Clamp-crushing versus stapler hepatectomy for transection of the parenchyma in elective hepatic resection (CRUNSH)--a randomized controlled trial (NCT01049607)

PARTIAL HEPATECTOMY USING LINEAR CUTTER STAPLER: ARE THERE ADVANTAGES?

BACKGROUND

Morbidity of liver resections is related to intraoperative bleeding and postoperative biliary fistulas. The Endo-GIA stapler (EG) in liver resections is well established, but its cost is high, limiting its use. The linear cutting stapler (LCS) is a lower cost device.

AIMS

To report open liver resections, using LCS for transection of the liver parenchyma and en bloc stapling of vessels and bile ducts.

METHODS

Ten patients were included in the study. Four patients with severe abdominal pain had benign liver tumors (three adenomas and one focal nodular hyperplasia). Among the remaining six patients, four underwent liver resection for the treatment of colorectal liver metastases, three of which had undergone preoperative chemotherapy. The other two cases were one patient with metastasis from a testicular teratoma and the other with metastasis from a gastrointestinal neuroectodermal tumor.

RESULTS

The average length of stay was five days (range 4-7 days). Of the seven patients who underwent resections of segments II/III, two presented postoperative complications: one developed a seroma and the other a collection of abdominal fluid who underwent percutaneous drainage, antibiotic therapy, and blood transfusion. Furthermore, the three patients who underwent major resections had postoperative complications: two developed anemia and received blood transfusions and one had biloma and underwent percutaneous drainage and antibiotic therapy.

CONCLUSIONS

The use of the linear stapler in hepatectomies was efficient and at lower costs, making it suitable for use whenever EG is not available. The size of the LCS stapler shaft is more suitable for en bloc transection of the left lateral segment of the liver, which is thinner than the right one. Further studies are needed to evaluate the safety of LCS for large liver resections and resections of tumors located in the right hepatic lobe.

Effective sealing of biliary and pancreatic fistulas with a novel biodegradable polyurethane-based tissue sealant patch

BACKGROUND

To date, no approved sealants for the prevention of postoperative pancreatic fistulas (POPFs) or bile leakage are available. The aim of the study is to assess the feasibility of a new synthetic and biodegradable polyurethane-based sealant patch (PBSP) for hepato-pancreato-biliary (HPB) surgery.

METHODS

Benchmarking of the PBSP with commercially available products with a historical use in HPB surgery (Tachosil®, Hemopatch®, Surgicel® and Veriset®) was followed by performance testing in randomized controlled porcine animal studies. These studies focused on haemostasis as well as the prevention of POPFs and bile leakage.

RESULTS

The newly designed PBSP demonstrated the strongest adherence to liver tissue compared to Tachosil®, Hemopatch® and Veriset®. The new patch was the only patch with complete intra- and postoperative hemostasis (72 h after application) compared to Tachosil and Veriset in a porcine liver abrasion study on 12 animals. In addition, the new patch demonstrably prevents the development of POPFs. The rate of postoperative pancreatitis and clinically relevant POPFs was significantly lower compared to the control groups in a porcine pancreatic fistula model based on 14 animals (14-day follow-up). Furthermore, the incidence of biloma after 7 days, considered as significant bile leakage, was significantly lower in the new PBSP compared to the Veriset® group. The PBSP was as effective as suturing in a porcine bile leakage model (7-day follow-up).

CONCLUSION

The PBSP induces constant hemostasis in the context of liver resection and prevents pancreatic fistulas and bile leakage. The promising preclinical data implicate clinical trials for further evaluation of this newly developed patch.

Intraoperative Increase of Portal Venous Pressure is an Immediate Predictor of Posthepatectomy Liver Failure After Major Hepatectomy: A Prospective Study

OBJECTIVES

The aim of this study was to assess intraoperative changes of hepatic macrohemodynamics and their association with ascites and posthepatectomy liver failure (PHLF) after major hepatectomy.

SUMMARY OF BACKGROUND DATA

Large-scale ascites and PHLF remain clinical challenges after major hepatectomy. No study has concomitantly evaluated arterial and venous liver macrohemodynamics in patients undergoing liver resection.

