Liver Resection For Malignant Tumors Research Articles

Evaluation of transaminases on the first postoperative day as predictors of morbidity and mortality in liver resections for malignant tumors

Evaluation of transaminases on the first postoperative day as predictors of morbidity and mortality in liver resections for malignant tumors

Sarcopenia negatively affects postoperative short-term outcomes of patients with non-cirrhosis liver cancer

BackgroundLiterature review have shown that sarcopenia substantially alters the postoperative outcomes after liver resection for malignant tumors. However, these retrospective studies do not distinguish cirrhotic and non-cirrhotic liver cancer patients, nor combine the assessment of muscle strength in addition to muscle mass. The purpose of this study is to study the relationship between sarcopenia and short-term outcomes after hepatectomy in patients with non-cirrhotic liver cancer.MethodsFrom December 2020 to October 2021, 431 consecutive inpatients were prospectively enrolled in this study. Muscle strength and mass were assessed by handgrip strength and the skeletal muscle index (SMI) on preoperative computed tomographic scans, respectively. Based on the SMI and the handgrip strength, patients were divided into four groups: group A (low muscle mass and strength), group B (low muscle mass and normal muscle strength), group C (low muscle strength and normal muscle mass), and group D (normal muscle mass and strength). The main outcome was major complications and the secondary outcome was 90-d Readmission rate.ResultsAfter strictly exclusion, 171 non-cirrhosis patients (median age, 59.00 [IQR, 50.00–67.00] years; 72 females [42.1%]) were selected in the final analysis. Patients in group A had a statistically significantly higher incidence of major postoperative complications (Clavien–Dindo classification ≥ III) (26.1%, p = 0.032), blood transfusion rate (65.2%, p < 0.001), 90-day readmission rate (21.7%, p = 0.037) and hospitalization expenses (60,842.00 [IQR, 35,563.10–87,575.30], p < 0.001) than other groups. Sarcopenia (hazard ratio, 4.21; 95% CI, 1.44–9.48; p = 0.025) and open approach (hazard ratio, 2.56; 95% CI, 1.01–6.49; p = 0.004) were independent risk factors associated with major postoperative complications.ConclusionsSarcopenia is closely related to poor short-term postoperative outcomes in non-cirrhosis liver cancer patients and the assessment that combines muscle strength and muscle mass can simply and comprehensively identify it.Trial registrationClinicalTrials.gov identifiers NCT04637048. (19/11/2020).

Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.

Clinical outcome of hepatic resection for malignant liver tumors in elderly patients

Background: Aging hinders the liver capacity to restitute its volume and function after partial hepatectomy. Concomitant hepatic parenchyma disorders and major resections may increase the susceptibility of elderly patients to worse postoperative outcome.Methods: Prospectively collected medical records of adult patients who underwent elective partial hepatectomy for malignant liver tumors at Sohag University Hospital (June 2014–May 2020) were analyzed. A group of elderly (≥65 years) were compared with a matched control group of non-elderly (&lt;65 years) patients as regards posthepatectomy liver failure (PHLF) and overall complications, including mortality. Markers associated with PHLF and postoperative death were investigated.Results: Forty-eight patients were enrolled, 24 per group. 34 were males (71%). All patients had primary hepatic malignancy or metastatic tumors. Hepatocellular carcinoma (HCC) was the most common indication for liver resection in both groups (32 patients, 66.6%). Elderly patients exhibited significantly higher grades of overall postoperative complications (p&lt;0.05). PHLF was significantly increased in the elderly group, in evident connection with significant persistence of higher bilirubin levels and reduced prothrombin concentration (p&lt;0.05) until 5th postoperative day. Subgroup analysis showed that major resections and cirrhosis correlated with increased morbidity among elderly compared with younger patients. Postoperative mortality occurred in 3 elderly cirrhotic patients, who failed to recover normal platelet count postoperatively.Conclusions: In elderly patients, major liver resection for malignant tumors is associated with worse outcome, particularly in those with coexisting cirrhosis. Predictors include early postoperative thrombocytopenia and persistent hyperbilirubinemia and coagulopathy.

