Background
Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could ...offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).
Methods
Data for all patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were reviewed retrospectively. Risk factors for conversion were determined using multivariable analysis. After propensity score matching, the outcomes of patients who underwent conversion were compared with those of matched patients undergoing laparoscopic hepatectomy who did not have conversion, operated on at the same centres, and also with matched patients operated on at another tertiary centre during the same period by an open laparotomy approach.
Results
Conversion was needed in 30 (13·5 per cent) of the 223 patients undergoing LMH. The most frequent reasons for conversion were bleeding and failure to progress, in 14 (47 per cent) and nine (30 per cent) patients respectively. On multivariable analysis, risk factors for conversion were patient age above 75 years (hazard ratio (HR) 7·72, 95 per cent c.i. 1·67 to 35·70; P = 0·009), diabetes (HR 4·51, 1·16 to 17·57; P = 0·030), body mass index (BMI) above 28 kg/m2 (HR 6·41, 1·56 to 26·37; P = 0·010), tumour diameter greater than 10 cm (HR 8·91, 1·57 to 50·79; P = 0·014) and biliary reconstruction (HR 13·99, 1·82 to 238·13; P = 0·048). After propensity score matching, the complication rate in patients who had conversion was higher than in patients who did not (75 versus 47·3 per cent respectively; P = 0·038), but was not significantly different from the rate in patients treated by planned laparotomy (79 versus 67·9 per cent respectively; P = 0·438).
Conclusion
Conversion during LMH should be anticipated in patients with raised BMI, large lesions and biliary reconstruction. Conversion does not lead to increased morbidity compared with planned laparotomy.
Conversion does not increase morbidity
Among various reported techniques for inferior vena cava (IVC) reconstruction, the superiority of one technique over another has not been clearly established. This study aimed at reporting the ...technical aspects of caval reconstruction using peritoneal patch during extended liver resections.
All consecutive patients who underwent extended liver resection associated with anterolateral caval reconstruction using a peritoneal patch from 2016 to 2019 were included in this study. Technical insights, intra-operative details, short and long-term results were reported.
Overall six patients underwent caval reconstruction using peritoneal patch under total vascular exclusion. Half of them required veno-venous bypass. Caval involvement ranged from 30 to 50% of the circumference and from 5 to 7 cm of the length of the IVC. Caval reconstructions was performed using a peritoneal patch harvested from the falciform ligament in four cases and from the right pre-renal peritoneum and right part of the diaphragm in one Case each. Three cases underwent associated reimplantation the remnant hepatic vein. Median intra-operative blood loss and TVE duration were 500 ml and 41 min, respectively. One case experienced a severe complication (liver failure leading to death). R0 resection was achieved in all patients. All patients had patent IVC and remnant hepatic vein at last follow-up and none was on long-term therapeutic anticoagulation.
Caval reconstruction using a peritoneal patch in patients undergoing extended liver resection is feasible and cost-effective and associated with excellent long-term results.
•The peritoneal patch is a safe and cost-effective graft for caval reconstruction.•Its plasticity makes it suitable for hepato-caval confluent reconstructions.•Falciform ligament should be harvested in Case of anticipated caval involvement.
Background
The aim was to analyse the impact of cirrhosis on short‐term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.
Methods
This retrospective study ...included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short‐term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.
Results
Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).
Conclusion
Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.
Antecedentes
El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional.
Métodos
Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non‐cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección.
Resultados
Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post‐hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92‐0,41; P = 0,096) y de
PHLF (OR 7,13; i.c. del 95% 0,91‐323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08‐48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14‐0,76; P = 0,010) pacientes CL.
Conclusión
La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.
The aim was to analyse the impact of cirrhosis on short‐term outcomes after laparoscopic liver resection in a multicentre national cohort study. Short‐term outcomes of patients with and without cirrhotic liver were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection. Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing laparoscopic liver resection, even in expert centres.
Cirrhosis leads to impaired outcomes even in expert centers
Background
Quantification of liver surface nodularity (LSN) on routine preoperative CT images allows detection of cirrhosis and clinically significant portal hypertension. This study aimed to assess ...the relevance of LSN in preoperative assessment of operative risks for patients with resectable hepatocellular carcinoma (HCC).
