Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

Combined thoraco-laparoscopic hepatectomy concomitant with resection of the diaphragm for solitary peritoneal seeding from cervical cancer: A case report

Combined thoraco-laparoscopic resection can aid in precise resection of an invasive tumor of the diaphragm. A 44-year-old woman was referred to our department for resection of solitary peritoneal seeding from cervical cancer following systemic chemotherapy. The tumor was located in the right diaphragm with an ill-defined border of the liver. Combined thoraco-laparoscopic resection was proposed. Laparoscopy portrayed that the right diaphragm was partially attached to the liver, and the depth of tumor invasion to the diaphragm was ambiguous. Observation from the thoracic cavity indicated a white-colored distortion following the location of peritoneal seeding. Partial resection and repair of the diaphragm were made using the thoracoscopic-assisted approach, followed by laparoscopic hepatectomy. The postoperative course was uneventful, and pathological findings revealed that peritoneal metastases of the diaphragm and surgical margin was negative for cancer. Combined thoraco-laparoscopic resection can cover the drawbacks of each approach and is among the options for minimally invasive surgery for invasive tumor of the diaphragm.

Laparoscopic surgical management of hepatocellular carcinoma patients with diaphragmatic involvement

BACKGROUND

Hepatocellular carcinoma (HCC) is a common malignancy of the digestive system with high morbidity and high mortality worldwide. Currently, surgical resection is considered the most effective treatment for HCC. Laparoscopic surgery is a major trend in contemporary minimally invasive surgery. However, is laparoscopic resection suitable for HCC patients with diaphragmatic involvement? If so, then what is the preferred resection method, and how safe and effective is this treatment? Are there any factors that require special attention?

METHODS

Clinical data of 17 patients who underwent laparoscopic surgery in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from January 2018 to February 2021 were retrospectively analyzed.

RESULTS

The mean age was 48.9 ± 14.0 years; mean operation time, 186.00 ± 18.3 min; median blood loss, 170.0 ml (140.8-207.5 ml); and median length of hospital stay, 8.0 days (7.0-9.5 days). There was no case of open conversion. Pathologic findings revealed all cases of HCC. Intraoperative frozen pathology and postoperative pathology showed free surgical margins. Six patients had pathologically confirmed diaphragmatic invasion (DI), and eleven was confirmed as having diaphragmatic fibrous adhesion (DFA) only. Post-operative complications included liver section effusion, pleural effusion, pneumonia and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. Sixteen patients survived tumor-free; one patient with HCC developed intrahepatic metastasis 1 year after surgery, and this patient survived with tumor after treatment.

CONCLUSIONS

Our experience initially provides valuable support for the laparoscopic surgical treatment of HCC patients with diaphragmatic involvement.

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis

The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

Laparoscopic liver resection with open partial resection of the thoracoabdominal wall for cancer along the transhepatic biliary drainage tract: A case report

Introduction and importance

Recently, laparoscopic liver resection has been established as a standard procedure for a certain group of hepatic resections; its indications and procedures have been expanding.

Case presentation

A 67-year-old woman was referred with a chief complaint of left subcostal pain. Eight years and nine months before, she underwent pancreatoduodenectomy for cancer of the ampulla of Vater after endoscopic retrograde biliary drainage for obstructive jaundice. A trans-anastomotic internal-external retrograde transhepatic biliary drainage (RTBD) catheter was placed intraoperatively. Based on radiological findings, intrahepatic cholangiocarcinoma, or local recurrence of cancer of the ampulla of Vater, invading the anterior thoracoabdominal wall, diaphragm, and pericardium, without distant metastasis, were considered. Laparoscopic lateral segmentectomy of the liver combined with open en bloc resection of the invaded portion of the anterior thoracoabdominal wall with costal cartilage, diaphragm, and pericardium was performed. The postoperative course was uneventful, and the patient was discharged 17 days post-surgery. The patient died of cancer recurrence 46 months later.

Clinical discussion

The cancer invaded along the RTBD tract. Although the mechanisms of carcinogenesis remain unclear, transhepatic biliary drainage is a risk factor for cancer invasion along the tract. Laparoscopic liver resection before open thoracoabdominal wall resection ensured clear delineation of the cancer margins invading the thoracoabdominal wall and minimized the defect of the thoracoabdominal wall.

Conclusion

Laparoscopic liver resection for hepatic cancer invading adjacent structures or organs would be feasible and useful in selected patients, even if resection of the invaded area is performed by open surgery.

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Cancer developed along the retrograde transhepatic biliary drainage tract after pancreatoduodenectomy.

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Laparoscopic liver resection and simultaneous open en bloc partial resection of the thoracoabdominal wall was performed.

