Non-anatomical Resection Research Articles

Finding the seed of recurrence: Hepatocellular carcinoma circulating tumor cells and their potential to drive the surgical treatment.

The treatment for hepatocellular carcinoma (HCC) relies on liver resection, which is, however, burdened by a high rate of recurrence after surgery, up to 60% at 5 years. No pre-operative tools are currently available to assess the recurrence risk tailored to every single patient. Recently liquid biopsy has shown interesting results in diagnosis, prognosis and treatment allocation strategies in other types of cancers, since its ability to identify circulating tumor cells (CTCs) derived from the primary tumor. Those cells were advocated to be responsible for the majority of cases of recurrence and cancer-related deaths for HCC. In fact, after being modified by the epithelial-mesenchymal transition, CTCs circulate as “seeds” in peripheral blood, then reach the target organ as dormant cells which could be subsequently “awakened” and activated, and then initiate metastasis. Their presence may justify the disagreement registered in terms of efficacy of anatomic vs non-anatomic resections, particularly in the case of microvascular invasion, which has been recently pointed as a histological sign of the spread of those cells. Thus, their presence, also in the early stages, may justify the recurrence event also in the contest of liver transplant. Understanding the mechanism behind the tumor progression may allow improving the treatment selection according to the biological patient-based characteristics. Moreover, it may drive the development of novel biological tailored tests which could address a specific patient to neoadjuvant or adjuvant strategies, and in perspective, it could also become a new method to allocate organs for transplantation, according to the risk of relapse after liver transplant. The present paper will describe the most recent evidence on the role of CTCs in determining the relapse of HCC, highlighting their potential clinical implication as novel tumor behavior biomarkers able to influence the surgical choice.

Anatomic Resection for Hepatocellular Carcinoma: Prognostic Impact Assessed from Recurrence Treatment

The oncologic advantage of anatomic resection (AR) for primary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the clinical advantages of AR for primary HCC by using propensity score-matching and by assessing treatment strategies for recurrence after surgery. The study reviewed data of patients who underwent AR or non-anatomic resection (NAR) for solitary HCC (≤5cm) in two institutions between 2004 and 2017. Surgical outcomes were compared between the two groups in a propensity score-adjusted cohort. The time-to-interventional failure (TIF), defined as the elapsed time from resection to unresectable/unablatable recurrence, also was evaluated. The inclusion criteria were met by 250 patients: 77 patients (31%) with AR and 173 patients (69%) with NAR. In the propensity score-matched populations (AR, 67; NAR, 67), the 5-year recurrence-free survival (RFS) for AR was better than for NAR (62% vs 35%; P=0.005). No differences, however, were found in the 5-year overall survival between the two groups (72% vs 78%; P=0.666). The 5-year TIF rates for the NAR group (60%) also were similar to those for the AR group (66%) (P=0.413). In the cohort of 67 patients, curative repeat resection or ablation therapy was performed more frequently for the NAR patients (42%) than for the AR patients (10%) (P<0.001). For solitary HCC, AR decreases recurrence after the initial hepatectomy. However, aggressive curative-intent interventions for recurrence compensate for the impaired RFS, even for patients undergoing NAR.

Approach to Resectable Biliary Cancers.

Biliary malignancies, although rare, can be some of the most challenging to manage surgically. Intrahepatic cholangiocarcinomas are resectable if there is no evidence of metastatic disease. These tumors are managed with anatomic resection and portal lymphadenectomy when centrally located or multiple in a single lobe. Non-anatomic resection can be performed for solitary peripheral tumors with minimally invasive techniques. It is not our practice to routinely employ neoadjuvant chemotherapy prior to resection of these tumors. Hepatic arterial infusion chemotherapy is utilized at our institution in highly selected patients in the context of an ongoing clinical trial for unresectable tumors. Hilar cholangiocarcinomas, when resectable (i.e., ipsilateral arterial involvement or lack of vascular involvement), are managed with right or left (extended) hepatectomy, caudate resection, and portal lymphadenectomy. Distal cholangiocarcinomas are managed with pancreaticoduodenectomy. Neoadjuvant chemotherapy is not routinely used in our treatment algorithm of extrahepatic cholangiocarcinomas. Nodal involvement and positive margin (R1) resection necessitates adjuvant chemotherapy. Finally, gallbladder carcinoma is managed with radical cholecystectomy, anatomic segment IVb/V resection, and portal lymphadenectomy. Adjuvant chemotherapy is employed routinely amongst patients with T2 or higher tumors and those with positive lymph nodes.

