"Radical but conservative" is the main goal for ultrasonography-guided liver resection: prospective validation of this approach

Achievement of textbook outcome after hepatectomy combined with thermal ablation for colorectal liver metastases

BACKGROUND

Hepatic resection combined with intraoperative ablation has been described as a technical solution potentially widening the resectability rate of patients with colorectal liver metastases (CRLM). Nevertheless, the perioperative and oncological benefit provided by this combined approach remains unclear. We hypothesized that textbook outcome (TO), which is a composite measure achieved for patients for whom some desired health indicators are met, may help to refine the indications of this approach.

METHODS

Patients submitted to hepatectomy with curative intent in combination with radiofrequency ablation or microwave ablation for CRLM ≤ 3 cm in two tertiary referral centers were included. TO was defined according to a recent definition for liver surgery based on a Delphi process including also the achievement of complete radiological response of the ablated lesion/s at 4 weeks.

RESULTS

Between 2015 and 2022, 112 patients were enrolled. Among them, 63 (56.2%) achieved a TO. According to multivariate analysis, minimally invasive (MI) approach (OR 2.72, 95% CI 0.99-7.48, p = 0.050), simultaneous CR resection (OR 0.28, 95% CI 0.11-0.70, p = 0.007), tumor burden score (OR 0.89, 95% CI 0.82-0.96, p = 0.004), and major hepatectomy (OR 0.12, 95% CI 0.03-0.52, p = 0.004) were significantly associated with the achievement of TO. Median overall survival was longer in those patients who were able to achieve a TO compared to those who did not.

CONCLUSIONS

The combination of hepatectomy and ablation constitutes a valuable solution in patients affected by multiple CRLM and it may provide, also using a MI approach, adequate perioperative and oncological outcomes, allowing to achieve TO, however, in a selected number of patients and depending on several factors including the burden of disease.

Robotic versus open resection for colorectal liver metastases in a "referral centre Hub&Spoke learning program". A multicenter propensity score matching analysis of perioperative outcomes

Background

Surgical resection is still considered the optimal treatment for colorectal liver metastasis (CRLM). Although laparoscopic and robotic surgery demonstrated their reliability especially in referral centers, the comparison between perioperative outcomes of robotic liver resection (RLR) and open (OLR) liver resection are still debated when performed in referral centers for robotic surgery, not dedicated to HPB. Our study aimed to verify the efficacy and safety of perioperative outcomes after RLR and OLR for CRLM in an HUB&Spoke learning program (H&S) between a high volume center for liver surgery and high volume center for robotic surgery.

Methods

We analyzed prospective databases of Pineta Grande Hospital (Castel Volturno) and Robotic Surgical Units (Foligno-Spoleto and Arezzo) from 2011 to 2021. A 1:1 propensity score matching (PSM) was performed according to baseline characteristics of patients, solitary/multiple CRLM, anterolateral/posterosuperior location.

Results

383 patients accepted to be part of the study (268 ORL and 115 RLR). After PSM, 45 patients from each group were included. Conversion rate was 8.89 %. RLR group had a significantly lower blood loss (226 vs. 321 ml; p=0.0001), and fewer major complications (13.33 % vs. 17.78 %; p=0.7722). R0 resection was obtained in 100% of OLR (vs.95.55%, p =0.4944. Hospital stay was 8.8 days in RLR (vs. 15; p=0.0001).Conclusion: H&S represents a safe and effective program to train general surgeons also in Hepatobiliary surgery providing R0 resection rate, blood loss volume and morbidity rate superimposable to referral centers. Furthermore, H&S allow a reduction of health mobility with consequent money saving for patients and institutions.

Resection of Colorectal Liver Metastases with Major Vessel Involvement

BACKGROUND

Treatment of CRLM with major vessel involvement is still challenging and valid data on outcomes are still rare. We analyzed our experience of hepatectomies with resection and reconstruction of major hepatic vessels with regard to operative and perioperative details, histopathological findings and oncological outcome.

METHODS

Data of 32 hepatectomies with major hepatic vessel resections and reconstructions were included. Results were correlated with perioperative and oncological outcome.

RESULTS

Out of 1236 surgical resections due to CRLM, we performed 35 major hepatic vessel resections and reconstructions in 32 cases (2.6%) during the study period from January 2008 to March 2023. The vena cava inferior (VCI) was resected and reconstructed in 19, the portal vein (PV) in 6 and a hepatic vein (HV) in 10 cases. Histopathological examination confirmed a vascular infiltration in 6/32 patients (VCI 3/17, HV 2/10 and PV 1/6). There were 27 R0 and 5 R1 resections. All R1 situations affected the parenchymal margin. Vascular wall margins were R0. Ninety-day mortality was 0. The median overall survival (OS) for the patient group with vascular infiltration (V1) was 21 months and for the V0 group 33.3 months.

CONCLUSION

Liver resections with vascular resection and reconstruction are rare and histological vessel infiltration occurs seldom. In cases with presumed vascular wall infiltration, liver resection combined with major vessel resection and reconstruction can be performed with low morbidity and mortality. We prefer a parenchymal sparing liver resection with vascular resection and reconstruction to achieve negative resection margins, but in technically difficult cases with higher risk for postoperative complications, tumor detachment from vessels without resection is a most reasonable surgical alternative.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223 min (range 181-260 min). The median blood loss was 200 ml (range 150-310 ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

Intraoperative Imaging in Hepatopancreatobiliary Surgery

Hepatopancreatobiliary surgery belongs to one of the most complex fields of general surgery. An intricate and vital anatomy is accompanied by difficult distinctions of tumors from fibrosis and inflammation; the identification of precise tumor margins; or small, even disappearing, lesions on currently available imaging. The routine implementation of ultrasound use shifted the possibilities in the operating room, yet more precision is necessary to achieve negative resection margins. Modalities utilizing fluorescent-compatible dyes have proven their role in hepatopancreatobiliary surgery, although this is not yet a routine practice, as there are many limitations. Modalities, such as photoacoustic imaging or 3D holograms, are emerging but are mostly limited to preclinical settings. There is a need to identify and develop an ideal contrast agent capable of differentiating between malignant and benign tissue and to report on the prognostic benefits of implemented intraoperative imaging in order to navigate clinical translation. This review focuses on existing and developing imaging modalities for intraoperative use, tailored to the needs of hepatopancreatobiliary cancers. We will also cover the application of these imaging techniques to theranostics to achieve combined diagnostic and therapeutic potential.

Tumor attachment to Major intrahepatic vascular for Colorectal liver metastases

BACKGROUND

Colorectal liver metastases attached major intrahepatic vessels has been considered to be a risk factor for survival outcome after liver resection. The present study aimed to clarify the outcomes of R1 surgery (margin < 1 mm) in CRLM patients, distinguishing parenchymal margin R1 and attached to major intrahepatic vessels R1.