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The patient’s 46-month survival post-operation was relatively long for recurrent cancer of the ampulla of Vater.

A safe and simple procedure for laparoscopic hepatectomy with combined diaphragmatic resection

Diaphragmatic resection may be required beneath the diaphragm in some patients with liver tumors. Laparoscopic diaphragmatic resection is technically difficult to secure in the surgical field and in suturing. We report a case of successful laparoscopic hepatectomy with diaphragmatic resection. A 48-year-old man who underwent laparoscopic partial hepatectomy for liver metastasis of rectal cancer 20 months ago underwent surgery because of a new hepatic lesion that invaded the diaphragm. The patient was placed in the left hemilateral decubitus position. The liver and diaphragm attachment areas were encircled using hanging tape. Liver resection preceded diaphragmatic resection with the hanging tape in place. Two snake retractors were used to secure the surgical field for the inflow of CO₂ into the pleural space after diaphragmatic resection. The defective part of the diaphragm was repaired using continuous or interrupted sutures. Both ends of the suture were tied with an absorbable suture clip without ligation. In laparoscopic liver resection with diaphragmatic resection, the range of diaphragmatic resection can be minimized by performing liver resection using the hanging method before diaphragmatic resection. The surgical field can be secured using snake retractors. Suturing with an absorbable suture clip is conveniently feasible.

Laparoscopic liver resection with simultaneous diaphragm resection

Background

Liver resection or ablation remains the only curative treatment for patients with colorectal metastases. Simultaneous resection of tumors in the liver with invasion to the diaphragm is challenging and controversial. Therefore, we wanted to assess the safety of simultaneous laparoscopic liver and diaphragm resection (SLLDR) in a large single center.

Methods

Patients who underwent primary laparoscopic liver resection (LLR) for colorectal liver metastases at Oslo University Hospital between 2008 and 2019 were included in this study. Patients who underwent SLLDR (group 1) were compared to patients who underwent LLR only (group 2). Perioperative and oncologic outcomes were analyzed.

Results

A total of 467 patients were identified, of whom 12 patients needed a simultaneous diaphragm resection (group 1) while 455 underwent laparoscopic liver surgery alone (group 2). The conversion rate was 16.7% in group 1 and 2.4% in group 2 (P=0.040). In 10 of 12 (83.3%) cases the diaphragm resection was performed en bloc with the liver tumor. There was no significant difference in operative time, blood loss, resection margins, hospital stay or postoperative complications. One patient died within 30 postoperative days (0.2%) in group 2 and none in group 1. Overall survival was not statistically different between the groups.

Conclusions

In selected patients, SLLDR can be performed safely with good surgical and oncological outcomes.

Multivisceral Resection for Locally Invasive Colorectal Liver Metastases: Outcomes of a Matched Cohort Analysis

Local invasion of adjacent viscera by colorectal liver metastases (CRLM) is no longer considered an absolute contraindication to curative hepatic resection. A growing number of observational analyses have illustrated the feasibility of such resections; however, the evidence base is at best heterogeneous with a lack of evidence comparing similar patient groups. We aimed to evaluate the outcomes of hepatectomy for CRLM when combined with other viscera and compare to a matched cohort of isolated hepatic resections.

METHODS

From 2005 to 2015, 523 patients underwent hepatic resection for CRLM at our institution, 19 of whom underwent hepatectomy with extrahepatic resection. A 3: 1 matched cohort analysis was performed between those who underwent isolated hepatectomy (control group) and those who underwent hepatectomy with extrahepatic resection (combined group). Clinicopathological data were reviewed along with 30-day postoperative morbidity and mortality. Furthermore, overall survival for the multivisceral cohort was compared to all other isolated hepatectomies over the same time period.

RESULTS

Nineteen patients underwent liver resection accompanied by either/or diaphragmatic resection (n = 13), major vein resection and reconstruction (n = 5), and visceral resection (n = 3). Maximum tumor size was significantly larger in the combined group (60.58 vs. 15.34 mm p < 0.0001). Postoperative morbidity was similar in both groups (p = 0.41). Following multivisceral resection, 1-, 3- and 5-year survival rates were 75, 56.6, and 25.7% respectively. Overall survival showed no significant difference between combined and control groups (p = 0.78). Similarly, when compared to the total cohort of isolated liver resections (n = 504), no significant difference in overall mortality was noted.

CONCLUSION

In patients presenting with concomitant CRLM and extrahepatic extension where R0 margins can be achieved, this present study supports the rationale to proceed to -surgery with comparable morbidity and mortality rates to -isolated hepatectomy.