Parenchymal preserving liver resection for centrally located liver tumors: how I do it?

Central liver tumors often require extended hepatectomy or a central hepatectomy with complex biliary reconstructions. Extended resections are prone to higher chances of post-operative liver failure, while the resections mandating reconstructions run a risk of biliary leaks. Non-anatomical liver resections for these centrally located tumors provide a benefit of functional parenchymal preservation but a higher perceived risk of oncological inadequacy. This manuscript is an attempt to showcase author's technique of parenchymal sparing liver resection for central located liver tumor without the need for any biliary reconstruction while ensuring oncological adequacy during the conduct of the procedure.

What is the optimal surgical treatment for hepatocellular carcinoma beyond the debate between anatomical versus non-anatomical resection?

The optimal type of hepatectomy for hepatocellular carcinoma (HCC)-anatomical or non-anatomical resection-remains controversial despite numerous comparative studies. There are common fundamental issues in published studies comparing anatomical resection with non-anatomical resection: (1) confounding by indication, (2) setting primary outcomes, and (3) a lack of a clear definition of non-anatomical resection. This degrades the quality of the comparison of the two types of surgery. To measure the therapeutic effect of hepatectomy, it is essential to understand the accumulated knowledge underlying these issues, such as the mechanism of hepatocellular carcinoma spread, tumor blood flow drainage theory, and the three patterns of hepatocellular carcinoma recurrence: (1) local intrahepatic metastasis, (2) systemic metastasis, and (3) multicentric carcinogenesis recurrence. Based on evidence that the incidence of local intrahepatic metastasis was so low it was almost negligible, the therapeutic effect of anatomical resection on the oncological survival was determined to be similar to that of non-anatomical resection. Recent research progress demonstrating the clinical impact of subclinical dissemination of HCC after surgery may stimulate new debate on the optimal surgical treatment for HCC beyond the comparison of anatomical and non-anatomical resection.

Predicting Intraoperative Difficulty of Open Liver Resections: The DIFF-scOR Study, An Analysis of 1393 Consecutive Hepatectomies From a French Multicenter Cohort.

The aim of this study was to build a predictive model of operative difficulty in open liver resections (LRs). Recent attempts at classifying open-LR have been focused on postoperative outcomes and were based on predefined anatomical schemes without taking into account other anatomical/technical factors. Four intraoperative variables were perceived by the authors as to reflect operative difficulty: operation and transection times, blood loss, and number of Pringle maneuvers. A hierarchical ascendant classification (HAC) was used to identify homogeneous groups of operative difficulty, based on these variables. Predefined technical/anatomical factors were then selected to build a multivariable logistic regression model (DIFF-scOR), to predict the probability of pertaining to the highest difficulty group. Its discrimination/calibration was assessed. Missing data were handled using multiple imputation. HAC identified 2 clusters of operative difficulty. In the "Difficult LR" group (20.8% of the procedures), operation time (401 min vs 243 min), transection time (150 vs.63 minute), blood loss (900 vs 400 mL), and number of Pringle maneuvers (3 vs 1) were higher than in the "Standard LR" group. Determinants of operative difficulty were body weight, number and size of nodules, biliary drainage, anatomical or combined LR, transection planes between segments 2 and 4, 4, and 8 or 7 and 8, nonanatomical resections in segments 2, 7, or 8, caval resection, bilioentric anastomosis and number of specimens. The c-statistic of the DIFF-scOR was 0.822. By contrast, the discrimination of the DIFF-scOR to predict 90-day mortality and severe morbidity was poor (c-statistic: 0.616 and 0.634, respectively). The DIFF-scOR accurately predicts open-LR difficulty and may be used for various purposes in clinical practice and research.

