Intermittent vascular exclusion of the liver (without vena cava clamping) during major hepatectomy

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept

BACKGROUND

Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion.

PATIENTS AND METHODS

The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range).

RESULTS

Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero.

CONCLUSIONS

This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.

Turning points in the practice of liver surgery: A historical review

The history of liver surgery is a tale of progressive resolution of issues presenting one after another from ancient times to the present days when dealing with liver ailments. The perfect knowledge of human liver anatomy and physiology and the development of a proper liver resective surgery require time and huge efforts and, mostly, the study and research of giants of their own times, whose names are forever associated with anatomical landmarks, thorough descriptions, and surgical approaches. The control of parenchymal bleeding after trauma and during resection is the second issue that surgeons have to resolve. A good knowledge of intra and extrahepatic vascular anatomy is a necessary condition to develop techniques of vascular control, paving the way to liver transplantation. Last but not least, the issue of residual liver function after resection requires advanced techniques of volume redistribution through redirection of blood inflow. These are the same problems any young surgeon would face when approaching liver surgery for the first time. Therefore, obtaining a wide picture of historical evolution of liver surgery could be a great starting point to serve as an example and a guide.

Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control

PURPOSE

To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM.

METHODS

Data from patients undergoing LLR between 2013 and 2020 were reviewed retrospectively. Univariate and multivariate analyses were performed and the outcomes of patients who underwent PM or alternative procedures were compared.

RESULTS

Among 106 patients who underwent LLR, PM could not be performed in 18 (17.0%) because of abdominal adhesions in 14 (77.8%) and/or collateral flow around the hepatoduodenal ligament in 5 (27.8%). Multivariate analysis revealed that Child-Pugh classification B (p = 0.034) and previous liver resection (p < 0.001) were independently associated with difficulty in performing PM in LLR. We evaluated pre-coagulation of liver tissue using microwave tissue coagulators, saline irrigation monopolar, clamping of the hepatoduodenal ligament using an intestinal clip, and hand-assisted laparoscopic surgery as alternatives procedures to PM. There were no significant differences in blood loss (p = 0.391) or transfusion (p = 0.518) between the PM and alternative procedures.

CONCLUSIONS

Child-Pugh classification B and previous liver resection were identified as predictors of a difficult PM in LLR. The alternative procedures were found to be effective.

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Hepatectomy: A Systematic Review and Meta-Analysis

Objectives

Mortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion (SHVE) compared to a Pringle maneuver in hepatic resection reduces rates of morbidity and mortality.

Methods

A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and SCOPUS for comparative studies meeting the inclusion criteria. Pooled odds ratios or mean differences were calculated for outcomes using either fixed- or random-effects models.

Results

Six studies were identified: three randomised controlled trials and three observational studies reporting a total of 2,238 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, blood loss, transfusion requirements, air embolism, liver failure and multi-organ failure in the SHVE group. Rates of hepatic vein rupture, post-operative hemorrhage, operative and warm ischemia time, length of stay in hospital and intensive care unit were not statistically significant between the two groups.

Conclusion

Performing SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle maneuver. The results of this meta-analysis are based on studies where tumors were adjacent to major vessels. Further RCTs are required to validate these results.

Clinical Trial Registration

PROSPERO (CRD42020212372) https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=212372.

[Robot-Assisted Right Hemihepatectomy for Hepatocellular Carcinoma]

Since the introduction of robot-assisted surgery, increasingly complex operations have been performed with this technique. Robot-assisted operations are also of increasing importance in hepatobiliary surgery. With articulated and scaled movements in a three-dimensional surgical field, permit precise preparation, as is needed for major hepatic resection. This video demonstrates the feasibility and precision of completely robotic surgery in right hemihepatectomy in hepatocellular carcinoma (HCC) of segments V - VIII in non-alcoholic steatohepatitis (NASH). The patient was 72 years old for the operation, with concomitant marked metabolic syndrome.

Techniques for laparoscopic liver parenchymal transection

Laparoscopic liver surgery has gained wide acceptance resulting in a paradigm shift of liver surgery. Technical innovations and accumulation of surgeon's experience have allowed laparoscopic liver resection (LLR) to become an effective procedure with favorable peri- and post-operative outcomes. Through the overall process of LLR, liver parenchymal transection remains the most critical step with the aim of minimizing blood loss and secures the appropriate cutting line, i.e., securing major vessels and obtaining adequate surgical margin clearance for malignancies. Multiple preoperative imaging modalities and intraoperative ultrasonography findings may contribute to the best determination of the appropriate cutting line during the LLR; however, technical expertise in minimizing and controlling bleeding during liver parenchymal transection is still a challenge for safe LLR, and therefore represents a major concern for hepatobiliary surgeons. Along with the historical fact that the technique of liver parenchymal transection itself is chosen according to surgeon's preference and "savoir-faire", the best technical modality in laparoscopic liver parenchymal transection remains to be determined. However, better understanding the technical issue may serve a contribution to the standardization of LLR. This review article therefore focuses on the technical aspects of the laparoscopic liver parenchymal transection.

Radiofrequency Assisted Hepatic Parenchyma Resection Using Radiofrequent Generator (RF) Generator

INTRODUCTION

The role of Radio frequent Generator (RF) has been extended from simple tumor ablation to routine hepatic resection. RF energy precoagulates the tissue and thus allows the closure of small blood vessels and bile ducts. The development of surgical techniques and modern technological advances have enabled liver resections to be significantly surgically better controlled in the sense of bleeding, and are more successful and safer for patients. The RF generator has its advantages and disadvantages and as such can be equally used in resective liver surgery.

AIM

Display the intraoperative and postoperative complications among patients that had been subjected to liver resection using a RF generator (RF resection), compared to those that had been subjected to liver resection without the use of RF generators (classical liver resection methods of CC resection).

MATERIAL AND METHODS

The study included 60 patients of both sexes which had resective operative surgery or metastasectomy on the liver due to the basic process. The study was conducted at the Clinic for General and Abdominal Surgery of the Clinical Center of the University of Sarajevo in a four-year period. The study was designed as a comparative study of outcome and postoperative complications of surgical treatment, i.e. resective liver interventions using two operating techniques (RF-liver resection and Classical resection techniques on the liver).

