Number Of Resected Segments Research Articles

Segmentectomy versus lobectomy: does FEV1.0 change accurately reflect the postoperative cardiopulmonary function?

The postoperative respiratory function has been compared between lobectomy and segmentectomy based on the resting spirometric change in many previous studies. However, spirometric change has only been assessed in static conditions, and it is unclear whether it accurately reflects the cardiopulmonary function. We used spirometry and a 6-min walk test to evaluate patients who underwent lobectomy and segmentectomy and examined the changes in heart rate (HR), respiratory rate (RR), and saturation of percutaneous oxygen (SpO2) before and after walking between the two groups. The present study included 24 patients who underwent segmentectomy and 21 who underwent lobectomy. There was no significant difference in the reduction of the median forced expiratory volume in 1s (FEV1.0) after surgery. In the 6-min walk test, the increase in HR and RR after surgery has no significant differences between lobectomy and segmentectomy (HR: p = 0.372 and RR: p = 0.131). However, the two groups showed a significant difference in the reduction of SpO2 (p < 0.001). In addition, correlation analysis found that the more the number of resected segments, the more the reduction of SpO2 with a statistical significance (p = 0.002). Patients who received segmentectomy showed to suppress the reduction of SpO2 with a statistical difference after the 6-min walk test in comparison to those who received lobectomy. These results suggest that segmentectomy has less impact on the cardiopulmonary function and the 6-min walk test is useful for evaluating the postoperative cardiopulmonary function.

Predictive nomograms for postoperative 90-day morbidity and mortality in patients undergoing liver resection for various hepatobiliary diseases.

Postoperative complications affect the long-term survival and quality of life in patients undergoing liver resection. No model has yet been validated to predict 90-day severe morbidity and mortality. The prospective recruitment of patients undergoing liver resection for various indications was performed. Preoperative clinical and laboratory data, including liver stiffness, indocyanine green retention, and intraoperative parameters, were analyzed to develop predictive nomograms for postoperative severe morbidity and mortality. Calibration plots were used to perform external validation. The most common indications in 418 liver resections performed were colorectal metastases (N = 149 [35.6%]), hepatocellular carcinoma (N = 106 [25.4%]), and benign liver tumors (N = 60 [14.3%]). Major liver resections were performed in 164 (39.2%) patients. Severe morbidity and mortality were observed in 87 (20.8%) and 9 (2.2%) of patients, respectively, during the 90-day postoperative period. Post-hepatectomy liver failure was observed in 19 (4.5%) patients, resulting in the death of 4. The independent predictors of 90-day severe morbidity were age (odds ratio:1.02, P= .06), liver stiffness (odds ratio: 1.23, P= .04], number of resected segments (odds ratio: 1.28, P= .004), and operative time (odds ratio: 1.01, P= .01). Independent predictors of 90-day mortality were diabetes mellitus (odds ratio: 6.6, P= .04), tumor size >50 mm (odds ratio:4.8, P= .08), liver stiffness ≥22 kPa (odds ratio:7.0, P= .04), and operative time ≥6 hours (odds ratio: 6.1, P= .05). Nomograms were developed using these independent predictors and validated by testing the Goodness of fit in calibration plots (P= .64 for severe morbidity; P= .8 for mortality). Proposed nomograms would enable a personalized approach to identifying patients at risk of complications and adapting surgical treatment according to their clinical profile and the center's expertise.

Risk factors for long-term decline in post-operative pulmonary function after lung resection.