METHODS

Portal venous pressure (PVP), portal venous flow (PVF), and hepatic arterial flow (HAF) were measured intraoperatively pre- and postresection in 67 consecutive patients with major hepatectomy (ie, resection of ≥3 liver segments). A group of 30 patients with minor hepatectomy served as controls. Liver macrohemodynamics and their intraoperative changes (ie, Δ) were analyzed as predictive biomarkers of ascites and PHLF using Fisher exact, t test, or Wilcoxon rank sum test for univariate and logistic regression for multivariate analyses.

RESULTS

Major hepatectomy increased PVP by 26.9% (P = 0.001), markedly decreased HAF by 40.7% (P < 0.001), and slightly decreased PVF by 13.4% (P = 0.011). Minor resections had little effects on hepatic macrohemodynamics. There was no significant association of liver macrohemodynamics with ascites. While middle hepatic vein resection caused higher postresection PVP after right hepatectomy (P = 0.04), the Pringle maneuver was associated with a significant PVF (P = 0.03) and HAF reduction (P = 0.03). Uni- and multivariate analysis revealed an intraoperative PVP increase as an independent predictor of PHLF (P = 0.025).

CONCLUSION

Intraoperative PVP kinetics serve as independent predictive biomarker of PHLF after major hepatectomy. These data highlight the importance to assess intraoperative dynamics rather than the pre- and postresection PVP values.

Outcome after liver resection for primary and recurrent intrahepatic cholangiocarcinoma

BACKGROUND

Liver resection is the only curative therapeutic option for intrahepatic cholangiocarcinoma (ICC), but the approach to recurrent ICC is controversial. This study analysed the outcome of liver resection in patients with recurrent ICC.

METHODS

Demographic, radiological, clinical, operative, surgical pathological and follow-up data for all patients with a final surgical pathological diagnosis of ICC treated in a tertiary referral centre between 2001 and 2015 were collected retrospectively and analysed.

RESULTS

A total of 190 patients had liver resection for primary ICC. The 1-, 3- and 5-year overall survival (OS) rates were 74·8, 56·6 and 37·9 per cent respectively. Independent determinants of OS were age 65 years or above (hazard ratio (HR) 2·18, 95 per cent c.i. 1·18 to 4·0; P = 0·012), median tumour diameter 5 cm or greater (HR 2·87, 1·37 to 6·00; P = 0·005), preoperative biliary drainage (HR 2·65, 1·13 to 6·20; P = 0·025) and local R1-2 status (HR 1·90, 1·02 to 3·53; P = 0·043). Recurrence was documented in 87 patients (45·8 per cent). The mean(s.d.) survival time after recurrence was 16(17) months. Independent determinants of recurrence were median tumour diameter 5 cm or more (HR 1·71, 1·09 to 2·68; P = 0·020), high-grade (G3-4) tumour (HR 1·63, 1·04 to 2·55; P = 0·034) and local R1 status (HR 1·70, 1·09 to 2·65; P = 0·020). Repeat resection with curative intent was performed in 25 patients for recurrent ICC, achieving a mean survival of 25 (95 per cent c.i. 16 to 34) months after the diagnosis of recurrence. Patients deemed to have unresectable disease after recurrence received chemotherapy or chemoradiotherapy alone, and had significantly poorer survival.

CONCLUSION

Patients with recurrent ICC may benefit from repeat surgical resection.

Clamp-Crush Technique Versus Harmonic Scalpel for Hepatic Parenchymal Transection in Living Donor Hepatectomy: a Randomized Controlled Trial

BACKGROUND

Hepatic parenchymal transection is the most invasive step in donor operation. During this step, blood loss and unintended injuries to the intrahepatic structures and hepatic remnant may occur. There is no evidence to prove the ideal techniques for hepatic parenchymal transection. The aim of this study is to compare the safety, efficacy, and outcome of clamp-crush technique versus harmonic scalpel as a method of parenchymal transection in living-donor hepatectomy.

METHODS

Consecutive living liver donors, undergoing right hemi-hepatectomy, during the period between May 2015 and April 2016, were included in this prospective randomized study. Cases were randomized into two groups; group (A) harmonic scalpel group and group (B) Clamp-crush group.