Methods
All patients undergoing hepatectomy for HCC between 2012 and 2017 were analysed retrospectively. LSN was assessed at the liver–fat interface on the left liver lobe on preoperative CT images. The feasibility of LSN quantification was assessed. The association between LSN and outcomes (severe complications and posthepatectomy liver failure (PHLF)) was evaluated by multivariable analysis and after propensity score matching.
Results
Among 210 patients, LSN measurement was successful in 187 (89·0 per cent). Among these, the median LSN score was 2·42 (i.q.r. 2·21–2·66) and 52·9 per cent had severe fibrosis, including 33·7 per cent with cirrhosis. LSN score increased with hepatic venous pressure gradient (P = 0·048), severity of steatosis (P = 0·011) and fibrosis grade (P = 0·001). LSN score was independently associated with severe complications (odds ratio (OR) 5·25; P = 0·006) and PHLF (OR 6·78; P = 0·003). After matching with respect to model for end‐stage liver disease, aspartate aminotransferase‐to‐platelet ratio index and fibrosis‐4 score, patients with a LSN score of 2·63 or higher retained an increased risk of PHLF (OR 5·81; P = 0·018). In the subgroup of patients without severe fibrosis, LSN was accurate in predicting severe complications (P = 0·005). Patients with (P = 0·039) or without (P = 0·018) severe fibrosis with increased LSN score had a higher comprehensive complication index score. Among patients with cirrhosis who had clinically significant portal hypertension, a LSN value below 2·63 ruled out the risk of PHLF.
Conclusion
LSN measurement represents a practical tool that may allow improvement in the preoperative evaluation and management of patients with HCC.
Antecedentes
La cuantificación de la nodularidad de la superficie hepática (liver surface nodularity, LSN) en las imágenes de la tomografía computarizada (TC) de rutina preoperatoria permite detectar la cirrosis y la hipertensión portal clínicamente significativa (clinically significant portal hypertension, CSPH). Este estudio tuvo como objetivo evaluar la relevancia de la LSN en la evaluación preoperatoria del riesgo quirúrgico en pacientes con carcinoma hepatocelular resecable (hepatocellular carcinoma, HCC).
Métodos
Todos los pacientes sometidos a hepatectomía por HCC entre 2012 y 2017 fueron analizados de forma retrospectiva. La LSN se evaluó en la interfase hígado‐grasa en el lóbulo hepático izquierdo en la TC preoperatoria. Se evaluó la viabilidad de la cuantificación de la LSN. La asociación entre la LSN y los resultados (complicaciones graves e insuficiencia hepática poshepatectomía (post‐hepatectomy liver failure, PHLF) se analizó en un análisis multivariable y después del método de emparejamiento por puntaje de propensión.
Resultados
Del total de 210 pacientes, la medición de la LSN fue exitosa en 187 (89,0%). En estos pacientes, la mediana de LSN fue de 2,42 (rango intercuartílico 2,21‐2,66) y el 53,0% tenía fibrosis severa, incluyendo un 33,7% con cirrosis. La LSN aumentó con el gradiente de presión venosa hepática (P = 0,048), la gravedad de la esteatosis (P = 0,011) y el grado de fibrosis (P = 0,001). La LSN se asoció de forma independiente con complicaciones graves (razón de oportunidades, odds ratio, OR = 5,25; P = 0,006) y PHLF (OR = 6,78; P = 0,003). Después de emparejar para el modelo de enfermedad hepática terminal, el índice de relación aspartato amino transferase‐plaquetas y el grado de fibrosis‐4, los pacientes con LSN ≥ 2,63 mantuvieron un mayor riesgo de PHLF (OR = 5,81; P = 0,018). Dentro del subgrupo de pacientes sin fibrosis severa, la LSN fue precisa en predecir complicaciones graves (P = 0,005). Los pacientes con (P = 0,039) y sin (P = 0,018) fibrosis severa con aumento de la LSN tuvieron un índice de complicación global más alto. De los pacientes cirróticos con CSPH, un valor de LSN de 2,63 descartó el riesgo de PHLF.
