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Forton C, Sandoval V, Schwantes IR, Patel RK, Kolbeck KJ, Dewey EN, Korngold EK, Mayo SC. Clinician overconfidence in visual estimation of the posthepatectomy liver remnant volume: A proximal source of liver failure after major hepatic resection? Surgery 2024; 175:1533-1538. [PMID: 38519407 DOI: 10.1016/j.surg.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Post-hepatectomy liver failure is a source of morbidity and mortality after major hepatectomy and is related to the volume of the future liver remnant. The accuracy of a clinician's ability to visually estimate the future liver remnant without formal computed tomography liver volumetry is unknown. METHODS Twenty physicians in diagnostic radiology, interventional radiology, and hepatopancreatobiliary surgery reviewed 20 computed tomography scans of patients without underlying liver pathology who were not scheduled for liver resection. We evaluated clinician accuracy to estimate the future liver remnant for 3 hypothetical major hepatic resections: left hepatectomy, right hepatectomy, and right trisectionectomy. The percent-difference between the mean and actual computed tomography liver volumetry (mean percent difference) was tested along with specialty differences using mixed-effects regression analysis. RESULTS The actual future liver remnant (computed tomography liver volumetry) remaining after a hypothetical left hepatectomy ranged from 59% to 75% (physician estimated range: 50%-85%), 23% to 40% right hepatectomy (15%-50%), and 13% to 29% right trisectionectomy (8%-39%). For right hepatectomy, the mean future liver remnant was overestimated by 95% of clinicians with a mean percent difference of 22% (6%-45%; P < .001). For right trisectionectomy, 90% overestimated the future liver remnant by a mean percent difference of 25% (6%-50%; P < .001). Hepatopancreatobiliary surgeons overestimated the future liver remnant for proposed right hepatectomy and right trisectionectomy by a mean percent difference of 25% and 34%, respectively. Based on years of experience, providers with <10 years of experience had a greater mean percent difference than providers with 10+ years of experience for hypothetical major hepatic resections, but was only significantly higher for left hepatectomy (9% vs 6%, P = .002). CONCLUSION A clinician's ability to visually estimate the future liver remnant volume is inaccurate when compared to computed tomography liver volumetry. Clinicians tend to overestimate the future liver remnant volume, especially in patients with a small future liver remnant where the risk of posthepatectomy liver failure is greatest.
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Affiliation(s)
- Camelia Forton
- Department of Diagnostic Radiology, Oregon Heath & Science University (OHSU), Portland, OR. https://twitter.com/CamiForton
| | - Victor Sandoval
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, OHSU, Portland, OR
| | - Issac R Schwantes
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, OHSU, Portland, OR
| | - Ranish K Patel
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, OHSU, Portland, OR
| | - Kenneth J Kolbeck
- Department of Interventional Radiology, Dotter Institute, OHSU, Portland, OR; Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, OHSU, Portland, OR
| | | | - Elena K Korngold
- Department of Diagnostic Radiology, Oregon Heath & Science University (OHSU), Portland, OR
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, OHSU, Portland, OR.
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Rühlmann F, Azizian A, Moosmann C, Bernhardt M, Keck J, Flebbe H, Al-Bourini O, Hosseini ASA, Grade M, Lorf T, Ghadimi M, Perl T, Gaedcke J. Perioperative LiMAx Test Analysis: Impact of Portal Vein Embolisation, Chemotherapy and Major Liver Resection. Biomedicines 2024; 12:254. [PMID: 38397856 PMCID: PMC10886999 DOI: 10.3390/biomedicines12020254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/31/2023] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Postoperative liver failure (PLF) is a severe complication after major liver resection (MLR). To increase the safety of patients, clinical bedside tests are of great importance. However, limitations of their applicability and validity impair their value. METHODS Preoperative measurements of the liver maximum capacity (LiMAx) were performed in n = 40 patients, who underwent MLR (≥3 segments). Matched postoperative LiMAx was measured in n = 21 patients. Liver function was compared between pretreated patients (n = 11 with portal vein embolisation (PVE) and n = 19 patients with preoperative chemotherapy) and therapy naïve patients. The LiMAx values were compared with liver-specific blood parameters and volumetric analysis. RESULTS In total, n = 40 patients were enrolled in this study. The majority of patients (n = 33; 82.5%) had high preoperative LiMAx values (>315 µg/kg/h), while only seven patients (17.5%) had medium values (140-315 µg/kg/h), and none of the patients had low values (<140 µg/kg/h). A comparison of pretreated patients (with PVE and/or chemotherapy) and therapy naïve patients showed no significant difference in the preoperative LiMAx values (p > 0.05). The preoperative LiMAx values were significantly higher than the matched postoperative values on postoperative day 1 (p < 0.0001). A comparison between the expected and measured postoperative LiMAx showed a difference (≥10%) in 7 out of 13 patients (53.8%). After an initial postoperative decrease in the LiMAx, the patients without complications (n = 12) showed a continuous increase until 14 days after surgery. In the patients with postoperative complications, a decrease in the LiMAx was associated with a prolonged recovery. CONCLUSIONS For patients undergoing MLR within the 0.5% rule, which is the clinical gold standard, the LiMAx values do not offer any additional information. Additionally, the LiMAx may have reflected liver function, but it did not deliver additional information regarding postoperative liver recovery. The clinical use of LiMAx might be relevant in selected patients beyond the 0.5% rule.
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Affiliation(s)
- Felix Rühlmann
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Azadeh Azizian
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Christian Moosmann
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Markus Bernhardt
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Jan Keck
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Hannah Flebbe
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Omar Al-Bourini
- Institute for Diagnostic and Interventional Radiology, University Medical Centre Göttingen, D-37075 Göttingen, Germany (A.S.A.H.)
| | - Ali Seif Amir Hosseini
- Institute for Diagnostic and Interventional Radiology, University Medical Centre Göttingen, D-37075 Göttingen, Germany (A.S.A.H.)
| | - Marian Grade
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Thomas Lorf
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Thorsten Perl
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
| | - Jochen Gaedcke
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre, D-37075 Göttingen, Germany; (F.R.); (A.A.); (C.M.); (M.B.); (J.K.); (H.F.); (M.G.); (T.L.); (M.G.); (T.P.)
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Makridis G, Reese T, Zádori ZS, Suling AI, Stark M, Horling K, Brüning R, Schneider MA, Beumer M, Oldhafer KJ. Is an intraoperative liver function assessment possible? Application of the 13C-methacetin-breath-test during major liver resections - a pilot study. HPB (Oxford) 2024; 26:91-101. [PMID: 37806830 DOI: 10.1016/j.hpb.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND As prevention of posthepatectomy-liver-failure is crucial, there is need of dynamic assessment of liver function, even intraoperatively. 13C-methacetin-breath-test estimates the organ's microsomal functional capacity. This is its first intraoperative evaluation in major liver surgery. METHODS 30 patients planed for resection of ≥3 liver segments, between March-November 2019, were prospectively enrolled in this "single-center", pilot study. Using the 13C-methacetin-breath-test, liver function was assessed four times: preoperatively, intraoperatively before and after resection and postoperatively. The resulted maximum-liver-function-capacity (LiMAx)-values and delta-over-baseline (DOB)-curves were compared, further analyzed and correlated to respective liver volumes. RESULTS The intraoperative LiMAx-values before resection were mostly lower than the preoperative ones (-11.3% ± 28%). The intraoperative measurements after resection resulted to mostly higher values than the postoperative ones (42.35% ± 46.19%). Pharmacokinetically, an interference between the two intraoperative tests was observed. There was no strong correlation between residual liver volume and function with a percentual residual-LiMAx mostly lower than the percentual residual volume (-17.7% ± 4.1%). CONCLUSIONS Intraoperative application of the 13C-methacetin-breath-test during major liver resections seems to deliver lower values than the standard preoperative test. As multiple intraoperative tests interfere significantly to each other, a single intraoperative measurement is suggested. Multicentric standardized measurements could define the "normal" range for intraoperative measurements and control their predictive value.