RESULTS

The highest number of surgical procedures was due to colorectal cancer. A slightly smaller number was performed due to primary liver cancer and gallbladder cancer. The highest number of surgical interventions remain on non-anatomic resections. Smaller number remains to large resective operations. The length of hospitalization was significantly correlated with blood loss (r = 713 p = 0,000) and the average hospitalization time ranged from 10.5 to 53.3 days.

CONCLUSION

We have shown that the use of RF generators does not significantly reduce intraoperative and postoperative complications. There is a justification for using both techniques for resection on the liver. The resective liver operation depends mostly on the personal stance and the surgeons training.

Modified liver hanging maneuver focusing on outflow control in pure laparoscopic left-sided hepatectomy

BACKGROUND

Outflow control during laparoscopic liver resection necessitates the use of technically demanding procedures since the hepatic veins are fragile and vulnerable to damage during parenchymal transection. The liver hanging maneuver reduces venous backflow bleeding during deep parenchymal transection. The present report describes surgical outcomes and a technique to achieve outflow control during application of the modified liver hanging maneuver in patients undergoing laparoscopic left-sided hepatectomy.

METHODS

A retrospective review was performed of clinical data from 29 patients who underwent laparoscopic left-sided hepatectomy using the modified liver hanging maneuver between February 2013 and March 2017. For this hanging technique, the upper end of the hanging tape was placed on the lateral aspect of the left hepatic vein. The tape was then aligned with the ligamentum venosum. The position of the lower end of the hanging tape was determined according to left-sided hepatectomy type. The hanging tape gradually encircled either the left hepatic vein or the common trunk of the left hepatic vein and middle hepatic vein.

RESULTS

The surgical procedures comprised: left lateral sectionectomy (n = 10); left hepatectomy (n = 17); and extended left hepatectomy including the middle hepatic vein (n = 2). Median operative time was 210 min (range 90-350 min). Median intraoperative blood loss was 200 ml (range 60-600 ml). Two intraoperative major hepatic vein injuries occurred during left hepatectomy. Neither patient developed massive bleeding or air embolism. Postoperative major complications occurred in one patient (3.4%). Median postoperative hospital stay was 7 days (range 4-15 days). No postoperative mortality occurred.

CONCLUSIONS

The present modified liver hanging maneuver is a safe and effective method of outflow control during laparoscopic left-sided hepatectomy.

Curative cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis and synchronous resectable liver metastases arising from colorectal cancer

OBJECTIVES

This study describes the outcomes of patients with colorectal peritoneal carcinomatosis (PC) with or without liver metastases (LMs) after curative surgery combined with hyperthermic intraperitoneal chemotherapy, in order to assess prognostic factors.

BACKGROUND

Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) increases overall survival (OS) in patients with PC. The optimal treatment both for PC and for LMs within one surgical operation remains controversial.

METHODS

Patients with PC who underwent CRS followed by HIPEC were evaluated from a prospective database. Overall survival and disease free survival (DFS) rates in patients with PC and with or without LMs were compared. Univariate and multivariate analyses were performed to evaluate predictive variables for survival.

RESULTS

From 1999 to 2011, 22 patients with PC and synchronous LMs (PCLM group), were compared to 36 patients with PC alone (PC group). No significant difference was found between the two groups. The median OS were 36 months [range, 20-113] for the PCLM group and 25 months [14-82] for the PC group (p > 0.05) with 5-year OS rates of 38% and 40% respectively (p > 0.05). The median DFS were 9 months [9-20] and 11.8 months [6.5-23] respectively (p = 0.04). The grade III-IV morbidity and cytoreduction score (CCS) >0 (p < 0.05) were identified as independent factors for poor OS. Resections of LMs and CCS >0 impair significantly DFS.

CONCLUSIONS

Synchronous complete CRS of PC and LMs from a colorectal origin plus HIPEC is a feasible therapeutic option. The improvement in OS is similar to that provided for patients with PC alone.

Retrograde laparoscopic resection of left side of the liver: a safe and effective way

OBJECTIVE

The safety and feasibility of retrograde laparoscopic resection of the left side of the liver.

METHODS

Ninety-three laparoscopic left hepatic lobe cases were selected between August 2010 and August 2014 from our institution. A retrospective cohort study was performed between the antegrade partial hepatectomy group (47 cases; dissection from the first porta hepatis to the second) and the retrograde partial hepatectomy group (46 cases; dissection from the second porta hepatis to the first), to compare the length of time needed for resection, the amount of bleeding, post-operative time in the hospital, and the incidence of major complications, such as bile leakage, abdominal abscess, and post-hepatectomy hemorrhage.

RESULTS

All of the cases had a successful laparoscopic partial hepatectomy without the need for an intraoperative blood transfusion. Patients were able to ambulate on post-operative day 1 and tolerated a liquid diet on post-operative day 1 or 2. There were no statistical differences of post-operative hospital length of stay or incidence of major complications between the two groups. Both duration of resection and the amount of bleeding were less in the retrograde group than of those in the antegrade group, due to the lower incidence of hepatic vein injury in the retrograde group.

CONCLUSION

Occlusion of both the inflow and outflow hepatic vessels combined with retrograde hepatectomy from the second porta hepatis to the first, demonstrated less hemorrhage and lower incidence of hepatic veins injury during laparoscopic partial hepatectomy.

Prognostic similarities and differences in optimally resected liver metastases and peritoneal metastases from colorectal cancers

PURPOSE

To analyze and compare survival in patients operated for colorectal liver metastases (LM) with that in patients optimally resected for peritoneal metastases (PM).

PATIENTS AND METHODS

This study concerns 287 patients with LM and 119 patients with PM treated with surgery plus chemotherapy between 1993 and 2009, excluding patients presenting both LM and PM.

RESULTS

Mortality (respectively, 2.7% and 4.2%), morbidity (respectively, 11% and 17%), and 5-year overall survival (OS) rates (respectively, 38.5% and 36.5%) were not statistically different between the LM group and the PM group. Multivariate analysis showed that the extent of the disease was the main prognostic factor, which led us to divide the population into 5 subgroups. The best 5-year OS rate (72.4%) was obtained in patients with minimal peritoneal disease [peritoneal cancer index (PCI) ≤5]. OS was similar for the patients with less than 10 LM and those with a PCI between 6 and 15 (respectively, 39.4% and 38.7%). Five-year OS was lower in patients with more than 10 LM (18.1%), and dramatically low for patients with a PCI > 15 (11.8%).

