Hepatic Inflow Research Articles

2462 Rapid Development of Bleeding Esophageal Varices After Placement of Continuous Flow Left Ventricular Assist Device

INTRODUCTION: Upper gastrointestinal bleeding – typically due to arterio-venous malformations - is common in patients with continuous-flow LVAD, and is due to acquired von Willebrand disease and systemic anticoagulation. We present a patient with compensated cirrhosis in whom large esophageal varices developed within a few weeks of LVAD placement, resulting in hemorrhage and eventual fatal outcome. CASE DESCRIPTION/METHODS: A 62-year old male with a history of non-ischemic cardiomyopathy presented with recurrent pulmonary edema requiring intra-aortic balloon pump (IABP) to maintain stability. Workup for placement of a LVAD was initiated. An abdominal CT scan unexpectedly revealed cirrhotic liver changes. The patient had no physical exam stigmata of advanced liver disease. The INR was 1.1, platelets 170,000, albumin 3.7, transaminases and bilirubins were normal. EGD revealed no varices. A liver biopsy revealed a portal-systemic gradient of 20 mmHg and histology confirmed cirrhosis but revealed no specific etiology. The patient's MELD score of 11 and Child-Pugh class A were consistent with well-compensated cirrhosis, and the patient underwent uneventful placement of a LVAD. Seventeen days after placement, the patient sustained an acute upper GI bleeding episode. Emergent EGD revealed large, actively bleeding esophageal varices, which were successfully ligated. Over the following days, the patient developed ascites, hepatic encephalopathy and renal failure. Twelve days later, the patient developed recurrent bleeding. EGD revealed active bleeding in the esophagus and a large clot. No specific bleeding source could be identified and endoscopic attempts at hemostasis were unsuccessful. Placement of a transjugular intrahepatic portosystemic shunt was considered, but the patient's MELD score of 40 was prohibitively high. The patient continued to bleed and expired on the following morning. DISCUSSION: We hypothesize that the fluid shifts and increased hepatic arterial inflow following LVAD placement caused rapid increases in esophageal variceal pressures and bleeding. The patient's low cardiac output prior to LVAD placement likely masked the extent of his portal hypertension. In hindsight, the markedly elevated pre-LVAD portal-systemic gradient was the clearest predictor of post-LVAD variceal complications in our patient. Our experience suggests that even well-compensated cirrhotic patients with significant portal hypertension are at risk for variceal bleeding after LVAD placement.

Laparoscopic Versus Open Left Lateral Segmentectomy for Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis.

With the advancement of endoscopic technology, laparoscopic liver resection has become the standard procedure for left lateral segmentectomy. The aim of this study was to compare perioperative and oncological outcomes between laparoscopic and open left lateral segmentectomy for hepatocellular carcinoma (HCC) >5 cm. A total of 66 patients underwent left lateral segmentectomy for HCC (>5 cm) during the period spanning between 2013 and 2015. To overcome selection bias, 1:3 match using propensity score-matched analysis was performed between laparoscopic and open liver resection. Relatively smaller tumor size (6.0 vs. 7.0 cm; P=0.030) and more frequent incidence of complete tumor capsule (93.3% vs. 58.8%; P=0.013) were observed in the laparoscopic group compared with the open group before matching. Although the longer operation time (195 vs. 150 min; P=0.022) was consumed in the laparoscopic procedure after matching, the laparoscopic group had shorter postoperative hospital stay (6 vs. 7 d; P=0.002) and less blood loss volume (50 vs. 100 mL; P=0.022). The Pringle maneuver for hepatic inflow occlusion was more likely to be applied in patients who underwent open surgery. The incidence of postoperative complication seemed to be lower in the laparoscopic group (6.7%) compared with that in the open group (11.8%) before matching. On the basis of propensity score-matched analysis, the complication rates were comparable between the 2 groups (7.1% vs. 6.7%, P=0.953). No difference in the 1-year and 3-year overall and recurrence-free survival rates was found between the laparoscopic and open groups. Laparoscopic left lateral segmentectomy for large HCC patients showed better perioperative outcomes and equivalent oncologic outcomes as the open procedure, providing evidence for considering as a standard laparoscopic practice through careful selection.

