Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections

Stage IV Colorectal Cancer Management and Treatment

(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis

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.

Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.

Parenchyma-Sparing Central Hepatectomy Versus Extended Resections for Liver Tumors: a Value-Based Comparative Analysis

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.

Feasibility of Right Upper Transversal Hepatectomy in the Absence of an Inferior Right Hepatic Vein: New Insights regarding This Complex Procedure

Background

Right upper transversal hepatectomy (RUTH) is defined as the removal of liver segments 7, 8, and 4A with ligature of the right and middle hepatic veins and is considered one of the most complex techniques of parenchymal-sparing hepatectomies. This procedure can be performed, without venous reconstruction, if collateral veins are present communicating within remnant liver segments to a large inferior right hepatic vein and/or to the left hepatic vein. This venous network could maintain outflow from the inferior right segments (S5, S6) to the left liver when a RUTH is performed, even in the absence of an inferior right hepatic vein. The aim of this study is to present our experience with RUTH without venous reconstruction in patients with and without the presence of an inferior right hepatic vein (IRHV).

Methods

Patients submitted to RUTH for treatment of liver metastases were selected from our database. The presence of an IRHV, clinical and surgical characteristics of the patients, immediate outcomes, viability of liver segments 5 and 6, and long-term survival were analyzed.

Results

RUTH was successfully performed in four patients. In two patients, IRHV was not present, but intrahepatic communicating veins between proximal right and middle hepatic veins and left hepatic vein were present. No venous reconstructions were performed. Mild congestion of the inferior right segments occurred in the patients where there was no IRHV but no immediate, early, or late complications were observed.

Conclusions

RUTH is feasible and can be performed even in the absence of an IRHV, without venous reconstruction. Some degree of congestion of the right inferior liver segments might occur when an IRHV is absent, yet this is not clinically significant when communicating veins are present. Maximum parenchyma preservation might prevent postoperative liver failure and allow repeated resections in case of hepatic recurrence.

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review

BACKGROUND

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

METHODS

A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

RESULTS

The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

CONCLUSIONS

Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.

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

OBJECTIVE

To elucidate minor hepatectomy (MiH) outcomes.

SUMMARY BACKGROUND DATA

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

METHODS

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

EXCLUSION CRITERIA

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

RESULTS

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

CONCLUSIONS

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

Perihilar Glissonian Approach for Anatomical Parenchymal Sparing Liver Resections: Technical Aspects: The Taping Game

OBJECTIVE

To present technical details for central hepatectomy and right anterior and posterior sectionectomies using perihilar Glissonian approach for anatomical delineation and selective inflow occlusion.

BACKGROUND

Central tumors and those deeply located in the right liver may require extensive resections because of their proximity to major vascular structures. In such cases, anatomical more limited resections such as central hepatectomy or sectionectomies may provide an alternative to extensive surgery by assuring both parenchymal sparing and suitable oncologic resection.

METHODS

We present the global concept for performing a perihilar Glissonian approach and its application to each individual anatomical procedure. This includes detailed descriptions, illustrations, and videos demonstrating the technique.

RESULTS

This technique was applied since 1991 for anatomical parenchymal resections including central hepatectomy (resection of segments 4, 5, and 8), right anterior sectionectomy (resection of segments 5 and 8), and right posterior sectionectomy (resection of segments 6 and 7). The feasibility rate of the Glissonian approach was 88%.

CONCLUSIONS

Perihilar Glissonian approach is a safe and reproducible technique that enables anatomical parenchymal preserving liver resections for selected central and right-sided deeply located tumors.

Central Hepatectomy versus Extended Hepatectomy for Malignant Tumors: A Propensity Score Analysis of Postoperative Complications

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.

Twelve-year experience of "radical but conservative" liver surgery for colorectal metastases: impact on surgical practice and oncologic efficacy

BACKGROUND

Liver surgery for colorectal metastases (CLM) is moving toward parenchyma-sparing approaches. The authors reported the technical feasibility of parenchyma-sparing hepatectomy for deeply located tumors, but its impact on daily practice and long-term outcomes remain unclear.

METHODS

The patients undergoing liver resection (LR) for CLM with vascular contact (first-/second-order pedicle or hepatic vein (HV) trunk) were considered. Those undergoing major hepatectomy were excluded. The authors' technique included tumor-vessel detachment, partial resection of marginally infiltrated HVs, and detection of communicating vessels (CVs) among HVs to preserve outflow after HV resection.

