Indications For Liver Resection Research Articles

The Russian consensus on the treatment of intrahepatic cholangiocarcinoma

The Russian consensus on the treatment of intrahepatic cholangiocarcinoma was prepared by the group of experts consisting of surgeons, interventional radiologists, radiation therapists and oncologists. The purposes of this consensus are clarification and consolidation of opinions of multidisciplinary team on the following issues of management of patients with intrahepatic cholangiocarcinoma: indications for surgical treatment, features of therapeutic tactics for mechanical jaundice, technical aspects of liver resection, prevention of post-resection liver failure, indications for liver resection using transplantation technologies, laparoscopic and robot-assisted liver resection, perioperative systemic chemotherapy, local non-resection/non-radiotherapy methods of treatment, radiotherapy, follow-up and choice of treatment for recurrence.

Surgical Approach to Liver Metastases in GEP-NET in a Tertiary Reference Center

Indications for liver resection in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NET) vary from liver resection with curative intent to tumor debulking or tissue sampling for histopathological characterization. With increasing expertise, the number of minimally invasive liver surgeries (MILS) in GEP-NET patients has increased. However, the influence on the oncological outcome has hardly been described. The clinicopathological data of patients who underwent liver resection for hepatic metastases of GEP-NET at the Department of Surgery, Charité-Universitätsmedizin Berlin, were analyzed. Propensity score matching (PSM) was performed to compare MILS with open liver surgery (OLS). In total, 22 patients underwent liver surgery with curative intent, and 30 debulking surgeries were analyzed. Disease-free survival (DFS) was longer than progression-free survival (PFS) (10 vs. 24 months), whereas overall survival (OS) did not differ significantly (p = 0.588). Thirty-nine (75%) liver resections were performed as OLS, and thirteen (25%) as MILS. After PSM, a shorter length of hospital stay was found for the MILS group (14 vs. 10 d, p = 0.034), while neither DFS/PFS nor OS differed significantly. Both curative intended and cytoreductive resection of hepatic GEP-NET metastases achieved excellent outcomes. MILS led to a reduced length of hospital, while preserving a good oncological outcome.

Defining the surgical management for non-colorectal liver metastases.

Surgical resection is indicated for resectable colorectal liver metastases (CLM), but it is controversial for non-colorectal liver metastases (NCLM). This study aimed to compare survival outcomes of patients with resection of NCLM versus CLM and to identify prognostic factors for resection of NCLM. Consecutive patients who underwent surgical resection of liver metastases at Queen Mary Hospital, Hong Kong from January 1989 to December 2019 were retrospectively reviewed. Patients with resected NCLM were compared to those with CLM. Overall and recurrence-free survival were determined. Subgroup analyses with patients grouped according to the year of liver resection, from 1989 to 2004 and from 2005 to 2019, were conducted. Univariate and multivariate analyses were performed to identify prognostic factors. Among 674 patients included, 151 (22.4%) had NCLM while 523 (77.6%) had CLM. There were no statistically significant differences in median overall survival (65.2 vs 43.6months, p = 0.555) and recurrence-free survival (12.5 vs 11.7months, p = 0.425). The 1-year, 3-year, 5-year and 10-year overall survival rates were 89.8% vs 91.5%, 59.4% vs 58.8%, 50.6% vs 38.7% and 34.1% vs 26.3% in NCLM and CLM groups, respectively. Subgroup analyses demonstrated no statistically significant difference in overall survival between resection of NCLM versus CLM in both time intervals. In the NCLM group, better overall survival was found in liver metastasis of gastrointestinal stromal tumour (GIST) origin (hazard ratio (HR) 0.138, p = 0.003) and with a longer time interval from resection of primary tumour to resection of NCLM (HR 0.982, p = 0.042). Poor prognostic factors were presence of blood transfusion (HR 5.588, p = 0.013) and post-operative complications of Clavien-Dindo Grade IIIa or above (HR 74.853, p = 0.003). Surgical resection of NCLM had comparable survival outcomes with CLM. With appropriate patient selection, the indication of liver resection could be expanded to NCLM.

