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.
Abstract Background The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually ...follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. Study Design This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at two centers from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of i ) hepatic insufficiency and ii ) liver failure–related death. Results The study included 133 patients with right or left major (n=67) or extended (n=66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III-IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them of liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p<0.05) were preoperative cholangitis (odds ratio OR=3.2), future liver remnant (FLR) volume <30% (OR=3.5), preoperative total bilirubin level >3 mg/dl (OR=4), and albumin level <3.5 mg/dl (OR=3.3). Only preoperative cholangitis (OR=7.5, p=.016) and FLR volume <30% (OR=7.2, p=.019) predicted postoperative liver failure–related death. Conclusions Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure–related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.
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
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
The liver-first approach in patients with synchronous colorectal liver metastases (CRLM) has gained wide consensus but its role is still to be clarified. We aimed to elucidate the outcome ...of the liver-first approach and to identify patients who benefit at most from this approach.
Methods
Patients with synchronous CRLM included in the LiverMetSurvey registry between 2000 and 2017 were considered. Three strategies were analyzed, i.e. liver-first approach, colorectal resection followed by liver resection (primary-first), and simultaneous resection, and three groups of patients were analyzed, i.e. solitary metastasis, multiple unilobar CRLM, and multiple bilobar CRLM. In each group, patients from the three strategy groups were matched by propensity score analysis.
Results
Overall, 7360 patients were analyzed: 4415 primary-first, 552 liver-first, and 2393 simultaneous resections. Compared with the other groups, the liver-first group had more rectal tumors (58.0% vs. 31.2%) and higher hepatic tumor burden (more than three CRLMs: 34.8% vs. 24.0%; size > 50 mm: 35.6% vs. 22.8%;
p <
0.001). In patients with solitary and multiple unilobar CRLM, survival was similar regardless of treatment strategy, whereas in patients with multiple bilobar metastases, the liver-first approach was an independent positive prognostic factor, both in unmatched patients (3-year survival 65.9% vs. primary-first 60.4%: hazard ratio HR 1.321,
p =
0.031; vs. simultaneous resections 54.4%: HR 1.624,
p <
0.001) and after propensity score matching (vs. primary-first: HR 1.667,
p =
0.017; vs. simultaneous resections: HR 2.278,
p =
0.003).
Conclusion
In patients with synchronous CRLM, the surgical strategy should be decided according to the hepatic tumor burden. In the presence of multiple bilobar CRLM, the liver-first approach is associated with longer survival than the alternative approaches and should be evaluated as standard.
Background
Liver surgery is the gold-standard treatment of colorectal liver metastases. Five-year survival rates may be inadequate to evaluate surgical outcomes because some patients are alive with ...recurrence and late recurrences are possible. The aim of this study was to analyze 10-year survival outcome in terms of late recurrence rate and prognostic factors of survival.
Methods
One hundred twenty-five patients underwent liver resection for colorectal liver metastases between 1985 and 1996. Four patients who experienced postoperative mortality were excluded. The analysis was performed on 121 patients.
Results
Five- and 10-year survival rates were 23.1% and 15.7%, respectively. Nineteen patients were alive 10 years after liver resection and 17 were disease-free (5 after re-resection). Five- and 10-year disease-free survival rates were 17.4% and 14.8%, respectively. In patients with recurrence, re-resection significantly improved survival (
P
< 0.001); 98% of recurrences occurred within the first 5 years, but 15% of patients disease-free at 5 years developed later recurrence. Multivariate analysis evidenced five independent negative prognostic factors of survival: male sex (
P
= 0.029), synchronous metastases (
P
= 0.011), >3 metastases (
P
< 0.001), metastatic infiltration of nearby structures (
P
< 0.001), and postoperative morbidity (
P
< 0.001). In 17 patients without negative prognostic factors the 10-year survival rate was 35.3%.
Conclusion
Liver resection for colorectal liver metastases may be curative in more than one-third of patients without negative prognostic factors. Postoperative morbidity significantly worsens long-term outcomes. The risk of recurrence after liver resection is high even after 5 years of follow-up, but re-resection can improve the outcome.
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
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.
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.
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