Conclusión
La LSN representa una herramienta práctica, que puede permitir mejorar la evaluación preoperatoria y el manejo de pacientes con HCC.
Liver surface nodularity (LSN) quantification on routine preoperative CT images allows detection of cirrhosis and clinically significant portal hypertension. In 187 patients with resectable hepatocellular carcinoma (HCC), LSN was associated with severe postoperative complications and predicted liver failure independently of preoperative liver biology. This study showed that LSN is a practical tool, which may allow improved preoperative evaluation and management of patients with HCC.
Suitable for risk assessment
Purpose
The purpose of this study is to review indications and results of surgical treatments of hepatocellular carcinoma (HCC). This tumor, which represents one of the most common malignancies ...worldwide, is characterized by its prominent development in patients with chronic liver disease (CLD). Liver transplantation (LT) is considered as the ideal treatment of limited HCC removing both tumor(s) and the pre-neoplasic underlying diseased liver. However, this treatment, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. The risk of recurrence is minimized in patients fulfilling the Milan criteria with a tendency to accept slight expansion of size in patients with favourable natural history and low AFP level. Increasing duration in the waiting list before LT leads several teams to use neoadjuvant therapies such as percutaneous ablation, TACE and liver resection. Liver resection in cirrhotic patients with good liver function remains the most available efficient treatment of patients with HCC. Better liver function assessment, understanding of the segmental liver anatomy with more accurate imaging studies and surgical technique refinements are the most important factors that have contributed to reduce mortality with an expecting 5 years survival of 70%. There is considerable interest in combined treatment associating resection and LT. Transplantable patients with good liver function should be considered for liver resection as primary therapy and for LT in case of tumor recurrence. This salvage strategy is refined using pathological analysis of the resected specimen which identifies histological pejorative factors allowing selecting patients who should transplanted before recurrence.
Conclusions
The improvement of survival in HCC patients after surgical treatment results from refinements in surgical technique and better identification of adverse prognostic factors.
Asymptomatic right diaphragmatic rupture with liver and gallbladder herniation and secondary Budd-Chiari syndrome is a rare complication of abdominal trauma. In this setting, the management of ...gallbladder stones remains poorly described and may require a thoracic approach.
Metabolic syndrome and hepatic surgery Hobeika, C.; Ronot, M.; Beaufrere, A. ...
Journal of visceral surgery,
06/2020, Letnik:
157, Številka:
3
Journal Article
Recenzirano
•Non-alcoholic fatty liver disease (NAFLD), a hepatic manifestation of metabolic syndrome, currently represents a major problem in liver disease.•Metabolic syndrome and NAFLD are major risk factors ...for the development of hepatocellular carcinoma and intrahepatic cholangiocarcinoma.•Non-alcoholic steatohepatitis (NASH) is becoming the most frequent cause of liver transplantation in Western countries.•Patients with metabolic syndrome and/or NAFLD are subject to heightened operative risk after liver resection and transplantation and need to be provided with adequately targeted evaluation and perioperative management.
In Europe, the prevalence of metabolic syndrome (MS) has reached the endemic rate of 25%. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of MS. Its definition is histological, bringing together the different lesions associated with hepatic steatosis (fat deposits on more than 5% of hepatocytes) without alcohol consumption and following exclusion of other causes. MS and NAFLD are implicated in the carcinogenesis of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). At present, HCC and ICC involving MS represent 15–20% and 20–30% respectively of indications for hepatic resection in HCC and ICC. Moreover, in the industrialized nations NAFLD is tending to become the most frequent indication for liver transplantation. MS patients combine the operative risk associated with their general condition and comorbidities and the risk associated with the presence and/or severity of NAFLD. Following hepatic resection in cases of HCC and ICC complicating MS, the morbidity rate ranges from 20 to 30%, and due to cardiovascular and infectious complications, post-transplantation mortality is heightened. The operative risk incurred by MS patients necessitates appropriate management including: (i) precise characterization of the subjacent liver; (ii) an accurately targeted approach privileging detection and optimization of treatment taking into account the relevant cardiovascular risk factors; (iii) a surgical strategy adapted to the histology of the underlying liver, with optimization of the volume of the remaining (postoperative) liver.
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