Objective
Major hepatectomy in cirrhotic patients still represents a great challenge for liver surgeons. Hence, the aim in the present study is to investigate the clinical impact of major hepatectomy ...and to assess whether the surgical approach influences the outcome of cirrhotic patients.
Methods
Multicenter retrospective study including cirrhotic patients undergoing major laparoscopic (mjLLR) and open liver resection (mjOLR) in 14 Western liver centers was performed (2009–2020). Clinical, demographic, and perioperative data were compared using propensity score matching (PSM). Long‐term outcome after resection for hepatocellular carcinoma was analyzed.
Results
Overall, 352 patients were included; 108 after mjLLR and 244 after mjOLR. After PSM, 88 patients were matched in each group. In the mjLLR group, compared to mjOLR, less blood loss (P = .042), lower overall and severe complication (P < .001, .020), such as surgical site infection, acute kidney injury and liver failure were observed, parallel to a shorter length of hospital stay. Stratifying patients based on the type of resection, less severe complications was observed only after laparoscopic left hepatectomy (P = .044), while the advantages of laparoscopy tend to decrease during right hepatectomy. Subgroup analysis of long‐term survivals following liver resection for hepatocellular carcinoma showed no difference between mjLLR and mjOLR.
Conclusions
This multicenter experience suggests potential short‐term benefits of mjLLR in cirrhotic patients compared to mjOLR, without compromising long‐term outcome. These findings might have interesting clinical implications for the management of patients with chronic liver disease.
Major vascular involvement often constitutes a contraindication to the laparoscopic approach. Lopez‐Ben and colleagues described a purely laparoscopic surgical technique consisting of two stages, ...eight weeks apart, utilizing the caudal view and proximal approach for complete removal of colorectal liver metastases in close proximity to all three hepatic veins.
KRAS mutation is a negative prognostic factor for colorectal liver metastases. Several studies have investigated the resection margins according to KRAS status, with conflicting results. The aim of ...the study was to assess the oncologic outcomes of R0 and R1 resections for colorectal liver metastases according to KRAS status.
All patients who underwent resection for colorectal liver metastases between 2010 and 2015 with available KRAS status were enrolled in this multicentric international cohort study. Logistic regression models were used to investigate the outcomes of R0 and R1 colorectal liver metastases resections according to KRAS status: wild type versus mutated. The primary outcomes were overall survival and disease-free survival.
The analysis included 593 patients. KRAS mutation was associated with shorter overall survival (40 vs 60 months; P = .0012) and disease-free survival (15 vs 21 months; P = .003). In KRAS-mutated tumors, the resection margin did not influence oncologic outcomes. In multivariable analysis, the only predictor of disease-free survival and overall survival was primary tumor location (P = .03 and P = .03, respectively). In KRAS wild-type tumors, R0 resection was associated with prolonged overall survival (74 vs 45 months, P < .001) and disease-free survival (30 vs 17 months, P < .001). The multivariable model confirmed that R0 resection margin was associated with prolonged overall survival (hazard ratio = 1.43, 95% confidence interval: 1.01–2.03) and disease-free survival (hazard ratio = 1.42; 95% confidence interval: 1.06–1.91).
KRAS-mutated colorectal liver metastases showed more aggressive tumor biology with inferior overall survival and disease-free survival after liver resection. Although R0 resection was not associated with improved oncologic outcomes in the KRAS-mutated tumors group, it seems to be of paramount importance for achieving prolonged long-term survival in KRAS wild-type tumors.
Laparoscopic liver resections of lesions in the postero-superior segments (Sg 4a, 7, 8) can be technically challenging. A profound experience in open and laparoscopic surgery is essential to ensure ...success without compromising surgical safety and oncologic efficiency when applying the laparoscopic approach for these segments. While many experienced surgeons have initially called the postero-superior segments the non-laparoscopic segments, this dogma has been challenged by different groups reporting good results in terms of safety and feasibility for parenchymal-sparing non-anatomical and, however less so, for anatomical resections (AR).
Parenchymal-sparing liver resection is nowadays the gold standard for the treatment of colorectal liver metastases where repeated resections have demonstrated to improve patient's cancer related short and long-term outcome. This can be achieved by performing anatomical or non-anatomical segmental resections. Different surgical techniques to facilitate such resections have been described.
The diamond technique has specifically been developed for the non-anatomical resection of non-peripheral lesions in the postero-superior segments and reported to be feasible, reproducible and moreover, oncologic efficient. Similarly, techniques for AR have been described acknowledging that in the minimally invasive setting such resections are technically more demanding requiring precise preoperative planning and a standardized surgical technique to allow pursuing oncological quality of the parenchyma sparing principle.
We herein discuss technique, results and tips and tricks of applying the diamond technique for non-anatomical liver resection as well as the practice for AR of lesions in the postero-superior segments.
