Anatomical Liver Resection Research Articles

Anatomic resection, surgical margin positivity and primary tumor site do not have effect on overall survival after liver resection for colorectal metastases

Introduction: Liver resection performed for colorectal cancer liver metastases prologs survival even in cases of resectable extrahepatic disease. Several factors that related to disease and operation are advocated to provide survival benefit in this patient group. In here we present our ten year experience of resections performed for CRCLMs. Method: One hundred and eight patients were operated for CRCLM between January 2007 and January 2017 at Ankara University Hospitals. Patient and disease characteristics and overall survival data were obtained retrospectively from hospital records. Overall survival of patients were compared according to gender, primary tumor site, tumor T status if it was T4, liver resection type if it was anatomic resection, preoperative chemotherapy, metastasis presentation and surgical margin positivity with Log-rank Test. Overall 1, 3 and 5 year survival of all patients were calculated. Result: None of the variables mentioned above were found to have significant effect on overall survival in our cohort (p>0.05). Surgical margin negative patients, patients with metachronously presented liver metastasis and patients underwent anatomic liver resections have a non significant tendency for better survival. One-year, 3 year and 5 year survival rates were calculated 88.1%, 53.7% and 40.6% respectively. Conclusion: Although large series are needed for evaluation of these factors on survival, according to our patient cohort disease related factors and surgical approach does not have effect on survival. This Result may be the greater effect of chemotherapies on stage 4 disease. Resections performed at our center resulted comparable outcomes.

Perihilar Glissonian Approach for Anatomical Parenchymal Sparing Liver Resections: Technical Aspects: The Taping Game: Erratum.

Perihilar Glissonian Approach for Anatomical Parenchymal Sparing Liver Resections: Technical Aspects: The Taping Game: Erratum.

Accuracy of actual resected liver volume in anatomical liver resections guided by 3-dimensional parenchymal staining using fusion indocyanine green fluorescence imaging.

The aim of this study was to assess the accuracy of actual resected liver volume (ARLV) in anatomical liver resections (ALRs) guided by 3-dimensional parenchymal staining using fusion indocyanine green fluorescence imaging (IGFI). Patients eligible for hepatic resection were enrolled in the current study from January 2016 to November 2017. All patients underwent surgery planning based on Medical Image Three-Dimensional Visualization System (MI-3DVS) before the operation, in which predicted resected liver volumes (PRLVs) were calculated. Under 3-dimensional guidance by fusion IGFI, ALRs were performed and ARLVs were measured. Simple linear regression, intra-class correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the relationship and agreement between PRLV and ARLV. Of the 27 patients who achieved valid demarcation by fusion IGFI, 12 (44.4%) received hemihepatectomy, while 10 (37.0%) and five (18.5%) underwent sectionectomy and segmentectomy, respectively. The relationship and agreement between PRLV (481.37 ± 189.47 cm³) and ARLV (450.57 ± 205.19 cm³) were then evaluated. The simple regression equation obtained was PRLV = 0.874 × ARLV + 87.75 (R = 0.946; P = 0.000). Meanwhile, ARLV (ICC = 0.943) achieved an excellent agreement with PRLV ( P < 0.001); 25 of 27 dots were in the range of 95% confidence interval in Bland-Altman analysis. In the study, these findings validated the consistency between PRLV calculated by MI-3DVS and ARLV guided by fusion IGFI, which proved that IGFI can accurately guide anatomical hepatectomy. Generally, fusion IGFI can provide a valid, feasible and accurate demarcation line, which can confer precision to hepatic resection.

A Novel Navigation for Laparoscopic Anatomic Liver Resection Using Indocyanine Green Fluorescence.