The study aimed to examine the risk factors for long-term decline in pulmonary function after anatomical resection for lung cancer and the effects of the decrease on survival. We retrospectively examined 489 patients who underwent anatomical resection for lung cancer between 2010 and 2020. Pulmonary function tests were performed preoperatively and at 1, 3, 6 and 12months after surgery. The lower interquartile medians of the reduction rates of forced expiratory volume in 1s and vital capacity at 12months after surgery were taken as the cut-off values of risk factors for the decrease in post-operative pulmonary function. Forced expiratory volume in 1s and vital capacity decreased the most in the first month after surgery and then gradually recovered. Vital capacity continued to increase even after 6months post-surgery, whereas forced expiratory volume in 1s stabilized. Multivariable logistic analysis showed that the number of resected segments (odds ratio, 2.09; 95% confidence interval, 1.12-3.89; P=0.019) was a risk factor for the decrease in forced expiratory volume in 1s at 12months, and the numbers of resected segments (odds ratio, 1.36; 95% confidence interval, 1.13-1.63; P<0.001) and post-operative complications (odds ratio, 2.32; 95% confidence interval, 1.01-5.35; P=0.047) were independent risk factors for decrease in vital capacity. Multivariate cox regression analysis showed that the decrease in vital capacity at 12months was significantly associated with overall survival (hazard ratio, 2.02; 95% confidence interval, 1.24-3.67; P=0.004). Long-term decrease in vital capacity, which was influenced by the number of resected segments and post-operative complications, adversely affected survival.

Computed tomography volumetric analysis for predicting postoperative lung function for segmentectomy.

OBJECTIVESWe compared the computed tomographic (CT) volumetric analysis and anatomical segment counting (ASC) for predicting postoperative forced expiratory volume in 1 s (FEV1) and diffusing capacity for carbon monoxide (DLCO) in patients who had segmentectomy for early-stage lung cancer.METHODSA total of 175 patients who had segmentectomy for lung cancer and had postoperative pulmonary function test were included. CT volumetric analysis was performed by software, which could measure total lung and target segment volume from CT images. ASC and CT volumetric analysis were used to determine predicted postoperative (PPO) values and the concordance and difference of these values were assessed. The relationship between PPO values and actual postoperative values was also investigated.RESULTSThe PPO-FEV1 and PPO-DLCO showed high concordance between 2 methods (concordance correlation coefficient = 0.96 for PPO-FEV1 and 0.95 for PPO-DLCO). There was no significant difference between PPO values as determined by 2 methods (P = 0.53 for PPO-FEV1, P = 0.25 for PPO-DLCO) and actual postoperative values [P = 0.77 (ASC versus actual) and P = 0.20 (CT versus actual) for FEV1; P = 0.41 (ASC versus actual) and P = 0.80 (CT versus actual) for DLCO]. We subdivided the patients according to poor pulmonary function test, the number of resected segments and the location of the resected lobe. All subgroup analyses revealed no significant difference between PPO values and actual postoperative values.CONCLUSIONSBoth CT volumetric analysis and ASC showed high predictability for actual postoperative FEV1 and DLCO in segmentectomy.

Pulmonary function changes after thoracoscopic lobectomy versus intentional thoracoscopic segmentectomy for early-stage non-small cell lung cancer.

BackgroundThoracoscopic segmentectomy is increasingly used in the surgical treatment of early-stage non-small cell lung cancer. However, it remains unclear whether pulmonary function loss after thoracoscopic lung resection is in direct proportion to the number of resected segments, and thus intentional thoracoscopic segmentectomy has the function-preserving advantage over thoracoscopic lobectomy.MethodsIn this prospective observational study, spirometry tests were performed preoperatively and 6 months postoperatively. The observed functional loss was compared with the expected loss estimated by the segment counting method. Resection extent index was introduced as the number of resected segments to total number of segments in the corresponding lobe. Spirometry changes after thoracoscopic lobectomy and intentional thoracoscopic segmentectomy were compared using propensity score matching.ResultsThere were 338 thoracoscopic lobectomies and 321 thoracoscopic segmentectomies. Overall, the observed pulmonary function loss after segmentectomy was significantly less than after lobectomy. But the observed functional loss was significantly greater than the expected loss after segmentectomy. And pulmonary function loss per segment resected was almost doubled after segmentectomy comparing to lobectomy. For segmentectomies with a resection extent index less than 0.5, especially single segmentectomies, pulmonary function loss was significantly less than after corresponding lobectomies. Otherwise, no significant differences in spirometry changes between lobectomies and segmentectomies were detected.ConclusionsPulmonary function loss after thoracoscopic lung resection cannot be accurately evaluated by the number of resected segments. According to the resection extent index, intentional thoracoscopic segmentectomy may help preserve more pulmonary function than thoracoscopic lobectomy only when less than half of the corresponding lobe are resected.