METHODS

In present study, 283 CRLM patients who were evaluated to be attached to major intrahepatic vessels initially and underwent liver resection following preoperative chemotherapy. They were assigned to two following groups: R0 (n = 167), R1 parenchymal (n = 58) and R1 vascular (n = 58). The survival outcomes and local recurrence rates were analyzed in each group.

RESULTS

Overall, 3- and 5-year overall survival rates after liver resection were 53.0% and 38.2% (median overall survival 37 months). Five-year overall survival was higher in patients with R0 than parenchymal R1 (44.9%% vs. 26.3%, p = 0.009), whereas there was no significant difference from patients with vascular R1 (34.3%, p = 0.752). In the multivariable analysis, preoperative chemotherapy > 4 cycles, clinical risk score 3-5, RAS mutation, parenchymal R1 and CA199 > 100 IU/ml were identified as independent predictive factors of overall survival (p < 0.05). There was no significant difference for local recurrence among three groups.

CONCLUSION

Parenchymal R1 resection was independent risk factor for CRLM. Vascular R1 surgery achieved survival outcomes equivalent to R0 resection. Non-anatomic liver resection for CRLM attached to intrahepatic vessels might be pursued to increase patient resectability by preoperative chemotherapy.

Prognostic impact of R1 resection margin in synchronous and simultaneous colorectal liver metastasis resection: a retrospective cohort study

BACKGROUND

A margin ≥ 1 mm is considered a standard resection margin for colorectal liver metastasis (CRLM). However, microscopic incomplete resection (R1) is not rare since aggressive surgical resection has been attempted in multiple and bilobar CRLM. This study aimed to investigate the prognostic impact of resection margins and perioperative chemotherapy in patients with CRLM.

METHODS

A total of 368 of 371 patients who underwent simultaneous colorectal and liver resection for synchronous CRLM between 2006 and June 2017, excluding three R2 resections, were included in this study. R1 resection was defined as either abutting tumor on the resection line or involved margin in the pathological report. The patients were divided into R0 (n = 304) and R1 (n = 64) groups. The clinicopathological characteristics, overall survival, and intrahepatic recurrence-free survival were compared between the two groups using propensity score matching.

RESULTS

The R1 group had more patients with ≥ 4 liver lesions (27.3 vs. 50.0%, P < 0.001), higher mean tumor burden score (4.4 vs. 5.8%, P = 0.003), and more bilobar disease (38.8 vs. 67.2%, P < 0.001) than the R0 group. Both R0 and R1 groups showed similar long-term outcomes in the total cohort (OS, P = 0.149; RFS, P = 0.414) and after matching (OS, P = 0.097, RFS: P = 0.924). However, the marginal recurrence rate was higher in the R1 group than in the R0 group (26.6 vs. 16.1%, P = 0.048). Furthermore, the resection margin did not have a significant impact on OS and RFS, regardless of preoperative chemotherapy. Poorly differentiated, N-positive stage colorectal cancer, liver lesion number ≥ 4, and size ≥ 5 cm were poor prognostic factors, and adjuvant chemotherapy had a positive impact on survival.

CONCLUSIONS

The R1 group was associated with aggressive tumor characteristics; however, no effect on the OS and intrahepatic RFS with or without preoperative chemotherapy was observed in this study. Tumor biological characteristics, rather than resection margin status, determine long-term prognosis. Therefore, aggressive surgical resection should be considered in patients with CRLM expected to undergo R1 resection in this multidisciplinary approach era.

Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?

Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.

Transversal hepatectomies: Classification and intention-to-treat validation of new parenchyma-sparing procedures for deep-located hepatic tumors

BACKGROUND

Deep-located liver tumors involving hepatic veins at the caval confluence or main Glissonean pedicles generally require a major hepatectomy. An intraoperative ultrasound guidance policy opened a possibility to opt for parenchyma-sparing procedures as alternatives to major hepatectomy, called transversal hepatectomies. We ought to standardize the procedure and analyze the surgical outcome, oncological suitability, and salvageability.

METHODS

This is a retrospective cohort study. All consecutive patients undergoing hepatectomies for liver tumors between January 2005 and August 2020 were reviewed. Transversal hepatectomies were classified as follows: upper transversal hepatectomy: resection of the posterosuperior segments along with at least 1 hepatic vein and preservation of the anteroinferior ones; roller coaster hepatectomy: transversal hepatectomy with tumor vessel detachment from at least 2 hepatic veins; and lower transversal hepatectomy: amputation of the distal portion of at least 1 hepatic vein with tumor vessel detachment from first/second-order Glissonean pedicles. Morbidity, mortality, local recurrences, and salvageability in cases of relapse were considered.

RESULTS

A total of 61 transversal hepatectomies were performed: 40 (66%) upper transversal hepatectomies, 19 (31%) roller coaster hepatectomies, and 2 (3%) lower transversal hepatectomies. The median preserved liver volume was 67% (range 41-86). Mortality was 0, and major morbidity was 6%. Local recurrence occurred in 7 (11%) patients. Ten out of 34 (29%) patients with liver-only recurrence received redo surgery.

CONCLUSION

Transversal hepatectomies offer a new parenchyma-sparing perspective for the management of complex tumor presentation, which would otherwise demand major tissue removal or even unresectability. Safety, adequate local control, and salvageability are further pillars of this approach herein systematized.

Surgical Strategies for Recurrent Hepatocellular Carcinoma after Resection: A Review of Current Evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, and both liver resection and liver transplantation are considered potentially curative options. However, high recurrence rates affect the prognosis depending both on the primary HCC pathology characteristics or on the type and time of the relapse. While great attention has been usually posted on treatment algorithms for the first HCC, treatment algorithms for recurrent HCC (rHCC) are lacking. In these cases, surgery still represents a curative option with both redo hepatectomy and/or salvage liver transplantation, which are considered valid treatments in selected patients. In the current era of personalised medicine with promises of new systemic-targeted immuno-chemotherapies, we wished to perform a narrative review of the literature on the role of surgical strategies for rHCC.

Efficacy of laparoscopic repeat hepatectomy compared with open repeat hepatectomy: a single-center, propensity score matching study

Introduction

Laparoscopic repeat hepatectomy (LRH) is considered to be a technically challenging procedure which has not been widely applied. This study aimed to assess the accessibility and security of LRH for patients with hepatic tumor recurrence.

Methods

Between January 2010 and October 2020, we performed 48 LRHs and 31 open repeat hepatectomies (ORHs) for recurrent liver cancer. LRHs were matched to ORHs (1:1) using propensity score matching (PSM) created by comparing preoperative factors. The perioperative data of patients were retrospectively analyzed, including baseline data, operative time, intraoperative blood loss, pathology, days of postoperative stay, complication morbidity, and mortality within 30 days. Overall survival and recurrence-free survival rates with appropriate follow-up were obtained to evaluate the long-term outcomes.