Intake of Selective Serotonin Re-uptake Inhibitors Modulates Postoperative Outcome after Liver Resection for Malignant Tumors

Intake of Selective Serotonin Re-uptake Inhibitors Modulates Postoperative Outcome after Liver Resection for Malignant Tumors

Association of Sarcopenia and Body Composition With Short-term Outcomes After Liver Resection for Malignant Tumors

Previous retrospective studies have shown that sarcopenia substantially alters the postoperative and oncological outcomes after liver resection for malignant tumors. However, the evidence is limited to small retrospective studies with heterogeneous results and the lack of standardized measurements of sarcopenia. To investigate the role of sarcopenia as a risk factor associated with 90-day morbidity after liver resection for malignant tumors. This cohort study included 234 consecutive patients undergoing liver resection for malignant tumors at San Camillo Forlanini Hospital, Rome, Italy, between June 1, 2018, and December 15, 2019. Muscle mass and strength were assessed using the skeletal muscle index (SMI) on preoperative computed tomographic scans and the handgrip strength test, respectively. Patients were then divided into the following 4 groups: group A (normal muscle mass and strength), group B (reduced muscle strength), group C (reduced muscle mass), and group D (reduced muscle mass and strength). The primary outcome of the study was 90-day morbidity. The following secondary outcomes were investigated: 90-day mortality, hospital stay, and readmission rate. Sixty-four major and 170 minor hepatectomies were performed in 234 patients (median age, 66.50 [interquartile range, 58.00-74.25] years; 158 men [67.5%]). The median SMI of the entire population was 46.22 (interquartile range, 38.60-58.20) cm/m2. The median handgrip strength was 30.80 (interquartile range, 22.30-36.90) kg. Patients in group D had a statistically significantly higher rate of 90-day morbidity than patients in the other groups (51.5% [35 of 68] vs 38.7% [29 of 75] in group C, 23.1% [3 of 13] in group B, and 6.4% [5 of 78] in group A; P < .001). Compared with patients in the other groups, those in group D had a longer hospital stay (10 days vs 8 days in group C, 9 days in group B, and 6 days in group A; P < .001), and more patients in this group were readmitted to the hospital (8.8% [6 of 68] vs 5.3% [4 of 75] in group C, 7.7% [1 of 13] in group B, and 0% [0 of 78] in group A; P = .02). Sarcopenia, portal hypertension, liver cirrhosis, and biliary reconstruction were independent risk factors associated with 90-day morbidity. Sarcopenia appears to be associated with adverse outcomes after liver resection for malignant tumors. Both muscle mass measurements on computed tomographic scans and muscle strength assessments with the handgrip strength test should be performed at the first clinical encounter to better classify patients and to minimize the risk of morbidity.

The application of indocyanine green-fluorescence imaging during robotic-assisted liver resection for malignant tumors: a single-arm feasibility cohort study

BackgroundThe fluorescence properties of Indocyanine Green (ICG) make it a useful technique in the armamentarium of liver surgeons in order to enhance the visualization of anatomical structures by providing a real-time liver mapping. MethodsWe have analyzed the impact of ICG-fluorescence staining technique in 40 consecutive patients who underwent robotic-assisted liver resection for malignancies from June 2014 to November 2017. ResultsFor the 55% of patients the surgical indication was colorectal liver metastasis followed by hepatocarcinoma in 35% of cases. The R0 resection rate was 100%, and the mean resection margin was 12 mm. Twenty percent of patients experienced tumor recurrence. The 1-year and 2-year overall survival rates were 91% and 84%, respectively. The 1-year and 2-year disease free survival were 77.2% and 65%, respectively. The previously marked transaction line was changed after the staining method in 12 out of 40 patients. Through intra-operative ultrasonography and white-light exploration of the liver surface 43 lesions were detected, whereas with the ICG-F 52 lesion of the liver surface were identified, including two superficial colorectal metastases missed at the intra-operative ultrasonography. ConclusionThe ICG-F is a promising navigational tool, that can potentially overcome the limitations of the minimally invasive liver surgery.

Effects of terlipressin infusion on blood loss and transfusion needs during liver resection: A randomised trial.

Blood loss and perioperative blood transfusion requirements affect the long-term survival after liver resection for malignant tumours. Terlipressin is a synthetic vasopressin analogue with relative specificity for the splanchnic circulation where it causes vasoconstriction with subsequent reduction of blood loss during abdominal surgeries. We tried to examine the impact of terlipressin on blood loss and blood transfusion needs during liver resection. In this randomised, double-blind placebo-controlled trial 84 patients scheduled for major liver resections were randomly assigned to receive either terlipressin at the onset of surgery as an initial bolus dose of (1 mg over 30 minutes) followed by a continuous infusion of 2 μg/kg/h throughout the procedure (Terlipressin group) or the same volume and rate of 0.9% saline (Placebo group).The primary outcome was the amount of intra-operative blood loss. The mean (SD) of the amount of intra-operative blood loss was 1351 (887) in the terlipressin group versus 1892 (889) mL in the placebo group (P = 0.006). Thirteen (30%) patients received blood transfusion in the terlipressin group compared with t27 (64.2%) in the placebo group (P = 0.002) with a statistically significant difference in the median (range) number of the transfused units of packed RBCs [0 (0-5) units and 1 (0-6) units in the two groups respectively; P = 0.001]. Terlipressin infusion during major liver resection was associated with less bleeding compared to placebo. More studies are required to confirm our results especially in patients with normal portal pressure.