Comparison of the effect on the prognosis of HCC in terms of different surgical approaches for hepatic inflow occlusion

Background: To investigate the effect of surgical approaches for hepatic inflow occlusion performed during hepatectomy on postoperative tumor-free survival (TFS) in patients treated with R0 resection. Methods: In total, 343 hepatocellular carcinoma (HCC) patients who underwent hepatectomy (R0) with different surgical approaches for hepatic inflow occlusion were analyzed retrospectively. Results: In total, 68.80% of the patients underwent hepatic inflow occlusion, including 46.65% with a routine Pringle maneuver and 22.16% with selective hemi-hepatic vascular exclusion (SHVE), during surgery. The TFS did not significantly differ among the Pringle group, the SHVE group and the no hepatic inflow occlusion group. After further stratifying the patients according to the Barcelona clinic liver cancer (BCLC) staging system, the patients with BCLC stage A disease in the SHVE group and no hepatic inflow occlusion group displayed better TFS than those in the Pringle maneuver group (P=0.04; P=0.002), but the patients with BCLC stage B–C disease did not show significant differences among the groups. Furthermore, all 214 patients with BCLC stage A disease were classified into two subgroups according to the microvascular invasion (MVI) status. Interestingly, among the patients with MVI, those in the SHVE group and no hepatic inflow occlusion group had significantly longer TFS than those in the Pringle group (P=0.025; P=0.006); however, the patients without MVI did not show differences among the groups. Additionally, the multivariate analysis revealed that a tumor size ≥5 cm, an absent capsule, a low Edmondson grade, MVI positivity and performance of the Pringle maneuver were independent risk factors of the prognosis in patients with BCLC stage A disease. Conclusions: Hepatic inflow occlusion and the surgical approach used to address this issue may have an impact on HCC prognosis in patients with BCLC stage A disease, especially among those with MVI positivity. No hepatic inflow occlusion or an SHVE approach rather than the Pringle maneuver should be considered first during hepatectomy for patients with BCLC stage A disease.

Intraoperative Hepatic Blood Inflow Can Predict Early Acute Kidney Injury following DCD Liver Transplantation: A Retrospective Observational Study.

Purpose Acute kidney injury (AKI) is a major and severe complication following donation-after-circulatory-death (DCD) liver transplantation (LT) and is associated with increased postoperative morbidity and mortality. However, the risk factors and the prognosis factors of AKI still need to be further explored, and the relativity of intraoperative hepatic blood inflow (HBI) and AKI following LT has not been discussed yet. The purpose of this study was to investigate the correlation between HBI and AKI and to construct a prediction model of early acute kidney injury (EAKI) following DCD LT with the combination of HBI and other clinical parameters. Methods Clinical data of 132 patients who underwent DCD liver transplantation at the first hospital of China Medical University from April 2005 to March 2017 were analyzed. Data of 105 patients (the first ten years of patients) were used to develop the prediction model. Then we assessed the clinical usefulness of the prediction models in the validation cohort (27 patients). EAKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria based on serum creatinine increase during 7-day of postoperative follow-up. Results After Least Absolute Shrinkage and Selection Operator (LASSO) regression and simplification, a simplified prediction model consisting of the Child-Turcotte-Pugh (CTP) score (p=0.033), anhepatic phase (p=0.014), packed red blood cell (pRBC) transfusion (p=0.027), and the HBI indexed by height (HBI/h) (p=0.002) was established. The C-indexes of the model in the development and validation cohort were 0.823 [95% CI, 0.738-0.908] and 0.921 [95% CI, 0.816-1.000], respectively. Conclusions In this study, we demonstrated the utility of HBI/h as a predictor for EAKI following DCD LT, as well as the clinical usefulness of the prediction model through the combination of the CTP score, anhepatic phase, pRBC transfusion and HBI/h.

Comparison of the effect on the prognosis of HCC in terms of different surgical approaches for hepatic inflow occlusion.

