Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry

Nutritional risk in major abdominal surgery: NURIMAS Liver (DRKS00010923) - protocol of a prospective observational trial to evaluate the prognostic value of different nutritional scores in hepatic surgery

Background

Malnutrition is commonly known as a risk factor in surgical procedures. The nutritional status seems particularly relevant to the clinical outcome of patients undergoing hepatic resection. Thus, identifying affected individuals and taking preventive therapeutic actions before surgery is an important task. However, there are only very few studies, that investigate which existing nutritional assessment score (NAS) is suited best to predict the postoperative outcome in liver surgery.

Objective

Nutritional Risk in Major Abdominal Surgery (NURIMAS) Liver is a prospective observational trial that analyses the predictive value of 12 different NAS for postoperative morbidity and mortality after liver resection.

Methods

After admission to the surgical department of the University Hospital in Heidelberg or the municipal hospital of Karlsruhe, all patients scheduled for elective liver resection will be screened for eligibility. Participants will fill in a questionnaire and undergo a physical examination in order to evaluate nutritional status according to Nutritional Risk Index, Nutritional Risk Screening Score, Subjective Global Assessment, Malnutrition Universal Screening Tool, Mini Nutritional Assessment, Short Nutritional Assessment Questionnaire, Imperial Nutritional Screening System, Imperial Nutritional Screening System II, Nutritional Risk Classification and the ESPEN malnutrition criteria. Postoperative morbidity and mortality will be tracked prospectively throughout the postoperative course. The association of malnutrition according to each score and occurrence of at least one major complication will be analysed using both chi-squared tests and a multivariable logistic regression analysis. Already established risk factors in liver surgery will be added as covariates.

Discussion

NURIMAS Liver is a bicentric, prospective observational trial. The aim of this study is to investigate the predictive value of clinical nutritional assessment scores on postoperative morbidity and mortality after hepatic resection. This is necessary, as only a validated identification of malnourished patients at high risk for postoperative complications, enables targeted preventive action.

Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review

AIM

To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review.

METHODS

Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.

RESULTS

From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.

CONCLUSION

Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.

Predicting the risk of postoperative liver failure and overall survival using liver and spleen stiffness measurements in patients with hepatocellular carcinoma

Postoperative liver failure (PLF) is the primary cause of morbidity and mortality after hepatic resection for hepatocellular carcinoma (HCC). In this study, we evaluated the efficacy of liver stiffness (LS) and spleen stiffness (SS), as measured by transient elastography (TE), for predicting the risk of PLF and overall survival (OS) in these patients.This prospective cohort study included 54 patients diagnosed with HCC who underwent hepatic resection between March 2013 and March 2014. Preoperative measurement of LS and SS using TE was performed on all patients underwent. The predictivity of LS and SS for PLF was assessed by receiver operating characteristic curve analysis. OS according to LS and SS was analyzed using the Kaplan-Meier method and compared using the log-rank test.PLF developed in seven (12.96%) patients. LS was significantly higher in patients with than in those without PLF (P = .03). The area under the curve of LS for predicting PLF was 0.76 (95% confidence interval, 0.62-0.86; P = .02). However, there was no significant difference in SS between patients with and without PLF (P = .36). Moreover, patients with an LS <16.2 kPa had significantly better OS than those with an LS ≥16.2 kPa (P = .028). No significant difference in OS was observed between patients with an SS of <22.3 and ≥22.3 kPa (P = .378).LS measured by TE can be used to predict the risk of PLF as well as OS in patients with HCC who have undergone hepatic resection. However, SS obtained using TE was not found to be a significant predictor for PLF and OS in our patients.

Factors associated with fatal liver failure after extended hepatectomy

BACKGROUND

Posthepatectomy liver failure (PHLF) is the leading cause of posthepatectomy mortality. This study aimed to revisit the etiology and pattern of PHLF and its role in posthepatectomy morbidity and mortality.

METHODS

The pattern and etiology of PHLF and subsequent morbidity and mortality were analysed in the subgroup of patients without cirrhosis undergoing an extended hepatectomy (≥4 segments) over a 5 year period. PHLF was defined using ISGLS criteria and/or 50-50 and/or peak serum bilirubin >7 mg/dl.

RESULTS

Among 285 included patients (median age 62 [20-89]), 81 (28%) developed PHLF with higher rates of major complications (38%) and mortality (27%) than patients without PHLF (13% and 2%, respectively; p < 0.001). Twenty-six patients (9%) died, 22 of whom had PHLF. Of these 22 patients, only 4 patients died from complications purely-attributed to PHLF. All the remaining 18 patients had additional peri-operative factors that contributed to the mortality of which severe vascular events were the most common.

CONCLUSION

PHLF is associated with higher rates of morbidity and mortality following extended resection. The etiology of PHLF is multifactorial with vascular events being common precipitant. The multifactorial origin of PHLF may explain the low predictive value of current clinical risk scores.

Hepatic atrophy following preoperative chemotherapy predicts hepatic insufficiency after resection of colorectal liver metastases

BACKGROUND & AIMS

For patients with colorectal liver metastases (CLM) undergoing major hepatectomy, extensive preoperative chemotherapy has been associated with increased morbidity and mortality. The impact of extensive chemotherapy on total liver volume (TLV) change is unclear. The aims of the current study were twofold: (1) to determine the change of TLV following preoperative chemotherapy in patients undergoing resection for CLM and (2) to investigate the correlations among TLV change, postoperative hepatic insufficiency (PHI), and death from liver failure.

METHODS

Clinicopathological features of patients with CLM who underwent preoperative chemotherapy and curative resection were reviewed (2008-2015). TLV change (degree of atrophy) was defined as the percentage difference of TLV (estimated by manual volumetry)/standardized liver volume (SLV) ratio: ([Pre-chemotherapy TLV]-[Post-chemotherapy TLV])×100÷SLV (%). Receiver operating characteristic (ROC) analysis was performed to decide the accurate cut-off value of degree of atrophy to predict PHI. The Cox proportional hazard model was performed to identify the predictors of severe degree of atrophy and PHI.

RESULTS

The study cohort consisted of 459 patients, of which 154 patients (34%) underwent extensive preoperative chemotherapy (≥7 cycles). ROC analysis identified the degree of atrophy ≥10% as an accurate cut-off to predict PHI, which was significantly correlated with ≥7 cycles of preoperative chemotherapy. Four factors independently predicted PHI: standardized future liver remnant ≤30% (odds ratio [OR] 4.03, p=0.019), high aspartate aminotransferase-to-platelet ratio index (OR 5.27, p=0.028), degree of atrophy ≥10% (OR 43.5, p<0.001), and major hepatic resection (OR 5.78, p=0.005). Degree of atrophy ≥10% was associated with increased mortality from liver failure (0% [0/374] vs. 15% [13/85], p<0.001).

