Major Hepatectomy In Patients Research Articles

Higher efficacy of antiviral therapy after major hepatectomy in patients with hepatitis B virus-related hepatocellular carcinoma of less than 3 cm.

Little is known about the role of antiviral therapy for patients with hepatitis B who underwent curative hepatectomy for hepatocellular carcinoma (HCC). The aim of this study was to assess whether antiviral therapy after hepatectomy improves the prognosis of HCC in preoperatively antiviral-free patients. This was a retrospective study of postoperative antiviral treatment in patients (n=87) who underwent curative hepatectomy for HCC. Clinicopathological features and disease-free survival (DFS) were assessed. Patients were followed up to monitor HCC recurrence (median of 31 months). In patients with HCC up to 3 cm (n=36), antiviral therapy reduced serum alanine transminase levels after 6 months of treatment (-26.3%, P<0.01). Among these patients, there was a significant prolongation of DFS in patients who received antiviral therapy after hepatectomy compared with those who did not (P=0.006). However, in patients with HCC greater than 3 cm (n=51), antiviral therapy did not decrease alanine transminase levels (+32.8%, P<0.01). In these patients, antiviral therapy had no effect on DFS (P>0.05). Using multivariate analysis, postoperative antiviral therapy was found to be an independent prognostic factor that was associated with a better DFS in patients with HCC up to 3 cm (odds ratio=0.220, 95% confidence interval: 0.120-0.434, P=0.008). Antiviral therapy improved the prognosis of hepatitis B virus-related HCC up to 3 cm. Antiviral therapy should be considered a standard postoperative adjuvant therapy of hepatitis B virus-related HCC.

Mo2031 The Importance of Portal Vein Embolization Before Major Hepatectomy for Patients With Predicted Insufficiency of the Remnant Liver

Mo2031 The Importance of Portal Vein Embolization Before Major Hepatectomy for Patients With Predicted Insufficiency of the Remnant Liver

Reappraisal of the Risks and Benefits of Major Liver Resection in Patients With Initially Unresectable Colorectal Liver Metastases

To determine short- and long-term outcomes of major hepatectomy in patients with downstaged colorectal liver metastases considered initially unresectable (IU). Improvements in both surgical technique and efficacy of chemotherapy have increased the rate of resection for IU colorectal liver metastases. The outcome of these patients needs to be reassessed. From 2000 to 2011, 257 patients underwent major hepatectomy for colorectal liver metastases. Of these, 87 (34%) IU patients required portal vein occlusion after chemotherapy downstaging. Patients requiring less than 12 cycles and 12 or more cycles of chemotherapy before resection were defined as fast responders and slow responders, respectively. Compared with fast responders, slow responders had increased mortality (0% vs 19%, P = 0.003) and major morbidity rates (20% vs 55%, P < 0.001) despite almost identical tumor characteristics and similar procedures. In multivariate analysis, the only factor associated with increased major morbidity was the existence of a number of chemotherapy cycles of 12 or more (hazard ratio [HR]: 5.32, confidence interval [CI]: 1.69-16.7, P = 0.004). One-, 3-, and 5-year disease-free survival rates for the entire population were 48%, 17.5%, and 13%, respectively. Multivariate analysis found that slow responders (HR: 2.89, CI: 1.67-5.04, P < 0.001) and patients without adjuvant chemotherapy (HR: 2.38, CI: 1.33-4.35, P = 0.004) had a significantly decreased disease-free survival. All slow responders postoperatively recurred within 3 years. Liver resection in slow responders, that is, IU patients requiring 12 or more chemotherapy cycles and portal vein occlusion to achieve resectability, is associated with poor short- and long-term outcomes. These patients would probably benefit from more conservative strategies.

Influence of Hepatic Parenchymal Histology on Outcome Following Right Hepatic Trisectionectomy

BackgroundHistological abnormalities in the non-tumour-bearing liver (NTBL) may influence outcome following hepatectomy. Effects will be most pertinent following right trisectionectomy but have yet to be specifically examined in this context. This study aimed to investigate the influence of perioperative factors, including NTBL histology, on outcome following right trisectionectomy. MethodsPathological review of the NTBL of 103 consecutive patients undergoing right trisectionectomy between January 2003 and December 2009 was performed using established criteria for steatosis, non-alcoholic steatohepatitis (NASH), sinusoidal injury (SI), fibrosis and cholestasis. Perioperative and pathological factors were correlated with post-operative outcome (morbidity, major morbidity, hepatic insufficiency and mortality). ResultsMorbidity, hepatic insufficiency and major morbidity occurred in 37.9 %, 14.6 % and 22.3 % of cases, respectively. Ninety-day mortality rate was 5.8 %. NASH (P = 0.007) and perioperative blood transfusion (P = 0.001) were independently associated with hepatic insufficiency following trisectionectomy. NASH (P = 0.028), perioperative transfusion (P = 0.016), diabetes mellitus (P = 0.047) and coronary artery disease (P = 0.036) were independently associated with major morbidity. Steatosis, SI, fibrosis and cholestasis in the NTBL demonstrated no association with any adverse outcome. ConclusionNASH, but not steatosis or SI, is associated with adverse outcome following right trisectionectomy and caution must be exerted when considering major hepatectomy in patients with NASH.