Two-port versus three-port video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: feasibility, postoperative outcome and long-term recurrence rates

BackgroundTwo-port VATS (2-P-VATS) and three-port VATS (3-P-VATS) are well-established techniques for surgical therapy of primary spontaneous pneumothorax (PSP). However, comparisons of both techniques in terms of postoperative outcome and recurrence are limited.MethodsFrom January 2010 to March 2020, we retrospectively reviewed data of 58 PSP patients who underwent VATS in our institution. For statistical analysis, categorical and continuous variables were compared by chi-square test or Fisher’s exact test and the Student´s t-test, respectively. Twenty-eight patients underwent 2-P-VATS and 30 were treated with 3-P-VATS. Operation time, length of hospital stay (LOS), total dose of analgesics per stay (opioids and non-opioids), duration of chest tube drainage, pleurectomy volume (PV), postoperative complications and recurrence rates were compared between both groups.ResultsClinical and surgical characteristics including mean age, gender, Body-Mass-Index (BMI), pneumothorax size, smoking behaviour, history of contralateral pneumothorax, side of pneumothorax, pleurectomy volume and number of resected segments were similar in both groups. The mean operation time, LOS and total postoperative opioid and non-opioid dose was significantly higher in the 3-P-VATS group compared with the 2-P-VATS group. Despite not being statistically significant, duration of chest tube was longer in the 3-P-VATS group compared with the 2-P-VATS group. In terms of postoperative complications, the occurrence of hemothorax was significantly higher in the 3-P-VATS group (3-P-VATS vs. 2-P-VATS; p = 0.001). During a median follow-up period of 61.6 months, there was no significant statistical difference in recurrence rates in both groups (2/28 (16.7%) vs. 5/30 (7.1%); p = 0.274).ConclusionOur data demonstrate that 2-P-VATS is safer and effective. It is associated with reduced length of hospital stay and decreased postoperative pain resulting in less analgesic use.

Midterm survival of imaging-assisted robotic lung segmentectomy for non-small-cell lung cancer.

OBJECTIVESOur goal was to report our midterm results using imaging-assisted modalities with robotic segmentectomies for non-small-cell lung cancer (NSCLC).METHODSThis was a retrospective study of all robotic segmentectomies, with confirmed NSCLC, performed at our general and thoracic surgery unit in the Rouen University Hospital (France), from January 2012 through December 2019. Benign and metastatic lesions were excluded. Data were extracted from the EPITHOR French nationwide database.RESULTSA total of 121 robotic segmentectomies were performed for 118 patients with a median age of 65 (interquartile range: 60, 69) years. The majority had clinical stage T1aN0M0 (71.9%) or T1bN0M0 (13.2%). The mean (standard deviation) number of resected segments was 1.93 (1.09) with 80.2% imaging-assisted segmentectomies. Oriented (according to tumour location) or systematic lymphadenectomy or sampling was performed for 72.7%, 23.1% and 4.1% of patients. The postoperative course was uneventful for 94 patients (77.7%), whereas 34 complications occurred for 27 patients (22.3%), including 2 patients (1.7%) with Clavien-Dindo ≥III complications. The mean thoracic drainage duration was 4.12 days, and the median hospital stay was 4 days (interquartile range: 3, 5) after the operation. The 2-year survival rate was 93.9% (95% confidence interval: 86.4–97.8%). Excluding stage IV (n = 3) and stage 0 tumours (n = 6), the 2-year survival rate was 95.7% (95% confidence interval: 88.4–98.8%) compared to an expected survival rate of 94.0% according to stage-specific survival rates found in a large external reference cohort.CONCLUSIONSImaging-guided robotic-assisted thoracic surgery segmentectomy seems to be useful and oncological with good midterm results, especially for patients with early-stage NSCLC.