CONCLUSIONS

This study underlines the prognostic impact of the tumor burden in metastatic colorectal disease. In selected patients, similar survival rates can be obtained after optimal treatment of LM and PM. As the role of optimal surgical resection of LM is widely accepted, our results confirm that an optimal attitude should also be adopted to treat PM with a PCI < 16, particularly in patients with very low PCI (<5) where survival could be better than LM.

Intraoperative surgical margin re-resection for colorectal liver metastasis: is it worth the effort?

OBJECTIVE

This study was conducted to evaluate recurrence and survival among patients who underwent intraoperative margin re-resection for colorectal cancer liver metastases (CRLM).

BACKGROUND

Among patients who receive intraoperative margin re-resection, the relation between final margin status, pattern of recurrence, and survival is largely unknown.

METHODS

Three hundred thirty-two patients who underwent hepatic resection for CRLM between 2000 and 2013 were identified. Demographics, operative data, pathologic margin status, site of recurrence, and long-term survival data were collected and analyzed. Patients were stratified in three groups based on their margin status: R0, R1, and R1 → R0.

RESULTS

R0 resections were achieved in 247 (74.4%) patients, 61 (18.4%) patients had an R1 resection, whereas 24 (7.2%) had an R1 → R0. Median survival for patients undergoing R0 resections was 50.2 (95% confidence interval (CI) 49.2-66.2) months versus 63.0 (95% CI 50.3-70.5) months for patients undergoing R1 resections versus 49.2 (95% CI 29.9-NA) months for patients undergoing intraoperative margin re-resection (P > 0.05). Differences in recurrence rate and pattern were not significant between the three groups (P > 0.05).

CONCLUSION

In the era of modern systemic chemotherapy, it seems that the impact of margin status on outcomes may be minimal compared to that of patient and tumor factors. In this scenario, margin re-resection to achieve R0 status does not improve long-term outcomes.

Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors

Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involving or adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia can be prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenous bypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnic venous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the need for VVB. However this technique remains limited in duration as it is performed under warm ischemia (so-called normothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVE with preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermic perfusion of the liver. We describe here the first two cases of this new technique. Two patients underwent left hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrally located tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative course was uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alive without recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can be controlled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion and VVB and obviates the need and the subsequent risks of the latter.

Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: a randomized comparative study

OBJECTIVE

To compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction.

METHODS

A randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality.

RESULTS

160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group.

CONCLUSIONS

SHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.

A simple tumor load-based nomogram for surgery in patients with colorectal liver and peritoneal metastases

BACKGROUND

The decision to perform optimal surgery when peritoneal metastases (PM) are associated with liver metastases (LM) is extremely complex. No guidelines exist. The purpose of this study was to present a simple and useful statistical tool that generates a graphical calculator (nomogram) to help the clinician rapidly estimate individualized patient-specific survival before undergoing optimal surgery.

MATERIALS AND METHODS

An analysis of 287 patients with liver metastasis (LM), 119 patients with peritoneal metastasis (PM), and 37 patients with LM + PM, who underwent optimal surgery plus chemotherapy between 1995 and 2010 was performed. A minimal number of parameters were taken into account to obtain a nomogram that would be very simple to use. With the overall tumor load as the main prognostic factor, we included the number of lesions for LM and the peritoneal carcinomatosis score (PCI) for PM. The Cox model was used to generate the nomogram.

RESULTS

The 5-year overall survival was, respectively, 38.5, 36.5, and 26.4 % in the LM group, the PM group, and the LM + PM group. The summation of 3 parameters (the number of LM, the PCI, and the type of surgery [liver resection, HIPEC, or both]), makes it easy to calculate a score that graphically corresponds to an estimation of survival after optimal surgery (nomogram). It can be used for LM alone, PM alone, or both.

CONCLUSIONS

A graphic nomogram that is simple to calculate and easy to use enables us to rapidly appreciate the prognosis of patients according to the number of LM, the PCI, or both. This nomogram must be validated in prospective studies in other tertiary centers.

Vascular reconstruction combined with liver resection for malignant tumours

BACKGROUND

The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre.

METHODS

Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality.

RESULTS

Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively.

CONCLUSION

Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.

Minimizing blood loss during hepatectomy: a literature review

There are numerous techniques surgeons employ to reduce blood loss during partial hepatectomy. In this literature review, prospective studies from the last 20 years are examined to determine the techniques that are best supported by the literature. Some of the techniques include vascular control, multiple parenchymal transection techniques, various hemostatic agents, low central venous pressure, and hemodilution. The strategies supported most convincingly by the literature include low CVP and total hepatic inflow occlusion.

Should patients with peritoneal carcinomatosis of colorectal origin with synchronous liver metastases be treated with a curative intent? A case-control study

OBJECTIVE

This study aimed to assess the prognostic impact of liver metastases (LM) in patients with colorectal peritoneal carcinomatosis (PC) who underwent complete cytoreductive surgery and resection of LM, followed by intraperitoneal chemotherapy.

BACKGROUND

Synchronous surgical treatment of PC and LM with curative intent remains controversial.

METHODS

From a prospective database, all patients with PC and synchronous LM who had undergone cytoreductive surgery and LM resection followed by intraperitoneal chemotherapy were matched with patients with PC alone according to the following criteria: age, peritoneal cancer index (PCI), site and lymph node involvement (pN) of primary cancer, and postoperative chemotherapy.

RESULTS

From 1993 to 2009, 37 patients with PC and LM were matched with 61 patients with PC alone. After a mean follow-up of 36 months, 3-year overall survival (OS) and disease-free survival rates were significantly lower in patients with PC and LM, respectively, 40% and 66% (P = 0.04) and 6% and 27% (P = 0.001). A PCI of 12 or more [odds ratio (OR): 4.6], a pN+ status (OR: 3.3), no adjuvant chemotherapy (OR: 3.0), and presence of LM (OR: 2.0) were identified as independent factors for poor OS. Three groups were singled out: (1) patients with a low PCI (<12) and no LM (median OS: 76 months); (2) patients with a low PCI (<12) and 1 or 2 LM (median OS: 40 months); and (3) patients with a high PCI (≥12) or patients with 3 LMs or more (median OS: 27 months).