RESULTS

During the study period, 72 cases underwent right hemi-hepatectomy for adult living donor liver transplantation and were randomized into two groups. There were no statistically significant differences between the two groups regarding preoperative demographic and radiological data. Longer operation time and hepatectomy duration were found in group B. There were no significant differences between the two groups regarding blood loss, blood loss during hepatectomy, and blood transfusion. More unexpected bleeding events occurred in group A. Higher necrosis at the cut margin of the liver parenchyma was noted in group A. There were no statistically significant differences between the two groups regarding postoperative ICU stay, hospital stay, postoperative morbidities, and readmission rates.

CONCLUSION

Clamp-crush technique is advocated as a simple, easy, safe, and cheaper method for hepatic parenchymal transection in living donors.

Influence of neoadjuvant chemotherapy on resection of primary colorectal liver metastases: A propensity score analysis

BACKGROUND AND OBJECTIVES

There is ongoing debate about whether patients planned for liver resection of colorectal liver metastases (CRLM) benefit from neoadjuvant chemotherapy (NC). Therefore, we performed a retrospective survival analysis of patients with and without NC prior to surgery.

METHODS

Data prospectively collected from 468 consecutive patients were analyzed in a retrospective design. We performed a survival analysis and added propensity score matching (PSM). Univariate and multivariate analysis was performed to determine independent prognostic risk factors.

RESULTS

NC was performed in 145/468 patients. NC did not have a significant influence on overall survival (OS) either before or after PSM. Patients receiving NC showed increased complication rates, especially concerning non-surgical complications after primary resection (P = 0.025) of CRLM. Multivariate analysis before and after PSM revealed that the Memorial Sloan Kettering Cancer Center (MSKCC) score and CEA values are strong predictors for OS in patients with CRLM.

CONCLUSIONS

NC was not associated with increased OS in patients suffering from CRLM. Additionally, potentially harmful chemotherapy prior to surgery increases the risk of postoperative complications in these patients.

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor

BACKGROUND

Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy.

PATIENT AND METHOD

Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001).

CONCLUSION

Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.

Methods to decrease blood loss during liver resection: a network meta-analysis

BACKGROUND

Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown.

OBJECTIVES

To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE.

MAIN RESULTS

We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work.

AUTHORS' CONCLUSIONS

Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.

Methods to decrease blood loss during liver resection: a network meta-analysis

BACKGROUND

Liver resection is a major surgery with significant mortality and morbidity. Various methods have been attempted to decrease blood loss and morbidity during elective liver resection. These methods include different methods of vascular occlusion, parenchymal transection, and management of the cut surface of the liver. A surgeon typically uses only one of the methods from each of these three categories. Together, one can consider this combination as a treatment strategy. The optimal treatment strategy for liver resection is unknown.

OBJECTIVES

To assess the comparative benefits and harms of different treatment strategies that aim to decrease blood loss during elective liver resection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to July 2012 to identify randomised clinical trials. We also handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) where the method of vascular occlusion, parenchymal transection, and management of the cut surface were clearly reported, and where people were randomly assigned to different treatment strategies based on different combinations of the three categories (vascular occlusion, parenchymal transection, cut surface).

DATA COLLECTION AND ANALYSIS

Two review authors identified trials and collected data independently. We assessed the risk of bias using The Cochrane Collaboration's methodology. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4 following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) (which are similar to confidence intervals in the frequentist approach for meta-analysis) for the binary outcomes and mean differences (MD) with 95% CrI for continuous outcomes using a fixed-effect model or random-effects model according to model-fit.