CONCLUSION

Extensive preoperative chemotherapy induced significant atrophic change of TLV. Degree of atrophy ≥10% is an independent predictor of PHI and death in patients with CLM undergoing preoperative chemotherapy and resection.

LAY SUMMARY

Extensive preoperative chemotherapy for patients with colorectal liver metastases (CLM) could induce hepatic atrophy. A higher degree of atrophy is an independent predictor of postoperative hepatic insufficiency and death in patients with CLM undergoing preoperative chemotherapy and resection.

Efficacy of Preoperative Portal Vein Embolization Among Patients with Hepatocellular Carcinoma, Biliary Tract Cancer, and Colorectal Liver Metastases: A Comparative Study Based on Single-Center Experience of 319 Cases

BACKGROUND

Efficacy of preoperative portal vein embolization (PVE) has been established; however, differences of outcomes among diseases, including hepatocellular carcinoma (HCC), biliary tract cancer (BTC), and colorectal liver metastases (CLM), are unclear.

METHODS

Subjects included patients in a prospectively collected database undergoing PVE (from 1995 to 2013). A future liver remnant (FLR) volume ≥40% is the minimal requirement for patients with an indocyanine green retention rate at 15 min (ICGR15) <10%, and stricter criteria (FLR volume ≥50%) have been applied for patients with 20% > ICGR15 ≥ 10%. Patient characteristics and survivals were compared among those three diseases, and predictors of dropout and better FLR hypertrophy were determined.

RESULTS

In 319 consecutive patients undergoing PVE for HCC (n = 70), BTC (n = 172), and CLM (n = 77), the degree of hypertrophy did not significantly differ by cancer types (median 10, 9.6, and 10%, respectively). Eighty percent (256 of 319) of patients completed subsequent hepatectomy after a median waiting interval of 24 days (range 5-90), while dropout after PVE was more common in BTC or CLM (odds ratio 2.75, p = 0.018), mainly because of disease progression. Ninety-day liver-related mortality after hepatectomy was 0% in the entire cohort, and 5-year overall survival of patients with HCC, BTC, and CLM was 56, 50, and 51%, respectively (p = 0.948). No patients who dropped out survived more than 2.5 years after PVE.

CONCLUSION

PVE produced equivalent FLR hypertrophy among the three diseases as long as liver function was fulfilling the preset criteria; however, the completion rate of subsequent hepatectomy was highest in HCC. PVE followed by hepatectomy was a safe and feasible strategy for otherwise unresectable disease irrespective of cancer types.

Portal vein ligation versus portal vein embolization for induction of hypertrophy of the future liver remnant: A systematic review and meta-analysis

An important risk of major hepatic resection is postoperative liver failure, which is directly related to insufficient future liver remnant (FLR). Portal vein embolization (PVE) and portal vein ligation (PVL) can minimize this risk by inducing hypertrophy of the FLR. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of PVE and PVL for FLR hypertrophy. A systematic search was conducted on the17^th of January 2017. The methodological quality of the studies was assessed using the Oxford Critical Appraisal Skills Program for cohort studies. The primary endpoint was the relative rate of hypertrophy of the FLR. Number of cancelled hepatic resection and postoperative morbidity and mortality were secondary endpoints. For meta-analysis, the pooled hypertrophy rate was calculated for each intervention. The literature search identified 21 eligible studies with 1953 PVE and 123 PVL patients. All studies were included in the meta-analysis. No significant differences were found regarding the rate of FLR hypertrophy (PVE 43.2%, PVL 38.5%, p = 0.39). The number of cancelled hepatic resections due to inadequate hypertrophy was significantly lower after PVL (p = 0.002). No differences were found in post-intervention mortality and morbidity. This meta-analysis demonstrated no significant differences in safety and rate of FLR hypertrophy between PVE and PVL. PVE should be considered as the preferred strategy, since it is a minimally invasive procedure. However, during a two-stage procedure, PVL can be performed with expected comparable outcome as PVE.

Other non-surgical treatments for liver cancer

Interventional radiology plays a major role in the modern management of liver cancers, in primary hepatic malignancies or metastases and in palliative or curative situations. Radiological treatments are divided in two categories based on their approach: endovascular treatment and direct transcapsular access. Endovascular treatments include mainly three applications: transarterial chemoembolization (TACE), transarterial radioembolization (TARE) and portal vein embolization (PVE). TACE and TARE share an endovascular arterial approach, consisting of a selective catheterization of the hepatic artery or its branches. Subsequently, either a chemotherapy (TACE) or radioembolic (TARE) agent is injected in the target vessel to act on the tumor. PVE raises the volume of the future liver remnant in extended hepatectomy by embolizing a portal vein territory which results in hepatic regeneration. Direct transcapsular access treatments involve mainly three techniques: radiofrequency thermal ablation (RFA), microwave thermal ablation (MWA) and percutaneous ethanol injection (PEI). RFA and MWA procedures are almost identical, their clinical applications are similar. A probe is deployed directly into the tumor to generate heat and coagulation necrosis. PEI has known implications based on the chemical toxicity of intra-tumoral injection with highly concentrated alcohol by a thin needle.

Planned Treatment of Advanced Metastatic Disease with Completion Ablation After Hepatic Resection

PURPOSE

The aim of this study is to describe a modified treatment strategy with image-guided percutaneous ablation after hepatic resection as a completion method to surgical eradication of liver metastases ("completion ablation [CA]").

METHODS

We conducted a retrospective analyses of patients who underwent CA within 180 days from the liver surgical resection to eradicate liver metastases present on the pre-surgical cross-sectional imaging or identified during intraoperative ultrasound that were not resected due to various reasons. Lesions treated with CA were evaluated for local tumor progression (LTP). Patients were evaluated for hepatic- and overall-recurrence-free survivals (hepatic-RFS and overall-RFS, respectively) and overall survival (OS).

RESULTS

Sixteen patients (10 females; median age 55 years, range 28-69) underwent CA of 21 lesions (median size 8 mm, range 6 to 22). Indications for the use of CA were small future liver remnant in 10 (63%), inability to identify the lesion during surgical exploration in 3 (19%), and technical difficulty of resection in 3 (19%) patients. No liver-related complications were recorded following the surgical resection or the CA procedures. Primary and secondary CA efficacy rates were 95 and 100%, respectively. LTP was 0% at a median clinical follow-up of 27 months (range 4.0-108 months). Five-year hepatic-RFS, overall-RFS, and OS were 36, 16, and 51%, respectively.

