Background
Laparoscopic liver resection (LLR) is reported as a safe procedure with potential advantages over open surgery albeit with inherent limitations, such as loss of haptic perception and ...spatial orientation. Ultrasound is considered the best tool to identify anatomic landmarks and the transection plane during liver surgery. The aim of this study was to analyse the outcomes of LLR performed with a standardized US guidance technique.
Methods
We have standardized a 4-step technique for ultrasound-guided LLR: (1) compose a 3-D mind map by studying relationships among lesions and surrounding anatomic structures, (2) sketch the map on the liver surface, (3) check, and (4) correct the transection plane in real time.
Results
Between 01/2006 and 12/2016, 190 consecutive patients treated with US-guided LLR were analysed. The indications for LLR included malignant tumours in 148 patients (81.8%). The procedures were classified according to a difficulty scale. There were 18 major hepatectomies (9.9%), 80 anatomic bi- and monosegmentectomies (44.2%), and 101 non-anatomic resections (55.8%). Redo resection was performed in 17 patients (9.4%), and multiple liver resections were performed in 25 patients (24.7%). Median intraoperative blood loss was 100 ± 154 mL. Overall and major morbidity rates were 14.9% and 1.6%, respectively. Mortality was nil.
Conclusions
Ultrasound liver map technique enables planning and real-time guidance during laparoscopic liver resections.
Background
Difficulty scores (DSs) have been proposed to rate laparoscopic liver resection (LLR) technical difficulty increasing surgical safety. The aim of the study was to validate three DSs ...(Hasegawa, Halls and Kawaguchi) and compare their ability to predict technical difficulty and postoperative outcomes.
Materials and methods
All patients who underwent LLR from January 2006 to January 2019 were analyzed. Exclusion criteria were cyst fenestrations, thermal ablation, missing data for the computation of the DS and a follow-up < 90 days.
Results
The population comprised 300 patients. The DS distribution in the study population was: Halls low 55 (18.3%), moderate 82 (27.3%), high 111 (37%) and extremely high 52 (17.3%); Hasegawa low 130 (43.3%), medium 105 (35%) and high 65 (21.7%); Kawaguchi Grade I 194 (64.7%), Grade II 47 (15.7%) and Grade III 59 (19.7%). Hasegawa and Kawaguchi showed the strongest correlation (
r
= 0.798,
p
< 0.001). Technical complexity, evaluated using the Pringle maneuver, Pringle time, blood loss and operative time, increased significantly with Hasegawa and Kawaguchi score classes (
p
< 0.001 for all comparisons). None of the scores properly stratified postoperative complications. The highest Kawaguchi (23.7% grade III vs. 13.7% grades I and II,
p
= 0.057) and Hasegawa (24.6% high vs. 13.2% low/medium,
p
= 0.025) classes had a higher overall morbidity rate than medium–low ones.
Conclusions
Kawaguchi and Hasegawa scores predicted LLR’s technical difficulty. None of the scores discriminated the postoperative complication risk of low classes compared with medium ones.
Background
Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come ...from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI.
Methods
All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results.
Results
Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2–10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS).
Conclusions
Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.
Background
To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies.
Methods
Since May 2015, PP was considered as the first option for ...venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed.
Results
Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270–960). Blood loss was a median 300 cc (range 40–1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22).
Conclusions
Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.
Background
The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to ...analyze correlations between anthropometric data and intraoperative outcomes.
Study design
All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes.
Results
Forty-one patients (wedge resection,
n
= 32; segmentectomy,
n
= 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (
r
= 0.655,
p
< 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (
r
= 0.372,
p
= 0.008) and anteroposterior abdominal diameter (
r
= 0.371,
p
= 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (
p
= 0.002) and shorter LLabd (
p
< 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (
r
= 0.382,
p
= 0.037) and blood loss (
r
= 0.352,
p
= 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (
r
= 0.577,
p
= 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757;
p
= 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes.
Conclusion
Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight.
Background
Laparoscopic segment 7 segmentectomy and segment 6–7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right ...posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach.
Methods
The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally.
Results
Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days.
Conclusions
The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.
Only a fraction of patients with metastatic colorectal cancer receive clinical benefit from therapy with anti-epidermal growth factor receptor (EGFR) antibodies, which calls for the identification of ...novel biomarkers for better personalized medicine. We produced large xenograft cohorts from 85 patient-derived, genetically characterized metastatic colorectal cancer samples ("xenopatients") to discover novel determinants of therapeutic response and new oncoprotein targets. Serially passaged tumors retained the morphologic and genomic features of their original counterparts. A validation trial confirmed the robustness of this approach: xenopatients responded to the anti-EGFR antibody cetuximab with rates and extents analogous to those observed in the clinic and could be prospectively stratified as responders or nonresponders on the basis of several predictive biomarkers. Genotype-response correlations indicated HER2 amplification specifically in a subset of cetuximab-resistant, KRAS/NRAS/BRAF/PIK3CA wild-type cases. Importantly, HER2 amplification was also enriched in clinically nonresponsive KRAS wild-type patients. A proof-of-concept, multiarm study in HER2-amplified xenopatients revealed that the combined inhibition of HER2 and EGFR induced overt, long-lasting tumor regression. Our results suggest promising therapeutic opportunities in cetuximab-resistant patients with metastatic colorectal cancer, whose medical treatment in the chemorefractory setting remains an unmet clinical need.
