Hepatic Resection For Malignancy Research Articles

Vascular Resection During Hepatectomy for Liver Malignancies. Results from a Tertiary Center using Autologous Peritoneal Patch for Venous Reconstruction.

To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies. Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed. Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456min (range 270-960). Blood loss was a median 300cc (range 40-1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22). Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.

Intraoperative fluorescence imaging with indocyanine green in hepatic resection for malignancy: a systematic review and meta-analysis of diagnostic test accuracy studies.

Fluorescence imaging during hepatic resection has the potential to identify additional malignant tumors, increasing the chance for complete tumor resection. Indocyanine green (ICG) is an FDA approved, fluorescent dye used in a variety of surgical procedures. The objective of this study was to define the sensitivity of intraoperative ICG fluorescent imaging in the detection of hepatic malignancy in adult patients during hepatic resection, which was accomplished by performing a systematic review and meta-analysis. The databases Medline, EMBASE, Scopus and Web of Science were assessed in September 2018. Article inclusion criteria was (1) Liver resection for malignancy (2) ICG injected pre or intraoperatively (3) Use of infrared electronic endoscopy or near-infrared fluorescence imaging intraoperatively (4) Patient age ≥ 18years (5) N > 5 patients (6) Human and English studies only. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines were used for quality assessment. Data synthesis was completed using Meta-Disc and MedCalc software. A DerSimonian-Laird random effects model was used for the meta-analysis. 21 studies and 841 patients were included in our systematic review. Seven studies and 319 patients were included in the meta-analysis. The pooled sensitivity of intraoperative ICG fluorescence was 0.75 (0.71-0.79). Sensitivity for superficial tumors ranged from 0.96 to 1.00. Heterogeneity (I2) was calculated at 65.1%. ICG-related fluorescence imaging detected new malignant tumors not detected by conventional means in 42 of 362 patients across 13 studies. The sensitivity of intraoperative ICG-related imaging for superficial tumors is high; however, overall sensitivity is low, at 0.75, suggesting that it would have to be used in combination with current identification methods such as intraoperative ultrasound. Our study also found that intraoperative ICG fluorescence imaging was able to detect additional malignant hepatic tumors in 11.6% of patients.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Hepatic resection for malignancy in the elderly: NSQIP predictors of morbidity and mortality

Background: Liver resection for malignancy in the elderly is common given most malignancies occur in the 6th and 7th decades. Previous studies show increasing age in surgical patients is the most important predictor of morbidity and mortality. The aim was to evaluate patients > 65yrs undergoing liver resection for malignancy and determine risk factors for morbidity and mortality. Methods: The National Surgical Quality Improvement Program (NSQIP) database (2014-2016) was queried for patients age>65 who underwent liver resection for malignancy. Odds ratios for factors associated with increased risk of post-hepatectomy complications and death were evaluated with Cox logistical regression. Results: 3,460 patients underwent liver resection with a 3% mortality and 32% complication rate. Post-operative bile leak occurred in 9.4% of patients, liver failure occurred in 5.7%, and transfusions occurred in 20% of patients. On univariate analysis, there was no association between complications and age (p=.75), neoadjuvant therapy (p= 0.13), diabetes (p=.44), and smoking (p=0.73). Factors associated with complications: decreased BMI (p< 0.01), higher ASA (p< .01), pringle maneuver (p< .01), hilar cholangiocarcinoma (p< .01), and open surgery (p< .01). On multivariate analysis, factors associated with increased risks can be seen in Figure 1.Tabled 1FP28-05 Table [Table 1]Multivariable Adjusted Odds Ratios ond 95% Confidence intervals for Post Hepotectomy Compactions and Mortality for Elderly Patients Age ≥ 65TermMultivariate model: at least one complicationMultivariate model: modalityOdds95% CIOdds95% CIRatioLowerUpperp-valueRatiolowerUpperp-valueBMI (per ↑ 1)0.980.971.000.01490.990.961.020.5036Pre-operative platelet count (per ↑ 25)1.000.981.030.95680.930.870.990.0191Preoperative serum albumin (per ↑ 1)0.600.500.72<.00010.640.430.960.0313Pre-operative serum creatinine (per ↑ 0.25)1.111.051.180.00021.071.001.160.0636Pre-operative total bilirubin (per ↑ 1)1.020.911.140.77831.080.961.230.2012Total operation time (per ↑ 15 minutes)1.081.071.10<.00011.051.031.08<.0001Biliary Stent (Yes vs No)1.521.042.240.03271.690.923.110.0930Open Approach vs Minimally Invasive2.141.652.78<.00011.590.773.280.2100Primary hepatobiliary cancer vs Secondary (metastatic) tumor1.261.051.500.01141.941.203.110.0064Inflow Occlusion (Pringle Maneuver) During Resection1.000.831.210.99590.850.531.350.4906ASA classificationSevere vs None/Mild1.040.811.320.77744.911.7413.860.0026Life-Threatening vs None/Mild1.861.322.620.00046.292.0019.770.0016Life-Threatening vs Severe1.801.362.37<.00011.280.712.310.4110Principal Operative ProcedureTOTAL l£FT LOBECTOMY vs PARTIAL LOBECTOMY1.040.781.380.80520.970.452.120.9470TOTAL RIGHT LOBECTOMY vs PARTIAL LOBECTOMY1.831.462.30<.00012.291.353.880.0021TOTAL RIGHT LOBECTOMY vs TOTAL LEFT LOBECTOMY1.771.282.440.00052.351.085.130.0319TRlSEGMENTECTOMY vs PARTIAL LOBECTOMY2.001.492.70<.00012.341.264.360.0071TRlSEGMENTECTOMY vs TOTAL LEFT LOBECTOMY1.931.332.800.00052.411.045.550.0391TRlSEGMENTECTOMY vs TOTAL RIGHT LOBECTOMY1.090.791.510.58721.020.561.870.9380 Open table in a new tab Conclusions: Age was not associated with increased complications. Decreased BMI was associated with complications. Increasing albumin was associated with improved mortality and morbidity. These findings suggest that cachexia effects surgical outcomes in elderly and indirectly reflects the frailty of patients.