•Laparoscopic liver resections of lesions in the postero-superior segments are technically challenging.•Parenchymal-sparing and anatomical resections can be safely performed in the hands of experienced surgeons.•The diamond technique has been developed for non-anatomical resection of non-peripheral lesions and it is oncological effective.•Anatomical resections have a role in the management of hepatocellular carcinoma and gained recent interest in colorectal liver metastasis.
Background
Laparoscopic liver resection (LLR) may improve outcomes for cirrhotic patients with hepatocellular carcinoma (HCC) and portal hypertension (PHT). The aim of this study was to compare the ...short-term outcomes after LLR for HCC in cirrhotic patients with and without PHT.
Methods
This multicentric study included 96 HCC patients who underwent LLR. Clinically significant portal hypertension (CSPH) was defined by a hepatic venous pressure gradient ≥10 mmHg. Short-term outcomes and liver-specific complications including post-hepatectomy liver failure (PHLF), ascites and encephalopathy were compared between patients with and without CSPH.
Results
Thirty-one patients (32%) had CSPH. The CSPH group had higher post-operative morbidity (52% vs. 15%;
p
< 0.001), PHLF (10% vs. 0%;
p
= 0.03) and encephalopathy (10% vs. 0%;
p
= 0.03). There was no difference in terms of post-operative ascites between the two groups (CSPH: 16% vs. no CPSH: 8%,
p
= 0.28). The length of stay was longer in patients with CSPH than in those without CSPH (6 vs. 4 days;
p
< 0.001).
Conclusions
The laparoscopic approach is feasible in selected HCC patients with CSPH, at the price of significant increases in liver-specific complications and length of stay.
BACKGROUNDBleeding is an intraoperative and postoperative complication of liver surgery of concern, and yet evidence to support utility and reproducibility of bleeding scales for liver surgery is ...limited. We determined the reproducibility of the clinician-reported validated intraoperative bleeding severity scale and its clinical value of implementation in liver surgery. METHODSIn this descriptive and observational multicenter study, we assessed the performance of liver surgeons instructed on the clinician-reported intraoperative bleeding severity scale using training videos that covered all 5 grades of bleeding severity. Surgeons were stratified according to years of surgical experience and number of surgeries performed per year based on a median split in low and high values. Intraobserver and interobserver agreement was assessed using Kendall's coefficient of concordance (Kendall's W). RESULTSForty-seven surgeons from 10 hospitals in Spain participated in the study. The overall intraobserver concordance was 0.985, and the overall interobserver concordance was 0.929. For "high experience" surgeons, the intraobserver and interobserver agreement values were 0.990 and 0.941, respectively. For "low experience" surgeons, the intraobserver and interobserver agreement was 0.981 and 0.922, respectively. Regarding the annual number of surgeries, intraobserver and interobserver agreement values were 0.995 and 0.940, respectively, for surgeons performing >35 surgeries per year, with 0.979 and 0.923, respectively, for surgeons who perform ≤35 surgeries year. CONCLUSIONThe clinician-reported intraoperative bleeding severity scale shows high interobserver and intraobserver concordance, suggesting it is a useful tool for assessing severity of bleeding during liver surgery; years of surgical experience and number of annual procedures performed did not affect the applicability of the clinician-reported intraoperative bleeding severity scale.
Background
Anatomical resection of segment 8 (s8) is a challenging procedure. S8 can be subdivided into two areas: ventral (s8v) and dorsal (s8d). In the last years, different approaches for ...performing laparoscopic resection of s8 or any of its subsegments have been described, i.e. the hilar extrafascial approach, transfissural approach for s8v, transparenchymal approach for s8d, and the intrahepatic Glissonean approach. We recently described the dorsal approach of the right hepatic vein (RHV) for anatomical segment 7 resection. This video report describes the approach to a dorsal s8 pedicle using the RHV dorsal approach.
Methods
A 50-year-old woman with a history of morbid obesity and sleep apnea was diagnosed after episodes of hematochezia sigmoid cancer and a 2-cm liver metastases in the s8d, according to vascular reconstruction (Cella Medical Solutions, Murcia, Spain). The surgical technique started with mobilization of the right liver until the root of the RHV was identified and exposed in a craniocaudal fashion and until the s8d Glissonean pedicle was identified and clamped. Indocyanine green counterstaining depicted an intersegmental plane between the s8d and segment 5 and s8v. Transection continued until the anterior fissural vein was exposed at its root, as a landmark of the medial plane.
Results
Operative time lasted 265 min. Transection was carried out using the intermittent Pringle maneuver over a period of 81 min. Estimated blood loss was 252 cc. There were no postoperative complications and the patient was discharged on postoperative day 2.
Conclusions
In some cases, the RHV dorsal approach can be used as the landmark for the s8d Glissonean pedicle, allowing anatomical resection of this particular area.
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