RESULTS

Among 169 patients with major vascular contact, parenchyma-sparing LR was feasible in 146 (86%). Twenty-eight SERPS, 13 transversal hepatectomies, 6 mini-mesohepatectomies, and 4 liver tunnels were performed. Sixty-six (45%) patients underwent CLM-vessel detachment, 25 (17%) underwent partial HV resection, and 30 (21%) achieved outflow preservation by CV identification. The mortality and severe morbidity rates were 1.4% and 8.2%, respectively. The 5-year survival rate was 30.7%. The parenchyma-sparing strategy failed in 14 (7%) patients because of recurrence in the spared parenchyma or cut edge; 13 were radically retreated.

CONCLUSION

Ultrasound-guided parenchyma-sparing surgery is feasible in most patients with ill-located CLMs. This procedure is safe and achieves adequate oncologic outcomes.

Mesohepatectomy Versus Extended Hemihepatectomies for Centrally Located Liver Tumors: A Meta-Analysis

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.

Left hepatectomy after right paramedian sectoriectomy

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.

Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review

INTRODUCTION

Colorectal liver metastases develop in 50% of patients diagnosed with colorectal cancer. Surgical resection for colorectal liver metastasis typically involves either anatomical resection (AR) or parenchymal-sparing hepatectomy (PSH). The objective of the current study was to analyze data on parenchymal versus non-parenchymal-sparing hepatic resections for CLM.

METHODS

A systematic review of the literature regarding parenchymal-sparing hepatectomy was performed. MEDLINE/PubMed, Cochrane, and EMBASE databases were searched for publications containing the following medical subject headings (MeSH): "Colorectal Neoplasms," "Neoplasm Metastasis," "Liver Neoplasms" and "Hepatectomy". Besides, the following keywords were used to complete the literature search: "Hepatectomy," "liver resection," "hepatic resection," "anatomic/anatomical," "nonanatomic/ nonanatomical," "major," "minor," "limited," "wedge," "CRLM/CLM," and "colorectal liver metastasis." Data was reviewed, aggregated, and analyzed.

RESULTS

Two thousand five hundred five patients included in 12 studies who underwent either PSH (n = 1087 patients) or AR (n = 1418 patients) were identified. Most patients had a primary tumor that originated in the colon (PSH 52.2-74.4% vs. AR 53.9-74.3%) (P = 0.289). The majority of studies included a large subset of patients with only a solitary tumor with a reported median tumor number of 1-2 regardless of whether the patient underwent PSH or AR. Median EBL was no different among patients undergoing PSH (100-896 mL) versus AR (200-1489 mL) for CLM (P = 0.248). There was no difference in median length-of-stay following PSH (6-17 days) versus AR (7-15 days) (P = 0.747). While there was considerable inter-study variability regarding margin status, there was no difference in the incidence of R0 resection among patients undergoing PSH (66.7-100%) versus AR (71.6-98.6%) (P = 0.58). When assessing overall survival, there was no difference whether resection of CLM was performed with PSH (5 years OS: mean 44.7%, range 29-62%) or AR (5 years OS: mean 44.6%, range 27-64%) (P = 0.97).

CONCLUSION

PSH had a comparable safety and efficacy profile compared with AR and did not compromise oncologic outcomes. PSH should be considered an appropriate surgical approach to treatment for patients with CLM that facilitates preservation of hepatic parenchyma.

Outcome after laparoscopic and open resections of posterosuperior segments of the liver

BACKGROUND

Laparoscopic resection of posterosuperior (PS) segments of the liver is hindered by limited visualization and curvilinear resection planes. The aim of this study was to compare outcomes after open and laparoscopic liver resections of PS segments.

METHODS

Patients who underwent minor open liver resection (OLR) and laparoscopic liver resection (LLR) between 2006 and 2014 were identified from the institutional databases of seven tertiary referral European hepatobiliary surgical units. Propensity score-matched analysis was used to match groups for known confounders. Perioperative outcomes including complications were assessed using the Dindo-Clavien classification, and the comprehensive complication index was calculated. Survival was analysed with the Kaplan-Meier method.

