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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach

BACKGROUND

Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE.

METHODS

A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed.

RESULTS

The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection.

CONCLUSION

Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Optimal future liver remnant in patients treated with extensive preoperative chemotherapy for colorectal liver metastases

BACKGROUND

Patients with colorectal liver metastases (CLM) are increasingly treated with preoperative chemotherapy. Chemotherapy associated liver injury is associated with postoperative hepatic insufficiency (PHI) and mortality. The adequate minimum future liver remnant (FLR) volume in patients treated with extensive chemotherapy remains unknown.

METHODS

All patients with standardized FLR > 20 %, who underwent extended right hepatectomy for CLM from 1993-2011, were divided into three cohorts by chemotherapy duration: no chemotherapy (NC, n = 30), short duration (SD, ≤12 weeks, n = 78), long duration (LD, >12 weeks, n = 86). PHI and mortality were compared by using uni-/multivariate analyses. Optimal FLR for LD chemotherapy was determined using a minimum p-value approach.

RESULTS

A total of 194 patients met inclusion criteria. LD chemotherapy was significantly associated with PHI (NC + SD 3.7 vs. LD 16.3%, p = 0.006). Ninety-day mortality rates were 0 % in NC, 1.3 % in SD, and 2.3% in LD patients, respectively (p = 0.95). In patients with FLR > 30 %, PHI occurred in only two patients (both LD, 2/20, 10 %), but all patients with FLR > 30 % survived. The best cutoff of FLR for preventing PHI after chemotherapy >12 weeks was estimated as >30 %. Both LD chemotherapy (odds ratio [OR] 5.4, p = 0.004) and FLR ≤ 30 % (OR 6.3, p = 0.019) were independent predictors of PHI.

CONCLUSIONS

Preoperative chemotherapy >12 weeks increases the risk of PHI after extended right hepatectomy. In patients treated with long-duration chemotherapy, FLR > 30 % reduces the rate of PHI and may provide enough functional reserve for clinical rescue if PHI develops.

Right and extended-right hepatectomies for unilobar colorectal metastases: impact of portal vein embolization on long-term outcome and liver recurrence

BACKGROUND

Portal vein embolization (PVE) is an effective procedure to increase the future remnant liver (FRL) before major hepatectomy. A controversial issue is that PVE may stimulate tumor growth and can be associated with poor prognosis after liver resection for colorectal liver metastases (CRLM). The aim of this study was to evaluate the impact of PVE on long-term survival following major hepatectomy for CRLM.

METHODS

Between 1998 and 2010, 100 right and extended-right hepatectomies for unilobar, right-sided CRLM were performed. Of the group, 20 patients underwent preoperative PVE (group A). The control patients (group B; 20 patients) were selected by matching with the group A patients.

RESULTS

It was found that 25 patients (25/40; 62.5%) had developed tumor recurrence. The rate of global recurrence was not significantly different in groups A and B (65% vs 60%, respectively; P = .744). The specific overall intrahepatic recurrence rate was 42.5% (17 of 40 patients) and was not significantly different in groups A and B (45% vs 40%, respectively; P = .749). The 5-year overall and disease-free survival rates were similar in groups A and B (42.9% and 33.6% vs 42.1% and 27.7%, respectively). The 5-year specific liver-disease-free survival was 45.3% in group A and 53.5% in group B (P = .572). On multivariate analysis of all 100 hepatectomies, R1 resection (P = .013) was found to be the only independent predictor of liver-disease-free survival.

CONCLUSION

This study showed that PVE did not affect overall survival and specific liver-disease-free survival in patients undergoing right or right-extended hepatectomy for unilobar, right-sided CRLM.

An extended dysfunctional area in the congestive area of the remnant liver after hemi-hepatectomy with middle hepatic vein resection for liver cancers evaluated on the gadoxetic acid disodium-enhanced magnetic resonance imaging

BACKGROUND

The aim of the present study was to evaluate the liver function in the congestive area of the remnant liver after hemi-hepatectomy with middle hepatic vein (MHV) resection for liver cancers.

METHODS

From November 2009 through December 2012, 18 patients underwent hemi-hepatectomy including the MHV for liver cancers. Post-hepatectomy, the volume of the congestive area, which appeared as a hyper-intense area on T2-weighted images and dysfunctional area, which appeared as a low intensity area on hepatobiliary phase images in the remnant liver was evaluated in all patients by gadoxetic acid disodium-enhanced magnetic resonance imaging.

RESULTS

Fifteen of 18 patients showed a congestive area, and 16 of 18 patients showed a dysfunctional area in the remnant liver. The dysfunctional rate (median 11%) was significantly larger than the congestive rate (median 5%, P = 0.0004). The dysfunctional rate was associated with tumor invasion to the root of the MHV, and no tumor invasion to the root of the MHV was identified as a significant predictor of a larger dysfunctional area (odds ratio 25.888, P = 0.0267) on multivariate analysis.

CONCLUSION

Hemi-hepatectomy with MHV resection for liver cancers should be performed considering the dysfunctional area in the remnant liver, which is associated with tumor invasion to the root of the MHV.

Sequential preoperative hepatic vein embolization after portal vein embolization for extended left hepatectomy in colorectal liver metastases

Background

The role of portal vein embolization to increase future liver remnant (FLR) is well-established in the treatment of colorectal liver metastases. However, the role of hepatic vein embolization is unclear.