Results

Compared with the ORH, LRH was related with shorter operative duration (169.9 versus 232.9 ml, p < 0.01), less intraoperative bleeding (100.0 versus 500.0 ml, p < 0.01), lower rate of blood transfusion (8.3% versus 58.1%, p < 0.01), and shorter hospitalization (5.0 versus 11.0 days, p < 0.01). The median follow-up was 31 months. The LRH 1-, 3-, and 5-year overall survival were 77.1%, 61.6%, and 46.2% versus 82.3%, 66.5%, and 29.5% for ORH (p = 0.77). The 1-, 3-, and 5-year disease-free survival rates of the two groups were 73.4%, 62.0%, and 44.3% versus 66.1%, 44.1%, and 14.7%, respectively (p = 0.22).

Conclusions

Laparoscopic repeated hepatectomy is safe and practicable with great short-term results for selected patients.

The Histopathological Growth Pattern of Colorectal Liver Metastases Impacts Local Recurrence Risk and the Adequate Width of the Surgical Margin

BACKGROUND

The histopathological growth pattern (HGP) of colorectal liver metastases (CLM) has been associated with prognosis. This study was designed to elucidate if the HGP is associated with local recurrence risk and impacts the adequate width of surgical margin.

METHODS

All consecutive patients resected for CLM in 2018-2019 were considered. HGP was prospectively classified as follows: desmoplastic, pushing, and replacement. Surgical margin was classified as follows: R0 (margin ≥ 1 mm), R1vasc (0-mm margin, tumor detachment from intrahepatic vessels), and R1par (tumor exposure along transection plane). R0 resections were further distinguished in R0min (1-mm margin) and R0wide (> 1-mm margin).

RESULTS

A total of 340 resection areas in 136 patients were analyzed (70 R0min, 143 R0wide, 31 R1vasc, 96 R1par). HGP was desmoplastic in 26 cases, pushing in 221, and replacement in 93. Thirty-six local recurrences occurred (11%, median follow-up 21 months): 1 after R0wide, 4 after R0min, 3 after R1vasc, and 28 after R1par resection. In R1par group, local recurrence rate was high independently of HGP (29%). In R1vasc and R0min groups, local recurrence risk was higher in the replacement group (R1vasc: 29% vs. 4% if pushing/desmoplastic; R0min: 11% vs. 4%). In R0wide group, local recurrence risk was low for all HGP ( < 1%). Independent predictors of local recurrence were replacement HGP (odds ratio = 1.654, P = 0.036), and R1par resection (odds ratio = 57.209, P < 0.001 vs. R0).

CONCLUSIONS

Replacement HGP is associated with an increased risk of local recurrence. In these patients, a wide surgical margin should be pursued, because R1vasc and R0min resections could be insufficient. R1par resection is inadequate, independently of the HGP.

Left Anterior Sectorectomy: An Alternative to Left Hepatectomy for Tumors Invading the Distal Part of the Left Portal Vein

Background: Liver tumors invading the distal part of the umbilical portion of the left portal vein usually require left hepatectomy. The recent introduction of the concept of left anterior sector, an independent anatomo-functional unit including the anterior portion of the left liver and supplied by the distal part of the umbilical portion of the left portal vein, could represent the rational for an alternative surgical approach. The aim of this study was to introduce the novel surgical procedure of ultrasound-guided left anterior sectorectomy. Methods: Among 92 consecutive patients who underwent hepatectomy, 3 patients with tumor invading the distal part of the umbilical portion of the left portal (two with colorectal liver metastases and one with neuroendocrine tumor liver metastases) underwent left anterior sectorectomy alone or in association with liver multiple metastasectomies. Results: Mean operation time was 393 min; post-operative morbidity and mortality were not observed. After a mean FU of 23 months (range 19–28), no local recurrence occurred. Conclusions: In presence of tumors invading the distal part of the umbilical portion of the left portal, left anterior sectorectomy could be considered as an anatomic radical surgical option that is safe but more conservative than a left hepatectomy.

Early Diagnosis of Liver Metastases from Colorectal Cancer through CT Radiomics and Formal Methods: A Pilot Study

BACKGROUND

Liver metastases are a leading cause of cancer-associated deaths in patients affected by colorectal cancer (CRC). The multidisciplinary strategy to treat CRC is more effective when the radiological diagnosis is accurate and early. Despite the evolving technologies in radiological accuracy, the radiological diagnosis of Colorectal Cancer Liver Metastases (CRCLM) is still a key point. The aim of our study was to define a new patient representation different by Artificial Intelligence models, using Formal Methods (FMs), to help clinicians to predict the presence of liver metastasis when still undetectable using the standard protocols.

METHODS

We retrospectively reviewed from 2013 to 2020 the CT scan of nine patients affected by CRC who would develop liver lesions within 4 months and 8 years. Seven patients developed liver metastases after primary staging before any liver surgery, and two patients were enrolled after R0 liver resection. Twenty-one patients were enrolled as the case control group (CCG). Regions of Interest (ROIs) were identified through manual segmentation on the medical images including only liver parenchyma and eventual benign lesions, avoiding major vessels and biliary ducts. Our predictive model was built based on formally verified radiomic features.

RESULTS

The precision of our methods is 100%, scheduling patients as positive only if they will be affected by CRCLM, showing a 93.3% overall accuracy. Recall was 77.8%.

CONCLUSION

FMs can provide an effective early detection of CRCLM before clinical diagnosis only through non-invasive radiomic features even in very heterogeneous and small clinical samples.

Contrast-Enhanced Intraoperative Ultrasonography with Kupffer Phase May Change Treatment Strategy of Metastatic Liver Tumors - A Single-Centre Prospective Study

Aim

To compare the diagnostic performance of contrast-enhanced intraoperative ultrasonography (CE-IOUS) with Kupffer phase in metastatic liver tumours.

Methods

Twenty-seven consecutive patients with liver metastasis were prospectively recruited from November 2019 to July 2020 in the Department of HPB, Beijing Hospital. MRI and Contrast Enhanced Ultrasonography (CEUS) were obtained preoperatively, and the diagnosis was made by radiologists independently and blindly. Intraoperative ultrasonography (IOUS) and CE-IOUS with Sonazoid were done by the same sophisticated surgeon and sonographer and Kupffer phase was used to detect lesions. The sensitivity and specificity to detect lesions were compared between different radiologic methods. Then, the changes in treatment strategy due to CE-IOUS with Sonazoid were analysed.

Results

Twenty-seven patients were included. In MRI, 91 lesions were detected with sensitivity 93.3% (70/75) and specificity 68.8% (11/16). In CEUS, it was 97.1% (68/70) and 86.7% (13/15) in 85 lesions. Meanwhile, in the Kupffer phase in CE-IOUS, 99 lesions were found and 8 new lesions were discovered in 7 cases, with sensitivity 97.5% (80/82) and specificity 94.1% (16/17). The four imaging methods showed no statistic significance in sensitivity and specificity in detecting lesions (Cochran’s Q 10.825, P=0.055). Treatment strategies were altered in 7 patients, 6 achieved R0 resection or ablation, and 1 patient changed from planned R0 resection to palliative surgery.