Among all laparoscopic liver resection techniques, anatomic liver resection is one of the most challenging procedures, with disorientation readily occurring during the laparoscopic approach compared with the open approach.1 Thus, navigation is warranted for laparoscopic anatomic liver resection. Recent research has remarkably established intraoperative fluorescence imaging techniques using indocyanine green fluorescence (ICG) in the field of liver surgery.2-4 This report describes real-time navigation for anatomic liver resection using the novel ICG system, PINPOINT (Stryker, Kalamazoo, MI). The target Glissonian pedicle was identified and temporally clamped after confirmation of blood supply to the preserved adjacent segment using ultrasonography. Next, 1.5 mg of ICG was intravenously administered using the negative counterstaining method. After 3 min of administration, the ICG-stained area could be readily recognized. Parenchymal transection was subsequently initiated along the interface between the ICG-positive and ICG-negative areas using the Pringle maneuver. Using PINPOINT, laparoscopic anatomic liver resection was performed for 16 patients. The extent of liver resection comprised two left hepatectomies, three right-anterior sectionectomies, three right-anterior sectionectomies, and eight segmentectomies. The identification rate of clear demarcations in the ICG images was 100%. The intraoperative blood loss was 226mL, and the operative time was 305min. Only one patient encountered the major postoperative complication of ascites, and all the patients attained R0 resection. Because the images provided by the ICG system are clearer than conventional ICG images, it could facilitate real-time navigation for laparoscopic anatomic liver resection.

Parenchyma-preserving anatomical liver resection using 3D image analysis results in long-term preservation of liver functional reserve after surgery

Parenchyma-preserving anatomical liver resection using 3D image analysis results in long-term preservation of liver functional reserve after surgery

Laparoscopic vs. open left lateral sectionectomy: an update systematic review and meta-analysis of randomized and non-randomized controlled trials

Background: Left lateral sectionectomy (LLS) is considered the most suitable anatomical liver resection to be performed laparoscopically. Laparoscopic LLS has been increasingly performed, however studies specifically comparing laparoscopic and open LLS are mostly retrospective with small sample size. Only recently prospective trials were reported. The aim of this study was to perform an update systematic review and meta-analysis of studies comparing perioperative outcomes of laparoscopic vs. open LLS. Methods: A systematic review was performed in Medline, EMBASE, Cochrane Library Central and Scielo/LILACS. Randomized and observational studies comparing perioperative results between laparoscopic and open LLS were included. The latest date for the search was December 31st, 2017. Treatment outcomes, including conversion rate, estimated blood loss, transfusion rate, operative time, hospital stay, morbidity and mortality were evaluated. Results: A total of 2566 articles were initially evaluated, and 20 studies included in the meta-analysis (18 observational and 2 randomized trials). Conversion rate was 8.7%. Laparoscopic LLS showed shorter hospital stay [mean difference (MD)=-2.19days; 95%CI -2.70-(-1.67); I2=78%, P=< 0.001; N=3116]; lower blood loss [MD=-119.81ml; 95%CI -127.90-(-111.72); I2=32%; P=< 0.001, N=618]; lower transfusion rate [risk difference [RD]=-0.06; 95%CI -0.08-(-0.04); P=< 0.001; I2=12%; N=2924]; marginal decrease in overall morbidity [RD=-0.03; 95%CI -0.06-(-0.00); P=0.07; I2=0%; N=3224]; and lower perioperative mortality [RD=-0.02; 95%CI -0.02-(-0.01); P=0.01; I2=0%; N=3288]. There was no difference regarding operative time, cardiac and pulmonary complications and reoperation rate between the groups. Conclusion: Laparoscopic had better perioperative results than open approach and should be recommended as the gold-standard approach for LLS.

The Impact of Extent of Liver Resection Among Patients with Neuroendocrine Liver Metastasis: an International Multi-institutional Study