Case report

A patient with colorectal liver metastases received neoadjuvant chemotherapy prior to attempted resection. At the time of resection his tumor appeared to invade the left and middle hepatic vein, requiring an extended left hepatectomy including segments five and eight. Post-operatively, he underwent sequential left portal vein embolization followed by left hepatic vein embolization and finally, middle hepatic vein embolization. Hepatic vein embolization was performed to increase the FLR as well as to allow collateral drainage of the FLR to develop. A left trisectionectomy was then performed and no evidence of postoperative liver congestion or morbidity was found.

Conclusion

Sequential portal vein embolization and hepatic vein embolization for extended left hepatectomy may be considered to increase FLR and may prevent right hepatic congestion after sacrificing the middle vein.

Portal vein embolization: rationale, technique, and current application

Portal vein embolization (PVE) is a technique used before hepatic resection to increase the size of liver segments that will remain after surgery. This therapy redirects portal blood to segments of the future liver remnant (FLR), resulting in hypertrophy. PVE is indicated when the FLR is either too small to support essential function or marginal in size and associated with a complicated postoperative course. When appropriately applied, PVE has been shown to reduce postoperative morbidity and increase the number of patients eligible for curative intent resection. PVE is also being combined with other therapies in novel ways to improve surgical outcomes. This article reviews the rationale, technical considerations, and current use of preoperative PVE.

Are two-stage hepatectomies associated with more complications than one-stage procedures?

BACKGROUND

Two-stage liver resections with portal vein occlusion have become standard in patients with low volume future liver remnants. Whether they are associated with more complications is unclear. The aim of this study was to compare complications of one- and two-stage resections in a retrospective study.

METHODS

Patients with two-stage right liver resections with a previous portal vein occlusion were compared with patients with one-stage right liver resections between 2002 and 2010. Primary endpoints were the incidence of complications by severity. Secondary endpoints were mortality, post-operative liver- and kidney function tests, length of hospitalization and transfusion events. Logistic and linear regression analyses were performed to adjust for confounders.

RESULTS

The groups were comparable except for right trisectionectomies, pre-operative chemotherapy and underlying liver disease. Overall complications occurred in 25 out of 35 patients with two-stage and 106 out of 163 in one-stage procedures. Severe complications were observed in 47 out of 163 patients versus 9 out of 35 patients, respectively. Two-stage procedures had no increased adjusted risk for complications [relative risk (RR) 0.9, P = 0.79]. Mortality (5.7% versus 3.7%) and post-operative liver failure rates (2.9% versus 3.1%) were low. Secondary endpoints showed no adjusted differences in risk.

CONCLUSION

This study suggests that liver resections in two stages are not associated with more post-operative complications than one-stage resections. These results should support the adoption of two-stage liver resections in selected patients.

Early post-operative prediction of morbidity and mortality after a major liver resection for colorectal metastases

BACKGROUND

An early prediction of poor outcomes is essential in the management of patients after a liver resection. The aim of this study was to evaluate the role of selected biochemical parameters on post-operative day 1 (POD 1) in the prediction of morbidity and mortality after a liver resection for colorectal metastases.

METHOD

This retrospective study was based on 236 major liver resections for colorectal metastases performed between 2006 and 2011. Results of biochemical tests of blood samples obtained on POD 1 were assessed as predictors of primary outcome measures (hepatic and overall morbidity, 90-day mortality) using multiple regression and receiver-operating characteristics (ROC).

RESULTS

Hepatic morbidity, overall morbidity and 90-day mortality rates were 18.6%, 28.0% and 4.7%, respectively. On the basis of multiple regression analysis and comparisons of the prediction models, serum bilirubin was selected for the prediction of hepatic (>2.05 mg/dl, sensitivity 69.2%, specificity 71.2%) and overall (>2.05 mg/dl, sensitivity 61.1% and specificity 71.2%) morbidity, and aspartate aminotransferase (AST) was selected for the prediction of 90-day mortality (>798 U/l, sensitivity 62.5% and specificity 90.4%).

DISCUSSION

Biochemical analyses of blood on POD1 enables stratification of patients into low- and high-risk groups for negative outcomes, with serum bilirubin associated with overall and hepatic morbidity and AST associated with mortality.

Kinetics of liver function tests after a hepatectomy for colorectal liver metastases predict post-operative liver failure as defined by the International Study Group for Liver Surgery

BACKGROUND

Post-hepatectomy liver failure (PHLF) has been defined by the International Study Group for Liver Surgery (ISGLS). The purpose of the present study was to examine the kinetics of conventional liver function tests (LFT) after a major liver resection and is the first to examine their utility in predicting PHLF in groups defined by the ISGLS.

METHODS

Consecutive patients undergoing a major liver resection for colorectal liver metastases were stratified into ISGLS groups and their LFT up to 1 year after surgery compared. Receiving-operating characteristic (ROC) analysis of LFT identified optimal thresholds in predicting category C liver failure.