MAIN RESULTS

We identified nine trials with 617 participants that met our inclusion criteria. Interventions in the trials included three different options for vascular occlusion, four for parenchymal transection, and two for management of the cut liver surface. These interventions were combined in different ways in the trials giving 11 different treatment strategies. However, we were only able to include 496 participants randomised to seven different treatment strategies from seven trials in our network meta-analysis, because the treatment strategies from the trials that used fibrin sealant for management of the raw liver surface could not be connected to the network for any outcomes. Thus, the trials included in the network meta-analysis varied only in their approaches to vascular exclusion and parenchymal transection and none used fibrin sealant. All the trials were of high risk of bias and the quality of evidence was very low for all the outcomes. The differences in mortality between the different strategies was imprecise (seven trials; seven treatment strategies; 496 participants). Five trials (six strategies; 406 participants) reported serious adverse events. There was an increase in the proportion of people with serious adverse events when surgery was performed using radiofrequency dissecting sealer compared with the standard clamp-crush method in the absence of vascular occlusion and fibrin sealant. The OR for the difference in proportion was 7.13 (95% CrI 1.77 to 28.65; 15/49 (adjusted proportion 24.9%) in radiofrequency dissecting sealer group compared with 6/89 (6.7%) in the clamp-crush method). The differences in serious adverse events between the other groups were imprecise. There was a high probability that 'no vascular occlusion with clamp-crush method and no fibrin' and 'intermittent vascular occlusion with Cavitron ultrasonic surgical aspirator and no fibrin' are better than other treatments with regards to serious adverse events. Quality of life was not reported in any of the trials.The differences in the proportion of people requiring blood transfusion was imprecise (six trials; seven treatments; 446 participants). Two trials (three treatments; 155 participants) provided data for quantity of blood transfused. People undergoing liver resection by intermittent vascular occlusion had higher amounts of blood transfused than people with continuous vascular occlusion when the parenchymal transection was carried out with the clamp-crush method and no fibrin sealant was used for the cut surface (MD 1.2 units; 95% CrI 0.08 to 2.32). The differences in the other comparisons were imprecise (very low quality evidence). Three trials (four treatments; 281 participants) provided data for operative blood loss. People undergoing liver resection using continuous vascular occlusion had lower blood loss than people with no vascular occlusion when the parenchymal transection was carried out with clamp-crush method and no fibrin sealant was used for the cut surface (MD -130.9 mL; 95% CrI -255.9 to -5.9). None of the trials reported the proportion of people with major blood loss.The differences in the length of hospital stay (six trials; seven treatments; 446 participants) and intensive therapy unit stay (four trials; six treatments; 261 participants) were imprecise. Four trials (four treatments; 245 participants) provided data for operating time. Liver resection by intermittent vascular occlusion took longer than liver resection performed with no vascular occlusion when the parenchymal transection was carried out with Cavitron ultrasonic surgical aspirator and no fibrin sealant was used for the cut surface (MD 49.6 minutes; 95% CrI 29.8 to 69.4). The differences in the operating time between the other comparisons were imprecise. None of the trials reported the time needed to return to work.

AUTHORS' CONCLUSIONS

Very low quality evidence suggested that liver resection using a radiofrequency dissecting sealer without vascular occlusion or fibrin sealant may increase serious adverse events and this should be evaluated in further randomised clinical trials. The risk of serious adverse events with liver resection using no special equipment compared with more complex methods requiring special equipment was uncertain due to the very low quality of the evidence. The credible intervals were wide and considerable benefit or harm with a specific method of liver resection cannot be ruled out.

Morbidity and mortality in 1,174 patients undergoing hepatic parenchymal transection using a stapler device

BACKGROUND

Transection of liver parenchyma using staplers is now commonly performed. Large studies are needed to assess the usefulness of the technique as well as perioperative outcomes.

METHODS

This is a retrospective study of a prospectively maintained database. A total of 1,174 patients undergoing liver resections in routine surgical practice, using a stapler device at MD Anderson Cancer Center between January 1, 1994 and November 10, 2011 were evaluated.

RESULTS

There were 900 major resections (3 segments or more) (77 %) and 274 minor resections (<3 segments or wedge resections) (23 %). A vast majority, 1,133 (96.5 %), were indicated for an underlying malignancy (24 % primary liver or gall bladder and 72.5 % metastatic) compared with benign disease, 41 (3.5 %), with the most common indication being metastatic colorectal cancer 584 (49.7 %). Of the total 1,174 patients 128 (10.9 %) had a prior liver resection. Median OR time and blood loss was 206 min and 300 mL, respectively, with 11 % of patients requiring transfusion in the perioperative or postoperative period. Overall morbidity and mortality rate was 14 and 3.2 %, respectively, with a median hospital stay of 7 days (interquartile range [IQR], 4 days). Multivariate logistic regression demonstrated blood loss and extent of liver resection to be independent predictors of adverse outcome. A total of 13 instances (1.1 %) of misfired staplers were noted and were associated with higher blood loss (p < 0.001) and mortality (15 vs. 3.1 %, p = 0.013).

