Benefit of Systematic Segmentectomy of the Hepatocellular Carcinoma: Revisiting the Dye Injection Method for Various Portal Vein Branches

Comparison of Anatomic and Non-Anatomic Liver Resection for Hepatocellular Carcinoma: A Retrospective Cohort Study

Background and Objectives: The survival benefit of anatomical liver resection for hepatocellular carcinoma has not been elucidated yet. In this study, we aimed to investigate the effects of anatomic and non-anatomic liver resection on surgical outcomes in patients with hepatocellular carcinoma. Materials and Methods: A retrospective analysis of patients undergoing anatomic or non-anatomic resections due to hepatocellular carcinoma between March 2006 and October 2019 was conducted. Demographics, preoperative laboratory assessments, treatment strategies, and postoperative outcomes were analyzed. Results: The total cohort consisted of 94 patients, with a mean age of 63.1 ± 8.9 years, and 74.5% were male. A total of 41 patients underwent anatomic liver resection, and 53 patients underwent non-anatomic resection. The overall survival rates were found to be similar (5-year overall survival was 49.3% for anatomic resection and 44.5% for non-anatomic resection). Estimated median overall survival times were 58.5 months and 57.3 months, respectively (p = 0.777). Recurrence-free 1-, 3-, and 5-year survival rates were found to be 73.6%, 39.1%, and 32.8% in the non-anatomic resection group and 48.8%, 22.7%, and 22.7% in the anatomic resection group, respectively. Grade three or higher complication rates were found to be similar among the groups. Conclusions: This study did not find a difference between two surgical methods, in terms of survival. A tailored selection of the resection method should be made, with the aim of complete removal of tumoral lesions and leaving a suitable functional liver reserve, according to the parenchymal quality and volume of the liver remnant.

Usefulness of ethiodized oil and gelatin sponge particles for delaying the washout of indocyanine green from the liver in swine

PURPOSE

To assess the effect of ethiodized oil (EO) and gelatin sponge particles (GS) on delaying the washout of indocyanine green (ICG) from the liver in swine.

METHODS

Fifteen swine were divided into 3 groups: injection of a mixture of ICG and water-soluble contrast medium (CM) followed by embolization with GS (group A), injection of a mixture of ICG and EO (group B) and injection of a mixture of ICG and EO followed by embolization with GS (group C). The liver surface was observed using an infrared camera system during and at 1, 2, 3, and 6 h after the procedure to measure ICG contrast. Livers were removed at 6 h for histopathological examination.

RESULTS

The contrast ratio between injected and non-injected regions at 6 h was 1.45 ± 0.44 in group A, 1.89 ± 0.37 in group B, and 3.62 ± 0.76 in group C. The contrast ratio in group C was significantly greater than that in groups A and B (P = 0.032 and 0.033, respectively).

CONCLUSIONS

EO and GS delayed the washout of ICG from the liver in swine and may extend intraoperative navigation in clinical use. Indocyanine green (ICG) mixed with ethiodized oil (EO) was injected into the left hepatic artery in swine, and the artery was embolized with gelatin sponge particles (GS). We confirmed that ICG remained in the liver parenchyma up to 6 h after the procedure. EO and GS delayed the washout of ICG from the liver in swine.

Evaluation of Safety-Related Outcomes of One-Segment and More-Than-One-Segment High-Level Hepatectomy in Hepatocellular Carcinoma Based on the Japanese Board Certification System

Background

We evaluated the impact of the Japanese board certification system for expert surgeons (JBCSES) on complications and survival outcomes in hepatectomy for hepatocellular carcinoma.

Methods

The postoperative outcomes of 493 patients who underwent high-level liver surgery involving one-segment (OSeg) hepatectomy and more-than-one-segment (MOSeg) resection were compared before and after JBCSES establishment. After the establishment of the JBCSES, the patients’ postoperative outcomes were compared using propensity score matching (PSM) to determine the influence of expert surgeons.

Results

The establishment of the JBCSES was associated with a decrease in the overall postoperative complication rates after high-level liver surgery from 50.2 to 38.1% (P = 0.008) and a decrease in Clavien–Dindo class ≥ IIIb complications from 10.2 to 5.0% (P = 0.035). The 90-day mortality rate decreased from 5.1 to 0.7% (P = 0.003), and the 5-year survival rate increased from 51.4 to 63.9% (P = 0.009). Using PSM, a comparison of OSeg hepatectomies that involved expert surgeons (n = 48) and those that did not (n = 48) showed significantly lower intraoperative blood loss in surgeries involving an expert surgeon (mean, 340 vs. 473 mL; P = 0.033). There were no significant differences in complication rates or long-term prognosis between these groups. A comparison of MOSeg hepatectomies that involved expert surgeons (n = 26) and those that did not (n = 26) showed no significant difference in surgical factors, complications, or overall survival between the two groups.