Conclusion

CE-IOUS may play a similar or even better role than other radiological methods in diagnosing liver metastasis. The CE-IOUS using Sonazoid demonstrated a high sensitivity and specificity for finding occult metastases intraoperatively and changing the treatment strategy.

The evolution of surgery for colorectal liver metastases: A persistent challenge to improve survival

Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.

Prediction of remnant liver volume using 3D simulation software in patients undergoing R1vasc parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases: reliability, clinical impact, and learning curve

BACKGROUND

Assessment of the future liver remnant (FLR) is routinely performed before major hepatectomy. In R1-vascular one-stage hepatectomy (R1vasc-OSH), given the multiplanar dissection paths, the FLR is not easily predictable. Preoperative 3D-virtual casts may help. We evaluated the predictability of the FLR using the 3D-virtual cast in the R1vasc-OSH for multiple bilobar colorectal liver metastases (CLM).

METHODS

Thirty consecutive patients with multiple bilobar CLMs scheduled for R1vasc-OSH were included. Predicted and real-FLRs were compared. Propensity score-matched analysis was used to determine the impact of 3D-virtual cast on postoperative complications.

RESULTS

Median number of CLM and resection areas were 12 (4-33) and 3 (1-8). Median predicted-FLR was 899 ml (558-1157) and 60% (42-85), while for the real-FLR 915 ml (566-1777) and 63% (43-87). Median discrepancy between predicted and real-FLR was -0.6% (p = 0.504), indicating a slight tendency to underestimate the FLR. The difference was more evident in more than 12 CLMs (p = 0.013). A discrepancy was not evident according to the number of resection areas (p = 0.316). No mortality occurred. Patients in virtual-group had lower major complications compared to nonvirtual-group (0% vs 18%, p-value 0.014).

CONCLUSION

FLR estimation based on 3D-analysis is feasible, provides a safe surgery and represents a promising method in planning R1vasc-OSH for patients with multiple bilobar CLMs.

Total upper transversal hepatectomy with outflow reconstruction for advanced mass-forming cholangiocarcinoma

We describe a complex case of extended hepatectomy with venous outflow reconstruction for the treatment of advanced mass-forming cholangiocarcinoma (MFCCC) invading the three main hepatic veins (HVs). A 50-year-old woman who received a diagnosis of MFCCC and judged unresectable, was referred to our hospital. After multidisciplinary team evaluation, the patient underwent abdominal computed tomography, gadoxetic acid-enhanced magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography. The radiological examinations showed a large mass located in S4s-8 and S1, in contact with the right hepatic vein (RHV), the inferior right hepatic vein, the anterior wall of the inferior vena cava (IVC), infiltrating the middle and left hepatic veins (MHV, LHV). Several communicating veins between the RHV, MHV and LHV were detected. The case was further investigated, and the surgical strategy planned by means of using three-dimensional simulation software. A total upper transversal hepatectomy with resection of the main HVs and outflow reconstruction was performed. The outflow of the remnant liver was restored performing a vascular anastomosis between the parenchymal stump of the RHV and the IVC. Meticulous review of pre-operative imaging techniques with three-dimensional simulation of hepatectomy together with advanced use of intra-operative ultrasound allowed us to offer the chance of cure to a patient otherwise considered unresectable.

Colorectal liver metastases: ADC as an imaging biomarker of tumor behavior and therapeutic response

PURPOSE

To correlate the ADC values of colorectal liver metastases, evaluated before (preADC) and after (postADC) neoadjuvant chemotherapy (ChT), as well as their difference (ΔADC), with the histological tumor regression grade (TRG) and to determine whether the preADC value can be predictive of the lesion ChT response.

METHOD

Twenty-four patients with colorectal liver metastases, who had undergone 3 T-MRI before and after ChT and were subsequently treated by parenchymal-spearing surgery, were retrospectively included. Diffusion-weighted MRI (DW-MRI) was performed using a spin-echo echo-planar sequence with multiple b values, obtaining an ADC map. Fitted ADC values were calculated for each lesion before and after ChT. The maximum diameter of each lesion in both examinations was recorded. Diameter variations and RECIST1.1 criteria were assessed. All MRI findings were histopathologically correlated to TRG of resected liver metastases. Statistical analysis was performed on a per-lesion basis.

RESULTS

A total of 58 colorectal liver metastases were analysed; after ChT, 8 out of 58 lesions disappeared. TRG1, TRG2, TRG3, TRG4 and TRG5 were observed in 6, 12, 12, 13 and 7 lesions, respectively. The preADC values showed a different distribution according to the TRG scores (p = 0.0027), even though the distribution was not linear. The postADC and ΔADC values were significant different based on the TRG system (both p < 0.0001). A significant correlation between the lesion TRG and the evaluation according to RECIST1.1 criteria was observed by a per-lesion analysis (p = 0.0009).

CONCLUSIONS

PostADC and ΔADC could be proposed as reliable biomarkers to assess tumor treatment response after preoperative ChT in patients with colorectal liver metastases.

Prognostic Value of Metabolic Imaging Data of 11C-choline PET/CT in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma

Simple Summary

Few data are available for the use of ¹¹C-choline positron emission tomography/computed tomography (PET/CT) in patients with hepatocellular carcinoma (HCC). The aim of the study was to analyze the clinical impact of this metabolic imaging in patients with HCC candidates for hepatectomy. Seven parameters were recorded for PET/CT in 60 patients. The Cox regression for overall survival (OS) showed that Barcelona stages (p = 0.003) and metabolic tumor volume (MTV) (p = 0.026) were the only factors independently associated with OS and furthermore, curve analysis revealed MTV ability in predicting OS. Patients with MTV ≥ 380 had worse OS (p = 0.015). The use of ¹¹C-choline PET/CT allows for better prognostic refinement in patients undergoing hepatectomy for HCC: integration of such metabolic modality into HCC staging system should be considered.