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Affiliation(s)
- Georgios Makridis
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Department of General and Visceral Surgery, St. Josef's-Hospital Wiesbaden, Wiesbaden, Germany; Semmelweis University, Asklepios Campus Hamburg, Hamburg, Germany
| | - Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University, Asklepios Campus Hamburg, Hamburg, Germany
| | - Zoltán S Zádori
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Anna I Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Stark
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katja Horling
- Institute for Hematopathology Hamburg, Hamburg, Germany
| | - Roland Brüning
- Semmelweis University, Asklepios Campus Hamburg, Hamburg, Germany; Department of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Martin A Schneider
- Semmelweis University, Asklepios Campus Hamburg, Hamburg, Germany; Department of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Michael Beumer
- Department of Anaesthesiology and Surgical Intensive Care, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University, Asklepios Campus Hamburg, Hamburg, Germany.
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Machry M, Ferreira LF, Lucchese AM, Kalil AN, Feier FH. Liver volumetric and anatomic assessment in living donor liver transplantation: The role of modern imaging and artificial intelligence. World J Transplant 2023; 13:290-298. [PMID: 38174151 PMCID: PMC10758682 DOI: 10.5500/wjt.v13.i6.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/17/2023] [Accepted: 10/17/2023] [Indexed: 12/15/2023] Open
Abstract
The shortage of deceased donor organs has prompted the development of alternative liver grafts for transplantation. Living-donor liver transplantation (LDLT) has emerged as a viable option, expanding the donor pool and enabling timely transplantation with favorable graft function and improved long-term outcomes. An accurate evaluation of the donor liver's volumetry (LV) and anatomical study is crucial to ensure adequate future liver remnant, graft volume and precise liver resection. Thus, ensuring donor safety and an appropriate graft-to-recipient weight ratio. Manual LV (MLV) using computed tomography has traditionally been considered the gold standard for assessing liver volume. However, the method has been limited by cost, subjectivity, and variability. Automated LV techniques employing advanced segmentation algorithms offer improved reproducibility, reduced variability, and enhanced efficiency compared to manual measurements. However, the accuracy of automated LV requires further investigation. The study provides a comprehensive review of traditional and emerging LV methods, including semi-automated image processing, automated LV techniques, and machine learning-based approaches. Additionally, the study discusses the respective strengths and weaknesses of each of the aforementioned techniques. The use of artificial intelligence (AI) technologies, including machine learning and deep learning, is expected to become a routine part of surgical planning in the near future. The implementation of AI is expected to enable faster and more accurate image study interpretations, improve workflow efficiency, and enhance the safety, speed, and cost-effectiveness of the procedures. Accurate preoperative assessment of the liver plays a crucial role in ensuring safe donor selection and improved outcomes in LDLT. MLV has inherent limitations that have led to the adoption of semi-automated and automated software solutions. Moreover, AI has tremendous potential for LV and segmentation; however, its widespread use is hindered by cost and availability. Therefore, the integration of multiple specialties is necessary to embrace technology and explore its possibilities, ranging from patient counseling to intraoperative decision-making through automation and AI.
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Affiliation(s)
- Mayara Machry
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Luis Fernando Ferreira
- Postgraduation Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Angelica Maria Lucchese
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Antonio Nocchi Kalil
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
- Postgraduation Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Flavia Heinz Feier
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
- Postgraduation Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
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Bekheit M, Grundy L, Salih AK, Bucur P, Vibert E, Ghazanfar M. Post-hepatectomy liver failure: A timeline centered review. Hepatobiliary Pancreat Dis Int 2023; 22:554-569. [PMID: 36973111 DOI: 10.1016/j.hbpd.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. DATA SOURCES This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. RESULTS This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. CONCLUSIONS Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
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Affiliation(s)
- Mohamed Bekheit
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Hépatica, Integrated Center of HPB Care, Elite Hospital, Agriculture Road, Alexandria, Egypt.
| | - Lisa Grundy
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Ahmed Ka Salih
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Petru Bucur
- Department of Surgery, University Hospital Tours, Val de la Loire 37000, France
| | - Eric Vibert
- Centre Hépatobiliaire, Paul Brousse Hospital, 12 Paul Valliant Couturier, 94804 Villejuif, France
| | - Mudassar Ghazanfar
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
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Horkaew P, Chansangrat J, Keeratibharat N, Le DC. Recent advances in computerized imaging and its vital roles in liver disease diagnosis, preoperative planning, and interventional liver surgery: A review. World J Gastrointest Surg 2023; 15:2382-2397. [PMID: 38111769 PMCID: PMC10725533 DOI: 10.4240/wjgs.v15.i11.2382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/30/2023] [Accepted: 09/27/2023] [Indexed: 11/26/2023] Open
Abstract
The earliest and most accurate detection of the pathological manifestations of hepatic diseases ensures effective treatments and thus positive prognostic outcomes. In clinical settings, screening and determining the extent of a pathology are prominent factors in preparing remedial agents and administering appropriate therapeutic procedures. Moreover, in a patient undergoing liver resection, a realistic preoperative simulation of the subject-specific anatomy and physiology also plays a vital part in conducting initial assessments, making surgical decisions during the procedure, and anticipating postoperative results. Conventionally, various medical imaging modalities, e.g., computed tomography, magnetic resonance imaging, and positron emission tomography, have been employed to assist in these tasks. In fact, several standardized procedures, such as lesion detection and liver segmentation, are also incorporated into prominent commercial software packages. Thus far, most integrated software as a medical device typically involves tedious interactions from the physician, such as manual delineation and empirical adjustments, as per a given patient. With the rapid progress in digital health approaches, especially medical image analysis, a wide range of computer algorithms have been proposed to facilitate those procedures. They include pattern recognition of a liver, its periphery, and lesion, as well as pre- and postoperative simulations. Prior to clinical adoption, however, software must conform to regulatory requirements set by the governing agency, for instance, valid clinical association and analytical and clinical validation. Therefore, this paper provides a detailed account and discussion of the state-of-the-art methods for liver image analyses, visualization, and simulation in the literature. Emphasis is placed upon their concepts, algorithmic classifications, merits, limitations, clinical considerations, and future research trends.