BackgroundTo investigate the effect of surgical approaches for hepatic inflow occlusion performed during hepatectomy on postoperative tumor-free survival (TFS) in patients treated with R0 resection.MethodsIn total, 343 hepatocellular carcinoma (HCC) patients who underwent hepatectomy (R0) with different surgical approaches for hepatic inflow occlusion were analyzed retrospectively.ResultsIn total, 68.80% of the patients underwent hepatic inflow occlusion, including 46.65% with a routine Pringle maneuver and 22.16% with selective hemi-hepatic vascular exclusion (SHVE), during surgery. The TFS did not significantly differ among the Pringle group, the SHVE group and the no hepatic inflow occlusion group. After further stratifying the patients according to the Barcelona clinic liver cancer (BCLC) staging system, the patients with BCLC stage A disease in the SHVE group and no hepatic inflow occlusion group displayed better TFS than those in the Pringle maneuver group (P=0.04; P=0.002), but the patients with BCLC stage B–C disease did not show significant differences among the groups. Furthermore, all 214 patients with BCLC stage A disease were classified into two subgroups according to the microvascular invasion (MVI) status. Interestingly, among the patients with MVI, those in the SHVE group and no hepatic inflow occlusion group had significantly longer TFS than those in the Pringle group (P=0.025; P=0.006); however, the patients without MVI did not show differences among the groups. Additionally, the multivariate analysis revealed that a tumor size ≥5 cm, an absent capsule, a low Edmondson grade, MVI positivity and performance of the Pringle maneuver were independent risk factors of the prognosis in patients with BCLC stage A disease.ConclusionsHepatic inflow occlusion and the surgical approach used to address this issue may have an impact on HCC prognosis in patients with BCLC stage A disease, especially among those with MVI positivity. No hepatic inflow occlusion or an SHVE approach rather than the Pringle maneuver should be considered first during hepatectomy for patients with BCLC stage A disease.

A novel model for predicting posthepatectomy liver failure in patients with hepatocellular carcinoma.

Posthepatectomy liver failure (PHLF) is the most leading cause of mortality following hepatectomy in patients with hepatocellular carcinoma (HCC). Platelet count was reported to be a simple but useful indicator of liver cirrhosis and function of spleen. Spleen stiffness (SS) was used to evaluate the morphological change of spleen and was reported to be related to liver cirrhosis and portal hypertension. However, the predictive value of platelet to spleen stiffness ratio (PSR) on PHLF remains unknown. A retrospective study was performed to analyze 158 patients with HCC following hepatectomy from August 2015 to February 2016. Univariate and multivariate analyses were performed to evaluate the value of each risk factor for predicting PHLF. The predictive efficiency of the risk factors was evaluated by receiver operating characteristic (ROC) curve. PHLF occured in 23 (14.6%) patients. PSR (P<0.001, odds ratio (OR) = 0.622, 95% confidence interval (CI) 0.493~0.784), hepatic inflow occlusion (HIO) (P = 0.003, OR = 1.044, 95% CI 1.015~1.075) and major hepatectomy (P = 0.019, OR = 5.967, 95% CI 1.346~26.443) were demonstrated to be the independent predictive factors for development of PHLF in a multivariate analysis. Results of the present study suggested PSR is a novel and non-invasive model for predicting PHLF in patients with HCC.

Portal venous deprivation in patients with portosystemic shunts and its effect on liver tumors

AimsTo outline the use of radiological investigations in patients with congenital portosystemic shunts (CPS) and to assess the degree of portal venous deprivation in relation to the development of liver tumors. MethodsSingle center retrospective cohort study of all patients with CPS referred from 1990 to 2016. Radiological investigations were reviewed for the presence of intrahepatic portal veins. Two groups were defined: Group 1 — without evidence of preservation of an intrahepatic portal venous system and, Group 2 — with evidence of intrahepatic portal venous flow. These groups were compared for the development of liver tumors, serum ammonia, and nature of subsequent surgical intervention. The ratio of infraceliac to supraceliac aortic diameter and hepatic enhancement in biphasic CT scans were also used to infer hepatic arterial in-flow and compared to age matched controls. Nonparametric tests were used throughout. A P value of 0.05 was considered significant. Data are quoted as median (IQR). Results45 patients (Group 1, n = 12: Group 2, n = 33) were investigated for CPS at a median age of 8 months (1 month–14 years). Liver tumors were more common in Group 1 than Group 2 [11/12 (92%) versus 10/33 (29%); P < 0.001]. Aortic ratio was significantly lower in patients with CPS compared to control (0.82 versus 0.96; P < 0.001), but there was no difference between patients with or without tumors (0.82 versus 0.82; P = 0.52). Enhancement of the liver parenchyma was greater in portal venous rather than arterial phases by a median difference of 28 (15–50) Hounsfield units in controls, compared to 15 (8.5–23.5) in CPS patients (P = 0.04). A single stage closure was possible in 2/6 (33%) operated patients in Group 1 and 14/20 (70%) in Group 2 (P = 0.32). ConclusionsPatients without radiological evidence of intrahepatic portal venous flow were significantly more likely to have associated hepatic tumors with a relative risk 3.1. Levels of evidenceThis manuscript includes data that are III and IV Levels-of-Evidence.

