Concomitant Liver Resection Research Articles

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases.

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.

Combined Liver and Colorectal Resection for Metastatic Colorectal Carcinoma: Institutional Experience and Clinical Outcomes

Introduction: Many patients with colorectal carcinoma present with liver metastases. Resection of both colorectal carcinomas and hepatic metastases brings potential for cure, but no consensus supports the resections should be concomitant. This study was undertaken to evaluate our initial outcomes with combined colorectal and hepatic resections. Methods: With IRB approval, we prospectively followed 26 consecutive patients who underwent combined liver and colorectal resections. ‘Major liver resection’ was defined as resection of ≥ 3 contiguous Couinaud segments. For illustrative purposes, data are presented as median(mean±SD). Results: Patients were 64(63±14.0) years old, 73% men, BMI of 29(29±5.7) kg/m2; 54% had previous abdominal operation(s). 62% underwent major liver resection; 77% had a robotic resection (no conversions to ‘open’). EBL was 150(210±181.8) mL. Total operative duration was 446(463±93.6) minutes with duration for liver resections being 206(226±103.0) minutes. All margins were R0. 3 patients developed postoperative complications of Clavien-Dindo score ≥III: 1 anastomotic leak requiring ileostomy, 1 effusion requiring thoracentesis, and 1 ascites requiring large-volume paracentesis. Length of stay was 5(6±3.5) days with 3 perioperative readmissions: 1 pleural effusion, 1 port site infection, and 1 fluid collection requiring percutaneous drainage. There were no deaths within 90 days. There were no differences in any metrics between robotic and ‘open’ operations. Conclusion: Concomitant liver and colon resections have shown to be safe and efficacious either via ‘open’ or robotic approach. For patients with metastatic colorectal cancer, our initial outcomes support concomitant colon and liver resections and the robotic approach.

Single-Centre Experience of Supra-Renal Vena Cava Resection and Reconstruction.

Tumours involving the supra-renal segment of IVC have dismal prognosis if left untreated. Currently, aggressive surgical management is the only potentially curative treatment but is associated with relatively high morbidity and mortality. This study aims to evaluate perioperative factors, associated with adverse postoperative outcomes, based on the perioperative characteristics and type of IVC reconstruction. We identified 44 consecutive patients, who underwent supra-renal IVC resection with a mean age of 57.3years. Isolated resection of IVC was performed in four patients, concomitant liver resection was performed in 27 patients and other associated resection in 13 patients. Total vascular exclusion was applied in 21 patients, isolated IVC occlusion in 11 patients. Neither venovenous bypass (VVB) nor hypothermic perfusion was used in any of the cases. The mean operative time was 205min (150-324min) and the mean estimated blood loss was 755ml (230-4500ml). Overall morbidity was 59% and major complications (Dindo-Clavien ≥ III) occurred in 11 patients (25%). The 90-day mortality was 11% (5pts). Intraoperative haemotransfusion was significantly associated with postoperative general complications (p < 0,001). With a mean follow-up of 26.2months, the actuarial 1-, 3- and 5-year survival is 69%, 34%, and 16%, respectively. IVC resection and reconstruction in the aspect of aggressive surgical management of malignant disease confers a survival advantage in patients, often considered unresectable. When performed in experienced centres it is associated with acceptable morbidity and mortality.

Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases

Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate.

A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC.

While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC. Patients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS). A total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22%vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS(2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years(HR, 3.61; 95% CI, 1.10-11.81), colorectal histology (HR, 3.84; 95% CI, 1.69-12.65), and multiple liver tumors (HR, 3.45; 95% CI, 1.21-9.85) (all p < .05). When assigning one point for each factor, there was an incremental decrease in 2-year survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%). As CRS/HIPEC + LR has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC + LR. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in OS.

A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC.

