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Safety and Perioperative Outcomes of Laparoscopic vs. Open Hepatectomy of Central-Located Liver Lesions: A Multicenter, Propensity Score-Matched, Retrospective Cohort Study. J Clin Med 2023; 12:jcm12062164. [PMID: 36983169 PMCID: PMC10057074 DOI: 10.3390/jcm12062164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
Background: Short-term outcomes of laparoscopic hepatectomy of central-located liver lesions (LHCL) compared with traditional open hepatectomy of central-located liver lesions (OHCL) remain unclear. The aim of this study was to explore the safety and efficacy of LHCL. Methods: A retrospective analysis was performed on 262 patients who underwent hepatectomies involving resections of liver segment II, IV or VIII from January 2015 to June 2021 in two institutions. Patients in the LHCL group were matched in a 1:2 ratio to patients in the OHCL group. Results: After propensity score-matched (PSM) analysis, 61 patients remained in the LHCL group and 122 patients were in the OHCL group. What needs to be mentioned is that although not significant, patients in the OHCL group had increased lesion size (4.3 vs. 3.6 cm, p = 0.052), number (single/multiple, 84.8%/15.2% vs. 93.4%/6.6%, p = 0.097), and number of liver segments involved (one/two/three, 47.3%/42.0%/10.7% vs. 57.4%36.1%/10.7%, p = 0.393). To ensure surgical safety, fewer patients in the LHCL group underwent vascular exclusion than those in the OHCL group (p = 0.004). In addition, LHCL was associated with lower blood loss (p = 0.001) and transfusion requirement (p = 0.004). In terms of short-term outcomes, the LHCL group had significantly lower levels of peak ALT (p < 0.001), peak DBIL (p = 0.042), peak PT (p = 0.012), and higher levels of bottom ALB (p = 0.049). Moreover, the LHCL group demonstrated quicker postoperative recovery, which was represented by shorter time to first flatus, time to oral intake, time to drain off, and hospital stay (all p < 0.001). Importantly, the LHCL group had a significantly reduced occurrence of postoperative complications (p < 0.001) and similar R0 resection rates (p = 0.678) when compared to the OHCL group. Conclusion: LHCL is associated with increased safety and better perioperative outcomes and thus could be recommended for patients with central space-occupying liver lesions when appropriately selecting the surgical procedure according to the total tumor burden and carefully handled by experienced surgeons. From the experience of our center, LHCL could be performed to solitary lesion involving liver segment IV/V/VIII, <5 cm, with good safety and feasibility.
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Gadallah EA, Elkomos BE, Khalil A, Fawzy FS, Abdelaal A. Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis. BMC Surg 2023; 23:2. [PMID: 36600282 DOI: 10.1186/s12893-022-01891-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND AIM For those with a centrally located HCC, the two types of liver sectionectomy that can be performed are extended hepatectomy (EH) and central hepatectomy (CH). This meta-analysis aimed to compare the short- and long-term outcomes between patients treated with CH and patients treated with EH for those with centrally located HCC. METHOD We searched PubMed, Scopus, Web of Science, and Cochrane library for eligible studies from inception to 1 April 2022 and a systematic review and meta-analysis were done to compare the outcomes between the two groups. RESULTS we included 9 studies with a total of 1674 patients in this study. The pooled results in this meta-analysis showed equal long-term overall survival, Disease-free survival, recurrence and mortality between the two groups (5-year OS, RR = 1.14, 95% CI = 0.96-1.35, P = 0.12; I2 = 56%), (5-year DFS, RR = 0.81, 95% CI = 0.61-1.08, P = 0.15; I2 = 60%), (Recurrence, RR = 1.04, 95% CI = 0.94-1.15, P = 0.45; I2 = 27%), and (Mortality, RR = 0.55, 95% CI = 0.26-1.15, P = 0.11; I2 = 0%). In addition to that, no significant difference could be detected in the overall incidence of complications between the two groups (Complications, RR = 0.94, 95% CI = 0.76-1.16, P = 0.57; I2 = 0%). However, CH is associated with a remarkable increase in the rate of biliary fistula (Biliary fistula, RR = 1.90, 95% CI = 1.07-3.40, P = 0.03; I2 = 0%). And Liver cell failure was higher in the case of EH (LCF, RR = 0.47, 95% CI = 0.30-0.76, P = 0.002; I2 = 0%). Regarding the operative details, CH is associated with longer operative time (Time of the operation, Mean difference = 0.82, 95% CI = 0.36, 1.27, P = 0.0004; I2 = 57%). CONCLUSION No significant difference in the short and long-term survival and recurrence between CH and MH for CL-HCC. However, CH is associated with greater future remnant liver volume that decreases the incidence of LCF and provides more opportunities for a repeat hepatectomy after tumour recurrence.
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Affiliation(s)
| | | | - Ahmed Khalil
- General Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Fawzy Salah Fawzy
- General Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Amr Abdelaal
- General Surgery Department, Ain Shams University Hospital, Cairo, Egypt
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Long-Term Outcomes of Mesohepatectomy for Centrally Located Liver Tumors: Two-Decade Single-Center Experience. J Am Coll Surg 2022; 235:257-266. [PMID: 35839400 DOI: 10.1097/xcs.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Parenchyma-Sparing Central Hepatectomy Versus Extended Resections for Liver Tumors: a Value-Based Comparative Analysis. J Gastrointest Surg 2022; 26:1406-1415. [PMID: 35266098 DOI: 10.1007/s11605-022-05292-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Parenchyma-sparing (PS) liver resection is recommended for liver tumors. The value of PS-approaches as compared to more extended resections is unknown. We sought to examine value-based differences (quality/cost) of central hepatectomy (CH) versus more extended resections. METHODS A retrospective cohort study including consecutive patients having CH or right/extended hepatectomies (R/EH) at a high-volume cancer center was performed (2015-2019). The primary outcome was the value ratio, calculated as quality/cost. Quality was defined as the proportion of patients achieving a textbook outcome. Perioperative actual direct costs ($USD) for each patient were abstracted from institutional financial records spanning throughout the perioperative period. Value ratios were calculated and compared for each approach; sensitivity analysis was performed by modelling TO and cost thresholds. RESULTS Among 651 hepatobiliary operations (426 liver resections), 90 patients met inclusion criteria: 19 CH and 71 R/EH. TO occurred in 68% and 69% of CH and R/EH, respectively (P = 0.96). Mean direct costs were $21,826 for CH and $28,599 for R/EH (P = 0.008). CH provided a greater value (value ratio CH = 0.33 vs. R/EH = 0.26; P = 0.004) with a shift favoring R/EH only when the TO threshold for CH was below 51% (CH = 0.23 vs. R/EH = 0.24) or that of R/EH was over 90% (CH = 0.31 vs. R/EH = 0.32). CONCLUSIONS These findings support a PS approach for central liver tumors (central hepatectomy) as it offers higher value than more extended resections. In the context of high-volume centers with outcomes within established national benchmarks, patients with central tumors should be considered for CH over more extended non-PS approaches.
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Mesohepatectomy: A Useful Tool in the Toolbox. J Am Coll Surg 2022; 235:266-267. [PMID: 35377862 DOI: 10.1097/xcs.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Barrera-Lozano LM, Ramírez JA, Becerra JA, Muñoz CL, Pineda DCP, Gutiérrez-Montoya JI. Mesohepatectomía, una alternativa para el manejo del hepatocarcinoma en paciente no cirrótico: serie de casos. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La resección quirúrgica es el tratamiento de elección de las neoplasias primarias y secundarias del hígado. Los pacientes con hepatocarcinoma de los segmentos centrales representan un reto, siendo la hepatectomía extendida la técnica más usada, sin embargo, el riesgo postquirúrgico de falla hepática es alto, dado que la resección puede comprometer entre el 65 % y el 80 % del volumen hepático. La mesohepatectomía es una alternativa que permite dejar un volumen hepático residual suficiente. El objetivo de este trabajo es presentar nuestra experiencia en el tratamiento de pacientes con hepatocarcinomas en segmentos centrales a quienes se les realizó mesohepatectomía.
Serie de casos. Se presentan tres pacientes no cirróticos, con hepatocarcinoma en los segmentos 4, 5 y 8, que fueron atendidos en el Hospital San Vicente Fundación, en las sedes de Medellín y de Rionegro, entre 2018 y 2020.
