Liver resection in Cirrhotic liver: Are there any limits?

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Unveiling the power of microenvironment in liver regeneration: an in-depth overview

The liver serves as a vital regulatory hub for various physiological processes, including sugar, protein, and fat metabolism, coagulation regulation, immune system maintenance, hormone inactivation, urea metabolism, and water-electrolyte acid-base balance control. These functions rely on coordinated communication among different liver cell types, particularly within the liver's fundamental hepatic lobular structure. In the early stages of liver development, diverse liver cells differentiate from stem cells in a carefully orchestrated manner. Despite its susceptibility to damage, the liver possesses a remarkable regenerative capacity, with the hepatic lobule serving as a secure environment for cell division and proliferation during liver regeneration. This regenerative process depends on a complex microenvironment, involving liver resident cells, circulating cells, secreted cytokines, extracellular matrix, and biological forces. While hepatocytes proliferate under varying injury conditions, their sources may vary. It is well-established that hepatocytes with regenerative potential are distributed throughout the hepatic lobules. However, a comprehensive spatiotemporal model of liver regeneration remains elusive, despite recent advancements in genomics, lineage tracing, and microscopic imaging. This review summarizes the spatial distribution of cell gene expression within the regenerative microenvironment and its impact on liver regeneration patterns. It offers valuable insights into understanding the complex process of liver regeneration.

Medical Applications and Advancement of Near Infrared Photosensitive Indocyanine Green Molecules

Indocyanine green (ICG) is an important kind of near infrared (NIR) photosensitive molecules for PTT/PDT therapy as well as imaging. When exposed to NIR light, ICG can produce reactive oxygen species (ROS), which can kill cancer cells and pathogenic bacteria. Moreover, the absorbed light can also be converted into heat by ICG molecules to eliminate cancer cells. In addition, it performs exceptionally well in optical imaging-guided tumor therapy and antimicrobial therapy due to its deeper tissue penetration and low photobleaching properties in the near-infrared region compared to other dyes. In order to solve the problems of water and optical stability and multi-function problem of ICG molecules, composite nanomaterials based on ICG have been designed and widely used, especially in the fields of tumors and sterilization. So far, ICG molecules and their composite materials have become one of the most famous infrared sensitive materials. However, there have been no corresponding review articles focused on ICG molecules. In this review, the molecular structure and properties of ICG, composite material design, and near-infrared light- triggered anti-tumor, and antibacterial, and clinical applications are reviewed in detail, which of great significance for related research.

Vascular endothelial growth factor protein and gene delivery by novel nanomaterials for promoting liver regeneration after partial hepatectomy

Partial hepatectomy (PH) can lead to severe complications, including liver failure, due to the low regenerative capacity of the remaining liver, especially after extensive hepatectomy. Liver sinusoidal endothelial cells (LSECs), whose proliferation occurs more slowly and later than hepatocytes after PH, compose the lining of the hepatic sinusoids, which are the smallest blood vessels in the liver. Vascular endothelial growth factor (VEGF), secreted by hepatocytes, promotes LSEC proliferation. Supplementation of exogenous VEGF after hepatectomy also increases the number of LSECs in the remaining liver, thus promoting the reestablishment of the hepatic sinusoids and accelerating liver regeneration. At present, some shortcomings exist in the methods of supplementing exogenous VEGF, such as a low drug concentration in the liver and the reaching of other organs. More-over, VEGF should be administered multiple times and in large doses because of its short half-life. This review summarized the most recent findings on liver regeneration and new strategies for the localized delivery VEGF in the liver.

Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery.

BACKGROUND

Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery.

METHODS

Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis.

RESULTS

Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%].

CONCLUSION

IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.

Long-term outcomes of laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: A single-center 10-year experience

Background

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) has increased. However, the long-term outcomes of LLR for HCCs should be validated further. Besides, the validity of laparoscopic minor liver resection in difficult segments (1, 4a, 7, 8) (LMLR-DS) and laparoscopic major hepatectomy (LMH) for HCCs need to be studied.

Methods

A total of 1773 HCC patients were collected: 683 received LLR and 1090 received OLR. Propensity score matching (PSM) with 1:1 ratio was used to eliminate the selection bias. Short-term and long-term outcomes were compared. In subgroup analyses, the validity of LMLR-DS or LMH for HCCs was studied.