Portal vein occlusion before major hepatectomy in patients with colorectal liver metastases: Rationale, indications, technical aspects, complications and outcome

Surgery is the only curative treatment for colorectal liver metastases (CRLM), but resection should be total with tumor-free margins and the remaining parenchyma, functionally evaluated. The rationale behind portal vein embolization (PVE) to reduce the risk of these hepatic resections is threefold: (i) surgery for CRLM has become more and more aggressive, and hepatocellular insufficiency represents the leading cause of mortality after major hepatectomy for hepatic metastasis (HM), (ii) underlying hepatic disease occurs more frequently than previously thought in these patients having undergone neoadjuvant chemotherapy, and can alter hepatic function and/or hinder postoperative regeneration, and (iii) the operative risk is increased if major hepatectomy is associated with resection of the primary tumor. The goal of this update is to review the reasons behind and the indications for PVE, to analyze the literature pertaining to whether PVE should be routine or selective, and to tackle certain technical aspects, all within the framework of the treatment of CRLM.

Prolonged Portal Triad Clamping Increases Postoperative Sepsis after Major Hepatectomy in Patients with Sinusoidal Obstruction Syndrome and/or Steatohepatitis

Portal triad clamping (PTC) has been widely adopted in an attempt to decrease bleeding during liver parenchymal transection. As a larger proportion of patients are treated with chemotherapy prior to liver resection, the safety of PTC in patients with chemotherapy-associated liver injury remains poorly investigated. This study aims to evaluate the influence of PTC on early postoperative outcomes in patients with chemotherapy-associated liver injury undergoing major hepatectomy for colorectal liver metastases (CLM). From January 2000 to October 2010, 53 patients with histologically proven chemotherapy-associated liver injuries [sinusoidal obstruction syndrome (SOS; n = 41), steatohepatitis (n = 5), and both SOS and steatohepatitis (n = 7)] who underwent major hepatectomy for CLM were divided into two groups; patients undergoing intermittent TPC (n = 20) and those who did not undergo TPC (n = 33). Perioperative clinicobiological factors, morbidity including septic complications, and mortality were analyzed and compared between the two groups. Intraoperative blood transfusions and postoperative liver function were comparable between the two groups. Sepsis and biloma occurred more often in patients undergoing PTC longer than 30 min than in those undergoing PTC ≤ 30 min (66.7 % versus 17.1 %, p = 0.002, and 33.3 versus 0 %, p = 0.002, respectively). A multiple logistic regression analysis showed that prolonged PTC (>30 min) and the ratio of future liver remnant volume to total liver volume ≤ 43 % were independent factors for predicting postoperative sepsis [odds ratio (OR): 32.68; 95 % confidence interval (95 % CI): 2.86-372.82; p = 0.005--and odds ratio: 9.70; 95 % CI: 1.04-90.86; p = 0.047, respectively]. Portal triad clamping can be safely used in patients with chemotherapy-associated liver injury who require major liver resection. Prolonged PTC can increase the occurrence of postoperative biliary and septic complications.

Prediction of Mortality Rate After Major Hepatectomy in Patients Without Cirrhosis

To assess the ability of preoperative biological parameters to predict a fatal outcome after a major liver resection in patients without cirrhosis. Retrospective descriptive cohort study. Department of Digestive Surgery and Transplantation, University of Strasbourg. From January 1, 2004, through December 31, 2007, 67 consecutive patients underwent resection of at least 4 contiguous liver segments. Perioperative data were prospectively recorded, and predictors of postoperative mortality rate and liver failure were analyzed. Five patients (7%) died after a mean (SD) of 32.4 (11.8) postoperative days. The overall morbidity was 73% (49 patients). Univariate analysis revealed that a preoperative alanine aminotransferase blood level greater than 40 U/L (to convert to microkatals per liter, multiply by 0.0167), a preoperative prothrombin ratio less than 70%, a preoperative Indocyanine green retention rate at 15 minutes of greater than 15%, preoperative biliary drainage, and performance of extrahepatic bile duct resection significantly predict the occurrence of in-hospital death. The number of preoperative biological parameters in each patient significantly increased the mortality rate. Indeed, the mortalities were 0%, 3%, and 67% in patients presenting with none, 1, and 2 or more risk factors, respectively. This study shows that preoperative liver tests and function can predict postoperative fatal outcome in patients presenting with biliary carcinomas and requiring a major liver resection. On the basis of these preoperative biological parameters, a decision-making algorithm is provided.