Randomized controlled trial on Pringle Maneuver to reduce blood loss during stapler hepatectomy - PriMal StHep

BackgroundExtended liver resections still bear the risk of severe haemorrhage. Moreover, the amount of blood loss during liver resection determines the need for perioperative blood transfusions and is of prognostic relevance in oncologic surgery. Even though there is an ongoing debate about its effectiveness and tolerable duration, the Pringle Maneuver (PM) as an occlusion of the hepatic inflow is routinely applied to reduce blood loss during parenchymal dissection. In combination with the stapler resection technique, PM is expected to minimize blood loss during major liver resection safely due to the short parenchymal dissection duration.MethodsIn a single center prospective, randomized, controlled, parallel, confirmatory trial the combination of PM and stapler resection technique in patients undergoing right and left hepatectomies will be tested against the control group that applies stapler resection without the use of PM. The primary endpoint of the study is the total intraoperative blood loss. The measurement of the intraoperative blood loss is conducted with respect to all handled rinse fluids during surgery and by weighing used swabs to generate accurate and comparable data. Secondary endpoints include intra- and postoperative blood transfusion requirements, liver function parameters and the 90-day mortality rate. A sample size of fifty-three patients in either group was calculated to detect a clinically significant difference in blood loss of at least 450 ml with an α of 5% at 80% power. The individual follow-up will be 90 days.DiscussionThis is the first clinical trial to test the combination of PM and stapler resection technique as a means to reduce intraoperative blood loss in hepatic left or right resection. Given the short parenchymal dissection duration in stapler resection, PM is expected to be applied shortly without compromising liver function postoperatively.Trial registrationThe PriMaL StHep trial has been prospectively registered to the German Clinical Trial Registry (WHO ID: DRKS00010427) on April 21st. 2016.

Utility of Doppler Ultrasonography in Liver Transplantation With Celiac Axis Compression Syndrome: A Case Report

BackgroundCeliac axis compression syndrome (CACS) blocks adequate hepatic arterial flow and is a risk factor for hepatic artery thrombosis after liver transplantation. We report a case of living donor liver transplantation in a 65-year-old Brazilian male with liver cirrhosis of Child-Pugh class C and hepatocellular carcinoma caused by hepatitis C virus infection. ResultsThe patient underwent living donor liver transplantation using the graft of his 34-year-old daughter. Stenosis of the celiac artery was detected on preoperative computed tomography (CT), and CACS was suspected. Maintaining blood supply through the hepatic artery to prevent potential graft loss is essential in liver transplantation. A decrease in common hepatic artery (CHA) flow due to CACS could disturb graft blood supply or lead to hepatic artery thrombosis. In this case, we confirmed CACS through dynamic CT and used intraoperative Doppler ultrasonography (US) to plan the surgical procedure. Three types of hepatic artery reconstruction have been described in liver transplantation for CACS, namely the release of the median arcuate ligament (MAL), aorto-hepatic graft reconstructions, and reconstruction preserving the gastroduodenal artery (GDA) without MAL release. We found that clamping the GDA completely abolished hepatic inflow, but clamping the CHA did not change the hepatic inflow. Therefore, we performed arterial reconstruction without division of the GDA. The patient's postoperative course was good, with excellent hepatic artery flow, as assessed by Doppler US. ConclusionsPreoperative dynamic CT evaluation, adequate preparation of surgical procedures, and intraoperative evaluation by Doppler US is recommended in liver transplantation patients with CACS.

The Impact of a Nitric Oxide Synthase Inhibitor (L-NAME) on Ischemia⁻Reperfusion Injury of Cholestatic Livers by Pringle Maneuver and Liver Resection after Bile Duct Ligation in Rats.

