Jin-Yao Teo

Importance of tumor size as a prognostic factor after partial liver resection for solitary hepatocellular carcinoma: Implications on the current AJCC staging system

Background Presently, the impact of tumors size as a prognostic factor after curative liver resection (LR) for solitary hepatocellular carcinoma (HCC) remains controversial. This study was performed to determine the prognostic factors of patients undergoing LR for solitary HCC with special emphasis on the importance of tumor size. Methods Between 2000 and 2013, 560 patients underwent curative LR for solitary primary HCC which met the study criteria. Results One-hundred and seventy-eight patients underwent major hepatectomies and the overall in-hospital mortality was 2.0%. There were 282 patients (50.4%) with liver cirrhosis. The 5-year overall survival (OS) was 64% and recurrence free survival (RFS) was 50%, respectively. Multivariate analyses demonstrated that cirrhosis, microvascular invasion and size were independent predictors of RFS and cirrhosis, microvascular invasion and age were independent prognostic factors of OS. Subset analysis demonstrated that tumor size was a prognostic factor for solitary HCC with microvascular invasion (AJCC T2) but not solitary HCC without microvascular invasion (AJCC T1). Conclusions Size, microvascular invasion, and cirrhosis are independent prognostic factors of RFS for solitary HCC after LR. Tumor size is an important prognostic factor in T2 but not T1 solitary tumors. These findings suggest that the current AJCC TNM staging system may need to be revised. J. Surg. Oncol.

Laparoscopic repeat liver resection for recurrent hepatocellular carcinoma

Repeat liver resection is effective for recurrent hepatocellular carcinoma (rHCC). This study aimed to determine the outcomes of laparoscopic repeat liver resection (LRLR) for rHCC.

Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases

BackgroundMost studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution.MethodsRetrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20–30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon’s experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies.ResultsAs individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR.ConclusionLLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.

Contra-lateral liver lobe hypertrophy after unilobar Y90 radioembolization: an alternative to portal vein embolization?

Liver resection (LR) with negative margins confers survival advantage in many patients with hepatic malignancies. However, an adequate future liver remnant (FLR) is imperative for safe LR. Presently, in patients with an inadequate FLR; the 2 most established clinical techniques performed to induce liver hypertrophy are portal vein embolization (PVE) and portal vein ligation. More recently, it has been observed that patients who undergo treatment via Y90 radioembolization experience hypertrophy of the contra-lateral untreated liver lobe. Based on these observations, several investigators have proposed the potential use of this modality as an alternative technique for increasing the FLR prior to liver resection. Y90 radioembolization induces hypertrophy at a slower rate than PVE but has the added advantage of concomitant local disease control and tumour down-staging.

Systematic review of the clinical utility and validity of the Sendai and Fukuoka Consensus Guidelines for the management of intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND This systematic review was performed to assess the clinical utility of the Sendai Consensus Guidelines (SCG) and Fukuoka Consensus Guidelines (FCG) for intraductal papillary mucinous neoplasm (IPMN). METHODS A computerized search of PubMed was performed to identify all the studies which evaluated the SCG and FCG in surgically resected, histologically confirmed IPMNs. RESULTS Ten studies evaluating the FCG, 8 evaluating the SCG and 4 evaluating both guidelines were included. In 14 studies evaluating the FCG, out of a total of 2498 neoplasms, 849 were malignant and 1649 were benign neoplasms. Pooled analysis showed that 751 of 1801 (42%) FCG+ve neoplasms were malignant and 599 neoplasms of 697 (86%) FCG-ve neoplasms were benign. PPV of the high risk and worrisome risk groups were 465/986 (47%) and 239/520 (46%) respectively. In 12 studies evaluating the SCG, 1234 neoplasms were analyzed of which 388 (31%) were malignant and 846 (69%) were benign. Pooled analysis demonstrated that 265 of 802 (33%) SCG+ve neoplasms were malignant and 238 of 266 SCG-ve (90%) neoplasms were benign. CONCLUSION The FCG had a higher positive predictive value (PPV) compared to the SCG. However, the negative predictive value (NPV) of the FCG was slightly lower than that of the SCG. Malignant and even invasive IPMN may be missed according to both guidelines.

Perioperative Outcomes of Laparoscopic Repeat Liver Resection for Recurrent HCC: Comparison with Open Repeat Liver Resection for Recurrent HCC and Laparoscopic Resection for Primary HCC

BackgroundThis study aims to determine the safety and efficacy of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma (rHCC).MethodsTwenty patients underwent LRLR for rHCC between 2015 and 2017. The control groups consisted of 79 open RLR (ORLR) for rHCC and 185 LLR for primary HCC. We undertook propensity score-adjusted analyses (PSA) and 1:1 propensity score matching (PSM) for the comparison of LRLR versus ORLR. Comparison of LRLR versus LLR was done using multivariable regression models with adjustment for clinically relevant covariates.ResultsTwenty patients underwent LRLR with three open conversions (15%). Both PSA and 1:1-PSM demonstrated that LRLR was significantly associated with a shorter stay, superior disease-free survival (DFS) but longer operation time compared to ORLR. Comparison between LRLR versus LLR demonstrated that patients undergoing LRLR were significantly older, had smaller tumors, longer operation time and decreased frequency of Pringle’s maneuver applied. There was no difference in other key perioperative outcomes.ConclusionThe results of this study demonstrate that in highly selected patients; LRLR for rHCC is feasible and safe. LRLR was associated with a shorter hospitalization but longer operation time compared to ORLR. Moreover, other than a longer operation time, LRLR was associated with similar perioperative outcomes compared to LLR for primary HCC.

Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: a contemporary single-institution experience with 400 consecutive resections

BackgroundSeveral studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience.MethodsThis is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion.ResultsFour hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality.ConclusionThe case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.

Short-Term Outcomes of Extended Pancreatectomy: A Single-Surgeon Experience

Background/Aims: The International Study Group of Pancreatic Surgery recently published a consensus statement on the definition of extended pancreatectomy (EP). We aimed to determine the safety profile and short-term outcomes of EP compared to standard pancreatectomy (SP). To mitigate surgeon bias, only pancreatectomies performed by a single surgeon were included. Methods: Ninety consecutive patients who underwent pancreatectomy by a single surgeon over a period of 5 years and who met our study criteria were classified into an SP or an EP group. Sixty-two patients underwent pancreaticoduodenectomy (PD), including total pancreatectomy, and 28 patients underwent distal pancreatectomy. Results: The 25 patients who underwent EP had significantly increased operation time, estimated blood loss, postoperative intensive care unit (ICU) transfer, and postoperative stay compared to the 65 patients who underwent SP. There was 1 (1.1%) 30-day mortality and 4 (4.4%) in-hospital mortalities. Postoperative morbidity and mortality were similar between both groups. Subgroup analysis of the patients who underwent PD demonstrated that the EP group (n = 22) had significantly increased operation time and postoperative ICU transfers. Conclusion: Although patients who underwent EP experienced significantly increased operative time, blood loss, and postoperative stay, they did not experience significantly higher postoperative morbidity or mortality compared to patients who underwent SP.