BackgroundLiver resection in patients with neuroendocrine liver metastasis (NELM) provides a survival benefit, yet the optimal extent of resection remains unknown. We sought to examine outcomes of patients undergoing non-anatomic (NAR) versus anatomic liver resection (AR) for NELM using a large international cohort of patients. MethodsTwo hundred and fifty-eight patients who underwent curative intent liver resection from January 1990 to December 2016 were identified from eight institutions. Patients were excluded if they underwent concurrent ablation, had extrahepatic disease, underwent a debulking operation, or had mixed anatomic and non-anatomic resections. Overall (OS) and recurrence-free (RFS) survival were compared among patients based on the extent of liver resection (AR vs. NAR). ResultsMost primary tumors were located in the pancreas (n = 117, 45.4%) or the small intestine (n = 65, 25.2%). Liver resection consisted of NAR (n = 126, 48.8%) or AR (n = 132, 51.2%) resection. The overwhelming majority of patients who underwent NAR had an estimated liver involvement of < 50% (NAR 109, 97.3% vs. AR n = 82, 65.6%; P < 0.001). Patients who underwent NAR also had higher rates of primary tumor lymph node metastasis (NAR n = 79, 71.2% vs. AR n = 37, 33.6%; P < 0.001) and microscopically positive margins (R1) (NAR n = 29, 25.7% vs. AR n = 16, 12.5%; P = 0.009). After a median follow-up of 47.7 months, 48 (18.6%) patients died and 37.0% (n = 95) had evidence of disease recurrence. Patients who underwent AR had both longer median OS (not reached) and RFS (not reached) versus patients who underwent NAR (median OS 138.3 months; median RFS 31.3 months) (both P < 0.01). After controlling for patient and disease-related factors, extent of liver resection was independently associated with an increased risk of recurrence (HR 2.39, 95% CI 1.04–5.48; P = 0.04) but not death (HR 1.92, 95% CI 0.40–9.28; P = 0.42). ConclusionNAR was independently associated with a higher incidence of recurrence versus patients who undergo a formal anatomic hepatectomy among patients with NELM.

Gamma-glutamyl transpeptidase to platelet ratio predicts short-term outcomes in hepatocellular carcinoma patients undergoing minor liver resection

BackgroundThere is a strong correlation between liver fibrosis and postoperative morbidity after hepatectomy in hepatocellular carcinoma (HCC) patients. The aim of this study was to evaluate which noninvasive fibrosis index (gamma-glutamyl transpeptidase to platelet ratio [GPR], aspartate aminotransferase to platelet ratio index, fibrosis-4 index, or Forns index) was best able to predict complications in patients undergoing hepatectomy for HCC. Materials and methodsThis retrospective analysis included 275 patients who underwent hepatectomy for HCC from January 2008 to December 2012. Postoperative mortality was defined as death within 90 d after surgery. Complications were grouped into seven grades on the basis of the modified Clavien classification, and major postoperative complications were defined as grade 3 or above. The influence of noninvasive fibrosis indices on postoperative outcomes was assessed by receiver operating characteristic analysis. The primary outcomes were overall complications and major complications, estimated by univariate and multivariate analysis. ResultsPatients with HCC undergoing anatomical liver resection in the authors’ department were evaluated for this study. Finally, 275 patients who underwent minor liver resection (≤2 liver segments) were included. Of these, 231 (84%) were male. The multivariate analysis indicated that the GPR index was not only independently associated with overall complications (hazard ratio, 2.692; 95% confidence interval [CI], 1.626-4.250; P < 0.001) but also independently predictive of major complications (hazard ratio, 1.143; 95% CI, 1.046-1.249; P = 0.03). The areas under the receiver operating characteristic curve for predicting overall complications and major complications for the GPR index were 0.704 (95% CI, 0.643-0.765; P < 0.001) and 0.752 (95% CI, 0.638-0.865; P < 0.001), respectively. ConclusionsThe data suggested that the GPR index could be a promising predictor of overall postoperative complications and major complications after minor hepatectomy for HCC.

Real-time Navigation for Liver Surgery Using Projection Mapping With Indocyanine Green Fluorescence: Development of the Novel Medical Imaging Projection System.