The Pringle maneuver (PM) has been widely used to control blood loss during liver resection. However, hepatic inflow occlusion can also result in hepatic ischemia–reperfusion injury (IRI), especially in patients with a cholestatic, fibrotic, or cirrhotic liver. Here we investigate a nitric oxide synthase (NOS) inhibitor N-Nitroarginine methyl ester (L-NAME) on IRI after the PM and partial hepatectomy of cholestatic livers induced by bile duct ligation (BDL) in rats. Control group (non-BDL/no treatment), BDL + T group (BDL/L-NAME treatment) and BDL group (BDL/no treatment) were analyzed. Cholestasis was induced by BDL in the L-NAME and BDL group and a 50% partial hepatectomy with PM was performed. L-NAME was injected before PM in the BDL + T group. Hepatocellular damage, portal venous flow, microcirculation, endothelial lining, and eNOS, iNOS, interleukin (IL)-6, and transforming growth factor-β (TGF-β) were evaluated. Microcirculation of the liver in the BDL + T group tended to be higher. Liver damage and apoptotic index were significantly lower and Ki-67 labeling index was higher in the BDL + T group while iNOS and TGF-β expression was decreased. This was corroborated by a better preserved endothelial lining. L-NAME attenuated IRI following PM and improved proliferation/regeneration of cholestatic livers. These positive effects were considered as the result of improved hepatic microcirculation, prevention of iNOS formation, and TGF-β mRNA upregulation.

Application value of extra-glissonian pedicle transection approach guided by arantius′ ligament in laparoscopic left hemihepatectomy

Objective To explore the application value of the extra-glissonian pedicle transection approach guided by arantius′ ligament in laparoscopic left hemihepatectomy. Methods The retrospective cohort study was conducted. The clinical data of 57 patients who underwent laparoscopic left hemihepatectomy in the First Affiliated Hospital of Fujian Medical University from January 2015 to January 2018 were collected. There were 18 males and 39 females, aged from 29 to 75 years, with an average age of 57 years. Of the 57 patients, 22 undergoing the laparoscopic left hemihepatectomy with extra-glissonian pedicle transection approach guided by arantius′ ligament and 35 undergoing laparoscopic left hemihepatectomy with regular intra-glissonian pedicle transection approach were allocated into the extra-glissonian transection group and intra-glissonian transection group, respectively. Observation indicators: (1) intraoperative situations and postoperative short-term outcomes; (2) postoperative complications; (3) follow-up. Patients were followed up by outpatient examination and telephone interview to investigate postoperative recurrence of diseases up to June 2018. Measurement data with normal distribution were represented as Mean±SD and comparison between groups was analyzed using the t test.Count data were described as absolute number or percentage and comparison between groups was analyzed using the chi-square test. Results (1) Intraoperative situations and postoperative short-term outcomes: the operation time, dissection time of left hepatic pedicle, volume of intraoperative blood loss were (123±37)minutes, (14±5)minutes, (337±169)mL in the extra-glissonian transection group and (148±27)minutes, (22±3)minutes, (495±203)mL in the intra-glissonian transection group, respectively, showing statistically significant differences between the two groups (t=2.992, 7.733, 3.045, P 0.05). There was no uncontrolled hemorrhage or air embolism in the two groups. (2) Postoperative complications: 3 patients had complications of Clavien-Dindo classification Ⅰ in the extra-glissonian transection group including 1 of pulmonary infection, 1 of abdominal infection, 1 of incisional infection and 7 had complications in the intra-glissonian transection group including 2 of pulmonary infection, 2 of liver sectional effusion, 1 of subphrenic abscess, 1 of biliary leakage, 1 of incisional infection, showing no statistically significant difference between the two groups (χ2=0.066, P>0.05). Patients with postoperative complications were cured and discharged after symptomatic treatment. There was no perioperative death in the two groups. (3) Follow-up: 57 patients were followed up for 5-41 months, with a median time of 23 months. Two and 1 patients had tumor recurrence and hepatolithiasis recurrence in the intra-glissonian transection group, without recurrence of hepatic hemangioma or cholangiocarcinoma. Five patients had tumor recurrence in the intra-glissonian transection group, without recurrence of hepatic hemangioma, hepatolithiasis or cholangiocarcinoma. The disease recurrence rate was 13.6%(3/22) and 14.3%(5/35) in the extra-glissonian transection group and intra-glissonian transection group, respectively, showing no statistically significant difference between the two groups (χ2=0.104, P>0.05). Conclusions Extra-glissonian pedicle transection approach guided by arantius′ ligament in laparoscopic left hemihepatectomy is feasible and effective, which can control hepatic blood inflow of left liver, simplify the surgery procedure and shorten dissection time of left pedicle, in order to save operation time and reduce volume of intraoperative blood loss. Key words: Liver neoplasms; Liver cancer; Hepatic hemangioma; Hepatolithiasis; Extra-glissonian dissection; Hemihepatectomy; Arantius′ ligament; Hepatic pedicle; Laparoscopy

A New Minimally Invasive Approach to the Posterior Right Segments of the Liver: Report of the First Two Cases.