Defining Textbook Outcome in liver surgery and assessment of hospital variation: A nationwide population-based study

IntroductionTextbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to assess factors associated with TO, and evaluate hospital and network variation after case-mix correction in TO rates for liver surgery. MethodsThis was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of hospital stay, and readmission, and obtaining adequate resection margins. Multivariable logistic regression was used for case-mix adjustment. Results2376 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51–0.95 p = 0.02), extrahepatic disease (aOR 0.64, CI 0.44–0.95, p = 0.02), tumour size >55 mm on preoperative imaging (aOR 0.56, CI 0.34–0.94, p = 0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54–0.98, p = 0.04), and major liver resection (aOR 0.50, CI 0.36–0.69, p < 0.001). After case-mix correction, no significant hospital or oncological network variation was observed. ConclusionTO differs between indications for liver resection and can be used to assess between hospital and network differences.

Efficacy and Safety of mFOLFOX6 as Perioperative Chemotherapy for Resectable Liver Metastases from Colorectal Cancer: A Case-Control Study.

Although resection is effective for managing resectable liver metastases from colorectal cancer, the clinical significance of chemotherapy for such metastases has remained undetermined. Therefore, we conducted a phase II trial of perioperative chemotherapy with mFOLFOX6 to examine its efficacy. A total of 41 patients were examined. The liver resection rate was the primary endpoint, whereas the response rate, adverse events, completion rate, liver injury rate, R0 resection rate, and histological results were the secondary endpoints. Overall, 34 (82.9%) patients underwent liver resection, and 77.4% and 100% had synchronous and metachronous liver metastases, respectively. The seven remaining patients did not undergo resection because of progressive disease. Moreover, 2, 15, 17, and 7 patients had a complete response, partial response, stable disease, and progressive disease, respectively, which indicated that the response rate was 41.5%. Regarding adverse events, three patients exhibited Grade 3 myelosuppression and one patient had gastrointestinal symptoms. On the basis of histopathological examination, 27, 5, and 2 patients belonged to grades 1a:1b, 2, and 3, respectively. Regarding liver injury, 29.4% had liver sinusoidal injury, whereas 11.7% had steatohepatitis. Meanwhile, all patients underwent postoperative chemotherapy. mFOLFOX6 is safe and yields favorable therapeutic effects. The indication for liver resection after a certain waiting period is clinically significant.

The role of liver resection in metastatic nephroblastoma: a systematic review and Meta-regression analysis

BackgroundThe impact of hepatic resection for liver metastases (LM) on the survival of pediatric patients with Wilms’ tumor (WT) is unclear. So far, there is a lack of studies investigating the best suited treatment for patients with WTLM, and the role of liver resection has rarely been investigated. Thus, the development of evidence-based guidelines concerning indications of liver resection for WTLM remains difficult.AimTo investigate the role of surgery in the therapy of WTLM. All available data on liver resections and subgroup outcomes of patients with WTLM are analyzed. Main research question is whether liver resection improves survival rates of patients with WTLM compared to non-surgical treatment.MethodsA systematic literature search of MEDLINE, Web of Science, and Central provided the basis for this PRISMA-compliant systematic review. For the main analysis (I), all studies reporting on surgical treatment of pediatric WTLM were included. To provide a representative overview of the general outcome of WTLM patients, in analysis II all studies with cohorts of at least five WTLM patients, regardless of the kind of treatment, were reviewed and analyzed. A Multiple meta-regression model was applied to investigate the impact liver resection on overall survival.Results14 studies with reports of liver resection for WTLM were found (Analysis I). They included a total of 212 patients with WTLM, of which 93 underwent a liver resection. Most studies had a high risk of bias, and the quality was heterogenous. For the analysis II, eight studies with subgroups of at least five WTLM patients were found. The weighted mean overall survival (OS) of WTLM patients across the studies was 55% (SD 29). A higher rate of liver resection was a significant predictor of better OS in a multiple meta-regression model with 4 covariates (I2 29.43, coefficient 0.819, p = 0.038).ConclusionsThis is the first systematic review on WTLM. Given a lack of suited studies that specifically investigated WTLM, ecological bias was high in our analyses. Generating evidence is complicated in rare pediatric conditions and this study must be viewed in this context. Meta-regression analyses suggest that liver resection may improve survival of patients with WTLM compared to non-surgical treatment. Especially patients with persisting disease after neoadjuvant chemotherapy but also patients with metachronous LM seem to benefit from resection. Complete resection of LM is vital to achieve higher OS. Studies that prospectively investigate the impact of surgery on survival compared to non-surgical treatment for WTLM are highly needed to further close the current evidence gap.Study RegistrationPROSPERO 2021 CRD42021249763 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249763.