Video-assisted thoracoscopic transdiaphragmatic liver resection for malignant tumors located in the posterosuperior segments.

Video-assisted thoracoscopic transdiaphragmatic liver resection for malignant tumors located in the posterosuperior segments.

Video-assisted thoracoscopic transdiaphragmatic liver resection for malignant tumors located in the posterosuperior segments.

469 Background: Laparoscopic liver resection has recently become more common. However, it is difficult to resect laparoscopically the liver tumor located in the posterosuperior segments (IVa, VII and VIII), especillay for patients with liver cirrhosis. Compared to laparoscopy, gaining access to tumors in the dome of the liver may be more easily obtained via thoracoscopy.Therefore, we describe the technique and outcome of a video-assisted thoracoscopic transdiaphragmatic liver resection in patients with a malignant tumor of the liver. Methods: Five female patients underwent video-assisted thoracoscopic transdiaphragmatic partial hepatectomy. The tumors were located at segment VIII in 4 patients and segment VII in 1. Three patients were preoparatively diagnosed with hepatocellular carcinoma, and two were metastatic tumor of the colorectal cancer. Underlying cirrhosis was staged as Child-Pugh B in 2 cases and Child-Pugh A in 1. Thoracoscopic transdiaphragmatic partial hepatic resection was chosen due to the tumor’s location and impaired liver function. The patient was placed in an oblique position with her left side on the table. The ports were placed around the tumor at three levels, the ninth (3cm mini-thoracotomy), the seventh (two ports, 5mm and 12mm), and the fifth (12mm) intercostals spaces. Using thoracoscopic ultrasonography, the portion of the diaphragm located just above the tumor was cut and opened using electric cautery. The partial liver resection was performed using coagulating shears and electric cautery. Results: No conversion to laparotomy occurred. The median blood loss was 200 g (20-500g), and median operating time was 220 min (135-347 min). There were no perioperative deaths, and no patients underwent reoperation. Conclusions: Thoracoscopic hepatic resection can be safely performed in patients with subdiaphragmatic tumors, especially with cirrhosis or previous upper abdominal surgery.

Vascular reconstruction combined with liver resection for malignant tumours (Br J Surg 2013; 100: 1764–1775)

Vascular reconstruction combined with liver resection for malignant tumours (<i>Br J Surg</i> 2013; 100: 1764–1775)

Vascular reconstruction combined with liver resection for malignant tumours

The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre. Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality. Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively. Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.

First Report of Hepatectomy without Endotracheal General Anesthesia

Local anesthesia, including epidural anesthesia, has much merit over general anesthesia for the reduction of perioperative cardiac and respiratory complications. Liver operations commonly require general anesthesia. This is the first report of hepatectomy performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation. We devised the following protocol for hepatectomy under epidural anesthesia with conscious sedation: the patient receives 10 mg diazepam orally 1 hour before surgery, followed by 10 mg diazepam and 15 mg pentazocine intravenously just before surgery. An epidural catheter is inserted via the thoracic vertebra 7 to 9 interspaces. Intraoperatively, the patient receives a bolus of 7 mL 2% mepivacaine hydrochloride every 40 minutes through the epidural catheter. We conducted 4 left hepatectomies, 1 left lateral sectorectomy, and 5 partial hepatectomies under this protocol. We assessed the efficacy and safety of hepatectomy under epidural anesthesia with conscious sedation in terms of mortality rate, surgical time, amount of bleeding, and central venous pressure during the procedure. Every patient was managed without endotracheal intubation and laryngeal masks. There was no perioperative mortality. Median intraoperative blood loss was 453.0 mL (range 144.0 to 1292.0 mL) and median surgical time was 273.0 minutes (range 137.0 to 440.0 minutes). Median total amount of 2% mepivacaine hydrochloride used was 52.0 mL (range 23.0 to 95.0 mL). Central venous pressure values were significantly lower during the Pringle maneuver than at preclamp. The traditional belief is that liver resection should be performed under general anesthesia. We report the world's first series of liver resections for malignant tumors performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation.

