An evidence-based review to ascertain the operative strategy for oncologic resection of malignant tumors of the liver and an optimal postoperative outcome.
Recommendations for resection of malignant ...tumors of the liver based on traditional considerations of locoregional control and survival benefit are modified by the functional reserve of the liver remnant.
Recent publications including prospective randomized trials reporting outcomes with various surgical approaches were reviewed to establish the best current practices.
The goal of hepatectomy for primary or metastatic tumors of the liver is complete resection with evidence that an anatomic resection in hepatocellular carcinoma and hilar cholangiocarcinoma improves survival. For nonanatomic resections the optimal width of the resection margin varies with the pathological type of tumor. Anterior approach to major hepatectomy is a "no-touch" technique that minimizes manipulation of the tumor-bearing liver. Vascular invasion is associated with dismal prognosis and limited major vascular resection is indicated to achieve an R0 (no residual disease) resection for prolongation of survival. Concomitant regional lymphadenectomy is of prognostic value, however it is not performed routinely because its therapeutic value remains unproven. Perioperative blood transfusion and postoperative morbidity are independent predictors of survival emphasizing the importance of measures such as portal vein embolization, hepatic pedicle clamping and preservation of venous drainage of the liver remnant.
The operative strategy for resection of malignant tumors of the liver should address the key components of the extent of hepatectomy including anatomic resection and optimal pathologic margins, use of the anterior approach, necessity for vascular resection, regional lymphadenectomy and measures to minimize blood loss and postoperative morbidity for maximal survival benefit.
Background & Aims
Although hepatocellular adenoma (HCA) is more frequently observed in obese patients, however, the effect of weight loss as a therapeutic option was never studied.
Methods
In this ...rapid communication we described our non‐surgical management of large HCA (>5 cm) encountered in patients with morbid obesity. Non‐surgical management consisted mainly of oral contraception withdrawal and weight loss, which was the only option in two patients. All demographics, radiological and histological data were studied. Patients were followed regularly every 6 months.
Results
Between 2004 and 2013, 116 patients presented with HCA and 15 with morbid obesity (13%) were studied. Five men underwent surgery and females were either operated (period before 2010; n = 5) or proposed to non‐surgical management (period after 2010; n = 5).Weight loss was advocated to all females, including four with residual HCA after resection and to non‐operated patients, including two with haemorrhagic HCA. Four (40%) females showed significant weight loss. In resected patients, weight loss allowed stability (n = 1) or slight regression (n = 1) of residual HCA. In the two patients treated only by weight loss, significant decrease was observed in the weight with significant decrease (>50%) in the size and number of HCA to a non‐surgical size (<5 cm). Severe morbidity was 40% in operated patients and 0% in non‐operated patients. After a follow‐up period of 38 months (18–60), no complication or degeneration was encountered in the non‐operated group.
Conclusion
Like oral contraception, weight loss should be considered as the first therapeutic option in the management of HCA in obese patients.
