Liver Resection In Patients Research Articles

Liver resection for patients with colorectal cancer liver metastases: single center experience

Liver resection for patients with colorectal cancer liver metastases: single center experience

Benefits of laparoscopic liver resection in patients with Hepatocellular carcinoma and portal hypertension: A casematched study

Benefits of laparoscopic liver resection in patients with Hepatocellular carcinoma and portal hypertension: A casematched study

Benefits of laparoscopic liver resection in patients with Hepatocellular carcinoma and portal hypertension: a casematched study

Benefits of laparoscopic liver resection in patients with Hepatocellular carcinoma and portal hypertension: a casematched study

SIRT for downsizing to resection

Background: Different strategies have been developed to achieve resectability in patients initially considered as unresectable. Selective internal radiation therapy (SIRT) has emerged as an effective therapy for patients with primary non-resectable malignancies of the liver. Our group combined SIRT with liver surgery for downsizing for resection. Methods: Starting 2010 all patients with liver malignancies were evaluated in an interdisciplinary tumor board. Patients with marginally resectable liver metastases treated by SIRT followed by liver resection were identified and prospectively documented in a database for subsequent retrospective analysis. Results: Fifteen patients (7 female, 8 male) with marginally resectable liver metastases were planned for liver resection after SIRT. In thirteen patients (87%) liver metastases were from colorectal malignancies, and in two patients from breast cancer. After performing SIRT (90Y resin microspheres, mean administered activity 1260 MBq, range: 600 – 1990 MBq), twelve patients had potentially curative hepatic resection. In three patients liver resection after SIRT could not be performed due to the appearance of new extrahepatic metastases. Analyzing the effect of SIRT, we observed a decrease in tumor size with central scaring. Due to the selectivity of SIRT the future liver remnant was not effected in all patients. Conclusion: The combination of SIRT with modern liver surgery enables new therapeutic options in patients with marginally resectable liver metastases.

SIRT for downsizing to resection

Background: Different strategies have been developed to achieve resectability in patients initially considered as unresectable. Selective internal radiation therapy (SIRT) has emerged as an effective therapy for patients with primary non-resectable malignancies of the liver. Our group combined SIRT with liver surgery for downsizing for resection. Methods: Starting 2010 all patients with liver malignancies were evaluated in an interdisciplinary tumor board. Patients with marginally resectable liver metastases treated by SIRT followed by liver resection were identified and prospectively documented in a database for subsequent retrospective analysis. Results: Fifteen patients (7 female, 8 male) with marginally resectable liver metastases were planned for liver resection after SIRT. In thirteen patients (87%) liver metastases were from colorectal malignancies, and in two patients from breast cancer. After performing SIRT (90Y resin microspheres, mean administered activity 1260 MBq, range: 600 – 1990 MBq), twelve patients had potentially curative hepatic resection. In three patients liver resection after SIRT could not be performed due to the appearance of new extrahepatic metastases. Analyzing the effect of SIRT, we observed a decrease in tumor size with central scaring. Due to the selectivity of SIRT the future liver remnant was not effected in all patients. Conclusion: The combination of SIRT with modern liver surgery enables new therapeutic options in patients with marginally resectable liver metastases.

Using insulin clamp technique as part of the perioperative care

Operatively induced inflammation has been the focus of many studies to evaluate the most efficient responses and protocols to be used for its control. Insulin has been characterized with nonmetabolic properties and is used as a preoperative anti-inflammatory agent. We reviewed the published evidence in the past 10 years reporting on the use of glucose–insulin-normoglycemia therapy as a potential anti-inflammatory therapy to improve surgical outcomes about tissue trauma, with the challenges and progress attenuated so far. We also portray our experience in the use of insulin therapy on our liver resection patients as well as the significant knowledge gaps that still exist and the need for a multidisciplinary approach to bridge them.

Going through laparoscopic liver resection in patients with colorectal liver metastases-A qualitative study.

