Field Of Liver Surgery Research Articles

Safety of perioperative intravenous lidocaine in liver surgery - A pilot study.

Perioperative lidocaine infusion has many interesting properties such as analgesic effects in the context of enhanced recovery after surgery. However, its use is limited in liver surgery due to its hepatic metabolism. This prospective, monocentric study was conducted from 2020 to 2021. Patients undergoing liver surgery were included. They received a lidocaine infusion protocol until the beginning of hepatic transection (bolus dose of 1.5 mg kg-1, then a continuous infusion of 2 mg kg-1 h-1). Plasma concentrations of lidocaine were measured four times during and after lidocaine infusion. Twenty subjects who underwent liver resection were analyzed. There was 35% of preexisting liver disease before tumor diagnosis, and 75% of liver resection was defined as "major hepatectomy." Plasmatic levels of lidocaine were in the therapeutic range. No blood sample showed a concentration above the toxicity threshold: 1.6 (1.3-2.1) μg ml-1 one hour after the start of infusion, 2.5 (1.7-2.8) μg ml-1 at the end of hepatic transection, 1.7 (1.3-2.0) μg ml-1 one hour after the end of infusion, and 1.2 (0.8-1.4) μg ml-1 at the end of surgery. Comparative analysis between the presence of a preexisting liver disease or not and the association of intraoperative vascular clamping or not did not show significant difference concerning lidocaine blood levels. Perioperative lidocaine infusion seems safe in the field of liver surgery. Nevertheless, additional prospective studies need to assess the clinical usefulness in terms of analgesia and antitumoral effects.

Accumulation of TOX high mobility group box family member 3 promotes the oncogenesis and development of hepatocellular carcinoma through the MAPK signaling pathway.

Microvascular invasion (MVI) has been widely valued in the field of liver surgery because MVI positivity indicates poor prognosis in hepatocellular carcinoma (HCC) patients. However, the potential molecular mechanism underlying the poor prognosis of MVI-positive HCC patients is unclear. Therefore, this study focused on identifying the key genes leading to poor prognosis in patients with a high degree of malignancy of HCC by examining the molecular signaling pathways in MVI-positive HCC patients. Through RNA sequencing, TOX high mobility group box family member 3 (TOX3) was demonstrated to be significantly highly expressed in MVI-positive HCC tissues, which was associated with poor prognosis. The results of in vivo and in vitro showed that TOX3 can promote the oncogenesis and development of HCC by targeting key molecules of the MAPK and EMT signaling pathways. The IP-MS results indicated that proteasome degradation of TOX3 in HCC cells is potentially mediated by a tripartite motif containing 56 (TRIM56, an E3 ligase) in HCC cells. Inhibiting TRIM56 enhances TOX3 protein levels. Overall, our study identified TOX3 as a key gene in the MAPK and EMT signaling pathways in HCC, and its overexpression confers significant proliferation and invasiveness to tumor cells.

A single-center experience performing robotic liver caudate lobectomy

BackgroundRobotic liver resection is a hot topic in the field of liver surgery in recent years. We report our initial experience with robotic liver caudate lobectomy and discuss its safety. MethodsWe retrospectively analyzed the clinical data of 13 patients who underwent the robotic liver caudate lobectomy between May 2018 and May 2021 in a single institution. The details of the surgical strategy were described. ResultsAll operations were performed robotically, and six operations were combined with other sites resection. The average operation time was 207.69 ​± ​104.81 ​min (single caudate lobectomy: 155.71 ​± ​45.41 ​min); intraoperative bleeding volume was 102.31 ​± ​158.84 ​ml (single: 42.14 ​± ​30.26 ​ml); and the average postoperative hospital stay was 5.08 ​± ​3.04 days (single: 3 ​± ​0.82 days). No deaths or serious surgical complications occurred perioperatively. ConclusionThis study suggests that robotic surgery is safe, effective, and feasible for liver caudate lobectomy.