Background: Minimally invasive liver surgery has gained increasing popularity over the past decade. Nevertheless, laparoscopic treatment of lesions located in the posterior-superior locations remains challenging because of the difficulty to reach a safe exposition of those regions of the liver. We present a new retroperitoneoscopic approach for the minimally invasive treatment of posterior tumors. Materials and Methods: Between May and July 2018, 2 patients with solitary liver metastasis of colorectal origin underwent retroperitoneoscopic liver resection in the prone position. The operation was conducted with three to four trocars, the CO2 insufflation pressure was set at 20 mmHg. Liver transection was carried out by alternating bipolar coagulation and clips, without clamping of the hepatic inflow. Results: There were no intra- or postoperative complications. The procedure was completed in both cases without conversion after 120 to 180 minutes, respectively. Complete resection was achieved in both cases. Hospital stay was 3 and 5 days. Conclusions: Retroperitoneoscopic liver resection is feasible and safe. This approach could be suggested as an additional therapeutic option, especially in cases of redo resection at the posterior segments.

Saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation.

Occasionally, a recipient's native hepatic arteries are not suitable for reconstruction in living donor liver transplantation (LDLT). The use of the great saphenous vein (GSV) conduits in such patients is seldom practiced since arterial conduits from deceased donors are available. Here, we share our experience with a significantly large group of LDLT recipients who underwent arterial reconstruction with GSV conduits. We reviewed patients who underwent LDLT between 2012 and 2017. Patients who had arterial reconstruction using native hepatic arteries (group 1)(n = 452) were compared with those who had GSV interposition conduits for reconstruction (group 2)(n = 21). We compared hepatic artery thrombosis (HAT) rate, allograft dysfunction, morbidity, mortality, and actuarial 5-year survival in the two groups. HAT was seen in 0/452 (0%) versus 1/21(4.7%) patients (P = 0.04). Allograft dysfunction was seen in 89/423 (21%) versus 6/19(31.5%) (P = 0.2) patients. Overall mortality was 81/452 (17.9%) versus 8/21(38%) (P = 0.02). Death after a biliary complication was seen in 24/452 (5.3%) versus 4/21 (19%) patients (P = 0.02). Actuarial 1- and 5-year overall survival was 85% versus 67% and 79% versus 58% (P = 0.008). GSV conduits are a suboptimal alternative for establishing hepatic arterial inflow in LDLT, but remain valuable in ominous situations.

Liver Resection with In Situ Hypothermic Perfusion: An Old but Effective Method

BackgroundMore than 40 years ago, patients with tumors infiltrating the confluence of the hepatic veins were deemed unresectable; however, in situ hypothermic perfusion, first described by Fortner et al. (Ann Surg 180(4):644–652, 1974), allowed resection of these tumors. In order to prevent liver ischemia after total vascular exclusion, the liver was flushed with a cooled organ preservation solution. The surgeon was able to resect the tumor and reconstruct the hepatic veins with occlusion of the hepatic inflow and outflow.MethodsA 55-year-old female suffering from a leiomyosarcoma of the inferior vena cava (IVC) presented to our clinic. Three years ago, the IVC was replaced with a synthetic graft. During the patient’s follow-up, a computed tomography (CT) scan revealed three hepatic metastases of the sarcoma. A central metastasis in Segment 8 infiltrated the right hepatic vein (RHV), and two additional metastases were located in the left lateral segments. We used Fortner’s technique to resect these tumors.ResultsThe postoperative course of the patient was prolonged due to a hematoma that partially compressed the new RHV graft. A re-laparotomy was performed and drains were placed. On the 15th postoperative day, the patient was discharged in good health.ConclusionsAlthough nowadays patients with these unfortunate tumor locations can, to some extent, be managed non-operatively, surgery remains an option with a chance of cure. Azoulay et al. (Ann Surg 262(1):93–104, 2015) were able to show satisfactory 5-year-survival in 77 patients (30.4%), however 90-day mortality was high (19.5%). Therefore, patients need to be selected carefully. In the era of minimally invasive liver surgery, these old techniques should not vanish from the armamentarium of liver surgeons.