Regular versus irregular liver resection for malignant tumors of the liver

Regular versus irregular liver resection for malignant tumors of the liver

Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments

BackgroundTotally laparoscopic liver resection of lesions located in the posterosuperior segments is reported to be technically challenging. This study aimed to define whether these technical difficulties affect the surgical outcome.MethodsA total of 220 patients underwent laparoscopic liver resection during 244 procedures from August 1998 to December 2010. The patients who underwent primary minor single liver resection for malignant tumors affecting either posterosuperior segments 1, 7, 8, and, 4a (group 1) or anterolateral segments 2, 3, 5, 6, and 4b (group 2) were included in the study. Seventy-five procedures found to be eligible for the study, including 28 patients in group 1 and 47 patients in group 2. Intraoperative unfavorable incidents were graded on the basis of the Satava approach and postoperative complications were graded in agreement with the Accordion classification.ResultsThe operative time (median, 127 min) and blood loss (median, 200 ml) were equivalent in the two groups. The rates for blood transfusions and intraoperative accidents did not differ statistically between the groups. A tumor-free margin resection was achieved in 94.7% of the procedures, equivalently in both groups. The postoperative course was similar in the two groups. Postoperative complications developed in 2 cases (7.1%) in group 1 and 2 cases (4.3%) in group 2 (p = 0.626). The median hospital stay was 2 days in both groups.ConclusionsLaparoscopic liver resection for lesions located in posterosuperior segments represents certain technical challenges. However, appropriate adjustment of surgical techniques and optimal patient positioning enables the laparoscopic technique to provide safe and effective parenchyma-sparing resections for lesions located in both posterosuperior and anterolateral segments.

Intraoperative ultrasound for ethanol tumor ablation and liver resection for malignant tumors

IntroductionIntraoperative ultrasound (IOUS) is a safe and reproducible tool and it is considered an essential component of major hepatobiliary procedures. The aim of this study was to define the place of IOUS as an adjuvant for ethanol tumor ablation and liver resection.Material and methodsA review of clinical files of patients operated with liver tumors between August 1998 and January 2001 was performed.ResultsFifty-two patients (30 men, 22 women) age ranging from 17 and 86 years (mean=45) were included for analysis and 26 had primary liver carcinomas (24 HCC and 2 CCC), 16 were considered resectable by preoperative imaging studies. However, IOUS avoid resection in 6 patients (37.5%). in 2 patients (20%) a change in the plane of resection was made. Eight patients with large single HCC lesions were managed with a single session of large volume intraoperative ethanol injection. IOUS detected the distribution of ethanol within the lesion and helped determine the dosage. This technique detected spillage of ethanol into a hepatic vein and helped to avoid a major complication in one patient (12.5 %). Twenty patients presented liver metastases of which, 16 were resected. IOUS avoid resection in 4 patients (20%); a change in the plane of resection was made in 5 (31%). Of 6 benign liver tumors that were operated with an unconfirmed diagnosis, IOUS made the diagnosis in 4. In all, IOUS influenced in the final decision in 70% of patients.ConclusionIOUS has become in creasingly important in hepatic resection in our center and is an essential tool for intraoperative elthanol tumor ablation.

Laparoscopic liver resection.

certainly feasible; possibly effective

Cryosurgery of Close or Positive Margins after Hepatic Resection for Primary and Metastatic Hepatobiliary Malignancies

Obtaining a one-centimeter negative margin is an important factor in preventing disease recurrence after surgery for hepatic tumors. Cryotherapy of the resected edge has been used to achieve optimal margin clearance in cases in which the alternative would be an extended high-risk liver resection. The effect of this technique on margin recurrence was examined. Between 1994 and 2001 a total of 56 patients underwent cryosurgery with or without resection for primary and metastatic hepatobiliary malignancies. A 5-cm cryotherapy lollipop probe was used to ablate surgical margins less than one centimeter in 13 of these patients. There were seven colorectal metastases, three hepatocellular carcinomas, and three gallbladder carcinomas. The median size of the colorectal and hepatocellular lesions was 3 cm (range 2-14 cm), and all gallbladder primaries were T2 tumors. All tumors except three were located centrally in the liver requiring cryoablation of margins at segments 4, 5, and 8. Most patients had one site frozen (n = 9) with a median target temperature of -190 degrees C and a median of two freeze-thaw cycles. Final pathological analysis of the resected specimens revealed nine close (<1 cm) and four positive margins. With a median follow-up of 16 months seven patients are alive with no evidence of disease and six have developed recurrences with three of them dying of their disease. Only one (8%) of the initial recurrences was at the cryoablated margin. Cryosurgery of the resection edge facilitates liver resection for malignant tumors when margins are close or positive. Because disease recurrence at the cryoablated margin is low this technique may allow more patients to undergo effective surgical treatment of their hepatobiliary cancers.