The Learning Curve of Hepatobiliary Robotic Surgery: The First 100 Cases

Introduction: Minimally invasive surgery has been increasingly and successfully used across different surgical areas. Minimally invasive liver surgery (MILS) is an expanding field, and robotic surgery is currently in the frontline. The authors present the first Portuguese robotic liver surgery series. Methods: Clinical-pathological data was prospectively collected between October 2019 and August 2021. A retrospective review of the most relevant variables and results was performed. Statistical analysis was performed using SPSS 26. Results: At our institution, 100 consecutive patients were submitted to robotic hepatobiliary surgery. Median age was 60 years old (18-80). Malignancy was the most frequent indication for surgery n=67 (Liver colorectal metastasis n=36, hepatocellular carcinoma n=17, cholangiocarcinoma n=4). 39 patients were submitted to a major hepatectomy and the average intervention duration was 253 min (70-740min). Starting with minor operations, increasingly complex procedures, such as central hepatectomy of liver resection for perihilar cholangiocarcinoma, were performed. Conversion rate to open surgery was 3%, and average blood loss was 226cc. Three patients required transfusional support during the perioperative period. We report a morbidity rate of 13% (major: 4 patients) and a mortality rate of 1%. The median duration of post-operative hospital stay was 4 days (1-19). Conclusion: This represents the first and only reported Portuguese series of robotic hepatobiliary surgery. Robotic surgery can be safely performed for major liver resections with a low rate of conversion and post-operative complications. The introduction of robotics may be one of the most significant recent achievements in the field of liver surgery.

Effectiveness of a Clinical Pathway for Hepatic Cystic Echinococcosis Surgery in Kashi Prefecture, Northwestern China: A Propensity Score Matching Analysis.

IntroductionSurgical treatment for hepatic cystic ehinococcosis (CE) is not standardized in Kashi Prefecture. Previous evidence identified effectiveness of a clinical pathway in the field of liver surgery. However, proof of a clinical pathway program, especially for CE patients, is lacking. This study aimed to assess the validity of a clinical pathway for hepatic CE surgery performed on patients from Kashi Prefecture.MethodsA clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing hepatic CE surgery. Two groups were formed from patients undergoing hepatic CE surgery during a defined period before and after implementing a clinical pathway. Additionally, a propensity score matching analysis was performed.ResultsIn the overall analysis (n = 258) as well as the matched analysis (n = 166), after implementing the clinical pathway, hospital stay was significantly reduced from 13 to 10 days and from 14 to 10 days, respectively (P < 0.05). Postoperative morbidity did not increase. Cost analysis showed a significant decrease in median costs of medication and nursing in favor of the clinical pathway (medication: 5400 CNY vs. 6400 CNY, P = 0.038; nursing: 3200 CNY vs. 4100 CNY, P = 0.02).ConclusionImplementing the clinical pathway for hepatic CE surgery is feasible and safe. The clinical pathway achieved significant reduction of hospital stay without compromising postoperative morbidity. Costs of medication and nursing are significantly reduced. The clinical pathway program is valid and propagable to a certain extent, especially in remote, poor-resourced medical centers in endemic areas.

Our Strategy to Overcome Hepatic Ischemia Reperfusion Injury -From Bench to Bedside-

Background: In the field of liver surgery, especially transplantation, ischemia reperfusion injury (IRI) causes approximately 10% of early graft failure and leads to a higher incidence of acute and chronic rejection. It is an urgent issue to overcome IRI from the viewpoint of organ preservation. This study aims to reveal the molecular mechanism and develop the effective protective way to prevent the liver IRI for a safer liver surgery. Methods :We applied the established partial warm hepatic IRI model in mice and investigated changes of immune responses due to IR, and compared the efficacy of various biological molecules (neutrophil elastase inhibitor, recombinant Galectin-9, recombinant thrombomodulin and so on), antioxidant agents (vitamins C and E) and maneuvers (preoperative short-term fasting). The liver damage was assessed by serum alanine aminotransferase (sALT) level, histological observations, change in expression profile of various cytokines and analysis of intracellular molecules. Results: The most effective way to improve IRI was the preoperative short-term (12 hours) fasting. It exhibited a remarkable therapeutic effect compared with any other drug or diet we have so far examined. The up-regulation of Forkhead Box O1 (FOXO-1) induced by the raised acetylated histone and β-hydroxybutyric acid was a crucial factor for the short-term fasting to ameliorate the liver injury due to IR. Conclusion: Preoperative short-term dietary restriction might play an important role to overcome liver IRI and have a therapeutic potential for clinical setting.

A narrative review of near-infrared fluorescence imaging in hepatectomy for hepatocellular carcinoma.