37 Background: While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery(CRS) and heated intraperitoneal chemotherapy(HIPEC), liver resection(LR) is increasingly performed concomitantly with CRS/HIPEC. As this practice continues to expand, identification of preoperative factors associated with poor outcomes is paramount. Methods: Patients from the US HIPEC Collaborative(2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival(OS). Results: 658 patients were included. Average age was 54 years and 45% were male; 83 (15%) underwent liver resection of colorectal (58%) or invasive appendiceal (42%) metastases. Liver resection patients had more complications (81 vs 60%; p = 0.001), greater number of complications (2.3 vs 1.5; p &lt; 0.001), and required more reoperations (22 vs 11%; p = 0.007) and readmissions (39 vs 25%; p = 0.014) than non-liver resection patients. Liver resection patients had decreased OS (2-year OS 62% vs 79%, p &lt; 0.001), which persisted on multivariable Cox regression when accounting for PCI and histology type. Preoperative factors associated with decreased OS on multivariable analysis in patients undergoing liver resection included age &lt; 60 years (HR:3.61), colorectal histology (HR:3.84), and multiple liver tumors (HR:3.45) (all p &lt; 0.05). When assigning one point for each factor, there was an incremental decrease in 2-yr survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%; p &lt; 0.001). Conclusions: As concurrent liver resection with CRS/HIPEC has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC with liver resection. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in overall survival.

Laparoscopic Multiple Parenchyma-sparing Concomitant Liver Resections for Colorectal Liver Metastases.

Parenchyma-sparing concept in liver surgery has received a new incitement with the introduction of laparoscopic techniques. Multiple concomitant liver resections are a major component in the parenchyma-sparing concept. In total, 689 patients underwent laparoscopic liver resection for colorectal liver metastases from August 1998 to 2017, and 171 patients were eligible for this study. Patients were divided into 3 groups: group I with single liver resection (36 patients); group II with multiple concomitant liver resections (104 patients); group III with liver resection(s) combined with concomitant liver ablation (31 patients). Perioperative outcomes and survival were compared between the groups I and II, whereas variables of group III were presented as complementary information, avoiding statistically exigent multiple comparisons. There were 6 conversions, 0, 3 (2.9%), and 2 (6.5%), respectively in the groups I, II, and III. Median operative time was 161, 186, and 224 minute in the groups I, II, and III, respectively. Median blood loss was 300 mL in groups I and II, and 200 mL in group III. It was a tendency to higher rate of postoperative complications in the group of single resections with morbidity rate of 31%, 19%, and 23% in group I, II, and III, respectively. Median postoperative stay was 3 days in all groups. Tumor-free margin resection was achieved in 92%, 86%, and 93%, respectively in the groups I, II, III. The median weight of resected specimen was significantly lower in group II (90 vs. 257 g; P<0.001). There were no significant differences in survival between the groups. The 5-year overall survival was 31%, 42%, and 43% for groups I, II, and III, respectively. Laparoscopic multiple concomitant parenchyma-sparing liver resections provide surgical and oncologic outcomes comparable with single greater resections for multiple lesions. This approach could be recommended for a wide application in specialized hepatopancreatobiliary centers.

Staging gallbladder cancer with lymphadenectomy: the practical application of new AHPBA and AJCC guidelines

BackgroundCurrent guidelines recommend harvesting a total lymph node count (TLNC) ≥6 from portal lymphadenectomy in ≥pT1b gallbladder cancers (GBC) for accurate staging and prognostication. This study aimed to determine nodal yields from portal lymphadenectomy and identify measures to maximize TLNC. MethodsWe retrospectively reviewed all ≥pT1b GBC which underwent resection with curative intent including portal lymphadenectomy at our specialized HPB center from 2007 to 2017. We compared outcomes of TLNC < 6 and TLNC ≥ 6 cohorts and determined factors predictive of TLNC. ResultsOf 92 patients, 20% had a TLNC ≥ 6 (IQR 7–11) and 9% had no nodes found on pathology. Malignant lymphadenopathy was twice as common in TLNC ≥ 6 as TLNC < 6 (p = 0.003) most frequently from portal, cystic and pericholedochal stations. On logistic regression analysis, concomitant liver resection was an independent predictor of higher TLNC [4b/5 wedge resection (OR 0.166, CI 0.057–0.486, p = 0.001) extended hepatectomy (OR 0.065, CI 0.012–0.340, p = 0.001)]; biliary resection and en bloc adjacent organ resection were not. ConclusionAt our center, prior to current guidelines, a TLNC≥6 was not met in 80% undergoing portal lymphadenectomy for ≥ pT1b GBC. To increase nodal yield, future guidelines should consider including additional lymph node stations and incorporation of frozen section analysis.