Clinical efficacy of laparoscopic versus open hepatectomy for the treatment of hepatocellular carcinoma

Objective To evaluate the clinical efficacy of laparoscopic hepatectomy and open hepatectomy for the treatment of hepatocellular carcinoma. Methods Two hundred and sixteen patients with hepatocellular carcinoma who were admitted to the Chongqing Three Gorges Central Hospital from October 2014 to December 2017 were enrolled in this study, 52 patients undergoing laparoscopic hepatectomy (laparoscopic group) and 164 patients undergoing open hepatectomy, 52 patients(open group) were matched by propensity score matching method to reduce confounding bias. The operation time, tumor sizes, resection margin, time of hepatic inflow occlusion, volume of blood loss, blood transfusion, postoperative complication rate, drainage tube removal time, postoperative anal exhaust time, duration of postoperative hospital stay and survival rates were compared. T test was used for the measurement data in line with the normal distribution, and the results were represented by (Mean±SD) tandard deviation; Wilcoxon test was used for the measurement data in the skewed distribution, and M(range) was used for represention, and the chi-square test or Fisher′s exact probability test was used for the counting data. Kaplan-meier method was used to describe the survival curve, and log-rank test was used to compare the survival rate. Cox regression model was used to evaluate the risk factors affecting the survival of patients with hepatocellular carcinoma. Results All patients were recovered with no perioperative death. The operation time, tumor sizes, resection margin, time of hepatic inflow occlusion were (226.1±67.5) min, (49.2±15.5) mm, (14.3±4.9) mm, (34.1±18.1) min and (227.0±55.7) min, (49.4±16.6) mm, (14.6±4.0) mm, (38.2±16.1) min, with no significant differences between the two groups(P>0.05). The volume of blood loss, blood transfusion, postoperative complication rate, drainage tube removal time, postoperative anal exhaust time, duration of postoperative hospital stay were 325(50-1 200) ml, 11.5%, 15.4%, (4.8±0.9) d, 3(2-5) d, (11.9±3.5) d and 375(100-2 000) ml, 19.2%, 23.1%, (5.9±0.8) d, 4(3-5) d, (14.9±6.2) d, with significant differences between the 2 groups(P 0.05). Cox regression analysis revealed that ICG R15, tumor size and tumor differentiation were independent risk factors of survival(hazard ratio>1, P<0.005). Conclusions Application of Laparoscopic hepatectomy for the treatment of selective hepatocellular carcinoma patients has better short-term efficacy than open hepatectomy and long-term efficacy is comparably. The propensity score matching can reduce confounding bias and have value for clinical research. Key words: Carcinoma, hepatocellular; Hepatectomy; Laparoscopes

Treatment of resectable hilar cholangiocarcinoma: a choice of right- or left-side hepatectomy

Introduction: Radical resection is the only curative treatment for patients with hilar cholangiocarcinoma. Some have argued that left-side hepatectomy has worse prognosis regarding its contiguous anatomical relationship between hepatic inflow and biliary confluence, otherwise right-side hepatectomy has worse surgical morbidity and mortality. This study aimed to compare the surgical morbidity and long-term outcome between right- and left-side hepatectomy to help the decision of which side to be resected in the surgical treatment of hilar cholangiocarcinoma. Method: A total of 83 patients attempting curative resection for hilar cholangiocarcinoma at the Korea University Medical Center between 2010 and 2017 were considered for this study. After excluding patients who did not undergo curative-intent surgery or hepatectomy, 57 patients undergoing right- or left-side hepatectomy were finally enrolled for analysis. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and survival were evaluated. Result: Right-side hepatectomy (RH) and left-side hepatectomy (LH) were performed for 33 and 24 patients, respectively. The proportion of R0 resection was comparable between both groups (75.8% for RH group and 75.0% for LH group, p=0.948). Posthepatectomy liver failure was significantly more prevalent in the RH group than the LH group (75.7% vs. 12.5%, p<0.001). 90-day mortality did not differ between both groups (9.1% vs. 4.2%, p=0.631). The 5-year overall survival rate was 37.7% for the RH group; and 41.9% for the LH group (p=0.500). The 5-year recurrence-free survival rate was 26.3% for the RH group; and 33.9% for the LH group (p=0.580). Conclusion: Posthepatectomy liver failure was more prevalent in the RH group than the LH group, but it did not affect the 90-day mortality. It is recommended to perform surgical resection only according to the possibility to achieve radical resection, regardless of right- or left-side hepatectomy.