COVID-19 After Lung Resection in Northern Italy

We reviewed surgical cases from 4 Thoracic Surgery departments in the Lombardia region of Italy, the area mostly affected by Coronavirus pandemic in Europe, with the aim to describe the impact of COVID-19 on the treatment of thoracic surgical patients. Clinical, radiological and laboratory data from patients who underwent lung resection from December 2019 to March 2020 were retrospectively collected until June 2020. Univariable Cox regression models were estimated to evaluate potential prognostic factors for developing COVID-19 and to investigate postoperative mortality among patients who developed symptomatic COVID-19 infection. We examined data from 107 patients. (74 lobectomies, 32 wedge/segmentectomies and 1 pneumonectomy). Twelve patients developed COVID-19 (Group 1), whereas 95 patients were not infected (Group 2). In Group 1, 6 patients (50%) died from complications related to infection; in Group 2, one patient (1%) died because of non-COVID-19-related causes. Median days from surgery to first symptoms, CT confirmation, clinical confirmation and PCR positivity was 48.1, 54.3, 55.1, and 55.2 respectively. At univariable analysis, DLCO/VA% (P = 0.008), duration of the surgery (P = 0.009), smoking history (pack/year) (P < 0.001), BMI (P< 0.001) and number of segments resected (P = 0.010) were associated with COVID-19 onset. Moreover, CCI (P < 0.001), DLCO/VA% (P = 0.002), cigarette pack/year (P < 0.001), BMI (P < 0.001) and COVID-19 (P < 0.001) were associated with death. Patients who undergo lung resection and then develop symptomatic COVID-19 infection are at higher risk of developing severe respiratory complications and postoperative death. Insidious symptoms’ onset may lead to a delay in diagnosis. We suggest two mitigating strategies: (1) Improve symptoms surveillance and isolation during recovery period, (2) Be aware of a potential greater risk of developing symptomatic COVID-19 and death correlated with elevated CCI, BMI, smoking history, DLCO/VA%, number of resected segments and duration of surgery.

Prevention of Liver Failure in Extended Hepatic Resection

Background. Postoperative failure is a major cause of adverse outcomes in extensive liver resection. Post-resection liver failure requires intensive, including extracorporeal, care. Issues in correcting liver failure warrant novel approaches to prevent severe cases.Materials and methods. A retrospective analysis of 228 various-extent liver resections included minor (55.7 %), major (26.8 %) and extended (17.5 %) operations for malignant, benign and parasitic liver lesions. The post-resection liver failure rate has ben graded according to ISGLS.Results and discussion. Postoperative hepatic failure developed in 58 (25.4 %) cases, including 5 of 127 minor (3.9 %) resections, 18 major (29.5 %) and 35 of 40 extended resections (87.5 %). Mild class A liver failures were reported in 12.3 %, and severe classes B and C — in 9.2 % and 3.9 % cases, respectively.CT volumetry in place of the number of resected segments is suggested as a criterion to grade the expected post-resection residual liver, with &gt;70 % defining a minor, 36–70 % — major and 25–35 % — extended expected residual liver.A two-staged extended hepatic resection approach is proposed to reduce postoperative liver failure, with vascular radiology-guided right portal vein embolisation (RPVE) or associating liver partition and portal vein ligation (ALPPS) at stage 1.A comparison of extended hepatic resection outcomes (n = 40) showed a significantly higher rate and severity of liver failure in single- vs. two-staged operations (p &lt; 0.05).Conclusion. Liver failure is a leading cause of death in major and extended hepatic resection. Preoperative CT volumetry allows a more accurate volumetric control of expected post-resection residual liver. Two-staged extended hepatic resection can reliably reduce the rate and severity of postoperative liver failure.

Perioperative risk factors of bleeding in extensive liver resections

To study the risk factors of severe blood loss in extensive liver resections, consequences of hemorrhagic problems and their correction. The study included 374 patients. Group 1 comprised 282 patients (118 men and 164 women aged 54.1±0.7 years) who underwent surgery between 2000 and 2012. Group 2 included 92 patients (34 women and 58 men aged 53.6±1.3 years) operated on for the period 2013-2019. Technical equipment for mobilization and dissection of hepatic parenchyma has fundamentally changed for the period 2013-2019. This processes reduced blood loss by more 50% and consumption of donor blood components (red blood cells by 2.8 times, FFP by 1.8 times). Compression of hepatoduodenal ligament (Pringle maneuver) and tumor type did not affect intraoperative blood loss. Neoplasms over 10 cm increased blood loss. An increase in the number of resected segments by 2 times contributed to increase of blood loss by 2.7 times. Body mass index >25 kg/m2 was also associated with higher blood loss.