RESULTS

In total, 32, 22 and 19 patients belonged to ISGLS groups A, B and C, respectively. The median international normalized ratio (INR) and bilirubin values on post-operative days 1, 3, 5 and 7 were significantly different among the groups (all P-values <0.05). ROC analysis of day 1 INR (AUC 0.813) and day 5 bilirubin (AUC 0.798) revealed thresholds of 1.35 and 52 μmol/l to have sensitivities of 85% and 81% and specificities of 63% and 73%, respectively, to predict group C liver failure.

DISCUSSION

Post-operative LFT after a major liver resection differs significantly among the three ISGLS groups. Thresholds of bilirubin and INR can be used to identify patients who are at a maximum risk of complications.

New paradigms in post-hepatectomy liver failure

INTRODUCTION

Liver failure after hepatectomy remains the most feared postoperative complication. Many risk factors are already known, related to patient's comorbidities, underlying liver disease, received treatments and type of resection. Preoperative assessment of functional liver reserve must be a priority for the surgeon.

METHODS

Physiopathology of post-hepatectomy liver failure is not comparable to fulminant liver failure. Liver regeneration is an early phenomenon whose cellular mechanisms are beginning to be elucidated and allowing most of the time to quickly recover a functional organ. In some cases, microscopic and macroscopic disorganization appears. The hepatocyte hyperproliferation and the asynchronism between hepatocytes and non-hepatocyte cells mitosis probably play a major role in this pathogenesis.

RESULTS

Many peri- or intra-operative techniques try to prevent the occurrence of this potentially lethal complication, but a better understanding of involved mechanisms might help to completely avoid it, or even to extend the possibilities of resection.

CONCLUSION

Future prevention and management may include pharmacological slowing of proliferation, drug or physical modulation of portal flow to reduce shear-stress, stem cells or immortalized hepatocytes injection, and liver bioreactors. Everything must be done to avoid the need for transplantation, which remains today the most efficient treatment of liver failure.

Right hepatectomy for living donation: role of remnant liver volume in predicting hepatic dysfunction and complications

BACKGROUND

Extensive attention has been placed on remnant liver volume (RLV) above other factors to ensure donor safety.

METHODS

We performed a retrospective review of 137 right hepatectomies in live donors between June 1999 and November 2010.

RESULTS

Median right lobe volume was 1,029 cm(3), which correlated with its actual weight (r = 0.63, P < .01); median RLV was 548 cm(3). Of the donors, 32 (24%) developed postoperative hepatic dysfunction (bilirubin >3 mg/dL or prothrombin time >18 s on postoperative day 4). RLV did not predict postoperative hepatic dysfunction (P = .9), but it was associated with peak international normalized ratio (INR) (P = .04). Donor age and male gender were predictors of increased bilirubin at postoperative day 4 (age, P = .03; gender, P = .02). Of the donors, 45 (33%) experienced complications, and 24 donors had RLVs <30%; 42% experienced complications compared to 31% of donors whose RLVs were greater than 30% (P = .3). Cell-saver utilization and aspartate-aminotransferase (AST) levels (OR = 3) were associated with complications. Volumetric assessment can predict RLV accurately.

CONCLUSION

Although no demonstrable association between RLV <30% and complications was found, an RLV of 30% should remain the threshold for donor safety. Age and gender should be balanced in donors with a near threshold RLV of 30%. Surgical complexity, suggested by the need for intraoperative autoinfusion of blood and postoperative levels of AST, remained the independent predictor of complications.

Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant

BACKGROUND

Standardized future liver remnant (sFLR) volume and degree of hypertrophy after portal vein embolization (PVE) have been recognized as important predictors of surgical outcomes after major liver resection. However, the regeneration rate of the FLR after PVE varies among individuals and its clinical significance is unknown.

STUDY DESIGN

Kinetic growth rate (KGR) is defined as the degree of hypertrophy at initial volume assessment divided by number of weeks elapsed after PVE. In 107 consecutive patients who underwent liver resection for colorectal liver metastases with an sFLR volume >20%, the ability of the KGR to predict overall and liver-specific postoperative morbidity and mortality was compared with sFLR volume and degree of hypertrophy.

RESULTS

Using receiver operating characteristic analysis, the best cutoff values for sFLR volume, degree of hypertrophy, and KGR for predicting postoperative hepatic insufficiency were estimated as 29.6%, 7.5%, and 2.0% per week, respectively. Among these, KGR was the most accurate predictor (area under the curve 0.830 [95% CI, 0.736-0.923]; asymptotic significance, 0.002). A KGR of <2% per week vs ≥2% per week correlates with rates of hepatic insufficiency (21.6% vs 0%; p = 0.0001) and liver-related 90-day mortality (8.1% vs 0%; p = 0.04). The predictive value of KGR was not influenced by sFLR volume or the timing of initial volume assessment when evaluated within 8 weeks after PVE.

CONCLUSIONS

Kinetic growth rate is a better predictor of postoperative morbidity and mortality after liver resection for small FLR than conventional measured volume parameters (ie, sFLR volume and degree of hypertrophy).

Update on portal vein embolization: evidence-based outcomes, controversies, and novel strategies

Portal vein embolization (PVE) is an established therapy used to redirect portal blood flow away from the tumor-bearing liver to the anticipated future liver remnant (FLR) and usually results in FLR hypertrophy. PVE is indicated when the FLR is considered too small before surgery to support essential function after surgery. When appropriately applied, PVE reduces postoperative morbidity and increases the number of patients eligible for curative hepatic resection. PVE also has been combined with other therapies to improve patient outcomes. This article assesses more recent outcomes data regarding PVE, reviews the existing controversies, and reports on novel strategies currently being investigated.