ALPPS: Challenging the concept of unresectability – A systematic review

Introduction: Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. Materials and methods: A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. Results: To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61–93% over a median 9–14 days, 95–100% completion of the second stage, and high likelihood of R0 resection (86–100%). Discussion: ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. Conclusions: A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.

Mo1733 Influence of Preoperative Laboratory Values on Perioperative Mortality Following Hepatic Resection for Malignancy

Mo1733 Influence of Preoperative Laboratory Values on Perioperative Mortality Following Hepatic Resection for Malignancy

Indeterminate Pulmonary Nodules Represent Lung Metastases in a Significant Portion of Patients Undergoing Liver Resection for Malignancy

IntroductionDespite detection on imaging before resection of hepatic malignancies, the natural history of indeterminate pulmonary nodules (IPN) is unknown. The objective of this study is to determine how often IPN detected on imaging before surgery for hepatic malignancies represent lung metastases. MethodsDemographics, comorbidities, tumor characteristics, and surgical treatments of patients with pre-operative IPN who underwent liver resection and/or radiofrequency ablation for malignant diagnoses were reviewed. ResultsFrom 2000 to 2010, 90 patients with at least one IPN underwent liver resection or radiofrequency ablation for malignancy. Of these, 44 (48.9 %), 32 (35.6 %), and 14 (15.6 %) patients had colorectal cancer liver metastases (CRCLM), primary hepatobiliary malignancies (HB), and other cancers, respectively. The median number of IPN was 1. The median size was 4 mm. Twenty (22 %) patients had isolated lung recurrence after hepatic surgical therapy. Eighty percent occurred in the exact location of the pre-operative IPN. Isolated lung recurrence was more common among patients with CRCLM compared to those with HB and other cancers (42.9 vs. 9.4 vs. 14.3 %, p = 0.004). ConclusionPre-operatively detected IPN represent lung metastases in a substantial portion of patients undergoing surgery for hepatic malignancy. IPN are more likely to represent lung metastases in patients with CRCLM compared to those with primary HB and other cancers.

