammatory state (elevated group), preoperatively low inflammatory state (normal group), and preoperatively high but postoperatively low inflammatory state (normalized group). Multivariate Cox proportional hazard models were conducted to assess disease-free and overall survival, adjusting for potential confounders., Results: In multivariate analysis, sex (p = 0.002), hepatitis B surface antigen (HBsAg) positivity (p = 0.002), serum α-fetoprotein (AFP) level ≥ 20 ng/mL (p < 0.001), multiple tumors (p < 0.001), microvascular invasion (p = 0.003), type of resection (p = 0.007), and elevated CAR (hazard ratio [HR] 2.40, 95% confidence interval [CI] 1.55-3.73; p < 0.001) were independent and significant predictors of cancer recurrence, while sex (p = 0.05), HBsAg positivity (p = 0.03), serum AFP level ≥20 ng/mL (p = 0.009), multiple tumors (p = 0.03), microvascular invasion (p = 0.006), and elevated CAR (HR 2.10, 95% CI 1.13-3.91; p = 0.02) were independent predictors of overall survival., Conclusions: Sustained elevated CAR may be an independent and significant indicator of poor long-term outcomes in patients with HCC after hepatic resection, suggesting the interplay of the host's inflammatory state and tumor recurrence and progression in HCC., (© 2022. Society of Surgical Oncology.)

Background: Cancer cachexia has been associated with unfavorable outcomes in several malignancies. The cachexia index (CXI), which consists of skeletal muscle, inflammation, and nutritional status, has been proposed as a novel biomarker of cachexia. Therefore, we here investigated prognostic value of the CXI in patients with hepatocellular carcinoma (HCC) after hepatic resection., Methods: The study comprised 213 patients who had undergone primary hepatic resection for HCC between 2008 and 2018. First, the skeletal muscle index (SMI) was calculated as the area of the psoas muscle at the third lumbar vertebra/(the height) 2 . The CXI was then calculated by the following formula: SMI x serum albumin level/neutrophil-to-lymphocyte ratio (NLR). We retrospectively investigated the relationship between the CXI and disease-free survival as well as overall survival., Results: In multivariate analyses, female (p < 0.01), hepatitis B surface antigen-positivity (p < 0.01), preoperative serum alpha-fetoprotein level ≥20 ng/mL (p = 0.01), preoperative serum protein induced by vitamin K absence or antagonist-II level ≥200 mAU/mL (p = 0.02), multiple tumors (p < 0.01), macrovascular invasion (p = 0.04), type of resection (p < 0.01), and low CXI (p = 0.03) were significant predictors of disease-free survival, while Child-Pugh grade B (p < 0.01), poor tumor differentiation (p = 0.05), multiple tumors (p = 0.01), macrovascular invasion (p = 0.04), NLR (p = 0.04), and low CXI (p < 0.01) were significant predictors of overall survival. In the subgroup analysis of advanced T stage, the CXI was associated with both disease-free (p < 0.01) and overall survival (p = 0.06)., Conclusions: The CXI can be a prognostic indicator in patients with HCC after hepatic resection, suggesting the importance of comprehensive biomarker which includes skeletal muscle, inflammation, and nutritional status., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Hepatocellular carcinoma is associated with a relatively high rate of paraneoplastic syndrome, but the frequency of erythrocytosis is low. We report a case of hepatocellular carcinoma with preoperative erythrocytosis and hypererythropoietinemia. The case is a 50-year-old man who has been cured by interferon treatment for hepatitis C 20 years ago(SVR). He visited our hospital with the complaint of right hypochondrial pain, and was diagnosed with hepatocellular carcinoma, which occupied S8/5/7 of the liver, and showed erythrocytosis and high erythropoietin(Epo)as tumor-related symptoms. A right hepatic lobectomy was performed, and the patient was discharged 13 days after the operation. The red blood cell count and Epo were normalized immediately after the operation. One year and 2 months after the operation, multiple lung metastases recurred, and chemotherapy is currently underway. Hepatocellular carcinoma with erythrocytosis and hypererythropoietinemia has been reported to have a poor prognosis, and multimodal treatment and strict surveillance are considered necessary.