Conclusions

After establishment of the JBCSES, postoperative complication rates and mortality rates decreased and survival rates increased following liver surgery. Expert surgeon participation significantly decreased intraoperative blood loss during OSeg hepatectomies.

What is the optimal surgical treatment for hepatocellular carcinoma beyond the debate between anatomical versus non-anatomical resection?

The optimal type of hepatectomy for hepatocellular carcinoma (HCC)-anatomical or non-anatomical resection-remains controversial despite numerous comparative studies. There are common fundamental issues in published studies comparing anatomical resection with non-anatomical resection: (1) confounding by indication, (2) setting primary outcomes, and (3) a lack of a clear definition of non-anatomical resection. This degrades the quality of the comparison of the two types of surgery. To measure the therapeutic effect of hepatectomy, it is essential to understand the accumulated knowledge underlying these issues, such as the mechanism of hepatocellular carcinoma spread, tumor blood flow drainage theory, and the three patterns of hepatocellular carcinoma recurrence: (1) local intrahepatic metastasis, (2) systemic metastasis, and (3) multicentric carcinogenesis recurrence. Based on evidence that the incidence of local intrahepatic metastasis was so low it was almost negligible, the therapeutic effect of anatomical resection on the oncological survival was determined to be similar to that of non-anatomical resection. Recent research progress demonstrating the clinical impact of subclinical dissemination of HCC after surgery may stimulate new debate on the optimal surgical treatment for HCC beyond the comparison of anatomical and non-anatomical resection.

Risk Factors for Beyond Milan Recurrence After Hepatic Resection for Single Hepatocellular Carcinoma No Larger Than 5 Centimeters

Hepatic resection (HR) is considered a treatment of choice for a single hepatocellular carcinoma (HCC) ≤5 cm in patients with preserved liver function. However, it is possible for these patients to develop a severe form of recurrence (beyond Milan recurrence [BMR] criteria). This recurrence could have been avoided if liver transplantation (LT) was performed primarily, as LT is believed to yield a more favorable oncological outcome compared with HR. The aim of this study was to determine the risk factors for BMR after HR and to verify whether primary LT can provide a more favorable outcome in patients with BMR risk factors. Data from 493 patients who underwent HR for HCC ≤5 cm between 1995 and 2016 were analyzed. Among them, 74 patients (15%) experienced BMR. The 10-year survival rate of patients with BMR was significantly low compared with that of patients without BMR (22.6% versus 79.8%; P < 0.01). In multivariate analysis, calculated hepatic venous pressure gradient ≥7 mm Hg and microvascular invasion were identified as the risk factors for BMR (P < 0.05). During the same period, 63 eligible patients underwent LT as a primary treatment for HCC ≤5 cm. No significant difference in long-term survival rate was observed when no risk factor for BMR was present in the HR and LT groups (85.5% versus 100%; P = 0.39). However, 10-year survival was poorer in the HR group in the presence of risk factors for BMR (60.6% versus 91.8%; P < 0.001). Among the patients with HCCs ≤5 cm, which are resectable and transplantable, LT is indicated when calculated hepatic venous pressure gradient ≥7 mm Hg and/or microvascular invasion is present.

Ultrasound-guided anatomical liver resection using a compression technique combined with indocyanine green fluorescence imaging

BACKGROUND

Anatomical resection (AR) is a recommended surgical treatment for hepatocellular carcinoma (HCC). However, the conventional procedure (dye injection) for AR is difficult to reproduce. As an alternative, the tumour-feeding portal pedicle compression technique (finger-compression technique) has been proposed as an easy and reversible procedure. Here, we propose a new method combining indocyanine green (ICG) imaging with the finger-compression technique.

METHODS

Eligible patients were prospectively enrolled to undergo ICG compression (ICG-C) anatomical hepatectomy for HCC.

RESULTS

Fifteen patients underwent AR using the ICG-C technique. Overall, the surgical procedures included six segmentectomies, seven subsegmentectomies, and two right posterior sectionectomies. The median tumour size was 5.8 cm (range 2-7 cm). All procedures had an R0 margin. There were no major complications among patients, and minor morbidity occurred in three patients.

CONCLUSIONS

ICG-C is a safe, feasible and effective technique for patients eligible for AR.