Perioperative chemotherapy and liver resection for hepatic metastases of colorectal cancer

Surgical resection has played a major role in the treatment for colorectal liver metastases. The safety and efficacy of surgery for liver metastasis are obvious, although there are some differences between the western countries and Japan concerning the surgical indication, procedures, timing of chemotherapies in a perioperative period, and treatment of a primary disease. In future, long-term outcomes after surgical resection for colorectal liver metastases would be expected to be prolonged by combination of surgery and chemotherapies.

Colorectal liver metastases

BACKGROUND

With modern multimodality therapy, patients with resected colorectal cancer (CRC) liver metastases (CLM) can experience up to 50-60 % 5-year survival. These improved outcomes have become more commonplace via achievements in multidisciplinary care, improved definition of resectability, and advances in technical skill.

DISCUSSION

Even patients with synchronous and/or extensive bilateral disease have benefited from novel surgical strategies. Treatment sequencing of synchronous CRC with CLM can be simplified into the following three paradigms: (classic colorectal-first), simultaneous (combined), or reverse approach (liver-first). The decision of whether to treat the CLM or CRC first depends on which site dominates oncologically and symptomatically. Oxaliplatin with 5-fluorouracil/leucovorin (FOLFOX) and irinotecan with 5-fluorouracil/leucovorin (FOLFIRI) are the foundations of modern chemotherapy. Although each regimen has positively impacted survivals, both have the potential for negative effects on the non-tumor liver. Oxaliplatin is associated with vascular injury (sinusoidal ballooning, microvascular injury, nodular regenerative hyperplasia, and long-term fibrosis) but not steatosis. Irinotecan has been associated with steatohepatitis, especially in patients with obesity and diabetes. Steatohepatitis from irinotecan is the only chemotherapy-associated liver injury (CALI) associated with increased mortality from postoperative hepatic insufficiency. Extended duration of preoperative chemotherapy is also associated with CALI.

CONCLUSIONS

To determine resectability and to prevent overtreatment with systemic therapy, all patients should receive high-quality cross-sectional imaging and be evaluated by a hepatobiliary surgeon before starting chemotherapy. Even as chemotherapy improves, liver surgeons will continue to play a central role in treatment planning by offering the best chance for prolonged survival-safe R0 resection with curative intent.

Improved long-term survival after major resection for hepatocellular carcinoma: a multicenter analysis based on a new definition of major hepatectomy

BACKGROUND

Advances in the surgical management of hepatocellular carcinoma (HCC) have expanded the indications for curative hepatectomy, including more extensive liver resections. The purpose of this study was to examine long-term survival trends for patients treated with major hepatectomy for HCC.

PATIENTS AND METHODS

Clinicopathologic data for 1,115 patients with HCC who underwent hepatectomy between 1981 and 2008 at five hepatobiliary centers in France, China, and the USA were assessed. In addition to other performance metrics, outcomes were evaluated using resection of ≥4 liver segments as a novel definition of major hepatectomy.

RESULTS

Major hepatectomy was performed in 539 patients. In the major hepatectomy group, median tumor size was 10 cm (range: 1-27 cm) and 22 % of the patients had bilateral lesions. The TNM Stage distribution included 29 % Stage I, 31 % Stage II, 38 % Stage III, and 2 % Stage IV. The postoperative histologic examination indicated that chronic liver disease was present in 35 % of the patients and tumor microvascular invasion was identified in 60 % of the patients. The 90-day postoperative mortality rate was 4 %. After a median follow-up time of 63 months, the 5-year overall survival rate was 40 %. Patients treated with right hepatectomy (n = 332) and those requiring extended hepatectomy (n = 207) had similar 90-day postoperative mortality rates (4 % and 4 %, respectively, p = 0.976) and 5-year overall survival rates (42 % and 36 %, respectively, p = 0.523). Postoperative mortality and overall survival rates after major hepatectomy were similar among the participating countries (p > 0.1) and improved over time with 5-year survival rates of 30 %, 40 %, and 51 % for the years 1981-1989, 1990-1999, and the most recent era of 2000-2008, respectively (p = 0.004). In multivariate analysis, factors that were significantly associated with worse survivals included AFP level >1,000 ng/mL, tumor size >5 cm, presence of major vascular invasion, presence of extrahepatic metastases, positive surgical margins, and earlier time period in which the major hepatectomy was performed.

CONCLUSIONS

This multinational, long-term HCC survival analysis indicates that expansion of surgical indications to include major hepatectomy is justified by the significant improvement in outcomes over the past three decades observed in both the East and the West.

Greater complexity of liver surgery is not associated with an increased incidence of liver-related complications except for bile leak: an experience with 2,628 consecutive resections

BACKGROUND

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

METHODS

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

RESULTS

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p < 0.001), two-stage resection (4.0 vs 1 %; p < 0.001), extended right hepatectomy (17.6 vs 14.6 %; p = 0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p < 0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p = 0.02) and hemorrhage (0.9 vs 0.3 %; p = 0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p = 0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p = 0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

CONCLUSIONS

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.