Resection of primary pancreatic neuroendocrine tumors with concomitant liver resection: reasonable and safe

Background: Pancreatic neuroendocrine tumors (PNETs) are increasing in incidence. Resection of liver metastases and the ideal timing of resection is a matter of debate. Combination pancreatic and liver surgery raises the concern of increased morbidity and mortality, however there is little data. The objective of this study was to determine whether or not there were differences in morbidity between resection of PNET primary alone versus concomitant resection of liver metastases. Methods: California Cancer Registry (CCR) was queried for patients with a confirmed histologic diagnosis of PNET with liver metastases who underwent resection from 2000 to 2012. The group was then divided into those who underwent resection of primary PNET alone with either a distal pancreatectomy (DP) alone, Whipple procedure (WP) alone, distal pancreatectomy with liver resection (DPLR), and Whipple procedure and liver resection (WPLR). Demographic, clinical, treatment characteristics, and hospital length of stay (LOS) were assessed with Cox proportional hazards. Complications were assessed using Fisher’s exact test. Results: 113 patients with PNET metastatic to the liver underwent resection with or without liver resection between 2000 and 2012. Of these 113 patients, 39 (34.5%) underwent DP alone, 40 (35.4%) underwent DPLR, 18 (15.9%) underwent WP alone and 16 (14.1%) underwent WPLR. There was no significant difference in demographics or disease characteristics between the groups who underwent primary resection alone vs. combined liver resection, including age, gender, race, comorbidities, primary tumor size, grade, or lymph node positivity. There was an increased LOS for those who had a combination DPLR compared to DP alone (7.48 days vs. 10.4 days, p = 0.02) but there was no difference in LOS between those who underwent WP vs. WPLR (19.6 days vs. 16.2 days, p = 0.64). There was no difference in overall complication rate between the groups. When broken down by complication type, there was no difference in intra-abdominal abscess rates between those who underwent DP vs. DPLR (p = 0.116) or those who underwent WP vs. WPLR (p = 0.900). There was also no difference in pancreatic fistula rates between those who underwent DP vs. DPLR (p = 0.494) or WP vs. WPLR (p = 1.00). Conclusion: PNETs are increasing in frequency, and current standard of care is to resect metastatic disease if complete resection is possible. Debulking surgeries are also noted as a consideration in NCCN guidelines with some evidence already published that debulking may improve survival. Using the CCR database, there was no difference noted in complication rates between removal of the primary alone versus concomitant liver resection; however, there were increased LOS with combination DPLR compared to DP alone.

Surgical Outcomes of Liver Resection Combined with Inferior Vena Cava Resection and Reconstruction with Artificial Vascular Graft

Background/Aim: Inferior vena cava (IVC) resection and reconstruction with concomitant liver resection sometimes represent the only chance for patients with liver tumors involving the IVC to get cured. However, surgical outcomes of liver resection with IVC resection and reconstruction using an artificial vascular graft have not been well investigated. Methods: Out of a total of 1,179 cases, only 12 involving liver resection between 1998 and 2016 at our institution included IVC resection and reconstruction using an artificial vascular graft. An expanded polytetrafluoroethylene graft was used for the IVC reconstruction in all 12 cases. We investigated the surgical outcomes of these combined surgeries. Results: The median operative time was 650 min and the median blood loss was 2,600 mL. Postoperative complications (≥ grade III in the Clavien-Dindo classification) developed in 2 patients – 1 case of bleeding and one of bile leakage. There were no cases of operative mortality. No complications associated with the vascular graft were observed throughout the postoperative follow-up period, and the grafts remained patent in all cases. Conclusions: These results indicate favorable surgical outcomes of liver resection combined with IVC resection and reconstruction.