What is a precise anatomic resection of the liver? Proposal of a new evaluation method in the era of fluorescence navigation surgery

BACKGROUND/PURPOSE

Indocyanine green (ICG) fluorescence navigation has been adapted for anatomic liver resection (AR) but an objective method for evaluation of its validity is required. This pilot study aimed to propose a new method to evaluate the accuracy of parenchymal division along the plane between hepatic segments and estimate the real-time navigation efficacy for AR by the Medical Imaging Projection System (MIPS), which continuously demonstrates the transection plane using projection mapping with ICG fluorescence.

METHODS

Ten patients who underwent open AR using liver segmentation with ICG fluorescence technique between August 2016 and July 2019 were included: six patients under MIPS guidance (MIPS group), while four using only conventional ICG fluorescence technique before parenchymal resection (non-MIPS group). Densitometry of the captured fluorescence image was performed to evaluate the fluorescence area ratio of each transection plane. The accurate fluorescence area ratio was calculated by subtracting the fluorescence area rate on the resected side from that on the remnant side.

RESULTS

The accurate fluorescence area ratio of the MIPS group and the non-MIPS group was 23.0 ± 12.6% and 5.6 ± 9.5%, respectively (P = .038).

CONCLUSIONS

Based on the results of our new method, real-time navigation using the MIPS may facilitate performing AR along the plane between hepatic segments.

Successful Anatomic Resection of Tumor-Bearing Portal Territory Delays Long-Term Stage Progression of Hepatocellular Carcinoma

BACKGROUND

Optimal choice of surgical procedure for hepatocellular carcinoma (HCC) remains inconclusive. This study seeks to investigate the oncological superiority of anatomic resection (AR) of the tumor-bearing portal territory and potential mechanism of survival benefit for patients undergoing AR.

PATIENTS AND METHODS

In 203 patients who underwent curative resection for primary solitary HCC measuring ≤ 5 cm in diameter, which was resectable either by AR or limited resection (non-AR), long-term outcomes were compared with propensity score adjustment. Advantages of AR in local tumor control and postprogression survival were then evaluated by a multivariate analysis and a Markov model.

RESULTS

The AR group showed better recurrence-free survival [hazard ratio (HR), 0.51; 95% CI, 0.28-0.91; P = 0.023), time-to-interventional failure (TIF) (HR, 0.08; 95% CI, 0.01-0.60; P = 0.014), and overall survival (HR, 0.11; 95% CI, 0.01-0.79, P = 0.029) than the non-AR group. Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.13; 95% CI, 0.02-0.97; P = 0.047) and is correlated with smaller number and size of recurrent lesions, both of which were predictors for better TIF and postprogression survival. A Markov model demonstrated that annual transition rate from the early recurrence stage (i.e., curative-intent treatment indicated) to the intermediate stage (i.e., only palliative-intent treatment indicated) was significantly lower (9.0% versus 35.6%, P = 0.027) when AR was completed at the initial hepatectomy.

CONCLUSIONS

AR is oncologically advantageous for patients with primary solitary HCC. Initial choice of surgical procedure may have significant influence on the pattern of recurrence and postprogression clinical course that may affect overall survival of patients with HCC.

Feasibility and safety of bisegmentectomy 7-8 while preserving hepatic venous outflow of the right liver - A retrospective cohort study

BACKGROUND

When a hepatic tumor is deeply located in segments 7 and 8 around the right hepatic vein (RHV), right hemihepatectomy (RH) could be excessive owing to the resection of large tumor-free segments. This study aimed to evaluate the feasibility and safety of bisegmentectomy 7-8 (S7-8) and to compare its surgical outcomes with those of RH.

MATERIALS AND METHODS

Consecutive patients who underwent S7-8 and RH were enrolled in this study. In the S7-8 group, 14 patients with an obvious inferior right hepatic vein (IRHV) (median: 6 mm; range: 3.6-8.8 mm) underwent S7-8 without hepatic vein reconstruction. RHV reconstruction was performed in six patients without an IRHV, involving direct anastomosis of the RHV in five patients and reconstruction using a cryo-preserved iliac vein in one patient.

RESULTS

A total of 61 patients were included (20 in S7-8 group; 41 in RH group). No significant differences were observed other than higher a model of end-stage liver disease score in the RH group than in the S7-8 group (7 [6-20] vs. 6 [6-9], P = 0.003). Post-hepatectomy liver failure including severe grades was more frequent in the RH group (43.9% vs. 10%, P = 0.008). In the S7-8 group, two patients with direct RHV reconstruction had RHV anastomosis obstruction, and eventually required insertion of a metallic stent. However, computed tomography performed 4 weeks after the operation showed intact venous outflow of the right liver in the S7-8 group.

