Mesohepatektomie

Long-Term Outcomes of Mesohepatectomy for Centrally Located Liver Tumors: Two-Decade Single-Center Experience

BACKGROUND

Mesohepatectomy is a viable treatment option for patients diagnosed with centrally located liver tumors (CLLTs). There are several reports from Eastern centers, but few data are available on this topic from Western centers.

STUDY DESIGN

Data of 128 consecutive patients who underwent mesohepatectomy between September 2000 and September 2020 in our center were analyzed from a prospectively collected database. Patient demographic data, liver tumor characteristics, and intraoperative data were collected. In addition, posthepatectomy bile leakage (PHBL), posthepatectomy hemorrhage (PHH), posthepatectomy liver failure (PHLF), and 90-day mortality after mesohepatectomy were assessed. Long-term outcomes were also reported, and factors that may influence disease-free survival were evaluated.

RESULTS

Of 128 patients, 113 patients (88.3%) had malignant hepatic tumors (primary and metastatic tumors in 41 [32%] and 72 [56.3%] patients, respectively), and 15 patients suffered from benign lesions (11.7%). Among the relevant surgical complications (grade B or C), PHBL was the most common complication after mesohepatectomy and occurred in 11.7% of patients, followed by PHLF in 3.1% of patients and PHH in 2.3% of patients. Only four patients (3.1%) died within 90 days after mesohepatectomy. The 5-year overall survival and overall recurrence (for malignant lesion) rates were 76.5% and 45.1%, respectively.

CONCLUSION

Mesohepatectomy is a safe and feasible surgical treatment with low morbidity and mortality for patients with CLLT. Long-term outcomes can be improved by increased surgical expertise.

A model prediction of long-term prognosis in patients with centrally located hepatocellular carcinoma undergoing hepatectomy

BACKGROUND AND OBJECTIVES

The prognostic prediction for centrally located hepatocellular carcinoma (CL-HCC) after hepatectomy has not been well established. We aimed to develop prognostic nomograms for patients undergoing hepatectomy for CL-HCC.

METHODS

A cohort of 380 patients who underwent curative hepatectomy for CL-HCC at our hospital between 2009 and 2015 were retrospectively studied. We randomly divided the subjects into training (n = 210) and validation (n = 170) groups. Univariate and multivariate survival analysis were used to identify prognostic factors. Visually orientated nomograms were constructed using Cox proportional hazards models. The performance of the nomogram was evaluated by the area under the ROC curve (AUC), calibration curve and compared with the conventional staging systems.

RESULTS

The statistical nomogram for OS built on the basis of ALBI grade, tumor number, tumor size, classification, hepatectomy methods, capsule formation and microvascular invasion (MVI) had good calibration and discriminatory abilities, with AUC of 0.746 (65-month survival). The nomogram for DFS was based on tumor number, tumor size, classification, HBV-DNA load, capsule formation and MVI, with AUC of 0.733 (65-month survival). These nomograms showed satisfactory performance in the validation cohort (AUC, 0.733 for 65-month OS; and 0.702 for 65-month DFS). The AUC of our nomograms were greater than those of conventional staging systems in the validation cohort.

CONCLUSION

The established nomograms might be useful for estimating survival for patients with CL-HCC after liver resection.

Anatomic mesohepatectomy versus extended hepatectomy for patients with centrally located hepatocellular carcinoma

BACKGROUND

Both mesohepatectomy (MH) and extended hepatectomy (EH) can be performed for centrally located hepatocellular carcinoma (HCC). In this study, the long-term prognosis of these surgical approaches was assessed in patients with HCC.

METHODS

A retrospective review was undertaken of 171 HCC patients who underwent anatomic hepatectomy for centrally located HCC between January 2005 and January 2016 in West China Hospital, Sichuan University. The impact of the surgical methods on prognosis was assessed for these patients by multivariable regression analysis. In addition, the patients in the MH group were matched in a 1:2 ratio with EH controls.

RESULTS

In non-adjusted models, patients in the MH group had similar overall survival (OS, p = 0.066) and disease free survival (DFS, p = 0.654) compared to EH patients. After adjusting for all identified confounders, MH patients showed better OS in comparison with patients in the EH group (p = 0.001), while the DFS was similar. In the propensity score-matched (PSM) subset, patients in MH group had better OS (p = 0.033) but similar DFS (p = 0.328) compared to patients in the EH group.

CONCLUSION

Anatomic MH can be recommended as a reasonable surgical option in selected patients with centrally located HCC.

Is less than 5 mm as the narrowest surgical margin width in central resections of hepatocellular carcinoma justified?