Incisional hernia after surgery for colorectal cancer: a population-based register study

BackgroundOur knowledge on the incidence of incisional hernia and risk factors for developing incisional hernia following surgery for colorectal cancer is far from complete.MethodsAll procedures registered in the Swedish Colorectal Cancer Register (SCRCR) 2007–2013 were identified. Patients with comorbid disease diagnoses, registered at admissions and visits prior to the procedure and relevant to this study, were obtained from the National Patient Register (NPR). These diagnoses included cardiovascular disease, connective tissue disorders, liver cirrhosis, renal failure, diabetes, chronic obstructive lung disease and chronic inflammatory conditions. Data on occurrence of incisional hernias were obtained by combining data from the SCRCR and the NPR (International Classification of Diseases code).ResultsDuring 2007–2013, 39,984 procedures were registered in the SCRCR. After excluding laparoscopic procedures, procedures repeated on the same patient, procedures with concomitant liver resection and procedures without laparotomy, 28,913 cases remained for analysis. Five years after surgery, the cumulative incidence of incisional hernia was 5.3%. In multivariate proportional hazard analysis, significantly increased risk for incisional hernia was found for the male gender (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.21–1.62), operation time exceeding 180 min (HR 1.25, CI 1.08–1.45), body mass index (BMI) > 30 (HR 1.78, CI 1.51–2.09), age < 70 years (HR 1.34, CI 1.16–1.56) and postoperative wound complication (HR 2.09, CI 1.70–2.58).DiscussionMen, patients younger than 70 years and patients with BMI > 30 face a higher risk for incisional hernia. The risk is also increased in cases where the procedure takes longer than 3 h or where postoperative wound complications occur. These patients will benefit from measures aimed at preventing the development of incisional hernia.

Obesity is not associated with increased morbidity in patients undergoing cytoreductive surgery with intraperitoneal chemotherapy.

Recent single-institutional series have examined the relationship of body mass index (BMI) in patients undergoing cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) generally without significant increase in serious complications with increasing BMI. This study evaluates the impact of BMI on complication rates using a national cohort. The ACS NSQIP database was queried for patients undergoing concurrent CRS with IPC (2005-2012). Death and serious morbidity (DSM) was the primary outcome. Statistical analyses were performed to determine significant associations between peri-operative factors and DSM. Of 1,085 patients, there were 30.4% (n = 330) obese (BMI >30) and 32.1% (n = 348) normal weight (BMI 18.5-24.9) patients. DSM rates did not differ between these groups (P = 0.853). Obese patients were more likely to experience post-operative wound (P = 0.017) and renal (P = 0.002) complications. Hypoalbuminemia (OR 7.34; 95% CI 2.27-23.73), prolonged operative time (OR 3.02; 95% CI 1.83-4.97) and concomitant liver resection (OR 3.29; 95% CI 1.31-8.28) were independent risk factors for DSM among obese patients. Obesity is not significantly associated with DSM in patients undergoing CRS/IPC, and should not be a major deterrence for surgery. However, obese patients are more likely to experience wound and renal complications and hypoalbuminemia is a strong preoperative risk factor. J. Surg. Oncol. 2016;114:619-624. © 2016 Wiley Periodicals, Inc.