Resultados. La mesohepatectomía se realizó mediante ligadura selectiva de los pedículos del segmento 4 y del sector anterior derecho. Se utilizó aspirador ultrasónico y endograpadora para la transección hepática. La duración de la maniobra de Pringle varió entre 16 y 43 minutos. El sangrado promedio fue de 1000 ml. Solo un paciente presentó fuga biliar tipo B. No hubo mortalidad a 30 días.
Conclusiones. La mesohepatectomía es una alternativa segura para pacientes con tumores en los segmentos centrales, que permite disminuir el riesgo de falla hepática luego de la resección.
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Chen R, Wang Z, Zhu W, Luo W, Lin J, Chen Y, Fang C, Yang J. Laparoscopic in Situ Anatomical Mesohepatectomy for Solitary Massive HCC Using Combined Intrafascial and Extrafascial Approaches With Indocyanine Green Navigation (with Video). Ann Surg Oncol 2021; 29:2034-2040. [PMID: 34647203 DOI: 10.1245/s10434-021-10886-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Laparoscopic anatomic mesohepatectomy for patients with hepatocellular carcinoma (HCC) remains technically challenging, especially for those with a massive tumor larger than 10 cm. METHODS In this study, a 65-year-old man with a 13 × 10-cm2 solitary liver tumor located at segments 4, 5, and 8 underwent laparoscopic mesohepatectomy. To reduce the possibility of releasing cancer cells from the primary tumor, the in situ resection strategy for tumor removal was implemented. The intrafascial approach was used to dissect the right Glissonean pedicle, to transect the right anterior hepatic artery, and to ligate the right anterior portal vein. The extrafascial and transfissural approach was performed along the umbilical fissure to transect the Glissonean pedicle of segment 4. Indocyanine green (ICG) then was applied using "reverse staining" to visualize the resection extent and the right posterior hepatic duct (RPHD). During parenchymal resection, the right anterior Glissonean pedicle was adequately exposed and transected via the extrafascial approach above the plane of the RPHD. Finally, the right coronary ligament was dissected, and the tumor was removed. RESULTS The operation was completed in 360 min, with a blood loss of 200 mL. The histopathologic diagnosis indicated a moderately differentiated HCC. The patient was discharged on postoperative day 8 without any complications. CONCLUSION Laparoscopic in situ anatomic mesohepatectomy using combined intra- and extrafascial approaches with ICG navigation may be feasible for patients with a centrally located solitary massive HCC.
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Affiliation(s)
- Rui Chen
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Zhuangxiong Wang
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Wen Zhu
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Wang Luo
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Jinyu Lin
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Yunlong Chen
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China
| | - Chihua Fang
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China. .,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China.
| | - Jian Yang
- Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China. .,Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China.
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Relationship between hepatic venous anatomy and hepatic venous blood loss during hepatectomy. Surg Today 2021; 51:1953-1968. [PMID: 34129114 DOI: 10.1007/s00595-021-02314-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/25/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Predicting increased blood loss based on anatomical intervascular relationships is essential in major hepatectomy. METHODS We assessed 63 consecutive patients undergoing anatomical hepatectomy exposing the hepatic vein (HV) trunk at two institutes. Correlations between anatomical alterations of the hepatic inferior vena cava (IVC), HV, hepatic IVC, or right atrium (RA) and the blood loss per standard weight (BLSW) or blood transfusion (n = 18) were analyzed. The results of IVC partial clamping (PC) were additionally examined. RESULTS The BLSW in type V-up anatomical morphology was significantly higher than that in straight type (p < 0.05). The parameters associated with an increased BLSW (> 13.5 mL/kg) were tumor size (> 4 cm), prothrombin activity (< 87%), CVP (> 7 mmHg), area of suprahepatic IVC (< 360 mm2), IVC-RA gap (> 28 mm), longitudinal angle of IVC (< 160°), and axial angle of the MHV (< 55°). A multivariate analysis revealed that a high IVC-RA gap was a significant independent risk factor (odds ratio; 4.32, p < 0.05). Among 25 patients undergoing IVC-PC, only three showed a remarkable decrease in hepatic venous bleeding. No other statistically significant differences in the surgical records were observed in most cases. CONCLUSION The IVC-RA gap might be a promising novel predictive parameter reflecting increased blood loss leading to blood transfusion in anatomical hepatectomy.
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Orimo T, Kamiyama T, Kakisaka T, Shimada S, Nagatsu A, Asahi Y, Sakamoto Y, Kamachi H, Taketomi A. Central Hepatectomy Versus Major Hepatectomy for Centrally Located Hepatocellular Carcinoma: A Propensity Score Matching Study. Ann Surg Oncol 2021; 28:6769-6779. [PMID: 33646429 DOI: 10.1245/s10434-021-09751-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In terms of anatomical liver sectionectomy approaches, both a central hepatectomy (CH) and major hepatectomy (MH) are feasible options for a centrally located hepatocellular carcinoma (HCC). METHODS We retrospectively reviewed the surgical outcomes of central HCC patients who underwent CH or MH. MH includes hemihepatectomy or trisectionectomy, whereas CH involves a left medial sectionectomy, right anterior sectionectomy, or central bisectionectomy. The surgical outcomes were compared before and after propensity score matching (PSM). RESULTS A total of 233 patients were enrolled, including 132 in the CH group and 101 in the MH group. The MH group cases were pathologically more advanced and had poorer overall survival rates than the CH group. After PSM, 68 patients were selected into each group, both of which showed similar overall and recurrence-free survival outcomes. The CH group showed a tendency for a longer operation time; however, other perioperative outcomes were similar between the two groups. Multivariate analyses of our matched HCC patients revealed that the type of surgery (CH or MH) was not an independent prognostic factor. More patients in the matched CH group experienced a repeat hepatectomy for recurrence and no patients in this group underwent a preoperative portal vein embolization. CONCLUSIONS The short- and long-term surgical outcomes of CH and MH for a centrally located HCC are similar under a matched clinicopathological background. CH has the advantage of not requiring a preoperative portal vein embolization and increased chances of conducting a repeat hepatectomy for recurrence.
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Affiliation(s)
- Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Shingo Shimada
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Akihisa Nagatsu
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yoh Asahi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yuzuru Sakamoto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Orimo T, Kamiyama T, Taketomi A. ASO Author Reflections: Anatomical Liver Sectionectomy for Centrally Located Hepatocellular Carcinoma. Ann Surg Oncol 2021; 28:6780-6781. [PMID: 33634390 DOI: 10.1245/s10434-021-09791-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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The technique and outcomes of central hepatectomy by the Glissonian suprahilar approach. Eur J Surg Oncol 2019; 45:2369-2374. [DOI: 10.1016/j.ejso.2019.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/16/2019] [Accepted: 09/11/2019] [Indexed: 12/12/2022] Open
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Chan J, Bradshaw L, Houli N, Weinberg L, Perini MV, Fink M, Muralidharan V, Starkey G, Jones R, Wang BZ, Christophi C, Nikfarjam M. Outcomes of central hepatectomy versus extended hepatectomy. Hepatobiliary Pancreat Dis Int 2019; 18:249-254. [PMID: 30987899 DOI: 10.1016/j.hbpd.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/12/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Central hepatectomy (CH) is more difficult than extended hepatectomy (EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent post-hepatectomy liver failure (PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors. METHODS A total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups. RESULTS The main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four (16.7%) in the EH group (P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min (290-840) vs. 523 min (310-860), P = 0.328], intraoperative blood loss [850 mL (400-1500) vs. 650 mL (100-2000), P = 0.746] or patients requiring intraoperative blood transfusion [1 (9.1%) vs. 7 (30.4%), P = 0.227]. There was a trend towards fewer hepatectomy-specific complications in the CH group [3 (27.3%) vs. 13 (54.2%), P = 0.167], including PHLF (CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days (5-23) vs. 12 days (4-85), P = 0.244]. CONCLUSIONS CH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.
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Affiliation(s)
- Jenny Chan
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Luke Bradshaw
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia; Department of Surgery, University of Melbourne, Northern Health, Epping, Victoria, Australia
| | - Nezor Houli
- Department of Surgery, University of Melbourne, Northern Health, Epping, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Marcos V Perini
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Michael Fink
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Vijayaragavan Muralidharan
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Graham Starkey
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Robert Jones
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Bao Zhong Wang
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Melbourne, Victoria, Australia.