Methods to improve resectability of hepatocellular carcinoma

Liver resection is associated with prolonged survival in selected patients with hepatocellular carcinoma (HCC). Surgical resection of HCC may be decided on an individual basis according to the extent of the tumor and the severity of chronic liver disease. In patients with compensated cirrhosis, the volume of the future liver remnant (FLR) is the most reliable factor for predicting postoperative liver function. Methods of increasing the FLR volume, including portal vein embolization and sequential transarterial chemoembolization in patients who are primarily not eligible for liver resection, have been shown to be safe and have contributed to the increase in the number of surgical candidates.

Colorectal liver metastases

BACKGROUND

With modern multimodality therapy, patients with resected colorectal cancer (CRC) liver metastases (CLM) can experience up to 50-60 % 5-year survival. These improved outcomes have become more commonplace via achievements in multidisciplinary care, improved definition of resectability, and advances in technical skill.

DISCUSSION

Even patients with synchronous and/or extensive bilateral disease have benefited from novel surgical strategies. Treatment sequencing of synchronous CRC with CLM can be simplified into the following three paradigms: (classic colorectal-first), simultaneous (combined), or reverse approach (liver-first). The decision of whether to treat the CLM or CRC first depends on which site dominates oncologically and symptomatically. Oxaliplatin with 5-fluorouracil/leucovorin (FOLFOX) and irinotecan with 5-fluorouracil/leucovorin (FOLFIRI) are the foundations of modern chemotherapy. Although each regimen has positively impacted survivals, both have the potential for negative effects on the non-tumor liver. Oxaliplatin is associated with vascular injury (sinusoidal ballooning, microvascular injury, nodular regenerative hyperplasia, and long-term fibrosis) but not steatosis. Irinotecan has been associated with steatohepatitis, especially in patients with obesity and diabetes. Steatohepatitis from irinotecan is the only chemotherapy-associated liver injury (CALI) associated with increased mortality from postoperative hepatic insufficiency. Extended duration of preoperative chemotherapy is also associated with CALI.

CONCLUSIONS

To determine resectability and to prevent overtreatment with systemic therapy, all patients should receive high-quality cross-sectional imaging and be evaluated by a hepatobiliary surgeon before starting chemotherapy. Even as chemotherapy improves, liver surgeons will continue to play a central role in treatment planning by offering the best chance for prolonged survival-safe R0 resection with curative intent.

Metabolic disorders, non-alcoholic fatty liver disease and major liver resection: an underestimated perioperative risk

INTRODUCTION

Despite increasing evidence of an association of metabolic syndrome and liver degeneration, little is known about the results of major hepatic resection in patients with metabolic disorders. Following the observation of some unexplained perioperative deaths following uncomplicated right hepatectomy in patients presenting metabolic disorders, we analyzed the perioperative mortality in such population.

MATERIAL AND METHODS

A retrospective analysis of immediate outcome was performed of patients undergoing right hepatectomy and affected by two or more metabolic disorders (diabetes mellitus, hypertension, dyslipidemia, obesity/overweight) without any other known cause of liver disease from January 2001 to May 2010.

RESULTS

Among 151 patients undergoing right hepatectomy, 30 patients presented two or more metabolic disorders. Perioperative mortality in this group reached 30 % (nine patients). In patients presenting MS (≥3 disorders), mortality reached 54 %. Univariate analysis identified four criteria associated with poor prognosis: MS, perioperative bleeding ≥1,000 mL, middle hepatic vein resection and primary hepatic malignancy. At multivariate analysis, middle hepatic vein resection and underlying primary hepatic malignancy resulted as being related to mortality.

CONCLUSIONS

Patients presenting with multiple metabolic disorders should be carefully evaluated before major liver resection, especially when the procedure is planned for hepatocellular carcinoma and when a middle hepatic vein resection is required.

In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection

Background

Portal vein embolization (PVE) has become a standard procedure to increase the future liver remnant (FLR) and enable curative resection of initially unresectable liver tumours. This study investigated the safety and feasibility of a new two-stage liver resection technique that uses in situ liver transection (ISLT) and portal vein ligation before completion hepatectomy.

Methods

A consecutive series of patients undergoing ISLT and extended right hepatectomy between 2009 and 2011 were compared with consecutive patients undergoing extended right hepatectomy after PVE. All patients had initially unresectable primary or secondary liver tumours, owing to an insufficient FLR (liver segments II/III).

Results

Fifteen patients who had PVE and seven who underwent ISLT before extended right hepatectomy were evaluated. ISLT induced rapid growth of the FLR within 3 days, particularly after insufficient PVE, from a mean(s.d.) of 293(58) ml to 477(85) ml, corresponding to a volume increase of 63(29) per cent. All patients who had ISLT underwent completion extended right hepatectomy within 8 days (range 4–8 days).

Conclusion

ISLT is an effective and reliable technique to induce rapid growth of the FLR, even in patients with insufficient volume increase after PVE.

Influence of hepatic parenchymal histology on outcome following right hepatic trisectionectomy

BACKGROUND

Histological abnormalities in the non-tumour-bearing liver (NTBL) may influence outcome following hepatectomy. Effects will be most pertinent following right trisectionectomy but have yet to be specifically examined in this context. This study aimed to investigate the influence of perioperative factors, including NTBL histology, on outcome following right trisectionectomy.