Abstract

¹¹C-choline positron emission tomography/computed tomography (PET/CT) has been used for patients with some types of tumors, but few data are available for hepatocellular carcinoma (HCC). We queried our prospective database for patients with HCC staged with ¹¹C-choline PET/CT to assess the clinical impact of this imaging modality. Seven parameters were recorded: maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), liver standardized uptake value (SUVliver), metabolic tumor volume (MTV), photopenic area, metabolic tumor burden (MTB = MTVxSUVmean), and SUVratio (SUVmax/SUVliver). Analysis was performed to identify parameters that could be predictors of overall survival (OS). Sixty patients were analyzed: fourteen (23%) were in stage 0-A, 37 (62%) in stage B, and 9 (15%) in stage C of the Barcelona classification. The Cox regression for OS showed that Barcelona stages (HR = 2.94; 95%CI = 1.41–4.51; p = 0.003) and MTV (HR = 2.11; 95%CI = 1.51–3.45; p = 0.026) were the only factors independently associated with OS. Receiver operating characteristics curve analysis revealed MTV ability in discriminating survival (area under the curve (AUC) = 0.77; 95%CI = 0.57–097; p < 0.001: patients with MTV ≥ 380 had worse OS (p = 0.015)). The use of ¹¹C-choline PET/CT allows for better prognostic refinement in patients undergoing hepatectomy for HCC. Incorporation of such modality into HCC staging system should be considered.

Current role of intraoperative ultrasonography in hepatectomy

Hepatectomy had a high mortality rate in the previous decade because of inadequate techniques, intraoperative blood loss, liver function reserve misdiagnoses, and accompanying postoperative complications. However, the development of several modalities, including intraoperative ultrasonography (IOUS), has made hepatectomy safer. IOUS can provide real-time information regarding the tumor position and vascular anatomy of the portal and hepatic veins. Systematic subsegmentectomy, which leads to improved patient outcomes, can be performed by IOUS in open and laparoscopic hepatectomy. Although three-dimensional (3D) computed tomography and gadoxetic acid-enhanced magnetic resonance imaging have been widely used, IOUS and contrast-enhanced IOUS are important modalities for risk analyses and making decisions regarding resectability and operative procedures because of the vital anatomical information provided and high sensitivity for liver tumors, including "disappearing" liver metastases. Intraoperative color Doppler ultrasonography can be used to delineate the vascular anatomy and evaluate the blood flow volume and velocity in hepatectomy patients and recipients of deceased- and living-donor liver transplantation after vessel reconstruction and liver positioning. For liver surgeons, IOUS is an essential technique to perform highly curative hepatectomy safely, although recent advances have also been made in virtual modalities, such as real-time virtual sonography with 3D visualization.

Assessment of the American College of Surgeons surgical risk calculator of outcomes after hepatectomy for liver tumors: Results from a cohort of 950 patients

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator has been endorsed to counsel patients regarding complications. The aim of this study was to assess its ability to predict outcomes after hepatectomy.

METHODS

Outcomes generated by the ACS-NSQIP were recorded in a consecutive cohort of patients. By using established classifications of complications, post-hepatectomy insufficiency and bile leak, the calculator was tested by the comparison of expected versus observed rates of events. The performance of the calculator was tested by using c-statistic and Brier score.

RESULTS

950 patients who underwent hepatectomy between January 2014 and June 2019 were included. Predicted rates were significantly lower than actual rates: the mean ACS-NSQIP morbidity was 17.97% ± 8.4 vs. actual 37.01% ± 0.56 (P < 0.001); the mean ACS-NSQIP mortality was 0.91% ± 1.48 vs. actual 1.76% ± 0.11 (P < 0.001). Predicted length of stay (LOS) was significantly shorter: mean ACS-NSQIP was 5.81 ± 1.66 days vs. actual 10.91 ± 4.6 days (P < 0.001). Post-hepatectomy liver insufficiency and bile leak were recorded in 6.8% and 11.9% of patients, respectively. These events were not expressed by the calculator. C-statistic and Brier scores showed low performance of the calculator.

CONCLUSION

The calculator underestimates the risks of complications, mortality and LOS after hepatectomy. Refinements of the ACS-NSQIP model that account for organ-specific risks should be considered.

Microscopic resection margins adversely influence survival rates after surgery for colorectal liver metastases: An open ambidirectional Cohort Study

BACKGROUND

Liver resection is the most effective treatment for patients with colorectal liver metastases (CRLMs). Patients with tumour at the resection margin (R1) are reported to have worse survival compared to those with an uninvolved resection margin (R0). Recent data has questioned this finding. This study investigates whether R1 resections adversely influence survival when compared to R0 resections.

MATERIAL AND METHODS

Patients undergoing surgery for CRLM, identified from a prospectively maintained database, from January 2007 to January 2017, were included. Univariate and multivariate survival analyses were performed. p < 0.05 was significant.

RESULTS

282 patients were included. Median age 72 (32-90) years. 236 patients (83.7%) had chemotherapy and surgery, whilst 46 (16.3%) had surgery alone. 149 patients (52.8%) were alive at the end of the study period. R1 resection on univariate survival analysis was associated with better survival (HR 2.12, 95%CI 1.60-4.61, p = 0.0002). Multivariate analysis controlling for age and gender, identified presence of extrahepatic disease (HR 2.03, 95%CI 1.17-3.52, p < 0.001), R0 resection (HR 0.33, 95%CI 0.19-0.59, p = 0.003), primary tumour stage (HR 1.57, 95%CI 1.04-2.40, p = 0.034) and primary tumour differentiation (HR 2.56, 95%CI 1.01-6.46, p = 0.047), as prognostic factors for poorer survival. Five-year and 10-year survival were 54.3% and 41.7% respectively in patients with an R0 resection and, 25.8% and 17.2% in those with an R1 resection.

CONCLUSION

The presence of extrahepatic disease, an R1 resection margin, advanced T-stage and poorer tumour differentiation were associated with worse survival in CRLM surgery and R0 resection is recommended.

Laparoscopic versus open unisegmentectomy in two specialized centers. Feasibility and short-term results

BACKGROUND

Anatomical segmentectomy is defined as the complete removal of the Couinaud's segment. The aim of this study was to compare the perioperative outcomes of laparoscopic (LS) versus open (OS) unisegmentectomy in two high volume centers.

METHODS

A retrospective review of all consecutive unisegmentectomies from 2007 to 2017 was performed at the Institut Mutualiste Montsouris and at the Hepatobiliary Center of Paul Brousse Hospital.

RESULTS

A total of 177 patients underwent unisegmentectomy: 58 LS vs 52 OS in the anterolateral segments, 33 LS vs 34 OS in the posterosuperior segments. HCC were more frequent in the OS group, whereas colorectal liver metastases were more frequently treated with LS. Blood loss (200 vs. 400 ml, p = 0.006), operative time (238 vs. 267 min, p = 0.048) and median length of stay (6 vs. 8 days, p = 0.036) were significantly lower in the LS group. The resection margins (4 mm vs. 2 mm, p = 0.763) and the overall morbidity did not differ between the two groups. In the posterosuperior segment, OS group had more pulmonary complications (9 vs. 29%, p = 0.035).