RESULTS

Some 170 patients underwent OLR and 148 had LLR. After propensity score-matched analysis, 86 patients remained in both groups. Overall postoperative complication rates were significantly higher after OLR compared with LLR: 28 versus 14 per cent respectively (P = 0·039). The mean(s.d.) comprehensive complication index was higher in the OLR group, although the difference was not statistically significant (26·7(16·6) versus 18·3(8·0) in the LLR group; P = 0·108). The mean(s.d.) duration of required analgesia and the median (range) duration of postoperative hospital stay were significantly shorter in the LLR group: 3·0(1·1) days versus 1·6(0·8) days in the OLR group (P < 0·001), and 6 (3-44) versus 4 (1-11) days (P < 0·001), respectively. The 3-year recurrence-free survival rates for patients with hepatocellular carcinoma (37 per cent for OLR versus 30 per cent for LLR; P = 0·534) and those with colorectal liver metastases (36 versus 36 per cent respectively; P = 0·440) were not significantly different between the groups.

CONCLUSION

LLR of tumours in PS segments is feasible in selected patients. LLR is associated with fewer complications and does not compromise survival compared with OLR.

Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in mongolia

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.

The safety and effectiveness of liver resection for breast cancer liver metastases: A systematic review

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.

Parenchymal-sparing liver surgery in patients with colorectal carcinoma liver metastases

Liver resection is the treatment of choice for patients with colorectal liver metastases (CLM). However, major resections are often required to achieve R0 resection, which are associated with substantial rates of morbidity and mortality. Maximizing the amount of residual liver gained increasing significance in modern liver surgery due to the high incidence of chemotherapy-associated parenchymal injury. This fact, along with the progressive expansion of resectability criteria, has led to the development of a surgical philosophy known as "parenchymal-sparing liver surgery" (PSLS). This philosophy includes a variety of resection strategies, either performed alone or in combination with ablative therapies. A profound knowledge of liver anatomy and expert intraoperative ultrasound skills are required to perform PSLS appropriately and safely. There is a clear trend toward PSLS in hepatobiliary centers worldwide as current evidence indicates that tumor biology is the most important predictor of intrahepatic recurrence and survival, rather than the extent of a negative resection margin. Tumor removal avoiding the unnecessary sacrifice of functional parenchyma has been associated with less surgical stress, fewer postoperative complications, uncompromised cancer-related outcomes and higher feasibility of future resections. The increasing evidence supporting PSLS prompts its consideration as the gold-standard surgical approach for CLM.

The prognostic value of a classification system for centrally located liver tumors in the setting of hepatocellular carcinoma after mesohepatectomy

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.

Central bisegmentectomy for malignant liver tumors: experience in 8 patients

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.

Central hepatectomy versus extended hepatectomy for liver malignancy: a matched cohort comparison

OBJECTIVE

To compare surgical outcomes between matched central hepatectomy (CH) and extended hepatectomy (EH) groups.

BACKGROUND

Surgical choices for centrally located liver tumours are limited. The traditional EH harbours substantial risks, whereas CH is an alternative parenchymal-sparing resection that may improve peri-operative morbidity.

METHODS

A review of 4661 liver resections at a single institution was performed. The cases (CH) were matched in a 1:1 ratio with EH controls.

RESULTS

The CH group was matched for demographic, tumour and laboratory factors with either right EH or combined (right/left) EH groups (n = 63 per group). Colorectal liver metastases were the most common diagnosis occurring in 70% of the patients. Higher intra-operative blood loss was observed in the right EH(P = 0.01) and combined EH groups (P < 0.01) compared with the CH group. There was a trend towards lower 90-day morbidity in the CH group (43%) compared with the right EH(59%, P = 0.1) and combined EH groups (56%, P = 0.2). The length of hospital stay was significantly longer in the control groups (P < 0.01 for both). The control groups had significantly higher post-operative bilirubin and International Normalized Ratio (INR) levels compared with the CH group. A post-operative bilirubin higher than 4 mg/dl was observed in 2% of the CH group compared with 39% of the right EH group (P < 0.01) and 52% of the combined EH group (P < 0.01). No differences in the rates of bile leak/biloma, post-hepatectomy liver failure or 90-day mortality were found.

CONCLUSIONS

CH, as compared with EH, was safe and associated with a shorter hospital stay and less post-operative liver dysfunction. CH should be considered in patients with centrally located tumours amenable to such a resection.