The preoperative fibrosis score 4 predicts posthepatectomy liver failure in patients with hepatocellular carcinoma

Introduction and ObjectivesThe fibrosis score 4 (FIB-4) has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. This study investigates the impact of preoperative FIB-4 on postoperative liver failure of patients with hepatocellular carcinoma (HCC). Materials and methodsData from 205 patients who underwent curative resection for HCC were retrospectively analyzed. The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the FIB-4. Univariate analysis and multivariate analysis were performed to identify risk factors for postoperative liver failure. The clinical outcomes were compared between patients with high FIB-4 and low FIB-4. ResultsThe optimal cutoff value of the FIB-4 was set at 5.92 for postoperative liver failure according to ROC curve. By univariate and multivariate analysis, the number of resected segments, FIB-4, and model for end-stage liver disease score were identified as independent risk factors for postoperative liver failure. Patients with preoperative FIB-4>5.92 had poorer liver function and higher occurrence of postoperative liver failure. ConclusionsPreoperative FIB-4 was associated with postoperative liver failure. Patients with preoperative FIB-4>5.92 carry a high risk of postoperative liver failure.

Comparison of the Extent Classification and the New Complexity Classification of Hepatectomy for Prediction of Surgical Outcomes: a Retrospective Cohort Study

BackgroundIn predicting the risk for posthepatectomy complications, hepatectomy is traditionally classified into minor or major resection based on the number of resected segments. Recently, a new hepatectomy complexity classification was proposed. This study aimed to compare the value of the traditional and that of the new classification in perioperative outcomes prediction. MethodsDemographics, perioperative laboratory tests, intraoperative and postoperative outcomes, and follow-up data of patients with hepatocellular carcinoma who underwent liver resection were retrospectively analyzed. ResultsA total of 302 patients were included in our study. Multivariable analysis of intraoperative variables showed that the complexity classification could independently predict the occurrence of blood loss > 800 mL, operation time > 4 h, intraoperative transfusion, and the use of Pringle’s maneuver (all p < 0.05). For postoperative outcomes, the high-complexity group was independently associated with severe complications, and hepatic-related complications (all p < 0.05); the traditional classification was independently associated only with posthepatectomy liver failure (PHLF) (p = 0.004). ConclusionsComplexity classification could be used to assess the difficulty of surgery and was independently associated with postoperative complications. The traditional classification did not reflect operation complexity and was associated only with PHLF.

Fast-track rehabilitation following video-assisted pulmonary sublobar wedge resection: A prospective randomized study.

BACKGROUND:Postoperative morbidity and inhospital length of stay are considered major determinants of total health care expenditure associated with thoracic operations. The aim of this study was to prospectively evaluate the role of video-assisted thoracic surgery (VATS) compared to mini-muscle-sparing thoracotomy in facilitating early recovery and hospital discharge after pulmonary sublobar wedge resections.PATIENTS AND METHODS:A total number of 120 patients undergoing elective pulmonary sublobar wedge resection were randomly assigned to VATS (n = 60) or mini-muscle-sparing thoracotomy (n = 60). The primary endpoint was time to hospital discharge. Postoperative complications, cardiopulmonary morbidity and 30-day mortality served as secondary endpoints.RESULTS:Patients' baseline demographic and clinical data did not differ among study arms as well as the number of pulmonary segments resected and the morphology of the nodular lesions. Total hospital stay was significantly shorter in patients assigned to the thoracoscopic technique as opposed to those who were operated using the mini-muscle-sparing thoracotomy approach (4 ± 0.6 versus 4.4 ± 0.6 days respectively, P = 0.006). Multivariate analysis revealed that VATS approach was inversely associated with longer inhospital stay whereas the number of resected segments was positively associated with an increased duration of hospitalization. Patients in the VATS group were less likely to develop atelectasis (≥1 lobe) compared to those who underwent thoracotomy (0% versus 6.7% respectively, P = 0.042). Kaplan-Meier analysis revealed similar 30-day mortality rates in both study arms (Log-rank P = 0.560).CONCLUSION:VATS was associated with shorter duration of hospitalization positively affecting the patients' quality of life and satisfaction. Significant suppression of the total cost of recovery after thoracoscopic pulmonary resections is expected.