Appleby procedure – a challenging interdisciplinary treatment for extensive pancreatic body cancer

Background: Locally advanced pancreatic body cancer with invasion of the celiac axis is a severe finding that only rarely can undergo curative resection. Methods: We here present a video highlighting the crucial steps of a modified Appleby procedure. A 52-year old patient presented with a mass in pancreas body and infiltration of the celiac axis (CA) and splenic artery (SA). Results: Preoperative angiography and embolization of the common hepatic artery (CHA) is imperative to assure an adequate retrograde hepatic blood inflow via the gastroduodenal arcade. Occasionally, it is necessary an additional embolization of a hypertrophic right gastric artery to avoid flow steal phenomenon, as in this case. The patient underwent radical curative resection after neoadjuvant chemoradiation. Surgery started with mobilization of the tail of the pancreas and spleen. Dissection of hepatoduodenal ligament and identification of the junction of gastroduodenal artery (GDA) and hepatic artery is of utmost importance. For safety reasons, it is recommendable to preliminary clamp the common hepatic artery and to prove a sufficient hepatic arterial flow by Doppler ultrasound. The common hepatic artery is then divided proximal of the junction with the GDA. CA was ligated at the level of the aorta and resected en-bloc with the specimen of distal pancreas and spleen. Conclusion: The intra- and postoperative course was uneventful; the patient could be discharged on postoperative day eleven. The histopathological findings showed an R0 resection.

Beneficial impact of microwave ablation-assisted laparoscopic hepatectomy in cirrhotic hepatocellular carcinoma patients: a propensity score matching analysis

Purpose: In this study, we evaluated the efficacy of microwave ablation-assisted laparoscopic hepatectomy (MLH) for the management of hepatocellular carcinoma (HCC) in cirrhotic patients.Methods: Data from HCC patients with liver cirrhosis who underwent laparoscopic hepatectomy (LH) or MLH in Shengjing Hospital (Shenyang, China) were retrospectively analyzed from January 2013 to June 2017. The demographic characteristics, clinical features, intraoperative parameters and surgical outcomes were analyzed and compared. Propensity scores matching (PSM) analysis was used to minimize bias.Results: A total of 54 patients were enrolled in the MLH group and 39 patients in the LH group. Following 1:1 matching by PSM analysis, 26 patients were selected from each group. Compared to the LH group, patients in the MLH group had significantly decreased intraoperative bleeding (48.0 vs. 203.9 ml, p < .0001) and reduced demand for hepatic inflow occlusion (0 vs. 6, p = .009). No significant difference was observed in average operation time (155.7 vs. 148.5 min) and postoperative hospitalization time (8.3 vs. 9.3 d) between the MLH and LH groups. Similarly, the 1-year and 3-year recurrence-free survival (RFS) rates as well as the 1-year and 3-year overall survival (OS) rates of the MLH and LH groups were not significantly different (83.1 vs. 82.4% and 64.6 vs. 36.6% as well as 100 vs. 95.8% and 93.8 vs. 59.1%, respectively: p > .05).Conclusions: MLH significantly decreased intraoperative bleeding and reduced the need for hepatic occlusion without compromising the surgical outcome. Therefore, microwave ablation could be a valuable tool for LH in HCC patients with cirrhosis.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BackgroundFew studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis. MethodsPatients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed. ResultsAmong patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching. ConclusionsIn patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

The “Dorsal” approach to laparoscopic major hepatectomy

This new technique is a modification of the caudal approach of Soubrane. After a long experience of over 600 laparoscopic hepatectomies, this posterior to anterior procedure has enabled us to perform major hepatectomy more easily, via a standardised technique, for larger tumours, and for anatomical variations of the porta. As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral. A small hepatotomy anterior to the right inflow then allows stapling of the right hepatic inflow without blind force or risk of compromise to the confluence. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, with subsequent division of the anterior parenchyma. This maintains good surgical orientation, especially for tumours close to the midline or cava, and for the middle hepatic vein. This also aids haemostasis by allowing the application of pressure in a postero-anterior direction. After completion of the parenchymal transection, the right hepatic vein is divided, followed by the hepatocaval ligament, accessory hepatic veins, and peritoneal attachments. The same concepts can be applied to left and extended left hepatectomy. This technique has enabled expanded indications for a laparoscopic approach to major hepatectomies as well as a standardized operative technique. Schematic and case videos will be presented.