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Affiliation(s)
- Paramate Horkaew
- School of Computer Engineering, Suranaree University of Technology, Nakhon Ratchasima 30000, Thailand
| | - Jirapa Chansangrat
- School of Radiology, Institute of Medicine, Suranaree University of Technology, Nakhon Ratchasima 30000, Thailand
| | - Nattawut Keeratibharat
- School of Surgery, Institute of Medicine, Suranaree University of Technology, Nakhon Ratchasima 30000, Thailand
| | - Doan Cong Le
- Faculty of Information Technology, An Giang University, Vietnam National University (Ho Chi Minh City), An Giang 90000, Vietnam
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Kalshabay Y, Zholdybay Z, Di Martino M, Medeubekov U, Baiguissova D, Ainakulova A, Doskhanov M, Baimakhanov B. CT volume analysis in living donor liver transplantation: accuracy of three different approaches. Insights Imaging 2023; 14:82. [PMID: 37184628 DOI: 10.1186/s13244-023-01431-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES The aim of this retrospective study is to compare and evaluate accuracy of three different approaches of liver volume quantification in living donor transplantations. METHODS This is a single-center, retrospective study of 60 donors. The total and right lobe liver volumes were analyzed in the portal-venous phase by two independent radiologists who estimated the volumes using manual, semi-automated and automated segmentation methods. The measured right lobe liver volume was compared to the real weight of the graft after back-table examinations. RESULTS The mean estimated overall liver volume was 1164.4 ± 137.0 mL for manual, 1277.4 ± 190.4 mL for semi-automated and 1240.1 ± 108.5 mL for automated segmentation. The mean estimated right lobe volume was 762.0 ± 122.4 mL for manual, 792.9 ± 139.9 mL for semi-automated and 765.4 ± 132.7 mL for automated segmentation. The mean graft weight was 711.2 ± 142.9 g. The manual method better correlated with the graft weight (r = 0.730) in comparison with the semi-automated (r = 0.685) and the automated (r = 0.699) methods (p < 0.001). The mean error ratio in volume estimation by each application was 12.7 ± 16.6% for manual, 17.1 ± 17.3% for semi-automated, 14.7 ± 16.8% for automated methods. There was a statistically significant difference between the mean error ratio of the manual and the semi-automated segmentations (p = 0.017), and no statistically significant difference between the manual and the automated applications (p = 0.199). CONCLUSION Volume analysis application better correlates with graft weight, but there is no obvious difference between correlation coefficients of all three methods. All three modalities had an error ratio, of which the semi-automated method showed the highest value. CRITICAL RELEVANCE STATEMENT Volume analysis application was more accurate, but there is no drastic difference between correlation coefficients of all three methods.
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Affiliation(s)
- Yerkezhan Kalshabay
- Kazakh National Medical University Named After S.D. Asfendiyarov, Almaty, Republic of Kazakhstan.
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan.
| | - Zhamilya Zholdybay
- Kazakh National Medical University Named After S.D. Asfendiyarov, Almaty, Republic of Kazakhstan
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan
| | - Michele Di Martino
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ulykbek Medeubekov
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan
| | - Dinara Baiguissova
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan
| | - Akmaral Ainakulova
- Kazakh National Medical University Named After S.D. Asfendiyarov, Almaty, Republic of Kazakhstan
| | - Maksat Doskhanov
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan
| | - Bolatbek Baimakhanov
- National Scientific Center of Surgery Named After A.N. Syzganov, 51 Zheltoksan Street, A05F0D2, Almaty, Republic of Kazakhstan
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Huang J, Long H, Peng J, Zhong X, Shi Y, Xie X, Kuang M, Lin M. Predicting Post-hepatectomy Liver Failure Preoperatively for Child-Pugh A5 Hepatocellular Carcinoma Patients by Liver Stiffness. J Gastrointest Surg 2023:10.1007/s11605-023-05635-7. [PMID: 36977863 DOI: 10.1007/s11605-023-05635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/18/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) represents the major source of mortality after liver resection (LR) in hepatocellular carcinoma (HCC) patients. Child-Pugh (CP) score 5 is always considered to indicate a normal liver function but represents a heterogeneous population with a considerable number suffering from PHLF. The present study aimed to access the ability of liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) to predict PHLF in HCC patients with a CP score of 5. METHODS From August 2018 to May 2021, 146 HCC patients with a CP score of 5 who underwent LR were reviewed. The patients were randomly divided into training (n = 97) and validation (n = 49) groups. Logistic analyses were conducted for the risk factors and a linear model was built to predict the development of PHLF. The discrimination and calibration were assessed in the training and validation cohorts by the areas under the receiver operating characteristic curve (AUC). RESULTS Analyses revealed that the minimum of LS (Emin) higher than 8.05 (p = 0.006, OR = 4.59) and future liver remnant / estimated total liver volume (FLR/eTLV) (p < 0.001, OR < 0.01) were independent predictors of PHLF in HCC patients with CP score 5, and the AUC calculated by the model based on them for differentiation of PHLF in the training and validation group was 0.78 and 0.76, respectively. CONCLUSION LS was associated with the development of PHLF. A model combining Emin and FLR/eTLV showed proper ability in predicting PHLF in HCC patients with a CP score of 5.
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Affiliation(s)
- Jiayao Huang
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Haiyi Long
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Jianyun Peng
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Xian Zhong
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Yifan Shi
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Xiaoyan Xie
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Ming Kuang
- Department of Liver Surgery, Sun Yat-Sen University First Affiliated Hospital, Guangdong, China
| | - Manxia Lin
- Department of Medical Ultrasonics, Sun Yat-Sen University First Affiliated Hospital, No. 58, Zhongshan Road II, Yuexiu District, Guangzhou, 510080, Guangdong, China.
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9
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Cayot B, Milot L, Nempont O, Vlachomitrou AS, Langlois-Jacques C, Dumortier J, Boillot O, Arnaud K, Barten TRM, Drenth JPH, Valette PJ. Polycystic liver: automatic segmentation using deep learning on CT is faster and as accurate compared to manual segmentation. Eur Radiol 2022; 32:4780-4790. [PMID: 35142898 DOI: 10.1007/s00330-022-08549-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to develop and investigate the performance of a deep learning model based on a convolutional neural network (CNN) for the automatic segmentation of polycystic livers at CT imaging. METHOD This retrospective study used CT images of polycystic livers. To develop the CNN, supervised training and validation phases were performed using 190 CT series. To assess performance, the test phase was performed using 41 CT series. Manual segmentation by an expert radiologist (Rad1a) served as reference for all comparisons. Intra-observer variability was determined by the same reader after 12 weeks (Rad1b), and inter-observer variability by a second reader (Rad2). The Dice similarity coefficient (DSC) evaluated overlap between segmentations. CNN performance was assessed using the concordance correlation coefficient (CCC) and the two-by-two difference between the CCCs; their confidence interval was estimated with bootstrap and Bland-Altman analyses. Liver segmentation time was automatically recorded for each method. RESULTS A total of 231 series from 129 CT examinations on 88 consecutive patients were collected. For the CNN, the DSC was 0.95 ± 0.03 and volume analyses yielded a CCC of 0.995 compared with reference. No statistical difference was observed in the CCC between CNN automatic segmentation and manual segmentations performed to evaluate inter-observer and intra-observer variability. While manual segmentation required 22.4 ± 10.4 min, central and graphics processing units took an average of 5.0 ± 2.1 s and 2.0 ± 1.4 s, respectively. CONCLUSION Compared with manual segmentation, automated segmentation of polycystic livers using a deep learning method achieved much faster segmentation with similar performance. KEY POINTS • Automatic volumetry of polycystic livers using artificial intelligence method allows much faster segmentation than expert manual segmentation with similar performance. • No statistical difference was observed between automatic segmentation, inter-observer variability, or intra-observer variability.