Anatomical resection versus non-anatomical resection for hepatocellular carcinoma: A propensity score matched analysis

The relative benefit of anatomic resection (AR) versus non-anatomic resection (NAR) of hepatocellular carcinoma (HCC) remains controversial. The objective of this study is to review and compare survival outcomes and recurrence rates of HCC according to tumor size and extent of resection. Data of patients with HCC who underwent curative surgical resection between January 1999 and December 2009 from Asan Medical Center were retrospectively reviewed. To compare survival outcomes between AR and NAR, propensity score matching (PSM) was conducted according to tumor size. A total of 986 patients were analyzed; 812 patients received AR and 174 patients underwent NAR. The 5-year OS rate of HCC less than 5 cm was 78.1% and 62.4% in AR and NAR, respectively (p = 0.002). The 5-year RFS rate of HCC less than 5 cm was 48.2% and 36.8% in AR and NAR, respectively (p = 0.017). The 5-year OS rate of HCC greater than or equal to 5 cm was 48.6% and 47.1% in AR and NAR, respectively (p = 0.629). The 5-year RFS rate of HCC greater than or equal to 5 cm was 30.4% and 27.5% in AR and NAR, respectively (p = 0.462). After PSM, the OS and RFS rate of HCC less than 5 cm were significantly better in the AR group. However, in HCC greater than or equal to 5 cm, there were no significant difference between the AR and the NAR group. AR in HCC less than 5 cm decreased the risk of tumor recurrence and improved OS. In HCC with diameter over 5 cm, AR and NAR showed comparable survival outcomes.

Impact of anatomical liver resection for hepatocellular carcinoma: A systematic review and meta-analysis

Although several retrospective studies comparing anatomical liver resection (AR) and non-anatomical liver resection (NAR) for hepatocellular carcinoma (HCC) have been published, the efficacy of anatomic liver resection for HCC remains unclear. This study aimed to compare the oncologic and surgical outcomes of AR and NAR for HCC by performing meta-analysis of published studies. We systemically reviewed the MEDLINE, Embase, and Cochrane Library databases for propensity score matching (PSM) studies compared AR and NAR for HCC. The primary outcome was overall survival (OS) and recurrence free survival (RFS). Secondary outcomes were recurrence patterns and peri-operative outcomes. A total of 19 PSM studies were included. AR was superior to NAR in 3- and 5-year OS (3-year OS hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68-0.91, p = 0.001; 5-year OS HR: 0.83, 95% CI: 0.71-0.95, p = 0.009). AR showed a significantly better 1-, 3-, and 5-year RFS than NAR with low local recurrence rate, intra- and extra-hepatic recurrence (1-year RFS HR: 0.79, 95% CI: 0.69-0.90, p = 0.0005; 3-year RFS HR: 0.81, 95% CI: 0.75-0.87; p = 0.00001; 5-year RFS HR: 0.82, 95% CI: 0.76-0.88, p < 0.00001). In subgroup analyses about tumor with diameter less than 5cm and with microscopic cancer spread, RFS in AR group was significantly better than NAR. However, AR showed comparable 3- and 5-year RFS with NAR group in patients with cirrhotic liver. Also, post-operative overall complications including biliary leakage and hepatic failure were similar between two groups. Our meta-analysis revealed that AR showed better OS and RFS with low local recurrence than NAR especially patients with tumor diameter less than 5 cm and non-cirrhotic liver.

Assessment of Textbook Outcome in Laparoscopic and Open Liver Surgery

Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR). To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis. Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated. Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin. A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate. In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

