Left extended hepatectomy (H123458-B) versus right extended hepatectomy (H145678-B) for hilar cholangiocarcinoma: A single center comparative analysis of surgical outcomes and survival.

Segment 5 (S5) sparing liver resection for cases that require an anatomic left trisectionectomy has not been reported yet. The authors intended to verify the outcome of S5-sparing extended left hepatectomy (ELH) in respect to venous outflow. All adult patients who underwent S5-sparing ELH between 2012 and 2017 in authors' institute have been enrolled in this study. S5-sparring ELH was defined as resection of S2, S3, S4, and S8 with or without S1. The surgery planning was based on the images from two-dimensional triphasic computed tomography and/or magnetic resonance imaging. A three-dimensional image reconstruction and liver volumetric study were performed retrospectively. Out of 177 cases of major hepatic resection, only seven non-hilar cholangiocarcinoma patients underwent ELH during the study period. S5-sparing ELH was performed to five patients, in whom no tumor involvement in S5. The venous outflow of S5 has been maintained intraoperative, and S5 congestion has not been observed in all patients. Tailored management of the S5 venous outflow ensured an increase in functional remnant liver volume by 52.8% (range, 25.6 to 66.9%) by sparing of S5. A negative resection margin was achieved in all patients. One patient had postoperative bile leak requiring reoperation. No posthepatectomy liver failure (PHLF) has been observed. S5-sparing ELH is technically feasible. Under the tailored management of S5 venous outflow, the functional future liver remnant can be increased. Further studies with larger sample size are needed to evaluate which circumstances the liver segment 5 could be preserved without venous reconstruction during the left extended hepatectomy.

BackgroundExtended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal.MethodsFor this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed.ResultsSeventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients).ConclusionExtended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Surgical Outcomes of Hepatectomy with Vascular Resection for Colorectal Liver Metastases

Endoscopic management of major bile leaks complicating hepatic resections for hepatocellular carcinoma

Impact of the future liver remnant volume before major hepatectomy

BackgroundThe role of portal vein embolization to increase future liver remnant (FLR) is well-established in the treatment of colorectal liver metastases. However, the role of hepatic vein embolization is unclear.Case reportA patient with colorectal liver metastases received neoadjuvant chemotherapy prior to attempted resection. At the time of resection his tumor appeared to invade the left and middle hepatic vein, requiring an extended left hepatectomy including segments five and eight. Post-operatively, he underwent sequential left portal vein embolization followed by left hepatic vein embolization and finally, middle hepatic vein embolization. Hepatic vein embolization was performed to increase the FLR as well as to allow collateral drainage of the FLR to develop. A left trisectionectomy was then performed and no evidence of postoperative liver congestion or morbidity was found.ConclusionSequential portal vein embolization and hepatic vein embolization for extended left hepatectomy may be considered to increase FLR and may prevent right hepatic congestion after sacrificing the middle vein.

Posthepatectomy liver failure (PHLF) may occur after extended partial hepatectomy (PH). If malignancy is widespread in the liver, the size of PH and hence the size of the future liver remnant (FLR) may limit curability. We aimed to characterize differences in protein expression between different sizes of FLRs and identify proteins specific to the regenerative process of minimal-size FLR (MSFLR), with special focus on postoperative day (POD) 1 when PHLF is present. A total of 104 male Wistar rats were subjected to 30, 70, or 90% PH (MSFLR in rats), sham operation, or no operation. Blood and liver tissue were harvested at POD1, 3, and 5 (n = 8 per group). Protein expression was assessed by proteomic profiling by unsupervised two-dimensional polyacrylamide gel electrophoresis (2D-PAGE) liquid chromatography tandem mass spectrometry (LC-MS/MS), followed by supervised selected reaction monitoring (SRM)-MS/MS. In all, 1,035 protein spots were detected, 54 of which were significantly differentially expressed between groups and identifiable. During PHLF after PH(90%) at POD1, urea cycle and related proteins showed significant perturbations, including the urea cycle flux-regulating enzyme of carbamoyl phosphate synthase-1, ornithine transcarbamylase, and arginase-1, as well as the ornithine aminotransferase and propionyl-CoA carboxylase alpha chain. Plasma-ammonia increased significantly at POD1 after PH(90%), followed by a prompt decrease. At the protein level, we found perturbations of urea cycle and related enzymes in the MSFLR during PHLF. Our results suggest that these perturbations may augment urea cycle function, which may be pivotal for increased ammonia elimination after extensive PHs and potential PHLF.NEW & NOTEWORTHY Posthepatectomy liver failure (PHLF) is associated with high mortality. In a rat model of 90% hepatectomy, PHLF is present. Our results on liver tissue proteomics suggest that the ability of the liver remnant to sufficiently eliminate ammonia may be brought about by perturbation related to urea cycle proteins and that enhancing the urea cycle capacity may play a key role in surviving PHLF.