Pattern of tumour growth of the primary colon cancer predicts long-term outcome after resection of liver metastases

Objective: To identify significant predictive factors for overall survival (OS) and disease-free survival (DFS) after liver resection for colon cancer metastases, with special focus on features of the primary colon cancer, such as lymph node ratio (LNR), vascular invasion, and perineural invasion.Methods: Patients operated for colonic cancer liver metastases between 2006 and 2014 were included. Details on patient characteristics, the primary colon cancer operation and metastatic disease were collected. Multivariate analysis was performed to select predictive variables for OS and DFS.Results: Median OS and DFS were 67 and 20 months, respectively. 1-, 3- and 5-year OS were 97, 76, and 52%. 1-, 3- and 5-year DFS were 65, 42, and 37%. Multivariate analysis showed LNR to be an independent predictive factor for DFS but not for OS. Other identified predictive factors were vascular and perineural invasion of the primary colon cancer, size of the largest metastasis and severe complications after liver surgery for OS, and perineural invasion, number of liver metastases and preoperative CEA-level for DFS. Traditional N-stage was also considered to be an independent predictive factor for DFS in a separate multivariate analysis.Conclusions: LNR and perineural invasion of the primary colon cancer can be used as a prognostic variable for DFS after a concomitant liver resection for colon cancer metastases. Vascular and perineural invasion of the primary colon cancer are predictive for OS.

Radiofrequency ablation of unresectable colorectal liver metastases: trends in management and outcome during a decade at a single center.

BackgroundRadiofrequency ablation (RFA) is widely used for treatment of colorectal liver metastases (CRLM).PurposeTo evaluate the effect of increased experience in RFA of CRLM on morbidity and survival, and the trends in patient management and outcomes during the last decade.Material and MethodsHospital records of the initial 52 consecutive patients who underwent RFA (56 procedures/70 lesions) were retrospectively reviewed. The patients were divided into two groups according to time period of treatment, period I (2001–2006: n = 26) and period II (2007–2011: n = 26).ResultsConcomitant liver resection was performed in 15 patients in each period. Operative morbidity decreased from 47% to 19% (P = 0.047). Most complications were found in patients who underwent a concomitant liver resection and not related to the ablation per se. Local recurrence rate decreased from 19.4% to 12.9% (P = 0.526). At least one risk factor for recurrence was found in patients with local recurrence (n = 11): subcapsular localization (n = 4), tumor size >3 cm and subcapsular localization (n = 2), and perivascular localization (portal veins/hepatic veins) (n = 5). Median overall survival was 32 months in period I and 49 months in period II, whereas estimated 5-year survival was 19% and 36%, respectively (P = 0.09). Adjuvant chemotherapy was given to four patients (15.4%) in period I and 13 patients (50%) in period II (P = 0.017).ConclusionRFA alone or in combination with liver resection is a potentially curative treatment to selected patients with CRLM. Over time, the morbidity and survival have improved in RFA of CRLM. Although a possible effect of a learning curve should be taken into consideration in the appraisal of this improvement, it is more likely to be attributable to optimization of indication, development in surgical techniques, and increased use of perioperative chemotherapy.

The impact of changed strategies for patients with cholangiocarcinoma in this millenium.

Background. Cholangiocarcinoma is a cancer with a poor prognosis. In this millennium there are new diagnostic and therapeutic strategies for these patients. Aim. The aim of this study was to find if these changes influenced survival of individuals with proximal cholangiocarcinoma. Material. 627 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2000 to 2011 were registered in Sweden's Western Region. The material was divided into three consecutive time periods. Results. The overall survival curves for individuals with cholangiocarcinoma improved over the three time periods (n = 627) (P = 0.0013). Median survival increased from 2.6 months in the first period (2000–2003) to 3.6 months in the final four years (2008–2011). Patients with perihilar cholangiocarcinoma (PHC) had longer median survival than those with intrahepatic cholangiocarcinoma (IHC): 6.8 versus 3.2 months (P = 0.0003). An improvement in the survival curves over time was seen for those with IHC (P = 0.034) but not for patients with PHC (P = 0.38). Nine percent of the patients with IHC had potential curative surgical therapy. The three-year survival rate after liver resection for patients with IHC was 35% and 60% after liver transplantation. Among patients with PHC, 15.3% had potential curative bile duct resection with a concomitant liver resection and 6.1% bile duct resection alone. The three-year survival rate for these two groups was 32% and 20%, respectively. Conclusion. Overall survival for individuals with PHC was better than for those with IHC. Over time survival in IHC patients improved but not in those with PHC.