The Covid-19 Pandemic Has Had a Significant Impact on the Quantity and Quality of Liver Cancer Surgery - Reality or Myth?

Introduction: The Covid-19 pandemic in the UK quickly led to an overwhelming of the NHS from March 2020. This study investigates the impact of the Covid-19 pandemic on liver cancer surgical practice at a high volume Hepatobiliary unit. Methods: This is a retrospective analysis of prospectively collected database at St James’s University Hospital, Leeds, UK. The unit activity from 15 months preceding and following the national lock down was analysed. Data analysed included indications, the number and extent of operations performed, resection margins, and post-operative complications. Results: There were 275 liver resections in the 15 months before lockdown and 280 after. The indications for liver resection were similar; colorectal liver metastases (64% versus 61%), hepatocellular carcinoma (12% versus 11%), cholangiocarcinoma (9% versus 8%), gallbladder cancer (2% versus 3%), non-colorectal liver metastases (7% versus 6%) and benign disease (6% versus 11%). Pre-lockdown, 32% of the resections performed were anatomical resections in comparison to 27% post-lockdown. Resection margins were not compromised, and complication rates were the same. The ongoing success of the ERAS programme was highlighted by the median time to discharge of five days in both groups. Conclusion: The general perception is that elective surgery has suffered during the pandemic. Whilst this is true with benign diseases and in some cancers, this study demonstrates that our unit maintained the number of liver resections and patient outcomes during the pandemic. This is due to highly motivated and flexible staff who demonstrated resilience and innovation to maintain a vital cancer surgery service.

Defining Textbook Outcome in liver surgery and an assessment of hospital variation: a nationwide population-based study.

Introduction Textbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to define TO for liver surgery, assess factors associated with TO, and address hospital and network variation after case-mix correction. Methods This was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of stay, and readmission, and obtaining a tumour-free pathological margin. Multivariable logistic regression was used for case-mix adjustment. Results 2377 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51 – 0.95 p=0.02), extra-hepatic disease (aOR 0.64, CI 0.44 – 0.95, p=0.02), tumour size >55mm on preoperative imaging (aOR 0.56, CI 0.34 – 0.94, p=0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54 – 0.98, p=0.04), and major liver resection (aOR 0.50, CI 0.36 – 0.69, p<0.001). After case-mix correction, no significant hospital or oncological network variation was observed. Conclusion TO differs between indications for liver resection and can be used to evaluate hospital and network performances.

Levels of plasma homocysteine dynamics speciality in the development of acute postresection hepatic failure

This study aims to evaluate the level of plasma homocysteine in patients with acute post-resection hepatic failure, depending on the degree of the disease. Materials and Methods. The article presents the results of a study of plasma homocysteine levels in 40 patients with c different classes of acute post-resection liver failure. Indications for liver resection were: primary liver cancer 11 (27%), metastatic liver lesions 21 (53%), parasitic liver diseases 3 (7%), benign liver formations 5 (13%). Patients were divided into 3 groups - Patients with Post hepatectomy liver failure (PHLF) class developed in the postoperative period A, B and C. Results. Analysis of the data showed that the initially normal level of plasma homocysteine before liver resection (surgical treatment) and after has different developmental options. Depending on the class of post-resection hepatic failure, the level of plasma homocysteine changes and has deviations from the reference values. In a comparative analysis of the average homocysteine values in the group of patients with post-resection hepatic insufficiency of class A, after surgical treatment, they were significantly lower than in patients with PHLF B and C. In particular, in patients with class B and C PNF, there is a significant trend towards an increase in homocysteine levels after surgery. Hyperhomocysteinemia may be a risk factor for the development of acute liver failure after surgical treatment for focal liver disease. Possibly, its adverse effect on the function and restoration of the liver parenchyma, which requires further targeted study.

Renewed considerations on the utility (or the futility) of hepatic resections for breast cancer liver metastases.