BACKGROUND Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignancy, and complete resection may provide better patient survival. Hepatectomy for intrahepatic tumor recurrence has not been previously reported. CASE REPORT A 58-year-old woman underwent resection of an IVC-LMS with en bloc nephrectomy, adrenalectomy, and retroperitoneal soft tissue resection without IVC reconstruction 3 years 8 months ago. Twenty-nine months after the primary operation, a solitary intrahepatic liver tumor was found adjacent to the right and middle hepatic veins during imaging follow-up. The patient was diagnosed with LMS recurrence. As her liver functional parameters permitted major hepatectomy, right hepatectomy combined with resection of the vena cava wall leaving a tumor-free margin and securing the confluence of the middle hepatic vein were successfully accomplished via an anterior approach, without adverse events. Intrahepatic metastasis of LMS invading the vena cava wall has been diagnosed historically. Her postoperative course was uneventful, and at 1-year follow-up after the second surgery, she was observed to have no tumor relapse without any adjuvant treatment. Previous reports have shown that IVC-LMS is often observed, and operative risk or prognosis is based on the extension of the LMS toward the hepatic veins or cardiac atrium. CONCLUSIONS Radical hepatectomy for recurrent IVC-LMS has not been previously reported, and our case experience revealed that a challenging surgical intervention resulting in complete tumor removal can provide good survival outcomes.

Purpose: The effect of hepatic steatosis on the development of colorectal liver metastases (CRLM) remains unknown. This study evaluated the usefulness of fat signal fraction assessed with magnetic resonance imaging (MRI) and the effect of hepatic steatosis on hepatic recurrences following initial hepatectomy for CRLM., Methods: Between January 2013 and December 2019, 64 patients underwent initial hepatectomy for CRLM. The medical records of these patients were reviewed to evaluate the recurrence and survival outcomes., Results: The fat signal fraction was positively correlated with the nonalcoholic fatty liver disease activity score and liver-spleen ratio. Recurrence following the initial hepatectomy was observed in 48/64 patients, and hepatic recurrence was observed in 30/64 patients. The fat signal fraction was significantly higher in patients with hepatic recurrence after initial hepatectomy. The hepatic recurrence rate was 69.2% in patients with fat signal fraction ≥ 0.0258, which was significantly higher than that in patients with fat signal fraction < 0.0258. Hepatic recurrence-free survival rate was significantly higher in patients with fat signal fraction < 0.0258 than in those with fat signal fraction ≥ 0.0258. Multivariate analyses revealed that fat signal fraction ≥ 0.0258 was an independent risk factor for hepatic recurrence., Conclusion: The fat signal fraction assessed with MRI was significantly associated with hepatic recurrence following initial hepatectomy for CRLM., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Only a few studies have examined the impact of carcinoembryonic antigen variation in patients before and after curative resection of colorectal liver metastasis . This study examined the correlation between carcinoembryonic antigen levels and patient prognosis., Methods: Patients who underwent curative resection for colorectal liver metastasis between 2000 and 2017 were enrolled. This study examined patients with high preoperative carcinoembryonic antigen levels that normalized after resection of colorectal liver metastasis and the correlation between prognosis and time-dependent changes in carcinoembryonic antigen levels. The similarity in the risk of recurrence in patients with normal preoperative carcinoembryonic antigen levels was evaluated., Results: A total of 143 consecutive patients were included in the study cohort and classified into the normal preoperative (46 patients), normalized postoperative (57 patients), and elevated preoperative and postoperative (40 patients) carcinoembryonic antigen groups. All clinicopathologic characteristics were comparable between patients grouped according to carcinoembryonic antigen levels. The 5-year disease-free survival and overall survival rates for all patients were 30.4% and 56.0%, respectively. Multivariate analysis confirmed that elevated preoperative and postoperative carcinoembryonic antigen levels (hazard ratio = 1.73, 95% confidence interval: 1.04-2.87) were independently associated with poor disease-free survival; normalization of postoperative carcinoembryonic antigen (hazard ratio = 0.94, 95% confidence interval: 0.57-1.53) was statistically indistinguishable from normal preoperative carcinoembryonic antigen levels. The risk of recurrence was similar to that of patients with normal preoperative carcinoembryonic antigen levels CONCLUSION: Patients with elevated preoperative carcinoembryonic antigen levels that normalized after resection of colorectal liver metastasis were