Hepatectomy is a main therapeutic strategy for hepatocellular carcinoma (HCC), which requires removal of primary and disseminated tumors and maximum preservation of normal liver tissue. However, in a clinical operation, it is difficult to recognize the tumor tissue and its boundary with the naked eye and palpation, which often leads to insufficient or excessive resection. Near-infrared fluorescence (NIRF) imaging, a non-invasive, real-time, low-cost, and highly sensitive imaging technique has been extensively studied in surgical navigation. With the development of fluorescence imaging system and fluorescent probe, intraoperative tumor detection and margin definition can be achieved, making the operation more accurate. Advances in fluorescence imaging of HCC in the NIR region have focused on the traditional first NIR window (NIR-I, 700–900 nm), and have recently been extended to the second NIR window (NIR-II, 1,000–1,700 nm). Compared with NIR-I imaging, fluorescence imaging in the NIR-II exhibits great advantages, including higher spatial resolution, deeper penetration depth, and lower optical absorption and scattering from biological substrates with minimal tissue autofluorescence. There is no doubt that developing novel NIRF probes for in vivo imaging of HCC has high significance and direct impact on the field of liver surgery. In this article, the development of various NIRF probes for fluorescence image guided HCC hepatectomy is reviewed, and current challenges and potential opportunities of these imaging probes are discussed.

Abstract 2786: Color-coded fluorescence-guided surgery in a patient-derived orthotopic xenograft (PDOX) nude mouse model of colon-cancer liver metastasis with ICG and a fluorescent antibody

Abstract Background: Liver surgery is the mainstay curative treatment of liver cancer and metastasis. There are two main procedures for liver surgery. One is anatomic resection which is based on the portal flow and the other is partial resection for securing the surgical margin. Indocyanine green (ICG) fluorescence-guided surgery (FGS) has recently been developed in the field of liver surgery. Preoperative ICG administration provides tumor location for partial resection. Intraoperative ICG administration shows the liver segmentation for anatomic resection. However, it is difficult to distinguish between them, especially in the case that tumor lies close to a fluorescent liver segment in a single color image. Our laboratory previously developed color-coded FGS in an orthotopic mouse model of cancer that improved outcome over single color FGS (1). Our aim is to investigate a color-coded FGS to enhance the boundary between the tumor and the transection plane using ICG in combination with a fluorescent-labeled tumor-specific antibody. Methods: Anti-CEACAM monoclonal antibody (mAb 6G5j) was conjugated to near-infrared dye LI-COR IR700DX (6G5j-IR700DW). A fresh sample of colon-cancer liver metastasis was initially subcutaneously implanted in nude mice. Grown tumors were harvested and cut into small fragments and implanted into the left lobe of the liver of nude mice under anesthesia. After three weeks, mice were administered 50 μg of 6G5j-IR700DW via tail vein injection 48 hours before surgery. 10 μg of ICG was intravenously injected after isolation and ligation of the left Glissonean pedicle during surgery resulting in labeling of the right lobe of the liver. For intra-vital imaging and the FGS procedure, the Pearl Trilogy Small Animal Fluorescence Imaging system (LI-COR) and FLARE Imaging System (Curadel) were used. Results: On the 700 nm channel, the tumor had a clear fluorescence signal of 6G5j-IR700DW. On the 800 nm channel, the right lobe in the liver had the clear fluorescence signal of ICG and the left lobe had no fluorescence signal due to ligation of the left Glissonean pedicle. Overlay mode on the FLARE Imaging System (bright light, 700 nm and 800 nm) showed clear differentiation between tumor and segmental boundary on the same image. On the overlay mode, FGS for partial liver resection was performed using the 700 nm fluorescence signal of 6G5j-IR700DW. FGS for anatomic left hepatectomy as non-colored area was also well performed using the 800 nm fluorescence signal of ICG. Conclusions: This preliminary result shows that the combination of ICG (800 nm) and anti-CEACAM antibody conjugated to 700 nm dye has potential for visualization of transection lines and detection of colon-cancer liver metastases for FGS in a single image. (1) Yano S, et al. Cancer Gene Ther. 2015;22:344-50. Citation Format: Hiroto Nishino, Hannah M. Hollandsworth, Siamak Amirfakhri, Filemoni Filemoni, Jun Yamamoto, Yoshihiko Tashiro, Robert M. Hoffman, Michael Bouvet. Color-coded fluorescence-guided surgery in a patient-derived orthotopic xenograft (PDOX) nude mouse model of colon-cancer liver metastasis with ICG and a fluorescent antibody [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2786.