Indication for liver resection (LR) for localized hepatic metastases from breast cancer (BC) is still a matter of debate. A literature review of recent scientific papers pertaining to hepatectomies for BC liver metastases (LM). We based our systematic review on case series on literature reviews, comparative studies and cost-utility analysis which have been selected based on criteria regarding surgery, possible prognostic factors and evaluation of long-term survival. There is a strong inhomogeneity in the reported data, with 5-year survivals ranging from 21% to 58%. There is no agreement in the evaluation of prognostic variables predicting good survival, with the only exception of the time of treatment of the primary BC until the diagnosis of metastases. Three out of the four comparative studies report better survivals for patients who underwent a hepatectomy in comparison to those treated with chemotherapy alone, but their strength in terms of scientific evidence is weak. The only cost-utility analysis revealed that 2 out of the 3 scenarios considered were in favor of the treatment with surgery followed by conventional chemotherapy. There is no definitive proof on the effectiveness of LRs for BC LM. Surgery can be proposed when it is possible to perform radical surgery, with R0 margins and saving at least 30% of the liver with its vascular and biliary connections. Stable skeletal metastases are not a contraindication. The interval between treatment of the primary location and diagnosis of hepatic metastases is the only prognosis criteria available.

The role of indocyanine green fluorescence imaging in laparoscopic liver surgery

Purpose: Indocyanine fluorescence imaging (ICGFI) is increasingly being used to identify biliary anatomy, demarcation of liver transection margins, and blood supply to the remnant liver. However, the role of ICGFI in the identification of site, size and the number of liver tumours is not well established. The purpose of this study is to present our initial experience with ICGFI in laparoscopic liver surgery (LLS). Methods: We present our experience with ICGFI (Stryker Spy Fluorescence technology) guided LLS in four patients between July and November 2020. All patients received a bolus dose of 0.2-0.3ml/kg of ICG intravenously 3-4 hours before surgery Results: Four male patients with a median age of 73.1 (range: 30.6 -85.8) years underwent ICGF guided LLS surgery during the study period. The indication for liver resection was colorectal metastases (CRLM, n=3) and hepatoma (n=1). Patient with HCC had underlying liver fibrosis. ICGFI identified the exact location, size and the number of tumours (median 1; range 1-2). In all four patients the tumour had signet ring appearance (see photo). The tumour's final histology confirmed CRLM in two, the necrotic lesion in one, and HCC in the fourth patient. Interestingly, all three tumours were well to moderately differentiated tumours. ICGFI did not identify any additional lesions. Conclusions: Our initial experience confirms that ICGFI helps identify the site, size, and the number of superficially located colorectal metastasis/hepatomas.

Do liver metastases from gastric cancer contraindicate aggressive surgical resection? A 14-year single-center experience.

BACKGROUNDAdvanced gastric cancer (GC) with liver metastasis is often characterized by multiple and bilobular metastases and may also be associated with extrahepatic metastatic lesions. Hence, many physicians consider that radical surgeries are contraindicated for liver metastases from GC (LMGC). According to the 2017 Japanese treatment guideline for GC, a smaller number of liver metastases without unresectable factors may be an indication for liver resection (LR) with curability. The actual 5-year overall survival (OS) rate ranges from 0 to 0.37.AIMTo present the institutional indications for LR for LMGC and identify important factors for prognostic outcomes.METHODSIn total, 30 patients underwent LR for LMGC during a 14-year period, and we evaluated the clinical, surgical, and oncological findings. In all patients, radical surgery with intentional lymphadenectomy was performed for the primary GC. The median follow-up duration after the initial LR was 33.7 mo, and three patients with no recurrence died of causes unrelated to the LMGC. The OS and recurrence-free survival rates after the initial LR were assessed.RESULTSSeventeen patients had metachronous LMGC. The initial LR achieved curability in 29 patients. Perioperative chemotherapy was introduced in 23 patients. The median greatest LMGC dimension was 30 mm, and the median number of LMGC was two. Twenty-two patients had unilobular LMGC. The 5-year OS and recurrence-free survival rates were 0.48 and 0.28, respectively. The median survival duration and recurrence-free duration after the initial LR were 16.8 and 8.6 mo, respectively. Twenty-one patients developed recurrence after the initial LR. Additional surgeries for recurrence were performed in nine patients, and these surgeries clearly prolonged the patients’ survival. Pathological serosal invasion was an independent predictor of a poor prognostic outcome after the initial LR. Aggressive LR may be indicated for carefully selected patients with LMGC.CONCLUSIONOur results of LR for LMGC seem acceptable. Additional surgeries for recurrence after the initial LR might prolong OS. Pathological serosal invasion is important for poor prognostic outcomes.