not at risk of poor disease-free survival. Elevated carcinoembryonic antigen levels after surgery are independent prognostic factors for disease-free survival., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background/aim: Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure., Patients and Methods: Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy., Results: In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis., Conclusion: Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: It is difficult to laparoscopically approach tumors of the anatomically anomalous right lobe of the liver, such as cranially protruded liver. The intercostal port has been useful for laparoscopic hepatectomy, especially for tumors located in the dome of the liver. PLoS One. 15:e0234919; Surg Endosc. 31:1280-1286; J Gastrointest Surg. 21:2135-2143; J Hepatobiliary Pancreat Sci. 21:E65-68; Surg Oncol. 38:101576; Thus, we introduce our technique using triple intercostal transthoracic ports for laparoscopic hepatectomy for hepatocellular carcinoma located in segment 8. The right lobe of the liver was cranially protruded and located at the same level of the heart., Patient and Methods: The patient was placed in left lateral decubitus position. After the pneumoperitoneum and adhesiolysis, the hepatoduodenal ligament was controlled. Three additional intercostal ports with balloons were introduced transdiaphragmatically for liver parenchymal resection after confirmation of the lung edge by mandatory ventilation. A 12-mm and a 5-mm port were inserted into the sixth and seventh intercostal space for the operator's hands, while a 5-mm port was inserted into the fourth intercostal space for the assist's right hand. The liver parenchymal resection was performed using a cavitron ultrasonic surgical aspirator (CUSA) through the 12-mm intercostal port, followed by its completion without exposing the tumor. The 12-mm port hole on the diaphragm was sutured and a 12-Fr chest tube was introduced in the right thoracic cavity., Results: The operation time was 131 min, and the blood loss was 20 g. The patient was discharged on postoperative day 7 without any complication., Conclusion: Triple intercostal ports could be a feasible procedure for a tumor with limited laparoscopic access from the abdominal port due to the anatomically anomalous liver., (© 2022. Society of Surgical Oncology.)

Resection of huge hepatocellular carcinomas occupying the central portion of the liver is challenging. Exposure of an adequate liver transection plane using an anterior approach is likely to be difficult because of compression by the tumor. We herein propose a "triple liver hanging maneuver" technique for central bisectionectomy with caudate lobectomy for huge hepatocellular carcinomas stretching the hilar plate and the right and left hepatic veins. In this technique, the first tape is introduced for the transection plane along the right side of the umbilical portion to the anterior surface of the inferior vena cava. The second tape is introduced to lift the paracaval caudate Glissonean pedicles from the hilar plate. The third tape is introduced for the transection plane along the right hepatic vein to the anterior surface of the inferior vena cava. The triple liver hanging maneuver could be effective for huge tumors compressing major hepatic vessels., (© 2021. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Aim: Liver fibrosis influences liver regeneration and surgical outcomes. The fibrosis-4 (FIB-4) index is strongly associated with liver fibrosis and cirrhosis. This study aimed to examine the prognostic significance of the combination of FIB-4 index and Protein Induced by Vitamin K Absence or Antagonist-II (PIVKA-II) (PIVKA-II-FIB-4 index score) in patients who underwent curative resection for hepatocellular carcinoma (HCC)., Methods: We included 284 patients who underwent elective hepatic resection for HCC between January 2000 and December 2018. We retrospectively investigated how FIB-4 index is related to disease-free survival and overall survival., Results: According to a receiver operating characteristic (ROC) analysis, the optimal cutoff value of the FIB-4 index was 3.44. In a multivariate analysis, high PIVKA-II and FIB-4 index values were independent predictors of both disease-free survival (P = 0.013 and P = 0.005, respectively) and overall survival (P = 0.048 and P < 0.001, respectively). We classified the PIVKA-II and FIB-4 index levels into two groups (high vs. low) and calculated a new score (PIVKA-II-FIB-4 index score; 0-2) by the sum of each measurement (high, 1; low, 0). The 5 year overall survival rates of patients with PIVKA-II-FIB-4 index scores of 0, 1, and 2 were 84.9, 74.4, and 47.1%, respectively (P < 0.001)., Conclusion: The combination of the preoperative PIVKA-II and FIB-4 index may be a prognostic factor of HCC after hepatic resection, suggesting that the combined score is useful in assessing the liver fibrosis status in cancer cases., (© 2022. The Author(s) under exclusive licence to Japan Society of Clinical Oncology.)