CONCLUSION

The use of CA as a complement to surgical resection is safe and effective. Such approach could potentially expand the surgical candidacy for patients with limited liver functional reserve and reduce postoperative morbidity and mortality in this selected patient population with more advanced disease.

Prediction of the Total Liver Weight using anthropological clinical parameters: does complexity result in better accuracy?

BACKGROUND

The performance of linear models predicting Total Liver Weight (TLW) remains moderate. The use of more complex models such as Artificial Neural Network (ANN) and Generalized Additive Model (GAM) or including the variable "steatosis" may improve TLW prediction. This study aimed to assess the value of ANN and GAM and the influence of steatosis for predicting TLW.

METHODS

Basic clinical and morphological variables of 1560 cadaveric donors for liver transplantation were randomly split into a training (2/3) and validation set (1/3). Linear models, ANN and GAM were built by using the training cohort and evaluated with the validation cohort.

RESULTS

The TLW is subject to major variations among donors with similar morphological parameters. The performance of ANN and GAM were moderate and similar to that of linear models (concordance coefficient from 0.36 to 0.44). In 28-30% of cases, TLW cannot be predicted with a margin of error ≤20%. The addition of the variable "steatosis" to each model did not improve their performance.

CONCLUSION

TLW prediction based on anthropological parameters carry a significant risk of error despite the use of more complex models. Others determinants of TLW need to be identified and imaging-based volumetric measurements should be preferred when feasible.

Ablative Liver Partition and Portal Vein Embolization: Proof-of-Concept Testing in a Rabbit Model

PURPOSE

To test the hypothesis that a modified approach to portal vein embolization (PVE)-termed ablative liver partition (ALP) and PVE (ALP-PVE)-is feasible and results in greater future liver remnant (FLR) growth compared with PVE alone in a rabbit model.

MATERIALS AND METHODS

Eighteen rabbits (median weight, 2.7 kg) underwent PVE (n = 9) or ALP-PVE (n = 9). PVE to cranial liver lobes was performed with 100-300-μm microspheres and metallic coils; the caudal lobe was spared as the FLR. In the ALP-PVE cohort, a liver partition between cranial and caudal lobes was created by using microwave ablation (40 W, 1 min). Animals were euthanized and livers were harvested on postprocedure day 7. Caudal and cranial liver lobes were weighed after 4 weeks of oven drying. Ki-67 immunohistochemistry was used to quantify liver mitotic index. ALP-PVE feasibility was determined based on procedure technical success. Standardized FLR (sFLR; ie, FLR divided by whole liver weight) and mitotic index were compared between PVE and ALP-PVE groups by two-tailed independent-samples Mann-Whitney U test.

RESULTS

One PVE-group rabbit died during anesthesia induction and was excluded from technical success calculation. Eight of 8 (100%) and 8 of 9 rabbits (89%) underwent technically successful PVE and ALP-PVE, respectively. There was no difference in sex or weight distribution between groups. sFLR (0.32 vs 0.29; P = .022) and mitotic index (17.5% vs 6.2%; P = .051) were higher in ALP-PVE vs PVE caudal lobes when the first "learning-curve" case from each group was excluded.

CONCLUSIONS

ALP-PVE is feasible and may stimulate greater FLR growth compared with PVE in a rabbit model.

Animal Models for Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS): Achievements and Future Perspectives

Background: Since 2012, Associated Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been standing in the limelight of modern liver surgery and numerous questions have been raised regarding this novel approach. On the one hand, ALPPS has proved to be a valuable method in the treatment of hepatic tumors, while on the other hand, there are many controversies, such as high mortality and morbidity rates. Further surgical research is essential for a better understanding of underlying mechanisms and for enhancing patient safety. Summary: Until recently, only 8 animal models have been created with the purpose to mimic ALPPS-induced liver regeneration. From these 7 are rodent (6 rat and 1 mouse) models, while only 1 is a large animal model, which uses pigs. In case of rodent models, portal flow deprivation of 75-90% is achieved via portal vein ligation leaving only the right (20-25%) or left median (10-15%) lobes portally perfused, while liver splitting in general is carried out positioned according to the falciform ligament. As for the swine model, the left lateral and medial lobes (70-75% of total liver volume) are portally ligated, and the right lateral lobe (accounting for 20-24% of the parenchyma) is partially resected in order to reach critical liver volume. Each model is capable of reproducing the accelerated liver regeneration seen in human cases. However, all species have significantly different liver anatomy compared with the human anatomic situation, making clinical translation somewhat difficult. Key Messages: Unfortunately, there are no perfect animal models available for ALPPS research. Small animal models are inexpensive and well suited for basic research, but may only provide limited translational potential to humans. Clinically large animal models may provide more relevant data, but currently no suitable one exists.

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) does not affect proliferation, apoptosis, or angiogenesis as compared to standard liver resection for colorectal liver metastases

Background

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a novel two-stage strategy to induce rapid hypertrophy of the future liver remnant (FLR) when patients are in danger of postoperative liver failure due to insufficient FLR. However, the effects of ALPPS on colorectal liver metastases (CRLM) are not clear so far. The aim of our study was to determine whether ALPPS induces proliferation, apoptosis, or vascularization compared to standard (one-stage) liver resection.

Methods

Six patients who underwent ALPPS were matched with 12 patients undergoing standard liver resection regarding characteristics of the metastases (size, number), time of appearance (syn-/metachronous), preoperative chemotherapy, primary tumor (localization, TNM stage, grading), and patient variables (gender, age). The largest resected metastasis was used for the analyses. Tissue was stained for tumor cell proliferation (Ki67), apoptosis (TUNEL, caspase-3), vascularization (CD31), and pericytes (αSMA).

Results

Vascularization (CD31; p = 0.149), proliferation (Mib-1; p = 0.244), and αSMA expression (p = 0.205) did not significantly differ between the two groups, although a trend towards less proliferation and αSMA expression was observed in patients undergoing ALPPS. Concerning apoptosis, caspase-3 staining showed significantly fewer apoptotic cells upon ALPPS (p < 0.0001), but this was not confirmed by TUNEL staining (p = 0.7344).

Conclusions

ALPPS does not induce proliferation, apoptosis, or vascularization of CRLM when compared to standard liver resection.

Identification of liver metastases with probe-based confocal laser endomicroscopy at two excitation wavelengths

BACKGROUND

Metastasis of colorectal cancer to the liver is the most common indication for hepatic resection in a western population. Incomplete excision of malignancy due to residual microscopic disease normally results in worse patient outcome. Therefore, a method aiding in the real time discrimination of normal and malignant tissue on a microscopic level would be of benefit.