CONCLUSION

S7-8 can be performed safely in selected patients with a thick IRHV. For patients with no obvious IRHV, RHV reconstruction could be a good surgical strategy to retain venous outflow of the right liver with feasible outcomes.

Anatomic versus non-anatomic resection for hepatocellular carcinoma, do we have an answer? A meta-analysis

BACKGROUND

Anatomic resection (AR) is widely performed for hepatocellular carcinoma (HCC), but it is generally not considered superior to non-anatomic resection (NAR) in terms of prognosis. So we compared the prognosis of AR with that of NAR for HCC.

METHODS

We searched for articles about AR versus NAR for HCC published between January 1998 and December 2018 in PubMed, Cochrane Library, EMBASE and Wanfang database. Meta-analysis was performed on patient characteristics, tumor characteristics, operative characteristics, perioperative outcomes and long-term outcomes.

RESULTS

A total of 38 studies involving 9122 patients were included: 5062 were in the AR group and 4060 in the NAR group. Only one study included in our meta-analysis was randomized controlled trial, and others were comparative cohort studies. The AR group had an advantage over NAR group in the aspect of age, liver cirrhosis level and liver reserve function; but had a disadvantage in the aspect of tumor size, AFP level, operation time, blood loss, microvascular invasion, pathological differentiation and postoperative complication. The AR group gained 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS) benefits versus NAR group, but there was significant heterogeneity between groups in terms of patient and tumor characteristics.

CONCLUSION

AR is superior to NAR regarding the long-term outcomes considering the relatively acceptable heterogeneity. More prospective randomized controlled trials are required to further confirm the actual effect of AR or NAR on survival for HCC with less heterogeneity.

Laparoscopic anatomical segmentectomy using the transfissural Glissonean approach

BACKGROUND

Anatomical segmentectomy is a technically difficult procedure owing to the complexity of the segmental anatomy of the liver. In the conventional Glissonean approach from the liver hilum, the tertiary portal pedicles may be difficult to dissect because of their anatomical variations and deep location. We present a technique of purely laparoscopic anatomical segmentectomy of the liver using the transfissural Glissonean approach.

METHODS

We performed purely laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. This approach involved initially opening the liver parenchyma along the fissure line (main portal, right portal, and umbilical fissures). Thereafter, the target tertiary portal pedicles were approached and ligated within the liver parenchyma above the liver hilum.

RESULTS

Between August 2014 and September 2019, we performed 17 cases of laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. The median operative time was 200 min (range 120-310 min), and the intraoperative blood loss was 80 mL (range 30-280 mL). The median postoperative hospital stay was 6 days (range 3-9 days). There was no major morbidity or mortality.

CONCLUSION

The transfissural Glissonean approach in laparoscopic anatomical segmentectomy is technically feasible because opening the fissure allows direct access to the tertiary portal pedicles.

"Logic-Based Medicine" Is More Feasible than "Evidence-Based Medicine" in the Local Treatment for Hepatocellular Carcinoma

The optimal type of surgery (e.g., anatomic or non-anatomic resection) or radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is still under debate despite numerous comparative studies based on overall survival. This debate continues not only because these endpoints are influenced by non-surgical factors, such as liver function, but because the definition of non-anatomic resection for HCC has remained unclear. The optimal surgery could be logically determined based on the mechanism of local intrahepatic metastasis, that is, the drainage of tumour blood flow (TBF), because HCC spreads locally through tumour blood flowing to the peri-tumourous liver parenchyma. Since TBF is clearly demonstrated by CT scan under hepatic arteriography, the surgical margin can be determined individually based on the drainage of TBF without deteriorating local curability. Controversy regarding RFA and surgery does not result from the curability of treatment itself but from the lack of scientific evidence on safety margins. Based on proper concepts and self-evident truths, an algorithm of loco-regional treatment for HCC is proposed.

Hepatic Arterial Embolization with an Indocyanine Green-Lipiodol^® Mixture before Laparoscopic Anatomical Liver Resection

Here, we report a case of hepatocellular carcinoma detected on computed tomography and treated with laparoscopic anatomical liver resection in a 69-year-old woman who was being followed-up for hepatitis C. Intraoperative liver segmentation is necessary to accomplish laparoscopic anatomical liver resection. Therefore, the day before surgery, hepatic artery embolization was performed with an indocyanine green-Lipiodol^Ⓡ mixture and Gelpart^Ⓡ containing indocyanine green to mark the region for hepatectomy. The next day, surgeons visually confirmed the resection segments on indocyanine green fluorescence imaging and performed laparoscopic anatomical liver resection. No major complications resulted from this method. In conclusion, hepatic artery embolization with an indocyanine green-Lipiodol^Ⓡ mixture is effective and safe for liver segment identification during laparoscopic anatomical liver resection.