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Zhao J, Li W, Mao J. Early versus late recurrence of centrally located hepatocellular carcinoma after mesohepatectomy: A cohort study based on the STROBE guidelines. Medicine (Baltimore) 2019; 98:e15540. [PMID: 31169667 PMCID: PMC6571380 DOI: 10.1097/md.0000000000015540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to investigate the features, treatment, and prognosis of early versus late recurrence of centrally located hepatocellular carcinoma (CL-HCC) after mesohepatectomy (MH).Three hundred forty eight patients with CL-HCC undergoing MH were included. Data on clinicopathological characteristics, initial surgical details, timing and sites of tumor recurrence, management after recurrence, and long-term outcomes were analyzed.The optimal cutoff value to differentiate early (71 patients, 64.5%) versus late (39, 35.5%) recurrence was defined as 12 months. Patients with early recurrence (ER) had higher alpha fetoprotein (AFP) level (P < .001), more advanced tumor stage (P = .024), and higher incidence of microvascular invasion (MVI, P = .001). Patients with ER had higher incidence of local tumor recurrence (P = .027) and higher average number of recurrent nodules (P = .016) than patients with LR. Patients after ER showed a better overall survival (from date of diagnosis of recurrence) than after late recurrence (LR). Patients with ER had less chances of curative treatment (14.1% vs 41.0%, P = .004) after tumor recurrence than patients with LR. Multivariable analyses revealed that liver cirrhosis (P < .001) and tumor differentiation (P < .001) were associated with an increased likelihood of LR, while multiple tumor number (P = .005), type IV classification (P = .012), and MVI (P < .001) were independent risk factors related to ER.ER and LR after MH for CL-HCC were associated with different risk predictors and prognosis. Data on the timing of recurrence may inform decisions about postoperative adjuvant treatment, as well as help to predict long-term survival for these patients.
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Affiliation(s)
- Jun Zhao
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu Province
| | - Wei Li
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jie Mao
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu Province
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Li W, Li L, Minigalin D, Wu H. Anatomic mesohepatectomy versus extended hepatectomy for patients with centrally located hepatocellular carcinoma. HPB (Oxford) 2018; 20:530-537. [PMID: 29366813 DOI: 10.1016/j.hpb.2017.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 11/03/2017] [Accepted: 11/30/2017] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Wei Li
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Long Li
- Department of General Surgery, Dingxi People's Hospital/Lanzhou University Second Hospital Dingxi Hospital, Dingxi, Gansu Province, China
| | - Daniil Minigalin
- Department of General Surgery, Bashkir State Medical University (BSMU), Ufa, 450000, Russia
| | - Hong Wu
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
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Chan J, Perini M, Fink M, Nikfarjam M. The outcomes of central hepatectomy versus extended hepatectomy: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:487-496. [PMID: 29439847 DOI: 10.1016/j.hpb.2017.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/07/2017] [Accepted: 12/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Central hepatectomy (CH) is a relatively uncommon liver resection technique. It is generally perceived as a more complex operation than extended hepatectomies (EH), with potentially higher associated morbidity. The outcomes of CH compared with EH is not well defined and there is a need to reassess. METHODS A systematic literature search was conducted in PubMed, MEDLINE, EMBASE and Web of Science according to PRISMA guidelines for studies on the treatment of liver tumours with CH published from 1972 until February 2017. Outcomes of patients undergoing CH were assessed and compared to those undergoing EH. RESULTS 18 publications including 1380 CH were included for analysis. Mortality rates after CH ranged from 0 to 9%. There were 20 (1.4%) deaths after CH and the most common cause of death was post-hepatectomy liver failure (PHLF). Morbidity rates varied between 12 and 61% and 316 (23%) post-operative events were reported. Analysis of five comparative studies showed similar mortality between CH and EH groups (OR: 0.64, 95% CI = 0.24-1.70, p = 0.37). There were significantly fewer overall post-operative complications in the CH group (OR: 0.38, 95% CI = 0.28-0.51, p < 0.001) and reduced PHLF was found in the CH group compared to EH (OR: 0.53, 95% CI = 0.29-0.98, p = 0.04). The rates of post-hepatectomy biliary complications were similar between groups (OR: 0.98, 95% CI = 0.51-1.88, p = 0.96). Mean length of stay (days) was shorter in the CH group (MD: -2.67, 95% CI = -4.93 to -0.41, p = 0.02). CONCLUSION CH appears to have similar post-operative mortality rates compared to EH but is associated with fewer post-operative complications, including PHLF and shorter overall length of stay.
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Affiliation(s)
- Jenny Chan
- University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Marcos Perini
- University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Fink
- University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.
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Central Hepatectomy versus Extended Hepatectomy for Malignant Tumors: A Propensity Score Analysis of Postoperative Complications. World J Surg 2017; 40:2745-2757. [PMID: 27272270 DOI: 10.1007/s00268-016-3584-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The specific definition of central hepatectomy (CH) (i.e., resection of segments 4-5-8 ± 1) is not uniformly used, resulting in conflicting comparisons with the more commonly performed extended hepatectomy (EH). The study aimed to compare, using propensity score matching (PSM) analysis, the incidence of postoperative complications between CH and EH for centrally located liver tumors (CLLT). METHODS All consecutive CH and EH procedures for CLLT performed from 1980 to 2011 were retrospectively reviewed. Independent predictors of postoperative complications were identified. CH was compared to EH after PSM. RESULTS The study population consisted of 373 patients, 44 (11.8 %) of whom underwent CH and 329 (88.2 %) of whom underwent EH. Before PSM, the overall 90-day mortality was 7.2 % (27 patients) without a group difference (2 (4.5 %) for CH vs. 25 (7.6 %) for EH, p = 0.756). The CH and EH groups had similar postoperative morbidity rates (43.2 vs. 55.3 %; p = 0.108). Blood transfusion was the only independent predictor of postoperative complications (Hazard Ratio: 1.73; 95 % confidence interval: 1.11-2.68; p = 0.014). After PSM, 43 CH patients were matched with 43 EH patients. No group difference was observed for the postoperative mortality, morbidity, or duration of hospital stay. A higher number of EH patients (30.2 vs. 9.3 %, p = 0.028) presented with more than one postoperative complication. CONCLUSIONS CH and EH yield similar mortality and morbidity. For CLLT, CH may be an attractive procedure with the advantage of sparing the liver parenchyma compared with EH.
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Mesohepatectomy Versus Extended Hemihepatectomies for Centrally Located Liver Tumors: A Meta-Analysis. Sci Rep 2017; 7:9329. [PMID: 28839257 PMCID: PMC5571172 DOI: 10.1038/s41598-017-09535-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 07/27/2017] [Indexed: 02/05/2023] Open
Abstract
The comparison of Mesohepatectomy (MH) with conventional extended hemihepatectomies (EH) for patients with centrally located liver tumors (CLLTs) were inconsistent. Our aims were to systemically compare MH with EH and to determine whether MH can achieve a similar clinical outcome as EH through this meta-analysis. PubMed/Medline, EMBASE, Web of Knowledge and Cochrane Library were searched updated to June 11, 2016. Blood loss and operation time favored MH in elder patients (mean difference [MD] for blood loss: -692.82 ml, 95% CI: -976.72 to -408.92 ml, P < 0.001; MD for operation time: -78.75 min, 95% CI: -107.66 to -49.81, P < 0.001). Morbidity rate (29.2%, 95% CI: 24.1 to 34.8%), mortality rate (2.0%, 95% CI: 1.2 to 3.3%) and overall survival (median OS 38.2 m, 95% CI: 34.0 to 42.8 m) of MH were comparable with those of EH. The low liver failure rate favored MH (odds ratio [OR]: 0.29, 95% CI: 0.09 to 0.88, P = 0.03). For MH, bile leakage was the most common surgical complication (MH vs. EH: 13.5% vs. 6.7%, P = 0.016), while for EH, it was wound infection (MH vs. EH: 6.9% vs. 15.7%, P < 0.001). Thus MH might be in general safe and feasible for treating CLLTs with a similar clinical outcome as EH.