Laparoscopic Resection for the Treatment of Liver Tumors

Open hepatectomy remains the fundamental and one of the most common surgical techniques for the treatment of primary and secondary liver tumors, but Laparoscopic Liver Resection (LLR) is now gaining more and more importance. The aim of the study was to evaluate the efficacy and safety of laparoscopic resection of liver tumors based on the clinical experience of the authors. LLR was performed in 53 patients (26 women and 27 men). The most common indication for the laparoscopic resection of liver tumors was metastatic colon cancer. We performed 19 non-anatomical (wedge) resections, 11 segmentectomies, 10 anatomical resections, 8 hemihepatectomies, 3 radicalizations due to gallbladder cancer, and 2 liver cyst fenestrations. Simultaneous procedures were performed in 5 cases. The mean operating time for the laparoscopic resection of liver tumors was 307 min. The mean intraoperative blood loss was 270 ml. Complications were reported in 10% of cases. The mean hospitalization time was 7 days. Slightly longer operating time and greater blood loss were found in patients treated with LLR compared to those who had open surgery. Recovery time was shorter in patients who had laparoscopic surgery. Early results of cancer treatment were comparable to those for open surgeries. LLR was associated with lower rates of postoperative complications. Laparoscopic liver resections reduce intraoperative trauma and the number of postoperative complications, and shorten the hospitalization time and recovery. These procedures are safe in cancer patients. A particular advantage of laparoscopic surgery is observed in patients with cirrhosis, the elderly, and patients with coexisting internal diseases.

Video-assisted thoracoscopic surgical wedge resection using multiplanar computed tomography reconstruction-fluoroscopy after CT guided microcoil localization.

BackgroundWhen early‐stage lung cancer is diagnosed, the recommended treatment is anatomical resection using video‐assisted thoracoscopic surgery (VATS) or robotic lobectomy. However, nonanatomical resection, known as wedge resection (WR), which is performed to diagnose pulmonary nodules, can be problematic for clinicians performing VATS or robotic‐assisted thoracic surgery (RATS). The purpose of this study was to evaluate the safety and effectiveness of VATS WR using multiplanar computed tomography reconstruction (CT MPR)‐fluoroscopy after CT guided microcoil localization to achieve complete pulmonary nodule resection.MethodsBetween January 2016 to December 2020, the medical records of patients who underwent CT‐guided microcoil localization for suspicious malignant pulmonary nodules and VATS WR with CT MPR and intraoperative fluoroscopy were retrospectively reviewed.ResultsAll 130 patients successfully underwent CT‐guided localization. The success rate of VATS WR with CT MPR‐intraoperative fluoroscopy was 98.5%. Mean operation time was 58 min (range 50–84 min). The postoperative complication rate was 3.1%, and no major postoperative complications were reported. The mean postoperative length of hospital stay was 4.7 days (range 4–8 days).ConclusionsVATS WR using CT MPR‐fluoroscopy after CT guided microcoil localization is a safe and highly effective approach for complete pulmonary nodule resection. However, even in uniport VATS or recently performed robotic surgery, localization and resection of nonvisible, nonpalpable pulmonary nodules is a challenging problem. Consequently, satisfactory outcomes can be expected if this technique is used for suspicious malignant pulmonary nodule resection.

Long-Term Outcomes of Anatomic Versus Nonanatomic Resection in Hepatocellular Carcinoma Patients with Bile Duct Tumor Thrombus: A Propensity Score Matching Analysis.

Anatomic resection (AR) of the liver is generally recommended in hepatocellular carcinoma (HCC) patients. However, the benefits of AR and nonanatomic resection (NAR) in HCC patients with bile duct tumor thrombus (BDTT) are unknown. This study aimed to compare long-term outcomes of AR and NAR in HCC patients with BDTT after curative resection. A total of 175 consecutive HCC patients with BDTT after curative resection between April 2009 and December 2017 were included. One-to-one propensity score matching (PSM) was performed to minimize the influence of potential confounders. Recurrence-free survival (RFS) and overall survival (OS) were compared between the cohorts. After PSM, 120 patients were analyzed. The AR group had better RFS than the NAR group (P = 0.010). Even though there was no statistically significant difference in OS (P = 0.140, power = 0.33), the 3- and 5-year OS rates in the AR group (52.4% and 44.2%, respectively) were obviously higher than those in the NAR group (35.4% and 30.4%, respectively). When patients were further stratified according to tumor size, better RFS and OS were observed in patients with small (≤ 5 cm) tumors after AR (P < 0.001 and P = 0.004, respectively). Multivariate analysis identified AR (P = 0.024) as an independent favorable prognostic factor for RFS in HCC patients with BDTT. AR is recommended for HCC patients with BDTT, especially in patients with small (≤ 5 cm) tumors.