Pathological diaphragmatic invasion by colorectal liver metastases is associated with RAS mutation, peritoneal recurrence and worse survival

BACKGROUND

Risk factors for pathological diaphragmatic invasion from colorectal liver metastases (CRLM) and differences in recurrence patterns and survival between patients with true pathological diaphragmatic invasion versus inflammatory adhesions only remain poorly understood. This study aimed at identifying risk factors for and survival impact of pathological diaphragmatic invasion in patients with CRLM.

METHODS

Patients with CRLM who underwent hepatectomy with or without diaphragmatic resection from 1998 to 2015 were retrospectively analyzed. Recurrence-free survival (RFS), overall survival (OS), and recurrence patterns were examined according to the presence or absence of pathological invasion.

RESULTS

Of 1860 patients, 70 underwent hepatectomy with diaphragmatic resection and 1799 had hepatectomy only. Among the patients with gross diaphragmatic involvement, 15 (21%) had pathological invasion, and 55 (79%) had inflammatory adhesion only. Multiple tumors (p = 0.019) and RAS mutation (p = 0.047) were significantly associated with pathological invasion. Pathological invasion was associated with a higher incidence of peritoneal recurrence (33% vs. 11%, p = 0.041), worse median RFS (6 months vs. 11 months, p = 0.21) and OS (26 months vs. 51 months, p = 0.046) compared to inflammatory adhesion.

CONCLUSION

Multiple tumors and RAS mutant were predictors for pathological diaphragmatic invasion, which was associated with a higher incidence of peritoneal recurrence and worse OS.

Can retrohepatic tunnel be quickly and easily established for laparoscopic liver hanging maneuver by Goldfinger dissector in laparoscopic right hepatectomy?

OBJECTIVE

The liver hanging maneuver (LHM) is rarely applied in laparoscopic right hepatectomy (LRH) because of the difficulty encountered in retrohepatic tunnel (RT) dissection and tape positioning. Thus far no report has detailed how to quickly and easily establish RT for laparoscopic LHM in LRH, nor has employment of the Goldfinger dissector to create a total RT been reported. This study's aim was to evaluate the safety and feasibility of establishing RT for laparoscopic LHM using the Goldfinger dissector in LRH.

METHODS

Between March 2015 and July 2015, five consecutive patients underwent LRH via the caudal approach with laparoscopic LHM. A five-step strategy using the Goldfinger dissector to establish RT for laparoscopic LHM was adopted. Perioperative data were analyzed.

RESULTS

The median age of patients was 58 (range, 51-65) years. Surgery was performed for one intrahepatic lithiasis and four hepatocellular carcinomas with a median size of 90 (40-150) mm. The median operative time was 320 (282-358) min with a median blood loss of 200 (200-600) ml. Laparoscopic LHM was achieved in a median of 31 (21-62) min, and the median postoperative hospital stay was 14 (9-16) d. No transfusion or conversion was required, and no severe liver-related morbidity or death was observed.

CONCLUSIONS

The Goldfinger dissector is a useful instrument for the establishment of RT. A five-step strategy using the Goldfinger dissector can quickly and easily facilitate an RT for a laparoscopic LHM in LRH.

Laparoscopic Right Hepatectomy by the Caudal Approach Versus Conventional Approach: A Comparative Study

BACKGROUND

Laparoscopic right hepatectomy (LRH) is increasingly performed for the treatment of many liver diseases. However, it remains a challenging procedure and is limited to highly specialized centers. Increasing the safety and efficacy of LRH is crucial. This study evaluated the safety and feasibility of the novel caudal approach (CDA) in LRH and in comparison with the conventional approach (CA).

METHODS

Of a total of 40 patients who underwent LRH between June 2007 and July 2015 at our center, 10 cases underwent the CDA, while 30 underwent the CA. Operative and postoperative outcomes were analyzed.

RESULTS

Clinical data and patient characteristics were comparable between the two groups. Only 1 patient required a laparoscopic-assisted procedure in the CDA group, while 14 patients were converted to laparotomy (n = 10) or laparoscopic-assisted procedures (n = 4) in the CA group, although the difference did not reach statistical significance (P = .060). However, the difference in conversion to laparotomy between the two groups was significant (P = .043). In addition, when considering 23 patients with malignancies, the median surgical margin was significantly greater in the CDA group (n = 6) (20 mm versus 10 mm; P = .023) than in the CA group (n = 17). Other operative and postoperative outcomes were similar between the two groups.

CONCLUSIONS

The CDA achieves safety and feasibility similar to that of the CA in LRH and requires relatively less conversion to laparotomy. In selected patients, the CDA offers an alternative option to the CA for LRH in experienced hands. Further studies with larger samples are warranted to evaluate the CDA.