CONCLUSIONS

This case-control study seems to confirm that prolonged survival can be achieved in highly selected patients operated on for limited PC and fewer than 3 LM.

Hepatic microcirculation in inflow and inflow-outflow occlusion of the liver

BACKGROUND

Total vascular exclusion (TVE) causes warm liver ischemia. The aim of this study was to investigate the patterns of injury caused by inflow-outflow obstruction in the rat liver.

MATERIALS AND METHODS

Twenty-four Wistar-Albino rats were divided into three groups: liver inflow occlusion (Group A), inflow-outflow occlusion (Group B) and intermittent inflow-outflow occlusion applied for 15 minutes. Microcirculation was measured with laser Doppler flowmetry during the procedure. Samples for biochemical and histopathological analyses were collected at the end of the ischemia period.

RESULTS

Significant alterations in microcirculation were determined by application of vascular control maneuvers. Microcirculation in the central and dome segments were affected adversely compared with the dome segments in all experimental groups. TVE induced severe disturbances in hepatic microcirculation with more prominent hepatocellular damage. Damage to central segments of the rat liver was more prominent with inflow occlusion; whereas inflow-outflow occlusion produced more prominent damage to dome segments. Intermittent application of TVE clamping was associated with more hepatocellular damage compared with continuous TVE.

CONCLUSION

Our mapping methodology within the liver parenchyma suggested that hepatovenous back-perfusion is a principle source of continuity of microcirculation in the rat liver during inflow occlusion. Inflow-outflow occlusion caused more tissue damage compared with inflow occlusion. Ischemic preconditioning during TVE did not increase the tolerance of the liver against ischemia.

Giant focal nodular hyperplasia determining Budd-Chiari syndrome: an operative challenge requiring 210 min of liver ischemia

Focal nodular hyperplasia (FNH) is a relatively common benign liver tumor with rare indications to surgery. Early after pregnancy, a 35-year-old woman developed right upper quadrant abdominal pain with fever. A large abdominal mass was palpable. Abdominal CT scan showed a 18-cm FNH substituting all liver segments but S6 and S7, compressing middle and left hepatic vein near their origin, displacing and compressing right hepatic vein, with ascites. Surgery consisted of a left hepatectomy extended to S5-S8 and S1. Main technical challenge was the preservation of the right hepatic vein. Intermittent pedicle clamping was performed, associated with hepatic vascular exclusion with preservation of caval flow; total duration of ischemia was 210 min. The postoperative course was uneventful, except for a transient fall in prothrombin time, and the formation of a sub-diaphragmatic serous collection, which was percutaneously drained. The patient is well 25 months after the operation. To our knowledge, this is the second reported case requiring surgery for a FNH causing a Budd-Chiari syndrome. In these peculiar cases a cumbersome operation may be required, maximizing all precautions to perform a risk-free procedure.

Patients operated on for initially unresectable colorectal liver metastases with missing metastases experience a favorable long-term outcome

BACKGROUND

After chemotherapy, complete clinical responses of colorectal liver metastases (CRLMs) increasingly occur, but these responses are rarely complete pathological responses. The management of patients with missing metastases, that is, CRLMs that disappear under chemotherapy are undetectable intraoperatively and finally left in place, continues to be controversial. The aim of this study was to assess the long-term outcome of patients with "missing CRLMs."

PATIENTS

Between 1999 and 2007, among 523 patients operated on for CRLMs, 96 missing CRLMs were observed and left in place in 27 originally unresectable patients. All of these patients received preoperative chemotherapy. Hepatic arterial infusion (HAI) of oxaliplatin combined with systemic 5-fluorouracil was administered in 23 patients, including 12 before hepatectomy and 11 after. Hepatic surgery was performed after a minimal interval of 3 months during which CRLMs had disappeared on imaging.

RESULTS

After a median follow-up of 55 months (24-137) after hepatic surgery, an intrahepatic recurrence was diagnosed in 14 (52%) patients, but the recurrence rate was significantly lower in patients who had received adjuvant HAI compared with the others (27% vs 83%, P = 0.006). Recurrences arose at the site of the missing CRLMs in 9 (33%) patients, but was associated in all cases with another recurrence in the liver. The 5-year overall survival rate of these 27 highly chemosensitive patients was 80%, and the 5-year disease-free survival rate was 23%.

CONCLUSION

Highly chemosensitive patients, whose initially unresectable CRLMs become resectable because of missing CRLMs left in place, have a favorable long-term outcome. Missing CRLMs should not be longer, a contraindication to hepatic surgery. Use of postoperative HAI of oxaliplatin can help to reduce the risk of hepatic relapse.

Vascular clamping in liver surgery: physiology, indications and techniques

This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.

Minor Hepatic Resection Using Heat Coagulative Necrosis

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. In this study, we evaluated the effectiveness of a radiofrequency (RF) device using heat to cause coagulative necrosis of the hepatic parenchyma to control hemostasis in minor hepatic resection. Between December 2005 and November 2007, a study was conducted of 21 patients undergoing 22 hepatic resections with the RF-assisted technique. Sixteen of these were affected by hepatocellular carcinoma and five had liver metastases from colorectal cancer. Intraoperative blood loss, the need for blood transfusion, the complication rates, operating times, and the duration of postoperative hospitalization were evaluated. Four segmentectomies and 18 tumorectomies were performed. The average blood loss was of 15.7 mL (range, 0-40 mL); the average operating time was 25.7 minutes (range, 12-43 minutes); the mean postoperative hospital stay was 8.2 days (range, 3-49 days) with a median of 6.0 days. The authors concluded that the RF-assisted technique can be a useful method not only for reducing blood loss and avoiding blood transfusions, but also for reducing operating time and postoperative hospitalization for minor liver resections.

Combined liver surgery and RFA for patients with gastroenteropancreatic endocrine tumors presenting with more than 15 metastases to the liver

AIM

The aim of this study was to report the feasibility and early survival results of liver metastases (LM) resection combining cytoreductive surgery and radiofrequency ablation (RFA) during a one-step procedure, in patients presenting more than 15 bilateral LM from well-differentiated endocrine carcinoma. It is an extensive application of the current guidelines.

METHODS

In this retrospective review of a prospectively collected database, we used a combination of hepatectomy to treat large or contiguous LM, and extensively used multiple RFA to treat the remaining LM which were smaller than 2.5 cm. Patients were selected based on a low natural tumor burden slope, and the technical feasibility of treating all the detectable LM.