Liver Resection and role of Extended Histology (LiREcH study) in patients with multifocal colorectal cancer liver metastases

BackgroundThe aim of this study is to assess the correlation between the margin status on the specimen side (Rs) and that from the patient side (base of resection) (Rp) and the influence of positive margins (R1s and R1p) on cancer related outcomes in patients with colorectal liver metastases (CRLM). MethodsIn this prospective study, patients undergoing non-anatomical resection (NAR) of multifocal CRLM, with suspected close resection margins were included. The primary outcome evaluated was the correlation of Rs and Rp. ResultsTwenty-three patients had 89 NARs, and CUSA samples from the base of 36 specimens were analysed. Among 36 specimens where extended histology (EH) was performed, margin status on the specimen side (Rs) was positive in 69.4% (25/36), whereas on the patient side, the margin (Rp) was positive in only 8.3% (3/36) of specimens. On univariate analysis, there was no significant difference in the site-specific recurrence at previous resection with regards to Rs positivity (P = 0.56) and Rp positivity (P = 0.48). ConclusionThere is a poor correlation between Rs and Rp and the local recurrence rates in the liver. These results might further support that tumour biology is more relevant than the margin status in patients with multifocal CRLM.

Impact on Prognosis Following Nonanatomical Resection of Hepatocellular Carcinoma Postoperatively Proven as Micro Portal Vein Tumor Thrombus on Histology

Objective The prognostic impact of intrahepatic recurrence pattern and/or operative procedure (anatomical resection [AR] and nonanatomical resection [NAR]) for hepatocellular carcinoma (HCC) in patients with postoperatively proven portal vein tumor thrombus on histology has not yet been clearly examined. Summary of background data A total of 52 HCC patients who had no visible macroscopic vascular invasion preoperatively and histologically proven portal vein tumor thrombus distal to second-order portal branches after surgery were analyzed. Methods The overall survival and disease-free survival rates were analyzed using the Kaplan-Meier method. The risk factors for intrahepatic recurrence and distant metastasis were analyzed using the log-rank test. Results There was no significant difference in the overall survival rates at 5 years, based on the operative procedure. The disease-free survival rates at 3 years were 59.2% (AR group) and 30.1% (NAR group), respectively, and were statistically significant. Intrahepatic recurrence in the same remnant segment was seen in 5 patients undergoing NAR. These cases developed multiple bilobar recurrences simultaneously, including the same segment, and recurrence only in the same remnant segment was not seen in any case, irrespective of solitary or multiple recurrence. Conclusions Intrahepatic recurrence in the same remnant segment does not influence the disease-free survival rate in patients after NAR. Although AR would be an ideal procedure, the current study suggests NAR can achieve identical outcomes for patients who cannot be considered for AR.

Effectiveness of Anatomical Resection for Small Hepatocellular Carcinoma: a Propensity Score–Matched Analysis of a Multi-institutional Database

BackgroundThe superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score–matched (PSM) analysis. MethodsA total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis. ResultsApplying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33–0.90) for disease-free survival and 0.61 (95% CI, 0.24–1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014). ConclusionsAR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter.

Local lung coagulation post resection: an ex-vivo porcine model

Following non-anatomical resection of lung parenchyma with a Nd:YAG laser, a coagulated surface remains. As ventilation starts, air leakage may occur in this area. The aim of the present study was to investigate, whether additional coagulation either before or after ventilation has an additional sealing effect. Freshly slaughtered porcine heart-lung blocks were prepared. The trachea was connected to a ventilator. Using a Nd:YAG laser (wavelength: 1320 nm, power: 60 W), round lesions (1.5 cm in diameter) with a depth of 1.5 cm were applied to the lung using an 800-μm laser fiber (5 s per lesion). Group 1 (n = 12) was control. Additional coagulation was performed in group 2 (n = 12) without and in group 3 (n = 12) with ventilation restarted. Air leakage (ml) from the lesions was measured. The thickness of each coagulation layer was determined on histological slices. Differences between individual groups were analyzed by one-way ANOVA (significance p < 0.05). After resection, 26.2 ± 2.7 ml of air emerged from the lesions per single respiration in group 1. Air loss in group 2 was 24.6 ± 2.5 ml (p = 0.07) and in group 3 23.7 ± 1.8 ml (p = 0.0098). In comparison to groups 1 and 2 thickness of the coagulation layers in group 3 was significantly increased. After non-anatomical porcine lung resection with a Nd:YAG laser, additional coagulation of the ventilated resection area can reduce air leakage.