METHODS

Pathological review of the NTBL of 103 consecutive patients undergoing right trisectionectomy between January 2003 and December 2009 was performed using established criteria for steatosis, non-alcoholic steatohepatitis (NASH), sinusoidal injury (SI), fibrosis and cholestasis. Perioperative and pathological factors were correlated with post-operative outcome (morbidity, major morbidity, hepatic insufficiency and mortality).

RESULTS

Morbidity, hepatic insufficiency and major morbidity occurred in 37.9 %, 14.6 % and 22.3 % of cases, respectively. Ninety-day mortality rate was 5.8 %. NASH (P = 0.007) and perioperative blood transfusion (P = 0.001) were independently associated with hepatic insufficiency following trisectionectomy. NASH (P = 0.028), perioperative transfusion (P = 0.016), diabetes mellitus (P = 0.047) and coronary artery disease (P = 0.036) were independently associated with major morbidity. Steatosis, SI, fibrosis and cholestasis in the NTBL demonstrated no association with any adverse outcome.

CONCLUSION

NASH, but not steatosis or SI, is associated with adverse outcome following right trisectionectomy and caution must be exerted when considering major hepatectomy in patients with NASH.

Prognostic criteria for postoperative mortality in 170 patients undergoing major right hepatectomy

BACKGROUND

Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin >2.9 mg/dL and international normalized ratio >1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak >7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients.

METHODS

One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure.

RESULTS

The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin >7 mg/dL and ALT<188 U/L on postoperative day 1 were predictive of death from hepatic failure in the postoperative period. Age >65 years, HCV, reoperation, and renal failure were significant predictors of overall intra-hospital mortality on multivariate analysis.

CONCLUSIONS

The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak >7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level <188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.

Sequential intra-arterial therapy and portal vein embolization is feasible and safe in patients with advanced hepatic malignancies

BACKGROUND

A major hepatic resection for malignancies requires an adequate post-operative liver reserve. Portal vein embolization (PVE) with intra-arterial therapy (IAT) may increase future liver remnant (FLR) hypertrophy. As such, the feasibility, safety and efficacy of IAT+PVE were investigated.

METHODS

Between 2000 to 2011, 86 patients with malignancy of the liver were identified from a multi-institutional database. Twenty-nine patients underwent sequential IAT+PVE, 25 had PVE alone and 32 had IAT alone. Clinicopathological data were evaluated.

RESULTS

Most patients had hepatocellular carcinoma (HCC) (65.1%) and 31.4% had secondary metastatic disease. A complete or partial response using European Association for the Study of the Liver (EASLD) criteria was seen in 48.3% of patients undergoing IAT+PVE vs. 56.6% among patients undergoing IAT (P = 0.601). The median increase in percentage FLR volume was comparable in IAT+PVE (7.4%) vs. PVE only (7.9%) (P = 0.203). There were no IAT+PVE-associated deaths and only one complication. Among patients treated with IAT+PVE (n = 29), 27 underwent a subsequent hepatic resection. Peri-operative morbidity and mortality was 29.6% and 7.4%, respectively. Among the patients with HCC who underwent curative intent surgery after IAT+PVE, the median survival was 59.0 months.

CONCLUSIONS

Sequential IAT and PVE are feasible and safe. Utilization of IAT+PVE before a resection can lead to long-term survival and should be considered in the treatment of patients with advanced hepatic malignancies.

Early regeneration of the remnant liver volume after right hepatectomy for living donation: a multiple regression analysis

Early liver regeneration was studied in a series of 70 patients who underwent right hepatectomy for living donation between November 2004 and January 2010. Liver regeneration was evaluated with multidetector computed tomography (MDCT) at a mean of 61.07 days after surgery. Presurgical variables [eg, age, weight, height, body mass index (BMI), liver function tests, creatinine levels, platelet counts, international normalized ratio, and glucose levels] and variables detected with preoperative MDCT imaging [eg, main portal vein diameter, steatosis, original liver volume, and spleen volume (SV)] were investigated as potential predictors of liver regeneration. The future remnant liver volume (FRLV) was preoperatively calculated with a virtual surgical cut. Liver function tests and creatinine levels were recorded on the 30th postoperative day. In addition, the onset of postoperative complications occurring within 90 days of surgery was analyzed, and the complications were codified according to the 5 tiers of the Clavien-Dindo classification. In 26 of the 70 patients (37.14%), 100% or greater hepatic regeneration had occurred at 2 months. There was no association between the clinical outcome and the liver regeneration rate. A stepwise multiple regression analysis showed that a higher BMI (coefficient = 0.035, P < 0.0001) and preoperative parameters such as a smaller FRLV (coefficient = -0.002, P < 0.0001) and a greater SV/FRLV ratio (coefficient = 1.196, P < 0.0001) were predictors of greater liver regeneration.

Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases

AIM

In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma.

PATIENTS AND METHODS

Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE.

RESULTS

The median FRV was higher in the patients with PVE, rising from 501 ml (range 309-703) to 636 ml (range 387-649), than those with PVL, rising from 510 ml (range 203-824) to 595 ml (range 313-1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21-65%) than those with PVL (median 30%; range 21-60%) (p < 0.05).

