An optimal approach for major liver resections in patients with cystic echinococcosis

With the recent rapid increase in the prevalence of obesity, the number of obese patients requiring liver resection, including laparoscopy, has increased. Accordingly, evaluating the outcome of laparoscopic liver resection in obese patients is increasingly important. This study aimed to compare the safety and feasibility of laparoscopic major liver resection (LMR) and open major liver resection (OMR) in patients with a high body mass index (BMI > 25.0kg/m2). We reviewed 521 patients with high BMI (> 25.0kg/m2) who underwent major liver resection for various indications between January 2009 and November 2018 at Asan Medical Center. We performed 1:1 propensity score matching of the LMR and OMR groups, with 120 patients subsequently included in each group. LMR was associated with lower blood loss and shorter postoperative hospital stays (p < 0.001). Although there was no significant difference in overall complications (p = 0.080), non-liver-specific complications were observed less frequently after LMR (p = 0.025). American Society of Anesthesiologists class > II, BMI > 30kg/m2, and malignancy were independent predictors of morbidity. In a subgroup analysis of patients with hepatocellular carcinoma, there was no significant difference between the two groups in overall survival (hazard ratio 0.225; 95% confidence interval 0.049-1.047; p = 0.057) and recurrence-free survival (hazard ratio 0.761; 95% confidence interval 0.394-1.417; p = 0.417). Obesity should not be considered a contraindication for major liver resection using a laparoscopic approach; however, when applying this approach for resecting malignancies in patients with a BMI > 30kg/m2 and comorbid diseases, special attention should be paid to the possibility of complications.

Is hepatic venous pressure gradient assessment required before liver resection in patients with cirrhosis and hepatocellular carcinoma?

Liver resection in cirrhotic patients is associated with increased morbidity and mortality. The objective of this study was to compare short-term results of laparoscopic resection (LR) and open surgery (OS) for minor liver resection in patients with hepatocellular carcinoma (HCC) hepatocellularcarcinoma on nontumor cirrhotic liver (HCC/F4) and patients with colorectal cancer liver metastases (CRLMs) colorectal liver metastases on healthy liver (CRLM/F0). Between January 2005 and December 2014, all patients undergoing liver resection (n = 754) were included in this study. Liver resections for cholangiocarcinoma or benign tumor, major liver resection (≥3 segments), HCC on healthy liver, CRLM on cirrhotic liver, and liver resection with technically difficult accessibility (segments I, VII, and VIII) were excluded. The primary endpoint of the study was a validated composite endpoint (CEP), which included specific liver surgery complications (Clavien ≥III), allowing comparison of the postoperative course after LR versus OR for HCC/F4 patients and CRLM/F0 patients using propensity score (PS) analysis. Secondary endpoints were major postoperative morbidity according to the Clavien-Dindo classification (≥III) and intensive care unit (ICU) length of hospital stay (LOS) and overall LOS. The test group was defined as HCC/F4 patients operated by LR, and the control group was defined as HCC/F4 patients and CRLM/F0 patients operated by OS and CRLM/F0 patient operated by LR. Sixty patients (38.7%) underwent LR and 95 patients (61.3%) underwent OS. Surgery was performed for CRLM in 93 patients (60%) and for HCC in 62 patients (40%). No difference was demonstrated between HCC/F4 patients and CRLM/F0 patients in the LR group in terms of the CEP (7% versus 18.1%; P = .23), while a significant difference for the CEP was observed between HCC/F4 patients and CRLM/F0 patients after OS (50% versus 21%; P = .021). A higher rate of CEP was observed for HCC/F4 patients operated by OS compared to HCC/F4 patients operated by LR (50% versus 7.8%; P = .009). No significant difference in Clavien-Dindo score ≥III was observed between HCC/F4 patients and CRLM/F0 patients operated by LR (10% versus 4.5%; P = .98). A higher postoperative ascites rate was observed for HCC/F4 patients operated by OS compared to CRLM/F0 patients operated by OS (25% versus 2.8%; P = .006). This difference was no longer observed when HCC/F4 patients were compared to CRLM/F0 operated by LR (7.8% versus 2.8%; P = .09). The postoperative mortality rate was 1.8% and was not correlated with nontumor liver or surgical approach. A shorter LOS was observed for HCC/F4 patients operated by LR compared to HCC/F4 patients operated by OS (7.53 versus 17.13; P = .011). The laparoscopic approach for malignant liver tumor is associated with a lower specific complication rate. LR for HCC/F4 could eliminate excess morbidity and decrease LOS in patients with cirrhotic liver.