The aim of the present study was to evaluate the usefulness of a new imaging device, the Medical Imaging Projection System (MIPS), which uses the indocyanine green emission signal and active projection mapping, for liver resection. During anatomic liver resection, surgeons cannot completely view the intraparenchymal structure. Although a fluorescent imaging technique using indocyanine green has recently been developed for hepatobiliary surgery, limitations in its application for real-time navigation persist. We conducted a retrospective review of surgical and clinical outcomes for 23 patients who underwent anatomic hepatectomy using the MIPS and 29 patients who underwent the procedure without MIPS guidance, between September 2014 and September 2015. Preoperative characteristics were comparable between the 2 groups. No significant between-group differences were identified with regard to surgical and clinical outcomes. The demarcation lines were clearly projected by the MIPS in 21 patients; however, the boundary line was undetectable in 2 patients. We developed the MIPS to address limitations in current intraoperative imaging methods. Our retrospective analysis provides evidence of the feasibility and clinical utility of the MIPS to identify anatomical landmarks for parenchymal dissection. The MIPS holds promise as a novel real-time navigation system for liver resection.

Contribution of the Glissonian approach for laparoscopic anatomical liver resection

Laparoscopic surgery has transformed many procedures over the past three decades. Greater experience along advances in laparoscopic devices have augmented the number of laparoscopic liver resection (LLR). Today laparoscopic hepatectomy is a stablished technique worldwide with more than 9,000 cases reported so far (1). International consensus conferences in 2008 and 2014 established steps to safe implementation of this technique such as dual training in advanced minimally invasive surgery and liver surgery, showed short-term equivalence and suggested that laparoscopy should be the standard of care for minor liver resections and left-lateral sectionectomy (2,3).

Results of Surgical Treatment of Patients with Liver Alveolar Echinococcosis

Aim . To evaluate surgical outcomes in patients with liver alveococcosis. Material and Methods. 581 patients have been included for the period 2000–2016. There were 366 (62.9%) women and 215 (37.1%) men. Mean age was 35.0 ± 1.5 years. Right liver lobe lesion was observed in 380 (65.4%) cases, left lobe involvement – in 140 (24.1%) cases, both lobes lesion – in 61 (10.5%) patients. 8 patients had lungs metastases, 3 – brain metastases, 1 – metastases in right ventricle and lungs. One patient had a rare coinfection of alveococcosis with echinococcosis. 570 patients underwent surgery. Results. Radical surgery was performed in 424 (74.3%) cases, palliative procedures – in 146 (25.5%) patients. 163 (28.1%) patients underwent right-sided hemihepatectomy including tangential inferior vena cava resection in 3 patients. Advanced right- sided hemihepatectomy was carried out in 36 (6.2%) cases including 2 cases of concomitant tangential resection of inferior vena cava and 4 cases of common bile duct resection followed by hepaticojejunostomy. Left-sided hemihepatectomy was made in 95 (16.4%) patients, 2 of them underwent concomitant tangential resection of inferior vena cava. Advanced left-sided hemihepatectomy was performed in 22 (3.6%) cases including tangential resection of portal vein in 1 patient and common bile duct resection followed by hepaticojejunostomy in 1 patient. Atypical or anatomic liver resection (segmentectomy, double segmentectomy, triple segmentectomy) was made in 64 (11.1%) patients. Hemihepatectomy followed by resection of the other lobe was carried out in 44 (7.5%) cases. Percutaneous transhepatic cholangiostomy was made in 28 (4,8%) cases, explorative laparotomy – in 25 (4.3%) patients. Transhepatic drainage of bile ducts was performed in 42 (7.2%) cases, cytoreductive procedures – in 51 (8.8%) cases. Postoperative morbidity rate was 9.8% (n = 56), mortality – 2.1% (n = 12). Conclusion. Radical surgery for liver alveococcosis is difficult but provides positive results in timely diagnosis. Proportion of radical procedures is much greater in case of early diagnosis of the disease. Palliative surgery combined with chemotherapy with albendazole is justified to improve quality of life.