Short-term outcomes of laparoscopic extended hepatectomy versus major hepatectomy: a single-center experience

Postoperative plasma lactate clearance has been established as an important prognostic factor for liver resection morbidity and mortality. The aim of this study was to analyse continuous monitoring of plasma lactate in patients submitted to extended hepatectomy (EH) with special attention to those who received preoperative portal vein branch embolization (PVE) to augment the future remnant liver. In this single center retrospective study, a full revision of 45 medical records was performed from patients who underwent EH at ISMETT from October 1999 to August 2013. Plasma lactates from admission to ICU to day 5 were recorded. Postoperative lactate clearance (ΔLAC) was defined as lactate at postoperative day 5 minus lactate at ICU presentation (hour 0). ΔLAC was analysed in relation to total hospital stay and 90 days' perioperative morbidity and mortality, using Clavien-Dindo classification, and by presence or absence of PVE. Forty-one right and four left EH were performed. 17 patients underwent previous PVE with a mean of 44 ± 28.9 days-to-surgery time and a 24 ± 8.3% degree of hypertrophy. In 39 cases (86.7%), a malignant etiology was the indication for EH, length of surgery was 486 ± 122 min with a median of 300 ml of blood transfusion. In 25 patients, a Clavien grade IIIa or worst complication has been experienced, and in three cases the death occurred during the first 3 months after EH. The median length of hospitalization was 11 days. In patients with preoperative PVE a significative association with an early post-resectional lactate clearance was obtained (p 0.01). Conversely, the univariate analysis measured by t test did not show any significative associations between ΔLAC and a median time of hospital stay longer than 11 days (p 0.08), or the onset of any complications (p 0.67) and of a Clavien's grade of complications ≥IIIa patients (p 0.48). After adjusting for co-variables, results of the multivariate logistic regression analyses confirmed that ΔLAC is not independent or significant predictor for initial poor liver function following EH. In our single center experience, the continuous monitoring of postoperative lactate clearance did not work as an early marker of postoperative liver dysfunction following EH. Although lactate clearance, worked as guide having a clinical utility in the ICU statement for hemodynamic optimization and systemic fluid balance management.

Osler-Rendu-Weber syndrome is a genetic disease that involves organs, liver included, characterized by alterations in the vessel walls, making them more vulnerable to spontaneous rupture and bleeding indeed. Our aim is to report a case of patient with Osler-Rendu-Weber syndrome undergoing extended hepatectomy with biliary resection for hilar cholangiocarcinoma and a review of literature on liver resection performed in patients with this syndrome. Preoperative, intraoperative, postoperative, radiographic, and pathologic data of case report's patient were collected. Review of literature included studies from 2000 to 2024, searching them with following search keywords: (liver resection OR hepatectomy) AND (Osler-Rendu-Weber disease OR hereditary hemorrhagic telangiectasia). A 78-year-old woman with Osler-Rendu-Weber syndrome presented hilar lesion compatible with cholangiocarcinoma. Before surgery, the patient underwent embolization of an aneurysm in segment 6. A left extended hepatectomy with biliary resection was performed. Intraoperative blood loss was 500cc. Post-operative course was uneventful and length of hospital stay was 10days. 5 cases of liver resection in patient with this syndrome are reported in literature, including 2 cases of major hepatectomies. Major complications' rate was 60% (3 cases): two cases of post-operative bleeding and one case of ascites decompensation. In one case exitus, consequent to massive bleeding, was reported (20%). This is the first case of extended hepatectomy with biliary resection performed in patient with Osler-Rendu-Weber syndrome. This underlying condition makes surgical approach demanding and challenging also in high volume centers. Proper patient selection and management could allow treatment and execution of a safe liver resection in patients with this syndrome.