The history of liver surgery: Achievements over the past 50 years.

We reviewed the progress made in the field of liver surgery over the past 50 years. The widespread use and improved outcomes of the hepatectomy were, primarily, due to pioneer surgeons who were responsible for technological advances and rapid improvements in the safety of the procedure in the last century. These advances included the hepatic functional evaluation used to determine the safety limit of liver resections, the introduction of intraoperative ultrasonography, and the development of innovative techniques such as portal vein embolization to increase the remnant liver volume. Cadaveric liver transplantation has been attempted since 1963. However, the clinical outcomes only began improving and becoming acceptable in the 1970s‐1980s due to refinements in technology and the development of new immunosuppressants. Partial liver transplantation from living donors, which was first attempted in 1988, required further technological innovation and sophisticated perioperative management plans. Moreover, these developments allowed for further overall improvements to take place in the field of liver surgery. Since the turn of the century, advances in computation and imaging technology have made it possible for safer and more elaborate surgeries to be performed. In Japan, preoperative 3‐dimensional simulation technology has been covered by health insurance since 2012 and is now widely used. An urgent need for real‐time navigation tools will develop in the future. Indocyanine green (ICG) fluorescence imaging was first used in 2007 and has led to the creation of a new surgical concept known as fluorescence navigation surgery. Laparoscopic surgery and robotic surgery have solved the issue of large incisions, which used to be a major drawback of open liver surgery; however, further improvements are required in order to achieve the level of safety and accuracy observed during open liver resection when performing all minimally invasive procedures. In the near future, liver surgery will become more precise and less invasive due to substantial progress including the development of navigation surgery, cancer imaging, and minimally invasive surgery. This overview of the history of liver surgery over the past 50 years may provide useful insights for further innovation in the next 50 years.

Implementing an enhanced recovery program after liver surgery. Lessons from 100 cases

Introduction: Implementing an enhanced recovery program (ERP) requires a coherent sequence starting from the preoperative period in order to improve postoperative outcomes. Compliance to the protocol is paramount to ensure protocol success. In the field of liver surgery, risk factors of compliance failure are poorly reported. Methods: Through an ERP (ERAS) dedicated to liver surgery, all consecutive patients who underwent hepatectomy from June to December 2018 were included (n=53). Perioperative outcomes were compared to 50 patients consecutively operated on before June 2018 (pre-ERAS group). Risk factors for compliance failure were identified. Results: There was no difference regarding patient demographics and hepatectomy extent (Table 1). Consequently to the ERP implementation, anaesthesioly and surgery data have evolved with a decrease in intraoperative vascular filling (p=0.005), estimated blood loss (p=0.082) and intraoperative drain (p<0.001). Postoperative time to deperfusion, oral feeding and bowel function recovery significantly decreased in the ERAS group (p=0.001). Postoperative severe morbidity rate (p=0.087) and inhospital length of stay (p=0.031) reduced significantly in the ERAS group. Compliance failure rate was higher in the postoperative period (48%), as compared to preoperatively (30%) and intraoperatively (20%, p<0.001). Upon univariate analysis, ASA>2, extended hepatectomy, low hemoglobin and albumin levels, high intraoperative vascular filling an estimated blood loss were associated with postoperative compliance failure. Upon multivariable analysis, ASA>2 (OR=4.765, p=0.015) and extended hepatectomy (OR=2.864, p=0.014) were independently associated with postoperative compliance failure. Conclusion: After implementing an ERP for liver surgery, peroperative and intraoperative practices have significantly changed, translating into improved postoperative outcomes. Postoperative compliance to the protocol remains challenging to reach, especially in frail patients and after extended hepatectomy. Prehabilitation to control preoperative factors could help improving outcomes.

Associations of Oxidative Stress and Postoperative Outcome in Liver Surgery with an Outlook to Future Potential Therapeutic Options.

