Robotic donor hepatectomy: a niche advancement or the way forward? A perspective from the world’s largest center

The application of minimally invasive liver surgery (MILS) in the field of living donor hepatectomy has been exceedingly slow, and its impact is limited to a handful of centers worldwide. Widespread adoption has been primarily hampered by the technical limitations of laparoscopy, namely rigid instrumentation, suboptimal optics, and a seemingly steep learning curve. These deficiencies are magnified in the donor hepatectomy operation wherein the parenchyma and vasculature must be handled atraumatically to produce a pristine allograft fit for implantation. Donor safety concerns and medicolegal ramifications are also cited as impediments to MILS in donor surgery. In 2013, our institution embraced a purely laparoscopic approach to living donor left lateral sectionectomy, and it quickly became our default technique. However, with donor hemi-hepatectomy, we gravitated to the robotic surgical system as our preferred modality. Herein, we describe our experience with minimally invasive donor hepatectomy, which we now universally offer to all living donors. Our extensive familiarity with robotic donor hepatectomy will provide the reader with an instructive perspective on the attributes and merits of the robotic approach. With appropriate collaboration and proctorship, we believe that the robotic platform will actualize a more rapid and widespread adoption than that experienced with the purely laparoscopic technique.

Molecular mechanisms of liver carcinogenesis related to metabolic syndrome

Global prevalence of non-alcoholic fatty liver disease (NAFLD) and of NAFLD-hepatocellular carcinoma (HCC) is estimated to grow in the next years. The burden of NAFLD and the evidence that NAFLD-HCC arises also in non-cirrhotic patients, explain the urgent need of a better characterization of the molecular mechanisms involved in NAFLD progression. Obesity and diabetes cause a chronic inflammatory state which favors changes in serum cytokines and adipokines, an increase in oxidative stress, DNA damage, and the activation of multiple signaling pathways involved in cell proliferation. Moreover, a role in promoting NAFLD-HCC has been highlighted in the innate and adaptive immune system, dysbiosis, and alterations in bile acids metabolism. Several dietary, genetic, or combined mouse models have been used to study nonalcoholic steatohepatitis (NASH) development and its progression to HCC, but models that fully recapitulate the biological and prognostic features of human NASH are still lacking. In humans, four single nucleotide polymorphisms (PNPLA3, TM6SF2, GCKR, and MBOAT7) have been linked to the development of both NASH and HCC in cirrhotic and non-cirrhotic patients, whereas HSD17B13 polymorphism has a protective effect. In addition, higher rates of somatic ACVR2A mutations and a novel mutational signature have been recently discovered in NASH-HCC patients. The knowledge of the molecular pathogenesis of NAFLD-HCC will be helpful to personalized screening programs and allow for primary and secondary chemopreventive treatments for NAFLD patients who are more likely to progress to HCC.

Histopathology of hepatocellular carcinoma - when and what

When do you need to take biopsies of the liver, and what information will you get is the topic of this review on hepatocellular carcinoma (HCC). If, clinically, the differential diagnosis of HCC after imaging is suggested, a biopsy has become obligatory as a diagnostic confirmation of HCC in the non-cirrhotic liver prior to definitive therapeutic interventions, as well as in a palliative therapy concept. In the case of hepatic lesions with an uncharacteristic contrast uptake, a biopsy should be performed immediately to confirm the diagnosis of HCC. After diagnosing HCC, a treatment strategy is evaluated. Further, the biopsy, or in case of surgical treatment, the resected tissue, shows us the different subtypes of HCC, with the steatohepatitic subtype being the most common and the lymphocyte-rich subtype being the least common. Further, the histological grade of HCC is determined according to the grading system of the WHO or the Edmonson and Steiner System. Through biopsies, HCC can be differentiated from intrahepatic cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma or metastases of other malignant tumors, especially metastases of the gastrointestinal tract. In summary, biopsies are fundamental in the diagnosis of HCC.

Radiological imaging and non-surgical local treatments for cholangiocarcinoma

Cholangiocarcinoma (CC) is a malignancy with a very heterogeneous spectrum of morphopathological and prognostic characteristics. Diagnostic imaging is fundamental for early detection, preoperative staging, and resectability assessment, as well as early recognition of prognostic factors. Radical surgical treatment is limited by disease stage and technical feasibility. Interventional radiology has acquired a critical function in addressing disease control and survival improvement through loco-regional therapies, specifically in the setting of intrahepatic CC. In this review, we will describe the current state of art of diagnostic imaging, focusing on intrahepatic CC and proximal extrahepatic CC, and delineate the available loco-regional therapies strategies for unresectable intrahepatic CC.

Advances in Y-90 radioembolization for the treatment of hepatocellular carcinoma

Hepatocellular carcinoma remains a prominent cause of cancer-related mortality globally. Transarterial yttrium-90 radioembolization is a versatile therapy and plays an important role in the treatment of hepatocellular carcinoma. This review summarizes the establishment of radioembolization in the hepatocellular carcinoma treatment paradigm, treatment considerations across cancer stages, and recent advances in evidence.