CONCLUSION

Laparoscopic anatomical unisegmentectomies for selected patients, even with postero-superior based tumors, in specialized centers seems to be safe and feasible.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Oncological outcome of R1 vascular margin for mass-forming cholangiocarcinoma. A single center observational cohort analysis

BACKGROUND

Recent studies validated the possibility to detach colorectal liver metastases from vessels (R1vasc) featuring R1vasc equivalent to R0 and superior to tumor exposure along the transection plane (R1par). To clarify the outcome of R1 surgery (margin <1 mm) in patients with intrahepatic cholangiocarcinoma (MFCCC), distinguishing R1par and R1vasc resections.

METHODS

Patients undergoing resection for MFCCC between 2008 and 2016 were considered. Tumor detachment from 1st/2nd-order Glissonean pedicles or hepatic veins was performed in advanced diseases. R0, R1par, and R1vasc were compared.

RESULTS

The study included 84 resection areas in 59 patients (17 R1vasc). R1vasc group had local recurrence risk similar to R1par group (per-patient analysis 29% vs. 36%; per-resection area analysis 29% vs. 32%), higher than R0 group (3% and 2%, p = 0.003 and p = 0.0003). R1vasc and R1par groups had similar overall and recurrence-free survival (median OS 30 vs. 30 months; RFS 10 vs. 8 months), lower than R0 group (70 and 39 months, p = 0.066 and p = 0.007).

CONCLUSION

In MFCCC patients, R1vasc resection is not an adequate treatment. Local disease control and survival after R1vasc resection are lower than after R0 resection and similar to R1par resection. R1vasc resection could be exclusively considered to achieve resectability in otherwise unresectable patients.

Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis

OBJECTIVE

To elucidate minor hepatectomy (MiH) outcomes.

SUMMARY BACKGROUND DATA

Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures.

METHODS

We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers.

EXCLUSION CRITERIA

cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders.

RESULTS

Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02).

CONCLUSIONS

MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.

Robotic approach as a valid strategy to improve the access to posterosuperior hepatic segments-Case series and review of literature

INTRODUCTION

Although the laparoscopy liver resection (LLR) has become a useful approach for minor resections, it seems that lesions in posterosuperior (PS) segments still represent technical challenges. We report a series of robotic approach as an alternative option for these lesions, and a systematic review of the literature to show its feasibility.

METHODS

Consecutive patients who underwent liver resection for solitary lesions in PS segments by da Vinci SI robot, and by the same team. A systematic review of the literature was made to evaluate the feasibility of a robotic approach for PS hepatectomies.

RESULTS

From April 2016 to April 2017, five cases of robotic nonanatomical PS resections of colorectal liver metastases (CRLM) were performed. A systematic review encountered five articles plus this series reporting outcomes for this approach. Briefly, a total of five patients in our series underwent this approach, all females, and one patient presented a grade 2 complication.

CONCLUSION

Robotic hepatectomy seems to be a useful and valid strategy to resect lesions on PS hepatic segments simplifying liver-sparing hepatectomies. Even though the operative time is still high, the short length of stay, low number of complications and the low need for blood transfusions seems to surpass the intrinsic cost of robotic surgery.

Does KRAS mutation status impact the risk of local recurrence after R1 vascular resection for colorectal liver metastasis? An observational cohort study

INTRODUCTION

R0 margin is the standard in the surgical treatment of colorectal liver metastases (CLM). Recently R1 surgery, at least that enabling CLM vessel-detachment (R1vasc), seems comparable to R0. As a possible background of that biologic factors could play some role. Among them, KRAS has been investigated in the present study.

METHODS

Patients who underwent curative surgery for CLM between 2008 and 2016 were identified. R0, R1vasc and parenchymal R1 (R1par; tumor exposure once dissected from the parenchyma) resections with known KRAS status were analyzed.

RESULTS

Of 1000 resection areas in 340 patients, 654 (65%) R0, 98 (10%) R1vasc and 248 (25%) R1par. In mutated KRAS (mKRAS), local recurrence (LR) was similar between R0 and R1vasc (per-patient 4,8% vs. 2%, p = 0.628; per-area 2,1% vs. 1,9%, p = 0.940), while higher in R1par (per-patient 25,4% and per-area 19,5%; p < 0.001 for both). In wild-type KRAS (wtKRAS), R0 had less LR compared to R1vasc (per-patient 7,6% vs 14,6%, p = 0.335; per-area 3,1% vs 13,3%, p = 0.012) and R1par (per-patient 18,3%, p = 0.060; per-area 9,9%, p = 0.013). KRAS did not impact LR in R0 (per-patient 7,6% vs. 4,8%, p = 0.491; per-area 3,1% vs. 2,1%, p = 0.555), while wtKRAS R1par had less LR compared to mKRAS R1par (per-patient 18,3% vs 25,4%, p = 0.404; per-area 9,9% vs 19,5%, p = 0.048). Inversely, LR was increased in wtKRAS R1vasc compared to mKRAS R1vasc (per-patient 14,6% vs 2%, p = 0.043; per-area 13,3% vs 1,9%, p = 0.046).

CONCLUSION

KRAS status does not impact LR risk in R0 resection. Inversely, R1vasc vs R1par LR risk is reduced in mKRAS, and increased in wtKRAS. If confirmed these results are of note.

Tumor-Infiltrating Lymphocytes and Macrophages in Intrahepatic Cholangiocellular Carcinoma. Impact on Prognosis after Complete Surgery

BACKGROUND

Immune infiltrate impacts prognosis of several tumors. To assess the prognostic impact of tumor-infiltrating lymphocytes and macrophages in patients undergoing resection for intrahepatic cholangiocellular carcinoma (ICC).

METHODS

All consecutive patients undergoing surgery for ICC between 2008 and 2016 were considered. Inclusion criteria were complete resection and follow-up > 12 months. Tissue sections were immunostained for CD3+, CD4+, CD8+, Foxp3+, and CD68+. The number of positive cells was quantified using a computer-aided image analysis system. Different cut-off values were tested as predictors of overall survival (OS).

RESULTS

Fifty-three patients were analyzed. ICC were T1 in 28 patients, multifocal in 11, and N+ in 13. After a median follow-up of 42 months, 5-year OS was 52.1%. The following immune infiltrate values were associated with better OS: CD3+ > 0.10% (5-year OS 63.3% vs. 13.6% if ≤ 0.10%, p = 0.001); CD8+ > 0.10% (56.2% vs. 28.6% if ≤ 0.10%, p = 0.051); Foxp3+ absent (59.4% vs. 16.0% if present, p = 0.049). CD4+ and CD68+ infiltrates were not associated with OS. Three-year OS rates in patients with 0, 1, and ≥ 2 negative prognostic factors were 73.6%, 47.3%, and 14.3%, respectively (p < 0.001). CD3+ infiltrate stratified prognosis in T1 tumors (3-year OS 71.7% if CD3+ > 0.10% vs. 14.3% if ≤ 0.10%, p < 0.001).

