Liver Resection For Malignancy Research Articles

Neodadjuvant therapy influences sceletal muscle mass after liver resection for malignancies

Background: The prevalence of sarcopenia as surrogate for the frailty syndrome is often linked to worse outcomes after liver resection for hepatic malignancies. Recent research shows that sarcopenia also increased the toxicity of chemotherapy and lessens its effect. Sarcopenia is usually measured preoperatively. We aimed to measure sarcopenia in the long term follow up after liver resection.

Minimally invasive liver resections for malignancies: where is the limit?

Minimally invasive liver resections for malignancies: where is the limit?

Three-dimensional (3D) Models Based on Pre-operative Computed Tomography Scans to Personalize the Planned Liver Surgery in Complex Cases

Purpose: In the last two decades, an increased number of patients has been submitted to liver resection for malignancy. That was possible thank to a better knowledge of tumor biology, perioperative management as well as improvement of surgical technique. Recently, three-dimensional (3D) models visualization systems based on pre-operative imaging has been proposed to plan liver surgery in complex cases. The aim of this study was to assess the feasibility and accuracy of a 3D models for patients undergoing major/extended liver resection for malignancies. Method: The Medical Device Custom Made with Hyper Accuracy 3DTM reconstruction method was applied to preoperative computed tomography (CT) scans of patients undergoing major/extended liver resections for malignancies at our institution since February 2020. The 3D models were used to guide the liver resections, including details regarding anatomical variations of the main vessels (hepatic artery, hepatic veins and portal vein) and the bile ducts as well as their relationship with the tumor and an accurate estimation of the future remnant liver volume (FRLV). Results: A total of 17 patients were included In this preliminary study. The most frequent diagnoses were hilar cholangiocarcinoma (PH-CCA, 52.9%) and intrahepatic cholangiocarcinoma (I-CCA, 23.5%). The 3D reconstruction showed anatomical vessels’ variations in 12 (70.6%) patients that were confirmed intraoperatively. A total of 5 (29.4%) patients underwent portal resection for tumor invasion. A good to optima correspondence between the hepatectomy planned using the 3D models and the intraoperative data was found in terms of bile duct and vessels resected. With a median FRLV at the 3D reconstruction of 31%, 4 (23.5%) patients had transient post hepatectomy liver failure (PHLF) of grade A/B. The median estimated blood loss was 750 mL and the median operative time was 532 minute while the median length of stay was 12 days. In 2 (11.7%) patients the resection planned on the basis of the CT imaging was changed after the pre-operative analysis of 3D reconstructions. Conclusion: These preliminary data regarding the use of 3D models in the accurate and personalize planning of complex liver resections showed that the 3D liver reconstruction might provide useful and additional information about anatomical vessels’ variations and tumor extension. The analysis of 3D reconstructions might lead the surgeon to change the planned resection.

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.

Detours on the Road to Recovery: What Factors Delay Readiness to Return to Intended Oncologic Therapy (RIOT) After Liver Resection for Malignancy?

BackgroundPoor recovery after oncologic hepatic resection delays Return to Intended Oncologic Therapy (RIOT) and shortens survival. In order to identify at-risk patients, this study was designed to determine which psychosocial and perioperative factors are associated with delayed RIOT readiness. MethodsA prospectively maintained database was queried to identify consecutive patients undergoing hepatectomy for malignancy from 2015 to 2017. Perioperative factors were compared between patients with early (≤ 28 postoperative days) vs. delayed (> 28 postoperative days) clearance to RIOT. Univariate analysis and multivariable logistic regression were performed. ResultsOf 114 patients, 76 patients (67%) had an open surgical approach, 32 (28%) had a major hepatectomy, and 6 (5%) had a major complication, with no mortalities. Eighty-two patients (72%) had early and 32 patients (28%) had delayed RIOT readiness. Patients with high preoperative symptom burden were more likely to have delayed RIOT readiness (OR 3.1, 95% CI 1.1–8.4, p = 0.024). On multivariable analysis, open surgical approach (OR 6.9, 95% CI 1.4–34.7, p = 0.018), length of stay > 5 days (OR 3.6, 95% CI 1.4–9.4, p = 0.010), and any complication (OR 3.4, 95% CI 1.1–10.7, p = 0.033) were associated with delayed RIOT readiness. Postoperative factors associated with delayed RIOT readiness included nutritional and wound-healing parameters. ConclusionsThis study highlights the previously under-described importance of preoperative patient symptom burden on delayed postoperative recovery. As a cancer patient’s return to oncologic therapy after hepatectomy has a substantial impact on survival, it is critical to adhere to enhanced recovery principles and address all other modifiable factors that delay recovery.