Impact of body composition on survival and morbidity after liver resection in hepatocellular carcinoma patients

Liver resection (LR) and liver transplantation (LT) are considered the only two potentially curative treatments for hepatocellular carcinoma (HCC). Recently, there has been an intense debate as to whether LR or LT is the optimal initial treatment for patients with Child A or B cirrhosis. The aim of this study was to compare the results of LR and LT in patients with HCC and with Child A or B cirrhosis in a single center over a 10-year period. Seventy-eight patients were treated with LT and 130 were treated with LR. We evaluated patient characteristics, short-term results such as hospital stay, postoperative complication, mortality, and long-term results such as overall and recurrence-free survival and recurrence. The hospital stay of the LT group was significantly longer than that of the LR group (P < 0.001). The postoperative complication rate and the early operative mortality rate were similar between the two groups. The overall survival rate was higher after LT than it was after LR, but not to a statistically significant degree (P = 0.267). The recurrence-free survival rate was significantly higher after LT than it was after LR (P = 0.002). Within and beyond the Milan criteria, the overall survival rate was higher after LT than it was after LR, but not to a statistically significant degree. The recurrence-free survival rate was significantly higher after LT than it was after LR in the patients within Milan criteria (P < 0.001). HCC recurred more frequently after resection (51.5%) than it did after transplantation (29.5%) (P < 0.001), and HCC recurrence developed in the liver more frequently after LR than it did after LT (P = 0.002). However, after recurrence, LR had better survival than LT did, but not to a statistically significant degree (P = 0.177). LT should be considered as the primary treatment in patients with HCC within the Milan criteria. LR is recommended for patients with HCC beyond the Milan criteria. The LT group showed a significantly lower recurrence rate than the LR group. However, in the case of recurrence, the LT group showed a poorer long-term outcome than the LR group.

Radio-frequency assisted liver partition with portal vein embolization in staged liver resection (RALPPS) in patients with hilar and intrahepatic cholangiocarcinoma

Background:Transarterial chemoembolisation (TACE) is the primary treatment for intermediate-stage hepatocellular carcinoma (HCC), according to the updated Barcelona Clinic Liver Cancer (BCLC) staging system. Although growing evidence favours liver resection (LR) over TACE for intermediate-stage HCC, the best treatment option remains controversial. This meta-analysis aimed to compare the overall survival (OS) after LR versus TACE for intermediate-stage HCC.Methods:A comprehensive literature review of PubMed, Embase, Cochrane Library, and Web of Science was performed. Studies that compared the efficacy of LR and TACE in patients with intermediate (BCLC stage B) HCC were selected. According to the recent updated BCLC classification, intermediate stage of HCC was defined as follows: (a) four or more HCC nodules of any size, or (b) two or three nodules, but if at least one tumour is larger than 3 cm. The main outcome was OS, expressed as the hazard ratio.Results:Nine eligible studies of 3355 patients were included in the review. The OS of patients who underwent LR was significantly longer than that of patients who underwent TACE (hazard ratio=0.52; 95% CI: 0.39–0.69; I2=79%). Prolonged survival following LR was confirmed after sensitivity analysis of five studies using propensity score matching (HR=0.45; 95% CI: 0.34–0.59; I2=55%).Conclusion:Patients with intermediate-stage HCC who underwent LR had a longer OS that those who underwent TACE. The role of LR in patients with BCLC stage B should be clarified in future randomised controlled trials.

Antiviral therapy improves survival in patients with HBV infection and intrahepatic cholangiocarcinoma undergoing liver resection

The aim of this study was to compare the postoperative outcome and long-term results after management of liver hydatid cyst by radical and non-radical surgeries. From January 2015 to December 2017, 86 patients were treated with various surgical interventions for liver hydatid cyst. These patients were retrospectively divided into two groups according to the surgical method for treatment: radical methods (e.g., liver resection and pericystectomy) and non-radical methods (e.g., echinococcectomy). Of the 86 patients, 50 (58%) underwent radical treatment and 36 (42%) underwent non-radical treatment. Clinical data and outcomes were retrospectively analyzed. Eighty (93%) patients were considered to have been completely cured of their hydatid disease. Surgery duration in the non-radical treatment group was significantly shorter than in the radical treatment group (p < 0.01). There were no cases of biliary leakage in the liver resection patients during the postoperative period. In contrast, among the echinococcectomy patients, biliary leakage occurred in 6 (16.7%), which was significantly higher than with other modalities (p < 0.05). Recurrence occurred at a median of 32 months after surgery. Recurrent liver hydatid disease occurred in 6 cases (7%): radical group, 1 (2%); non-radical group, 5 (13.9%). There were no mortalities in either group in the postoperative period. Postoperative hospital stay was significantly shorter in the liver resection patients than in the other patients (p < 0.01). Radical surgical treatment of liver hydatid cyst is more effective than non-radical surgery, resulting in a reduced recurrence rate, reduced postoperative complication rate, and early recovery of patients.