CONCLUSIONS

Tumor-infiltrating lymphocytes are associated with prognosis of ICC patients after complete surgery. CD3+ and CD8+ infiltrate is associated with higher survival and lower recurrence risk, while Foxp3+ infiltrate is associated with worse prognosis. CD3+ infiltrate allows refining prediction of prognosis in early tumors.

Outcomes of enhanced one-stage ultrasound-guided hepatectomy for bilobar colorectal liver metastases compared to those of ALPPS: a multicenter case-match analysis

BACKGROUND

In case of bilobar colorectal liver metastases (CLM) associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed. Enhanced one-stage ultrasound-guided hepatectomy (e-OSH) may represent a further solution for these patients. Aim of this study was to compare by case-match analyses the outcome of ALPPS and e-OSH.

METHODS

Between 2012 and 2017, patients undergoing ALPPS for bilobar CLM were matched 1:2 with patients receiving e-OSH. Patients were matched according to the Fong Score (1-3/4-5), the number of CLM (3-7/≥8), the number of CLM in the left liver (1-2/≥3) and preoperative chemotherapy. All the patients in the e-OSH group had a right -sided major vascular contact. The main endpoints of the study were perioperative outcomes, overall (OS) and disease-free survival (DFS).

RESULTS

Seventy-eight patients were selected (26 ALPPS and 52 e-OSH) based on matching process. The two treatments differed significantly in major morbidity (26.9% ALPPS vs 7.7% e-OSH, p = 0.017). Median OS (31.7 vs 32.6 months) and DFS (10.6 vs 7.8 months) were comparable between the two groups.

CONCLUSIONS

This study demonstrates that ALPPS and e-OSH for bilobar CLM achieve comparable long-term results, despite higher morbidity reported after ALPPS. These findings should drive to reposition e-OSH in managing these patients.

Surgical and oncological outcomes after ultrasound-guided robotic liver resections for malignant tumor. Analysis of a prospective database

AIM

Robotic surgery is thought to have a role in widening the application of minimally invasive liver surgery. Nonetheless, data concerning surgical results for liver malignancies are presently still lacking. We aimed to evaluate the surgical and oncological outcomes of ultrasound guided robotic liver resections for hepatic malignancies.

METHODS

All consecutive patients who received robotic resection of primary and secondary liver malignancies from September 2008 to January 2017 were analyzed. The same surgical team performed all procedures following the principle of parenchymal-sparing surgery.

RESULTS

From a total of 51 patients, 13 patients (25%) underwent major and 38 (75%) minor hepatectomy. No mortality occurred. Two procedures were converted to open surgery. Five patients experienced major complications, with a reintervention rate of 6%. Median hospital stay was 5 days.

CONCLUSIONS

Robotic surgery is a safe and feasible procedure for liver resection even when dealing with malignancies. Our data show that robotic surgery can be considered a valid option to treat patients with liver malignancies in a minimally invasive manner, without compromise the oncological results.

Is R1 vascular hepatectomy for hepatocellular carcinoma oncologically adequate? Analysis of 327 consecutive patients

BACKGROUND

R1 vascular resection for liver tumors was introduced in the early twenty-first century. However, its oncologic adequacy remains controversial. The aim of this study was to determine the oncologic adequacy of R1 vascular hepatectomy in hepatocellular carcinoma patients.

METHODS

A prospective cohort of patients with hepatocellular carcinoma resected between the years 2005 and 2015 was reviewed. R0 was any resection with a minimum 1 mm of negative margin. R1 vascular was any resection with tumor exposure attributable to the detachment from major intrahepatic vessel. R1 parenchymal was any resection with tumor exposure at parenchymal margin. The end points were the calculation of the local recurrence of R0, R1 parenchymal, and R1 vascular hepatectomy and their prognostic significances.

RESULTS

We analyzed 327 consecutive patients with 532 hepatocellular carcinoma and 448 resection areas. We found that 205 (63%) resulted R0, 56 (17%) resulted R1 parenchymal, 50 (15%) resulted R1 vascular, and 16 (5%) resulted both R1 parenchymal and R1 vascular. After a median follow-up of 33.5 months (range 6.1-107.6), the 5-year overall survival rates were 54%, 30%, 65%, and 36%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .031). Local recurrence rates were 3%, 14%, 4%, and 19%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .001) per patient, and 4%, 4%, 12%, and 18%, respectively for R0, R1 vascular, R1 parenchymal, and R1 parenchymal + R1 vascular (P = .001) per resection area. At multivariate analysis R1 parenchymal and R1 vascular + R1 parenchymal were independent detrimental factors.

CONCLUSION

R1 vascular hepatectomy for hepatocellular carcinoma is not associated with increased local recurrence or decreased survival. Thus, detachment of hepatocellular carcinoma from intrahepatic vessels should be considered oncologically adequate.

New two-step wedge liver resection technique: "zoom resection": A case report

Different surgical procedures have been described for the treatment of colorectal liver metastases. The appropriate surgical approach depends, among many other factors, on the relationship between liver metastases and suprahepatic veins. If possible, the detachment of colorectal liver metastasis from suprahepatic veins is a good alternative liver parenchyma sparing technique. In this study, we describe a new two-step wedge liver resection technique for colorectal liver metastases located between suprahepatic veins. Prior to resection, intraoperative ultrasound is employed in order to plan and guide both steps. Initially, we place stitches and resect a cylindrical piece of normal liver parenchyma above the tumor and suprahepatic veins. Next, we place stitches on the future specimen located between suprahepatic veins, then resect it. The main advantages of this procedure are the good visualization and vascular control that may be achieved during the detachment of the tumor from suprahepatic veins. We call this procedure "zoom resection" because its dynamics are similar to the workings of a photograph camera's telescopic system. We present the case of a 55-year-old patient diagnosed with multiple colorectal liver metastases, one of which was resected through this technique.

Oncologic superiority of anatomic resection of hepatocellular carcinoma by ultrasound-guided compression of the portal tributaries compared with nonanatomic resection: An analysis of patients matched for tumor characteristics and liver function

BACKGROUND

The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound-guided compression of the tumor-feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection.

METHODS

Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1-to-2 with nonanatomic resection cases based on the Child-Pugh class, Model for End-Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/>1), and hepatocellular carcinoma size (>30, 30-50, and >50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90-day mortality (0 compression technique anatomic resection), non-cancer-related death, and follow-up <12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases.

RESULTS

All patients were Child-Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5-year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2-year local recurrence-free survival (94% vs 78%; P = .012). Nonlocal recurrence-free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3-year survival after recurrence (65% vs 42%; P = .043).

CONCLUSION

Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma-bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.

Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases

Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

R1 Resection for Colorectal Liver Metastases: a Survey Questioning Surgeons about Its Incidence, Clinical Impact, and Management

BACKGROUND

A ≥ 1-mm margin is standard for resection of colorectal liver metastases (CLM). However, R1 resection is not rare (10-30%), and chemotherapy could mitigate its impact. The possibility of detaching CLM from vessels (R1 vascular margin) has been described. A reappraisal of R1 resection is needed.