How Far Can We Go with Laparoscopic Liver Resection for Hepatocellular Carcinoma? Laparoscopic Sectionectomy of the Liver Combined with the Resection of the Major Hepatic Vein Main Trunk

Although the reports of laparoscopic major liver resection are increasing, hepatocellular carcinomas (HCCs) close to the liver hilum and/or major hepatic veins are still considered contraindications. There is virtually no report of laparoscopic liver resection (LLR) for HCC which involves the main trunk of major hepatic veins. We present our method for the procedure. We experienced 6 cases: 3 right anterior, 2 left medial, and 1 right posterior extended sectionectomies with major hepatic vein resection; tumor sizes are within 40–75 (median: 60) mm. The operating time, intraoperative blood loss, and postoperative hospital stay are within 341–603 (median: 434) min, 100–750 (300) ml, and 8–44 (18) days. There was no mortality and 1 patient developed postoperative pleural effusion. For these procedures, we propose that the steps listed below are useful, taking advantages of the laparoscopy-specific view. (1) The Glissonian pedicle of the section is encircled and clamped. (2) Liver transection on the ischemic line is performed in the caudal to cranial direction. (3) During transection, the clamped Glissonian pedicle and the peripheral part of hepatic vein are divided. (4) The root of hepatic vein is divided in the good view from caudal and dorsal direction.

Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective

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.

Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis

BACKGROUND & AIMS

Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors.

METHODS

Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model.

RESULTS

Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69).

CONCLUSION

By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.

Three-dimensional morphometric analysis for hepatectomy of centrally located hepatocellular carcinoma: A pilot study

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.

Extended central hepatectomy with preservation of segment 6 for patients with centrally located hepatocellular carcinoma

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.

Inferior right hepatic vein-preserving major right hepatectomy for hepatocellular carcinoma in patients with significant fibrosis or cirrhosis

BACKGROUND

Liver resection represents a most effective treatment for hepatocellular carcinoma (HCC). The extent of hepatectomy for HCC involves maintaining a tricky balance between radical resection of tumors and preservation of sufficient liver parenchyma. Generally, removal of the right hepatic vein often involves resection of the whole posterior right lobe, which may prevent patients with impaired liver function from maintaining a functional reserve and could also limit the future liver remnant from curative hepatectomy. As a common anatomic variation, preservation of the inferior right hepatic vein (IRHV) may enable preservation of liver segment 6, even when the right hepatic vein has to be removed. In the present study, we report our experience with IRHV-preserving major right hepatectomy.

METHODS

From February 2009 to December 2011, eight trisegmentectomies 5-7-8 and two segmentectomies 4-5-7-8 were performed with the IRHV-sparing technique on patients with HCC and significant fibrosis or cirrhosis. Data including demographic information, preoperative evaluations, postoperative outcomes, and follow-up results were collected and evaluated.

RESULTS

All patients survived and recovered from hepatectomy. The incidence of complications was higher in cirrhotic patients. The 1-year overall survival rate was 80 %, and the 1-year disease free survival rate was 60 %.

CONCLUSIONS

IRHV-preserving major right hepatectomy increases the resectability of HCC. Intraoperative ultrasonography is recommended to facilitate protection of the IRHV. This technique is safe with careful preoperative evaluation and meticulous perioperative care. The short-term outcome of IRHV-preserving liver resections is satisfactory.

Mesohepatectomy versus extended hemihepatectomy for centrally located hepatocellular carcinoma

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.

Central hepatectomy for centrally located malignant liver tumors: A systematic review

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.

Mesohepatectomy for centrally located liver tumours

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.

A comparison of right posterior sectorectomy with formal right hepatectomy: a dual-institution study

OBJECTIVES

Right posterior sectorectomy (RPS) preserves liver volume but typically requires a longer parenchymal transection distance than does right hepatectomy (RH). This study was conducted to define the advantages of one approach over the other.

METHODS

Databases at two institutions were retrospectively reviewed for all patients submitted to RPS or RH between January 2000 and August 2012. Primary outcomes were perioperative complications and 90-day mortality.