Liver resection (LR) for hepatocellular carcinoma (HCC) as the first‐line treatment in transplantable patients followed by “salvage transplantation” (ST) in case of recurrence is an attractive ...concept. The aim was to identify patients who gain benefit from this approach in an intention‐to‐treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention‐to‐treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five‐year overall and disease‐free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio HR 2.38 range, 1.10‐7.29), satellite nodules (HR 2.46 range, 1.01‐6.68), tumor size > 3 cm (HR 1.34 range, 1.03‐3.12), poorly differentiated tumor (HR 3.18 range, 1.31‐7.70), and liver cirrhosis (HR 1.90 range, 1.04‐3.12). Conclusion: The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors. (HEPATOLOGY 2012;;55:132–140)
Background & Aims Waiting-list mortality in patients with cirrhosis and a relatively low MELD score is a matter of concern. The aim of this study was to determine whether a marker of muscle waste ...could improve prognostication. Methods A pre-MELD cohort (waiting time-based allocation; n = 186) and a MELD-era cohort (n = 376) were examined. At evaluation, transversal psoas muscle thickness (TPMT) was measured on a computed tomography (CT) image at the level of the umbilicus. In the pre-MELD cohort, TPMT/height (mm/m) and the MELD score were entered in univariate and multivariate models to predict mortality after registration. Applicability of pre-MELD findings was tested in the MELD-era. Results In the pre-MELD cohort, the MELD score and TPMT/height were significantly associated with mortality. The discrimination of a score combining MELD and TPMT/height (MELD-psoas) was 0.84 (95% CI, 0.62–0.95). In the MELD-era, TPTM/height was significantly associated with mortality, independent of the MELD and MELD-Na scores. There was a 15% increase in mortality risk per unit decrease in TPMT/height. The discrimination of MELD-psoas score (0.82; 95% CI, 0.64–0.93) was superior to that of the MELD score and similar to that of the MELD-Na score. In patients with refractory ascites, mortality was significantly higher when TPMT/height was <16.8 mm/m (42% vs. 9%, p = 0.02). Conclusions TPMP/height on CT at the level of the umbilicus, an objective marker of muscle waste, may be predictive of mortality in cirrhotic patients, independent of the MELD and MELD-Na scores. It may help to better assess the prognosis of patients with refractory ascites.
Background & Aims Prothrombin induced by vitamin K absence-II (PIVKA-II) is a diagnostic and surveillance marker for HCC mainly used in Asia, and has also been shown to be a predictor of ...microvascular invasion (MVI), a major prognostic factor in HCC. However, experience with PIVKA-II in Europe remains limited. Methods In a French cohort, we conducted a case-control study to compare the performances of α-fetoprotein (AFP) and PIVKA-II serum levels for diagnosis of early stage HCC, and we determined the value of PIVKA-II serum and tissue expression in pre-operative detection of MVI. 43 cirrhotic control patients and 85 HCC cases were included, of which 54 (63.5%) had early stage HCC (n = 22 very early, n = 32 early). PIVKA-II tissue expression was assessed by immunohistochemistry in HCC surgical samples. Results For the diagnosis of early HCC, PIVKA-II had a sensitivity of 77% and a specificity of 82% at a cut-off of 42 mAU/ml, vs. 61% and 50% for AFP at a cut-off of 5.5 ng/ml (AUC 0.81 vs. 0.58, respectively). A PIVKA-II level >90 mAU/ml was an independent predictor of MVI (HR 3.5; 95% CI 1.08–11.8; p = 0.043). High PIVKA-II tissue expression was significantly associated with the presence of MVI ( p = 0.001). When combining PIVKA-II immunostaining with the PIVKA-II serum level, sensitivity and specificity for the diagnosis of MVI increased from 70% to 87% and 63% to 90%, respectively. Conclusions PIVKA-II was more efficient than AFP for the diagnosis of early HCC, and could be used as a predictive biomarker of MVI.
Abstract Background Although laparoscopic pancreatic resection (LPR) has become a routine, large single center series are still lacking. Our aim was to analyze the results of a large European single ...center series of LPR. Study Design Between January 2008 and September 2015, 300 LPR were performed and studied prospectively including 165 (55%) distal pancreatectomies, 68 (23%) pancreatoduodenectomies (PD), 30 (10%) enucleations, 35 (11%) central pancreatectomies and 2 (1%) total pancreatectomies. Results Mean age was 54 ± 15.4 years old (17-87) and most patients were women (58%). LPR was performed for malignancy (46%), low potential malignant (44%) or benign (10%) diseases. The mean operative duration was 211 ± 102 min (30-540) and 351± 59 (240-540) min for PD, and decreased with the learning curve. Mean blood loss was 229 ±269 ml (0-1500) and 13 patients (4%) were transfused. Conversion was required in 12 patients (4%), and only 5 in the last 250 patients (2% vs 14%, P<0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n=124, 41%), bleeding (n=35, 12%) and reoperation (n=28, 9%). The postoperative outcome was less favorable in procedures with a reconstruction phase (n=105) than in those without (n=195) with increased mortality (3.8% vs 0%, p=0.04), overall morbidity (76% vs % 52%, p<0.001) and mean hospital stay (26 ±15vs 16±10 days, p<0.001). Conclusions LPR without a reconstruction phase has an excellent outcome. LPR with a reconstruction phase, especially PD, has a less favorable outcome and further randomized studies are required to conclude on the safety and benefits of this approach.