The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution

BackgroundResection and reconstruction of the inferior vena cava (IVC) is occasionally required in the surgical treatment of intra‐abdominal tumours. IVC reconstruction can be performed with biological or synthetic graft material, with most centres preferring synthetic grafts. In spite of the potential advantages of biological grafts in terms of handling characteristics, and safety, very limited data are available about their use in patients requiring an IVC resection. MethodsMedical records of 32 patients who underwent an IVC resection and reconstruction from 1990 and 2011 with autogenous peritoneo‐fascial (N = 22) and bovine pericardial (N = 10) grafts were reviewed. ResultsA tangential resection with patch repair was performed in 10 patients, whereas in the remaining 22 it was necessary to resect and replace a segment or all of the retrohepatic IVC. A concomitant liver resection was performed in 14 patients, nephrectomy in 10 and pancreaticoduodenectomy in 2 patients. There were no acute or late complications related to graft thrombosis or infection. Three patients died as a consequence of multi‐organ failure. Overall survival at 1 and 5 years was 78% and 48%, respectively. ConclusionsThe preferential use of synthetic grafts in IVC replacement is not evidence based. Selection of an appropriate prosthetic graft for IVC reconstruction should be based on the safety and its handling features. The use of biological grafts for IVC repair is a valid alternative to current synthetic materials and may in fact be superior in terms of biocompatability, ease of handling, reduced rate of infection and improved long‐term patency without permanent anticoagulation.

Liver resection with concomitant inferior vena cava resection: experiences without veno-venous bypass

Liver resection offers the chance of a cure for liver cancer. However, when extended hepatectomies were performed in combination with resection of the inferior vena cava (IVC), the procedures were reported to have a surgical mortality rate in excess of 5 %. While most of these operations were performed with the use of veno-venous bypass, this study presents our experience performing the procedure without the bypass. Data were collected from a prospectively maintained database. A retrospective evaluation of a consecutive series of concomitant IVC and liver resections was performed. Five hundred and seventy-five liver resections were performed between June 2008 and November 2011. Eleven patients (1.9 %) underwent concomitant IVC and liver resections. One patient required segmental IVC replacement, and four IVC defects were closed using a bovine pericardial patch without bypass. Only one patient had histologically confirmed IVC invasion. There was no postoperative mortality. Nine postoperative complications occurred in five patients. No complications in terms of IVC patency were seen. Five patients had disease recurrence, one of whom died within 12 months of surgery. Concomitant liver and IVC resection is safe without using a bypass procedure, with acceptable short-term results. Meticulous technique, careful patient selection and a specialized anesthetic team are key to obtaining low postoperative morbidity and mortality rates and an acceptable oncological outcome.

Recurrence after microwave ablation of liver malignancies: a single institution experience