MATERIAL AND METHODS

The ability of fluorescent probe-based confocal laser endomicroscopy (pCLE) to identify normal and malignant liver tissue was evaluated in an orthotopic murine model of colorectal cancer liver metastasis (CRLM). To maximise information yield, two clinical fluorophores, fluorescein and indocyanine green (ICG) were injected and imaged in a dual wavelength approach (488 and 660 nm, respectively). Visual tissue characteristics on pCLE examination were compared with histological features. Fluorescence intensity in both tissues was statistically analysed to elucidate if this can be used to differentiate between normal and malignant tissue.

RESULTS

Fluorescein (488 nm) enabled good visualisation of normal and CRLM tissue, whereas ICG (660 nm) visualisation was limited to normal liver tissue only. Fluorescence intensity in areas of CRLM was typically 53-100% lower than normal hepatic parenchyma. Using general linear mixed modelling and receiver operating characteristic analysis, high fluorescence intensity was found to be statistically more likely in normal hepatic tissue.

CONCLUSION

Real time discrimination between normal liver parenchyma and metastatic tissue with pCLE examination of fluorescein and ICG is feasible. Employing two (rather than a single) fluorophores allows a combination of qualitative and quantitative characteristics to be used to distinguish between hepatic parenchyma and CRLM. Lasers Surg. Med. 49:280-292, 2017. © 2016 Wiley Periodicals, Inc.

Hammer versus Swiss Army knife: Developing a strategy for the management of bilobar colorectal liver metastases

For patients with bilobar colorectal liver metastases, the recent increase in surgical approaches has resulted in more opportunities to extend the benefits of surgery to patients who were previously deemed unresectable. Surgical options now include anatomic hepatectomy, 1-stage parenchymal sparing hepatectomy, traditional 2-stage hepatectomy with or without portal vein embolization, associated liver partition and portal vein ligation for staged hepatectomy, local ablative techniques, and hepatic arterial infusion therapy. As the diversity of options has increased, controversy has arisen as to the optimal operative management of patients with complex bilateral disease. Moreover, there has been a tendency for various surgeons and groups to champion a single strategy. In contrast to this trend, this article introduces a novel "tailored approach" that takes advantage of all available tools and individually applies them based on an algorithmic assessment of the extent and distribution of metastatic disease.

Assessment of Volumetric versus Manual Measurement in Disseminated Testicular Cancer; No Difference in Assessment between Non-Radiologists and Genitourinary Radiologist

BACKGROUND

The aim of this study was to assess the feasibility and reproducibility of semi-automatic volumetric measurement of retroperitoneal lymph node metastases in testicular cancer (TC) patients treated with chemotherapy versus the standardized manual measurements based on RECIST criteria.

METHODS

21 TC patients with retroperitoneal lymph node metastases of testicular cancer were studied with a CT scan of chest and abdomen before and after cisplatin based chemotherapy. Three readers, a surgical resident, a radiological technician and a radiologist, assessed tumor response independently using computerized volumetric analysis with Vitrea software® and manual measurement according to RECIST criteria (version 1.1). Intra- and inter-rater variability were evaluated with intra class correlations and Bland-Altman analysis.

RESULTS

Assessment of intra observer and inter observer variance proved non-significant in both measurement modalities. In particularly all intraclass correlation (ICC) values for the volumetric analysis were > .99 per observer and between observers. There was minimal bias in agreement for manual as well as volumetric analysis.

CONCLUSION

In this study volumetric measurement using Vitrea software® appears to be a reliable, reproducible method to measure initial tumor volume of retroperitoneal lymph node metastases of testicular cancer after chemotherapy. Both measurement methods can be performed by experienced non-radiologists as well.

Transition from open to laparoscopic ALPPS for patients with very small FLR: the initial experience

BACKGROUND

Laparoscopic ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) has previously been reported but has been the authors' default option since 2015 in patients with small future liver remnant.

METHODS

A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center was performed using a prospective database from July 2011 to June 2016. Feasibility was studied by assessing conversions. The 90-day mortality and complications were analyzed using a Dindo-Clavien score and the comprehensive complication index. Operative time, blood loss, volumetric growth, and hospital stay were examined. The CUSUM analysis was performed.

RESULTS

ALPPS was performed in 30 patients, 10 of whom underwent a laparoscopic approach. There was no mortality and no complication grade ≥3A observed in laparoscopic ALPPS. In open ALPPS, 10 of 20 patients experienced complications grade ≥3A (p = 0.006) and one patient died. Liver failure was not observed after laparoscopic ALPPS, but two patients in the open ALPPS group developed complications that precluded the second stage. The total hospital stay was shorter in the laparoscopic ALPPS group.

CONCLUSION

Laparoscopic ALPPS is feasible as the default procedure for patients with very small FLR, and it is not inferior to the open approach. Surgeons experienced with complex laparoscopy should be encouraged to use a laparoscopic approach to ALPPS.

Parenchymal-sparing hepatectomies (PSH) for bilobar colorectal liver metastases are associated with a lower morbidity and similar oncological results: a propensity score matching analysis

OBJECTIVE

The aim of this study is to evaluate whether a parenchymal-sparing strategy provides similar results in terms of morbidity, mortality, and oncological outcome of non-PSH hepatectomies in a propensity score matched population (PSMP) in case of multiple (>3) bilobar colorectal liver metastases (CLM).

BACKGROUND

The surgical treatment of bilobar liver metastasis is challenging due to the necessity to achieve complete resection margins and a sufficient future remnant liver. Two approaches are adaptable as follows: parenchymal-sparing hepatectomies (PSH) and extended hepatectomies (NON-PSH).

METHODS

A total of 3036 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched in a 1:1 propensity score analysis in order to compare PSH versus NON-PSH resections.

RESULTS

PSH was associated with a lower number of complications (≥1) (25% vs. 34%, p = 0.04) and a lower grade of Dindo-Clavien III and IV (10 vs. 16%, p = 0.03). Liver failure was less present in PSH (2 vs. 7%, p = 0.006), with a shorter ICU stay (0 day vs. 1 day, p = 0.004). No differences were demonstrated in overall and disease-free survival.

CONCLUSION

In conclusion, PSH resection for bilobar multiple CLMs represents a valid alternative to NON-PSH resection in selected patients with a reduced morbidity and comparable oncological results.

Anesthetic and operative considerations for laparoscopic liver resection

We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.

A Nomogram to Predict Hypertrophy of Liver Segments 2 and 3 After Right Portal Vein Embolization

BACKGROUND

Portal vein embolization (PVE) reduces the risks of hepatic insufficiency after major hepatectomy for small predicted liver remnant. The extent of liver hypertrophy after PVE depends on various clinical factors. We sought to develop a nomogram for predicting the increase in the volume of segments 2 and 3 after right PVE (RPVE).