Results

After PSM, 567 patients were in LLR or OLR group. LLR had lower intraoperative blood-loss and shorter postoperative hospital-stays than OLR. The postoperative complications were lower in LLR group (23.8% vs. 32.8%, P=0.001). The Overall survival (OS) and disease-free survival (DFS) had no significant difference between LLR and OLR groups (P=0.973, P=0.812). The cumulative 1-, 3-, and 5-year OR rates were 87.9%, 68.9%, and 57.7% for LLR group, and 85.9%, 68.8%, 58.8% for OLR group. The cumulative 1-, 3-, and 5-year DFS rates were 73.0%, 51.5%, 40.6% for LLR group, and 70.3%, 49.0%, 42.4% for OLR group. In subgroup analyses, 178 patients were in LMLR-DS or open surgery (OMLR-DS) group after PSM. LMLR-DS had lower intraoperative blood-loss and shorter postoperative hospital-stays than OMLR-DS. The postoperative complications were lower in LMLR-DS group. The OS and DFS had no difference between LMLR-DS and OMLR-DS groups. The cumulative 5-year OR and DFS rates were 61.6%, 43.9% for LMLR-DS group, and 66.5%, 47.7% for OMLR-DS group. In another subgroup analyses, 115 patients were in LMH or open major hepatectomy (OMH) group. LMH had lower blood-loss and shorter postoperative hospital-stays than OMH. The complications, OS and DFS had no significantly differences between two groups. The cumulative 5-year OR and DFS rates were 44.3%, 29.9% for LMH group, and 44.7%, 33.2% for OMH group.

Conclusions

LLR for HCCs showed better short-term outcomes and comparable long-term outcomes with OLR, even for patients who received LMLR-DS or LMH. LLR could be reliable and recommended for HCC treatment.

A Mesenchymal-Epithelial Transition Factor-Agonistic Antibody Accelerates Cirrhotic Liver Regeneration and Improves Mouse Survival Following Partial Hepatectomy

Small-for-size syndrome (SFSS) is a common complication following partial liver transplantation and extended hepatectomy. SFSS is characterized by postoperative liver dysfunction caused by insufficient regenerative capacity and portal hyperperfusion and is more frequent in patients with preexisting liver disease. We explored the effect of the Mesenchymal-epithelial transition factor (MET)-agonistic antibody 71D6 on liver regeneration and functional recovery in a mouse model of SFSS. Male C57/BL6 mice were exposed to repeated carbon tetrachloride injections for 10 weeks and then randomized into 2 arms receiving 3 mg/kg 71D6 or a control immunoglobulin G (IgG). At 2 days after the randomization, the mice were subjected to 70% hepatectomy. Mouse survival was recorded up to 28 days after hepatectomy. Satellite animals were euthanized at different time points to analyze liver regeneration, fibrosis, and inflammation. Serum 71D6 administration significantly decreased mouse mortality consequent to insufficient regeneration of the cirrhotic liver. Analysis of liver specimens in satellite animals revealed that 71D6 promoted powerful activation of the extracellular signal-regulated kinase pathway and accelerated liver regeneration, characterized by increased liver-to-body weight, augmented mitotic index, and higher serum albumin levels. Moreover, 71D6 accelerated the resolution of hepatic fibrosis as measured by picrosirius red, desmin, and α-smooth muscle actin staining, and suppressed liver infiltration by macrophages as measured by CD68 and F4/80 staining. Analysis of gene expression by reverse-transcription polymerase chain reaction confirmed that 71D6 administration suppressed the expression of key profibrotic genes, including platelet-derived growth factor, tissue inhibitor of metalloproteinase 3, and transforming growth factor-β1, and of key proinflammatory genes, including tumor necrosis factor-α, interleukin-1β, chemokine (C-C motif) ligand 3, and chemokine (C-C motif) ligand 5. These results suggest that activating the MET pathway via an hepatocyte growth factor-mimetic antibody may be beneficial in patients with SFSS and possibly other types of acute and chronic liver disorders.

Impact of cirrhosis on long-term survival outcomes of patients with intrahepatic cholangiocarcinoma

BACKGROUND

The correlation between cirrhosis and the long-term oncological outcome in intrahepatic cholangiocarcinoma (ICC) is debatable, and this study aimed to explore the impact of cirrhosis on the long-term prognosis of patients with ICC.

METHODS

A total of 398 ICC patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2018. The diagnosis of cirrhosis was based on the Ishak fibrosis score provided by the SEER database. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analysis were performed to minimize the potential confounders. Overall survival (OS) and cancer-specific survival (CSS) were observed, and the Cox regression model was used to select potential factors that affect the prognosis of the patients with ICC.