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Fonouni H, Kashfi A, Stahlheber O, Konstantinidis L, Kraus TW, Mehrabi A, Oweira H. Analysis of the biliostatic potential of two sealants in a standardized porcine model of liver resection. Am J Surg 2017; 214:945-955. [PMID: 28683896 DOI: 10.1016/j.amjsurg.2017.06.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/28/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Improved resection techniques has decreased mortality rate following liver resections(LRx). Sealants are known as effective adjuncts for haemostasis after LRx. We compared biliostatic effectiveness of two sealants in a standardized porcine model of LRx. MATERIAL AND METHODS We accomplished left hemihepatectomy on 27 pigs. The animals were randomized in control group(n = 9) with no sealant and treatment groups (each n = 9), in which resection surfaces were covered with TachoSil® and TissuFleece®/Tissucol Duo®. After 5 days the volume of ascites(ml), bilioma and/or bile leakages and degree of intra-abdominal adhesions were analysed. RESULTS Proportion of ascites was lower in TissuFleece/Tissucol Duo® group. The ascites volume was lower in TachoSil® group. In sealant groups, increased adhesion specially in the TachoSil® group was seen. A reduction of the "bilioma rate" was seen in sealant groups, which was significantly lower in TissuFleece®/Tissucol Duo® group. CONCLUSION In a standardized condition sealants have a good biliostatic effect but with heterogeneous potentials. This property in combination with the cost-benefit analysis should be the focus of future prospective studies.
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Affiliation(s)
- H Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - A Kashfi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - O Stahlheber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - L Konstantinidis
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - T W Kraus
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - A Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - H Oweira
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Takamoto T, Hashimoto T, Makuuchi M. Left hepatectomy after right paramedian sectoriectomy. Surg Today 2017; 47:1533-1538. [PMID: 28667439 DOI: 10.1007/s00595-017-1561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/05/2017] [Indexed: 11/28/2022]
Abstract
Repeat hepatectomy is beneficial for selected patients with recurrence of liver malignancies. However, the operative procedure becomes technically demanding when the previous hepatectomy was complex, with hepatic veins and stump of portal pedicles exposed on the liver transection surface. We performed left hepatectomy after right paramedian sectoriectomy (RPMS) for three patients. Here, we describe our surgical technique and the postoperative outcomes achieved. This procedure allowed for safe adhesiolysis between the middle and right hepatic veins by following a fibrous plane. The mean operative time was 8.7 h, including 4.9 h of adhesiolysis. The mean remnant liver volume (right lateral sector and the caudate lobe) was calculated as 704 ml, being 62% of total liver volume. There was no postoperative liver failure or mortality. In conclusion, left hepatectomy after RPMS is a feasible procedure for patients with sufficient remnant liver volume, even though the middle and right hepatic veins run side by side after liver regeneration.
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Affiliation(s)
- Takeshi Takamoto
- Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan.
| | - Takuya Hashimoto
- Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Masatoshi Makuuchi
- Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
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20
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Yu WB, Rao A, Vu V, Xu L, Rao JY, Wu JX. Management of centrally located hepatocellular carcinoma: Update 2016. World J Hepatol 2017; 9:627-634. [PMID: 28539990 PMCID: PMC5424292 DOI: 10.4254/wjh.v9.i13.627] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Centrally located hepatocellular carcinoma (HCC) is sited in the central part of the liver and adjacent to main hepatic vascular structures. This special location is associated with an increase in the difficulty of surgery, aggregation of the recurrence disease, and greater challenge in disease management. This review summarizes the evolution of our understanding for centrally located HCC and discusses the development of treatment strategies, surgical approaches and recurrence prevention methods. To improve patient survival, a multi-disciplinary modality is greatly needed throughout the whole treatment period.
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Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in mongolia. Int Surg 2016; 100:268-74. [PMID: 25692429 DOI: 10.9738/intsurg-d-14-00006.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Approaches to surgical resection of centrally located HCC remain controversial. Traditionally, hemi- or extended hepatectomy is suggested. However, it carries a high risk of postoperative complications in patients with cirrhosis. An alternative approach is Glissonean pedicle transection method. This study was conducted to assess the surgical and survival outcomes associated with central liver resection using the Glissonean pedicle transection. Sixty-nine patients with centrally located HCC were studied retrospectively. They were divided into conventional approach group with hemi- or extended hepatectomy, and Glissonean approach group with multisegmental central liver resection using the Glissonean pedicle transection. Glissonean pedicle transection method has comparable or superior surgical and survival outcomes to conventional hemi- or extended hepatectomy with regard to intraoperative bleeding, complications, hospital stay, and postoperative mortality and survival outcomes in patients with centrally located HCC. The 1-, 3-, and 5-year overall survival rates of the conventional approach group were 74%, 64%, and 55% respectively. For the Glissonean approach group, the 1 and 3-year overall survival rates were 86% and 61%, respectively. Glissonean pedicle transection method is a safe and effective surgical procedure in patients with centrally located HCC.
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Qiu J, Chen S, Wu H, Du C. The prognostic value of a classification system for centrally located liver tumors in the setting of hepatocellular carcinoma after mesohepatectomy. Surg Oncol 2016; 25:441-447. [PMID: 26987943 DOI: 10.1016/j.suronc.2016.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 12/09/2015] [Accepted: 03/04/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND A classification system of centrally located liver tumors (CLLTs) was proposed by our group in 2013, which divided CLLTs into four subtypes by focusing on the involvement of resected segments and the anatomical location of lesions relative to the principal hepatic vascular structures. The current study aimed to analyze the clinical characteristics and compare the surgical outcomes of the different CLLTs classification system for patients with hepatocelluar carcinoma (HCC) underwent mesohepatectomy (MH). Moreover, we sought to validate the prognostic value of the new classification system. METHODS Data from 353 consecutive patients with centrally located HCC who were treated with MH between 2005 and 2013 were prospectively collected and retrospectively reviewed. RESULTS The 1-, 3-, and 5-y overall recurrence rates were 21.4%, 41.3%, and 55.6%, respectively. The 1-, 3-, and 5-y overall (OS) and corresponding recurrence-free survival rates (RFS) were 82.5%, 61.6%, 40.2%, and 68.8%, 42.5%, 30.7%, respectively. According the CLLTs classification system, 106 patients were classified as type I, 68 as type II, 94 as type III and 85 as type IV. There were no significant differences in RFS rate among the CLLTs groups, however, a significant decrease in OS rates was observed in the type IV classification, respectively. Multivariate analysis reveal that patients with microvascular invasion, portal vein thrombosis, the largest tumor size≥5 cm, tumor number≥3, liver cirrhosis, hepatic inflow occlusion ≥60 min, intraoperative blood loss≥1500 ml, pTNM staging and CLLTs classification of Type IV to be independent adverse factors for long-term survivals. CONCLUSION The classification system of CLLTs is meant to help clinicians in defining the extent of resection, providing a risk assessment and predicting prognosis. However, it is need to be validated in more HCC patients and medical centers.
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Affiliation(s)
- Jianguo Qiu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Shuting Chen
- Department of Hepatobiliary Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong Wu
- Department of Hepatobiliary Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chengyou Du
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Abstract
Central bisegmentectomy (CBS) of the liver is an en bloc hepatic resection of Couiaud segments 4, 5, and 8. The indications for CBS include benign and malignant tumors occupying both the left medial and right anterior segments. However, CBS has rarely been reported. Here, we investigate CBS in patients with suboptimal liver function for whom an extended lobectomy is not an optimal solution. Each case was 1 of 8 patients who underwent CBS for hepatocellular carcinoma (HCC) or colorectal cancer liver metastasis (CRLM) at the Department of Surgery, Jikei University Hospital. Indications for CBS consisted of CRLM in 3 patients and HCC in 5 patients. The median duration of operation was 552 minutes, and median blood loss was 2263 g. No postoperative nor in-hospital mortalities occurred. In this study, 1-, 2-, and 3-year disease-free survival rates were 62.5%, 12.5%, and 12.5%, respectively, and 1-, 2-, and 3-year overall survival rates were 100%, 100%, and 85.7%, respectively. CBS is advocated for central liver tumors in patients with suboptimal liver function for whom extended lobectomy could result in less than optimal remnant liver volume and function.