AimColorectal cancer is one of the most common cancers worldwide. Surgery is seen as the only curative treatment. There are two approaches to liver resection: open or laparoscopic surgery. Knowledge from the patient perspective can illuminate how it is experienced going through laparoscopic surgery. We aimed to study patient perspectives of the experience of undergoing laparoscopic liver resection surgery in patients with colorectal liver metastases.DesignThis study has a qualitative research design. Nine patients participated in semi‐structured interviews 6 months after surgery. Data were analysed according to Kvale's five‐step analysis method.ResultsThough the patients were satisfied with the laparoscopic approach, they expressed unmet informational needs about the new technique, time after discharge and surgery outcomes related to having metastatic cancer. Healthcare professionals should provide information and support that recognizes the needs of patients with cancer undergoing laparoscopic liver resection surgery.

Elevated ADAMTS13 Activity is Associated with Poor Postoperative Outcome in Patients Undergoing Liver Resection

Recently, von-Willebrand-Factor (vWF) has been shown to correlate with postoperative liver dysfunction (LD). Accordingly, “disintegrin-like metalloprotease with thrombospondin type1 motif” (ADAMTS13) is known to cleave vWF in less active fragments. Thus, we aimed to evaluate the diagnostic potential of ADAMTS13-activity (ADAMTS13-AC) to identify patients with postoperative LD after hepatectomy. Accordingly 37 patients undergoing hepatectomy for different neoplastic entities were included in this study. Plasma ADAMTS13-AC and vWF-Ag were measured 1 day prior to (preOP), 1 and 5 days (POD1/5) after hepatectomy. In accordance to the ISGLS-criteria LD was prospectively recorded. In this context, perioperative ADAMTS13-AC- and vWF-Ag/ADAMTS13-AC-ratio- levels revealed a significant increase after hepatectomy. Accordingly, elevated vWF-Ag/ADAMTS13-AC-ratio significantly predicted LD (preOP AUC: 0.75, p = 0.02; POD1 AUC: 0.80, p = 0.03). Patients who fulfilled our perioperative vWF-Ag/ADAMTS13-AC-ratio cut-off-levels (preOP: ≥116, POD1: ≥165) suffered from significantly higher incidences of LD (preOP: 70% vs. 30%, p = 0.01; POD1: 83% vs. 17%, p = 0.001). In conclusion, perioperative ADAMTS13-AC measurement may serve as a useful parameter to early detect high-risk patients developing postoperative LD prior to liver resection in patients suffering from hepatic malignancies. Indeed, further investigations have to be performed to consolidate its role as a predictive marker for LD.

Prognostic factors of hepatectomy in initially unresectable colorectal liver metastasis: Indication for conversion therapy.

The aim of the present study was to retrospectively identify prognostic factors for long-term cumulative survival following liver resection in patients with primarily unresectable colorectal cancer who had previously received conversion therapy. A multicentre study was designed to ascertain the appropriate indication for conversion therapy. The study included 34 patients who underwent conversion therapy at 5 university hospitals. Patients' background, operative factors, recurrence rate and survival rate were evaluated, and factors influencing therapy outcomes were identified. The median duration of preoperative chemotherapy was 3 months and the response rate was 39.8%. Upon resection, the median tumour size was 47 mm and the median number of tumours was 4. The recurrence-free and cumulative survival rates 5 years after liver resection were 13.7 and 39.3%, respectively. Postoperative complications developed in 12 patients. A response rate >40% was indicated with regards to the assessed prognostic factors for long-term cumulative survival following liver resection and an absence of postoperative complications was noted. It was revealed that conversion therapy should be considered prior to liver resection, particularly for patients with response rates exceeding 40%. Absence of postoperative complications is also an independent predictor of long-term cumulative survival after liver resection. In light of these findings, it was consisted that an optimal response rate >40% could be used as an indicator for surgical resection in conversion therapy. In addition, meticulous intra- and postoperative managements are important for decreasing postoperative complications and improving long-term cumulative survival.