CONCLUSIONS

PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume.

"Inherent limitations" in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions

OBJECTIVE

The aim of this study was to identify "inherent limitations" in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT).

BACKGROUND

Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some "inherent limitations" in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve.

METHODS

To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien's system.

RESULTS

The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035).

CONCLUSIONS

Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent "inherent limitation" in healthy donors that makes them more vulnerable for postoperative complications.

What is a safe future liver remnant size in patients undergoing major hepatectomy for colorectal liver metastases and treated by intensive preoperative chemotherapy?

BACKGROUND

A multidisciplinary approach involving preoperative chemotherapy has become common practice in patients with colorectal liver metastases (CLM). The definition of a safe future liver remnant (FLR) volume based on preoperative clinical data in these patients is lacking. Our aim was to identify predictors of postoperative morbidities in patients undergoing major hepatectomy after intensive preoperative chemotherapy for CLM.

METHODS

Between January 2000 and August 2010, a total of 101 consecutive patients with CLM underwent major hepatectomy after preoperative chemotherapy (≥6 cycles of oxaliplatin or irinotecan regimen with or without targeted therapies). The FLR ratio was calculated by two formulas: actual FLR (aFLR) ratio, and standardized FLR (sFLR) ratio. Predictors of postoperative overall morbidity, sepsis, and liver failure were identified by univariate and multivariate analyses.

RESULTS

Fifty-eight patients (57.4%) had 95 postoperative complications. Sepsis and postoperative liver failure occurred in 23 (22.8%) and 16 patients (15.8%), respectively. On univariate analysis, small aFLR ratio was significantly associated with all complications, and sFLR ratio was associated with sepsis and liver failure. In receiver-operating characteristic analysis, the cutoff of aFLR ratio in predicting overall morbidity, sepsis, and liver failure was 44.8, 43.1, and 37.7%, respectively, and that of sFLR ratio in predicting sepsis and liver failure was 43.6 and 48.5%, respectively. On multivariate analysis, these aFLR and sFLR ratio cutoffs were independent predictors of all complications and of sepsis and liver failure, respectively.

CONCLUSIONS

This study provides a cutoff FLR ratio for safe postoperative outcome after major hepatectomy in CLM patients receiving six or more cycles of preoperative chemotherapy.

Liver Transplantation for HCC: A Review

Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease or cirrhosis. Liver transplantation for hepatocellular carcinoma has the potential to eliminate both the tumor as well as the underlying cirrhosis and is the ideal treatment for HCC in cirrhotic liver as well as massive HCC in noncirrhotic liver. Limitations in organ availability, necessitate stringent selection of patients who would likely to derive most benefit. Selection criteria have considered tumor size, number, volume as well as biological features. The Milan criteria set the benchmark for tumors that would benefit from liver transplantation but were found to be excessively restrictive. Modest expansion in criteria has also been shown to be associated with equivalent survival. Microvascular invasion is the single most important adverse prognostic factor for survival. Living donor liver transplantation has expanded donor options and has the advantage of lower waiting period and not impacting the non-HCC waiting list. Acceptable outcomes have been obtained with living donor liver transplantation for larger and more numerous tumors in the absence of microvascular invasion. Downstaging of tumors to prevent progression while waiting for an organ or for reduction in size to allow enrolment for transplantation has met with variable success.

Safety and efficacy of preoperative right portal vein embolization in patients at risk for postoperative liver failure following major right hepatectomy

BACKGROUND

Right portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis.

METHODS

Records of patients who underwent RPVE during 2006-2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported.

RESULTS

A total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE.

CONCLUSIONS

Right portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.

Metabolic syndrome and hepatic resection: improving outcome

OBJECTIVE

A review of the peri-operative risk associated with hepatic resection in patients with metabolic syndrome (MetS) and identification of measures for the improvement of cardiometabolic disturbances and liver-related mortality.

BACKGROUND

MetS and its hepatic manifestation non-alcoholic fatty liver disease (NAFLD) are associated with an increased operative mortality in spite of a significant improvement in peri-operative outcome after hepatic resection.

METHODS

A review of the English literature on MetS, liver resection and steatosis was performed from 1980 to 2011 using the MEDLINE and PubMed databases.

RESULTS

MetS is a predictor of NAFLD and patients with multiple metabolic risk factors may harbour non-alcoholic steatohepatitis (NASH) predictive of operative and cardiovascular mortality. Pre-operative diagnosis of unsuspected NASH with the selective use of a liver biopsy can modify the operative strategy by limiting the extent of hepatic resection, avoiding or altering the pre-operative chemotherapy regimen and the utilization of portal vein embolization. Thiazolidinediones are therapeutic for MetS and NASH and Vitamin E for active NASH; however, their utility in improving the peri-operative outcome after hepatic resection is unknown. A short-term regimen for weight loss improves post-operative patient and liver-related outcomes in patients with >30% steatosis. Cardiovascular disease associated with MetS or NAFLD should be managed aggressively. Peri-operative measures to minimize thrombotic events and acute renal injury secondary to the pro-inflammatory, prothrombotic state of MetS may further improve the outcome.

