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Hayashi D, Mizuno T, Kawakatsu S, Baba T, Sando M, Yamaguchi J, Onoe S, Watanabe N, Sunagawa M, Ebata T. Liver remnant volume to body weight ratio of 0.65% as a lower limit in right hepatic trisectionectomy with bile duct resection. Surgery 2024; 175:404-412. [PMID: 37989634 DOI: 10.1016/j.surg.2023.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Previous studies have suggested the utility of an indocyanine green plasma clearance rate of the future liver remnant (FLR) (ICGK-F) ≥0.05 in hepatobiliary resection to reduce the surgical risk. The present study aimed to verify whether future liver remnant size rather than ICGK-F matters in extended hepatobiliary resection. METHODS Between 2004 and 2021, patients who underwent right hepatic trisectionectomy with bile duct resection were included. The effect of the FLR volume-to-body weight ratio (FLR/BW) and ICGK-F on posthepatectomy liver failure was evaluated along with other parameters. RESULTS Among 91 study patients, the median ICGK-F, FLR, and FLR/BW were 0.057 (range, 0.027-0.099), 392 mL (145-705), and 0.78% (0.40-1.37), respectively. Posthepatectomy liver failure occurred in 23 patients. The incidence was 10 (40%) in 25 patients with an ICGK-F <0.05 and 12 (18%) in 65 patients with an ICGK-F ≥0.05 (P = .053); 13 (52%) in 25 patients with a FLR/BW <0.65% and 10 (15%) in 66 patients with a FLR/BW ≥0.65% (P = .001). Multivariate analysis showed that a FLR/BW <0.65% (odds ratio, 11.7; P = .005), age ≥65 years (odds ratio, 31.7; P < .001), and blood loss ≥25 mL/kg (odds ratio, 22.1; P = .004) were independent predictors of posthepatectomy liver failure, but ICGK-F <0.05 was not (P = .499). According to the meeting number of 3 factors, posthepatectomy liver failure incidence was 0 of 22 (0%) in patients with 0 factors, 6 of 43 (14%) in patients with 1, and 17 of 26 (65%) in patients with 2 or 3 (P < .001). CONCLUSION A FLR/BW ≥0.65% may serve as a volumetric basis to reduce posthepatectomy liver failure after extended hepatobiliary resection.
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Affiliation(s)
- Daisuke Hayashi
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Shoji Kawakatsu
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Taisuke Baba
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Masanori Sando
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Masaki Sunagawa
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan.
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Kawano F, Yoshioka R, Ichida H, Mise Y, Saiura A. Essential updates 2021/2022: Update in surgical strategy for perihilar cholangiocarcinoma. Ann Gastroenterol Surg 2023; 7:848-855. [PMID: 37927920 PMCID: PMC10623956 DOI: 10.1002/ags3.12734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/21/2023] [Accepted: 08/10/2023] [Indexed: 11/07/2023] Open
Abstract
Resection is the only potential curative treatment for perihilar cholangiocarcinoma (PHC); however, complete resection is often technically challenging due to the anatomical location. Various innovative approaches and procedures were invented to circumvent this limitation but the rates of postoperative morbidity (20%-78%) and mortality (2%-15%) are still high. In patients diagnosed with resectable PHC, deliberate and coordinated preoperative workup and optimization of the patient and future liver remnant are crucial. Biliary drainage is recommended to relieve obstructive jaundice and optimize the clinical condition before liver resection. Biliary drainage for PHC can be performed either by endoscopic biliary drainage or percutaneous transhepatic biliary drainage. To date there is no consensus about which method is preferred. The volumetric assessment of the future remnant liver volume and optimization mainly using portal vein embolization is the gold standard in the management of the risk to develop post hepatectomy liver failure. The improvement of systemic chemotherapy has contributed to prolong the survival not only in patients with unresectable PHC but also in patients undergoing curative surgery. In this article, we review the literature and discuss the current surgical treatment of PHC.
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Affiliation(s)
- Fumihiro Kawano
- Department of Hepatobiliary‐Pancreatic SurgeryJuntendo University Graduate School of MedicineHongo, TokyoJapan
| | - Ryuji Yoshioka
- Department of Hepatobiliary‐Pancreatic SurgeryJuntendo University Graduate School of MedicineHongo, TokyoJapan
| | - Hirofumi Ichida
- Department of Hepatobiliary‐Pancreatic SurgeryJuntendo University Graduate School of MedicineHongo, TokyoJapan
| | - Yoshihiro Mise
- Department of Hepatobiliary‐Pancreatic SurgeryJuntendo University Graduate School of MedicineHongo, TokyoJapan
| | - Akio Saiura
- Department of Hepatobiliary‐Pancreatic SurgeryJuntendo University Graduate School of MedicineHongo, TokyoJapan
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Emmen AMLH, Görgec B, Zwart MJW, Daams F, Erdmann J, Festen S, Gouma DJ, van Gulik TM, van Hilst J, Kazemier G, Lof S, Sussenbach SI, Tanis PJ, Zonderhuis BM, Busch OR, Swijnenburg RJ, Besselink MG. Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections. Surg Endosc 2023; 37:2659-2672. [PMID: 36401105 PMCID: PMC10082117 DOI: 10.1007/s00464-022-09735-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center. METHODS Single center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010-February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications. RESULTS Among 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100-500] to 150 ml [IQR 50-300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001). CONCLUSION The introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value.
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Affiliation(s)
- Anouk. M. L. H. Emmen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B. Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - M. J. W. Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F. Daams
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - J. Erdmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S. Festen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - D. J. Gouma
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - T. M. van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - G. Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - S. Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S. I. Sussenbach
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B. M. Zonderhuis
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - O. R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R. J. Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - M. G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - for HPB-Amsterdam
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
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