Real-time navigation during hepatectomy using fusion indocyanine green-fluorescence imaging: protocol for a prospective cohort study

INTRODUCTION

In-vivo fluorescence imaging techniques using indocyanine green (ICG) to identify liver tumours and hepatic segment boundaries have been recently developed. The purpose of this study is to evaluate the efficacy of fusion ICG-fluorescence imaging for navigation during hepatectomy.

METHODS AND ANALYSIS

This will be an exploratory single-arm clinical trial; patients with liver tumours will undergo hepatectomy using the ICG-fluorescence imaging system. In total, 110 patients with liver tumours scheduled for elective hepatectomy will be included in this study. Preoperatively, ICG will be intravenously injected at a dose of 0.5 mg/kg body weight within 2 days. To detect liver tumours intraoperatively, the hepatic surface will be initially observed using the ICG-fluorescence imaging system. After identifying and clamping the portal pedicle corresponding to the hepatic segments, including the liver tumours to be resected, additional ICG will be injected intravenously at a dose of 0.5 mg/kg body weight to identify the boundaries of the hepatic segments. The primary outcome measure will be the success or failure of the ICG-fluorescence imaging system in identifying hepatic segments. The secondary outcomes will be the success or failure in identifying liver tumours, liver function indicators, operative time, blood loss, rate of postoperative complications and recurrence-free survival. The findings obtained through this study are expected to help to establish the utility of ICG-fluorescence imaging systems, and therefore contribute to prognostic outcome improvements in patients undergoing hepatectomy for various causes.

ETHICS AND DISSEMINATION

The protocol has been approved by the Kobe University Clinical Research Ethical Committee. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000031054 and jRCT1051180070.

Real-time Navigation for Liver Surgery Using Projection Mapping With Indocyanine Green Fluorescence: Development of the Novel Medical Imaging Projection System

OBJECTIVE

The aim of the present study was to evaluate the usefulness of a new imaging device, the Medical Imaging Projection System (MIPS), which uses the indocyanine green emission signal and active projection mapping, for liver resection.

BACKGROUND

During anatomic liver resection, surgeons cannot completely view the intraparenchymal structure. Although a fluorescent imaging technique using indocyanine green has recently been developed for hepatobiliary surgery, limitations in its application for real-time navigation persist.

METHODS

We conducted a retrospective review of surgical and clinical outcomes for 23 patients who underwent anatomic hepatectomy using the MIPS and 29 patients who underwent the procedure without MIPS guidance, between September 2014 and September 2015.

RESULTS

Preoperative characteristics were comparable between the 2 groups. No significant between-group differences were identified with regard to surgical and clinical outcomes. The demarcation lines were clearly projected by the MIPS in 21 patients; however, the boundary line was undetectable in 2 patients.

CONCLUSIONS

We developed the MIPS to address limitations in current intraoperative imaging methods. Our retrospective analysis provides evidence of the feasibility and clinical utility of the MIPS to identify anatomical landmarks for parenchymal dissection. The MIPS holds promise as a novel real-time navigation system for liver resection.

Is the anatomical resection necessary for single hepatocellular carcinoma smaller than 3 cm?: single-center experience of liver resection for a small HCC

Backgrounds/Aims

The superiority of anatomical resection (AR) for a small HCC remains controversial. In this study, we investigated the clinical outcomes after AR and non-anatomical liver resection (NAR) for single HCC smaller than 3 cm and the risk factors for HCC recurrence.

Methods

A total of 116 consecutive patients who underwent liver resection for single HCC (<3 cm) between Jan 2006 and Dec 2015 were included in this study. The medical records of these patients were reviewed and analyzed retrospectively.

Results

There was no significant difference in tumor recurrence and survival between AR and NAR group. Multivariate analysis showed that hepatitis B (p=0.035, HR=8.72), presence of satellite nodule (p=0.029, HR=3.97) and microvascular invasion (MVI) (p=0.039, HR=2.79) were independent risk factors for early recurrence within 1 year. The overall recurrence was independently related to the presence of satellite nodule (p=0.001, HR=4.98) and background liver cirrhosis (p=0.032, HR=1.96). In patients with MVI, HCC recurrence was significantly more frequent in width of safety margin <1 cm group than ≥1 cm group (p=0.049).