Criteria for liver resection for metastasis from bile duct cancer.

The surgical indications for liver metastasis from bile duct cancer remain contentious, because surgery is generally thought unlikely to improve survival. However, recent reports show that long-term survival has been achieved with liver resection of metastasis from recurrent bile duct cancer in selected patients. Liver resection for liver metastasis from bile duct cancer was proposed only when the following criteria were met: liver-only metastasis, a solitary tumor, and no increase in the number of lesions during 3months of observation. This study aimed to validate our criteria and to analyze which factors impact on survival. Between 2003 and 2017, 164 patients underwent pathologically curative resection for bile duct cancer. Recurrence developed in 98 of these patients, as liver-only metastasis in 25. Eleven of these 25 patients underwent liver resection (liver resection group), and 14 did not (non-liver resection group). The median overall survival was longer in the liver resection group than in all the patients (44months vs. 17.8months, respectively p = 0.040). The median overall survival was better in the liver resection group than in the non-liver resection group (44months vs. 19.9months, p = 0.012). The disease-free interval was also significantly longer in the liver resection group than in the non-liver resection group [22months (range; 4-34months) vs. 3months (2-11), p < 0.001]. Potentially, metachronous solitary liver metastasis from bile duct cancer is an indication for liver resection when the patient has had a long disease-free interval. Observation for 3months from first detection of metastasis may optimize the selection for this surgery.

Our Experience in Epidural Analgesia Following Large Abdominal Surgeries.

Background: Epidural analgesia is a gold standard in post-operative pain control in patients undergoing large abdominal interventions. Different studies report a failure ratio of epidural analgesia of 20-32%.&#x0D; The aim of this study is to analyze the success rate of epidural analgesia and its consequences in patients that have been subject to large abdominal surgeries.&#x0D; Materials and methods: We have prospectively collected the data of 50 patients that were subject to open abdominal surgeries during a 2 year timeframe (September 2015 – September 2017) at University Clinical Center of Kosovo. Experienced anesthesiologists inserted the epidural catheters. A dedicated team used the Verbal Scale to collect the data regarding post-operative pain during coughing or moving. The success rate of eidural catheter was measured in terms of: the scale of pain, pulmonary post-operative infection and length of hospital stay.&#x0D; Results: The study group included 33 males and 17 females, most of whom were subject to liver surgery. The secondary liver formations (70%), primary tumours (20%) as well as beningn liver disorders(10%) were an indication for liver resection. Large resections (≥3 segments) were completed in 44% of patients, small liver resections were (≤2 segments) completed in 48% of patients, while 8% of patients were considered inoperative. Epidural analgesia was successful in 46 patients (92%). Bacterial colonisation of the catheter was observed in only one case. There were no neurological complications. 5 (10%) patients showed radiologicalsigns of a pulmonary infection. Three patients (6%) had surgical wound infection. One patient died of hepatic insufficiency after massive right liver resection and cholecystectomy due to gallbladder carcinoma. The average length of hospital stay was 6 days.&#x0D; Conclusions: Our experience concludes that epidural analgesia is a safe and effective way of pain relief after abdominal surgeries.

Health economic implications of postoperative complications following liver resection surgery: a systematic review.

Limited data exists concerning the health economics of liver resection, with even less information on the costs emerging from complications, despite this remaining an important target from a health economic perspective. Our objective was to describe the financial burden of complications following liver resection. We conducted a systematic search and included studies reporting resource use of in-hospital complications during the index liver resection admission. All indications for liver resection were considered. All techniques were considered. Data was collected using a data extraction table and a narrative synthesis was performed. We identified 12 eligible articles. There was considerable heterogeneity in study designs, patient populations and outcome definitions. We found weak evidence of increased costs associated with major liver resection compared to minor resections. We found robust evidence supporting the increasing economic burden arising from complications after liver resection. Acceptable evidence for increased cost due to the presence and grade of complication was found. Strong evidence concerning the association of length of stay with costs was demonstrated. The presence and grade of complications increase hospital cost across diverse settings. The costing methodology should be transparent and complication grading systems should be consistent in future studies.