Radio-frequency assisted liver partition with portal vein embolization in staged liver resection (RALPPS) in patients with hilar and intrahepatic cholangiocarcinoma

Objective: Estimation of the short-term results of Radio-frequency Assisted Liver Partition with Portal vein embolization in Staged liver resection (RALPPS) compared with Portal Vein Embolization (PVE) and subsequent major liver resection in patients with hilar (h-CCA) and intrahepatic (i-CCA) cholangiocarcinoma. Summary background data: Unsatisfactory immediate outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in surgery of cholangiocarcinoma suggested that patients with biliary cancer should not be treated by ALPPS. Short-term results of ALPPS variants with reduced surgical trauma on the first stage in patients with cholangiocarcinoma were not yet estimated. Methods: RALPPS and PVE were applied in 10 and 18 patients respectively. Future liver remnant (FLR) was estimated by CT. The propensity score matching method was used in compared groups. Results: The mean rate of FLR hypertrophy after RALPPS/PVE before and after matching was 42%/32% and 49%/31%, respectively. The mean duration of hypertrophy after RALPPS/PVE before and after matching was 16/20 days and 14/17 days, respectively. Major morbidity rate (IIIa grade, Clavien-Dindo) after the stage 1 was significantly larger for RALPPS before matching. There were no differences in morbidity of stage 1 after matching as well as for stage 2 before and after matching. Conclusions: According to preliminary short-term results estimation RALPPS may be considered as an effective and safe minimally invasive variant of ALPPS for rapid FLR hypertrophy in patients with h-CCA and i-CCA.

Impact of performance status on recurrence and survival after liver resection for patients with hepatocellular carcinoma: A Chinese Multicenter Study

Introduction: According to the BCLC staging, advanced hepatocellular carcinoma (HCC) could be determined only if performance status (PS) is 1∼2, which was not recommended performing hepatectomy. In the real clinical practice, however, PS is not a key indicator of hepatectomy for HCC. We aimed to investigate the impact of PS on recurrence and survival after HCC resection. Methods: Multicenter data of 1,531 Chinese patients undergoing liver resection of HCC between 2005 and 2015 were retrospectively analyzed. They were divided into PS 0 group and PS 1 group. Perioperative mortality and morbidity, overall survival (OS) and recurrence-free survival (RFS) were compared, and multivariable Cox-regression analyses of OS and RFS were performed. Results: The perioperative mortality and major morbidity rates of PS 0 and 1 patients were similar (P = 0.875 and 0.235, respectively). The median OS and RFS of PS 1 patients were significantly poorer than PS 0 patients (both P < 0.001). Multivariable analyses revealed that PS 1 was independent risk factors of OS (HR: 1.301, P < 0.001) and RFS (HR: 1.420, P = 0.007). In the subgroup analysis, the OS and RFS of PS 1 patients without vascular invasion (VI)/extrahepatic metastasis (ES) were significantly better than PS 1 patients with VI/ES. Conclusions: Liver resection of HCC for PS 1 patients was as safe as for PS 0 patients. Although PS 1 was an independent risk factor of recurrence and survival, the prognosis after liver resection was still acceptable, especially when without VI/ES.

Oncologic benefit of repeat liver resection in patients with liver-only recurrent colorectal metastases

Oncologic benefit of repeat liver resection in patients with liver-only recurrent colorectal metastases

Liver Transplantation in the Treatment of Unresectable Hepatocellular Carcinoma in the Absence of Liver Cirrhosis

Aim. The aim of the study is to determine the effectiveness of liver transplantation (LT) in the treatment of unresectable hepatocellular carcinoma (HCC) occurred in normal liver.Material and methods. 6 patients with unresectable HCC underwent orthotopic liver transplantation (OLT). The long-term OLT results were compared with survival results of liver resection in patients with late stage HCC.Results. Hepatocellular carcinoma is one of the most common types of cancer, which occurs mainly in patients with liver cirrhosis and chronic viral hepatitis. Only about 10 % of HCC develops in non-cirrhotic liver among young and somatically healthy patients. 1-, 3-, 5-year recurrence-free and overall survival in LT group was significantly better than in the control group.Conclusion. LT is indicated for patients with unresectable HCC in non-cirrhotic liver and its extrahepatic localization. A large tumor size and macrovascular invasion should not be a contraindication for LT in such patients.