Background. It is a novel idea that platelet counts may be associated with postoperative outcome following liver surgery. This may help in planning an extended hepatectomy (EH), which is a surgical procedure with high morbidity and mortality. Aim. The aim of this study was to evaluate the predictive potential of platelet counts on the outcome of EH in patients without portal hypertension, splenomegaly, or cirrhosis. Methods. A series of 213 consecutive patients underwent EH (resection of ≥ five liver segments) between 2001 and 2016. The association of preoperative platelet counts with posthepatectomy liver failure (PHLF), morbidity (based on Clavien-Dindo classification), and 30-day mortality was evaluated using multivariate analysis. Results. PHLF was detected in 26.3% of patients, major complications in 26.8%, and 30-day mortality in 11.3% of patients. Multivariate analysis revealed that the preoperative platelet count is an independent predictor of PHLF (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.3–15.0, p=0.020) and 30-day mortality (OR 4.4, 95% CI 1.1–18.8, p=0.043). Conclusions. Preoperative platelet count is associated with PHLF and mortality following extended liver resection. This association was independent of other related parameters. Prospective studies are needed to evaluate the predictive role and to determine the impact of preoperative correction of platelet count on postoperative outcomes after EH.

Preoperative Portal Vein Embolization with N-Butyl Cyanoacrylate Plus Ethiodized Oil: More Rapid and Robust Hypertrophy of the Future Liver Remnant.

BackgroundIn patients undergoing major liver resection, portal vein embolization (PVE) has been widely used to induce hypertrophy of the non-embolized liver in order to prevent post-hepatectomy liver failure. PVE is a safe and effective procedure, but does not always lead to sufficient hypertrophy of the future liver remnant (FLR). Hepatic vein(s) embolization has been proposed to improve FLR regeneration when insufficient after PVE. The sequential right hepatic vein embolization (HVE) after right PVE demonstrated an incremental effect on the FLR but it implies two different procedures with no time gain as compared to PVE alone.We have developed the so-called liver venous deprivation (LVD), a combination of PVE and HVE during the same intervention, to optimize the phase of liver preparation before surgery. The main objective of this randomized phase II trial is to compare the percentage of change in FLR volume at 3 weeks after LVD or PVE.MethodsPatients eligible to this multicenter prospective randomized phase II study are subjects aged from 18 years old suffering from colo-rectal liver metastases considered as resectable and with non-cirrhotic liver parenchyma. The primary objective is the percentage of change in FLR volume at 3 weeks after LVD or PVE using MRI or CT-Scan. Secondary objectives are assessment of tolerance, post-operative morbidity and mortality, post-hepatectomy liver failure, rate of non-respectability due to insufficient FLR or tumor progression, per-operative difficulties, blood loss, R0 resection rate, post-operative liver volume and overall survival. Objectives of translational research studies are evaluation of pre- and post-operative liver function and determination of biomarkers predictive of liver hypertrophy. Sixty-four patients will be included (randomization ratio 1:1) to detect a difference of 12% at 21 days in FLR volumes between PVE and LVD.DiscussionAdding HVE to PVE during the same procedure is an innovative and promising approach that may lead to a rapid and major increase in volume and function of the FLR, thereby increasing the rate of resectable patients and limiting the risk of patient’s drop-out.Trial registrationThis study was registered on clinicaltrials.gov on 15th February 2019 (NCT03841305).

The impact of post-hepatectomy liver failure on long-term survival after liver resection for perihilar cholangiocarcinoma

Clinician Overconfidence in the Visual Estimation of the Post-Hepatectomy Liver Remnant Volume: A Proximal Source of Liver Failure after Major Hepatic Resection?