Liver Volume Restoration and Hepatic Microarchitecture in Small-for-Size Syndrome.

We investigated preoperative parameters that could work as markers of liver regeneration (LR), and tried to create an algorithm for therapeutic decision-making, looking at the clinical setting of post-hepatectomy liver failure (PHLF) after major liver resection for malignancies (LRM) and of the small-for-size syndrome (SFSS) after adult-to-adult living related liver transplantation (LRLT), considering PHLF and SFSS a single clinical entity. The clinical data of 2 series of 10 consecutive patients who experienced liver-specific complications after LRLT or LRM between 2008 and 2013 were analyzed. LR was evaluated by multidetector computed tomography (MDCT) and hepatic parenchymal findings with specific re-examinations of liver biopsies. The analysis was done according to demographics, tumor characteristics, and postoperative complications occurring within 90 days of surgery and codified within the Clavien classification. A total of 13 cases of SFSS occurred in 8 LRLT recipients (61.5%) and in 5 patients after LRM (38.5%). The incidence of SFSS was significantly associated with a greater spleen volume/future remnant liver volume ratio (1.08±0.5; P=0.02) and a reduced number of hepatic tumors (0.58±0.6; P=0.04). A greater degree of LR was not associated with a lesser likelihood of developing SFSS (P=0.31). SFSS incidence and re-examination of post-operative liver biopsies differed according to the evidence of focal endothelial denudation in the portal vein and centrilobular hepatocanalicular cholestasis. We found an association between SFSS incidence and the immunohistochemical overexpression of cytological proliferation marker Ki-67 (29.3±29.8%; P=0.007), which was a significant predictor of poor post-operative survival (OR=1.12, C.I.: 1.013; 1.242). SFSS is a rare but dangerous clinical entity characterized by anarchic hepatic regeneration. We suggest focusing on early diagnosis in order to establish non-surgical modulation of the portal inflow, in conjunction with optimization of medical management.

Metastatic Cholangiocarcinoma at Percutaneous Drain Site

We report the case of metastatic tumor recurrence at the chest wall exit site of percutaneous transhepatic biliary drainage (PTBD) catheter four months after surgical resection for cholangiocarcinoma. We discuss the risks and benefits of using PTBD catheters preoperatively in patients with planned major liver resection for malignancy.

External validation of a pre-operative nomogram predicting peri-operative mortality risk after liver resections for malignancy

AimA pre-operative nomogram using a population-based database to predict peri-operative mortality risk after liver resections for malignancy has recently been developed. The aim of the present study was to perform an external validation of the nomogram using data from a high volume institution. MethodsThe National Inpatient Sample (NIS) database (2000–2004) was used initially to construct the nomogram. The dataset for external validation was obtained from a high volume centre specializing in hepatobiliary surgery. Validation was performed using calibration plots and concordance index. ResultsA total of 794 patients who underwent liver resection from the years 2000–2010 at the external institute were included in the validation set with an observed mortality rate of 1.6%. The mean total points for this sample of patients was 124.9 [standard error (SE) 1.8, range 0–383] which translates to a nomogram predicted mortality rate of 1.5%, similar to the actual observed overall mortality rate. The nomogram concordance index was 0.65 [95% confidence interval (CI) 0.46–0.82] and calibration plots stratified by quartiles revealed good agreement between the predicted and observed mortality rates. ConclusionsThe present study provides an external validation of the pre-operative nomogram to predict the risk of peri-operative mortality after liver resection for malignancy.

Effect of blood transfusion on early outcome of liver resection for colorectal hepatic metastases.