Sequential Transcatheter Arterial Chemoembolization and Portal Vein Embolization versus Portal Vein Embolization Only before Major Hepatectomy for Patients with Hepatocellular Carcinoma

To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in hepatocellular carcinoma (HCC) patients and to compare the clinical outcome of the combined procedure with that of a matched group of patients undergoing PVE alone. From 1997 to 2008, 135 patients with HCC underwent sequential TACE and PVE (n = 71) or PVE alone (n = 64) before right hepatectomy. PVE was performed mean 1.2 months after TACE. In both groups, computed tomography (CT) and liver volumetry were performed before and 2 weeks after PVE to assess degree of left lobe hypertrophy. Baseline patient and tumor characteristics were similar in the two groups. After PVE, the chronological changes of liver enzymes were similar in the two groups. The mean increase in percentage future liver remnant (FLR) volume was higher in the TACE + PVE group (7.3%) than in the PVE-only group (5.8%) (P = 0.035). After surgery, incidence of hepatic failure was higher in the PVE-only group (12%) than in the TACE + PVE (4%) group (P = 0.185). Overall (P = 0.028) and recurrence-free (P = 0.001) survival rates were significantly higher in the TACE + PVE group than in the PVE-only group. Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC.

Is embolization of segment 4 portal veins before extended right hepatectomy justified?

Preoperative portal vein embolization (PVE) is increasingly used as a preparation for major hepatectomy in patients with inadequate liver remnant volume or function. However, whether segment 4 (S4) portal veins should be embolized is controversial. The effect of S4 PVE on the volume gain of segments 2 and 3 (S2+3) was examined. Among 73 patients with uninjured liver who underwent right portal vein embolization (RPVE, n = 15) or RPVE extended to S4 portal veins (RPVE+4, n = 58), volume changes in S2+3 and S4 after embolization were compared. Clinical outcomes and PVE complications were assessed. After a median of 27 days, the S2+3 volume increased significantly after both RPVE and RPVE+4, but the absolute increase was significantly higher for RPVE+4 (median, 106 mL vs 141 mL; P = .044), as was the hypertrophy rate (median, 26% vs 54%; P = .021). There was no significant difference between RPVE and RPVE+4 in the absolute S4 volume increase (52 mL for RPVE vs 55 mL for RPVE+4; P = .61) or the hypertrophy rate of S4 (30% for RPVE vs 26% for RPVE+4; P = .45). Complications of PVE occurred in 1 patient (7%) after RPVE and 6 (10%) after RPVE+4 (P > .99). No PVE complication precluded subsequent resection. Curative hepatectomy was performed in 13 patients (87%) after RPVE and 40 (69%) after RPVE+4 (P = .21). RPVE+4 significantly improves S2+3 hypertrophy compared with RPVE alone. Extending RPVE to S4 does not increase PVE-associated complications.

Sinusoidal Injury Increases Morbidity After Major Hepatectomy in Patients With Colorectal Liver Metastases Receiving Preoperative Chemotherapy

To investigate whether sinusoidal injury (SI) was associated with a worse outcome after hepatectomy in patients with colorectal liver metastases (CRLM). Correlation between SI and oxaliplatin-based chemotherapy (OBC) was recently shown in patients with CRLM. However, it has yet to be fully clarified whether SI affects liver functional reserve and outcome after hepatectomy. Between 2003 and 2005, 90 patients with CRLM who underwent an elective hepatectomy after preoperative chemotherapies were included. Diagnosis of SI was established pathologically in the nontumoral liver parenchyma of the resected specimens, and perioperative data were assessed in these patients. OBC was significantly associated with a higher incidence of SI. Preoperative indocyanine green retention rate at 15 minutes (ICG-R15) and postoperative value of total-bilirubin were significantly higher, and hospital stay was significantly longer in patients presenting with SI. Multivariate analysis showed that female gender, administration of 6 cycles or more of OBC, abnormal value of preoperative aspartate aminotransferase >36 IU/L, or abnormal value of preoperative ICG-R15 (>10%) were preoperative factors significantly associated with SI. Among patients undergoing a major hepatectomy, SI was significantly associated with higher morbidity and longer hospital stay. The present study suggests that SI resulted in a poorer liver functional reserve and in a higher complication rate after major hepatectomy. Therefore, female patients who received 6 cycles or more of OBC, or presenting with abnormal preoperative aspartate aminotransferase and ICG-R15 values should be carefully selected before deciding to undertake a major hepatectomy.