Retailoring Donor-Recipient Size Mismatch in Double Lung Transplantation, Non-Anatomical Pulmonary Resections, Gratifying Early Surgical Outcomes

Purpose The uniqueness and immunological complexity, makes double lung transplantation a challenging high end surgical management for end stage lung disease. Finding the ideal donor organ offers a multitude of logistical barriers., and when that happens, a size mismatch should never be an excuse to waddle the opportunity. The objective of this retrospective review was to observe the clinical outcomes of double lung transplant recipients who underwent non anatomical pulmonary resections. Methods Our team had done 67 double lung transplantations in 2019 and 20 double lung transplants in 2020. A significant reduction by volume was possibly because of lesser donor organ availability in a covid inflicted scenario,thereby creating greater momentum to salvage every donor organ available. A total of sixteen recipients (11 in 2019, 5 in 2020)had undergone size reduction to accomodate oversized lungs. We reviewed the data (case series) of all the sixteen patients who had undergone non anatomical pulmonary resections prior to primary chest closure. Results Out of the 87 double lung transplantation recipients, 16 recipients had to undergo size reduction, 10 recipients underwent resections isolated to right lung, the segments resected were the anterior part of middle lobe, and lower lobe basal and posterior segments.6 patients had both right and left lung resections, the lingulae being the resected segment . Linear endovascular stapples were used for resection, enhanced with bovine pericardium or donor pericardium. Fifteen of the recipients had no post-operative air leak, one had trivial air leak that settled with conservative management and did not require an additional intercostal drainage. Conclusion With good prerequisites, non anatomical resection in an oversized donor organ does not add to the morbidity in the short follow up.

Importance of Microvascular Invasion Risk and Tumor Size on Recurrence and Survival of Hepatocellular Carcinoma After Anatomical Resection and Non-anatomical Resection

Purpose: To establish a valid prediction model to prognose the occurrence of microvascular invasion (MVI), and to compare the efficacy of anatomic resection (AR) or non-anatomic resection (NAR) for hepatocellular carcinoma (HCC).Methods: Two hundred twenty-eight patients with HCC who underwent surgical treatment were enrolled. Their hematological indicators, MRI imaging features, and outcome data were acquired.Result: In the multivariable analysis, alpha-fetoprotein >15 ng/mL, neutrophil to lymphocyte ratio >3.8, corona enhancement, and peritumoral hypointensity on hepatobiliary phase were associated with MVI. According on these factors, the AUROC of the predictive model in the primary and validation cohorts was 0.884 (95% CI: 0.829, 0.938) and 0.899 (95% CI: 0.821, 0.967), respectively. Patients with high risk of MVI or those with low risk of MVI but tumor size >5 cm in the AR group were associated with a lower rate of recurrence and death than patients in the NAR group; however, when patients are in the state of low-risk MVI with tumor size >5 cm, there is no difference in the rate of recurrence and death between AR and NAR.Conclusion: Our predictive model for HCC with MVI is convenient and accurate. Patients with high-risk of MVI or low-risk of MVI but tumor size >5 cm executing AR is of great necessity.

Robotic Right Hepatectomy with Portal Vein Thrombectomy for Colorectal Liver Metastasis (with Video)

BackgroundHepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. MethodWe present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. ResultsThe Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retrohepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 min with no transfusion. Pathology conformed the diagnosis with free surgical margins. ConclusionRobotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.

Repeated hepatectomy after ALPPS for recurrence of colorectal liver metastasis: the edge of limits?

BackgroundRepeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described. MethodsPatients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival. ResultsThirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy. ConclusionRepeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.