Postero-superior liver segments resection for benign tumors. Short-term results

Introduction: Indication for laparoscopic postero-superior liver segments resection in patients with benign tumors remains controversial. We aimed to evaluate the short-term results of minimally invasive resections (MILR) for benign tumors of postero-superior liver segments. Method: Data were accumulated since 2014 to 2018. Indications for liver resection were giant (>8 cm) growing lesions with clinical signs (abdominal pain on physical activity) and suspicion for malignancy. Result: Liver resection were performed in 75 patients. MILR were applied in 68 (91%), including 55 lap and 13 robotic resections. The benign lesions were presented by hemangioma (36), adenoma (13), FNH (12) and cystadenoma (7). Mean tumor size 8,8 cm (max 20 cm). Tumor size in 62% of cases was more than 8 cm. In 32 (47%) cases tumor adjoining to vessels. Partial resection of postero-superior segments and caudate lobe was performed in 25 (37%) patients. Robotic system was used in 8 of them. Open approach was applied only for 7 major hepatectomy (9%). Major morbidity after MILR of postero-superior segments was observed in 2 (2,9%) patient (IIIA, Clavien-Dindo): hematoma, after lap S6,7 resection and biloma after lap S3,4,8 resection, requiring additional drainage. There was no mortality. After major open liver resections bile leakage took place in 3 patients and required additional drainage. Mean operation time of MILR and open resection was comparable: 273 (160-490) min and 324 (260-395) min, respectively. The mean blood loss for MILR and open procedures was 300 (10-1000) ml and 1542 (100-4500) ml, respectively. The mean postoperative hospital stay after MILR and open resection was 6 (4-12) and 7(6-10) days, respectively. Conclusion: MILR for benign lesions located in postero-superior segments is the safe option for treatment of symptomatic and large benign tumors and may be considered as the first choice approach if surgery is indicated.

The role of liver resection in patients with intermediate and advanced stage hepatocellular carcinoma. Retrospective study from two Greek HPB centers

Background: The indications for liver resection in patients with intermediate (BCLC B: single tumor >5 cm or multiple tumors >3 cm each) or advanced stage (BCLC C: presence of macrovascular thrombosis) hepatocellular carcinoma (HCC) are not clear yet. Liver resection is not recommended for this group of patients in the European and the American Association for the Study of Liver Disease guidelines. The aim of this retrospective study was to present the experience of two Greek HPB centers in the surgical management of patients with HCC. Methods: Data from patients with HCC who underwent surgical resection from 01.01.2007 till 30.06.2016 were analyzed. Results: 70 patients were included in the study, with a median age of 69 yrs (range: 21-82). There were 54 male and 16 female patients. The majority of the patients developed HCC on a background of liver cirrhosis (59%) and the most common causes were alcoholic liver disease (ALD) (39%), Hepatitis B (HBV) infection (31%) and hepatic steatosis (23%). The majority of the patients (38/70, 54%) were in intermediate or advanced stage. The 90-day mortality rate was 0. The overall morbidity was 39%. The 1-, 3- and 5yrs overall survival was 89%, 60% and 40 % for all patients and 82%, 50% and 39 % for the patients with BCLC B and BCLC C stage HCC. Conclusion: This study shows that liver resection has a clear role in the management of patients with non-early HCC as is was used widely with acceptable short and long term Results.