Risk factors, patterns and outcomes of late recurrence after liver resection for patients with hepatocellular carcinoma: analysis of a multicenter cohort over 15 years

Risk factors, patterns and outcomes of late recurrence after liver resection for patients with hepatocellular carcinoma: analysis of a multicenter cohort over 15 years

Liver resection in patients with metastatic breast cancer

Introduction: Breast cancer is the secondary cause of cancer mortality in women. The majority of deaths are caused by metastasis. Isolated liver metastases are diagnosed in 2-12 % of patients. Liver resection is nowadays part of the multidisciplinary therapy in selected patients. The data about long-term survival are scarce. The aim of our study was to elucidate overall and recurrence- free survival of these patients. Method: We identified 16 patients who underwent liver resection because of isolated breast cancer metastasis over a period between 04/2006 and 12/2017 at the University Hospital of Salzburg. Results: All patients were women, the median age was 64 years (range 35- 76). The median time from diagnosis of breast cancer to metastasectomy was 37 months (range 1- 189). Liver metastasectomy was performed in all except one patient in whom left hemihepatectomie was performed. Six resections (37,5%) were done laparoscopically. Complications grade Clavien- Dindo IIIb and higher was in 1 (6,25%) patient and 30 days mortality was 0%. Recurrence was diagnosed in 10 (62,5%) patients with median recurrence-free survival of 15 months after liver resection (range 4- 39). Six patients (37,5%) were alive without recurrence, five of them over 5 years. The overall survival in the whole group was 45 months (range 7- 126). Conclusion: The resection of breast cancer liver metastasis promises in significant portion of selected patients long term survival. Further parameters need to be identified for personalized therapy.

Comparative study of laparoscopic liver resection and open liver resection in patients over 70 years of age

Comparative study of laparoscopic liver resection and open liver resection in patients over 70 years of age

Combined laparoscopic colorectal and liver resection for patients with synchronous liver metastases of colorectal origin: a retrospective, multicenter, propensity score matched study

Background: Laparoscopic simultaneous colorectal and liver resection (LSCLR) is an option with potential benefits, but there are concerns whether SCLR could increase the risk of morbidity compared with staged resections. This study aimed to identify the impact on postoperative morbidity of adding a liver resection to a colorectal resection using a laparoscopic approach. Methods: A retrospective, multicenter, propensity score matched study was performed comparing LSCLR (2009-2016; four centers) with laparoscopic colorectal resection alone. Data from the Dutch ColoRectal Audit of two participating centers were used to match control patients based on propensity scores in a 1:1 ratio. Propensity scores were calculated based on 7 pre-operative variables. Pre-, intra- and post-operative outcomes were compared using paired test. Results: A well-balanced cohort of 122 patients was analyzed (61 patients undergoing LSCLR and 61 patients undergoing laparoscopic colorectal resection alone). Liver resections consisted of minor resections only. LSCLR was associated with a small increase in operating time (206 (166-308) vs 197 (148-231) minutes, p=0.057) and increased blood loss (200 (100-700) vs 75 (5-200) ml, p=0.011). Conversion rates were 5 and 8%, p=0.687. The incidence of severe complications (Clavien-Dindo grade 3 or higher) (15% vs 21%), anastamotic leakage (8% vs 7%) and mortality (0% vs 2%) specifically did not differ between LSCLR and colorectal resection alone. Conclusion: In selected patients, LSCLR can be safely performed without increasing the risk of postoperative morbidity compared to laparoscopic colorectal resection alone.

Short and long-term outcomes after laparoscopic or robotic liver resection in patients with HCC located in posterosuperior segments: comparision with open liver resection