Background: Laparoscopic total caudate lobectomy remains a challenging procedure because of its deep location (Xu et al., Surg Endosc. 35:1138-47, 2021). Placement of intercostal ports can overcome the barriers of the ribcage for laparoscopic access (Hayashi et al., PLoS One.15:e0234919, 2020). We herein present a novel technique in which a left intercostal port was used as the main working port during laparoscopic caudate lobectomy., Methods: An 84-year-old man with a 1-cm intrahepatic cholangiocarcinoma located in segment 1 (S1) was referred to our hospital. We planned laparoscopic isolated caudate lobectomy using a left intercostal port as the main working port. The patient was placed in the supine position. A 12-mm left intercostal port with a balloon was introduced in the seventh intercostal space as the main working port. After Arantius' ligament was divided, the left Glissonean pedicle of S1 (G1) was divided using an endo-stapling device. The surgeon moved to the right side of the patient and divided the right G1, followed by transection to the inferior right hepatic vein. Again, the surgeon moved to the left side, and the left intercostal port was used for mobilization of the Spiegel lobe and parenchymal resection using a cavitron ultrasonic surgical aspirator, exposing the root of the left and middle main hepatic veins for completion of total caudate lobectomy., Results: The operative time was 264 min and blood loss was 400 mL. The patient was discharged on a postoperative day 9 without complications., Conclusions: A laparoscopic approach to the caudate lobe using a left intercostal port is a new and ideal technique providing effective manipulation., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: Nutritional status assessment is essential in cancer patients because a poor nutritional status has been associated with poor outcomes; however, the impact of rapid turnover proteins (RTPs), such as prealbumin, transferrin, and retinol-binding protein, on the outcomes of hepatocellular carcinoma (HCC) has not been well-investigated. We therefore examined the prognostic significance of RTPs in patients with HCC after curative resection., Methods: This study included 150 patients who underwent elective hepatic resection for HCC between January 2011 and December 2018. The prealbumin, transferrin, and retinol-binding protein levels were classified into two groups (high vs. low); the RTP score (0-3) was calculated as the sum of each RTP measurement (high = 0; low = 1). We retrospectively investigated the relationship between the RTP score and disease-free and overall survival., Results: Multivariate analysis showed that a high RTP score (P = 0.022), presence of sarcopenia (P = 0.001), and stage III or higher (P = 0.005) were independent predictors of disease-free survival, while a high RTP score (P < 0.001), presence of sarcopenia (P = 0.017), and stage III or higher (P = 0.012) were independent predictors of overall survival. In patients with high RTP scores, positive hepatitis B and C viral infection, high indocyanine green (ICG) at 15 min (ICG R15 ), Child-Pugh grade B, poorly differentiated carcinoma, and postoperative ascites were more common than in patients with low RTP scores., Conclusion: The preoperative RTP score may be a prognostic factor in patients with hepatocellular carcinoma after hepatic resection, suggesting an important role of RTP in the assessment of nutritional status in cancer patients., (© 2021. Society of Surgical Oncology.)

Background: Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-side massive hepatectomy, (Kobayashi et al. in Surgery 167:917-923, 2020, Heil J, Schadde E. in Langenbecks Arch Surg 2020, Narita et al. in Ann Surg 256:e7-8, 2012) and has demonstrated comparable results to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) (Chan et al. in Transl Gastroenterol Hepatol 5:37, 2020) in terms of liver hypertrophy. In this video, we describe our DHVE techniques to perform a safe right trisectionectomy., Methods: A 40-year-old man with unresectable intrahepatic cholangiocarcinoma with multiple intrahepatic metastases and vena cava invasion received 20 cycles of gemcitabine plus cisplatin, resulting in remarkable shrinkage of the tumor. Conversion surgery was planned to achieve no evidence of disease status. The future liver remnant (FLR) after right trisectionectomy was 363 ml (29.6% of the whole liver) and simultaneous DHVE was performed. The right portal vein embolization was performed via a transhepatic approach, while the right and middle hepatic veins were accessed via a transjugular approach and self-expandable mesh devices were deployed. Remarkable atrophy of the right lobe and hypertrophy of the left lobe was observed 2 weeks after the procedure. Volumetry showed the FLR increased to 485 ml (40.2% of the whole liver). Three weeks after DHVE, right trisectionectomy with combined resection of the vena cava was performed., Results: The operation time was 311 min, and the blood loss was 420 ml. Pathological examination revealed complete resection of liver tumors, and the volumetry on postoperative day 7 revealed an increased remnant liver volume of 874 ml. He was discharged on postoperative day 10 without any complications., Conclusion: Simultaneous DHVE could be an effective procedure to increase FLR with safety for massive hepatectomy., (© 2021. Society of Surgical Oncology.)