METHOD

In 360 patients who underwent RPVE from 1998 through 2013, clinicopathologic data were analyzed, including body mass index (BMI), diabetes, aspirin use, viral hepatitis status, preoperative albumin level, total bilirubin level, prothrombin time, platelet count, type of liver neoplasm, preoperative chemotherapy, previous laparotomy or hepatectomy, segment 4 embolization, two-stage hepatectomy, and liver volumes before and after PVE. Multivariate linear regression analysis was used to identify variables predicting the degree of hypertrophy of segments 2 and 3.

RESULTS

Multivariate regression analysis revealed that BMI (p = 0.002), previous hepatectomy (p = 0.03), RPVE in the setting of two-stage hepatectomy (p < 0.001), and segment 4 embolization (p = 0.003) independently predicted the degree of hypertrophy of segments 2 and 3. Based on the fitted model, a nomogram was constructed.

CONCLUSION

The constructed nomogram predicts the degree of hypertrophy of segments 2 and 3 after RPVE and can be used in clinical decision making for patients undergoing right hepatectomy.

Portal Venous Interventions: State of the Art

In recent decades, there have been numerous advances in the management of liver cancer, cirrhosis, and diabetes mellitus. Although these diseases are wide ranging in their clinical manifestations, each can potentially be treated by exploiting the blood flow dynamics within the portal venous system, and in some cases, adding cellular therapies. To aid in the management of these disease states, minimally invasive transcatheter portal venous interventions have been developed to improve the safety of major hepatic resection, to reduce the untoward effects of sequelae from end-stage liver disease, and to minimize the requirement of exogenously administered insulin for patients with diabetes mellitus. This state of the art review therefore provides an overview of the most recent data and strategies for utilization of preoperative portal vein embolization, transjugular intrahepatic portosystemic shunt placement, balloon retrograde transvenous obliteration, and islet cell transplantation.

Transarterial Radioembolization with Yttrium-90 for the Treatment of Hepatocellular Carcinoma

Background

Hepatocellular carcinoma (HCC) is a common cause of worldwide mortality. Transarterial radioembolization (TARE) with yttrium-90 (Y90), a transcatheter intra-arterial procedure performed by interventional radiology, has become widely utilized in managing HCC.

Methods

The following is a focused review of TARE covering its commercially available products, clinical considerations of treatment, salient clinical trial data establishing its utility, and the current and future roles of TARE in the management of HCC.

Results

TARE is indicated for patients with unresectable, intermediate stage HCC. The two available products are glass and resin microspheres. All patients undergoing TARE must be assessed with a history, physical examination, clinical laboratory tests, imaging, and arteriography with macroaggregated albumin. TARE is safe and effective in the treatment of unresectable HCC, as it has a safer toxicity profile than chemoembolization, longer time-to-progression, greater ability to downsize and/or bridge patients to liver transplant, and utility in tumor complicated by portal vein thrombosis. TARE can also serve as an alternative to ablation and chemotherapy.

Conclusion

TARE assumes an integral role in the management of unresectable HCC and has been validated by numerous studies.

Serum levels of endothelin-1 after liver resection as an early predictor of postoperative liver failure. A prospective study

AIM

Besides the residual liver volume, damage of the microcirculation secondary to increased portal blood flow is a main determinant of postoperative liver failure (PLF). Endothelin-1 (ET-1), produced by sinusoidal endothelial cells, plays a key role in the regulation of hepatic microcirculation. The aim of this study was to determine whether ET-1 levels has any prognostic utility in predicting PLF.

METHODS

Patients undergoing liver resection for primary or secondary liver tumors at San Raffaele Hospital, Milan, were prospectively enrolled in the study. Serial postoperative serum ET-1 levels in patients undergoing liver resections were correlated with indices of inflammatory response, liver failure and death.

RESULTS

A total of 144 patients were included. ET-1 levels in patients who underwent major or extended liver resection were significantly higher than in patients who had a minor resection on postoperative day (POD) 1 (P = 0.003), POD 2 (P = 0.0001) and POD 5 (P = 0.0001). Eight patients developed PLF and ET-1 was significantly higher compared with patients without PLF on POD 2 (P = 0.002) and POD5 (P = 0.006). Serum ET-1 concentration on POD 2 was an independent predictor of PLF in multivariate analysis.

CONCLUSION

ET-1 is as an early index of PLF and provides a rationale for therapeutic manipulation, with many potential clinical implications to prevent PLF onset and reduce its severity.

(90) Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes

BACKGROUND

The purpose of this study is to assess operative, post-operative, and long-term outcomes in patients who underwent radiation lobectomy (RL) for tumor control and/or hypertrophy of small future liver remnant (FLR) prior to resection.

METHODS

Right lobar +/- segment 4 radioembolization was performed prior to lobectomy/tri-segmentectomy in patients with hepatic tumor but inadequate FLR. Parenchymal/tumor volumes were calculated from pre/post-RL imaging; FLR/%FLR hypertrophy were determined. Complications were graded by the Clavien-Dindo classification.

RESULTS

Thirteen patients (HCC n = 10, cholangiocarcinoma n = 2, mCRC n = 1) underwent RL prior to resection. The median time between RL and post-RL imaging was 40 days (23-190 days); the median time to resection was 86 days (30-210 days). Median FLR increased significantly [pre: 33% (22-43%); post: 43% (29-69%), P < 0.01] to yield a median %FLR hypertrophy of 30% (4-105%). The median hospital stay after resection was 4 days (3-11 days). Transient hepatobiliary toxicities normalized post-operatively. Ninety-two percent of resected tumors had >50% pathologic necrosis. Median follow up time after surgery was 604 days (144-1,416 days); one death occurred.

CONCLUSIONS

In this preliminary study, radiation lobectomy was a safe and effective method to achieve remnant liver hypertrophy while providing tumor control. This approach may facilitate safe resection and favorable post-operative outcomes.J. Surg. Oncol. 2016;114:99-105. © 2016 Wiley Periodicals, Inc.

Comprehensive treatments for hepatocellular carcinoma with tumor thrombus in major portal vein

AIM: To evaluate the efficacy of transcatheter arterial chemoembolisation (TACE) compared with surgical intervention and sorafenib for treatment of hepatocellular carcinoma (HCC) in patients with tumor thrombus extending to the main portal vein.

METHODS: From 2009 to 2013, a total of 418 HCC patients with tumor thrombus extending to the main portal vein were enrolled in this study and divided into four groups. These groups underwent different treatments as follows: TACE (n = 307), surgical intervention (n = 54), sorafenib (n = 15) and palliative treatment (n = 42). Overall survival rates were determined by Kaplan-Meier method, and differences between the groups were identified through log-rank analysis. Cox’s proportional hazard model was used to identify the risk factors for survival.