The risk of thrombotic events in patients with primary versus secondary hepatic malignancies who are undergoing surgical resection

15178 Background: The increased risk of thromboses is well documented in patients with malignancies, and those undergoing abdominal surgery. Furthermore, patients requiring hepatic resection for underlying malignant disease have been reported to be at increased risk for thrombotic complications. However, guidelines for thromboprophylaxis in this patient population are still under investigation. A cursory review performed at our institution determined the incidence of thrombotic events to be comparable to that reported in the literature. We, therefore, went further to study if there was a difference in the risk of thromboses between those undergoing resection for primary hepatic cancer, versus metastatic disease. Methods: We performed a retrospective chart review of patients undergoing surgical resection for hepatic malignancies. The primary end point was to determine whether there was a difference in the incidence of thrombotic events between primary and secondary malignancies. Results: A total of 99 patients at our institution underwent surgical resection for either primary or secondary hepatic malignancies in the past 5 years. There were 7 patients who developed thrombotic events within three months of their resection. Of these patients, all 7 underwent resection for secondary hepatic malignancies. Based on the nature of this study, and its lack of standardized thromboprophylaxis, statistical analysis was not performed. Conclusions: Patients undergoing surgical resection of hepatic malignancies appear to be at increased risk of thrombotic events, and may require more specific standardization of their thromboprophylaxis. Furthermore, based on our observation it appears those associated with metastatic disease may derive an even greater benefit from this. Future prospective studies will be required to evaluate this difference in thromboses, and to better define the guidelines for thromboprophylaxis. No significant financial relationships to disclose.

Central hepatic resection for pediatric tumors

Background/Purpose: Resection of hepatic malignancies in childhood has been facilitated greatly by an understanding of hepatic segmental anatomy. This report documents the indications and technique of central hepatic resection (mesohepatectomy) in children with hepatic malignancies. Methods: This is a retrospective study, and data are obtained from patient charts and operative reports. Three patients underwent central hepatic resection on or between June 27, 1997 and October 1, 1999. Results: All patients were boys, and their ages at diagnosis were 0.3, 0.8, and 3.8 years. Two had hepatoblastoma and one central hepatic metastases from a poorly defined epithelial malignancy. All 3 received neoadjuvant chemotherapy before hepatic resection. Segments IV, V, and VIII were removed in 2, and IV and V in the third. All patients survived, and histopathologic margins were clear in each. One patient had a postoperative bile collection treated with percutaneous catheter drainage. At follow-up, all patients remain alive without evidence of disease, and all have normal hepatic function. Conclusion: Central hepatic resection of malignant tumors involving segments IV, V, and VIII is feasible and effective in childhood. J Pediatr Surg 37:986-989. Copyright 2002, Elsevier Science (USA). All rights reserved.

The impact of new technology on hepatic resection for malignancy.

Relatively high morbidity rates remain problematic in hepatic resection for malignant neoplasms. Technological innovations coupled with surgical expertise can ameliorate morbidity and mortality rates. Medical records survey. Tertiary care university hospital. Five hundred one patients underwent liver resection at our hospital from March 1, 1988, through November 30, 1999. Three hundred twenty-one patients (64.1%) had primary carcinoma, whereas 180 (35.9%) had metastatic disease, mainly colorectal secondary disease (83.3%). Morbidity and mortality rates were compared with those of a previous series in the same setting. Special attention was paid to the impact of new technology (eg, newer imaging techniques, ultrasonic aspiration, intraoperative ultrasonography, argon beam coagulation, and autotransfusion) and improved anesthetic and surgical management on mortality and morbidity rates. Five patients died after liver resection and 93 patients had various complications, representing mortality and morbidity rates of 1.0% and 18.6%, respectively. These results compare favorably with the results of a previous unpublished series (mortality, 5/55 [9.1%]; morbidity, 28/55 [50.9%]). Intraoperative ultrasonography resulted in a change in operative strategy in 7 (17.5%) of a recent group of 40 patients. Morbidity after major hepatic resection for malignancy can be reduced considerably by applying newer technologies to preoperative and intraoperative decision making. Advanced technology also assists in reducing intraoperative risk by minimizing bleeding during resection of the hepatic parenchyma.

What is the yield of intraoperative ultrasonography during partial hepatectomy for malignant disease?

