Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a ...systematic review and meta-analysis of the main strategies used for this purpose.
A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential transarterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated.
A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = <0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE.
Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.
Colorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate ...following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.
Background
Histomorphological features have been described as prognostic factors after resection of colorectal liver metastases (CLM). The objectives of this study were to assess the prognostic ...significance of tumor budding (TB) and poorly differentiated clusters (PDC) among CLM, and their association with other prognostic factors.
Methods
We evaluated 229 patients who underwent a first resection of CLM. Slides stained by HE were assessed for TB, PDC, tumor border pattern, peritumoral pseudocapsule, peritumoral, and intratumoral inflammatory infiltrate. Lymphatic and portal invasion were evaluated through D2‐40 and CD34 antibody.
Results
Factors independently associated with poor overall survival were nodules>4 (P = 0.002), presence of PDC G3 (P = 0.007), portal invasion (P = 0.005), and absence of tumor pseudocapsule (P = 0.006). Factors independently associated with disease‐free survival included number of nodules>4 (P < 0.001), presence of PDC G3 (P = 0.005), infiltrative border (P = 0.031), portal invasion (P = 0.006), and absent/mild peritumoral inflammatory infiltrate (P = 0.002). PDC and TB were also associated with histological factors, as portal invasion (TB), peritumoral inflammatory infiltration (PDC), infiltrative border, and absence of tumor pseudocapsule (TB and PDC).
Conclusions
This is the first study demonstrating PDC as a prognostic factor in CLM. TB was also a prognostic factor, but it was not an independent predictor of survival.
Laparoscopic major hepatectomy (LMH) remains restricted to a few specialized centers and poses a challenge to surgeons performing laparoscopic resections. Laparoscopic extended resections are even ...more complex and rarely conducted.
From a single-institution database, we compared the short-term outcomes of patients who underwent major and extended laparoscopic resections, stratifying the entire retrospective cohort into four groups: right hepatectomy, left hepatectomy, right extended hepatectomy, and left extended hepatectomy. Patient demographics, tumor characteristics, operative variables, and especially postoperative outcomes were evaluated.
250 patients underwent major and extended laparoscopic liver resections, including 160 right, 31 right extended, 36 left, and 23 left extended laparoscopic hepatectomies. The most common indication for resection was colorectal liver metastases (64%). Laparoscopic extended hepatectomy (LEH) showed significantly longer operative time, more blood loss, need for Pringle maneuver, conversion to open surgery, higher rates of liver failure, postoperative ascites, and intra-abdominal hemorrhage, R1 margins and length of stay when compared with the LMH group. Mortality rates were similar between groups. Multivariate analysis revealed intraoperative blood transfusion (OR = 5.1CI-95%: 1.15–6.79; p = 0.02) as an independent predictor for major complications.
LEH showed to be feasible, however with higher blood loss and significantly associated to major complications.
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Abstract Background Surgical resection is the gold standard therapy for the treatment of colorectal liver metastases (CRM). The aim of this study was to investigate the impact of tumor growth ...patterns on disease recurrence. Methods We enrolled 91 patients who underwent CRM resection. Pathological specimens were prospectively evaluated, with particular attention given to tumor growth patterns (infiltrative vs pushing). Results Tumor recurrence was observed in 65 patients (71.4%). According to multivariate analysis, 3 or more lesions ( P = .05) and the infiltrative tumor margin type ( P = .05) were unique independent risk factors for recurrence. Patients with infiltrative margins had a 5-year disease-free survival rate significantly inferior to patients with pushing margins (20.2% vs 40.5%, P = .05). Conclusions CRM patients with pushing margins presented superior disease-free survival rates compared with patients with infiltrative margins. Thus, the adoption of the margin pattern can represent a tool for improved selection of patients for adjuvant treatment.
Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary ...incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation.
A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed.
21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference MD = 34 min; 95%CI: 22–47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss MD = −43 ml; 95%CI: −74–(−13); P = 0.005, N = 1738; shorter hospital stay MD = −1.9 days; 95%CI: −3.2–(−0.5); P = 0.008; N = 833 and lower morbidity risk difference (RD) = −0.05; 95%CI: −0.10–(−0.01); P = 0.010; N = 1359. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality.
Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.
Background
En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver ...resections (MLRs).
Objectives
To compare the short and long‐term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies.
Methods
From a prospective database, a case‐matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long‐term survival.
Results
Fifty‐three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 320‐525 vs 360 270‐440 minutes, P = .005); higher estimated blood loss (600 400‐800 vs 400 100‐600 mL; P = .011); longer hospital stay (8 6‐14 vs 7 5‐9 days; P = .003); and higher postoperative mortality (9.4% vs 1.9%, P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio OR, 1 organ = 1.8 0.54‐6.05; OR ≥ 2, organs = 4.0 0.35‐13.84) or perioperative mortality (OR, 1, organ = 5.2 0.91‐29.51; OR ≥ 2, organs = 6.5 0.52‐79.60). No differences in overall (P = .771) and disease‐free survival (P = .28) were observed.
Conclusion
MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long‐term outcomes.
Background and objective:
The ideal margin width for surgical resection of colorectal liver metastases has been extensively studied, but not sufficiently in accordance with other pathological ...factors. The aim of this study was to assess for the first time the prognostic impact of margin widths according to different prognostic pathological factors in colorectal liver metastasis.
Methods:
We evaluated 101 patients with a single resected metastasis. Slides stained by HE were assessed for the presence of poorly differentiated clusters, peritumoral inflammatory infiltrate, tumor pseudocapsule, and tumor borders pattern. Overall survival, disease-free survival, and hepatic recurrence were evaluated. The pathologic factors prognostic impact was evaluated according to a (< or ⩾) 10-mm margin size.
Results:
Factors independently associated with a shorter overall survival were absence of tumor pseudocapsule (p < 0.001) and infiltrative tumor border pattern (p = 0.019). The absence of tumor pseudocapsule was the only factor independently associated with shorter disease-free survival (p < 0.001). Hepatic recurrence was associated with infiltrative tumor border and absence of pseudocapsule. Margin width ⩾10 mm did not impact overall survival independently of the studied histological prognostic factors.
Conclusions:
In colorectal liver metastasis resection, the absence of tumor pseudocapsule was significantly associated with shorter overall survival and disease-free survival and hepatic recurrence. However, margins larger than 10 mm did not offer survival benefit when other pathologic negative prognostic factors were concomitantly analyzed, reinforcing the idea that biology, rather than margin size, is crucial for prognosis.
AIM:To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury.METHODS:From a prospective database of patients ...treated for benign biliary strictures at our hospital,cases that underwent liver resections were reviewed.All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy(open or laparoscopic).Liver resection was indicated in patients with Strasberg E3/E4(hilar stricture)bile duct lesions associated with vascular damage(arterial and/or portal),ipsilateral liver atrophy/abscess,recurrent attacks of cholangitis,and failure of previous hepaticojejunostomy.RESULTS:Of 148 patients treated for benign biliary strictures,nine(6.1%)underwent liver resection;eight women and one man with a mean age of 38.6 years.Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery.The mean number of surgical procedures before definitive treatment was 2.4.All patients had Strasberg E3/E4injuries,and vascular injury was present in all cases.Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality.Mean time of follow up was 69.1 mo and after longterm follow up,eight patients are asymptomatic.CONCLUSION:Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.
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