Background:The Institut Mutualiste Montsouris (IMM) 3-level complexity classification has been validated for laparoscopic liver resection (LLR) in several studies with small sample size. However, it has not been well-validated in large studies down to the individual procedure type. Hence, in order to address current limitations in the studies validating the IMM complexity classification, we performed an international multicenter study to validate the IMM complexity classification across its three complexity levels and the categorization of the 11 distinct procedure types. Methods:A retrospective cohort study of 22,252 patients undergoing LLR across 64 centers worldwide between 2005 and 2021 was performed. Baseline characteristics and perioperative outcomes were analyzed across the three difficulty levels and 11 procedure types of the IMM complexity classification. Results:A total of 14,765 patients were included in our final analysis. The main indications for LLR in our study was hepatocellular carcinoma or intrahepatic cholangiocarcinoma (n=7,781, 52.7%) followed by liver metastasectomy (n=3,911, 26.5%). In terms of underlying liver pathology, 5,127 (34.7%) cases had cirrhosis, and 1,214 (8.3%) had portal hypertension. Perioperative outcomes including operative time, open conversion rate, intraoperative blood loss, need for intraoperative blood transfusion, need for Pringle's application, length of stay, postoperative morbidity, major postoperative morbidity and 90-day mortality all demonstrated a significant increasing trend with increasing IMM complexity grades (P<0.001). These trends remained significant following adjustment for baseline characteristics (P<0.001). Notably, when examining the 11 LLR procedure types, all procedures within each IMM complexity grade were individually higher than all procedures in the preceding complexity grade for operative time, blood loss, length of stay, postoperative morbidity and major postoperative morbidity. Conclusions:The three IMM complexity grades were well associated with LLR complexity as determined by key surrogate perioperative measures. Our findings also supported the categorization of the 11 distinct LLR procedures into the three complexity levels.
Backgrounds/Aims: The definition of textbook outcome (TO) for liver surgery in patients with intrahepatic cholangiocarcinoma (ICC) varies depending on the data and TO model utilized in the study. This study aimed to clarify the separate estimation of TO in relation to its negative predictors, using two validated TO models for ICC surgery. Methods: We assessed the rates of achieving TO and failure of TO for both models in liver resection. Independent predictors of non-TO were identified through logistic regression and validated using AUC estimation. Results: TO was achieved in a similar proportion of patients across both models: 40% and 43%. The TO models did not differ in preoperative data affecting TO achievement. Independent predictors of non-TO for both models included tumor size > 10 cm,, open surgical approach, and biliary resection. TO achievement significantly differed among sub-groups that were homogeneous concerning the opposing values of the independent predictors, regardless of the TO model. The ratio of the frequency of negative predictors in the TO and non-TO groups, referred to as the TO coefficient, determines the likelihood of achieving TO given the presence of that predictor. Predictors were ranked by their negative impact on TO achievement, from the highest risk of TO failure (tumor size > 10 cm) to the lowest risk (open approach). Conclusions: Independent predictors of non-TO may improve the transparency of TO assessment and reduce biases related to unaccounted negative prognostic factors. The impact of these independent predictors on TO realization can be estimated and ranked using TO coefficient calculations.
The OBJECTIVE was to conduct a comparative analysis of short- and long-term outcomes following extended versus standard mesenteric resection in patients with stricturing Crohn’s disease. METHODS AND MATERIALS. This study was conducted at the Department of Coloproctology of the Loginov Moscow Clinical Scientific Center (2015–2023). The study included 120 patients with confirmed diagnosis “Crohn’s disease” (stricturing phenotype). The main group included 60 patients (prospective group) who underwent extended mesenteric resection. The comparison group included 60 patients (retrospective group) who underwent standard mesenteric resection. RESULTS. Multivariate regression analysis incorporating gender, age at diagnosis, surgical history, postoperative medical prophylaxis, smoking status, extent of mesenteric resection (standard vs extended), intestinal continuity restoration method (primary anastomosis vs stoma formation), disease phenotype, and perianal manifestations revealed that standard mesenteric resection was the only independent risk factor for postoperative Crohn’s disease recurrence (HR 2.83; 95 % CI 1.01–7.96; p=0.048). CONCLUSION. Extended mesenteric resection represents a promising surgical approach for Crohn’s disease that may reduce postoperative recurrence rates through complete removal of inflammation-sustaining mesenteric tissues.
BACKGROUND:The optimal surgical technique for hepatocellular carcinoma (HCC) remains debated, particularly regarding the balance between perioperative morbidity and long-term oncological outcomes when comparing anatomical resection (AR) with non-anatomical resection (NAR). METHODS:This international, retrospective multicenter study included patients undergoing resection for solitary HCC ≤5 cm. Patients undergoing major hepatectomy (≥3 segments), two-stage hepatectomy, portal vein embolization, or non-curative procedures were excluded. After propensity score matching (PSM), perioperative outcomes, disease-free survival (DFS), and overall survival (OS) were analyzed, with subgroup analyses by surgical approach and tumour size. RESULTS:After propensity score matching, 442 patients were included in each group. NAR was associated with more favourable perioperative outcomes, including shorter operative time, lower blood loss, and lower rates of severe morbidity. DFS did not differ between groups. AR was associated with improved OS in the overall matched cohort (5-year OS: 77.2% vs. 67.2%; p = 0.041), in patients with larger tumours (≥3.6 cm; 81.3% vs. 61.3%; p = 0.022), and in those undergoing minimally invasive liver resection (74.5% vs. 63.2%; p = 0.001). No significant OS difference was observed in patients with smaller tumours (≤3.5 cm). CONCLUSION:NAR was associated with better perioperative outcomes, whereas AR was associated with improved OS in selected analyses. As DFS did not differ between groups and subgroup findings were exploratory, these results should be interpreted cautiously. Overall, the findings support an individualized, tumour-tailored surgical approach.
BACKGROUND:Robotic liver surgery (RLS) provides technical advantages over laparoscopic liver surgery, but no validated robotic-specific difficulty scoring system (DSS) exists. We evaluated the applicability of the Southampton DSS to RLS and developed a dedicated RLS difficulty model. STUDY DESIGN:This multicenter retrospective cohort study included adults undergoing planned RLS across 24 international hepatobiliary centers. The Southampton DSS was assessed for calibration and discrimination in predicting intraoperative complications. Given limited performance, a robotic-specific model (International RoboLiver DSS) was developed using multivariable logistic regression with prolonged operative time (more than 280 minutes; 75th percentile) as a surrogate of technical difficulty. Model discrimination, calibration, and bootstrap internal validation were performed. RESULTS:Among 1,497 RLS patients, higher Southampton DSS categories were associated with increased intraoperative complications (p = 0.003); however, discrimination was poor (area under the curve [AUC] 0.571, 95% CI 0.530 to 0.612) with miscalibration (slope 0.43; intercept 0.06). Independent predictors of prolonged operative time included neoadjuvant chemotherapy, earlier extrahepatic surgery, lesion greater than 50 mm, multiple lesions, bilobar disease, and technically or anatomically major resection. The International RoboLiver DSS demonstrated moderate discrimination (AUC 0.719, 95% CI 0.686 to 0.751) with excellent calibration (intercept 0.00; slope 1.14). Bootstrap validation confirmed model stability (corrected AUC 0.719). CONCLUSIONS:Difficulty factors in RLS partially overlap with laparoscopic liver surgery but are not directly transferable. The International RoboLiver DSS provides a calibrated, robot-specific tool for preoperative complexity stratification and operative planning in RLS. External validation is required.