BACKGROUND: Previous studies have shown that intraoperative ultrasonography (IOUS) during hepatic resection for malignancy changes the operative plan or identifies occult unresectable disease in a large proportion of patients. This study was undertaken to reassess the yield of IOUS in light of recent improvements in preoperative staging. STUDY DESIGN: Patients with potentially resectable primary or metastatic hepatic malignancies subjected to exploration, bimanual palpation of the liver, and IOUS were evaluated prospectively. Intraoperative findings were recorded, and preoperative imaging studies were reanalyzed by radiologists blinded to the intraoperative findings. The extent of disease based on preoperative imaging was compared with the intraoperative findings. RESULTS: From October 1997 until November 1998, 111 patients were evaluated. At exploration, a total of 77 new findings or findings different than suggested on the imaging studies were identified in 61 patients (55%), the most common of which was additional hepatic tumors (n = 37). Thirty-five of 77 (45%) new findings were identified by IOUS alone and 10 (13%) by palpation alone; the remainder were identified by both palpation and IOUS. Forty-seven of 61 patients (77%) underwent a complete resection despite new intraoperative findings, with a modification (n = 28) or no change (n = 19) in the planned operation. Twenty-one patients (19%) had new findings identified only on IOUS. Thirteen of these patients underwent resection with no change in the operative plan, six underwent a modified resection and two were considered to have unresectable disease based solely on the findings of IOUS. CONCLUSIONS: In patients with hepatic malignancies submitted to a potentially curative resection, new intraoperative findings or findings different than suggested on preoperative imaging studies are common. But resection with no change in the operative plan or a modified resection is still possible in the majority of patients despite such findings. The findings on IOUS alone rarely lead to a change in the operative plan.

Relationship between particles in a foil and the planar projected image: I.Kohutek, M.Besterci. (Ustav Materialoveho Vyskumu SAV, Kosice, Slovak Republic.) Pokroky Praskove Metal., vol 36, no 4, 1998, 29–34. (In Czech.)

Background/Purpose: Resection of hepatic malignancies in childhood has been facilitated greatly by an understanding of hepatic segmental anatomy. This report documents the indications and technique of central hepatic resection (mesohepatectomy) in children with hepatic malignancies. Methods: This is a retrospective study, and data are obtained from patient charts and operative reports. Three patients underwent central hepatic resection on or between June 27, 1997 and October 1, 1999. Results: All patients were boys, and their ages at diagnosis were 0.3, 0.8, and 3.8 years. Two had hepatoblastoma and one central hepatic metastases from a poorly defined epithelial malignancy. All 3 received neoadjuvant chemotherapy before hepatic resection. Segments IV, V, and VIII were removed in 2, and IV and V in the third. All patients survived, and histopathologic margins were clear in each. One patient had a postoperative bile collection treated with percutaneous catheter drainage. At follow-up, all patients remain alive without evidence of disease, and all have normal hepatic function. Conclusion: Central hepatic resection of malignant tumors involving segments IV, V, and VIII is feasible and effective in childhood. J Pediatr Surg 37:986-989. Copyright 2002, Elsevier Science (USA). All rights reserved.

Role of staging laparoscopy in the treatment of hepatic malignancy

Despite current radiologic imaging capabilities, 40% to 70% of patients with primary or metastatic hepatic malignancies are found to have unresectable disease at the time of laparotomy. The present study evaluates the use of laparoscopy in the staging of hepatic malignancy. Twenty-nine patients underwent staging laparoscopy prior to a planned laparotomy for resection of a hepatic malignancy that was deemed resectable by computed axial tomographic scan and ultrasonography. Twelve patients had primary hepatic malignancies, and 17 had metastatic malignancies. Laparoscopy demonstrated evidence of unresectability in 48% (14 of 29) of patients studied. Four patients had unsuspected cirrhosis, and 10 had unresectable or extrahepatic metastatic disease. Patients who underwent laparoscopy alone had shorter mean hospital lengths of stay than historical controls who underwent laparotomy alone. We conclude that diagnostic laparoscopy should precede laparotomy for planned resection of hepatic malignancies.

Intraoperative autotransfusion in hepatic resection for malignancy. Is it safe?

To evaluate whether intraoperative autologous transfusion increases the risk of hematogenous dissemination of tumor we reviewed the risk of lung metastasis as well as disease-free and long-term survival of patients who underwent resection of malignant hepatic neoplasms with this technique. A retrospective review of patients undergoing liver resection for malignant disease revealed 39 patients in whom intraoperative autologous transfusion was used. The 2-year actuarial survival in the patients in this series, as calculated with the Kaplan-Meier method, was predicted to be 75%. Two-year actuarial disease-free survival was predicted to be 28%, and the risk of developing lung metastasis at 3 years was estimated to be 40%. The predicted overall survival and risk of recurrence in this series compare favorably with published data for patients in whom intraoperative autologous transfusion was not used.