RESULTS

Patients undergoing RPS (n = 100) and RH (n = 480), respectively, were similar in demographics, comorbidities, operative indications and Model for End-stage Liver Disease (MELD) mean scores (7.8 in the RPS group and 7.7 in the RH group; P = 0.49). A comparison of the RPS group with the RH group showed no significant differences in mean estimated blood loss (697 ml versus 713 ml; P = 0.900), rate of transfusions (19.2% versus 17.1%; P = 0.720), margin-positive resection (9.2% versus 11.6%; P = 0.70), complications (41.8% versus 42.0%; P = 1.000), bile leak (3.0% versus 4.0%; P = 1.000), or length of stay (7.5 days versus 8.3 days; P = 0.360). Postoperative hepatic insufficiency (defined as a postoperative bilirubin level of >7 mg/dl or significant ascites), occurred less frequently after RPS (1.0% versus 8.5%; P = 0.005). Operation type remained an independent determinant of postoperative hepatic insufficiency after controlling for preoperative risk factors (RH: hazard ratio = 9.628, 95% confidence interval 1.295-71.573; P = 0.027). A total of 28 (4.8%) patients died within 90 days; these included 25 (5.2%) patients in the RH group and three (3.0%) in the RPS group (P = 0.449).

CONCLUSIONS

Despite similar blood loss and overall morbidity, RPS is associated with less hepatic insufficiency than RH. Right posterior sectorectomy is parenchyma-sparing and should be strongly considered when it is technically feasible and oncologically sound.

Percutaneous radiofrequency ablation versus partial hepatectomy for small centrally located hepatocellular carcinoma

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.

Outcomes of central bisectionectomy for hepatocellular carcinoma

BACKGROUND

Central bisectionectomy (resection of Couinaud segments IV, V and VIII) for malignant or benign disease poses a technical challenge to the surgeon but if feasible, has significant benefits in terms of conserving liver volume and options for future intervention. This study reviews a cohort of patients who underwent this procedure; outlines the indications, optimal operative technique as well as both short- and long-term outcomes.

METHODS

A retrospective review of a prospectively maintained database was performed. Pre-operative clinicopathological data, operative details and post-operative outcomes including overall and disease-free survival were analysed.

RESULTS

Between 1989 and 2009, 21 patients underwent a central bisectionectomy. All procedures were performed for hepatocellular carcinoma (HCC). All patients underwent a R0 resection with a median resection margin of 5 mm (1-15 mm). The 1-, 3- and 5-year disease-free survivals were 65%, 34.8% and 34.8%, and the corresponding overall survival rates were 90.5%, 66.8% and 66.8%, respectively.

CONCLUSION

These data support the use of a central bisectionectomy in selected cases in the management of HCC. With the use of a meticulous operative technique and adherence to surgical oncological principles, satisfactory long-term outcomes were achievable.

Clinical feasibility of inferior right hepatic vein-preserving trisegmentectomy 5, 7, and 8 (with video)

BACKGROUND AND AIM

Hepatic resection involves not only complete removal of tumors but also preservation of optimal liver function after surgery. This study introduces the technique of inferior right hepatic vein (IRHV)-preserving trisegmentectomy 5, 7, and 8 and evaluates its clinical feasibility.

METHODS

Between January 2008 and December 2011, four patients underwent this procedure. Postoperative outcomes and interim results were evaluated.

RESULTS

The median estimated volumes of the left lobe only and the left lobe plus preserved parenchyma relative to the total estimated liver volume were 22.8 % (range, 21.1-24.2 %) and 43.6 % (range, 38.0-47.5 %), respectively. The median total operating time and blood loss were 349 min (range, 348-417 min) and 650 ml (range, 300-1,700 ml), respectively. One patient developed the postoperative complication of bile leakage. The median hospital stay was 14.5 days (range, 14-50 days). Median follow-up was 23.5 months (range, 6-70 months), and two patients developed recurrence. One patient died of disease progression, and the other three patients were alive at the last follow-up.

CONCLUSION

Based on our experience, IRHV-preserving trisegmentectomy 5, 7, and 8 is a safe and feasible procedure. This technique could be an option for curative resection minimizing postoperative deterioration of liver function without preoperative portal vein embolization in patients with a reliable IRHV.

Single-center multidisciplinary management of patients with colorectal cancer and resectable synchronous liver metastases improves outcomes

BACKGROUND

Management of patients with synchronous liver metastasis (SLM) is complex and the surgical decision process should be based on a comprehensive oncological strategy. The aim of the study was to compare outcome of single-center management of patients with colorectal cancer (CRC) and resectable SLM to those of referred patients for liver resection only after removal of their primary tumor (PT).