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Wang WH, Wang Z, Wu JX, Zhang T, Rong WQ, Wang LM, Jin J, Wang SL, Song YW, Liu YP, Ren H, Fang H, Wang WQ, Liu XF, Yu ZH, Li YX. Survival benefit with IMRT following narrow-margin hepatectomy in patients with hepatocellular carcinoma close to major vessels. Liver Int 2015; 35:2603-10. [PMID: 25939444 DOI: 10.1111/liv.12857] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 04/22/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS To investigate the role of post-operative intensity-modulated radiotherapy (IMRT) in patients receiving narrow-margin hepatectomy for hepatocellular carcinoma (HCC) located close to the major vessels. METHODS This exploratory study involved 181 HCC patients. Of them, 116 were treated with narrow-margin (<1.0 cm) hepatectomy. Thirty-three of the 116 underwent postoperative IMRT (Group A), while 83 did not receive radiotherapy (Group B). The remaining 65 patients underwent wide-margin (≥1.0 cm) hepatectomy (Group C). Prognosis and patterns of recurrence were assessed in the three groups. RESULTS The 3-year overall survival (OS) and disease-free survival (DFS) rates were 89.1 and 64.2% in Group A, 67.7 and 52.2% in Group B and 86.0 and 60.1% in Group C respectively. The OS and DFS of Group A and Group C patients surpassed those of Group B patients (Group A vs. B, P = 0.009 and P = 0.038; and Group C vs. B, P = 0.002 and P = 0.010). Patients in Groups A and C experienced significantly fewer early recurrences than did patients in Group B (P = 0.002). Furthermore, patients in Groups A and C experienced substantially fewer intrahepatic marginal (P = 0.048) and diffuse recurrences (P = 0.018) and extrahepatic metastases (P = 0.038) than did patients in Group B. No patient developed radiation-induced liver disease. CONCLUSIONS Post-operative IMRT following narrow-margin hepatectomy may be a favourable therapy for both its safety profile and clinical benefit in patients with HCC located close to the major vessels.
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Affiliation(s)
- Wei-Hu Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Zhi Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jian-Xiong Wu
- Department of Abdominal Surgery, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Wei-Qi Rong
- Department of Abdominal Surgery, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Li-Ming Wang
- Department of Abdominal Surgery, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Wen-Qing Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Xin-Fan Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Zi-Hao Yu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
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Conrad C, Ogiso S, Inoue Y, Shivathirthan N, Gayet B. Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective. Surg Endosc 2015; 29:2410-7. [PMID: 25391984 DOI: 10.1007/s00464-014-3924-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/26/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Here we report the first systematic evaluation of laparoscopic parenchymal-sparing segmentectomies for the resection of lesions in the central liver segments and the first series of laparoscopic mesohepatectomies. PATIENTS AND METHODS From 1995 to 2012, 482 laparoscopic hepatectomies were performed. Thirty-two patients underwent isolated resection of IVa and VIII, bisegmentectomies of IVa/IVb and V/VIII, or mesohepatectomy. Sixteen isolated resections of IVb or V were excluded. Data was extracted from a retrolective database and chart review. Complications were classified (Clavien-Dindo) by three independent surgeons. Seventeen patients had colorectal liver metastasis, four had neuroendocrine tumors, five had hepatocellular carcinoma, two had GIST, and one each had esophageal cancer, breast cancer, and melanoma. Fifteen patients underwent anatomic- and 17 non-anatomic wedge resection. Average blood loss was 403 cc (SD 475), and overall operative time was 183 (SD 106) for hepatectomy and 253 min (SD 94) for mesohepatectomies. Major complications were mainly attributable to synchronous procedures. Mortality, transfusion, and morbidity rates were 0, 12, and 37 %, respectively. CONCLUSION Parenchymal-sparing laparoscopic central liver resections and mesohepatectomies are feasible, safe, and effective if specific technical details we have learned over time are considered. Concomitant procedures should be an exception. This approach exhibits an alternative to open surgery while avoiding unnecessary sacrifice of functional parenchyma.
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Affiliation(s)
- Claudius Conrad
- Department of Digestive Pathology, Institute Mutulatiste Montsouris, Paris Descartes University, Paris, France,
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Yu W, Rong W, Wang L, Wu F, Xu Q, Wu J. R1 hepatectomy with exposure of tumor surface for centrally located hepatocellular carcinoma. World J Surg 2015; 38:1777-85. [PMID: 24370545 DOI: 10.1007/s00268-013-2429-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatectomy with exposure of tumor surface (a special type of R1 resection) provides a chance of cure for selected patients with centrally located hepatocellular carcinoma (HCC) that is adherent to or compresses major vessels. However, the operative indications, safety, and patient outcomes are not well defined. METHODS We performed hepatectomy for removal of complex centrally located HCC using a selective and dynamic region-specific vascular occlusion technique. Between May 2006 and March 2012, a total of 118 patients underwent resection with exposure of tumor surface (exposure group) and 169 underwent conventional hepatectomy (without exposure of the tumor and vascular surface). The short- and long-term outcomes of patients were evaluated and compared. RESULTS The postoperative recovery of liver function was comparable between the two groups. Bile leakage occurred in five patients, all in the exposure group. The 1-, 3-, and 5-year recurrence-free survival rates were 74.4, 45.6, and 30.1 % in the exposure group and 80.9, 57.2, and 31.7 % in the control group (p = 0.041). Corresponding overall survival rates were 92.3, 70.3, and 44.9 % in the exposure group and 97.8, 81.4, and 53.1 % in the control group (p = 0.094). CONCLUSIONS Hepatectomy with exposure of tumor surface is technically demanding, but can be performed safely. It is also associated with a risk of tumor recurrence. Multidisciplinary combined therapy would be the solution and can contribute to improve overall survival.
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Affiliation(s)
- Weibo Yu
- Abdominal Surgery Department, Cancer Institute and Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, NO. 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, People's Republic of China
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Tian F, Wu JX, Rong WQ, Wang LM, Wu F, Yu WB, An SL, Liu FQ, Feng L, Bi C, Liu YH. Three-dimensional morphometric analysis for hepatectomy of centrally located hepatocellular carcinoma: A pilot study. World J Gastroenterol 2015; 21:4607-4619. [PMID: 25914470 PMCID: PMC4402308 DOI: 10.3748/wjg.v21.i15.4607] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/24/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe a three-dimensional model (3DM) to accurately reconstruct anatomic relationships of centrally located hepatocellular carcinomas (HCCs).
METHODS: From March 2013 to July 2014, reconstructions and visual simulations of centrally located HCCs were performed in 39 patients using a 3D subject-based computed tomography (CT) model with custom-developed software. CT images were used for the 3D reconstruction of Couinaud’s pedicles and hepatic veins, and the calculation of corresponding tumor territories and hepatic segments was performed using Yorktal DMIT software. The respective volume, surgical margin, and simulated virtual resection of tumors were also estimated by this model preoperatively. All patients were treated surgically and the results were retrospectively assessed. Clinical characteristics, imaging data, procedure variables, pathologic features, and postoperative data were recorded and compared to determine the reliability of the model.
RESULTS: 3D reconstruction allowed stereoscopic identification of the spatial relationships between physiologic and pathologic structures, and offered quantifiable liver resection proposals based on individualized liver anatomy. The predicted values were consistent with the actual values for tumor mass volume (82.4 ± 109.1 mL vs 84.1 ± 108.9 mL, P = 0.910), surgical margin (10.1 ± 6.2 mm vs 9.1 ± 5.9 mm, P = 0.488), and maximum tumor diameter (4.61 ± 2.16 cm vs 4.53 ± 2.14 cm, P = 0.871). In addition, the number and extent of portal venous ramifications, as well as their relation to hepatic veins, were visualized. Preoperative planning based on simulated resection facilitated complete resection of large tumors located in the confluence of major vessels. And most of the predicted data were correlated with intraoperative findings.
CONCLUSION: This 3DM provides quantitative morphometry of tumor masses and a stereo-relationship with adjacent structures, thus providing a promising technique for the management of centrally located HCCs.