Laparoscopic Resection of the Diaphragmatic Tumor Nodule for Management of Recurrent Endometrial Cancer

STUDY OBJECTIVE

To show a surgical video in which an isolated hemidiaphragmatic tumor nodule was resected laparoscopically in a patient with isolated recurrence of endometrial cancer.

DESIGN

Case report (Canadian Task Force Classification study design III).

SETTING

Tertiary referral center in New Haven, CT.

INTERVENTIONS

This is a step-by-step illustration of tumor nodule resection from the right hemidiaphragm. The patient was a 55-year-old white woman who was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in June 2011 after surgical debulking. She received adjuvant carboplatin and paclitaxel and vaginal brachytherapy. She was disease free until March 2015 when she presented with right upper abdominal pain. A computed tomographic scan showed a 1-cm implant on the right hepatic dome. The implant was noted to be enlarged to 1.8 cm on a subsequent computed tomographic scan in August 2015. The patient was taken to the operating room for exploratory laparoscopy and resection of the hepatic dome/hemidiaphragmatic tumor nodule. The tumor nodule was noted to involve the full thickness of the right hemidiaphragm. The resection of the entire nodule required perforation of the diaphragm, which was reapproximated after the excision.

MAIN RESULTS

The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 1. Pathology revealed metastatic endometrioid endometrial adenocarcinoma with negative resection margins.

CONCLUSION

Laparoscopic resection of the diaphragmatic tumor nodule and the reapproximation of the diaphragm were successfully performed in this patient with isolated disease recurrence. The laparoscopic approach should be considered for management of isolated recurrences in gynecologic cancers by experienced laparoscopic surgeons because it might otherwise be associated with significant morbidity and mortality [1-3].

National trends with a laparoscopic liver resection: results from a population-based analysis

BACKGROUND

Interest in laparoscopic liver resection (LLR) has grown since the International 'Louisville Statement' regarding laparoscopic liver surgery was published in 2009. However, limited population-based data on LLR utilization patterns and outcomes are available.

METHODS

LLR data from the Nationwide Inpatient Sample (NIS, 2000-2012) and the National Surgical Quality Improvement Project (NSQIP, 2005-2012) were compared before and after the Louisville Statement in 2009.

RESULTS

In total, 1131 and 642 LLR were identified from NIS and NSQIP, respectively. Three-quarters of patients underwent LLR for a malignant indication (NIS primary malignancy, 29.6% versus metastasis, 45.1%; NSQIP primary malignancy, 35.5% versus metastasis, 46.1%). The annual volume of LLR increased from 2000-2008 versus 2009-2012 (NIS: 63 versus 168, P < 0.001; NSQIP: 52 versus 127; both P = 0.001). The peri-operative mortality associated with LLR was 2.8% in NIS and 2.2% in NSQIP. The morbidity was 38.1% in NIS and 30.7% in NSQIP. Mortality and morbidity did not change over time (both P > 0.050). After 2009, LLR was associated with a shorter length of stay (LOS) (NIS: 5 versus 6 days, P = 0.007).

CONCLUSION

Since the Louisville Statement in 2009, utilization of LLR has increased. LLR is associated with a modest decrease in LOS and appears to be safe with mortality and morbidity similar to open surgery.

Hepatic arterial infusion plus systemic chemotherapy as third-line or later treatment in colorectal liver metastases

BACKGROUNDS

The present study aimed to evaluate benefit of hepatic arterial infusion chemotherapy (HAI) combined with systemic chemotherapy (SCT) for patients with colorectal liver metastases (CLMs) in a palliative setting.

METHODS

This was a retrospective single-center study including 43 consecutive patients with CLM after failure of standard SCT. Among them, 20 (47 %) patients underwent HAI combined with SCT (Group A) and 23 historical control patients who had received SCT with or without targeted agent treatment (Group B).

RESULTS

The two groups had similar characteristics. Compared with SCT alone, HAI combined with SCT prolonged survival (median 19.8 vs. 9.0 months; P = 0.045). Median hepatic progression-free survival was significantly longer for HAI combined with SCT vs. SCT alone (median 8.1 vs. 4.7 months; P = 0.027), as were response rates (25 and 0 %; P = 0.038) and progression-free survival (median 5.7 vs. 3.0 months; P = 0.02). Three patients (15 %) achieved conversion to potentially curative surgery. Grade 3/4 toxicities for Group A and Group B were neutropenia (5 and 8.7 %, respectively), anemia (5 and 0 %, respectively), and hyperbilirubinemia (0 and 4.3 %, respectively). Other complications were mostly grade 1 or 2.

CONCLUSIONS

HAI combined with SCT treatment can improve overall survival compared with SCT alone in highly advanced CLM refractory to intravenous chemotherapy.