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Affiliation(s)
- Bénédicte Cayot
- Department of Medical Imaging, Hospices Civils de Lyon, University of Lyon, Lyon, France. .,Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.
| | - Laurent Milot
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Department of Medical Imaging, Edouard Herriot Hospital, Civil Hospices of Lyon, University of Lyon, Lyon, France
| | - Olivier Nempont
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Philips France, 33 rue de Verdun, CS 60 055, Cedex 92156, Suresnes, France
| | - Anna S Vlachomitrou
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Philips France, 33 rue de Verdun, CS 60 055, Cedex 92156, Suresnes, France
| | - Carole Langlois-Jacques
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Unit of Biostatistics, Civil Hospices of Lyon, Lyon ,CNRS UMR5558, Laboratory of Biometry and Evolutionary Biology, Biostatistics-Health Team, Lyon, France
| | - Jérôme Dumortier
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Department of Hepatology and Gastroenterology, Civil Hospices of Lyon, Edouard Herriot Hospital, Federation of Digestive Specialties, University of Lyon, Lyon, France.,University of Lyon, Lyon, France
| | - Olivier Boillot
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,University of Lyon, Lyon, France.,Department of Hepatobiliary-Pancreatic Surgery and Hepatology, Civil Hospices of Lyon, Edouard Herriot Hospital, University of Lyon, Lyon, France
| | - Karine Arnaud
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Edouard Herriot Hospital, Civil Hospices of Lyon, Lyon, France
| | - Thijs R M Barten
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost P H Drenth
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pierre-Jean Valette
- Service d'imagerie médicale et interventionnelle, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Department of Medical Imaging, Edouard Herriot Hospital, Civil Hospices of Lyon, University of Lyon, Lyon, France
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10
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Joshi K, Nutu A, Wilson M, Marudanayagam R, Isaac J, Sutcliffe RP, Dasari BVM. Comparative Volumetric Analysis of Hermes and Synapse Software Systems in the Setting of Liver Surgery. J Gastrointest Surg 2022; 26:2588-2590. [PMID: 35831691 PMCID: PMC9674751 DOI: 10.1007/s11605-022-05407-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/11/2022] [Indexed: 01/31/2023]
Affiliation(s)
- K Joshi
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - A Nutu
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - M Wilson
- Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - R Marudanayagam
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - J Isaac
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - R P Sutcliffe
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - B V M Dasari
- The HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK.
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11
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Hadjittofi C, Feretis M, Martin J, Harper S, Huguet E. Liver regeneration biology: Implications for liver tumour therapies. World J Clin Oncol 2021; 12:1101-1156. [PMID: 35070734 PMCID: PMC8716989 DOI: 10.5306/wjco.v12.i12.1101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/22/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
The liver has remarkable regenerative potential, with the capacity to regenerate after 75% hepatectomy in humans and up to 90% hepatectomy in some rodent models, enabling it to meet the challenge of diverse injury types, including physical trauma, infection, inflammatory processes, direct toxicity, and immunological insults. Current understanding of liver regeneration is based largely on animal research, historically in large animals, and more recently in rodents and zebrafish, which provide powerful genetic manipulation experimental tools. Whilst immensely valuable, these models have limitations in extrapolation to the human situation. In vitro models have evolved from 2-dimensional culture to complex 3 dimensional organoids, but also have shortcomings in replicating the complex hepatic micro-anatomical and physiological milieu. The process of liver regeneration is only partially understood and characterized by layers of complexity. Liver regeneration is triggered and controlled by a multitude of mitogens acting in autocrine, paracrine, and endocrine ways, with much redundancy and cross-talk between biochemical pathways. The regenerative response is variable, involving both hypertrophy and true proliferative hyperplasia, which is itself variable, including both cellular phenotypic fidelity and cellular trans-differentiation, according to the type of injury. Complex interactions occur between parenchymal and non-parenchymal cells, and regeneration is affected by the status of the liver parenchyma, with differences between healthy and diseased liver. Finally, the process of termination of liver regeneration is even less well understood than its triggers. The complexity of liver regeneration biology combined with limited understanding has restricted specific clinical interventions to enhance liver regeneration. Moreover, manipulating the fundamental biochemical pathways involved would require cautious assessment, for fear of unintended consequences. Nevertheless, current knowledge provides guiding principles for strategies to optimise liver regeneration potential.
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Affiliation(s)
- Christopher Hadjittofi
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Michael Feretis
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Jack Martin
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Simon Harper
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Emmanuel Huguet
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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12
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Dasari BVM, Wilson M, Pufal K, Kadam P, Hodson J, Roberts KJ, Chatzizacharias N, Marudanayagam R, Gadvi R, Sutcliffe RP, Mirza DF, Muiesan P, Isaac J. Variations between the anatomical and functional distribution, based on 99 m technetium -mebrofinate SPECT-CT scan, in patients at risk of post hepatectomy liver failure. HPB (Oxford) 2021; 23:1807-1814. [PMID: 33975803 DOI: 10.1016/j.hpb.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of the current study is to investigate the variations of anatomical (LVRem%) and functional remnant volumes (fLVRem%) and the dynamic uptake of Technetium-Mebrofinate (FRLF) measured from 99m Technetium-Mebrofinate SPECT-CT scan (TMSCT) in patients at high risk of post-hepatectomy liver failure (PHLF). METHODS Variations in the measures of LVRem% and fLVRem% were assessed. The predictive accuracies of LVRem%, fLVRem% and FRLF with respect to PHLF were reported. RESULTS From the N = 92 scans performed, LVRem% and fLVRem% returned identical results in 15% of cases, and ±10 percentage points in 79% of cases. Some patients had larger discrepancies, with difference of >10 percentage points in 21% of cases. The difference was significant in those with primary liver cancers (-4.4 ± 9.2, p = 0.002). For the N = 29 patients that underwent surgery as planned on TMSCT, FRLF was a strong predictor of PHLF, with an AUROC of 0.83 (p = 0.005). CONCLUSION TMSCT is emerging as a useful modality in pre-operative assessment of patients undergoing major liver resection. For those with primary liver cancer, there is a significant variation in the anatomical and functional distributions that needs considered in surgical planning. Reduced FRLF, measured as the dynamic uptake in the future liver remnant, is a strong predictor of PHLF.