The role of liver resection in patients with intermediate and advanced stage hepatocellular carcinoma. Retrospective study from two Greek HPB centers

Background: The indications for liver resection in patients with intermediate (BCLC B: single tumor >5 cm or multiple tumors >3 cm each) or advanced stage (BCLC C: presence of macrovascular thrombosis) hepatocellular carcinoma (HCC) are not clear yet. Liver resection is not recommended for this group of patients in the European and the American Association for the Study of Liver Disease guidelines. The aim of this retrospective study was to present the experience of two Greek HPB centers in the surgical management of patients with HCC. Methods: Data from patients with HCC who underwent surgical resection from 01.01.2007 till 30.06.2016 were analyzed. Results: 70 patients were included in the study, with a median age of 69 yrs (range: 21-82). There were 54 male and 16 female patients. The majority of the patients developed HCC on a background of liver cirrhosis (59%) and the most common causes were alcoholic liver disease (ALD) (39%), Hepatitis B (HBV) infection (31%) and hepatic steatosis (23%). The majority of the patients (38/70, 54%) were in intermediate or advanced stage. The 90-day mortality rate was 0. The overall morbidity was 39%. The 1-, 3- and 5yrs overall survival was 89%, 60% and 40 % for all patients and 82%, 50% and 39 % for the patients with BCLC B and BCLC C stage HCC. Conclusion: This study shows that liver resection has a clear role in the management of patients with non-early HCC as is was used widely with acceptable short and long term results.

Complex liver resection under total vascular exclusion and hypothermic perfusion with versus without venous bypass

Background: While hypothermic perfusion of the liver has been shown to improve parenchymal tolerance to complex resections in patients requiring prolonged hepatic vascular exclusion (HVE), the benefit of associated veno-venous bypass (VVB) in this setting remains poorly evaluated. Methods: All patients undergoing liver resection requiring HVE for at least 60 minutes were retrospectively reviewed. Perioperative outcomes were compared between patients with (VVB+) or without VVB (VVB-). Results: Twenty-seven patients had liver resection with HVE and hypothermic perfusion of the liver between 2006 and 2017, including 13 (48%) VVB+ and 14 (52%) VVB- patients. Demographic characteristics and indications for liver resection were similar between the two groups. Median HVE exclusion durations were similar in (96 vs. 75 min, p=0.72) VVB+ and VVB- patients. VVB+ patients had increased operative time (460 vs. 375 min, p=0.05) but decreased amount of transfusion (p=0.05). . Five (19%) patients died postoperatively from liver failure (n=4) or sepsis (n=1), without significant difference between VVB+ and VVB- patients (p=0.56). Postoperative major morbidity rate (Dindo-Clavien 3-4, 30% vs. 50%) was not different between the two groups. The rates of liver failure, haemorrhage, renal insufficiency, and sepsis were not different between the two groups but VVB- patients experienced increased rates of respiratory complications than VVB+ patients (64% vs. 15%, respectively, p=0.01). Conclusion: During liver resection under HVE and hypothermic perfusion of the liver, the use of VVB allows reducing red blood cells transfusions and postoperative respiratory complications. VVB should be recommended in case of liver resection with prolonged HVE.

Laparoscopic donor hepatectomy.

Laparoscopic liver resection has been applied to treat most indications for liver resection during the past two decades. According to the literature, patient numbers have increased exponentially as a result, and surgical difficulty has increased as well. In expert centers, laparoscopic anatomical hemihepatectomy and major liver resection more than 3 segments have become the acceptable treatment. Moreover, with surgical innovations and accumulated experience, living donor liver transplantation has become an established treatment choice for patients on the transplant waiting list. It is even considered an inevitable choice in regions with limited access to organs from deceased donors. However, significant morbidity and rare but catastrophic mortality are associated with donor hepatectomy and remain major concerns. Therefore, to decrease the incidence of complications, a minimally invasive approach in donor hepatectomy was adopted in the early 2000s. Initially, a minimally invasive approach was used for left lateral sectionectomy for pediatric liver transplant, then for laparoscopy-assisted hemihepatectomy and pure laparoscopic/robotic right donor hepatectomy, and more recently, for adult living donor liver transplantation. The extent of procedure complexity and potential complications depends on the approach and the size of the graft to be harvested. Early results from expert teams have seemed promising in terms of shortened donor recovery and improved perioperative outcomes. However, the combination of these two highly sophisticated surgical procedures raise more concerns about donor safety, especially with regard to unexpected events during the operation. A high level of evidence is very difficult to achieve in this highly specialized surgical practice with limited penetration. Therefore, an international registry has been suggested to determine the risks and benefits before the use of laparoscopic right donor hepatectomy spreads.