RESULTS

From January 2002 to May 2007, 16 patients with a median of 23 LM per patient (mean number: 25.7 + or -12; range16-89) underwent this procedure. A mean of 15 + or - 9 LM per patient were surgically removed and a mean of 12 + or - 8 (median of 10) LM per patient were RF ablated. No mortality occurred. Morbidity was observed in 11 patients (69%). The 3-year overall survival and disease-free survival rates were similar to those observed in our preliminary series of 47 hepatectomized patients with a median of 7 LM per patient.

CONCLUSION

This new one-step combined technique allowed us to apply an "upgraded" therapeutic approach to a selection of patients presenting a median of 23 LM per patient and to improve their prognosis, putting it on par with that obtained by conventional hepatectomy.

Effect of infra-hepatic inferior vena cava clamping on bleeding during hepatic dissection: a prospective, randomized, controlled study

BACKGROUND

The success of hepatectomy can be associated with intraoperative blood loss because massive blood loss causes a poor prognosis. This study was designed to evaluate the effect of infrahepatic inferior vena cava (IVC) clamping on the bleeding amount during hepatectomy.

METHODS

Eighty-five patients scheduled to undergo hepatic resection were randomly assigned to the IVC clamping or an IVC nonclamping group according to age, indocyanine green retention rate at 15 minutes, operative procedure, and number of tumors by prospective, randomized method. All analyses were compared by Mann-Whitney U test.

RESULTS

Forty-three patients were assigned to the IVC clamping group and 42 to the nonclamping group (IVC clamping group vs. non-clamping): total blood loss (499 vs. 584 ml; p = 0.567), amount of bleeding during hepatectomy (233 vs. 285 ml; p = 0.474), amount of bleeding during hepatectomy/area of dissection (4.9 vs. 6.6 ml/cm(2); p = 0.63), CVP difference (-3 cmH(2)O vs. -1 cmH(2)O; p < 0.01), and diameter of the right hepatic vein (-2.2 cm vs. 0; p < 0.01).

CONCLUSIONS

Although we had speculated that infrahepatic IVC clamping would reduce blood loss during hepatectomy, we failed to demonstrate any beneficial effects in this clinical setting with low CVP.

A five-year disease-free survival after combined hepatectomy and radiofrequency ablation of large hepatocellular carcinoma adjacent to vena cava

Destroying the hepatic tumor located close to the large vessels is a major limiting factor of radiofrequency ablation (RFA) that is difficult to overcome. A long-term disease-free survival after combined hepatectomy and radiofrequency ablation of a large hepatic tumor adjacent to vena cava has not been previously published. We report a patient with a 23-cm large hepatocellular carcinoma occupying the left lateral segments and a 6-cm contralateral intrahepatic metastasis in Couinaud segments VII–VIII adjacent to the retrohepatic IVC, treated with a combination of resection of the larger tumor and intraoperative radiofrequency ablation of the paracaval tumor under intermittent total vascular exclusion of the right hemiliver. After five years of follow up the patient is disease free. This case demonstrates the importance of vascular control for eliminating the heat sink effect of caval blood flow during RFA of liver tumors adjacent to inferior vena cava.

Comparison of two methods of selective hepatic vascular exclusion for liver resection involving the roots of the hepatic veins

BACKGROUND

Selective hepatic vascular exclusion (SHVE) is an effective hepatic vascular exclusion in controlling both inflow and outflow without interruption of caval flow, as it combines Pringle maneuver with extrahepatic selective occlusion of hepatic veins. But SHVE has not been widely used due to difficulty in extrahepatic dissection of hepatic veins. When the tumor is very close to the roots of the hepatic veins, dissecting the posterior wall of the hepatic vein may lead to rupture and massive bleeding of the hepatic vein. With our experience, clamping hepatic veins with Satinsky clamps is a safer and easier occlusion method by which the posterior wall of the hepatic veins does not need to be separated and encircled. In this report, we compared the results of selective hepatic vascular occlusion with tourniquet and Satinsky clamp for major liver resection involving the roots of the hepatic veins.

METHODS

Between January 2003 to June 2006, 180 patients who underwent major liver resection with SHVE were divided into two groups according to different methods of hepatic vascular occlusion: occlusion with tourniquet (tourniquet group, n = 95) and occlusion with Satinsky clamp (Satinsky clamp group, n = 85). In the tourniquet group, the hepatic veins were encircled and occluded with tourniquet. In the Satinsky clamp group, the hepatic veins were not encircled and clamped directly by Satinsky clamp.

RESULTS

Intraoperative and postoperative consequences of the patients were analyzed. The dissecting time for each hepatic vein was significantly shorter in the Satinsky group (6.2 +/- 2.4 min vs 18.3 +/- 6.2 min) than in the tourniquet group. In the tourniquet group, five hepatic veins (one right hepatic vein and four common trunk of left-middle hepatic veins) could not be dissected and encircled because the tumors involved the cava hepatic junction, and another common trunk of the left-middle hepatic vein had a small rupture during the dissection. These six patients then received successful occlusion with Satinsky clamp. There was no difference between the two groups regarding the operation duration, ischemia time, intraoperative blood loss, and postoperative complication rate.

CONCLUSION

Both methods of the hepatic vein occlusion have the same effect on controlling hepatic vein bleeding, but occlusion with Satinsky clamp is safer, easier, and consumes less time in dissecting.

Liver resection with bipolar radiofrequency device: Habib 4X

BACKGROUND

Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib 4X, a new bipolar RF device designed specifically for liver resection is described here.

METHODS

Habib 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak.

RESULTS

Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringle's manoeuvre). Mean intraoperative blood loss was 305 ml (range 0-4300) ml, with less than 5% (n=18) rate of transfusion.

CONCLUSION

Habib 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.