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Affiliation(s)
- Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom.
| | - Michael Wilson
- Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Kamil Pufal
- University of Birmingham, B15 2TT, United Kingdom
| | - Prashant Kadam
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, B15 2TH, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Nikolaos Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Rakesh Gadvi
- Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Robert P Sutcliffe
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Darius F Mirza
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - Paolo Muiesan
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
| | - John Isaac
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, B15 2WB, United Kingdom
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13
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Chansangrat J, Keeratibharat N. Portal vein embolization: rationale, techniques, outcomes and novel strategies. Hepat Oncol 2021; 8:HEP42. [PMID: 34765107 PMCID: PMC8577518 DOI: 10.2217/hep-2021-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/08/2021] [Indexed: 12/14/2022] Open
Abstract
The incidence of liver cancer has grown in the past decade, with 905,677 new cases and 830,180 deaths in 2020. According to the highest annual fatality ratio, liver cancer is the third-leading cause of cancer-related deaths worldwide. Surgical resection is the mainstay treatment for long-term survival. However, only 25% of patients are surgical candidates. Recent surgical concepts, techniques and multidisciplinary management were developed, including interventional radiology procedures that improve the management algorithm, expand the indications and limit dropouts from curative treatment. This review summarizes up-to-date information on interventional radiology in the management of liver tumors.
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Affiliation(s)
- Jirapa Chansangrat
- School of Radiology, Institute of Medicine, Suranaree University of Technology, 30000, Thailand
| | - Nattawut Keeratibharat
- School of Surgery, Institute of Medicine, Suranaree University of Technology, 30000, Thailand
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14
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Benson AB, D'Angelica MI, Abbott DE, Anaya DA, Anders R, Are C, Bachini M, Borad M, Brown D, Burgoyne A, Chahal P, Chang DT, Cloyd J, Covey AM, Glazer ES, Goyal L, Hawkins WG, Iyer R, Jacob R, Kelley RK, Kim R, Levine M, Palta M, Park JO, Raman S, Reddy S, Sahai V, Schefter T, Singh G, Stein S, Vauthey JN, Venook AP, Yopp A, McMillian NR, Hochstetler C, Darlow SD. Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:541-565. [PMID: 34030131 DOI: 10.6004/jnccn.2021.0022] [Citation(s) in RCA: 404] [Impact Index Per Article: 134.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.
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Affiliation(s)
- Al B Benson
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Robert Anders
- 5The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | - Prabhleen Chahal
- 11Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Jordan Cloyd
- 13The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Evan S Glazer
- 14St. Jude Children's Research HospitalThe University of Tennessee Health Science Center
| | | | - William G Hawkins
- 16Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - R Kate Kelley
- 19UCSF Helen Diller Family Comprehensive Cancer Center
| | - Robin Kim
- 20Huntsman Cancer Institute at the University of Utah
| | - Matthew Levine
- 21Abramson Cancer Center at the University of Pennsylvania
| | | | - James O Park
- 23Fred Hutchinson Cancer Research CenterSeattle Cancer Care Alliance
| | | | | | | | | | | | | | | | - Alan P Venook
- 19UCSF Helen Diller Family Comprehensive Cancer Center
| | - Adam Yopp
- 31UT Southwestern Simmons Comprehensive Cancer Center; and
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15
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Guiu B, Deshayes E, Panaro F, Sanglier F, Cusumano C, Herrerro A, Sgarbura O, Molinari N, Quenet F, Cassinotto C. 99mTc-mebrofenin hepatobiliary scintigraphy and volume metrics before liver preparation: correlations and discrepancies in non-cirrhotic patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:795. [PMID: 34268408 PMCID: PMC8246210 DOI: 10.21037/atm-20-7372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/10/2021] [Indexed: 11/06/2022]
Abstract
Background Accurate identification of insufficient future liver remnant (FLR) is required to select patients for liver preparation and limit the risk of post-hepatectomy liver failure (PHLF). The objective of this study was to investigate the correlations and discrepancies between the most-commonly used FLR volume metrics and 99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Methods In 101 non-cirrhotic patients who underwent HBS before major hepatectomy, we retrospectively analyzed the correlations and discrepancies between FLR function and FLR volume metrics: actual percentage (FLRV%), standardized to body surface area (FLRV%BSA) and weight (FLRV%weight), and FLR to body weight ratio (FLRV-BWR). Results Among 67 patients with FLR function ≥2.69%/min/m2, PHLF was observed in none and 13 patients according to respectively 50-50 and ISGLS criteria. FLRV%, FLRV%BSA, FLRV%weight and FLRV-BWR significantly correlated with FLR function (P<0.001), with Spearman's correlation coefficients of 0.680, 0.704, 0.698, and 0.711, respectively. No difference was observed between the areas under the curve of FLRV%, FLRV%BSA, FLRV%weight and FLR-BWR (all P=ns). Overall, the percentages of patients misclassified by FLRV%, FLRV%BSA, FLRV%weight (thresholds: 30%) and FLR-BWR (threshold: 0.5) versus FLR function (threshold: 2.69%/min/m2) were 23.8% (95% CI: 15.9-33.3%), 18.8% (95% CI: 11.7-27.8%), 17.8% (95% CI: 11-26.7%), and 31.7% (95% CI: 22.8-41.7%), respectively. FLR volume metrics wrongly classified 1-13.9% of patients with sufficient FLR function (i.e., ≥2.69%/min/m2), and 9.9-30.7% of patients with insufficient FLR function. FLRV-BWR was the most and the least reliable measure to identify patients with sufficient and insufficient FLR function, respectively. Conclusions Despite significant correlations, the discrepancy rates between FLR volume and function metrics speaks in favor of implementing 99mTc-mebrofenin HBS in the work-up before liver preparation.
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Affiliation(s)
- Boris Guiu
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, St-Eloi University Hospital, Montpellier, France
| | - Florian Sanglier
- Department of Radiology, Limoges University Hospital, Limogesr, France
| | - Caterina Cusumano
- Department of Surgery, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Astrid Herrerro
- Department of Surgery, St-Eloi University Hospital, Montpellier, France
| | - Olivia Sgarbura
- Department of Surgery, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Nicolas Molinari
- IDESP, INSERM, Montpellier Univesity Hospital, Montpellier, France
| | - François Quenet
- Department of Surgery, Institut du Cancer de Montpellier (ICM), Montpellier, France
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16
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Madoff DC, Odisio BC, Schadde E, Gaba RC, Bennink RJ, van Gulik TM, Guiu B. Improving the Safety of Major Resection for Hepatobiliary Malignancy: Portal Vein Embolization and Recent Innovations in Liver Regeneration Strategies. Curr Oncol Rep 2020; 22:59. [PMID: 32415401 DOI: 10.1007/s11912-020-00922-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW For three decades, portal vein embolization (PVE) has been the "gold-standard" strategy to hypertrophy the anticipated future liver remnant (FLR) in advance of major hepatectomy. During this time, CT volumetry was the most common method to preoperatively assess FLR quality and function and used to determine which patients are appropriate surgical candidates. This review provides the most up-to-date methods for preoperatively assessing the anticipated FLR and summarizes data from the currently available strategies used to induce FLR hypertrophy before surgery for hepatobiliary malignancy. RECENT FINDINGS Functional and physiological imaging is increasingly replacing standard CT volumetry as the method of choice for preoperative FLR assessment. PVE, associating liver partition and portal vein ligation, radiation lobectomy, and liver venous deprivation are all currently available techniques to hypertrophy the FLR. Each strategy has pros and cons based on tumor type, extent of resection, presence or absence of underlying liver disease, age, performance status, complication rates, and other factors. Numerous strategies can lead to FLR hypertrophy and improve the safety of major hepatectomy. Which is best has yet to be determined.