Laparoscopic anatomical liver resection after complex blunt liver trauma: a case report

BackgroundVarious minimally invasive therapies are important adjuncts to management of hepatic injuries. However, there is a certain subset of patients who will benefit from liver resection, but there are no reports in the literature on laparoscopic anatomical liver resection for the management of complications after blunt liver trauma.Case presentationA 20-year-old male was admitted to the Emergency Unit of a tertiary referral center following a car accident. The patient was hemodynamically stable, and a radiologic workup demonstrated an isolated grade 3 injury of the left hemiliver. Initially, a nonoperative management was indicated, but during days following the injury, a high-volume biliary fistula complicated the clinical course. Despite percutaneous drainage, the development of devastating consequences of biliary peritonitis was imminent. A pure laparoscopic anatomical liver resection was performed. Left lateral sectionectomy eliminated the source of bile leak, and the surgery was completed with abdominal cavity lavage. Postoperative outcome was uneventful, and the patient was discharged on day 9 after injury and day 4 after surgery returning to his normal activity.ConclusionsIn highly selected, hemodynamically stable patients with no other life-threatening concomitant injuries, laparoscopic liver resection in elective setting is feasible and safe for the management of complications after complex blunt trauma of the left liver. Extensive experience with hepatic surgery is needed, and surgeons should understand the increased risk they assume by taking on more complex surgical techniques.

Evaluating the Ability of the New Subclassification to Prognosticate Outcomes Following Hepatectomy for Patients with HBV-Related HCC.

Recently, experts proposed subclassification for BCLC B patients. In this study, we aimed to evaluate the efficient of subclassification of patients with hepatitis B virus-related hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) staging system. Seven hundred twenty-nine consecutive hepatitis B virus-related HCC patients with BCLC stage B classification who underwent hepatectomy in the period 2006-2012 were retrospectively analyzed. Patients were reclassified based on the new proposed subclassification of the BCLC B stage from B1 to B4. The prognosis of subclassification was tested using Kaplan-Meier statistics analysis. There were 145 (19.9%), 480 (65.8%), 62 (8.5%), and 42 (5.8%) patients in B1, B2, B3, and B4, respectively. The result suggested that overall and tumor-free survival rates among the B1, B2, and B3 subclassification in the Bolondi system had significant difference (P < 0.05). However, no significant difference was found between B3 and B4 subclassifications. Cox regression showed that BCLC B subclassification, largest/smallest diameter, and anatomic liver resection were independent predictors of tumor-free survival. BCLC B subclassification and anatomic liver resection were independent predictors of overall survival. The subclassification of BCLC stage B can be used in patients with HBV-related HCC who underwent curative intent hepatectomy. Patients in BCLC B1 and B2 subgroups should be treated more aggressively than patients in B3 and B4 subgroups. B3 and B4 groups should be merged for patients with HBV-related HCC who underwent curative intent hepatectomy.

Surgical resection of hepatocellular carcinoma in the cirrhotic patient: anatomic versus non-anatomic resection?

Background: Surgical resection remains the standard treatment for hepatocellular carcinoma (HCC). Outcomes such as survival and recurrence vary in the literature regarding the type of liver resection; anatomic versus non-anatomic. The aim of this study was to review our institutions experience with anatomic versus non-anatomic hepatocellular carcinoma resection. Methods: A retrospective review from January 2011 to July 2016 was performed at a single university. Baseline characteristics were compared between non-anatomic and anatomic liver resection groups. The primary outcome analyzed were overall mortality, all complications, margin status and history of hepatitis/cirrhosis. Statistical analysis such as chi-square, ANOVA, cox proportional hazards and Kaplan Meier were performed. Results: Thirty-six patients underwent surgical resection for hepatocellular carcinoma. Seventeen patients had a history of hepatitis while twenty-three patients had a history of cirrhosis. Seventy-eight percent of patients underwent anatomic resection (n = 28) compared to twenty-two percent that underwent non-anatomic resection (n = 8). Overall complication rate, positive margin status, and history of cirrhosis were similar between the non-anatomic and anatomic groups ((38% vs. 54%, p-value = 0.69), (25% vs. 11%, p-value = 0.57), and (100% vs. 86%, p-value = 0.58), respectively). Overall survival was similar between the non-anatomic and anatomic groups (p-value = 0.64) (Table 1). Conclusion: The surgical margin for HCC associated with cirrhosis is a surgical dilemma because curative resection depends on adequate margin and preservation of liver function. Patients with severe liver disease may have better surgical outcomes with a non-anatomic resection if an adequate surgical margin is not obtained because of the preservation of liver function.