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Extended central hepatectomy with preservation of segment 6 for patients with centrally located hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2015; 14:63-8. [PMID: 25655292 DOI: 10.1016/s1499-3872(14)60302-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In order to preserve functional liver parenchyma, extended central hepatectomy (segments 4, 5, 7 and 8 resection) was proposed for the management of centrally located hepatocellular carcinoma invading the right and middle hepatic veins, reconstructing segment 6 outflow in the absence of the thick inferior right hepatic vein. The present study was to describe our surgical techniques of extended central hepatectomy. METHODS Between 2008 and 2012, 5 patients with centrally located hepatocellular carcinoma invading or in the vicinity of the right and middle hepatic veins underwent extended central hepatectomy. The thick inferior right hepatic vein was preserved during dissection. Gore-Tex graft was used for segment 6 outflow reconstruction in the absence of the thick inferior right hepatic vein. RESULTS The mean future remnant liver volume for segments 2 and 3 was 28% versus 45% on segment 6 preservation. The mean tumor diameter was 7.4 cm. The thick inferior right hepatic vein was found in 1 patient. Outflow reconstruction from segment 6 was performed in 4 patients. Postoperative complications included bile leakage (1 patient), pleural effusion (2) and liver failure (1). The rate of graft patency was 75%. There was no perioperative mortality. CONCLUSION Extended central hepatectomy is a safe alternative for extended hepatic resection in selected patients attempting to preserve the functional liver parenchyma.
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Mesohepatectomy for centrally located large hepatocellular carcinoma: Indications, techniques, and outcomes. Surgery 2014; 156:1177-87. [PMID: 25444316 DOI: 10.1016/j.surg.2014.05.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 05/14/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether mesohepatectomy should be performed for large hepatocellular carcinoma (HCC) located in the central part of the liver is controversial, and the safety and long-term survival after this operation remain to be investigated. METHODS Between January 2002 and December 2012, 696 patients with HCC located in the central part of the liver who received liver resection in our hospital were included in this study. These patients were divided into three groups: 158 patients with large HCC (tumor size >5.0 cm) and 192 patients with small HCC (tumor size ≤ 5.0 cm) who received mesohepatectomy were classified as the mesohepatectomy for large HCC (MHG-L) group and the mesohepatectomy for small HCC (MHG-S) groups, respectively, and 346 patients with large HCC who received hemihepatectomy or less were classified as the non-mesohepatectomy for large HCC (NMHG-L) group. The operative indications, techniques, and outcomes of the three groups were analyzed retrospectively. RESULTS There were no substantial differences among the three groups in in-hospital mortality or postoperative complication rates. The overall survival and disease-free survival were not different between the MHG-L group and the NMHG-L group or between the MHG-L group and the MHG-S group. Univariable and multivariable analyses of the MHG-L mesohepatectomy group indicated that cirrhosis, tumor number, and vascular invasion were independent risk factors of poor long-term survival of mesohepatectomy. In the MHG-L and NMHG-L groups, solitary large hepatocellular carcinoma had better long-term survival than nodular large hepatocellular carcinoma. CONCLUSION Mesohepatectomy is safe and efficacious for BCLC B/C patients who have centrally located large HCC, especially for solitary tumors, with good survival outcomes.
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Zuo CH, Qiu XX, Ouyang YZ, Zhang DI, Xiao H, Mo SC, Tan CQ, Tang M, Zhu HZ. Mesohepatectomy for the treatment of patients with centrally located hepatocellular carcinoma. Mol Clin Oncol 2014; 2:833-838. [PMID: 25054054 DOI: 10.3892/mco.2014.309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 05/27/2014] [Indexed: 01/11/2023] Open
Abstract
Mesohepatectomy is considered a feasible option for patients with centrally located hepatocellular carcinoma (HCC). However, mesohepatectomy is a technically demanding and less frequently used procedure. In this study, we summarized the surgical experience and evaluated the clinical outcomes of mesohepatectomy in 24 patients with centrally located HCC. Of these patients, 9 were treated with hepatectomy of Couinaud's segments IV, V and VIII with concurrent cholecystectomy; 8 underwent resection of segments IVb, V and VIII, including 7 patients who also received a cholecystectomy; 4 underwent hepatectomy of segments IVa, V and VIII; and 3 patients were treated with hepatectomy of segments I, IV, V and VIII, with concurrent cholecystectomy. The Pringle maneuver was used on 17 patients during hepatectomy. Total hepatic vascular exclusion (HVE) was performed on 3 patients and HVE was not used on 4 patients. The average mesohepatectomy operative time was 238 min and the average intraoperative blood loss was 480 ml (200-2,200 ml). There was no intraoperative mortality and the postoperative morbidity rate was 25% (6/24). The 1- and 3-year overall survival rates were 76 and 46%, respectively. Therefore, mesohepatectomy is a safe and effective surgical procedure for the treatment of centrally located HCC and HVE during mesohepatectomy for centrally located HCC is crucial to the success of the operation and postoperative patient recovery.
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Affiliation(s)
- Chao-Hui Zuo
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Xiao-Xin Qiu
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Yong-Zhong Ouyang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - DI Zhang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Hua Xiao
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Sheng-Chuan Mo
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Chun-Qi Tan
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Ming Tang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, P.R. China ; Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
| | - Hai-Zhen Zhu
- Liver Cancer Translational Medicine Center of Hunan University and Hunan Provincial Tumor Hospital, Changsha, Hunan 410082, P.R. China
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van Dam RM, Lodewick TM, van den Broek MAJ, de Jong MC, Greve JW, Jansen RLH, Bemelmans MHA, Neumann UP, Olde Damink SWM, Dejong CHC. Outcomes of extended versus limited indications for patients undergoing a liver resection for colorectal cancer liver metastases. HPB (Oxford) 2014; 16:550-9. [PMID: 24246003 PMCID: PMC4048077 DOI: 10.1111/hpb.12181] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/16/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Currently, resection criteria for colorectal cancer liver metastases (CRCLM) are only limited by remnant liver function. Morbidity and survival after a partial hepatectomy with limited or extended indication criteria were compared. METHODS/DESIGN Between 1991 and 2010, patients undergoing a liver resection for CRCLM with limited (n = 169) or extended indication criteria (n = 129) were retrospectively identified in a prospectively collected single-centre database. Limited indication criteria were defined as less than three unilateral, not centrally located liver metastases in the absence of extra hepatic metastases. The extended criteria were only limited by predicted remnant liver volume and patients fitness. Data on co-morbidity, resection margin, short- and long-term morbidity, disease-free (DFS) and overall survival were compared. RESULTS Patients with limited indications had less major complications (19.5% vs. 33.1%, P < 0.01), longer overall survival of 68.8 months [confidence interval (CI) 46.5-91.1] vs. 41.4 months (CI 33.4-49.0, P ≤ 0.001) and longer median DFS of 22.0 months [confidence interval (CI) 15.8-28.2] vs 10.2 months (CI 8.4-11.9, P < 0.001) compared with the extended indication group. Cure rates, defined as 10-year DFS, were 35.5% and 15.8%, respectively. Fewer patients in the extended indication group underwent an R0 resection (92.9% vs. 77.5%, P < 0.001). Only 17% of all R1 resected patients had recurrences at the transection plane. CONCLUSION A partial hepatectomy for CRCLM with extended indications seems justified but is associated with higher complication rates, earlier recurrence and lower overall survival compared with limited indications. However, the median 5-year survival was substantial and a cure was achieved in 15.8% of patients.