Prediction of postoperative dyspnea and chronic respiratory failure

BackgroundEven among patients considered to be functionally eligible for major lung resection, some experience postoperative dyspnea. Based on our previous study with quantitative computed tomography (CT), we hypothesized that postoperative dyspnea is associated with the collapse of the remaining lung, and thus, prediction of the postoperative lung volume may contribute to risk assessment for postoperative dyspnea. MethodsWe measured the emphysematous lung volume and functional lung volume (FLV) separately on whole lung CT using an image analysis software in 290 patients undergoing major lung resection for cancer between January 2006 and December 2012. The postoperative FLV was predicted by a stepwise multiple regression analysis. ResultsFourteen patients complained of postoperative dyspnea (complicated group), five of them presented with chronic respiratory failure. The postoperatively measured FLV was significantly lower in the complicated group than in the control group (P < 0.01). The postoperative FLV could be calculated using preoperative variables, including the forced vital capacity, number of resected segments, FLV, and emphysematous lung volume. The predicted postoperative FLV was significantly lower in the complicated group than in the control group (P < 0.01, area under the curve = 0.78; sensitivity 86%; specificity 73%). The predicted postoperative FLV was also useful in distinguishing complicated patients from matched-control patients who had similar preoperative pulmonary function (P = 0.02). ConclusionsPostoperative dyspnea is likely accompanied by a collapse of the remaining lung. Quantitative assessment of the lung morphology on preoperative CT is useful to screen for patients at risk of postoperative dyspnea.

Impact of future remnant liver volume on post-hepatectomy regeneration in non-cirrhotic livers.

Objective: The purpose of the study is to detect if some parameters can be considered as predictors of liver regeneration in two different patient populations composed of in living donors for adult to adult living donor liver transplant and patients with hepatic malignancies within a single institution.Summary Background Data: Preoperative multi-detector computed tomography volumetry is an essential tool to assess the volume of the remnant liver.Methods: A retrospective analysis from an ongoing clinical study on 100 liver resections, between 2004 and 2010. Seventy patients were right lobe living donors for liver transplantation and 30 patients were resected for treatment of tumors. Pre-surgical factors such as age, weight, height, body mass index (BMI), original liver volume, future remnant liver volume (FRLV), spleen volume, liver function tests, creatinine, platelet count, steatosis, portal vein embolization, and number of resected segments were analyzed to evidence potential markers for liver regeneration.Results: Follow-up period did not influence the amount of liver regenerated: the linear regression evidenced that there is no correlation between percentage of liver regeneration and time of follow-up (p = 0.88). The pre-surgical variables that resulted markers of liver regeneration include higher preoperative values of BMI (p = 0.01), bilirubin (p = 0.04), glucose (p = 0.05), and gamma-glutamyl transpeptidase (p = 0.014); the most important association was revealed regarding the lower FRLV (p < 0.0001) and percentage of liver regeneration. The stepwise regression revealed a strong impact of FRLV (p < 0.0001) on the other predictor variables.Conclusion: Liver regeneration follows similar pathway in living donor and in patients resected for cancer. Small FRLV tends to regenerate more and faster, confirming that a larger resections may lead to a greater promotion of liver regeneration in patients with optimal conditions in terms of body habitus, preoperative liver function tests, and glucose level.

An accurate predictor of liver failure and death after hepatectomy: A single institution’s experience with 478 consecutive cases