COMBINED TREATMENT OF PATIENTS WITH PANCREATIC NEUROENDOCRINE CARCINOMAS

Aim. To analyze the results of treatment of patients with pancreatic malignant neuroendocrine tumors. Materials and Methods . Since 2005 to 2014 period 49 patients with malignant neuroendocrine tumors were examined and treated. 76.6% patients (n = 38) were treated within 2010–2014 years. In 59.2% of cases liver metastatic lesion occured. Comprehensive specific treatment with surgical resection of primary tumor site was used in 73.5% of cases (n = 36). Some patients received perioperative intraarterial chemoembolization and surgical tumor removal was supplemented by radiofrequency or microvave ablation of metastatic liver sites, anatomical liver resections. Results. Postoperative mortality was observed only after extended surgical resection (8.3%, (n = 3)). All patients with low differentiated tumors had histological signs of perineural invasion, abcence of therapeutical effect of specific treatment even after surgical resection of primary tumor site. In view of this long-term survival was low. At present time most of surgically treated patients (85.2%, (n = 32)) with low and moderately differentiated neuroendocrine tumors live without signs of progression. Follow-up varies within 5–119 months. Conclusion. Combined treatment including aggressive surgical approach and perioperative intraarterial chemoembolization is associated with good remote results in case of highly and moderately differentiated neuroendocrine tumors.

The Incidence of Early Recurrence After Anatomical Versus Non-Anatomical Liver Resection in Patients with Hepatocellular Carcinoma

<i>Aim:</i> This retrospective study compares the incidence of early recurrence after anatomical versus non-anatomical resection in patients with hepatocellular carcinoma (HCC). <i>Patients and Methods:</i> This retrospective study included 26 patients who had a preoperative diagnosis of a single hepatocellular carcinoma (HCC) and who underwent anatomical and non-anatomical liver resection. The patients were divided into two groups. AR Group; anatomical resection group (n= 12) and NAR Group; Non-anatomical resection group (n = 14). The effect of the type of resection (anatomic vs non-anatomic) on early HCC recurrence was studied in both groups. Other risk factors that might play a role in early tumor recurrence such as the TNM staging, tumor size, vascular invasion, pathologic grading and high AFP values were also evaluated. <i>Results:</i> During the follow up period, 5 patients (41.7 %) from AR Group and 6 patients (42.9 %) from NAR Group developed recurrence. Mean time of recurrence was 13.05 ± 4.63 versus 12.53 ± 4.12 months (p 0.764). The univariate analysis method was used to analyze different epidemiological, clinical and pathological variables and there was no statistically significant risk factor in both groups in terms of recurrence. The mean disease-free survival was calculated for both groups using Kaplan–Meier curve and it was 16.013±2.324 for AR group versus 15.657±2.765 months for NAR group (p: 0.98). The cumulative overall survival proportion at end of research was 59.6% for AR group versus 69.87% for NAR group. The mean overall survival was 17.956±2.254 months for AR group versus 20.876±1.263 for NAR group (p: 0.21). The recurrence rate was 41.7%% in AR group and 42.9% in NAR group (p = 0.951). This suggests that the type of resection did not have an impact on early recurrence in HCC patients undergoing liver resection. <i>Conclusion:</i> This study concluded that recurrence-free and overall survivals after both anatomical and non-anatomical resection were not significantly different from the statistical point of view. Liver resection in cirrhotic patients should be performed with good expertise and should pursue strict selection criteria. Non-Anatomical resection may be more appropriate in cirrhotic patients with small HCC to preserve adequate functioning hepatic parenchyma and to avoid increased postoperative morbidity and mortality.

Resection of biliary mucinous cystic neoplasms of the liver: a prospective cohort series of 13 consecutive patients

Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. To assess the outcome of surgical resection of BMCNs. A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome. Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months. BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit.