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Affiliation(s)
- Ronald M van Dam
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Toine M Lodewick
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH AachenAachen, Germany,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Maartje AJ van den Broek
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Mechteld C de Jong
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Jan Willem Greve
- Department of Surgery, Atrium Medical CenterHeerlen, The Netherlands
| | - Rob LH Jansen
- Department of Medical Oncology, Maastricht University Medical CentreMaastricht, The Netherlands
| | - Marc HA Bemelmans
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Ulf P Neumann
- Department of General, Visceral and Transplant Surgery, University Hospital RWTH AachenAachen, Germany,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Steven WM Olde Damink
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, The Netherlands,Department of HPB Surgery and Liver Transplantation, Royal Free Hospital- University College LondonLondon, UK,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
| | - Cornelis HC Dejong
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, The Netherlands,Euregional Surgical HPB collaboration Aachen-MaastrichtGermany–The Netherlands
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Chen X, Li B, He W, Wei YG, Du ZG, Jiang L. Mesohepatectomy versus extended hemihepatectomy for centrally located hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2014; 13:264-70. [PMID: 24919609 DOI: 10.1016/s1499-3872(14)60253-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Extended hemihepatectomy is usually recommended to treat large centrally located hepatocellular carcinoma (HCC). However, the morbidity and mortality are high because of the postoperative liver failure. Mesohepatectomy is seldom used because of its technical complexity. This study aimed to evaluate the short-term and long-term curative effect of mesohepatectomy. METHODS From January 2002 to September 2008, a total of 198 consecutive patients with centrally located HCC underwent hepatectomy in our department. According to the surgical procedures, they were divided into mesohepatectomy (group M, n=118), extended right hemihepatectomy (group RE, n=47) and extended left hemihepatectomy (group LE, n=33) groups. The surgical techniques, clinical pathological characteristics and outcomes were compared between group M, group RE and group LE. RESULTS The operative time of group M was significantly longer than that of the other two groups (P<0.05); however the total bilirubin on postoperative day 3 in group M was the lowest among the three groups (P<0.01). In group M, the number of the patients whose resection margin achieving 1 cm was significantly lower than that of the other two groups (P<0.05). The mortality rates in groups M, RE and LE were 2.5%, 8.5% and 3.0%, respectively (P>0.05). The morbidity rate in group M was significantly lower than that in group RE (37.3% vs 55.3%, P=0.034), but not in group LE (37.3% vs 24.2%, P=0.163). The biliary leakage tended to be more common in group M (10.2%, P>0.05). The incidence of postoperative liver failure in group M was significantly lower than that in group RE (1.7% vs 10.6%, P=0.032), but not in group LE (1.7% vs 6.1%, P=0.208). The 1-, 3- and 5-year tumor-free survival rates and the overall survival rates after mesohepatectomy were 53.4%, 30.5% and 16.9% and 67.8%, 45.5% and 28.9%, respectively. CONCLUSIONS Mesohepatectomy is a safe and effective technique for centrally located HCC patients. Compared with extended right hemihepatectomy, mesohepatectomy can retain residual liver volume to the maximum limit and reduce postoperative liver failure rate. But no significant advantage was found compared mesohepatectomy to extended left hemihepatectomy.
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Affiliation(s)
- Xi Chen
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu 610041, China.
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Lee SY. Central hepatectomy for centrally located malignant liver tumors: A systematic review. World J Hepatol 2014; 6:347-357. [PMID: 24868328 PMCID: PMC4033292 DOI: 10.4254/wjh.v6.i5.347] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/23/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To study whether central hepatectomy (CH) can achieve similar overall patient survival and disease-free survival rates as conventional major hepatectomies or not.
METHODS: A systematic literature search was performed in MEDLINE for articles published from January 1983 to June 2013 to evaluate the evidence for and against CH in the management of central hepatic malignancies and to compare the perioperative variables and outcomes of CH to lobar/extended hemihepatectomy.
RESULTS: A total of 895 patients were included from 21 relevant studies. Most of these patients who underwent CH were a sub-cohort of larger liver resection studies. Only 4 studies directly compared Central vs hemi-/extended hepatectomies. The range of operative time for CH was reported to be 115 to 627 min and Pringle’s maneuver was used for vascular control in the majority of studies. The mean intraoperative blood loss during CH ranged from 380 to 2450 mL. The reported morbidity rates ranged from 5.1% to 61.1%, the most common surgical complication was bile leakage and the most common cause of mortality was liver failure. Mortality ranged from 0.0% to 7.1% with an overall mortality of 2.3% following CH. The 1-year overall survival (OS) for patients underwent CH for hepatocellular carcinoma ranged from 67% to 94%; with the 3-year and 5-year OS having a reported range of 44% to 66.8%, and 31.7% to 66.8% respectively.
CONCLUSION: Based on current literature, CH is a promising option for anatomical parenchymal-preserving procedure in patients with centrally located liver malignancies; it appears to be safe and comparable in both perioperative, early and long term outcomes when compared to patients undergoing hemi-/extended hepatectomy. More prospective studies are awaited to further define its role.
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Mesopancreas in pancreatic cancer: where do we stand - review of literature. Indian J Surg Oncol 2014; 6:69-74. [PMID: 25937767 DOI: 10.1007/s13193-014-0294-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/21/2014] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is associated with poor prognosis and surgery remains the main modality of treatment. Negative resection margin is an important prognostic factor for survival. Retropancreatic margin or the medial margin is the most common site of positive resection margin. Mesopancreas was proposed in analogy with mesorectum, which is considered as a fusion fascia formed embryologically during the development of pancreas. This mesopancreas lies posterior to the pancreas and contains pancreaticoduodenal vessels, lymphatics, nerve plexus and loose areolar tissue. Various technical modifications were proposed for better dissection of mesopancreas like posterior approach and artery first approach. There is an increased rate of R0 resection by these technical modifications but whether this will turn to increase in survival rates is yet to be established.
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Qiu J, Wu H, Bai Y, Xu Y, Zhou J, Yuan H, Chen S, He Z, Zeng Y. Mesohepatectomy for centrally located liver tumours. Br J Surg 2014; 100:1620-6. [PMID: 24264785 DOI: 10.1002/bjs.9286] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mesohepatectomy (MH) avoids unnecessary sacrifice of functional parenchyma compared with extended hepatectomy (EH). The aim of this study was to compare the results of MH with those of EH in the management of centrally located liver tumours (CLLTs). METHODS All patients with CLLTs treated by liver resection between 2005 and 2011 were enrolled in this retrospective study. The decision to use MH or EH was made on an individual basis. Outcomes of the procedures were compared and a classification system for MH was devised consisting of four types, with type IV representing the most complex procedure. RESULTS MH was performed in 292 patients and EH in 138. MH was associated with a longer duration of operation (P < 0.001), higher intraoperative transfusion rate (P < 0.001) and lower complication rates (P = 0.001) compared with EH. There were no significant differences in hepatic inflow occlusion rate (P = 0.075), blood loss (P = 0.241) and length of hospital stay (P = 0.804) between the two groups. Type IV lesions had the longest duration of operation, greatest blood loss, and highest intraoperative transfusion and morbidity rates (all P < 0.050). CONCLUSION MH is a feasible and safe alternative to EH in selected patients with CLLTs. The proposed classification system may be useful in guiding the surgical treatment of CLLTs.
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Affiliation(s)
- J Qiu
- Departments of Hepatobiliary Pancreatic Surgery and
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Adjuvant radiotherapy in centrally located hepatocellular carcinomas after hepatectomy with narrow margin (<1 cm): a prospective randomized study. J Am Coll Surg 2013; 218:381-92. [PMID: 24559953 DOI: 10.1016/j.jamcollsurg.2013.11.030] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/24/2013] [Accepted: 11/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although radiotherapy (RT) provides potential benefits for patients with hepatocellular carcinomas (HCCs) that are unsuitable for operation, the specific role of adjuvant RT in HCC after hepatectomy remains ill defined. The current study's aim was to evaluate the safety and efficacy of adjuvant RT for centrally located HCCs after narrow-margin (<1 cm) hepatectomy. STUDY DESIGN The study included 119 patients with centrally located HCCs who underwent narrow-margin hepatectomy between July 2007 and March 2012. Patients were prospectively randomized to receive adjuvant RT (n = 58) or were assigned to a control group (n = 61). Surgical outcomes, safety, and survival rates were evaluated. RESULTS Hepatectomy was successfully performed in all patients. No cases of radiation-induced liver disease were observed. One-, 3-, and 5-year recurrence-free survival rates were 78.1%, 56.5%, and 36.9% in the adjuvant RT group and 72.4%, 40.1%, and 16.0% in the control group, respectively (p = 0.06, log-rank test). Corresponding overall survival rates were 96.2%, 72.6%, 48.4%, and 89.6%, 74.5%, 37.2%, respectively (p = 0.48, log-rank test). One-, 3-, and 5-year recurrence-free survival rates in patients with small-diameter tumors (≤5 cm) were 88.8%, 67.4%, 42.9% in the adjuvant RT group and 82.3%, 42.9%, 21.5% in the control group (p = 0.03, log-rank test). Corresponding overall survival rates were 97.5%, 75.3%, 75.3%, and 94.7%, 84.1%, 65.4%, respectively (p = 0.92, log-rank test). CONCLUSIONS Adjuvant RT for centrally located HCCs after narrow-margin hepatectomy was technically feasible and relatively safe. No significant between-group difference was observed in recurrence-free and overall survival. The post-hoc subgroup comparison showed that adjuvant RT improved recurrence-free survival considerably, but not overall survival, in patients with small HCCs (≤5 cm). More in-depth studies are needed to validate this finding.