Conclusions

The outcomes of NAR are comparable with those of AR in single HCC smaller than 3 cm. The presence of satellite nodule, MVI and hepatitis B are the independent risk factors for early recurrence, however overall recurrence is correlated with background liver cirrhosis and the presence of satellite nodule rather than pathobiologic factors in single HCC smaller than 3 cm. Hepatic resection with sufficient margin (≥1 cm) is recommended for decreasing risk of recurrence in patients with suspected MVI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Innovative treatment for hepatocellular carcinoma (HCC)

Indocyanine green (ICG) is not new in the field of liver surgery. Early studies performed in the 1980s and 1990s revealed the value of the ICG clearance test in predicting post-hepatectomy morbidity and mortality. ICG clearance and retention tests are crucial for determining precise liver function before liver surgery and offer several benefits for safe surgery. Whereas ICG is well-known and has long history in medicine, recent progress in infrared light technology over the last decade has highlighted another feature of ICG. For example, ICG fluorescence-guided surgery may change the next generation of liver surgery. In the near future, ICG with near-infrared (NIR) light photodynamic therapy (PDT) is expected to become a new treatment method for hepatocellular carcinoma (HCC). Furthermore, several aspects of the mechanisms of ICG accumulation in HCC cells have been revealed by important basic research studies. New imaging technologies and mechanistic findings keep ICG in the spotlight. In this article, we review three recently described topics of ICG which may contribute to the development of innovative and new treatments method for HCC, fluorescence-guided surgery, mechanism of ICG accumulation in HCC cells, PDT for HCC.

Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy

BACKGROUND

Patients with a single hepatocellular carcinoma (HCC) ≤3 cm and preserved liver function have the highest likelihood to be cured if treated. The most adequate treatment methods are yet a matter that is debated.

METHODS

We reviewed the literature about open anatomic resection (AR), laparoscopic liver resection (LLR), and percutaneous thermal ablation (PTA).

RESULTS

PTA is effective as resection for HCC < 2 cm, when they are neither subcapsular nor perivascular. PTA in HCC of 2-3 cm is under evaluation. AR with the removal of the tumor-bearing portal territory is recommended for HCC > 2 cm, except for subcapsular ones. In comparison with open surgery, LRR has better short-term outcomes and non-inferior long-term outcomes. LLR is standardized for superficial limited resections and for left-sided AR.

CONCLUSIONS

According to the available evidences, the following therapeutic proposal can be advanced. Laparoscopic limited resection is the standard for any subcapsular HCC. PTA is the first-line treatment for deep-located HCC < 2 cm, except for those in contact with Glissonean pedicles. Laparoscopic AR is the standard for deep-located HCC of 2-3 cm of the left liver, while open AR is the standard for deep-located HCC of 2-3 cm in the right liver. HCC in contact with Glissonean pedicles should be scheduled for resection (open or laparoscopic) independent of their size. Liver transplantation is reserved to otherwise untreatable patients or as a salvage procedure at recurrence.

Indocyanine green fluorescence imaging techniques and interventional radiology during laparoscopic anatomical liver resection (with video)

BACKGROUND

To accomplish laparoscopic anatomical liver resection, intraoperative liver segmentation is necessary. Tattooing method or Glissonian approach will be used in a similar way to that in open liver resection. Moreover, in liver segment detection, the fluorescence of indocyanine green (ICG) means it has been recognized as a useful dye. In laparoscopy, however, there are technical difficulties in performing these conventional methods, so development of new techniques is necessary for liver segment identification. We report a pilot study using interventional radiology technique for laparoscopic intraoperative liver segmentation.

METHODS

Just prior to liver parenchymal resection, angiography was performed using a hybrid operation room. A catheter was inserted from the right femoral artery into the targeted arterial branch. After confirming the perfusion area by arteriography, embolic solution containing ICG was injected, and the branch was embolized. ICG fluorescence was observed by PINPOINT, a near-infrared imaging system.

RESULTS

Immediately after embolic solution injection, we were able to observe ICG fluorescence on the surface of the liver to be resected. This visual effect continued during liver parenchymal resection. We were able to confirm the intra-parenchymal boundary by observing ICG fluorescence on the cut surface of the resecting side and accomplished precise anatomical liver resection.

CONCLUSIONS

Our novel technique provides advances in laparoscopic anatomical liver resection performance. As two-dimensional laparoscopy lacks depth perception, additional visual information, such as ICG fluorescence imagery, is helpful as a navigation tool for precise laparoscopic anatomical liver resection.

Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC (e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection (AR) was introduced in the 1980s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.