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Affiliation(s)
- David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA.
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Schadde
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA.,Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland.,Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Ron C Gaba
- Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, IL, USA
| | - Roelof J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital-Montpellier, Montpellier, France
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17
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Abstract
The liver is a common site of metastatic cancer spread, and metastatic lesions are the most common malignant liver tumors. Diagnosis of liver metastases often is established based on clinical assessment, laboratory tests, and appropriate imaging. Surgical resection is the treatment of choice for resectable colorectal and neuroendocrine liver metastases. Long-term survival outcome data after treatment of hepatic metastases of noncolorectal non-neuroendocrine tumors are less robust. The treatment strategy for patients with liver metastases should be determined case by case in a multidisciplinary setting.
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Affiliation(s)
- Nikdokht Rashidian
- Department of GI Surgery, Ghent University Hospital, C. Heymanslaan 10, 2K12C Route1275, UZ Gent, Ghent 9000, Belgium
| | - Adnan Alseidi
- Division of Pancreas, Liver and Biliary Surgery, Virginia Mason Medical Center, Virginia Mason HPB Surgery, 1100 Ninth Avenue, MC GS C6, Seattle, WA 98101, USA.
| | - Russell C Kirks
- Division of Pancreas, Liver and Biliary Surgery, Virginia Mason Medical Center, Virginia Mason HPB Surgery, 1100 Ninth Avenue, MC GS C6, Seattle, WA 98101, USA
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18
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Interstage Assessment of Remnant Liver Function in ALPPS Using Hepatobiliary Scintigraphy: Prediction of Posthepatectomy Liver Failure and Introduction of the HIBA Index. Ann Surg 2019; 267:1141-1147. [PMID: 28121683 DOI: 10.1097/sla.0000000000002150] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate interstage liver function in associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) using hepatobiliary scintigraphy (HBS) and whether this may help to predict posthepatectomy liver failure (PHLF). BACKGROUND ALPPS remains controversial given the high rate of liver-related mortality after stage 2. HBS combined with single photon emission computed tomography (SPECT) accurately estimates future liver remnant function and may be useful to predict PHLF. METHODS Between 2011 and 2016, 20 of 39 patients (51.3%) underwent SPECT-HBS before ALPPS stage 2 for primary (n = 3) or secondary liver tumors (n = 17) at the Hospital Italiano de Buenos Aires (HIBA). PHLF was defined by the International Study Group of Liver Surgery criteria, 50-50 criteria, or peak bilirubin >7 mg/dL. Grade A PHLF was excluded, as it requires no change in clinical management. Receiver-operating characteristic curves were used to determine cutoff for HBS parameters. RESULTS Interstagely, 3 HBS parameters differed significantly between patients with (n = 4) and without PHLF (n = 16) after stage 2. Among these, the HIBA-index best predicted PHLF, with a cutoff value of 15%. The risk of PHLF in patients with cutoff <15% was 80%, whereas no patient with cutoff ≥15% developed PHLF. CONCLUSIONS Interstage HBS could help to predict clinically significant PHLF after ALPPS stage 2. An HIBA-index cutoff of 15% seemed to give the best diagnostic performance. Although further studies are needed to confirm our findings, the routine application of this noninvasive low-cost examination could facilitate decision-making in institutions performing ALPPS.
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19
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Valdimarsson VT, Hellberg K, Brismar TB, Sparrelid E, Sturesson C. Repeat procedures for recurrent colorectal liver metastases: analysis of long-term liver regeneration and outcome. Cancer Manag Res 2019; 11:2617-2622. [PMID: 31118767 PMCID: PMC6497974 DOI: 10.2147/cmar.s191653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/21/2019] [Indexed: 12/31/2022] Open
Abstract
Background and aim: Repeat hepatectomy is increasingly performed for the management of recurrent colorectal liver metastases (CRLM). The aim of this study was to evaluate long-term functional liver volume (FLV) after a second hepatic procedure and to measure survival outcome. Methods: In this retrospective cohort study, patients treated for recurrent CRLM in the years 2005-2015 at two liver centers were included. Total FLV was calculated before the first procedure and before and after the second procedure. Overall survival was calculated. Results: Eighty-two patients were identified. The median follow-up was 53 (40-71) months from the first procedure. The median interval between first and second procedure was 13 (8-22) months. The initial FLV was 1584 (1313-1927) mL. The FLV was 1438 (1204-1896) mL after the first procedure and 1470 (1172-1699) mL after the second procedure (P<0.001). After the second procedure, a total of ten patients (12%) had a residual liver volume of less than 75% of the initial liver volume. The 5-year overall survival was 37 (26-54)% after the second procedure. Conclusion: Small changes in FLV were found after two hepatic procedures but with considerable inter-individual variation. Patients selected for a repeated hepatic procedure for recurrent CRLM had an acceptable survival.
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Affiliation(s)
- Valentinus T Valdimarsson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Katarina Hellberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Sturesson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skane University Hospital, Lund, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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20
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Abstract
Introduction: Liver volumetry is a routine procedure performed before major hepatectomy or living donor liver transplantation (LDLT) to anticipate the remnant liver volume and prevent liver failure. However, many parameters may impact its accuracy and no large-scale studies have evaluated inter-rater variabilities. We aimed to determine the reliability of volumetric assessments for whole organs in deceased-donor liver transplantations (DDLT) and partial organs in LDLT settings. Patients & Methods: Eight operators (four surgeons + four radiologists) analysed 30 preoperative CT scans (15 whole cirrhotic livers in the DDLT group + 15 partial healthy grafts in the LDLT group), using five software systems. The computed volumes were compared with liver weight; liver density being considered as1. Results: Inter-rater and inter-software concordances were excellent with coefficients of correlation >0.9. However, calculations overestimated the real volumes in 25 cases by a mean of 249 ± 206 [14-771] cc in the DDLT group and 138 ± 92cc [39-375] in the LDLT group. The mean calculations were significantly higher than liver weights in the LDLT group only (p=0.04). The radiologists overestimated the surgeons’ assessment in 24 cases, the differences exceeding 6% in some cases. The type of software used significantly impacted results in the DDLTgroup. Conclusions: Despite its unanimously recognised utility, we highlight significant discrepancies between estimated and real liver volumes. The global overestimation may lead to leave of too small remnant liver, with potentially dramatic consequences. In case of border-line estimations, we recommend a repetition of the evaluation by another operator (surgeon + radiologist working in concert).
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Xu F, Tang B, Jin TQ, Dai CL. Current status of surgical treatment of colorectal liver metastases. World J Clin Cases 2018; 6:716-734. [PMID: 30510936 PMCID: PMC6264988 DOI: 10.12998/wjcc.v6.i14.716] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/14/2018] [Accepted: 10/22/2018] [Indexed: 02/05/2023] Open
Abstract
Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.