RESULTS

Of the included patients, there were 142 patients and 256 patients in the cirrhotic and noncirrhotic groups, respectively. Additionally, 299 of 398 patients (75.1%) died following a median follow-up of 19 months (interquartile range [IQR], 7, 43). The OS and CSS indicated advantage trend in the noncirrhotic group than the cirrhotic group in either the original cohort (OS: 17 vs 12 months, p = 0.023; CSS: 26 vs 15 months, p = 0.004) or the PSM (OS: 17 vs 12 months, p = 0.52; CSS: 22 vs 14 months, p = 0.15) or IPTW (OS: 20 vs 13 months, p = 0.163; CSS: 22 vs 15 months, p = 0.059) cohorts. Subgroup analyses displayed that the prognosis of patients who experienced surgery for ICC in the noncirrhotic group was better than that of the cirrhotic group with regard to OS and CSS.

CONCLUSIONS

Collectively, it seems that the noncirrhotic patients have similar relative OS but better CSS compared with that of the cirrhotic patients.

Repeatability and reproducibility of deep-learning-based liver volume and Couinaud segment volume measurement tool

Purpose

Volumetric and health assessment of the liver is crucial to avoid poor post-operative outcomes following liver resection surgery. No current methods allow for concurrent and accurate measurement of both Couinaud segmental volumes for future liver remnant estimation and liver health using non-invasive imaging. In this study, we demonstrate the accuracy and precision of segmental volume measurements using new medical software, Hepatica™.

Methods

MRI scans from 48 volunteers from three previous studies were used in this analysis. Measurements obtained from Hepatica™ were compared with OsiriX. Time required per case with each software was also compared. The performance of technicians and experienced radiologists as well as the repeatability and reproducibility were compared using Bland–Altman plots and limits of agreement.

Results

High levels of agreement and lower inter-operator variability for liver volume measurements were shown between Hepatica™ and existing methods for liver volumetry (mean Dice score 0.947 ± 0.010). A high consistency between technicians and experienced radiologists using the device for volumetry was shown (± 3.5% of total liver volume) as well as low inter-observer and intra-observer variability. Tight limits of agreement were shown between repeated Couinaud segment volume (+ 3.4% of whole liver), segmental liver fibroinflammation and segmental liver fat measurements in the same participant on the same scanner and between different scanners. An underestimation of whole-liver volume was observed between three non-reference scanners.

Conclusion

Hepatica™ produces accurate and precise whole-liver and Couinaud segment volume and liver tissue characteristic measurements. Measurements are consistent between trained technicians and experienced radiologists.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03262-x.

Morbidity, Prognostic Factors, and Competing Risk Nomogram for Combined Hepatocellular-Cholangiocarcinoma

Background

Combined hepatocellular-cholangiocarcinoma (CHC) is a rare and heterogeneous histological subtype of primary liver cancer, which is still poorly understood. This study aimed to describe the epidemiological and clinical features, investigate the prognostic indicators, and develop a competing risk nomogram for CHC.

Methods

The study cohort was taken from the Surveillance, Epidemiology, and End Results database. The annual percent change (APC) in incidence was calculated using the joinpoint regression. The nomogram was developed based on multivariate competing risk survival analyses and validated by calibration curves. Akaike information criterion, Bayesian information criterion, Harrell's C-index, and area under the receiver operating characteristic curves were obtained to compare prognostic performance. Decision curve analysis was introduced to examine the clinical value of the models.

Results

The overall incidence of CHC was 0.062 per 100,000 individuals in 2004 and 0.081 per 100,000 individuals in 2018, with an APC of 1.0% (P > 0.05). CHC displayed intermediate clinicopathological features of hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Race, tumor size, vascular invasion, extrahepatic invasion, distant metastasis, grade, surgery, and Metavir stage were confirmed as the independent predictors of cancer-specific survival. The constructed nomogram was well calibrated, which showed better discrimination power and higher net benefits than the current American Joint Committee on Cancer staging system. Patients with liver transplantation had better survival than those with hepatectomy, especially patients within the Milan Criteria (P=0.022 and P=0.015). There was no survival difference between liver transplantation and hepatectomy in patients beyond the Milan Criteria (P=0.340).

Conclusion

The morbidity of CHC remained stable between 2004 and 2018. The constructed nomogram could predict the prognosis with good performance, which was meaningful to individual treatment strategies optimization. CHC patients should also be considered as potential liver transplantation recipients, especially those within the Milan Criteria, but the finding still needs more evidence to be further confirmed.