BackgroundMicrowave ablation (MWA) is increasingly used to achieve local control for liver tumours. This study sought to examine a monocentric experience with MWA, with a primary hypothesis that primary tumour histology was a significant predictor of early recurrence. MethodsRetrospective single‐institution review identified consecutive patients with liver tumours treated by MWA. Cox proportional hazards models assessed significance of prognostic variables. ResultsSeventy‐two patients (43 female, 60%) underwent 83 MWA procedures for 157 tumours. Tumour histologies included hepatocellular cancer (10 operations), colorectal metastases (39), metastatic carcinoid (20) and other (14). The median tumour size was 2.0 cm. A concomitant liver resection was performed in 50 cases (60%). Crude peri‐operative morbidity and mortality rates were 16% and 1%, respectively. The median follow‐up was 16 months. Ablations were complete for 149 out of 157 tumours (95%). The median overall and recurrence‐free survivals were 36 and 18 months, respectively. There was no difference in time to recurrence between the primary tumour types. In multivariable models, recurrence‐free survival was independently associated with the use of neoadjuvant [hazard ratio (HR): 2.90, 95% confidence interval (CI): 1.09–7.76, P = 0.034] and adjuvant chemotherapy (HR: 0.36, 95% CI: 0.15–0.82, P = 0.016). ConclusionsMWA is a safe and feasible approach for local control of liver tumours. While chemotherapy administration was associated with time to recurrence after MWA, larger studies are needed to corroborate these findings.

Hepaticojejunostomy Using Short-Limb Roux-en-Y Reconstruction

When performing biliary reconstruction, one of the long-standing tenets of surgery is that Roux-en-Y (RY) reconstruction should use a long hepatic limb to decrease the risk for postoperative cholangitis. However, this practice is not well supported and may also make postoperative biliary endoscopy difficult. While some authors recommend Roux limbs of up to 75 cm, we have routinely used a Roux length of 20 cm to facilitate possible postoperative endoscopic access. To review our experience with short-limb RY hepaticojejunostomy (HJ) and examine the short-term and long-term outcomes following this procedure, as well as the success of future biliary interventions. Retrospective medical record review of all patients who underwent short-limb RYHJ by 2 surgeons (N.N.N. and S.D.C.). Tertiary care, university-affiliated teaching hospital. One hundred patients who underwent RYHJ were identified, with 30 of those patients being excluded owing to creation of an RYHJ to intrahepatic bile ducts with concomitant liver resection. Patient records were reviewed to determine the incidence of postoperative cholangitis and biliary stricture. Secondary outcomes were the need for postoperative biliary endoscopy and success rates for endoscopic biliary interventions. RESULTS Seventy patients underwent short-limb RYHJ over an 11-year period (2001-2012). Indications included benign stricture (n = 18), malignant stricture (n = 12), choledochal cyst (n = 5), choledocholithiasis (n = 3), idiopathic cholangitis (n = 2), and deceased donor or live donor liver transplant (n = 30). Seven patients, including 4 liver transplant patients, developed clinical or radiographic evidence of postoperative biliary stricture, and all patients underwent successful endoscopic cholangiography. Four of these patients required dilation and/or stone extraction, which were accomplished endoscopically in all cases. Short-limb RYHJ is safe and associated with a low incidence of postoperative complications. In addition, biliary intervention, when indicated, can be performed endoscopically with a high degree of success. In the absence of any evidence demonstrating longer limbs to be superior, we recommend using short-limb RY reconstruction for HJ.

Liver Resection for Bismuth Type I and Type II Hilar Cholangiocarcinoma

In patients with Bismuth type I and II hilar cholangiocarcinoma (HCCA), bile duct resection alone has been the conventional approach. However, many authors have reported that concomitant liver resection improved surgical outcomes. Between January 2000 and January 2012, 52 patients underwent surgical resection for a Bismuth type I and II HCCA (type I: n = 22; type II: n = 30). Patients were classified into two groups: concomitant liver resection (n = 26) and bile duct resection alone (n = 26). Bile duct resection alone was performed in 26 patients. Concomitant liver resection was performed in 26 patients (right side hepatectomy [n = 13]; left-side hepatectomy [n = 6]; volume-preserving liver resection [n = 7]). All liver resections included a caudate lobectomy. Patient and tumor characteristics did not differ between the two groups. Although concomitant liver resection required longer operating time (P < 0.001), it had a similar postoperative complication rate (P = 0.764), high curability (P = 0.010), and low local recurrence rate (P = 0.006). Concomitant liver resection showed better overall survival (P = 0.047). Concomitant liver resection should be considered in patients with Bismuth type I and II HCCA.