Several types of surgical procedures have shown to elicit an inflammatory stress response, leading to substantial cytokine production and formation of oxygen-based or nitrogen-based free radicals. Chronic liver diseases including cancers are almost always characterized by increased oxidative stress, in which hepatic surgery is likely to potentiate at least in the short term and hereby furthermore impair the hepatic redox state. During liver resection, intermittent inflow occlusion is commonly applied to prevent excessive blood loss but resulting ischemia and reperfusion of the liver have been linked to increased oxidative stress, leading to impairment of cell functions and subsequent cell death. In the field of liver transplantation, ischemia/reperfusion injury has extensively been investigated in the last decades and has recently been in the scientific focus again due to increased use of marginal donor organs and new machine perfusion concepts. Therefore, given the intriguing role of oxidative stress in the pathogenesis of numerous diseases and in the perioperative setting, the interest for a therapeutic antioxidative agent has been present for several years. This review is aimed at giving an introduction to oxidative stress in surgical procedures in general and then examines the role of oxidative stress in liver surgery in particular, discussing both transplantation and resection. Results from studies in the animal and human settings are included. Finally, potential therapeutic agents that might be beneficial in reducing the burden of oxidative stress in hepatic diseases and during surgery are presented. While there is compelling evidence from animal models and a limited number of clinical studies showing that oxidative stress plays a major role in both liver resection and transplantation and several recent studies have suggested a potential for antioxidative treatment in chronic liver disease (e.g., steatosis), the search for effective antioxidants in the field of liver surgery is still ongoing.

Innovative treatment for hepatocellular carcinoma (HCC).

Indocyanine green (ICG) is not new in the field of liver surgery. Early studies performed in the 1980s and 1990s revealed the value of the ICG clearance test in predicting post-hepatectomy morbidity and mortality. ICG clearance and retention tests are crucial for determining precise liver function before liver surgery and offer several benefits for safe surgery. Whereas ICG is well-known and has long history in medicine, recent progress in infrared light technology over the last decade has highlighted another feature of ICG. For example, ICG fluorescence-guided surgery may change the next generation of liver surgery. In the near future, ICG with near-infrared (NIR) light photodynamic therapy (PDT) is expected to become a new treatment method for hepatocellular carcinoma (HCC). Furthermore, several aspects of the mechanisms of ICG accumulation in HCC cells have been revealed by important basic research studies. New imaging technologies and mechanistic findings keep ICG in the spotlight. In this article, we review three recently described topics of ICG which may contribute to the development of innovative and new treatments method for HCC, fluorescence-guided surgery, mechanism of ICG accumulation in HCC cells, PDT for HCC.

Laparoscopic liver resection: a review of current indications and surgical techniques.

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

Development and clinical usefulness of the liver hanging maneuver in various anatomical hepatectomy procedures.

To assess the clinical application and usefulness of the liver hanging maneuver (LHM), proposed by Belghiti, for major hepatectomy, including its (1) historical development, (2) usefulness and application and (3) advantages and disadvantages, by reviewing the English literature published during the period 2001-2014. In major hepatic transection via the anterior approach, the deep area of transection around the vena cava is critical with regard to bleeding during right hemi-hepatectomy. Belghiti and other investigators identified avascular spaces that are devoid of short hepatic veins at the front of the vena cava and behind the liver. Forceps can be inserted into this space easily and then maneuvered to lift the liver using hanging tape. This procedure, termed LHM significantly reduces intraoperative blood loss and the transection time during right hemi-hepatectomy. LHM has been used in various anatomical hepatectomy procedures worldwide, including laparoscopic hepatectomy. The use of LHM markedly improves the amount of intraoperative blood loss, operative time and postoperative outcome. We conclude that the application of LHM is an important development in the field of liver surgery, although a further evaluation of its true impact on clinical outcomes is necessary.

Impact of Living Donor Liver Transplantation Experience on Liver Resection

Living donor liver transplantation is well developed in India; experience of living donor liver transplantation has made significant impact on the techniques and approach to liver resection for non-transplant GI surgeons. There are differences the way surgeons with or without liver transplantation experience approaches the patient for liver resection. Liver transplantation positively affects the management of patient requiring liver resection in terms of techniques and preoperative and postoperative management. Visiting a liver transplant centre by those not having liver transplantation experience may help them to improve and expand their field of liver surgery.

How to successfully resect 70 % of the liver in pigs to model an extended hepatectomy with an insufficient remnant or liver transplantation with a small-for-size graft

An insufficient remnant in extended hepatectomy and small-for-size graft in liver transplantation are critical matters in the field of liver surgery, and reliable and reproducible animal models that can provide clinically relevant and reliable data are needed. We herein describe our detailed surgical procedures for performing 70 % hepatectomy in pigs, and discuss the critical anatomical features, key techniques and pitfalls based on our experience. The porcine liver is divided into four lobes. The right lateral lobe (RLL) accounts for 30 % of the liver volume. Important points, such as selective temporal clamping of the arterial branch, confirmation of a related demarcation line, a two-step process to skeletonize Glisson's capsules during liver resection and selective ligation of the portal venous branch to the right medial lobe without inducing any subtle injuries to Glisson's capsules from the RLL to common bile duct, are discussed.