Purpose: The prognostic significance of the surgical margin status remains controversial for patients who undergo hepatectomy for colorectal liver metastases. This study evaluated the influence of R1 resection on recurrence patterns and prognosis in these patients., Methods: Between January 2001 and December 2016, 232 consecutive Japanese patients underwent initial hepatic resection for colorectal liver metastases. Their medical records were reviewed to evaluate recurrence and survival outcomes., Results: Relative to patients with R0 resection, patients with R1 resection had significantly poorer recurrence-free survival (RFS) and overall survival (OS). However, after propensity score matching, there were no significant differences in RFS and OS associated with the margin status. Nevertheless, R1 resection was associated with a significantly higher incidence of intrahepatic recurrence and early recurrence, while R0 resection was associated with a significantly higher re-resection rate for hepatic recurrence. Only eight of 55 patients with R1 resection developed recurrence at the R1 resection margin, whereas 36 patients developed recurrence at other sites/organs., Conclusion: Among patients with similar characteristics, R1 resection does not affect long-term outcomes. This suggests that R1 resection itself is not a cause of a poor prognosis, but rather a potent indicator of aggressive tumor biology., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Under laparoscopy-specific caudal and lateral view, Aranitius' ligament could be the landmark for the root of the venous trunks in the left hepatic lobe.1-3 We performed laparoscopic hepatic extended medial segmentectomy including the middle hepatic vein (MHV) using the Arantius' approach., Methods: An 86-year-old man was referred to our hospital for hepatocellular carcinoma, 4.5 cm in size, located in the medial hepatic segment (Video 1). After pneumoperitoneum and placement of four working ports, the Arantius' ligament was exposed, isolated, and divided. The liver parenchyma underneath the Arantius' ligament was opened to widely expose the root of the MHV, umbilical fissure vein (UFV), and left hepatic vein (LHV). After dividing the Glissonean branches for segment 4 (G4), the parenchymal tissue between MHV and LHV was divided. The trunk of the MHV was fully exposed and was divided using the endo-stapling device. Parenchymal resection was further proceeded along the dorsal side of the MHV, and the planned hepatectomy was completed., Results: The operation time was 337 min, and the estimated blood loss was 400 g. His postoperative course was uneventful, and he was discharged on postoperative day 10., Conclusions: The significance of Arantius' ligament approach is short-cut exposure of the MHV as the anatomical landmark during the initial process of the surgery under laparoscopy-specific caudal and lateral view, and is a reasonable technique in extended medial segmentectomy including the MHV., (© 2021. Society of Surgical Oncology.)

Background: The superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score-matched (PSM) analysis., Methods: A total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis., Results: Applying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33-0.90) for disease-free survival and 0.61 (95% CI, 0.24-1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014)., Conclusions: AR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter., (© 2021. The Society for Surgery of the Alimentary Tract.)

A hepatic cone-unit represents an anatomical unit dominated by a smaller Glissonean pedicle. Anatomical resection of a tumor located in an intersegmental plane is challenging, but could be achieved effectively by performing multiple cone-unit resection. We performed double cone-unit laparoscopic resection of hepatocellular carcinoma located on the intersegmental plane between segments 6a, b. The liver parenchyma covering the posterior Glissonean pedicle was divided along Rouviere's sulcus, the Glissonean branches of segments 6a, b were isolated and ligated, and indocyanine green (ICG) negative counterstaining was performed. The hepatic parenchyma was dissected along the demarcation line to identify the right hepatic vein and the double cone-unit resection was then completed with a negative surgical margin. Thus, double cone-unit laparoscopic hepatectomy with ICG negative counterstaining may be a feasible option for tumors located in an intersegmental plane., (© 2021. Springer Nature Singapore Pte Ltd.)