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Affiliation(s)
- Feng Xu
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Bin Tang
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Tian-Qiang Jin
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Chao-Liu Dai
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
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22
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Alvarez FA, Castaing D, Figueroa R, Allard MA, Golse N, Pittau G, Ciacio O, Sa Cunha A, Cherqui D, Azoulay D, Adam R, Vibert E. Natural history of portal vein embolization before liver resection: a 23-year analysis of intention-to-treat results. Surgery 2018; 163:1257-1263. [DOI: 10.1016/j.surg.2017.12.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022]
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23
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Rassam F, Roos E, van Lienden KP, van Hooft JE, Klümpen HJ, van Tienhoven G, Bennink RJ, Engelbrecht MR, Schoorlemmer A, Beuers UHW, Verheij J, Besselink MG, Busch OR, van Gulik TM. Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience. Langenbecks Arch Surg 2018; 403:289-307. [PMID: 29350267 PMCID: PMC5986829 DOI: 10.1007/s00423-018-1649-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022]
Abstract
AIM Perihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor. METHODS We provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed. RESULTS AND CONCLUSION Upcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.
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Affiliation(s)
- F Rassam
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - E Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - K P van Lienden
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - H J Klümpen
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiotherapy, Academic Medical Center, Amsterdam, The Netherlands
| | - R J Bennink
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - M R Engelbrecht
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - A Schoorlemmer
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - U H W Beuers
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - J Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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24
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Hung ML, McWilliams JP. Portal vein embolization prior to hepatectomy: Techniques, outcomes and novel therapeutic approaches. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Matthew L. Hung
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P. McWilliams
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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25
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Rassam F, Olthof PB, Bennink RJ, van Gulik TM. Current Modalities for the Assessment of Future Remnant Liver Function. Visc Med 2017; 33:442-448. [PMID: 29344518 DOI: 10.1159/000480385] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
While imaging studies such as computed tomography or magnetic resonance imaging allow the volumetric assessment of the liver segments, only indirect information is provided concerning the quality of the liver parenchyma and its actual functional capacity. Assessment of liver function is therefore crucial in the preoperative workup of patients who require extensive liver resection and in whom portal vein embolization is considered. This review deals with the modalities currently available for the measurement of liver function. Passive liver function tests include biochemical parameters and clinical grading systems such as the Child-Pugh and MELD scores. Dynamic quantitative tests of liver function can be based on clearance capacity tests such as the indocyanine green (ICG) clearance test. Although widely used, discrepancies have been reported for the ICG clearance test in relation with clinical outcome. Nuclear imaging studies have the advantage of providing simultaneous morphologic (visual) and physiologic (quantitative functional) information about the liver. In addition, regional (segmental) differentiation allows specific functional assessment of the future remnant liver. Technetium-99m (99mTc)-galactosyl human serum albumin scintigraphy and 99mTc-mebrofenin hepatobiliary scintigraphy potentially identify patients at risk for post-resectional liver failure who might benefit from liver-augmenting techniques. As there is no one test that can measure all the components of liver function, liver functional reserve is estimated based on a combination of clinical parameters and quantitative liver function tests.
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Affiliation(s)
- Fadi Rassam
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Roelof J Bennink
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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26
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Gotra A, Sivakumaran L, Chartrand G, Vu KN, Vandenbroucke-Menu F, Kauffmann C, Kadoury S, Gallix B, de Guise JA, Tang A. Liver segmentation: indications, techniques and future directions. Insights Imaging 2017; 8:377-392. [PMID: 28616760 PMCID: PMC5519497 DOI: 10.1007/s13244-017-0558-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/03/2017] [Accepted: 05/02/2017] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Liver volumetry has emerged as an important tool in clinical practice. Liver volume is assessed primarily via organ segmentation of computed tomography (CT) and magnetic resonance imaging (MRI) images. The goal of this paper is to provide an accessible overview of liver segmentation targeted at radiologists and other healthcare professionals. METHODS Using images from CT and MRI, this paper reviews the indications for liver segmentation, technical approaches used in segmentation software and the developing roles of liver segmentation in clinical practice. RESULTS Liver segmentation for volumetric assessment is indicated prior to major hepatectomy, portal vein embolisation, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and transplant. Segmentation software can be categorised according to amount of user input involved: manual, semi-automated and fully automated. Manual segmentation is considered the "gold standard" in clinical practice and research, but is tedious and time-consuming. Increasingly automated segmentation approaches are more robust, but may suffer from certain segmentation pitfalls. Emerging applications of segmentation include surgical planning and integration with MRI-based biomarkers. CONCLUSIONS Liver segmentation has multiple clinical applications and is expanding in scope. Clinicians can employ semi-automated or fully automated segmentation options to more efficiently integrate volumetry into clinical practice. TEACHING POINTS • Liver volume is assessed via organ segmentation on CT and MRI examinations. • Liver segmentation is used for volume assessment prior to major hepatic procedures. • Segmentation approaches may be categorised according to the amount of user input involved. • Emerging applications include surgical planning and integration with MRI-based biomarkers.
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Affiliation(s)
- Akshat Gotra
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, 1058 rue Saint-Denis, Montreal, QC, H2X 3J4, Canada.,Department of Radiology, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Lojan Sivakumaran
- University of Montreal, 2900 boulevard Eduoard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montreal, QC, H2X 0A9, Canada
| | - Gabriel Chartrand
- Imaging and Orthopaedics Research Laboratory (LIO), École de technologie supérieure, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montreal, QC, H2X 0A9, Canada
| | - Kim-Nhien Vu
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, 1058 rue Saint-Denis, Montreal, QC, H2X 3J4, Canada
| | - Franck Vandenbroucke-Menu
- Department of Hepato-biliary and Pancreatic Surgery, University of Montreal, Saint-Luc Hospital, 1058 rue Saint-Denis, Montreal, QC, H2X 3J4, Canada
| | - Claude Kauffmann
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, 1058 rue Saint-Denis, Montreal, QC, H2X 3J4, Canada
| | - Samuel Kadoury
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montreal, QC, H2X 0A9, Canada.,École Polytechnique de Montréal, University of Montreal, 2500 chemin de Polytechnique Montréal, Montreal, QC, H3T 1J4, Canada
| | - Benoît Gallix
- Department of Radiology, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Jacques A de Guise
- Imaging and Orthopaedics Research Laboratory (LIO), École de technologie supérieure, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montreal, QC, H2X 0A9, Canada
| | - An Tang
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, 1058 rue Saint-Denis, Montreal, QC, H2X 3J4, Canada. .,Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montreal, QC, H2X 0A9, Canada.