Simple SummaryPerihilar cholangiocarcinoma (pCCA) is a relatively rare and aggressive hepatobiliary tumor with a general poor prognosis. Surgical therapy remains the only curative treatment option with the best prospects for long-term survival. However, tumor recurrence is frequent, and is associated with a poor prognosis. The identification of risk factors as well as appropriate selection of surgical candidates is essential to accurately predict prognosis and to maximize survival while decreasing tumor recurrence rates. Previous studies have already established a link between an increased BMI and the occurrence of various tumors. At present, data on BMI-associated long-term outcome following curative liver resection in pCCA patients are warranted. This study aims to investigate the impact of increased BMI on patient’s outcome, especially on tumor recurrence, following liver resection in patients with pCCA as well as to evaluate prognostic and risk factors for accurate prediction of outcome in this selective group of patients.Background: The association of body mass index (BMI) and long-term prognosis and outcome of patients with perihilar cholangiocarcinoma (pCCA) has not been well defined. The aim of this study was to evaluate clinicopathologic and oncologic outcomes with pCCA undergoing resection, according to their BMI. Methods: Patients undergoing liver resection in curative intention for pCCA at a tertiary German hepatobiliary (HPB) center were identified from a prospective database. Patients were classified as normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2) and obese (>30 kg/m2) according to their BMI. Impact of clinical and histo-pathological characteristics on recurrence-free survival (RFS) were assessed using Cox proportional hazard regression analysis among patients of all BMI groups. Results: Among a total of 95 patients undergoing liver resection in curative intention for pCCA in the analytic cohort, 48 patients (50.5%) had normal weight, 33 (34.7%) were overweight and 14 patients (14.7%) were obese. After a median follow-up of 4.3 ± 2.9 years, recurrence was observed in totally 53 patients (56%). The cumulative recurrence probability was higher in obese and overweight patients than normal weight patients (5-year recurrence rate: obese: 82% versus overweight: 81% versus normal weight: 58% at 5 years; p = 0.02). Totally, 1-, 3-, 5- and 10-year recurrence-free survival rates were 68.5%, 44.6%, 28.9% and 13%, respectively. On multivariable analysis, increased BMI (HR 1.08, 95% CI: 1.01–1.16; p = 0.021), poor/moderate tumor differentiation (HR 2.49, 95% CI: 1.2–5.2; p = 0.014), positive lymph node status (HR 2.01, 95% CI: 1.11–3.65; p = 0.021), positive resection margins (HR 1.89, 95% CI:1.02–3.4; p = 0.019) and positive perineural invasion (HR 2.92, 95% CI: 1.02–8.3; p = 0.045) were independent prognostic risk factors for inferior RFS. Conclusion: Our study shows that a high BMI is significantly associated with an increased risk of recurrence after liver resection in curative intention for pCCA. This factor should be considered in future studies to better predict patient’s individual prognosis and outcome based on their BMI.

Very few reports have evaluated the safety of laparoscopic liver resection in super-elderly patients. We assessed the short-term outcomes of laparoscopic liver resection in patients with hepatocellular carcinoma aged ≥80 years, using propensity score matching. We retrospectively analyzed the data of 287 patients (aged ≥80 years) who underwent liver resection for hepatocellular carcinoma at eight hospitals belonging to Hiroshima Surgical study group of Clinical Oncology, between January 2012 and December 2021. The perioperative outcomes were compared between laparoscopic and open liver resection, using propensity score matching. Of the 287 patients, 83 and 204 were included in the laparoscopic and open liver resection groups, respectively. Propensity score matching was performed, and 52 patients were included in each group. The operation (p = .68) and pringle maneuver (p = .11) time were not different between the groups. There were no significant differences in the incidences of bile leakage or organ failure. The laparoscopic liver resection group had significantly less intraoperative bleeding and a lower incidence of cardiopulmonary complications (both p < .01). Laparoscopic liver resection can be safely performed in elderly patients aged ≥80 years.