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El Gharbawy RM, Nour BM. Segment 4 architecture and proposed parenchyma-wise technique for Ex vivo graft procurement and implantation. Liver Transpl 2013; 19:1189-201. [PMID: 23840026 DOI: 10.1002/lt.23700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 06/19/2013] [Indexed: 02/07/2023]
Abstract
A parenchyma-wise technique for the ex vivo procurement of segment 4 (S4) grafts, based on the detailed architecture of the segment, is proposed. Eighteen normal, fresh livers from adult cadavers were injected differentially with colored latex; dissection casts were prepared; and the intricate architecture of S4 was studied. The portal vein elements of the sheath forming most of the inferior part of S4 (S4b) and the superficial major fraction of its superior part (S4a) arose constantly from the medial aspect of the umbilical part of the left portal vein branch. The arterial elements arose constantly from a branch, whose diameter ranged from 2.00 to 3.35 mm (mean = 2.61 ± 0.54 mm) and whose length ranged from 15.15 to 45.65 mm (mean = 27.98 ± 12.13 mm). The biliary elements coalesced as a single duct at the corner, which was formed from the umbilical and transverse parts of the left portal vein branch; the duct's diameter ranged from 2.90 to 6.85 mm (mean = 3.90 ± 1.34 mm). Theoretically, this parenchymal mass-S4b and the superficial fraction of S4a-could be procured for implantation in an infant, and the rest of the liver could be split for an adult and a child. The portal vein branches of the graft would be procured with a patch from the medial aspect of the donor's umbilical portion of the left portal vein branch. This umbilical portion would be reconstructed with a patch from the donor's round ligament. The recipient's portal vein would be reconstructed through the fashioning of a conduit anastomosed with the graft's venous patch.
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Affiliation(s)
- Ramadan M El Gharbawy
- Department of Anatomy, Alexandria Faculty of Medicine, Alexandria University, Egypt; Department of Anatomy, Faculty of Medicine, Beirut Arab University, Lebanon
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Guo WX, Sun JX, Cheng YQ, Shi J, Li N, Xue J, Wu MC, Chen Y, Cheng SQ. Percutaneous radiofrequency ablation versus partial hepatectomy for small centrally located hepatocellular carcinoma. World J Surg 2013; 37:602-7. [PMID: 23212793 DOI: 10.1007/s00268-012-1870-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is not known whether percutaneous radiofrequency ablation (PRFA) could get the same treatment efficacy and fewer complications as partial hepatectomy (PH) in patients with small centrally located hepatocellular carcinoma (HCC). The present study was designed to evaluate the efficacy of PH and PRFA in the treatment of small centrally located HCC. METHODS From January 2002 until December 2007, 196 patients with small centrally located HCC (≤5 cm) were included. Of these 196 patients, 94 received PRFA and 102 patients were treated with PH. Treatment outcomes, including major complications and survival data, were studied. RESULTS No treatment-related death occurred in either group. There were no significant differences in survival rates between the two groups. The 1-, 3-, and 5-year disease-free survival rates for the PRFA and PH groups were 57.9%, 36.4%, 34.0%, and 59.8%, 42.4%, 40.8%, respectively (P = 0.50). The 1-, 3-, and 5-year overall survival rates for the two groups were 94.3%, 74.7%, and 49.8%, and 89.2%, 74.1%, and 63.1%, respectively (P = 0.96). PRFA had a lower rate of major complications than PH (8.5 vs. 19.6%), and the hospital stay was also shorter in the PRFA group than in the PH subgroup (4 vs. 13 days). CONCLUSIONS Based on the data obtained, we concluded that PRFA might be equal to PH for the treatment of small centrally located HCC. However, PRFA has the benefits of shorter hospital stay as well as a lower rate of complications.
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Affiliation(s)
- Wei-Xing Guo
- Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, No. 225 Changhai Road, Shanghai, 200438, People's Republic of China
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Mesohepatectomy: an emerging technique. Indian J Surg Oncol 2013; 4:345-8. [PMID: 24426755 DOI: 10.1007/s13193-013-0253-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 06/18/2013] [Indexed: 10/26/2022] Open
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Ishii H, Ogino S, Ikemoto K, Toma A, Nakamura K, Itoh T, Ochiai T. Mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma. World J Surg Oncol 2013; 11:82. [PMID: 23557004 PMCID: PMC3621591 DOI: 10.1186/1477-7819-11-82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 03/10/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Mesohepatectomy with total resection of the caudate lobe and extrahepatic bile duct is sometimes performed for hilar cholangiocarcinoma or gallbladder carcinoma; however, only a few reports on mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma are available. METHODS A 71-year-old woman was preoperatively diagnosed with hepatocellular carcinoma in the central bisections (Couinaud's segments 4, 5, and 8) and the paracaval portion of the caudate lobe. Mesohepatectomy with total caudate lobectomy of the liver permitted the removal of tumors to provide a cancer-free raw surface of the liver. Mobilization of the caudate lobe is an important procedure in this surgery. Before the liver parenchyma was dissected, all short hepatic veins were ligated and divided from the left to the right side as the left lateral section was retracted to the right, and the caudate lobe branches of the portal vein and hepatic artery were ligated and divided. After the liver parenchymal dissection, both between the left lateral and medial sections and between the right anterior and posterior sections, the Glissonean branches of the caudate lobe were ligated and divided as the central bisections were anteriorly retracted. Finally, liver parenchymal dissection was performed between the caudate lobe and the right posterior section, which was along the right side of the inferior vena cava. RESULTS The surgery time was 538 minutes and blood loss was 1,207 mL. No blood transfusions were required during or after surgery. The postoperative course was uncomplicated. The patient is still alive 25 months after hepatectomy. CONCLUSION Although mesohepatectomy with total caudate lobectomy of the liver is technically more difficult than mesohepatectomy of the liver because the caudate lobe must be completely detached from the inferior vena cava and the hilar plate, it is a safe and effective treatment method in selected patients with hepatocellular carcinoma located at both the central bisections and the paracaval portion of the caudate lobe.
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Affiliation(s)
- Hiromichi Ishii
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Shinpei Ogino
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Koki Ikemoto
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Atsushi Toma
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Kenji Nakamura
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Tsuyoshi Itoh
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
| | - Toshiya Ochiai
- Division of Surgery, Kyoto Prefectural Yosanoumi Hospital, 481 Otokoyama, Yosano-cho, Yosa-gun, Kyoto, 629-2261, Japan
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Jeng KS, Jeng WJ, Sheen IS, Lin CC, Lin CK. Is less than 5 mm as the narrowest surgical margin width in central resections of hepatocellular carcinoma justified? Am J Surg 2013; 206:64-71. [PMID: 23388427 DOI: 10.1016/j.amjsurg.2012.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 06/05/2012] [Accepted: 06/17/2012] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Kuo-Shyang Jeng
- Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
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Central hepatectomy under sequential hemihepatic control. Langenbecks Arch Surg 2012; 397:1283-8. [PMID: 23011293 DOI: 10.1007/s00423-012-0984-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 07/18/2012] [Indexed: 01/07/2023]
Abstract
PURPOSE Central hepatectomy is a complex, parenchymal-sparing procedure which has been associated with increased blood loss, prolonged operating time, and increased duration of remnant hypoxia. In this report, we compare two different techniques of vascular control, namely sequential hemihepatic vascular control (SHHVC) and selective hepatic vascular exclusion (SHVE) in central hepatectomies. METHODS From January 2000 to September 2011, 36 consecutive patients underwent a central hepatectomy. SVHE was applied in 16 consecutive patients, and SHHVC was applied in 20 patients. Both groups were comparable regarding their demographics. RESULTS Total operative time and morbidity rates were similar in both groups. Warm ischemia time was significantly longer in SVHE patients (46 min vs 28 min, p = 0.03). Total blood loss and number of transfusions per patient were also higher in the SVHE group (650 vs. 400 mL, p = 0.04 and 2.2 vs. 1.2 units, p = 0.04, respectively). AST values were significantly higher in SVHE on days 1 and 3 compared to SHHVC patients (650 vs. 400, p = 0.04 and 550 vs. 250, p = 0.001, respectively). CONCLUSION Sequential hemihepatic vascular control is a safe technique for central hepatectomies. Decreased intraoperative blood loss and transfusions and attenuated liver injury are the main advantages of this approach.
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Mehrabi A, Houben P, Attigah N, Böckler D, Büchler M, Weitz J. Gefäßersatz in der abdominellen Tumorchirurgie. Chirurg 2011; 82:887-97. [DOI: 10.1007/s00104-011-2096-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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