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27
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Allard MA, Baillié G, Castro-Benitez C, Faron M, Blandin F, Cherqui D, Castaing D, Cunha AS, Adam R, Vibert É. Prediction of the Total Liver Weight using anthropological clinical parameters: does complexity result in better accuracy? HPB (Oxford) 2017; 19:338-344. [PMID: 28043763 DOI: 10.1016/j.hpb.2016.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/07/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Marc-Antoine Allard
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France; INSERM, Unit UMRS776, Villejuif, F-94800, France.
| | - Gaëlle Baillié
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France
| | - Carlos Castro-Benitez
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; INSERM, Unit 1193, Villejuif, F-94800, France
| | - Matthieu Faron
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France
| | - Frédérique Blandin
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; INSERM, Unit 1193, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France
| | - Denis Castaing
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; INSERM, Unit 1193, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; INSERM, Unit 1193, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France
| | - René Adam
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France; INSERM, Unit UMRS776, Villejuif, F-94800, France
| | - Éric Vibert
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, F-94800, France; INSERM, Unit 1193, Villejuif, F-94800, France; University of Paris-Sud, Villejuif, F-94800, France
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28
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Chapelle T, Op de Beeck B, Roeyen G, Bracke B, Hartman V, De Greef K, Huyghe I, Van der Zijden T, Morrison S, Francque S, Ysebaert D. Measuring future liver remnant function prior to hepatectomy may guide the indication for portal vein occlusion and avoid posthepatectomy liver failure: a prospective interventional study. HPB (Oxford) 2017; 19:108-117. [PMID: 27956027 DOI: 10.1016/j.hpb.2016.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/07/2016] [Accepted: 11/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Estimation of the future liver remnant function (eFLRF) can avoid post-hepatectomy liver failure (PHLF). In a previous study, a cutoff value of 2.3%/min/m2 for eFLRF was a better predictor of PHLF than future liver remnant volume (FLRV%). In this prospective interventional study, investigating a management strategy aimed at avoiding PHLF, this cutoff value was the sole criterion assessing eligibility for hepatectomy, with or without portal vein occlusion (PVO). METHODS In 100 consecutive patients, eFLRF was determined using the formula: eFLRF = FLRV% × total liver function (TLF). Group 1 (eFLRF >2.3%/min/m2) underwent hepatectomy without preoperative intervention. Group 2 (eFLRF <2.3%/min/m2) underwent PVO and re-evaluation of eFLRF at 4-6 weeks. Hepatectomy was performed if eFLRF had increased to >2.3%/min/m2, but was considered contraindicated if the value remained lower. RESULTS In group 1 (n = 93), 1 patient developed grade B PHLF. In group 2 (n = 7) no PHLF was recorded. Postoperative recovery of TLF in patients with preoperative eFLRF <2.3%/min/m2 occurred more rapidly when PVO had been performed. CONCLUSION A predefined cutoff for preoperatively calculated eFLRF can be used as a tool for selecting patients prior to hepatectomy, with or without PVO, thus avoiding PHLF and PHLF-related mortality.
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Affiliation(s)
- Thiery Chapelle
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium.
| | | | - Geert Roeyen
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Bart Bracke
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Vera Hartman
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kathleen De Greef
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Ivan Huyghe
- Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
| | | | - Stuart Morrison
- Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Sven Francque
- Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Dirk Ysebaert
- Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
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29
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Wiggers JK, Groot Koerkamp B, Cieslak KP, Doussot A, van Klaveren D, Allen PJ, Besselink MG, Busch OR, D'Angelica MI, DeMatteo RP, Gouma DJ, Kingham TP, van Gulik TM, Jarnagin WR. Postoperative Mortality after Liver Resection for Perihilar Cholangiocarcinoma: Development of a Risk Score and Importance of Biliary Drainage of the Future Liver Remnant. J Am Coll Surg 2016. [PMID: 27063572 DOI: 10.1016/j.jamcollsurg.2016.03.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with postoperative mortality ranging from 5% to 18%. The aim of this study was to develop a preoperative risk score for postoperative mortality after liver resection for PHC, and to assess the effect of biliary drainage of the future liver remnant (FLR). STUDY DESIGN A consecutive series of 287 patients submitted to major liver resection for presumed PHC between 1997 and 2014 at 2 Western centers was analyzed; 228 patients (79%) underwent preoperative drainage for jaundice. Future liver remnant volumes were calculated with CT volumetry and completeness of FLR drainage was assessed on imaging. Logistic regression was used to develop a mortality risk score. RESULTS Postoperative mortality at 90 days was 14% and was independently predicted by age (odds ratio [OR] per 10 years = 2.1), preoperative cholangitis (OR = 4.1), FLR volume <30% (OR = 2.9), portal vein reconstruction (OR = 2.3), and incomplete FLR drainage in patients with FLR volume <50% (OR = 2.8). The risk score showed good discrimination (area under the curve = 0.75 after bootstrap validation) and ranking patients in tertiles identified 3 (ie low, intermediate, and high) risk subgroups with predicted mortalities of 2%, 11%, and 37%. No postoperative mortality was observed in 33 undrained patients with FLR volumes >50%, including 10 jaundiced patients (median bilirubin level 11 mg/dL). CONCLUSIONS The mortality risk score for patients with resectable PHC can be used for patient counseling and identification of modifiable risk factors, which include FLR volume, FLR drainage status, and preoperative cholangitis. We found no evidence to support preoperative biliary drainage in patients with an FLR volume >50%.
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Affiliation(s)
- Jimme K Wiggers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kasia P Cieslak
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Alexandre Doussot
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Brudvik KW, Vauthey JN. Re "Comparison of techniques for volumetric analysis of the future liver remnant: implications for major hepatic resections". HPB (Oxford) 2016; 18:557. [PMID: 27317961 PMCID: PMC4913141 DOI: 10.1016/j.hpb.2016.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 12/12/2022]
Affiliation(s)
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Wiggers JK, Groot Koerkamp B, Cieslak KP, Doussot A, van Klaveren D, Allen PJ, Besselink MG, Busch OR, D'Angelica MI, DeMatteo RP, Gouma DJ, Kingham TP, van Gulik TM, Jarnagin WR. Postoperative Mortality after Liver Resection for Perihilar Cholangiocarcinoma: Development of a Risk Score and Importance of Biliary Drainage of the Future Liver Remnant. J Am Coll Surg 2016; 223:321-331.e1. [PMID: 27063572 DOI: 10.1016/j.jamcollsurg.2016.03.035] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/06/2016] [Accepted: 03/18/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with postoperative mortality ranging from 5% to 18%. The aim of this study was to develop a preoperative risk score for postoperative mortality after liver resection for PHC, and to assess the effect of biliary drainage of the future liver remnant (FLR). STUDY DESIGN A consecutive series of 287 patients submitted to major liver resection for presumed PHC between 1997 and 2014 at 2 Western centers was analyzed; 228 patients (79%) underwent preoperative drainage for jaundice. Future liver remnant volumes were calculated with CT volumetry and completeness of FLR drainage was assessed on imaging. Logistic regression was used to develop a mortality risk score. RESULTS Postoperative mortality at 90 days was 14% and was independently predicted by age (odds ratio [OR] per 10 years = 2.1), preoperative cholangitis (OR = 4.1), FLR volume <30% (OR = 2.9), portal vein reconstruction (OR = 2.3), and incomplete FLR drainage in patients with FLR volume <50% (OR = 2.8). The risk score showed good discrimination (area under the curve = 0.75 after bootstrap validation) and ranking patients in tertiles identified 3 (ie low, intermediate, and high) risk subgroups with predicted mortalities of 2%, 11%, and 37%. No postoperative mortality was observed in 33 undrained patients with FLR volumes >50%, including 10 jaundiced patients (median bilirubin level 11 mg/dL). CONCLUSIONS The mortality risk score for patients with resectable PHC can be used for patient counseling and identification of modifiable risk factors, which include FLR volume, FLR drainage status, and preoperative cholangitis. We found no evidence to support preoperative biliary drainage in patients with an FLR volume >50%.
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Affiliation(s)
- Jimme K Wiggers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kasia P Cieslak
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Alexandre Doussot
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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