METHODS

Between 2000 and 2007, 47 patients with CRC and SLM underwent resection of both the PT and metastases under our care (unicentric) and 32 were referred after resection of their PT.

RESULTS

The two groups were comparable for demographics, PT and metastatic disease data. In unicentric group, 23% received upfront chemotherapy with the PT in place, 53% had a combined CRC and SLM resection, 11% had a two-stage hepatectomy with resection of the primary during the first stage and 36% underwent delayed hepatectomy. The number of surgical interventions, the delay between diagnosis and liver resection (9 vs. 5 months, P < 0.001), the median number of cycles of chemotherapy before hepatectomy (12 vs. 6 months, P < 0.001) were significantly higher in the referred group. Postoperative morbidity was significantly higher in the referred group (75 vs. 47%, P = 0.023). The median follow-up was 43 months. OS and DFS were not significantly different between the two groups.

CONCLUSION

Although the survival benefit is not proven, single-center management of patients with CRC and resectable SLM reduces the number of interventions, the number of cycles of chemotherapy and postoperative morbidity.

Central hepatectomy under sequential hemihepatic control

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.

Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Locally advanced mid/low rectal cancer with synchronous liver metastases

BACKGROUND

Management of patients with T3/4 and/or N+ mid/low rectal cancer with synchronous liver metastases is not codified. The aim of this study was to analyze outcomes of our approach which consists of neoadjuvant chemotherapy or chemoradiotherapy, according to liver disease extension, followed by simultaneous rectal and liver resection.

METHODS

Between 2000 and 2009, 354 patients underwent hepatectomy for synchronous metastases. Thirty-six consecutive patients who underwent rectal and liver resection for metastatic T3/4 and/or N+ mid/low rectal cancer were analyzed.

RESULTS

Liver metastases were multiple in 27 patients, bilobar in 22, and >5 cm in six. Up-front treatment was chemotherapy in 15 patients, chemoradiotherapy in seven, chemotherapy followed by chemoradiotherapy in six, and surgery in eight (five symptomatic tumors). After chemotherapy alone (median number of cycles = 6), primary tumor response was observed in 11 patients (three complete responses). After chemoradiotherapy, only one patient had liver disease progression. Eighty-nine percent of patients underwent simultaneous rectal and hepatic resection. Mortality and morbidity rates were 2.8% (one pulmonary embolism) and 36%, respectively. After a mean follow-up of 39 months, 5-year overall and disease-free survival were 59.3 and 39.6%, respectively. Twenty-one patients had recurrence, including three pelvic recurrences (8.3%). No pelvic recurrence occurred among patients who correctly completed treatment strategy. All patients who received neoadjuvant chemoradiotherapy were alive and disease-free; 5-year overall and disease-free survival of patients receiving neoadjuvant chemotherapy were 59.3 and 25%, respectively.

CONCLUSIONS

For patients with metastatic T3/4 and/or N+ mid/low rectal cancer, the present strategy was safe and effective. Good disease control was achieved by neoadjuvant treatments, low morbidity rates were associated with simultaneous resection, and excellent long-term outcomes with low local relapse rate were obtained.

Conventional Surgical Treatment of Hepatocellular Carcinoma

Liver resection remains the standard therapy for solitary hepatocellular carcinoma in patients with preserved hepatic function. In well-selected patients, 5-year survival rates are good and can approach that of liver transplantation for early-stage disease. Patient selection is critical to optimizing therapeutic benefit, and the health of the native liver must be considered in addition to tumor characteristics. Hepatic recurrence after resection is common. The difficulty lies in deciding which patients with chronic liver disease and small solitary tumors are best served by resection and which should proceed with transplant evaluation; this is the focus of this article.

Liver resection in obese patients: results of a case-control study

OBJECTIVES

Obesity has been associated with worse postoperative outcomes. No data are available regarding short-term results after liver resection (LR). The aim of this study was to analyse outcomes in obese patients (body mass index [BMI] > 30 kg/m(2) ) undergoing LR.

METHODS

85 consecutive obese patients undergoing LR between 1998 and 2008 were matched on a ratio of 1:2 with 170 non-obese patients. Matching criteria were diagnosis, ASA score, METAVIR fibrosis score, extent of LR, and Child-Pugh score in patients with cirrhosis.