Precise diagnosis and treatment of hepatolithiasis

Hepatolithiasis is a complex condition and the lesion is extensive. It is necessary to introduce the notion of precise surgery during the diagnosis and treatment of hepatolithiasis because the commonly used clinical methods have their limitations. A variety of technical means should be comprehensively applied to improve the levels of precise diagnosis and treatment, and individualized treatment strategy should be used. In addition, surgeons must attach great importance to the latest achievements of precise medicine, biomedical and intelligent technology.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies.

DATA SOURCES

PubMed database was searched for relevant articles in English on the issue of HCC management.

RESULTS

Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.

CONCLUSION

Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Complete removal of the tumor-bearing portal territory decreases local tumor recurrence and improves disease-specific survival of patients with hepatocellular carcinoma

BACKGROUND & AIMS

Anatomic resection (AR) of the tumor-bearing portal territory has been reported to be associated with a decreased recurrence of hepatocellular carcinoma (HCC). However, because of the heterogeneity of the study populations, its oncologic advantage remains controversial. The objective of the present study was to determine the clinical advantage of AR for primary HCC, based on the data from a large prospective cohort treated under a constant surgical policy.

METHODS

In 209 Child-Pugh class A patients with primary, solitary HCC measuring ⩽5.0cm in diameter, which was resectable either by AR or limited resection (non-AR), the overall survival (OS) and disease-free survival (DFS) were compared with patients in whom complete AR was achieved and those who eventually ended up with non-AR after adjustment for the propensity scores to select AR. Advantages of AR in disease-specific survival and local recurrence were also evaluated by competing-risks regression to clarify the true oncologic impact of AR.

RESULTS

The AR group showed better DFS than the non-AR group (HR, 0.67; 95% CI, 0.45-0.99; p=0.046), while no significant difference was observed in OS (hazard ratio [HR], 0.82; 95% CI, 0.46-1.48; p=0.511). Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.12; 95% CI, 0.05-0.30; p<0.001) and improves disease-specific survival (HR, 0.50; 95% CI, 0.28-0.90; p=0.020), while the other cause of death was highly influenced by patient age (>65years) (HR, 7.51; 95% CI, 2.16-26.04; p=0.002) and not associated with AR.

CONCLUSION

Complete removal of tumor-bearing portal territory decreases the risk of local recurrence and death from HCC.

Anatomical liver resection of segment 4a en bloc with the caudate lobe

Anatomical segmentectomy is the complete resection of an area supplied by a segmental portal branch. Among segmentectomies, isolated segmentectomy 4 is a technically demanding procedure because there are two transection planes: on the left side along the umbilical fissure and, on the right side, along the middle hepatic vein. Although there are several reports on anatomic segmentectomies, only few regard the anatomic segmentectomy 4a. We report here the case of a 60-year-old man who underwent anatomical segmentectomy 4a en bloc with the caudate lobe to resect a colorectal liver metastasis located in segment 4a and involving the paracaval portion of the caudate lobe. This type of procedure was planned in order to maximize the postoperative functional hepatic reserve, thereby reducing the risk of postoperative liver failure and ultimately allowing the possibility for future repeat hepatectomy in case of recurrence. J. Surg. Oncol. 2016;113:665-667. © 2016 Wiley Periodicals, Inc.

Prognostic impact of surgery and radiofrequency ablation on single nodular HCC ⩽5 cm: Cohort study based on serum HCC markers

BACKGROUND & AIMS

Serological markers of hepatocellular carcinoma (HCC) indicate its invasiveness. We aimed to investigate whether the prognostic impact of surgical resection (SR) and radiofrequency thermal ablation (RFA) on patients with single nodular HCC ⩽5cm were different regarding positive conditions of the following three HCC markers: alpha-fetoprotein (AFP); lens culinaris agglutinin-reactive fraction of AFP; and des-γ-carboxy prothrombin.

METHODS

This study reviewed 296 patients with single nodular HCC ⩽5cm with Child-Pugh grade A between 2001 and 2011 (SR, n=136; RFA, n=160). Based on positive conditions of previous HCC markers (defined as non-positive, single-positive, double-positive, and triple-positive), overall survival (OS) and prognostic factors were analyzed.

RESULTS

Five-year OS rates of SR and RFA among all patients were 70.1% and 69.8%, respectively (p=0.14). However, when stratified by the positive conditions of three HCC markers, their rates of non-, single-, double-, and triple-positive patients were 60.6%, 78.2%, 54.2%, and 75.9% in the SR group, whereas rates were 83.3%, 75.7%, 62.2%, and 47.6% in the RFA group (p values between SR and RFA of each tumor marker condition were 0.45, 0.10, 0.77, and <0.01, respectively). Multivariate analyses showed that RFA itself became an independent prognostic factor in the triple-positive group, with an odds ratio of 1.78 (95% confidence interval, 1.16-2.72).