Strategies for resection using portal vein embolization: metastatic liver cancer

The oncological landscape is constantly changing with the development of new curatively intended therapeutic strategies. More and more, liver metastases are amenable to resection following the progress achieved as a result of new oncological concepts (i.e., treat detectable disease with surgery and ablative therapies and treat the remaining nondetectable disease with efficient chemotherapy) as well as improved chemotherapeutic and ablation techniques. One of the major limitations to extending the indications for liver resection is the volume of the future remnant liver (FRL). To overcome these limitations, portal vein embolization (PVE) has played a key role in obtaining preoperative hypertrophy of the FRL and thus has reduced postoperative morbidity and mortality. Interestingly, thermal ablation of multiple bilateral liver metastases makes it difficult to predict the volume of parenchyma scheduled for ablation. Furthermore, prolonged chemotherapy impairs liver parenchyma function, which has a negative impact on liver hypertrophy. In the future, both volumetric and functional assessment of the FRL will be used to determine whether PVE is necessary before hepatectomy in individual patients and new strategies (e.g., PVE used alone or combined with other treatments; timing of PVE may vary) will be based on these principles. This article presents various current strategies for the use of PVE in patients with metastatic liver cancer.

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND

Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding.

STUDY DESIGN

We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver.

RESULTS

Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins).

CONCLUSIONS

Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.

Outcome of posthepatectomy-missing colorectal liver metastases after complete response to chemotherapy: impact of adjuvant intra-arterial hepatic oxaliplatin

BACKGROUND

Dramatic responses to chemotherapy are occurring more and more frequently in patients with multiple colorectal liver metastases (LMs), leading to resection. In a few patients, some LMs vanish on imaging studies, remain undetected during hepatectomy, and are left in place, which defines the "missing LMs." The aim of our study was to assess the long-term outcome of such "missing LMs."

PATIENTS

Between January 1999 and June 2004, among 228 patients treated for colorectal LMs, missing LMs were observed in 16 patients. All the patients were operated within 4 weeks of imaging. Hepatic arterial infusion (HAI) with oxaliplatin was administrated in 12 patients (75%): seven before hepatectomy and five after.

RESULTS

Overall, 69 missing LMs were diagnosed and left in place. Among the persistent LMs resected, a complete pathological response was significantly more often observed in the group with preoperative HAI (6 of 7), than in the group without (2 of 9, P < .02). With a mean follow-up of 51 months (24-90), missing LMs did not reappear in 10 patients (62%). Adjuvant HAI was significantly correlated with the definitive eradication of missing LMs (P < .01), as it was not a complete pathological response. The overall 3-year survival rate of these highly selected 16 patients was 94%.

CONCLUSION

Colorectal LMs under chemotherapy that vanish on high-quality imaging studies, remain undetected during hepatectomy, and are left in place, are definitively cured in 62% of cases. This excellent result seems to be due to the administration of adjuvant hepatic arterial infusion of chemotherapy and should stimulate new investigations.

Selective hepatic vascular exclusion and Pringle maneuver: a comparative study in liver resection

OBJECTIVE

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

METHODS

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

RESULTS

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

CONCLUSION

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.

Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements

BACKGROUND

Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series.

METHODS

Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates.

RESULTS

There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days.

CONCLUSION

The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.

Transhepatic lactate gradient in relation to liver ischemia/reperfusion injury during major hepatectomies

Hepatectomies performed under selective hepatic vascular exclusion are associated with a series of events culminating in ischemia/reperfusion injury, a state that shares common characteristics with situations known to result in global or regional hyperlactatemia. Accordingly, we sought to determine whether lactate is released by the liver during hepatic resections performed under blood flow deprivation and what relation this has to a possible systemic hyperlactatemic state. After ethical approval, 14 consecutive patients with resectable liver tumors subjected to hepatectomy under inflow and outflow occlusion of the liver were studied. Lactate concentrations were assessed in simultaneously drawn arterial, portal venous, and hepatic venous blood before liver dissection and 50 minutes postreperfusion. Moreover, the transhepatic lactate gradient (hepatic vein - portal vein) was calculated to see if there was net production or consumption of lactate. Before hepatic dissection, the transhepatic lactate gradient was negative, suggesting consumption by the liver. Fifty minutes after reperfusion, this gradient became significantly positive, demonstrating release of lactate by the liver (0.12 +/- 0.31 vs. -0.38 +/- 0.30 mmol/L, P < 0.05). The magnitude of lactate release correlated with systemic arterial lactate levels at the same time point (r(2) = 0.63, P < 0.001). A weaker but significant correlation was demonstrated between the transhepatic lactate gradient postreperfusion and systemic arterial lactate levels 24 hours postoperatively (r(2) = 0.41, P = 0.013). A strong correlation between the transhepatic lactate gradient postreperfusion and peak postoperative aspartate aminotransferase values was also demonstrated (r(2) = 0.73, P < 0.001). The liver becomes a net producer of lactate in hepatectomies performed under blood flow deprivation. This lactate release can explain some of the systemic hyperlactatemia seen in this context and relates to the extent of ischemia/reperfusion injury.

Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience

BACKGROUND

Liver tumors with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach, with its high surgical risks and poor long-term prognosis, was precluded until the development of neoadjuvant chemotherapy, portal vein embolization, reinforced vascular prostheses, and technical advances in liver transplantation.

METHODS

We reviewed 22 cases of hepatectomy with retrohepatic IVC resection and reconstruction. The patients had a median age of 51.5 years (range, 32.8-75.3 years). Indications for resection were: liver metastases (n = 9), cholangiocarcinoma (n = 8), hepatocellular carcinoma (n = 2), other cancers (n = 3). The liver resections carried out included 18 first, 3 second, and one third hepatectomy. Segment 1 (caudate lobe) was included in the specimen in 19 cases (86%). Resection concerned 1 to 6 liver segments (median = 5.0). Vascular control was achieved by vascular exclusion of the liver preserving the caval flow (n = 1), standard vascular exclusion of the liver (n = 12), in situ cold perfusion of the liver (n = 9). Ex situ surgery was not necessary in any case. Venovenous bypass was used in 12 cases. The IVC was reconstructed with a ringed Gore-Tex tube graft (n = 10), primarily (n = 8), or by caval plasty (n = 4). A main hepatic vein was reimplanted in 6 cases: into the native IVC (n = 4) or into a Gore-Tex tube graft (n = 2).

RESULTS

One patient died (4.5%) due to catheter infection, 7 days after in situ cold perfusion with replacement of the vena cava. Eight patients (36%) had no complications and 14 patients (64%) had 23 complications. In all but 1 case, the complications were transient and successfully controlled. The patients stayed in intensive care for 3.3 +/- 2.0 days and in the hospital for 17.7 +/- 7.8 days. All vascular reconstructions were patent at last follow-up. With median follow-up of 19 months, 10 patients died of tumor recurrence and eleven were alive with (n = 5) or without (n = 6) disease. Actuarial 1-, 3-, and 5-year survival rates were 81.8%, 38.3%, and 38.3%, respectively.