To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery.
Venous resection during liver or pancreatic resection may ...require a rapidly available substitute especially when the need for venous resection is unforeseen.
The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans.
Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%).
A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.
Background Pancreatic fistula (PF) after pancreatoduodenectomy (PD) remains a challenging problem. The only commonly accepted risk factor is the soft consistency of the pancreatic remnant. Methods In ...all, 100 consecutive patients underwent PD. All data, including commonly accepted risk factors for PF and PF defined according to the International Study Group of Pancreatic Fistula, were collected prospectively. On the pancreatic margin, a score of fibrosis and a score of fatty infiltration were assessed by a pathologist blinded to the postoperative course. Results PF occurred in 31% of patients. In univariate analysis, male sex, age greater than 58 years, body mass index (BMI) ≥25 kg/m2 , pre-operative high blood pressure, operation for nonintraductal papillary and mucinous neoplasm (IPMN) disease and for ampullary carcinoma, operative time, blood loss, soft consistency of the pancreatic remnant, absence of pancreatic fibrosis, and presence of fatty infiltration of the pancreas were associated with a greater risk of PF. In a multivariate analysis, only BMI ≥25kg/m2 , absence of pancreatic fibrosis, and presence of fatty pancreas were significant predictors of PF. A score based on the number of risk factors present divided the patient population into 4 subgroups carrying a risk of PF that ranged from 7% (no risk factor) to 78% (3 risk factors) and from 0% to 81%, taking into account only symptomatic PF (grade B and C). Conclusion The presence of an increased BMI, the presence of fatty pancreas, and the absence of pancreatic fibrosis as risk factors of PF allows a more precise and objective prediction of PF than the consistency of pancreatic remnant alone. A predictive score based on these 3 factors could help to tailor preventive measures.
About 10 years ago, several studies made it clear that liver transplantation (LT) for patients with chronic liver disease and limited hepatocellular carcinoma (HCC) without vascular invasion offers ...better long-term survival than resection alone. However, during the past 10 years, the persistent imbalance between the increasing numbers of candidates for LT and a limited organ supply has made it necessary to temper the enthusiasm for LT. Organ shortage necessarily results in prolonged waiting time. In turn, prolonged waiting time results in tumor growth with an increasing risk of vascular invasion, a source of post-LT recurrence. In parallel, advances in liver surgery have significantly improved the safety of resection. It has been shown that, in contrast to what could be expected, prior resection neither increases operative morbidity nor impairs survival following deceased donor transplantation. Resection can be used as a treatment for HCC before LT in three different settings. First, resection can be used as a primary therapy, with LT reserved as a “salvage” therapy for patients who develop recurrence or liver failure. Second, resection can be used as an initial therapy to select patients who might obtain benefit from LT according to detailed pathological examination of the tumor and the surrounding liver parenchyma. Third, resection can be used as a “bridge” therapy for patients who have been already enlisted for LT. Resection and transplantation should be associated rather than opposed. The use of different strategies depends not only on the availability of graft and waiting time in different centers, but also the expertise of individual centers. This strategy opens a completely new field of investigation with multiple indications of resection in patients eligible for LT.
Background Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare ...the outcomes of LPD and open pancreaticoduodenectomy (OPD). Study Design Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database. Results Lower BMI (23 vs 27 kg/m2 , p < 0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p < 0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF. Conclusions This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.