Current surgical treatment for bile duct cancer.

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy (PD), plus extrahepatic bile duct resection and regional lymphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD (hepatopancreatoduodenectomy) has been applied to selected patients with widespread tumors. Preoperative biliary drainage (BD) followed by portal vein embolization (PVE) enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

Major hepatectomy in patients with synchronous colorectal liver metastases: whether or not a contraindication to simultaneous colorectal and liver resection?

Synchronous hepatic lesions account for 15-25% of newly diagnosed colorectal cancer and its optimal timing to surgery is not completely defined, but simultaneous colorectal and liver resection is recently gaining acceptance, at least in patients with a right colonic primary and liver metastases that need a minor hepatectomy to be fully resected. From September 2002 to December 2004, 16 patients underwent simultaneous resection as treatment of synchronous colorectal liver resection; in 10 patients (62.5%) a major hepatectomy was performed. The mean duration of intervention was 322.5 +/- 59.5 min, operative mortality and morbidity rates was 0% and 25% respectively; the hospitalization was 14.4 (range 8-60) days on average. Mean follow-up was 14 months and actuarial survival was 76.5% at 1 year and 63.5% at 2 years. We concluded that simultaneous colonic and liver resection should be undertaken in selected patients with synchronous colorectal liver resection regardless of the extent of hepatectomy; major liver resection, in fact, seems capable of providing better oncological results, allowing resection of liver micrometastases that, in almost one-third of the patients, are located in the same liver lobe of macroscopic lesions, without increased morbidity rates.

The small remnant liver after major liver resection: How common and how relevant?

The maximum extent of hepatic resection compatible with a safe postoperative outcome is unknown. The study goal was to determine the incidence and impact of a small remnant liver volume after major liver resection in patients with normal liver parenchyma. Among 265 major hepatectomies performed at our institution (1998 to 2000), 138 patients with normal liver and a remnant liver volume (RLV) systematically calculated from the ratio of RLV to functional liver volume (FLV) were studied. Patients were divided into five groups based on RLV-FLV ratio from ≤30% to ≥60%. Kinetics of postoperative liver function tests were correlated with RLV. Postoperative complications were stratified by RLV-FLV ratios. Ninety patients (65%) underwent resection of up to four Couinaud segments. The RLV-FLV ratio was ≤60% in 94 patients (68%) including only 13 (9%) with RLV-FLV ≤30%. There was no linear correlation between the number of resected segments and the RLV-FLV. Postoperative serum bilirubin but not prothrombin time correlated with extent of resection. The incidence of complications including liver failure was not different among groups. Analysis of the four groups with a RLV-FLV ratio <60% showed a trend toward more complications and a longer intensive care unit stay in patients with the smallest RLVs. After major hepatectomy in patients with normal livers, the proportion of patients with a small remnant liver is low and not directly related to the number of segments resected. Although the rate of postoperative complications, including liver failure, did not directly correlate with the volume of remaining liver, the postoperative course was more difficult for patients with smaller remnants. Therefore preoperative portal vein embolization should be considered in patients who will undergo extended liver resection who have (1) injured liver or (2) normal liver when the planned procedure will be complex or when the anticipated RLV-FLV will be <30%. (Liver Transpl 2003;9:S18-S25.)

Right portal vein ligation: a new planned two-step all-surgical approach for complete resection of primary gastrointestinal tumors with multiple bilateral liver metastases.