BACKGROUND

The aim of this study was to investigate whether <5 mm as the narrowest margin width may negatively affect a patient's outcome.

METHODS

A prospective cohort study was designed. From January 1994 to July 2010, 196 patients with hepatocellular carcinoma undergoing central hepatectomy were divided into group A (n = 172; narrowest margin, ≥5 to <10 mm) and group B (n = 24; narrowest margin, <5 mm), and outcomes were compared.

RESULTS

Significant differences between groups A and B included tumor size (P = .057), infiltrative border (P = .021), satellite lesions (P = .021), and major perivascular abutment (P = .028). Marginal recurrence occurred in 50% of the patients in group B but none of those in group A (P < .001). There were no significant differences between the groups regarding recurrence, recurrence-related death, disease-free survival, and speed of recurrence, but a borderline significant difference was found regarding the cumulative probability of overall survival. After excluding early recurrence (within 1 year), group B had significantly lower cumulative probabilities of disease-free survival (P = .020) and overall survival (P < .001).

CONCLUSIONS

In central resections, narrowest margin width of <5 mm does not negatively affect recurrence and overall survival. However, it increases perimargin recurrence and inversely affects late outcomes.

[Resection of Klatskin tumors]

Curative treatment of Klatskin tumors by radical surgical procedures with surgical preparation distant to the tumor region results in 5-year survival rates of 30-50%. This requires mandatory en bloc liver resection and resection of the extrahepatic bile duct often together with vascular resection. Nevertheless, the ideal safety margin of 0.5-1 cm remote from the macroscopic tumor extensions cannot be achieved in all cases. Based on hilar anatomy the probability of an adequate safety margin is higher using extended right hemihepatectomy together with portal vein resection compared to left hemihepatectomy. However, due to severe atrophy of the left liver lobe solely left-sided hepatectomy is feasible in some patients. In cases of eligibility for both procedures right hemihepatectomy is preferentially used due to the higher oncological radicality if sufficient liver function is present. Postoperative hepatic insufficiency and bile leakage after demanding biliary reconstruction, often with several small orifices, contribute to the postoperative complication rate of this complex surgical disease pattern.

Mesohepatectomy as an option for the treatment of central liver tumors

BACKGROUND

Despite substantial improvements in intra- and postoperative management of extended hemihepatectomy as the curative option for treatment of central liver tumors, the high morbidity and mortality rates accompanying the procedure still represent major obstacles. Mesohepatectomy preserves up to 35% more functional liver tissue than extended hepatectomy, but it has not been widely applied, perhaps because of its complexity as a resection method.

STUDY DESIGN

Forty-eight consecutive patients (29 men and 19 women) with centrally located liver tumors underwent mesohepatectomy. Peri- and postoperative morbidity and mortality rates were prospectively evaluated and analyzed. Mean age of the patients was 60.7 years. Indications for mesohepatectomy were liver metastasis (n = 29), hepatocellular carcinoma (n = 5), gallbladder carcinoma (n = 4), cholangiocellular carcinoma (n = 4), hemangioma (n = 2), and other benign diseases (n = 4).

RESULTS

Mean operative time was 238 minutes (range 65 to 480 minutes) and mean intraoperative blood loss was 1,120 mL (range 100 to 5,000 mL). Mean amount of intraoperative red blood cells and fresh frozen plasma transfusion was 3.6 U (range 1 to 12 U) and 3.8 U (range 2 to 14 U), respectively. Mean postoperative hospitalization was 15.8 days (range 6 to 104 days). Postoperative surgical complications were seen in 18.8% of patients (n = 9) and included liver failure (n = 1), intraabdominal abscess (n = 1), bilioma or bile leakage (n = 4), hemorrhage and hematoma (n = 2), peritonitis because of intestinal perforation (n = 1), and wound infection (n = 1). One patient (2%) died in the early postoperative phase from portal vein bleeding and disseminated intravascular coagulation, followed by liver failure.

CONCLUSIONS

Compared with extended liver resection, mesohepatectomy clearly leads to less parenchymal loss. Although it is a technically difficult operation and requires special attention to prevent surgical complications, it is justified in selected patients with centrally located tumors and is a feasible and safe alternative to extended liver resection.

[Liver resection: prt II. Operative procedure]

Hepatic surgery has grown considerably in importance during the last two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care and particularly advancements in general hepatic surgical techniques. We present the terminology of functional and segmental anatomy of the liver on which current hepatic surgery is based, along with operative strategies for standard, nonconventional, and repeat resections. Intraoperative complications are also discussed.

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.