METHODS

A 19-question survey regarding R1 resection for CLM was sent to hepatobiliary surgeons worldwide. Seven clinical cases were included.

RESULTS

In total, 276 surgeons from 52 countries completed the survey. Ninety percent reported a negative impact of R1 resection (74% local recurrence, 31% hepatic recurrence, and 36% survival), but 50% considered it sometimes required for resectability. Ninety-one percent of responders suggested that the impact of R1 resection is modulated by the response to chemotherapy and/or CLM characteristics. Half considered the risk of R1 resection to be an indication for preoperative chemotherapy in patients who otherwise underwent upfront resection, and 40% modified the chemotherapy regimen when the tumor response did not guarantee R0 resection. Nevertheless, 80% scheduled R1 resection for multiple bilobar CLM that responded to chemotherapy. Forty-five percent considered the vascular margin equivalent to R0 resection. However, for lesions in contact with the right hepatic vein, right hepatectomy remained the standard. Detachment from the vein was rarely considered (10%), but 27% considered detachment in the presence of multiple bilobar CLM.

CONCLUSIONS

A negative margin is still standard for CLM, but R1 resection is no longer just a technical error. R1 resection should be part of the modern multidisciplinary, aggressive approach to CLM.

Feasibility of Intraoperative Navigation for Liver Resection Using Real-time Virtual Sonography With Novel Automatic Registration System

BACKGROUND

The clinical feasibility and usability of intraoperative ultrasonography (IOUS) tracked by computed tomography (CT) images have been proposed; however, it requires technically demanding manual registration procedure.

STUDY DESIGN

A prospective study using real-time virtual sonography (RVS) with novel automatic registration system was conducted in four high-volume centers of liver resection from 2015 to 2016. The requiring time for registration of IOUS and CT images and positional error of confluence of middle hepatic venous tributaries (V8-MHV, V5-MHV) were measured in patients undergoing laparotomy.

RESULTS

Automatic registration was successful in 43 of 52 enrolled patients (83%), with error ranges of 11.4 (3.1-69.4) mm for V8-MHV and 16.2 (4.3-66.8) mm for V5-MHV. Time required for total registration process was 36 (27-74) s.

CONCLUSIONS

The RVS with novel automatic registration system can provide quick and easy registration and acceptable accuracy, which can promote the usage of IOUS.

The Shifting Paradigm of Prognostic Factors of Colorectal Liver Metastases: From Tumor-Centered to Host Immune-Centered Factors

The determinants of prognosis in patients with colorectal liver metastases (CLM) have been traditionally searched among the tumoral factors, either of the primary colorectal tumor or of the CLM. While many different scoring systems have been developed based on those clinic-pathological factors with disparate results, there has been the introduction of genetic biological markers that added a theranostic perspective. More recently, other important elements, such as those factors related to the host immune system, have been proposed as determinants of prognosis of CLM patients. In the present work, we review the current prognostic factors of CLM patients as well as the burgeoning shifting paradigm of prognostication that relies on the host immune system.

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study

BACKGROUND

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm).

METHODS

We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival.

RESULTS

Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival.

CONCLUSION

Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Oncological and surgical result of hepatoma after robot surgery

BACKGROUND

Most liver resections are currently performed using an open approach. Robotic hepatectomy has been suggested as a safe and effective approach for hepatocellular carcinoma; however, studies regarding oncological and surgical outcomes are still limited. Accordingly, we performed this study to compare the surgical and oncological outcomes between robotic and open approaches.

METHODS

Between June, 2013 and July, 2016, a total of 63 HCC patients undergoing robotic hepatectomy, and 177 patients undergoing open hepatectomy were included in this study to assess the surgical and oncological outcomes after hepatectomy. The data of demographic, clinical features, hepatitis profile, tumor characters, TNM stage, surgical type, pathological outcomes, and postoperative results were collected prospectively and analyzed retrospectively.

RESULTS

The demographic and clinical features of patients with HCC in both groups were statistically comparable. The robotic group had longer operative times (296 ± 84 vs. 182 ± 51 min, p = 0.032). The postoperative complications rate was slightly lower in the robotic group (11.1 vs. 15.3%, p = 0.418). The rate of Ro resection was similar in both groups (93.7 vs. 96%, p = 0.56). The length of hospital stay was significantly shorter in the robotic group (6.21 ± 2.06 vs. 8.18 ± 6.99 days, p = 0.001). The overall recurrence rate of HCC was lower in the robotic group (27 vs. 37.3%, p = 0.140). The 1, 2, 3 year disease-free survival rates were 72.5, 64.3, and 61.6%, respectively, for the open group, while they were 77.8, 71.9, and 71.9%, respectively, for the robotic group, (p = 0.325). The 1, 2, 3 year overall survival rates were 95.4, 92.3, and 92.3%, respectively, for the open group, while they were 100, 97.7, and 97.7%, respectively, for the robotic group (p = 0.137).

CONCLUSION

Robotic surgery is a safe and feasible procedure for liver resection in selected patients. The oncological and surgical outcomes of robotic hepatectomy were comparable to open surgery. The robotic hepatectomy carried significantly shorter length of hospital stay.

Is Enhanced One-Stage Hepatectomy a Safe and Feasible Alternative to the Two-Stage Hepatectomy in the Setting of Multiple Bilobar Colorectal Liver Metastases? A Comparative Analysis between Two Pioneering Centers

BACKGROUND

Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal metastases (CLM). As alternative, ultrasound-guided one-stage hepatectomy (E-OSH) has been proposed even for deep-located nodules to compare TSH and E-OSH.

METHODS

All consecutive TSH at the Paul Brousse Hospital and E-OSH at the Humanitas Research Hospital were considered. The inclusion criteria were ≥6 CLM, ≥3 CLM in the left liver, and ≥1 lesion with vascular contact. A total of 74 TSH and 35 E-OSH were compared.

RESULTS

The 2 groups had similar characteristics. Drop-out rate of TSH was 40.5%. In comparison with the cumulated hepatectomies of TSH, E-OSH had lower blood loss (500 vs. 1,100 mL, p = 0.009), overall morbidity (37.1 vs. 70.5%, p = 0.003), severe morbidity (14.3 vs. 36.4%, p = 0.04), and liver-specific morbidity (22.9 vs. 40.9%, p = 0.02). R0 resection rate was similar between groups. E-OSH and completed TSH had similar overall survival (5-year 38.2 vs. 31.8%), recurrence-free survival (3-year 17.6 vs. 17.7%), and recurrence sites.

CONCLUSIONS

E-OSH is a safe alternative to TSH for multiple bilobar deep-located CLM. Whenever feasible, E-OSH should even be considered the preferred option because it has excellent safety and oncological outcomes equivalent to completed TSH, without the drop-out risk.