Introduction: Hepatocellular carcinoma located in posterosuperior segemtents, especially segments VII and VIII, are considered to be difficult for minimally invasive liver resection (MLR) because of limited visualization, the risk of major bleeding and difficulty in bleeding control. This study compared outcomes after laparoscopic or robotic liver resections for HCCs located in segments VII or VIII with open liver resections. Methods: Between January 2005 to December 2016, 497 patients underwent liver resections for HCCs located in segments VII or VIII. Among them, 63 patients underwent minimally invasive liver resection (MLR), which included 48 patients in laparoscope approach and 15 patients in robotic approach. We retrospectively evaluated perioperative and oncologic outcomes between the groups. Results: In terms of perioperative outcomes, operative time was longer for MLR group than open group (421 min. vs, 274 min., p< 0.001). While intraoperative blood loss was higher for open group (334 ml vs. 773ml, p< 0.001) and postoperative stay was longer (8.3 days vs. 17.5 days, p=0.001), there were no significant differences in postoperative complication rates (20.6% vs. 17.3%, p=0.596), In terms of oncologic outcomes, 5-year overall survival (85.5% vs. 79%, p=0.085) and 5-year disease survival (45.3% vs. 64.3%, p=0.489) rates did not show significant difference between MLR group and open group. Conclusion: MLR for HCC located in segments VII or VIII may be more time-consuming compared to open, but benefits of lower hospital stay and lower blood loss with same oncologic outcomes should make it a more attractive option in deciding operative procedure.

The rolling leukocytes in the sublingual microcirculation during major liver resection: a new potential parameter for the monitoring of the inflammatory status?

Introduction: Systemic inflammatory response is a complication that occurs frequently in major liver resection patients. The surgical trauma and ischemia reperfusion injury due to the Pringle manoeuvre are the most important factors for triggering the inflammatory system. Aim of this study is to show the activation of the leukocytes in the microcirculation during surgery in order to introduce a new potential parameter; the rolling leukocytes. Methods: In this prospective observational study videos of the sublingual microcirculation were recorded using Cytocam, a handheld microscope which uses incident dark-field imaging technique. Two time points are measured, the baseline (T0) after induction of anesthesia, and the second time point (T1) at the end of the surgery. 14 patients were recruited, 12 are included, after undergoing evaluation using quality criteria in order to identify at least one post capillary venule (PCV) where focus is primarily important. Three clips for each time point with duration of 4 seconds (25 frames/sec) in different spots are captured. Identifying a PCV to count the activated leukocytes: sticking and rolling leukocytes in the wall of the PCV. Results: The count of the activated leukocytes from T0 (6.2±1.7 (L/PCV/4s)) to T1 (15.6±0.9 (L/PCV/4s)) increased significantly (P=< 0.0001). The count of the systemic leukocyte (8.2 ± 0.9 (x109/l)) and after (10.9 ± 1.4 (x109/l)) the surgery also increased significantly (p=0.0002). Conclusions: The leukocytes in the micro- and macrocirculation both increased. Monitoring the microcirculatory rolling leukocytes directly at the bedside can potentially assess the inflammatory status of the surgical patient.

Do Co-morbidities, clinical variables, or surgical approach predict readmission post liver resection?

Introduction: The ability to predict 30-day readmission for patients following liver resection can improve health outcomes and equity. Methods: A case-control retrospective study was conducted for readmission in a large single center including 743 liver resection patients from 2000-2016. Multivariate propensity score (PS)-adjusted regression was conducted for causal inference to determine the most predictive comorbidities and clinical variables. Regression analysis included age, sex, race, ASA (American Society of Anesthesiologist) score >2, body mass index (BMI), major resection, cirrhosis, hypertension (HTN), diabetes (DM), obesity, tumor size and margin, prior abdominal surgery, and the likelihood of undergoing laparoscopic versus open surgery. Results: The mean age in the study was 57.22 (standard deviation [SD] 13.61), 452 (43.88%) were female, and 100 (13.46%) were readmitted. Patients who were readmitted were significantly more likely to be African American and have American Society of Anesthesiologist scores >2, Medicare or Medicaid instead of commercial insurance, hypertension, and diabetes (all p< 0.01) . In multivariate regression, laparoscopic versus open surgery had no association with readmission. The top readmission predictors were hypertension (OR 8.56, p< 0.001) followed by African American race (OR 2.77, p< 0.001). Conclusions: Our analysis identified significant racial and insurance disparities in readmission following liver resection, in addition to specific comorbidities and clinical variables. This analysis suggests efforts to reduce health disparities and target patients with particular risks factors may produce more effective, equitable care.