Video-assisted transthoracic liver resection in patients with marginal liver function: a retrospective cohort study

Purpose: Laparoscopic hepatectomy has been widely performed by hepatobiliary surgeons for malignancy of liver and gained wide acceptance for various liver tumors, thanks to advances in surgical techniques and devices. But, there are some challenges for right side tumor in patients of cirrhotic liver. Especially, tumor located in right upper area is difficult for wedge resection in patients with marginal liver function, because trans-abdominal approach requires normal parenchymal dissection. Radiofrequency wave ablation is also difficult for such a lesion. So, we demonstrate unique technique of video-assisted transthoracic liver resection (VTLR) for overcome right upper side tumor abutting diaphragm.Methods: Four patients underwent VTLR. Four ports in right chest wall were created by a chest surgeon and diaphragm was open. Then traction of the diaphragm was done by suture. After exposure of liver surface, tumor localization was done by ultrasound. The mass excision was done by ultrasonic shear.Results: Four patients were discharged without complications within 11.3 days (range, 6–15 days). On average, patients started to consume a normal diet on an average of 2.4 days (range, 1–4 days).Conclusion: VTLR is could be performed by an experienced surgeon and chest surgeon for right upper liver malignancy abutting diaphragm in patient of marginal liver function.

Hypothyroidism and hypopituitarism as immune-related adverse events due to lenvatinib plus pembrolizumab therapy in the immediate postoperative period after laparoscopic hepatectomy for liver metastases from gastric cancer: a case report

Background Immune checkpoint inhibitors (ICIs) are emerging agents used for the treatment of various malignant tumors. As ICIs are generally used for unresectable malignant tumors, there have been only a few reports of patients who underwent surgery after receiving these drugs. Therefore, it remains unclear how immune-related adverse events (irAEs) affect the postoperative course. Here, we report a patient with advanced gastric cancer who underwent laparoscopic hepatectomy for liver metastases after an objective response with lenvatinib plus pembrolizumab and developed hypothyroidism and hypopituitarism as irAEs in the immediate postoperative period. Case presentation A 73-year-old man had undergone total gastrectomy for pT4aN2M0 gastric cancer followed by adjuvant chemotherapy with S-1 and docetaxel, and developed liver metastases in segments 6 and 7. He was enrolled in phase 2 clinical trial of lenvatinib plus pembrolizumab. He continuously achieved a partial response with the study treatment, and the liver metastases were decreased in size on imaging. The tumors were judged to be resectable and the patient underwent laparoscopic partial hepatectomy for segments 6 and 7. From the 1st postoperative day, the patient continuously presented with fever and general fatigue, and his fasting blood glucose level remained slightly lower than that before the surgery. On the 4th postoperative day, laboratory examination revealed hypothyroidism and hypopituitarism, which were suspected to be irAE caused by lenvatinib plus pembrolizumab after surgery. He received hydrocortisone first, followed by levothyroxine after adrenal insufficiency was recovered. Subsequently, his fever, general fatigue, and any abnormality regarding fasting blood glucose level resolved, and he was discharged on the 12th postoperative day. After discharge, his laboratory data for thyroid and pituitary function remained stable while receiving hydrocortisone and levothyroxine without recurrence of gastric cancer. Conclusion We present a case of laparoscopic hepatectomy after receiving lenvatinib plus pembrolizumab and developed hypothyroidism and hypopituitarism after surgery. Regarding surgery after ICI therapy, it is important to recognize that irAEs might occur in the postoperative period.

Factors affecting sufentanil consumption for intravenous controlled analgesia after hepatectomy: retrospective analysis

Background Pain control after hepatectomy is usually achieved by opioids. There are significant individual differences in the amount of opioids used after hepatectomy, and the metabolism of opioids is liver-dependent. The purpose of our study was to explore the possible risk factors for opioid consumption during the first 48 h after surgery. Methods In a retrospective study design involving 562 patients undergoing open or laparoscopic hepatectomy, all patients were treated with intravenous patient-controlled analgesia (IV-PCA) along with continuous and bolus doses of sufentanil for a duration of 48 h after surgery during the time period of August 2015 and February 2019. The primary endpoint was high sufentanil consumption 48 h after hepatectomy, and patients were divided into two groups: those with or without a high PCA sufentanil dosage depending on the third quartile (Q3). The secondary endpoint was the effect of a high PCA sufentanil dosage on various possible clinical risk factors. The relevant parameters were collected, and correlation and multivariate regression analyses were performed. Results The median operation time was 185 min (range, 115–250 min), and the median consumption of sufentanil 48 h after the operation was 91 μg (IQR, 64.00, 133.00). Factors related to the consumption of sufentanil at 48 h after hepatectomy included age, operation time, blood loss, intraoperative infusion (red blood cells and fresh-frozen plasma), pain during movement after surgery (day 1 and day 2), preoperative albumin, and postoperative blood urea nitrogen. Age (≤ 60 and > 60 years), extent of resection (minor hepatic resection and major hepatic resection), surgical approach (laparoscope and open) and operation time (min) were independent risk factors for sufentanil consumption at 48 h postoperatively. Conclusion Age younger than 60 years, major hepatic resection, an open approach and a longer operation are factors more likely to cause patients to require higher doses of sufentanil after hepatectomy, and the early identification of such patients can increase the efficacy of perioperative pain management.

Laparoscopic S7 hepatectomy for hepatic mucinous neoplasm: a case report and literature review

Background Mucinous cystic neoplasm of the Liver is rare tumors with malignant potential that occur in the biliary epithelium. Because of its rare presentation, it is often misdiagnosed before surgery. Case presentation A 63-year-old female patient presented with intermittent upper abdominal pain for three months. Laparoscopic hepatectomy of Segment 7 was conducted based on the preoperative diagnosis of space-occupying lesion in the right lobe of the liver. Postoperative pathology showed a low-grade mucinous cystic neoplasm in the right posterior lobe of the liver. The preoperative CA19-9 level was significantly increased while the postoperative CA19-9 returned to the normal range. Conclusions The diagnosis of mucinous cystic neoplasm of the liver is closely related to the thickening of the cystic wall or the increase of CA19-9, which has great significance and deserves clinical attention.

Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy

Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy.Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison.Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946).Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.