Although complete resection of liver metastases remains the only curative treatment for metastatic liver disease from colorectal and endocrine gastrointestinal (GI) tumors, only a small proportion of patients with liver metastases are candidates for potentially curative surgery. Among these, 4% to 21% are found to have unresectable disease because of multiplicity of the liver metastases, so a very small proportion of such patients can be eligible for complete resection. When the number and distribution of liver metastases create the need for extensive hepatic resection, the risk for postoperative liver failure and morbidity related to the small size of the remnant liver is increased. Additionally, substantial operative risk results from the combination of extensive hepatic resection with other major abdominal procedures at a single operation, such as extended hepatectomy with colorectal or pancreatic resections. On the other hand, minor hepatic surgery, such as left liver wedge resection, has been shown to be safe in combination with such extrahepatic procedures as those necessary to treat many GI primary tumors. So, multistep, multimodality therapies including surgery in several steps have been proposed and usually require resection of the primary tumor in one step, followed by extensive liver resection, with or without the use of percutaneous ablative therapy or systemic chemotherapy. Improved understanding of the benefits of liver regeneration has led to other approaches using intermediate steps between surgical procedures. In patients expected to have a small future liver remnant volume (FLR), most hepatic surgeons perform preoperative portal vein embolization (PVE), mainly to avoid postoperative liver failure and to decrease morbidity either after major hepatectomy in patients with injured liver parenchyma (such as that found in patients after extensive chemotherapy or in patients with chronic liver disease) or when major hepatectomy is associated to major abdominal procedures. But some investigators suggest that in patients with bilobar liver metastases from colorectal cancer, hypertrophy of the left liver induced by right PVE might accelerate the progression of left-sided disease and therefore caution against the reckless use of PVE in these cases. In order to use the benefits of diversion of portal flow to the FLR, to avoid the risk of progression of liver disease, and to minimize the risk and number of procedures necessary to treat patients with GI tumors with bilobar liver metastases, we developed a new planned two-step, totally surgical approach to clear all primary and metastatic disease. In the first step, the primary tumor and all left-sided liver metastases (Couinaud S1 to S4) are resected using straightforward resection techniques. Simultaneously, right portal vein ligation (RPVL) is performed to induce hypertrophy in the left lobe, which has been cleared of all detectable disease. Four to 8 weeks later, after hypertrophy of the diseasefree FLR, a second step consisting of a right or extended right hepatectomy is planned to completely clear the remaining right-sided liver metastases (Fig. 1). No competing interests declared.

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H2O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.

Total Vascular Exclusion for Major Hepatectomy in Patients With Abnormal Liver Parenchyma

Total vascular exclusion (TVE) of the liver has been used to increase the safety of hepatectomy and the feasibility of difficult resections. Until recently, however, concern about the detrimental effect of warm ischemia has limited the use of this technique to patients with normal liver parenchyma. To compare surgical outcomes of 12 patients with abnormal livers (group 1) with outcomes of 48 patients with normal parenchyma (group 2), based on the hypothesis that uncontrolled bleeding may be more detrimental than planned hepatic ischemia. Retrospective analysis of 60 consecutive patients undergoing liver resection under TVE in a university medical center. All 10 patients with cirrhosis had albumin levels of 30 g/L or higher and normal prothrombin times preoperatively; none had ascites. Two patients with cholestasis (one with cholangiocarcinoma and one with hepatocellular carcinoma) are included in group 1. All 12 group 1 patients and 44 of 48 group 2 patients underwent total or extended lobectomy, with TVE induced by clamping the hilum and the vena cava above and below the liver during parenchyma division. Hospital survival and selected surgical and laboratory parameters. Operative times, ischemic times, and blood loss (1975 +/- 1601 vs 1255 +/- 1291 mL) (P = .10) were comparable in both groups. Sixty-day operative mortality was zero in both groups. There was an increased rate of complications in group 1 (44% vs 17% [P = 0.06]). Transient abnormal liver function was observed in both groups. However, significant delay in restoration of normal function was observed in group 1 with respect to bilirubin levels and prothrombin time. Patients with cirrhosis can undergo successful resection using TVE. This conclusion must be limited to cirrhotic patients with good liver function. The trend toward increased blood loss may reflect greater difficulties in establishing hemostasis after reperfusion in group 1. While this group appears to have a higher risk for hepatic insufficiency, successful outcomes were achieved in all cases. Prospective study will be required to define the parameters for use of TVE in cirrhosis.

Bacterial translocation after major hepatectomy in patients and rats.

Bacterial infections are frequent complications after liver resection. Of 138 patients who underwent major hepatectomy, 11 patients (8%) developed intra-abdominal sepsis in the postoperative period. Seven bacterial strains of gut origin were isolated from the abdominal cavity. Eight patients had multiple bacteria cultured. In the experimental studies on rat models, positive mesenteric lymph node cultures were seen 2 hours after removal of 70% and 90% of the total weight of the rat liver, and 12 hours after 50% hepatectomy, persisting for 3 and 4 days after 50% and 70% hepatectomy, respectively. The incidences of bacteremia 2 and 4 hours after 90% hepatectomy were 80% and 100%, respectively; 6 hours after 70% liver resection, the incidence of bacteremia was 33%. Blood cultures were positive in only 6% of the rats following 50% hepatectomy, and in none of the controls. Thus, bacterial translocation occurs in the early course after hepatectomy, the incidence being proportional to the amount of liver tissue removed.