Background/aim: The aim of this study was to investigate the risk factors of surgical site infection (SSI) in patients who underwent liver resection for colorectal liver metastases (CRLM)., Patients and Methods: A total of 151 patients who underwent liver resection for CRLM were included in this study. We investigated the relationship between the patient characteristics and perioperative factors and the incidence of SSI., Results: Nineteen (13%) of these patients developed SSI. Multivariate analysis revealed that modified Glasgow Prognostic Score (mGPS) (1 or 2, odds ratio 3.86, p=0.03) and presence of an enterostomy (yes, odds ratio 3.93, p=0.04) were significant and independent risk factors for SSI., Conclusion: A higher mGPS and an enterostomy were risk factors for SSI in patients who underwent a liver resection for CRLM., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

It has been known that repeat laparoscopic hepatectomy (RLH) after open hepatectomy is technically challenging because of adhesions around the hilum. It is quite often that conventional tourniquet technique for the Pringle maneuver is difficult in RLH, and we introduced Laparoscopic Satinsky Vascular Clamp (LSVC) for inflow control in RLH. The Spiegel lobe is the anatomical landmark in LSVC technique. If a space behind the hepatoduodenal ligament and the Spiegel lobe was obtained, LSVC was applied laterally from the left side of the hepatoduodenal ligament, whereas LSVC was vertically applied for those with obstruction of a space behind the hepatoduodenal ligament. We performed 14 cases of RLH for those with histories of open hepatectomies by lateral (n = 6) and vertical (n = 8) LSVC technique with successful inflow control, confirmed by intraoperative Doppler ultrasound. Five patients underwent 2 or more previous histories of hepatectomies. The RLH included segmentectomy (n = 1), subsegmentectomy (n = 2) and partial hepatectomy (n = 11). The median time for the Pringle maneuver, operative time, and blood loss was 47 min, 237.5 min, and 160 mL. All the patients completed pure laparoscopic hepatectomy. In conclusion, LSVC technique is a safe and reliable technique for the Pringle maneuver in RLH., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/aim: Detection of hepatocellular carcinoma using intraoperative ultrasonography (IOUS) is indispensable for successful laparoscopic hepatectomy (LH). This study was performed to evaluate patients with intraoperatively unidentified tumours undergoing LH., Patients and Methods: Seven patients who underwent LH for hepatocellular carcinoma and whose tumours were not detected using IOUS were included in this study. Clinical features, preoperative imaging, intraoperative imaging, surgical procedures, and pathological findings were evaluated., Results: Using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging, all the tumours were enhanced in the arterial phase and rapidly washed out, becoming hypointense to the remainder of the liver. All tumours except one were <2 cm in size. Severe liver fibrosis was observed in all cases. Tumours that were invisible on preoperative ultrasonography also could not be detected using IOUS or indocyanine green fluorescence imaging. Five patients underwent hepatectomy based on anatomical landmarks and achieved curative resection, whereas curative resection failed in two patients., Conclusion: When tumours cannot be identified by IOUS, LH based on anatomical landmarks should be preferred. Importantly, invisible tumours on preoperative ultrasonography may not be identified intraoperatively during LH., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Phosphorylated mammalian target of rapamycin (p-mTOR) plays a crucial role in the process of cancer progression. Common gene mutations of colorectal cancer lead to the activation of the PI3k/Akt/mTOR pathway. In this study, we determined whether p-mTOR expression in colorectal liver metastases is a predictive marker of prognosis following liver resection., Methods: Eighty-one patients with colorectal liver metastases who had undergone curative resection were evaluated using immunohistochemistry of p-mTOR. Data regarding clinicopathological features and patient survival were analyzed., Results: The p-mTOR expression in colorectal liver metastases was detected in 55 (67.9%) patients. Patients whose metastases had high p-mTOR expression showed a significantly lower overall survival rate after resection as compared to patients with low p-mTOR expression (p = 0.016), while there was no significant difference in the disease-free survival between the two groups. Repeat resection for recurrence was performed more frequently in patients with p-mTOR positive than others (p = 0.024). Multivariate analysis showed that p-mTOR expression was an independent prognostic factor of overall survival after liver resection (p = 0.019)., Conclusions: mTOR was frequently activated in colorectal liver metastases, and the p-mTOR expression was a biological marker for predicting the overall survival of patients with colorectal liver metastases following liver resection., (© 2021 Wiley Periodicals LLC.)