RESULTS: The mean survival periods for patients in the TACE, surgical intervention, sorafenib and palliative treatment groups were 10.39, 4.13, 5.54 and 2.82 mo, respectively. For the TACE group, the 3-, 6-, 12- and 24-mo survival rates were 94.1%, 85.9%, 51.5% and 0.0%, respectively. The corresponding rates were 60.3%, 22.2%, 0.0% and 0.0% for the surgical intervention group and 50.9%, 29.5%, 0.0% and 0.0% for the sorafenib group. Evidently, the results in the TACE group were significantly higher than those in the other groups (P < 0.0001). Furthermore, no significant difference among survival rates was observed between TACE with/without sorafenib (10.22 mo vs 10.52 mo, P = 0.615). No significant difference in survival rates was also found among the surgical intervention, sorafenib and palliative treatment groups (P > 0.05). These values significantly increased after TACE with/without sorafenib compared with other treatments (P < 0.05).

CONCLUSION: For HCC patients with tumor thrombus extending to the main portal vein, TACE can yield a higher survival rate than surgical intervention or sorafenib treatment.

Liver regeneration after major liver hepatectomy: Impact of body mass index

BACKGROUND

Obese patients may present with metabolic abnormalities that impact liver regeneration. We sought to assess the impact of body mass index (BMI) on liver volume regeneration index (RI) and kinetic growth rate (KGR) among patients undergoing liver resection.

METHODS

The study included 102 patients undergoing major hepatectomy (≥3 segments) between July 2004 and April 2015 and stratified the patients by preoperative BMI, number of segments resected, and postoperative remnant liver volume (RLVp) to total liver volume ratio. Resected volume at operation was subtracted from total liver volume to calculate postoperative RLVp. RI was defined as the relative increase in RLV within 2 months [(RLV2m-RLVp)/RLVp] and 7 months [(RLV7m-RLVp)/RLVp] postoperatively; KGR was calculated as RI divided by time postoperatively (weeks).

RESULTS

Median patient age was 59.6 years (interquartile range 48.1-68.7 years), and most patients were men (52.0%). Liver failure was associated with the KGR at 2 months (KGR2m) and was greater among patients with KGR2m <2.5% per week (KGR <2.5%, 18.5% vs KGR ≥ 2.5%, 4.6%; P = .04). Although RI and KGR within 2 and 7 months postoperatively were similar among all patients, after excluding patients with fibrosis, obese (0.42% per week) and overweight patients (0.29% per week) had lesser KGR2-7m compared with patients of normal BMI (0.82% per week; P < .05). Additionally, risk of a major complication was greatest among obese patients (normal weight, 8.1% vs overweight, 12.9% vs obese, 29.4%; P = .04).

CONCLUSION

BMI did not impact liver regeneration during the first 2 months. In contrast, KGR per week between 2 and 7 months postoperatively was less among overweight and obese patients.

Controversies of preoperative portal vein embolization

Portal vein embolization (PVE) is a safe, percutaneous procedure that has been proven to lower the complication rates of curative intent large-volume hepatic resection by inducing hypertrophy of the future liver remnant. While the safety and efficacy of PVE has been well substantiated, there remains controversy with regards to the technical details, periprocedural management, and whether alternative methods of achieving future liver remnant hypertrophy are preferable to PVE. This paper will address those controversies and offer recommendations based on available data.

Determination of Resectability

The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.

Delayed diagnosis of alpha-1-antitrypsin deficiency following post-hepatectomy liver failure: A case report

Post-hepatectomy liver failure (PHLF) is a leading cause of morbidity and mortality following major liver resection. The development of PHLF is dependent on the volume of the remaining liver tissue and hepatocyte function. Without effective pre-operative assessment, patients with undiagnosed liver disease could be at increased risk of PHLF. We report a case of a 60-year-old male patient with PHLF secondary to undiagnosed alpha-1-antitrypsin deficiency (AATD) following major liver resection. He initially presented with acute large bowel obstruction secondary to a colorectal adenocarcinoma, which had metastasized to the liver. There was no significant past medical history apart from mild chronic obstructive pulmonary disease. After colonic surgery and liver directed neo-adjuvant chemotherapy, he underwent a laparoscopic partially extended right hepatectomy and radio-frequency ablation. Post-operatively he developed PHLF. The cause of PHLF remained unknown, prompting re-analysis of the histology, which showed evidence of AATD. He subsequently developed progressive liver dysfunction, portal hypertension, and eventually an extensive parastomal bleed, which led to his death; this was ultimately due to a combination of AATD and chemotherapy. This case highlights that formal testing for AATD in all patients with a known history of chronic obstructive pulmonary disease, heavy smoking, or strong family history could help prevent the development of PHLF in patients undergoing major liver resection.

Stepwise approach to curative surgery using percutaneous transhepatic cholangiodrainage and portal vein embolization for severe bile duct injury during laparoscopic cholecystectomy: a case report

Laparoscopic cholecystectomy (LC) has been recently adapted to acute cholecystitis. Major bile duct injury during LC, especially Strasberg-Bismuth classification type E, can be a critical problem sometimes requiring hepatectomy. Safety and definitive treatment without further morbidities, such as posthepatectomy liver failure, is required. Here, we report a case of severe bile duct injury treated with a stepwise approach using ^99mTc-galactosyl human serum albumin (^99mTc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging to accurately estimate liver function.

A 52-year-old woman diagnosed with acute cholecystitis underwent LC at another hospital and was transferred to our university hospital for persistent bile leakage on postoperative day 20. She had no jaundice or infection, although an intraperitoneal drainage tube discharged approximately 500 ml of bile per day. Recorded operation procedure showed removal of the gallbladder with a part of the common bile duct due to its misidentification, and each of the hepatic ducts and right hepatic artery was injured. Abdominal enhanced CT revealed obstructive jaundice of the left liver and arterial shunt through the hilar plate to the right liver. Magnetic resonance cholangiopancreatography revealed type E4 or more advanced bile duct injury according to the Bismuth-Strasberg classification. We planned a stepwise approach using percutaneous transhepatic cholangiodrainage (PTCD) and portal vein embolization (PVE) for secure right hemihepatectomy and biliary-jejunum reconstruction and employed ^99mTc-GSA SPECT/CT fusion imaging to estimate future remnant liver function. The left liver function rate had changed from 26.2 % on admission to 26.3 % after PTCD and 54.5 % after PVE, while the left liver volume rate was 33.8, 33.3, and 49.6 %, respectively. The increase of liver function was higher than that of volume (28.3 vs. 15.8 %). On postoperative day 63, the curative operation, right hemihepatectomy and biliary-jejunum reconstruction, was performed, and posthepatectomy liver failure could be avoided.