CONCLUSIONS

IVC resection and reconstruction combined with liver resection can be safely performed in selected patients. The lack of alternative treatments and the spontaneous poor prognosis justify this approach, provided that surgery is carried out at a center specialized in both liver surgery and liver transplantation. The development of adjuvant chemotherapy regimens is required to improve the long-term results of this salvage surgery.

Treatment of synchronous peritoneal carcinomatosis and liver metastases from colorectal cancer

AIM

To report our experience of peritoneal carcinomatosis (PC) discovered during abdominal exploration in patients with liver metastases (LM).

METHODS

Liver resection plus cytoreductive surgery were combined in 24 patients with LM and moderate PC from colorectal origin treated with a curative intent between January 1993 and November 2003.

RESULTS

The mean operative time was 357+/-112 min and median blood loss was 719 ml. One postoperative death occurred and postoperative morbidity was 58%. The mean hospital stay was 21.4+/-4.2 days. Three-year overall and disease-free survival rates were respectively 41.5% (confidence interval [CI]: 23-63) and 23.6% (CI: 11-45). Seven patients are disease-free with a mean follow-up of 27.8 months after their last surgery, 3 having a repeated hepatectomy. Three patients developed a peritoneal recurrence and 13 had recurrence in the liver. The only significant prognostic factor was a number of LMs of less than 3 (p < 0.01).

CONCLUSION

A combined treatment of LM plus PC is feasible and is beneficial in selected patients presenting three or fewer metastases.

Simplified hepatic resections with the use of a Chang's needle

OBJECTIVE

To demonstrate the use of Chang's needle for hepatic resections.

SUMMARY BACKGROUND DATA

Specialized instruments, fine surgical skills, and good control of hepatic inflow and backflow are essential for hepatic resections. This needle was specifically designed to simplify these requirements.

METHODS

Whole-thickness interlocking sutures of the liver can first be made along the designed resection line with a Chang's needle; then parenchyma transection can follow without inflow or backflow control. This was consecutively performed on 69 patients with primary (41), metastatic (10), and benign (18) diseases since 1997.

RESULTS

Blood loss during parenchyma transection was reduced in 11 right lobectomies (652 mL), 1 3-segmentectomy (300 mL), 14 bisegmentectomies (252 mL), 7 segmentectomies (104 mL), 12 subsegmentectomies (19 mL), 5 wedge resections (7 mL), 18 left lateral segmentectomies (110 mL), and 1 hepatorrhaphy (minimal). There was no procedure-related mortality. A mild bile leakage occurred in 1 case (1.5%) but healed spontaneously.

CONCLUSIONS

The preliminary results demonstrate that this maneuver is a simple, easy, and safe method for performing hepatic resections.

Ischemic preconditioning for major liver resection under vascular exclusion of the liver preserving the caval flow: a randomized prospective study

BACKGROUND

Two randomized prospective studies suggested that ischemic preconditioning (IP) protects the human liver against ischemia-reperfusion injury after hepatectomy performed under continuous clamping of the portal triad. The primary goal of this study was to determine whether IP protects the human liver against ischemia-reperfusion injury after hepatectomy under continuous vascular exclusion with preservation of the caval flow.

STUDY DESIGN

Sixty patients were randomly divided into two groups: with (n=30; preconditioning group) and without (n=30; control group) IP (10 minutes of portal triad clamping and 10 minutes of reperfusion) before major hepatectomy under vascular exclusion of the liver preserving the caval flow. Serum concentrations of aspartate transferase, alanine transferase, glutathione-S-transferase, and bilirubin and prothrombin time were regularly determined until discharge and at 1 month. Morbidity and mortality were determined in both groups.

RESULTS

Peak postoperative concentrations of aspartate transferase were similar in the groups with and without IP (851 +/- 1,733 IU/L and 427 +/- 166 IU/L respectively, p=0.2). A similar trend toward a higher peak concentration of alanine transferase and glutathione-S-transferase was indeed observed in the preconditioning group compared with the control group. Morbidity and mortality rates and lengths of ICU and hospitalization stays were similar in both groups.

CONCLUSIONS

IP does not improve liver tolerance to ischemia-reperfusion after hepatectomy under vascular exclusion of the liver with preservation of the caval flow. This maneuver does not improve postoperative liver function and does not affect morbidity or mortality rates. The clinical use of IP through 10 minutes of warm ischemia in this technique of hepatectomy is not currently recommended.

Trans-metastasis hepatectomy: Results of a 21-case study

AIM

The aim of this study was to report the feasibility and efficiency of a new approach, called post-RF trans-metastasis hepatectomy (PRFTMH). This technique consists in using RF to first ablate an ill-located liver metastasis (LM) along the planned hepatectomy resection line, the only one possible for volumetric reasons, and then to perform the hepatectomy passing via this initially ablated LM.

MATERIAL AND METHODS

Twenty-one patients were treated with PRFTMH between January 2000 and May 2004. Thirteen of them had a primary colorectal tumour, four had a primary endocrine tumour and four had miscellaneous primaries. The mean number of LMs per patient was 13.8 (10.7 for primary colorectal tumours and 22.2 for primary endocrine tumours). Pre-operative hypertrophy of the future remaining liver was obtained by selective portal vein embolisation in 11 patients.

RESULTS

One patient died post-operatively (4.7%) and five developed complications (24%). No local recurrence has occurred at the site of PRFTMH after a median follow-up of 19.4 months (range: 47-7), demonstrating the efficacy of this technique. All patients, except the patient who died post-operatively, are currently alive, and the median survival rate has not yet been attained, after a median follow-up of 19.4 months.

CONCLUSION

PRFTMH combining RF ablation and trans-metastasis hepatectomy is a new and safe technique, allowing a curative approach to be proposed to some patients with unresectable bilateral LMs.