RESULTS

Operative time, blood loss and blood transfusions were similar in the two groups. Mortality was 2.4% in both groups. Morbidity was significantly higher in the obese group (32.9% vs. 21.2%; P= 0.041). However, only grade II morbidity was increased in obese patients (14.1% vs. 1.8%; P < 0.001) and this was mainly related to abdominal wall complications (8.2% vs. 2.4%; P= 0.046). No differences were encountered in terms of grade III or IV morbidity. The same results were observed in major LR and cirrhotic patients. When patients were stratified by BMI (<20, 20-25, 25-30 and >30 kg/m(2) ), progressive increases in overall and infectious morbidity were observed (5.6%, 22.4%, 23.7%, 32.9%, and 5.6%, 11.8%, 14.5%, 18.8%, respectively). Rates of grade III and IV morbidity did not change.

DISCUSSION

Obese patients have increased postoperative morbidity after LR in comparison with non-obese patients, but this is mainly related to minor abdominal wall complications. Severe morbidity rates and mortality are similar to those in non-obese patients, even in cirrhosis or after major LR.

Vascular clamping in liver surgery: physiology, indications and techniques

This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.

Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.

Outcome of central hepatectomy for hepatoblastomas

BACKGROUND/PURPOSE

Central hepatoblastomas (CHBL) involving liver segments (IV + V) or (IV + V + VIII) are in contact with the portal bifurcation. Their resection may be achieved by central hepatectomy (CH) with thin resection margins on both sides of the liver pedicle, by extended right or left hepatectomy with thin resection margins on one side, or by liver transplantation with thick free margins. The aim of this study is to assess the operative and postoperative outcome of CH for hepatoblastoma.

METHODS

This was a retrospective monocentric study of 9 patients who underwent CH for CHBL between 1996 and 2008.

RESULTS

The operative time was 4 hours 50 minutes (2 hours 20 minutes to 7 hours), vascular clamping lasted 30 minutes (0-90 minutes), and the amount of blood cell transfusion was 250 mL (0-1800 mL). Two patients had biliary leakage requiring percutaneous drainage. Median follow-up time was 27 months (14-120 months). All of 8 nonmetastatic patients are alive and disease-free; 1 metastatic patient died of recurrent metastases at last follow-up. Although 3 of 9 patients had surgical margins less than 1 mm, none, including the patients who died from metastases, had local recurrence.

CONCLUSIONS

Our study demonstrates the feasibility of CH for CHBL without operative mortality or local recurrence. Central hepatectomy is an alternative to extensive liver resections in selected patients.

A new systematic small for size resection for liver tumors invading the middle hepatic vein at its caval confluence: mini-mesohepatectomy

OBJECTIVE

We describe a new ultrasound guided conservative procedure for patients with liver tumors invading the middle hepatic vein (MHV) at its caval confluence.

SUMMARY BACKGROUND DATA

Morbidity and mortality for major hepatectomies are not negligible. However, when tumors invade the MHV at the caval confluence, major surgery is usually recommended.

METHODS

Patients included in this study were those with tumors invading the MHV at its hepato-caval confluence (within 4 cm). Minimum follow-up was established at 6-months from surgery. Among 284 consecutive hepatectomies, 17 (6%) met the inclusion criteria. Partial sparing of segments 4, 5, and 8 was established intraoperatively, based on color-Doppler IOUS findings (NCT00600522 on ClinicalTrials.gov).

RESULTS

In all the 17 patients at least one of the color-Doppler IOUS criteria was disclosed, and limited resections of just segments 4sup and 8 were always feasible. The MHV tract involved was always resected. Seven patients had single tumor removed and 10 multiple: total number of resected tumors was 58 (median: 2; range: 1-18). There were no postoperative mortality and major morbidity. Overall morbidity occurred in 3 (18%) patients. Median blood loss was 250 (range: 50-1000). One patient (6%) received blood transfusion. No local recurrences were observed (median follow-up: 26 months).

CONCLUSIONS

IOUS assistance systematically allows conservative resection of liver tumor invading the MHV at caval confluence. This drastically limits the need for larger resections, and further broadens the role of IOUS in optimizing the surgical strategy.