To establish a reliable definition of postoperative liver failure (PLF) and allow the prediction of outcomes after hepatectomy. The clinical data of 478 consecutive patients who underwent hepatectomy were retrospectively analyzed. The examined prognostic factors included the ratio of total bilirubin (TBIL) on postoperative day (POD) X to TBIL on POD 1 (TBIL-r1) and the ratio of the international normalized ratio (INR) on POD X to the INR on POD 1 (INR-r1) for PODs 3, 5 and 7. Student's t test, the χ(2) test, logistic regression, survival analysis and receiver operating curve analysis were used to evaluate risk factors and establish the definition of postoperative liver failure (PLF). Fourteen patients (2.9%) died of liver failure within 3 mo of surgery. Significant differences were found between patients who died of liver failure and the remaining patients in terms of TBIL-r1 and INR-r1 on PODs 3, 5 and 7. The combination of TBIL-r1 and INR-r1 on POD 5 showed strong predictive power for liver failure-related death (sensitivity 92.9% and specificity 90.1%). The hepatic damage score (HDs), which was derived from TBIL-r1 and INR-r1, was used to define the degree of metabolic functional impairment after resection as mild (HDs = 0), reversible hepatic "dysfunction" (HDs = 1) or fatal hepatic failure (HDs = 2). Furthermore, the indocyanine green retention rate at 15 min (ICG-R15) and the number of resected segments (RSs) were identified as independent predictors of the HDs. A linear relationship was found between ICG-R15 and RSs in the HDs = 2 group. The regression equation was: RSs = -0.168 × ICG-R15 + 5.625 (r (2) = 0.613, F = 14.257, P = 0.004). PLF can be defined by the HDs, which accurately predicts liver failure-related death after liver resection. Furthermore, the ICG-R15 and RSs can be used as selection criteria for hepatectomy.

Volumetric Gain of the Liver after Major Hepatectomy in Obese Patients

The objective was to determine the liver volumetric recovering capacity and postoperative course after major hepatectomy in obese patients through a case-matched study. In literature, the impact of obesity on liver recovering has been analyzed only indirectly in terms of morbimortality but never through volumetric assessment. Between 2005 and 2011, 42 patients with body mass index (BMI) 30 or higher (Ob group) underwent major hepatectomy and were matched with 42 patients with BMI 25 or lower (NonOb group) on the magnitude of resection (number of resected segments ±1, remnant liver volume to total liver volume, RLV/TLV, ±5%). The RLV was measured on computed tomographic slices preoperatively and postoperatively at 1 month (RLV-1M) for all patients and within 3 to 12 months in 42 paired patients (median = 6 months, RLV-6M). Considering hepatomegaly in Ob group, RLV was also normalized to body weight (RLVBWR). The liver volumetric gain was expressed as a relative increase [(RLV-1M - RLV)/RLV] or increase in RLVBWR. The Ob and NonOb groups were comparable regarding clinicopathological data, except for arterial hypertension (48% vs 19%; P = 0.005), mean steatosis (24% vs 10%; P = 0.03), and fibrosis incidence (33% vs 10%; P = 0.008). Ob group showed longer operative time and higher blood losses. There were no intergroup differences in liver failure (both 7.1%) and 90-day morbimortality. Despite comparable RLV/TLV (38.1% vs 37.7%; P = 0.13), the relative liver volumetric gain at 1 month was significantly lower in Ob group (+93% vs +115%; P = 0.002), as well as RLVBWR increase (+0.59% vs +0.79%; P < 0.001). The RLV-1M represented 66.2% of initial TLV in Ob group compared with 73.8% (P = 0.005) in NonOb group. This delay in relative volumetric gain persisted at 6 months (+105.4% vs +137.6%; P = 0.009), the RLV-6M representing 71.2% vs 82.4% of initial TLV (P = 0.014). In a methodologically robust trial in the first cohort reported up to date, the regenerative response in obese patients was comparatively slower based on their initial TLV or body weight.

Radiologic evaluation for volume and weight of remnant lung in living lung donors