Direct transfer xenografts of tumor surgical specimens conserve the interindividual diversity and the genetic heterogeneity typical of the tumors of origin, combining the flexibility of preclinical analysis with the informative value of population-based studies. Our suite of patient-derived xenografts from metastatic colorectal carcinomas reliably mimicked disease response in humans, prospectively recapitulated biomarker-based case stratification, and identified HER2 as a predictor of resistance to anti-epidermal growth factor receptor antibodies and of response to combination therapies against HER2 and epidermal growth factor receptor in this tumor setting.
Background Outcomes in obese patients who underwent liver resection have been analyzed, but series are heterogeneous and data are controversial. The aim of this study was to analyze short-outcome in ...obese patients undergone hepatectomy for colorectal metastases. Study design A retrospective analysis on 1,021 consecutive hepatectomies between January 2000 and April 2014 for colorectal metastases was carried out. World Health Organization Classification of obesity (body mass index >30 kg/m2 ) was used to identify 140 obese patients. Outcomes were compared among obese and nonobese patients. Results Obese patients were mainly male (78%) and were associated more frequently with hypertension (51% vs 29%, P < .001), ischemic heart disease (9% vs 3%, P = .007), and diabetes (23% vs 10%, P < .001) compared with nonobese patients. Approximately 30% of patients underwent major hepatectomy in the 2 groups. Associated resections were performed in 36% of obese and 37% of nonobese patients. Median parenchymal transection time (80 ± 64 minutes vs 70 ± 50 minutes, P = .013) and blood loss (300 ± 420 vs 200 ± 282, P = .001) were greater in obese patients. Postoperative mortality was nil in obese patients and 0.6% in nonobese patients. Overall morbidity was greater in obese patients (41% vs 31%, P = .012) mainly related to pulmonary complications (16% vs 9%, P = .012). Reinterventions were more frequent in obese patients (3.6% vs 1.2%, P = .004). Median hospital stay was comparable. At pathologic examination, hepatic steatosis was greater in obese (69% vs 43%, P < .001). At multivariate analysis, age >65 years (odds ratio OR 1.43, 95% confidence interval 95% CI 1.09–1.88), obesity (OR 1.64, 95% CI 1.13–2.38), major hepatectomies (OR 1.65, 95% CI 1.31–2.33), and associated resections (OR 1.67, I95% CI 1.27–2.20) were independent predictors of overall morbidity ( P < .001). Among obese patients, there was a positive correlation between age and severity of complications (R = 0.173, P = .041). Conclusion Obese patients undergoing hepatectomy for colorectal metastases should be approached with caution because of an increased risk of postoperative morbidity.
Background
The role of extended resections in the management of advanced pancreatic neuroendocrine tumors (PNETs) is not well defined.
Methods
Between 1995 and 2012, 134 patients with PNET underwent ...isolated (isoPNET group: 91 patients) or extended pancreatic resection (synchronous liver metastases and/or adjacent organs) (advPNET group: 43 patients).
Results
The associated resections included 27 hepatectomies, 9 vascular resections, 12 colectomies, 10 gastrectomies, 4 nephrectomies, 4 adrenalectomies, and 3 duodenojejunal resections. R0 was achieved in 41 patients (95 %) in the advPNET. The rates of T3–T4 (73 vs 16 %;
p
< .0001) and N+ (35 vs 13 %;
p
= .007) were higher in the advPNET group. Mortality (5 vs 2 %) and major morbidity (21 vs 19 %) rates were similar between the 2 groups. The 5-year overall survival (OS) of the series was 87 % in the isoPNET group and 66 % in the advPNET group (
p
= .006). Only patients with both locally advanced disease and liver metastases showed worse survival (
p
= .0003). The advPNET group developed recurrence earlier disease-free survival (DFS) at 5 years: 26 vs 81 %;
p
< .001. In univariate analysis, negative prognostic factors of survival were: poor degree of differentiation (
p
< .001), liver metastasis (
p
= .011), NE carcinoma (
p
< .001), and resection of adjacent organs (
p
= .013). The multivariate analysis did not highlight any factor that influenced OS. In multivariate analysis independent DFS factors were a poor degree of differentiation (
p
= .03) and the European Neuroendocrine Tumor Society stage (
p
= .01).
Conclusions
An aggressive surgical approach for locally advanced or metastatic tumors is safe and offers long-term survival.
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