Liver resection for transplantable hepatocellular carcinoma: long-term survival and role of secondary liver transplantation

BACKGROUND/PURPOSE

Liver transplantation (LT) is the best theoretical treatment of hepatocellular carcinoma (HCC) fulfilling the Milan criteria (TNM stages 1-2). However, LT is limited by organ availability and tumor progression on the waiting list. Liver resection (LR) may represent an alternative in these patients. The aim of this study is to report the results of LR in transplantable patients.

PATIENTS

From 1990 to 2007, 274 patients underwent liver resection for HCC. Sixty-seven (24%) met the Milan criteria on pathologic study of the specimen. Ten were TNM stage 1 and 57 stage 2 and all had chronic liver disease. There were 56 men and 11 women with a mean age of 63. LR included 12 major hepatectomies, 14 bisegmentectomies, 14 segmentectomies, and 27 nonanatomic resections. Thirty-seven resections were performed through a laparoscopic approach and there were only 8 open resections since 1998.

RESULTS

Three patients died postoperatively (4.5%), none after laparoscopic resection. Morbidity rate was 34%. After a mean follow-up of 4.8 years, 36 patients (54%) developed intrahepatic tumor recurrence. Twenty-eight (77%) were again transplantable of which 16 (44%) were transplanted. Two additional patients underwent pre-emptive LT (ie before recurrence). When considering 44 patients <65 years at the time of resection (ie upper age limit for LT), the rates of recurrence, transplantable recurrence, and intention to treat salvage transplantation (patients with transplantable recurrence actually transplanted) were 59%, 80%, and 61%, respectively. Overall and disease free 5-year survival rates were 72% and 44%, respectively. Survival was not influenced by TNM stage 1 or 2, AFP level, tumor differentiation, or the presence microscopic vascular invasion. Survival after salvage LT was 70% and 87% when calculated from the date of LT and LR, respectively.

CONCLUSION

LR for small solitary HCC in compensated cirrhosis yields an overall survival rate comparable to upfront LT. Despite a significant recurrence rate, close imaging monitoring after resection allows salvage LT in 61% of patients with recurrence on intention to treat analysis.

Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach

BACKGROUND

Isolated segmentectomy VIII is a technically demanding operative procedure and is reported only rarely. To our knowledge, no reports on anatomic segmentectomy based on an intrahepatic approach have been described. For cirrhotic patients with hepatocellular carcinoma (HCC) limited to segment VIII, this is a parenchyma-preserving hepatectomy that can be tolerated.

METHODS

Eighteen patients with HCC underwent anatomic segment VIII segmentectomy from January 2005 to January 2008 in our institution. The operative techniques, postoperative, and oncologic outcomes were reviewed.

RESULTS

Anatomic segmentectomy VIII was feasible with the technology described herein in all patients. The perioperative and oncologic outcomes were comparable with those of other similar hepatic resections. The median follow-up time was 28 months. The 3-year survival rate was 65%.

CONCLUSION

Although complex and technically demanding, an intrahepatic Glissonian approach for anatomic segmentectomy of segment VIII is an oncologically radical but parenchyma-sparing hepatic resection. In terms of preserving greater functioning liver parenchyma, it may be a safe and effective alternative to extensive hepatectomy.

Selective metastatic tumor labeling with green fluorescent protein and killing by systemic administration of telomerase-dependent adenoviruses

We previously constructed telomerase-dependent, replication-selective adenoviruses OBP-301 (Telomelysin) and OBP-401 [Telomelysin-green fluorescent protein (GFP); TelomeScan], the replication of which is regulated by the human telomerase reverse transcriptase promoter. By intratumoral injection, these viruses could replicate within the primary tumor and subsequent lymph node metastasis. The aim of the present study was to evaluate the possibility of systemic administration of these telomerase-dependent adenoviruses. We assessed the antitumor efficacy of OBP-301 and the ability of OBP-401 to deliver GFP in hepatocellular carcinoma (HCC) and metastatic colon cancer nude mouse models. We showed that i.v. administration of OBP-301 significantly inhibited colon cancer liver metastases and orthotopically implanted HCC. Further, we showed that OBP-401 could visualize liver metastases by tumor-specific expression of the GFP gene after portal venous or i.v. administration. Thus, systemic administration of these adenoviral vectors should have clinical potential to treat and detect liver metastasis and HCC.

Mesohepatectomy as an option for the treatment of central liver tumors

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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