CONCLUSIONS

Positive conditions of three HCC markers differently influenced survival rates of those who underwent SR and RFA when treating single nodular HCC ⩽5cm. RFA itself became an independent prognostic risk when all three HCC markers were positive. Preoperative evaluation of multiple HCC markers might become an index for selecting treatment modalities.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Anatomical Liver Resections Guided by 3-Dimensional Parenchymal Staining Using Fusion Indocyanine Green Fluorescence Imaging

OBJECTIVE

To investigate the feasibility and efficacy of anatomical liver resection (ALR) guided by fused images comprising a macroscopic view and indocyanine green fluorescence imaging (fusion IGFI).

BACKGROUND

ALR is established in treating hepatocellular carcinoma or other malignancies to achieve curability and functional preservation. However, the conventional demarcation technique (CDT) marks only the organ surface and sometimes fails to execute a completely valid demarcation.

METHODS

Twenty-four consecutive ALRs for focal liver malignancy were studied using fusion IGFI. Indocyanine green was administered systemically after selective inflow clamping in 12 patients or by portal puncture and direct injection in 12 patients, and we compared demarcation findings between fusion IGFI and CDT. The strength of contrast between target and nontarget areas was quantitatively calculated as contrast index and compared between IGFI and CDT according to injection technique or state of the liver surface.

RESULTS

Fusion IGFI achieved valid demarcation in 23 of 24 patients (95.8%), whereas CDT achieved valid demarcation in only 10 patients (41.7%) (P < 0.0001). The contrast index of fusion IGFI was 0.81 (0.18-2.51), which was significantly higher than that of CDT at 0.12 (0.01-0.42) (P < 0.0001), and the same result was obtained regardless of the injection method or liver surface state used. ALR was conducted referring to 3-dimensional staining of target parenchyma, with no related perioperative adverse events.

CONCLUSIONS

Fusion IGFI is a safe imaging technique for ALR that attained valid 3-dimensional parenchymal demarcation with better feasibility and clearer demarcation than CDT.

A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma

BACKGROUND

The aim of this study was to compare the perioperative and long-term oncologic outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for single hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score.

PATIENTS AND METHODS

Between January 2005 and February 2013, 292 patients underwent surgical resection for HCC. Of these, 202 patients who underwent surgical resection for initial treatment for a single mass were enrolled. These patients were divided into two groups according to the method of operation: the Lap group (patients who underwent LLR) and the Open group (patients who underwent OLR). To correct different demographic and clinical factors in the two groups, propensity score matching was used at a 1:1 ratio, and, finally, 102 patients were enrolled in this study, 51 patients in each group. Preoperative characteristics, perioperative results, and long-term results were retrospectively analyzed based on the prospectively recorded database.

RESULTS

Preoperative baseline variables were well balanced in both groups. There were no differences of extent of surgery and rate of anatomical resection between the two groups. With the exception of a shorter postoperative hospital stay in the Lap group than that of the Open group (8.2 days versus 12.3 days; P=.004), there were no significant differences in perioperative, pathological, and long-term outcomes. The 5-year overall survival rates were 80.1% in the Lap group and 85.7% in the Open group, respectively (P=.173). The 5-year disease-free survival rates were 67.8% in the Lap group and 54.8% in the Open group, respectively (P=.519).

CONCLUSIONS

LLR for HCC is safe, and long-term oncologic outcomes in selected patients were comparable to those who underwent OLR.

Anatomy of the liver: an outline with three levels of complexity--a further step towards tailored territorial liver resections

The vascular anatomy of the liver can be described at three different levels of complexity according to the use that the description has to serve. The first--conventional--level corresponds to the traditional 8-segments scheme of Couinaud and serves as a common language between clinicians from different specialties to describe the location of focal hepatic lesions. The second--surgical--level, to be applied to anatomical liver resections and transplantations, takes into account the real branching of the major portal pedicles and of the hepatic veins. Radiological and surgical techniques exist nowadays to make full use of this anatomy, but this requires accepting that the Couinaud scheme is a simplification, and looking at the vascular architecture with an unprejudiced eye. The third--academic--level of complexity concerns the anatomist, and the need to offer a systematization that resolves the apparent contradictions between anatomical literature, radiological imaging, and surgical practice. Based on the real number of second-order portal branches that, although variable averages 20, we submit a system called the "1-2-20 concept", and suggest that it fits best the number of actual--as opposed to idealized--anatomical liver segments.