Outcome of liver resection for small bowel neuroendocrine tumour metastases

Background: Small bowel neuroendocrine tumours frequently metastasise to the liver. While liver resection improves survival and provides symptomatic relief, multifocal bilobar disease adds complexity to surgical management. Objectives: This study evaluated outcome in patients with small bowel neuroendocrine liver metastases who underwent liver resection at Groote Schuur Hospital and UCT Private Academic Hospital. Methods: All patients with small bowel neuroendocrine liver metastases treated with resection from 1990–2015 were identified from a prospective departmental database. Demographic data, operative management, morbidity and mortality using the Accordion classification were analysed. Survival was assessed using the Kaplan-Meier method. Results: Seventeen patients (9 women, 8 men, median age 55 years, range 31–76) underwent resection. Each patient had all identifiable liver metastases resected and/or ablated (median n = 3, range 1–20). Ten patients had major anatomical liver resections. Three patients had five segments resected, and seven had four resected. Nine patients (53%) had a concurrent bowel resection of the small bowel NET primary and a regional mesenteric lymphadenectomy. Median operating time was 255 min (range 150–720). Median blood-loss was 800 ml (range 200–10,000). Five patients required intraoperative blood transfusion. Hepatic vascular inflow control was used in ten patients (56.5 min median, range 20–150 min), which included hepatic inflow control n = 8, total hepatic exclusion n = 1, and selective hepatic exclusion n = 1. Median postoperative hospital stay was 9 days (range 2–28). Thirteen complications occurred in seven patients. Accordion grades were 1 n = 3, 2 n = 4, 3 n = 3, 4 n = 2, 6 n = 1. One patient required reoperation for bleeding and a bile leak. One patient died of a myocardial infarction 36 hours postoperatively. Sixteen patients (94%) had symptomatic improvement. Five-year overall survival was 91% (median follow-up 36 months, range 14–86 months). Conclusion: Our data show that liver resection can be safely performed for small bowel NET metastases with a good 5-year survival. However, a substantial number of patients require a major liver resection and these patients are best managed at a multidisciplinary referral centre.

Indocyanine green fluorescence imaging techniques and interventional radiology during laparoscopic anatomical liver resection (with video).

To accomplish laparoscopic anatomical liver resection, intraoperative liver segmentation is necessary. Tattooing method or Glissonian approach will be used in a similar way to that in open liver resection. Moreover, in liver segment detection, the fluorescence of indocyanine green (ICG) means it has been recognized as a useful dye. In laparoscopy, however, there are technical difficulties in performing these conventional methods, so development of new techniques is necessary for liver segment identification. We report a pilot study using interventional radiology technique for laparoscopic intraoperative liver segmentation. Just prior to liver parenchymal resection, angiography was performed using a hybrid operation room. A catheter was inserted from the right femoral artery into the targeted arterial branch. After confirming the perfusion area by arteriography, embolic solution containing ICG was injected, and the branch was embolized. ICG fluorescence was observed by PINPOINT, a near-infrared imaging system. Immediately after embolic solution injection, we were able to observe ICG fluorescence on the surface of the liver to be resected. This visual effect continued during liver parenchymal resection. We were able to confirm the intra-parenchymal boundary by observing ICG fluorescence on the cut surface of the resecting side and accomplished precise anatomical liver resection. Our novel technique provides advances in laparoscopic anatomical liver resection performance. As two-dimensional laparoscopy lacks depth perception, additional visual information, such as ICG fluorescence imagery, is helpful as a navigation tool for precise laparoscopic anatomical liver resection.

Illuminate hepatobiliary and pancreatic surgery using optical molecular imaging methods

Since the concept of molecular imaging was put forward in 1999, optical molecular imaging techniques have been widely applied in the field of biomedical and clinical research. Its unique application value is especially shown in hepatobiliary surgery, such as in liver tumor imaging, anatomical liver resection, liver transplant angiography, cholangiography, and bile or pancreatic leakage prevention. Optical molecular imaging techniquelights uptargeted areas in surgical operations and provides convenience in carrying out precision operation. This paper reviewed the advantages of optical molecular imaging technology in clinical research and discussed its limitations in translational surgery, and put forward possible directions in improvement for the future. Key words: Optical molecular imaging; Liver surgery; Intraoperative fluorescence image-guided surgery; Indocyanine green