Two-stage hepatectomy after autologous CD133+ stem cells administration: a case report

Liver resection is the mainstay of treatment for patients with primary and metastatic liver tumors. However, a large majority of patients present for initial medical evaluation with primary and metastatic liver tumors when their cancer is unresectable. Several trials have been undertaken to identify alternative treatments and complementary therapies. In the near future, the field of liver surgery will aim to increase the number of patients that can benefit from resection, since radical removal of the tumor currently provides the sole chance of cure. This paper reports the case of a patient with an advanced colonic cancer in the era of stem cell therapyIn 2011, a 57 years old white Caucasian man with a previous history of non-Hodgkin lymphoma (NHL) was diagnosed with colon cancer and bilobar liver metastases. Following neoadjuvant therapy, the patient was enrolled in a protocol of stem cell administration for liver regeneration. Surgery was initially performed on the primary cancer and left liver lobe. An extended right lobectomy to S1 was then performed after a portal vein embolization (PVE) and stem cell stimulation of the remaining liver. The postoperative course was uneventful and the patient was free of disease after 12 months. Extreme liver resection can provide a safer option and a chance of cure to otherwise unresectable patients when liver regeneration is boosted by PVE and stem cell administration.

The use of the Hirsch index in benchmarking hepatic surgery research

BackgroundThe Hirsch index (h-index) is recognized as an effective way to summarize an individual's scientific research output. However, a benchmark for evaluating surgeon scientists in the field of hepatic surgery is still not available. MethodsA total of 3,251 authors who published between 1949 and 2011 were identified using the Scopus identification number. The h-index, the total number of cited document, the total number of citations, and the scientific age were calculated for each author using both Scopus and Google Scholar. ResultsThe median h-index was 6 and the median scientific age, assessed with Google Scholar, was 19 years. The numbers of cited documents, numbers of citations, and h-indexes obtained from Scopus and Google Scholar showed good correlation with one another; however, the results from the 2 databases were modified in different ways by scientific age. By plotting scientific age against h-index percentiles an h-index growth chart for both Scopus database and Google Scholar was provided. ConclusionsThis analysis provides a first benchmark to assess surgeon scientists' productivity in the field of liver surgery.

Liver resection under hypothermic total vascular exclusion

Despite progress in the field of liver surgery, centrally located tumors that involve the inferior vena cava or the hepatic veins adjacent to the vena cava are a technical challenge. These patients usually need to be operated upon under total vascular exclusion to prevent massive blood loss. The duration of vascular exclusion often exceeds the maximum permissible warm ischemia time tolerated by the liver, particularly when vascular reconstructions are necessary as part of the resection. The role of hypothermia as an adjunct to total vascular exclusion (TVE) was first introduced in 1974 but is used infrequently. A clearer understanding of this technique might allow clinicians to consider tumors in these awkward situations for resection. Additional techniques that may extend the benefits of hypothermic TVE are ante situm and ex vivo resections with autotransplantation. This review discusses the role of hypothermic TVE in the modern management of liver tumors.

Liver function impairment in liver transplantation and after extended hepatectomy

Extended hepatectomy, or liver transplantation of reduced-size graft, can lead to a pattern of clinical manifestations, namely "post-hepatectomy liver failure" and "small-for-size syndrome" respectively, that can range from mild cholestasis to irreversible organ non-function and death of the patient. Many mechanisms are involved in their occurrence but in the recent past, high portal blood flow through a relatively small liver vascular bed has taken a central role. Therefore, several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation, such as portocaval shunt, mesocaval shunt, splenorenal shunt, splenectomy or ligation of the splenic artery. However, high portal flow is not the only factor responsible, and before major liver resections, preoperative assessment of the residual liver function is necessary. Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume, preventing post-hepatectomy liver failure. More recently, a new surgical procedure, that combines in situ splitting of the liver and portal vein ligation, has gradually come to light, inducing remarkable hypertrophy of the healthy liver in just a few days. Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.