Vascular control during hepatectomy: review of methods and results

The various techniques of hepatic vascular control are presented, focusing on the indications and drawbacks of each. Retrospective and prospective clinical studies highlight aspects of the pathophysiology, indications, and morbidity of the various techniques of hepatic vascular control. Newer perspectives on the field emerge from the introduction of ischemic preconditioning and laparoscopic hepatectomy. A literature review based on computer searches in Index Medicus and PubMed focuses mainly on prospective studies comparing techniques and large retrospective ones. All methods of hepatic vascular control can be applied with minimal mortality by experienced surgeons and are effective for controlling bleeding. The Pringle maneuver is the oldest and simplest of these methods and is still favored by many surgeons. Intermittent application of the Pringle maneuver and hemihepatic occlusion or inflow occlusion with extraparenchymal control of major hepatic veins is particularly indicated for patients with abnormal parenchyma. Total hepatic vascular exclusion is associated with considerable morbidity and hemodynamic intolerance in 10% to 20% of patients. It is absolutely indicated only when extensive reconstruction of the inferior vena cava (IVC) is warranted. Major hepatic veins/ and limited IVC reconstruction has been also achieved under inflow occlusion with extraparenchymal control of major hepatic veins or even using the intermittent Pringle maneuver. Ischemic preconditioning is strongly recommended for patients younger than 60 years and those with steatotic livers. Each hepatic vascular control technique has its place in liver surgery, depending on tumor location, underlying liver disease, patient cardiovascular status, and, most important, the experience of the surgical and anesthesia team.

Ischemic preconditioning versus intermittent vascular inflow control during major liver resection in pigs

Ischemic preconditioning (IPC) and intermittent vascular control (IVC) have been shown to reduce the number of ischemia/reperfusion injuries during liver resections with the Pringle maneuver. Our study aimed to compare the beneficial effect of these two modalities in relation to the duration of normothermic liver ischemia. A group of 24 Landrace pigs with a mean body weight of 25 to 30 kg were subjected to extended liver resection of more than 65%. Although, 12 animals underwent IPC (10 minutes of ischemia and 10 minutes of reperfusion), and subsequently the Pringle maneuver was applied for 90 minutes (n= 6) or 120 minutes (n= 6). Another 12 animals underwent liver resection by IVC (20 minutes of ischemia alternated with 5 minutes of reperfusion) for 60 minutes (n = 6) or 120 minutes (n = 6) of inflow vascular control. At 90 minutes of liver ischemia, the IPC group demonstrated lower levels of asportate aminotransferase (AST) (173 +/- 53 vs. 265 +/- 106 IU; p =0.089) and malondialdehyde (MDA) (2.60 +/- 1.03 vs. 5.33 +/- 2.25 micromol/L; p =0.022) and higher liver tissue cAMP (200 +/- 42 vs. 146 +/- 40 pmol/g wet wt, p = 0.04) compared to the IVC group. However, no pathologic differences were observed between the two groups. By contrast, at 120 minutes of liver ischemia, IVC proved to be more beneficial, reflected by lower levels of AST (448 +/- 135 vs. 857 +/- 268 IU; p = 0.006) and MDA (8.33 +/- 1.75 vs. 12.7 +/- 4.31 micromol/L; (p = 0.045), a higher cAMP level (127 +/- 10 vs. 97 +/- 31 pmol/g wet wt p = 0.045), and eventually less cellular necrosis (necrosis score 1.66 +/- 0.51 vs. 2.85 +/- 1.16; p = 0.04) compared to the IPC group. It appears that IPC should be employed when liver ischemia is anticipated to last less than 90 minutes, followed by IVC when the liver ischemia is expected to last 120 minutes.

Hepatic and extrahepatic colorectal metastases: when resectable, their localization does not matter, but their total number has a prognostic effect

BACKGROUND

The presence of extrahepatic disease (EHD) is considered a contraindication to hepatectomy in patients with colorectal liver metastases. After resection, the prognosis is based more on the total number of resected metastases (located inside and outside the liver) than on the site of these metastases (only inside the liver or not).

METHODS

A total of 308 patients with colorectal cancer underwent hepatectomy, and 84 (27%) also underwent resection of miscellaneous EHD. The study was a prospective data registration and retrospective analysis. When considering the total number of resected metastases, each liver metastasis and each EHD location was counted as one lesion. Univariate and multivariate analyses were performed.

RESULTS

The median follow-up was 99 months. The overall 5-year survival rate was 32%. In the multivariate analysis, the total number of metastases (inside or outside the liver) had a greater prognostic value than the criterion "presence or absence of EHD." Considering the total number of resected metastases (whatever their site), 5-year survival rates were 38% (SD: 4%) in the group with one to three metastases, 29% (SD: 5%) in patients with four to six metastases, and 18% (SD: 5%) in patients with more than six metastases (P = .002). A very simple prognostic score based on sex and the total number of metastases is proposed.

CONCLUSIONS

EHD, when resectable, is no longer a contraindication to hepatectomy. More importantly, the total number of the metastases, whatever their location, has a stronger prognostic effect than the site of these metastases.

Vascular occlusion to decrease blood loss during hepatic resection

BACKGROUND

Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed.

METHODS

A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed.

RESULTS

A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals.

CONCLUSIONS

Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.

Hepatectomy plus intraoperative radiofrequency ablation and chemotherapy to treat technically unresectable multiple colorectal liver metastases

BACKGROUND

Results and indications of intra-operative radiofrequency (RF) ablation of liver metastases (LM) are not well defined in the literature.

AIM

To appreciate the survival rate of patients with strictly unresectable LM (defined on technical but not oncological criteria) when undergoing liver resection plus RF, along with optimal systemic chemotherapy.

PATIENTS AND METHODS

Sixty three patients with technically unresectable LM (either >5, or bilateral with no sparing of at least one sector of the liver, or with tumor proximity to central major vascular structures) were treated. Extrahepatic metastases were also resected in 27% of patients. All patients received perioperative chemotherapy. The median follow-up was 27.6 months (range: 15-74).

RESULTS

There was no postoperative mortality and the morbidity rate was 27%. The 2-year overall survival rate of the 63 patients was 67% with a median survival of 36 months. The local recurrence rates were similar for the three types of local treatments: 7.1% for the 154 RF ablations, 7.2% for the 55 wedge resections, and 9% for the 44 segmental anatomic resections (P = 0.216). Hepatic recurrences occurred in 71% of patients.

CONCLUSION

The combination of anatomic segmental and wedge resections, RF ablation, and optimal chemotherapy in patients with technically unresectable LM results in a median survival of 36 months.