Careful consideration of treatment strategy for each case is necessary for severe bile duct injury with arterial injury requiring hepatectomy. The stepwise approach using PTCD and PVE could enable hemihepatectomy, and ^99mTc-GSA SPECT/CT fusion imaging was useful to estimate heterogeneous liver function.

Biological Substrate of the Rapid Volumetric Changes Observed in the Human Liver During the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Approach

BACKGROUND

The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) strategy induces rapid future liver remnant (FLR) hypertrophy. Hepatocyte cellular and molecular changes associated with liver hypertrophy during ALPPS remain ill-defined in humans.

METHODS

Patients undergoing the ALPPS approach between June 2011 and October 2014 were extracted. Biopsies from the FLR were obtained during the first and second stages. Hematoxylin-eosin staining and immunohistochemical analysis for expression of the proliferating cell nuclear antigen (PCNA) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) were performed. The proliferative index was defined as: PCNA-TUNEL ratio.

RESULTS

Eleven of 34 patients treated were studied during both stages. Median FLR hypertrophy was 104 % in 6 days, with a mean difference between preoperative and postoperative volume of 361 ml (P < 0.001). The mean hepatocyte number increased from 52.7 cells/mm(2) in the first stage to 89.6 cells/mm(2) in the second stage (P = 0.001). PCNA expression increased by 190 % between stages with a linear correlation (r = 0.58) with macroscopic hypertrophy. The proliferative index increased from -3.78 cells/mm(2) in first stage to 2.32 cells/mm(2) in the second stage (P = 0.034).

CONCLUSIONS

The results of the present study indicate that the rapid FLR volumetric increase observed in ALPPS is accompanied by histological and molecular features of hepatocyte cell proliferation.

Changes in Liver Volume in Patients with Chronic Hepatitis C Undergoing Antiviral Therapy

AIM

Liver volumetric analysis has not been used to detect hepatic remodelling during antiviral therapy before. We measured liver volume (LV) changes on volumetric magnetic resonance imaging during hepatitis C antiviral therapy.

METHODS

22 biopsy-staged patients (median [range] age 45(19-65) years; 9F, 13M) with chronic hepatitis C virus infection were studied. LV was measured at the beginning, end of treatment and 6 months post-treatment using 3D T1-weighted acquisition, normalised to patient weight. Liver outlines were drawn manually on 4 mm thick image slices and LV calculated. Inter-observer agreement was analysed. Patients were also assessed longitudinally using biochemical parameters and liver stiffness using Fibroscan™.

RESULTS

Sustained viral response (SVR) was achieved in 13 patients with a mean baseline LV/kg of 0.022 (SD 0.004) L/kg. At the end of treatment, the mean LV/kg was 0.025 (SD 0.004, P = 0.024 cf baseline LV/kg) and 0.026 (SD 0.004, P = 0.008 cf baseline LV/kg) 6 months post-treatment (P = 0.030 cf baseline, P = 0.004). Body weight-corrected end of treatment LV change was significantly higher in patients with SVR compared to patients not attaining SVR (P = 0.050). End of treatment LV change was correlated to initial ALT (R (2) = 0.479, P = 0.037), but not APRI, AST, viral load or liver stiffness measurements. There was a correlation of 0.89 between observers for measured slice thickness.

CONCLUSIONS

LV increased during anti-viral treatment, while the body weight-corrected LV increase persisted post-antiviral therapy and was larger in patients with SVR.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale, techniques, outcomes and future directions

The ability to modulate the future liver remnant (FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization (PVE), associating liver partition and portal vein ligation (ALPPS), and the recently reported transhepatic liver venous deprivation (LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.

Risk Factors Associated with Increased Morbidity in Living Liver Donation

Living donor liver donation (LDLD) is an alternative to cadaveric liver donation. We aimed at identifying risk factors and developing a score for prediction of postoperative complications (POCs) after LDLD in donors. This is a retrospective cohort study in 688 donors between June 1995 and February 2014 at Hospital Sírio-Libanês and A.C. Camargo Cancer Center, in São Paulo, Brazil. Primary outcome was POC graded ≥III according to the Clavien-Dindo classification. Left lateral segment (LLS), left lobe (LL), and right lobe resections (RL) were conducted in 492 (71.4%), 109 (15.8%), and 87 (12.6%) donors, respectively. In total, 43 (6.2%) developed POCs, which were more common after RL than LLS and LL (14/87 (16.1%) versus 23/492 (4.5%) and 6/109 (5.5%), resp., p < 0.001). Multivariate analysis showed that RL resection (OR: 2.81, 95% CI: 1.32 to 3.01; p = 0.008), smoking status (OR: 3.2, 95% CI: 1.35 to 7.56; p = 0.012), and blood transfusion (OR: 3.15, 95% CI: 1.45 to 6.84; p = 0.004) were independently associated with POCs. RL resection, intraoperative blood transfusion, and smoking were associated with increased risk for POCs in donors.

Effect of branched-chain amino acid supplementation on functional liver regeneration in patients undergoing portal vein embolization and sequential hepatectomy: a randomized controlled trial

BACKGROUND

Portal vein embolization (PVE) can decrease the resection ratio for major hepatectomy. (99m)Tc-galactosyl human serum albumin (GSA) scintigraphy is useful for evaluating quantitative functional liver volume. Branched chain amino acids (BCAAs) modulate liver function and regeneration. We analyzed the effects of BCAAs, in terms of liver function and regeneration after PVE, in combination with major hepatectomy.

METHODS

This randomized controlled trial was conducted for patients receiving PVE through to complete hepatectomy from September, 2011 to June, 2013. BCAA granules were added two times a day to a conventional diet in the BCAA administration group (BCAA group). The primary end point was functional liver regeneration of the future remnant liver after PVE followed by hepatic resection. Functional liver regeneration was assessed by the liver uptake value obtained from (99m)Tc-GSA scintigraphy single-photon-emission computed tomography/computed tomography fusion images. The secondary end points were volumetric liver regeneration and changes in liver function and laboratory data.

RESULTS

A BCAA group (n = 13) and a non-BCAA group (control group; n = 15) were included. The primary end point was partially met: the liver uptake value significantly increased in the BCAA group compared with the control group 6 months after hepatic resection (266.7% vs 77.6%, P = 0.04) and marginally increased after PVE (43.8% vs 17.4%, P = 0.079). Following PVE, the increment of the uptake ratio of the liver to the liver plus heart at 15 min was significantly less in the BCAA group than in the control group (0.0 and 0.01, P = 0.023).