Living-lung donors lose pulmonary function of a right or left lower lobe in exchange for a noble donation; however, Chen and colleagues reported postoperative pulmonary function of the donors was significantly better than the estimated values. The purpose of this study was to investigate if the improvement of postoperative pulmonary function is associated with hypertrophic phenomena of remnant lung. A total of 35 patients who underwent a right or left lower lobectomy for living-donor lobar lung transplantation in Kyoto University Hospital from 2008 to 2011 were evaluated by means of spirometry (forced vital capacity, forced expiratory volume in 1 second, and diffusing capacity for carbon monoxide), and computed tomography scans both before and 1 year after the surgery. Postoperative predictions of pulmonary function and radiologic parameters were made based on the number of resected segments. The average radiologic density of the lung was determined as follows: (mean computed tomography number + 1000)/1000, and weight of the lung was calculated as follows: lung volume (mL)×average radiologic lung density (g/mL). The radiologic analysis was performed on both the surgical and contralateral sides. Postoperative forced vital capacity, forced expiratory volume in 1 second, and diffusing capacity for carbon monoxide were significantly higher than estimated values by 17.3% ± 10.2% (P<.0001), 14.7% ± 10.2% (P<.0001), and 10.9% ± 16. % (P<.002), respectively. Postoperative lung volume and weight of the surgical side were significantly higher than estimated values by 54.4% ± 30.4% (P<.0001) and 28.1% ± 15.7% (P<.0001), respectively. On the contralateral side, the postoperative lung volume was significantly higher than the estimated value by 12.6% ± 15.3% (P<.0001), but postoperative weight was comparable with the estimated value (-2.3% ± 8.8%; P=.07). Hypertrophic change of the ipsilateral remnant lung may be recognized in living lung donors.

Detection of Restored Lung by Novel Radiologic Parameter in Living Lobar Lung Transplant Donors

Purpose Postoperative compensatory lung growth (CLG) after lung resection has been established in animal models. However, detecting CLG in clinical patients is limited. Our purpose was to determine CLG by evaluating preoperative and postoperative “estimated lung weight (ELW)” in living lobar lung transplant donors. Methods and Materials A total of 18 consecutive patients who underwent a right or left lower lobectomy as a living donor for lung transplantation from 2008 to 2010 were selected. The 18 patients were evaluated by spirometry, CT volumetry, and mean CT numbers (Hounsfield Units) both before and one year after surgery. “ELW” was calculated by multiplying lung volume (ml) and estimated mean lung density (g/ml): density = (mean CT number + 1000) / 1000. All parameters were evaluated by “%postoperative values”: actual postoperative values / predicted post operative values (%); predicted values were based on the number of resected segments. [figure 1] Results The predicted postoperative values of spirometry underestimated the actual values and the differences were significant (forced vital capacity, p<0.001, forced expiratory volume in 1 second, p<0.001 and diffusing capacity for carbon monoxide, p=0.002). The cohort had significantly larger % postoperative lung volumes (152±31.5%, p<0.001) and “ELW” (126±15.2%) than the predicted values on the surgical side. Conclusions Restored lung function, volume and quantity after major lung resection in living lobar lung transplant donors was revealed by the novel radiologic parameter. Major lung resection may trigger CLG on the surgical side that can be clinically evaluated by the “ELW.”

Laparoscopic resection vs. open liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: a case-matched study

Studies that compare laparoscopic to open liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients are rare and may have suffered from low patient numbers. This work was designed to determine the impact of laparoscopic resection on postoperative and long-term outcomes in a large series of cirrhotic patients with hepatocellular carcinoma (HCC) compared with open resection. From 2002 to 2009, 36 patients with chronic liver disease with complicating HCC were selected for laparoscopic resection (laparoscopic group, LG). The outcomes were compared with those of 53 patients who underwent open hepatectomy (open group, OG) during the same period in a matched-pair analysis. The two groups were similar in terms of tumor number and size and number of resected segments. Morbidity and mortality rates were similar in the two groups (respectively 25 and 0% in LG vs. 35.8 and 7.5% in OG; p = 0.3). Severe complications were more frequent in OG (13.2%) than in LG (2.8%; p = 0.09). Despite similar portal hypertension levels, complications related to ascites (namely evisceration or variceal bleeding) were fatal in 4 of 12 affected patients in OG but 0 of 5 cases in LG (p = 0.2). The mean hospitalization durations were 6.5 ± 2.7 days and 9.5 ± 4.8 days in LG and OG, respectively (p = 0.003). The surgical margins were similar in the two groups. Although there was a trend toward better 5-year overall survival in LG (70 vs. 46% in OG; p = 0.073), 5-year disease-free survival was similar (35.5 vs. 33.6%). Laparoscopic resection of HCC in patients with chronic liver disease has similar results to open resection in terms of postoperative outcomes, surgical margins, and long-term survival.