Background Hepatocellular carcinoma (HCC) usually occurs within an underlying chronic liver disease such as cirrhosis with limited liver function. Liver resection is an effective treatment option. Most studies investigating the benefits of anatomic (ALR) versus non-anatomic (NALR) liver resections in cirrhotic HCC patients involve Asian populations with different underlying chronic liver diseases. Aims NALR limits the resection of liver parenchyma, and therefore could reduce postoperative liver failure, while the effects on survival rates remain unclear. European data are desperately needed. Methods This is a retrospective and prospective multicentre cohort study, including all patients undergoing liver resection for HCC between 2009 and 2020 from 3 specialised centres in Switzerland and Germany. Patients were stratified for cirrhosis and no cirrhosis. Complications and survival rates were analysed using univariate and multivariate Cox regression models. Results 298 patients were included. Median follow-up time was 52.76 months. 158/298 (53%) patients presented with cirrhosis. Cirrhotic patients after ALR (n=64/158) showed a significantly longer ICU stay (p=0.017) and postoperative in-hospital stay (p=0.007) compared to after NALR (n=94/158), while the NALR group showed significantly more postoperative complications (p&amp;lt;0.001), but the rate of liver insufficiency was not significantly different after NALR versus ALR (p=0.846). Overall survival (OS) and recurrence free survival (RFS) in cirrhotic versus non-cirrhotic patients were not significantly different (adjusted HR 0.78 (95% CI 0.53-1.15, p=0.21) and adjusted HR 0.82 (95% CI 0.64-1.24, p=0.27), respectively). A trend towards better OS and RFS could be observed favouring NALR in cirrhotic patients (for OS adjusted HR 0.55 (95% CI 0.28-1.07, p=0.08) and for RFS adjusted HR 0.55 (95% CI 0.30-1.01, p=0.06)). Conclusions European patients with cirrhosis could benefit from NALR regarding longer OS and RFS. NALR is associated with a significantly higher complication rate compared to ALR, but not with a higher rate of postoperative liver insufficiency.

This study aimed to investigate the predictive factors and classifications for difficulty of laparoscopic repeated liver resection (LRLR) in patients with recurrent hepatocellular carcinoma. Sixty patients who underwent LRLR were included. Potential predictive factors for difficult LRLR included the approach of the previous liver resection (laparoscopic or open), the number of previous liver resections, a history of cholecystectomy in previous liver resection, the operative procedure of previous liver resection, whether the tumor was near the resected site of the previous liver resection, non-surgical treatments before the present surgery, and the difficulty scoring system for laparoscopic liver resection. The relationship between these factors and perioperative outcomes were evaluated to investigate the predictive factor for difficult LRLR. Univariate and multivariate analyses demonstrated that an open approach during previous liver resection, two or more previous liver resections, a history of previous liver resection with not less than sectionectomy, tumor near the resected site of the previous liver resection, and intermediate or high difficulty in the difficulty scoring system were independent risk factors for prolonged operative time and/or severe adhesion of LRLR. Three difficulty classifications were then suggested based on the number of these five predictive factors. The difficulty classification reflected operative time, intraoperative blood loss, and incidence of postoperative complication. The difficulty of LRLR may be predicted by three difficulty classifications using five preoperative predictive factors.

Background/Aims: Liver transplantation (LT) is promising method of treatment for hepatocellular carcinoma (HCC) patients, but is limited by donor organ shortages and tumor progression during long wait periods. This study investigated the efficacy of salvage living donor LT (LDLT) after initial liver resection (LR) in HCC patients. Methods: Sixty patients with HCC who underwent primary LDLT (n = 45) or salvage LDLT after initial LR (n = 15) were enrolled. Significant prognostic variables determined by univariate analysis were subjected to multivariate analysis using a Cox proportional hazard regression model. Cox proportional hazards models with inverse probability of treatment weighting (IPTW) based on propensity score were used to adjust for selection bias between groups. Results: The salvage group had significantly higher Child-Pugh class A (p = 0.003), ≥3 pretransplant treatments (p = 0.007), and reoperation rates for postoperative bleeding (p = 0.032) than the primary LDLT group, whereas overall and recurrence-free survival rates were comparable. After IPTW matching, the salvage LDLT group had significantly more reoperations for postoperative bleeding (hazard ratio 7.948, p = 0.017). Conclusions: First-line LR followed by salvage LDLT allows survival equal to that of primary LDLT. Salvage LDLT following primary LR could be an effective therapy.

Post-resection recurrence of hepatocellular carcinoma in cirrhotic patients: Is thrombocytopenia a risk factor for recurrence?