Outcome of major hepatectomy in cirrhotic patients; does surgical approach matter? A propensity score matched analysis

OBJECTIVE

Major hepatectomy in cirrhotic patients still represents a great challenge for liver surgeons. Hence, the aim in the present study is to investigate the clinical impact of major hepatectomy and to assess whether the surgical approach influences the outcome of cirrhotic patients.

METHODS

Multicenter retrospective study including cirrhotic patients undergoing major laparoscopic (mjLLR) and open liver resection (mjOLR) in 14 Western liver centers was performed (2009-2020). Clinical, demographic, and perioperative data were compared using propensity score matching (PSM). Long-term outcome after resection for hepatocellular carcinoma was analyzed.

RESULTS

Overall, 352 patients were included; 108 after mjLLR and 244 after mjOLR. After PSM, 88 patients were matched in each group. In the mjLLR group, compared to mjOLR, less blood loss (P = .042), lower overall and severe complication (P < .001, .020), such as surgical site infection, acute kidney injury and liver failure were observed, parallel to a shorter length of hospital stay. Stratifying patients based on the type of resection, less severe complications was observed only after laparoscopic left hepatectomy (P = .044), while the advantages of laparoscopy tend to decrease during right hepatectomy. Subgroup analysis of long-term survivals following liver resection for hepatocellular carcinoma showed no difference between mjLLR and mjOLR.

CONCLUSIONS

This multicenter experience suggests potential short-term benefits of mjLLR in cirrhotic patients compared to mjOLR, without compromising long-term outcome. These findings might have interesting clinical implications for the management of patients with chronic liver disease.

Does application of indocyanine green fluorescence imaging enhance clinical outcomes in liver resection? A meta-analysis

BACKGROUND

Indocyanine green fluorescence imaging technology has been widely used in liver resection. However, there has been a lack of strong evidence on whether application of indocyanine green fluorescence imaging enhances clinical outcomes in liver resection. This meta-analysis was performed to compare the latest clinical results of indocyanine green fluorescence imaging-guided hepatectomy (FIGH) and conventional hepatectomy (CH) in liver diseases.

METHODS

Relevant clinical studies were retrieved from PubMed, Embase, Cochrane Library, Medline and the Web of Science databases until June 21, 2021. Stata14.0 software was adopted in meta-analysis, in which the pooled effect size was calculated by the random-effects model or the fixed-effects model. Meta-regression and subgroup analysis were used to explore sources of heterogeneity. The publication bias was ascertained by egger's test and begg's test. The trim and fill method was used to adjust the occurrence of publication bias.

RESULTS

Overall twelve studies comprising 931 patients were included. Compared to the CH group, the FIGH group has lower complications (weighted mean difference [WMD] = 0.5238; 95% CI = 0.351-0.780; P = 0.001), shorter hospital stays (WMD = -1.857; 95% CI = -2.806--0.908; P = 0.000). Six of the studies indicated that no perioperative mortality occurred in either group. In overall analysis, there was no statistical difference in the estimated blood loss between the two groups (WMD = -42.509; 95% CI = -87.842 -2.825; P = 0.066), while in subgroup analysis of only literature from Japan or published between 2018 and 2019 years showed the consistent results above (WMD = 5.613; 95% CI = -45.101-56.328; P = 0.828. WMD = 5.582; 95% CI = -34.597-45.762; P = 0.785). No significant differences were found in operative time, blood transfusion rate, R0 resection, 1-year recurrence rate, 2-year-recurrence rate and the 1-year overall survival rate (P > 0.05).

CONCLUSION

This meta-analysis showed that during the liver resection operation, application of indocyanine green fluorescence imaging is a feasible and safe method in the treatment of liver diseases, which enhances some clinical outcomes, such as lower complications and shorter hospital stays.

[Living related liver transplantation]

Liver transplantation has become established as a standard procedure in the treatment of end-stage liver diseases. Despite intense efforts by all parties involved up to the amendment of the German Transplantation Act, the lack of suitable donor organs was still one of the limiting factors of this therapeutic procedure. One way out of this problem is to make so-called marginal organs usable, e.g. with the help of machine perfusion or by utilizing living liver donation, which are used in some countries for more than 90% of organ donations. In general, there is no difference in the indications for liver transplantation between a (partial) organ obtained by post-mortem or living donation. Before any living donation, a thorough evaluation of the donor is carried out in order to minimize postoperative morbidity as far as possible. Technically the partial liver donation is based on the oncological liver resection, while the partial liver transplantation is a further development of split liver transplantation after post-mortem liver donation. In specialized centers comparable or even better results can nowadays be achieved using living liver donation instead of post-mortem donation.