314 Background: The useof intraoperative blood transfusions (IBT) has been associated with worse surgical outcome in patients undergoing liver resection for malignancy. However, detailed analyses are required to define clinical findings impacting short-term outcome in this scenario.The aim of this study is to evaluate whether IBT are associated with a worse short-term outcome of liver resection in patients with colorectal hepatic metastases, and to assess whether certain patient characteristics and/or surgical variables affect the need for IBT. Methods: In a series of 127 consecutive patients who underwent partial liver resection for colorectal metastases, between July 1999 and March 2010, we studied postoperative 90 days surgical outcome relative to IBT, and the effect of a variety of factors, including type of resection, surgical technique used, concomitant colo-rectal resection, non-tumoral hepatic histological findings, site of primary tumor, and comorbidities, on the incidence of IBT. Results: Patients who received IBT during their liver resection were more likely to have a longer postoperative length of stay (p = 0.02), to experience complications (p = 0.0003), and to experience a Clavien Grade IIIa or worse complication (p = 0.003). Furthermore, undergoing a major resection, and the presence of portal fibrosis in the non-tumoral liver were both correlated with an increase in IBT (respectively, p = 0.003 and p = 0.049), while the surgical technique used (Kellyclasia or TissueLink), the presence of steatosis, undergoing a concomitant major colonic or rectal resection, and having a major comorbidity had no effect on the incidence of IBT (p ≥ 0.05). Conclusions: This study confirmed that receiving IBT during partial liver resection for colorectal hepatic metastases is associated with a worse short-term surgical outcome. These clinical findings suggest that although several significant factors (surgical technique chosen, comorbidities present, etc.) do not seem to influence the short-term outcome of surgery, it is important to be aware of the deleterious effects of the type of resection performed and the presence of portal fibrosis on blood loss during partial liver resection. No significant financial relationships to disclose.

Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of different types of complications: infectious complications, tumor recurrence, decreased survival. Even if there is clear evidence of transfusion-induced immunosuppression, it is difficult to demonstrate that transfusion is the only determinant factor that decisively affects the outcome. In any case there are several motivations to reduce the practice of blood transfusion. The advantages and drawbacks of different transfusion alternatives are reviewed here, emphasizing that surgeons and anesthetists who practice in centers with a high volume of liver resections, should be familiar with all the possible alternatives.

Major Liver Resections for Primary Liver Malignancies in the Elderly

Purpose: The aim of our prospective study was to assess the results of major hepatic resections for primary liver tumours in patients 75 years of age or older.Methods: From 10/1999 to 04/2006, 23 patients with non-cirrhotic livers > 75 years presented to our department to undergo curative resection for primary liver malignancies. Data were collected prospectively. Patients were assigned to two groups. Group A included those with resectable tumours, while Group B was made up of those with unresectable lesions.Results: Fourteen patients had intrahepatic cholangiocarcinoma while 9 had hepatocellular carcinoma. Comorbidities were present in every case. Morbidity and hospital mortality rates for group A patients were 25% and 8%, respectively. The corresponding rates for group B patients were 9% and 9%. The 1-, 2-, and 3-year cumulative group A survival was 71%, 51% and 26% for cholangiocarcinoma and 80%, 60% and 60% for hepatocellular carcinoma, respectively. The corresponding group B survival was 45%, 18% and 0%.Conclusion: Advanced age does not seem to negatively affect the outcome of liver resections for malignancies. Hepatic resections in patients 75 years of age or older may be carried out with relative safety as long as patients are appropriately selected.

Reduced transfusion requirements during major hepatic resection with use of intraoperative isovolemic hemodilution

Background: Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of tumor recurrence and decreased survival in some series. Isovolemic hemodilution (IH) has been utilized in cardiac, orthopedic, and major general surgery procedures to reduce the use of banked blood products. We therefore sought to determine the safety and efficacy of IH during major hepatic resection in an adult population. Methods: Thirteen consecutive patients undergoing major hepatic resection with IH were compared with 13 age- and disease-matched controls. The diseases included metastatic colorectal adenocarcinoma (8 versus 9), hepatoma (2 in each group) and other (3 versus 2); and the procedures included total (right or left) hepatic lobectomy (8 versus 11), partial lobectomy (3 versus 1) and trisegmentectomy (2 versus 1). Results: There was no significant difference in operating time, estimated blood loss, fresh frozen plasma, platelets, amount of crystalloid or colloid infused between the two groups. There was no perioperative morbidity related to IH. The use of IH resulted in a 60% reduction in mean packed red blood cells transfusion during major hepatic resection. Only 38% of patients undergoing IH required packed red cells transfusion, whereas 77% of historical control patients required allogenic transfusion. Conclusion: The use of IH reduces the need for homologous transfusion during major hepatic resection. IH is a safe technique during hepatic resection and is not associated with perioperative morbidity.

Pancreatic or Liver Resection for Malignancy Is Safe and Effective for the Elderly

Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes. Five hundred seventy-seven liver resections (July 1985-July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983-July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older. Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No differences were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay for the younger patients (median, 12 days vs. 13 days; p = 0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p = 0.03). Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronological age alone is not a contraindication to liver or pancreatic resection for malignancy.

Pancreatic or Liver Resection for Malignancy Is Safe and Effective for the Elderly

Pancreatic or Liver Resection for Malignancy Is Safe and Effective for the Elderly