Background: Laparoscopic repeat hepatectomy is a technically challenging procedure owing to adhesions around the liver, causing difficulties in performing hepatic inflow control by conventional tourniquet method [1], and failure in hepatic mobilization [2]., Method: Thus, we introduce our technique using double intercostal ports to manipulate the fixed liver under the rib cage and using the laparoscopic Satinsky vascular clamp to perform hepatic inflow control to overcome the aforementioned concerns in ipsilateral laparoscopic repeat hepatectomy after previous open hepatectomy., Video: The patient, with histories of abdominal aortic aneurysm repair and open Segment 7 subsegmentectomy, had recurrent hepatocellular carcinoma in the dorsal region of Segment 8. After establishing pneumoperitoneum with five abdominal ports, adhesiolysis around the liver was then performed, followed by identification of the caudal part of Spiegel's lobe as the landmark for the space between the left-side of the hepatoduodenal ligament and the vena cava. Although the space between the right side of the hepatoduodenal ligament and the vena cava was obstructed, the laparoscopic blunt-tip Satinsky vascular clamp successfully was applied on the stiff hepatoduodenal ligament due to previous hepatectomy and made inflow control. Because the liver could not be mobilized at all, double intercostal ports with balloons were introduced [3] for parenchymal resection for exposing the parenchymal resection plane and also to apply the vessel sealing device. A 12-Fr chest tube (Aspiration Kit. Argyle™, Tokyo, Japan) was introduced in the right thoracic cavity as our routine., Results: The operative time was 243 minutes and the blood loss was 50g. The postoperative course was uneventful and the patient was discharged on the day 8., Conclusions: The combination of intercostal ports and laparoscopic Satinsky vascular clamp could be significant aids for performing safe ipsilateral laparoscopic repeat hepatectomy, even after previous open hepatectomy., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: The aim of this study is to investigate the relationship between preoperative serum transferrin level and long-term outcomes in patients with colorectal liver metastases after hepatic resection., Methods: We retrospectively investigated 72 patients who underwent hepatic resection for colorectal liver metastases and explored the relationship between serum transferrin level and long-term outcomes., Results: In multivariate analysis, H3 (odds ratio 3.43, 95% confidence interval 1.11-10.89 and P = 0.03) was an independent and significant predictor of the disease-free survival, and a transferrin level ≥ 190 mg/dl (odds ratio 0.20, 95% confidence interval 0.05-0.79 and P = 0.02) and the time to recurrence after hepatectomy <1 year (odds ratio 11.30, 95% confidence interval 2.63-48.59 and P < 0.01) were independent and significant predictors of the overall survival., Conclusions: The serum transferrin level is a useful predictor of poor overall survival in patients with colorectal liver metastases after hepatic reaction., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection., Methods: Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, "scooping-out" versus "cutting." The participants were then further divided into "small" and "large" subgroups according to the tumor's depth and diameter. Finally, they were categorized into two groups, namely "standard" and "advanced." Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system., Results: Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P < 0.001), operation time (P < 0.001), volume of intraoperative blood loss (P = 0.001), rate of the Pringle maneuver (P = 0.044), and resected liver weight (P < 0.001) were significantly greater in the advanced than in the standard group. Differences in operation time and intraoperative blood loss were not identified by the existing difficulty scoring system., Conclusion: The proposed revised classification is useful for predicting the difficulty of laparoscopic partial liver resection., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Major hepatectomy with bile duct resection (BDR) is associated with severe postoperative complications; therefore, evaluation of preoperative liver function is important. However, little is known about mechanisms of increased severe complications in patients with poor liver function. The aim of this study was to evaluate whether indocyanine green retention rate after 15 minutes of injection (ICG-R15) is useful for predicting the risk of severe postoperative complications in this operation, and to reveal the mechanisms of increasing severe complications by focusing on immune function and liver regeneration after hepatectomy., Methods: Patients receiving major hepatectomy with BDR between 2000 and 2017 were retrospectively reviewed. Severe postoperative complications were defined as Clavien-Dindo grade ≥IV., Results: In 284 patients undergoing major hepatectomy with BDR, ICG-R15 was correlated with severe postoperative complications, with cut-off value of 11.8%. In brief, the incidences of hyperbilirubinemia, coagulopathy, liver failure, respiratory failure, severe complications, and mortality were higher in the high ICG-R15 group. Moreover, high ICG-R15 (≥11.8%) was an independent factor for predicting severe complications after major hepatectomy with BDR. Immune dysfunction in the early phase after operation, prolonged postoperative immunosuppression, and delayed liver regeneration were reasons for increasing severe postoperative complications in patients with high ICG-R15., Conclusions: High ICG-R15 is an independent risk factor for severe complications after major hepatectomy with BDR, and its cut-off value is 11.8%. Compromised condition and delayed liver regeneration induced by immune dysfunction are reasons of increased severe postoperative complications in patients with high ICG-R15.