CONCLUSION

Potential candidates for hepatic resection should be screened for MetS as the pre-operative identification of NASH, short-term treatment of significant steatosis, cardiovascular risk assessment and optimization of each component of MetS may improve the peri-operative outcome in this high-risk subset of patients.

Issues in surgery for hilar cholangiocarcinoma

Hilar cholangiocarcinoma provides a surgical challenge. Successful outcome depends upon preoperative imaging, appropriate use of biliary drainage and portal vein embolisation as well as appropriate liver resection with caudate lobe excision and nodal clearance.

Nutritional aspects in patient undergoing liver resection

In the past two decades, hepatic surgery has achieved important technical breakthroughs resulting in a drastic reduction of the onset of complications and in an improved post-resective survival. Pre-operative nutritional status is one of the key points for the success of a liver resection. Modern surgical achievement such as the development of living-related liver donation, and the possibility to perform more laparoscopic liver resection gave us the opportunity to extend post-operative protocol focused on early intestinal feeding to tumor patients. The aims of this review were to report the current status of the knowledge regarding nutritional aspects in liver resection patients.

The management of solitary colorectal liver metastases

Surgical resection of solitary colorectal liver metastases is associated with long-term survival. Radiofrequency ablation used as the primary treatment option of solitary resectable colorectal liver metastases is associated with an increased risk of local recurrence that generally leads to worse survival compared to resection. In contrast with treatment of other hepatic malignancies, radiofrequency ablation is not equivalent to resection for colorectal liver metastases and should not be used as an alternative but limited to inoperable patients. Although overall survival rate after resection can be up to 71% at 5 years, the majority of patients develop recurrence. Preoperative chemotherapy contributes to decrease the risk of recurrence after resection of colorectal liver metastases. In patients with advanced solitary colorectal liver metastasis initially non suitable for resection, chemotherapy and portal vein embolization contribute to increase the number of surgical candidates whereas radiofrequency is rarely an option.

Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion

OBJECTIVES

Defining perioperative mortality as death that occurs within 30 days of surgery may underestimate 'true' mortality among patients undergoing hepatic resection. To better define perioperative mortality, trends in the risk for death during the first 90 days after hepatectomy were assessed.

METHODS

Surveillance, Epidemiology and End Results (SEER) Medicare data were used to identify 2597 patients who underwent hepatic resection during 1991-2006. Data on their clinicopathological characteristics, surgical management and perioperative mortality were collected and survival was assessed at 30, 60 and 90 days post-surgery.

RESULTS

Overall, 5.7% of patients died within the first 30 days. Postoperative mortality at 60 and 90 days were 8.3% and 10.1%. In-hospital mortality after hepatic resection was greater among patients with hepatocellular carcinoma (HCC) than among those with colorectal liver metastases (CRLM) (8.9% and 3.8%, respectively; P < 0.001). In CRLM patients, mortality increased from 4.3% at 30 days to 8.4% at 90 days, whereas mortality in HCC patients increased from 9.7% at 30 days to 15.0% at 90 days (both P < 0.05). Patients with HCC were twice as likely as CRLM patients to die within 30 days [odds ratio (OR) 2.03], 60 days (OR = 1.74) and 90 days (OR = 1.71) (all P < 0.001). Differences in 30- and 90-day mortality were greatest among HCC patients undergoing major hepatic resection (P < 0.05).

CONCLUSIONS

Reporting deaths that occur within a maximum of 30 days of surgery underestimates the mortality associated with hepatic resection. Traditional 30-day definitions of mortality are misleading and surgeons should report all perioperative outcomes that occur within 90 days of hepatic resection.

Prospective volumetric assessment of the liver on a personal computer by nonradiologists prior to partial hepatectomy

Background

A small remnant liver volume is an important risk factor for posthepatectomy liver failure. ImageJ and OsiriX^® are both free, open-source image processing software packages. The aim of the present study was to compare ImageJ and OsiriX^® in performing prospective computed tomography (CT) volumetric analysis of the liver on a personal computer (PC) in patients undergoing major liver resection.

Methods

Patients scheduled for a right hemihepatectomy were eligible for inclusion. Two surgeons and one surgical trainee measured volumes of total liver, tumor, and future resection specimen prospectively with ImageJ and OsiriX^®. A radiologist also measured these volumes with CT scanner-linked Aquarius iNtuition^® software. Resection volumes were compared with the actual weights of the liver specimens removed during surgery, and differences between the measured liver volumes were analyzed.

Results

A total of 15 patients (8 men, 7 women) with a median age of 63 years (48–79 years) were included. There was a significant correlation between the measured weights of resection specimens and the volumes calculated prospectively with ImageJ and OsiriX^® (r = 0.89; r = 0.83, respectively). There was also a significant correlation between the volumes measured with radiological software iNtuition^® and the volumes measured with ImageJ and OsiriX^® (r = 0.93; r = 0.95, respectively).

Conclusions

There were no major differences in total liver volumes, resection volumes, or tumour volumes for these three software packages. Prospective hepatic CT volumetry with ImageJ or OsiriX^® is reliable and can be accurately used on a PC by nonradiologists. ImageJ and OsiriX^® yield results comparable to the radiological software iNtuition^®.

Conventional Surgical Treatment of Hepatocellular Carcinoma

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