CONCLUSIONS

BCAA supplementation improved functional liver regeneration and function in patients undergoing PVE followed by major hepatic resection.

[Preoperative imaging/operation planning for liver surgery]

The currently established standard for planning liver surgery is multistage contrast media-enhanced multidetector computed tomography (CM-CT), which as a rule enables an appropriate resection planning, e.g. a precise identification and localization of primary and secondary liver tumors as well as the anatomical relation to extrahepatic and/or intrahepatic vascular and biliary structures. Furthermore, CM-CT enables the measurement of tumor volume, total liver volume and residual liver volume after resection. Under the condition of normal liver function a residual liver volume of 25 % is nowadays considered sufficient and safe. Recent studies in patients with liver metastases of colorectal cancer showed a clear staging advantage of contrast media-enhanced magnetic resonance imaging (CM-MRI) versus CM-CT. In addition, most recent data showed that the use of liver-specific MRI contrast media further increases the sensitivity and specificity of detection of liver metastases. This imaging technology seems to lead closer to the ideal "one stop shopping" diagnostic tool in preoperative planning of liver resection.

Diagnostic and therapeutic management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasing health problem, representing the second cause of cancer-related mortality worldwide. The major risk factor for HCC is cirrhosis. In developing countries, viral hepatitis represent the major risk factor, whereas in developed countries, the epidemic of obesity, diabetes and nonalcoholic steatohepatitis contribute to the observed increase in HCC incidence. Cirrhotic patients are recommended to undergo HCC surveillance by abdominal ultrasounds at 6-mo intervals. The current diagnostic algorithms for HCC rely on typical radiological hallmarks in dynamic contrast-enhanced imaging, while the use of α-fetoprotein as an independent tool for HCC surveillance is not recommended by current guidelines due to its low sensitivity and specificity. Early diagnosis is crucial for curative treatments. Surgical resection, radiofrequency ablation and liver transplantation are considered the cornerstones of curative therapy, while for patients with more advanced HCC recommended options include sorafenib and trans-arterial chemo-embolization. A multidisciplinary team, consisting of hepatologists, surgeons, radiologists, oncologists and pathologists, is fundamental for a correct management. In this paper, we review the diagnostic and therapeutic management of HCC, with a focus on the most recent evidences and recommendations from guidelines.

Defining Post Hepatectomy Liver Insufficiency: Where do We stand?

BACKGROUND

Post-hepatectomy liver failure (PHLF) is a major source of morbidity and mortality in patients undergoing liver resection. The aim of this review is to summarize the recent literature available on PHLF including its definition, predictive factors, preoperative risk assessment, severity grading, preventative measures, and management strategies.

METHODS

A systematic literature search was carried out with the search engines PubMed, Medline, and Cochrane Database using the keywords related to "liver failure", "posthepatectomy", and "hepatic resection".

RESULTS

Liver resection is a curative treatment of liver tumors. However, it leads to concurrent death and regeneration of the remaining hepatocytes. Factors related to the patient, liver parenchyma and the extent of surgery can inhibit regeneration leading to PHLF.

CONCLUSION

Given its resistance to treatment and the high postoperative mortality associated with PHLF, great effort has been put in to both accurately identify patients at high risk and to develop strategies that can help prevent its occurrence.

Liver function following extended hepatectomy can be accurately predicted using remnant liver volume to body weight ratio

BACKGROUND

Standardised measurement of remnant liver volume (RLV), where total liver volume (TLV) is calculated from patients' body surface area (RLV-sTLV), has been advocated. Extrapolating the model of living donor liver transplantation, we showed in a pilot study that the simplified RLV/body weight ratio (RLVBWR) was accurate in assessing the functional limit of hepatectomy. The aim of the study was to compare in a prospective series of extended right hepatectomy the predictive value of the RLVBWR and the RLV-sTLV at a cut-off of 0.5% (RLVBWR0.5%) and 20% (RLV-sTLV20%), respectively.

METHODS

We studied the impact of RLVBWR0.5% and of RLV-sTLV20% on three months morbidity and mortality in 74 non-cirrhotic patients operated on for malignant tumours. Of these, 47 patients who were not included in the initial pilot study were enrolled in a prospective validation cohort to reappraise the predictive value of each method.

RESULTS

RLVBWR and RLV-sTLV were highly correlated (Pearson correlation coefficient, 0.966). Three months overall and severe morbidity (grade 3b-5) and mortality were significantly increased in groups RLVBWR ≤ 0.5% and RLV-sTLVs ≤ 20% compared to groups >0.5% and >20%, respectively. The sensitivity and specificity in predicting death from liver failure were 100 and 84.1% for RLVBWR0.5% and 60 and 94.2% for RLV-sTLV20%, respectively. Similar results were observed in the validation cohort for the RLVBWR0.5% (lack of statistical power for RLV-sTLV as only 2 patients showed a RLV-sTLV ≤ 20%).

CONCLUSIONS

The RLVBWR0.5% is a method of assessing the remnant liver that is simple and as reliable as the standardised RLV-sTLV20%.

Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series

BACKGROUND

The aim of this paper is to assess the current state of quality and outcomes measures being reported for hepatic resections in the recent literature.

METHODS

Medline and PubMed databases were searched for English language articles published between 1 January 2002 and 30 April 2013. Two examiners reviewed each article and relevant citations for appropriateness of inclusion, which excluded papers of liver donor hepatic resections, repeat hepatectomies or meta-analyses. Data were extracted and summarized by two examiners for analysis.

RESULTS

Fifty-five studies were identified with suitable reporting to assess peri-operative mortality in hepatic resections. In only 35% (19/55) of the studies was the follow-up time explicitly stated, and in 47% (26/55) of studies peri-operative mortality was limited to in-hospital or 30 days. The time period in which complications were captured was not explicitly stated in 19 out of 28 studies. The remaining studies only captured complications within 30 days of the index operation (8/28). There was a paucity of quality literature addressing truly patient-centred outcomes.

CONCLUSION

Quality outcomes after a hepatic resection are inconsistently reported in the literature. Quality outcome studies for a hepatectomy should report mortality and morbidity at a minimum of 90 days after surgery.

Complex Surgical Strategies to Improve Resectability in Borderline-Resectable Disease

Colorectal cancer is the third most common malignancy in the USA and continues to pose a significant epidemiologic problem, despite major advances in the treatment of patients with advanced disease. Up to 50 % of patients will develop metastatic disease at some point during the course of their disease, with the liver being the most common site of metastatic disease. In this review, we address the relatively poorly defined entity of borderline-resectable colorectal liver metastases. The workup and staging of borderline-resectable disease are discussed. We then discuss management strategies, including surgical techniques and medical therapies, which are currently utilized in order to improve resectability.