CONCLUSIONS

Use of stapler device for hepatic resection is safe and effective, but rare instances of a misfired stapler device are associated with an adverse outcome.

Randomized clinical trial of stapler versus clamp-crushing transection in elective liver resection

BACKGROUND

Various devices have been developed to facilitate liver transection and reduce blood loss in liver resections. None of these has proven superiority compared with the classical clamp-crushing technique. This randomized clinical trial compared the effectiveness and safety of stapler transection with that of clamp-crushing during open liver resection.

METHODS

Patients admitted for elective open liver resection between January 2010 and October 2011 were assigned randomly to stapler transection or the clamp-crushing technique. The primary endpoint was the total amount of intraoperative blood loss. Secondary endpoints included transection time, duration of operation, complication rates and resection margins.

RESULTS

A total of 130 patients were enrolled, 65 to clamp-crushing and 65 to stapler transection. There was no difference between groups in total intraoperative blood loss: median (i.q.r.) 1050 (525-1650) versus 925 (450-1425) ml respectively (P = 0·279). The difference in total intraoperative blood loss normalized to the transection surface area was not statistically significant (P = 0·092). Blood loss during parenchymal transection was significantly lower in the stapler transection group (P = 0·002), as were the parenchymal transection time (mean(s.d.) 30(21) versus 9(7) min for clamp-crushing and stapler transection groups respectively; P < 0·001) and total duration of operation (mean(s.d.) 221(86) versus 190(85) min; P = 0·047). There were no significant differences in postoperative morbidity (P = 0·863) or mortality (P = 0·684) between groups.

CONCLUSION

Stapler transection is a safe technique but does not reduce intraoperative blood loss in elective liver resection compared with the clamp-crushing technique.

REGISTRATION NUMBER

NCT01049607 (http://www.clinicaltrials.gov).

Treatment of hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with an increasing incidence. With advances in surgical techniques and instrumentation and the development of molecular-target drugs, a number of potentially curative treatments have become available. Management of HCC patients depends on the stage of their tumor. Liver resection remains the first choice for very early-stage HCC, but it is being challenged by local ablative therapy. For early-stage HCC that meet the Milan criteria, liver transplantation still offers a better outcome; however, local ablative therapy can be a substitute when transplantation is not feasible. Local ablation is also used as a bridging therapy toward liver transplantation. HCC recurrence is the main obstacle to successful treatment, and there is currently no effective means of preventing or treating HCC recurrence. Transarterial therapy is considered suitable for intermediate-stage HCC, while sorafenib is recommended for advanced-stage HCC. This stage-based approach to therapy not only provides acceptable outcomes but also improves the quality of life of HCC patients. Because of the complexity of HCC, therapeutic approaches must be adapted according to the characteristics of each individual patient. This review discusses the current standards and trends in the treatment of HCC.

Conformational technique for non-anatomic resection of liver lesions

Safe margin-negative hepatic resection with maximal preservation of normal liver parenchyma is the primary operative objective in treating patients with metastatic or primary liver malignancies. A technique to perform non-anatomic liver resection(s) for large lesions that may involve major hepatic vascular structures is herein described. This technique employs linear cutting stapler technology and specific mobilization of the liver to perform single or multiple large spherical resections of liver lesions.

Techniques of hepatic resection

Liver resections are high risk procedures performed by experienced surgeons. The role of liver resection in malignant disease has changed over the last 100 years with great improvement in morbidity, mortality and long term survival. New understanding in liver anatomy, improved perioperative care, anesthesia techniques, and technological advances has improved this aspect of patient care. With improved techniques, patients previously considered unresectable have an opportunity to undergo curative surgery. This review article describes the various approaches and techniques for liver resection. The relevant anatomy and terminology of hepatic resections is discussed, as well as the role of anatomic vs. nonanatomic resection. Methods of vascular control are examined and the multiple strategies of parenchymal transection are compared, as well as minimally-invasive techniques. Finally, a brief review of the authors' practice in terms of surgical technique is offered.