Parenchymal-sparing Hepatectomy Research Articles

Tunnel hepatectomy: A review of the parenchymal-sparing technique in colorectal liver metastasis and operative video

Introduction: Surgery of colorectal liver metastases (CRLM) has evolved over the past decades from an interest mainly focused on oncological margins to a new surgical policy known as parenchymal sparing hepatectomy (PSH). Contrary to anatomical resection (AR), this new approach combines the well-known issue of curative resections (R0 resections) in tumor removal with a new doctrine, reducing the unnecessary sacrifice of healthy parenchyma as much as possible (salvageability). Case Report: We report the case of a 60-year-old man diagnosed with rectal adenocarcinoma accompanied by seven synchronous bilobar liver metastases, including two closely situated metastases. The first was located in liver segment VIII, whereas the second was positioned between segments VIII and IV, just beneath the middle hepatic vein (MHV). In order to resect these two lesions without sacrificing the middle hepatic vein and preserving as much hepatic parenchyma as possible, we have chosen a conservative resection approach, the tunnel hepatectomy (TH). Conclusion: Parenchymal sparing hepatectomy is the recommended approach in CRLM disease. Beyond the need to ensure healthy oncological margins, every surgeon should pay special attention to preserving hepatic parenchyma. Therefore, 3D modeling of the liver and its lesions appear to be a great assistance before any sophisticated surgical intervention to ensure the most conservative surgery possible. And for patients with deep liver metastases having complex relationships, TH seems to be a suitable technique.

Parenchymal-sparing hepatectomy is associated with a higher rate of positive margins than single-stage major hepatectomy but not higher recurrence rate in patients with five or more bilateral colorectal liver metastases

Parenchymal-sparing hepatectomy is associated with a higher rate of positive margins than single-stage major hepatectomy but not higher recurrence rate in patients with five or more bilateral colorectal liver metastases

Outcomes of different parenchymal-sparing hepatectomies in patients with colorectal liver metastases and prognostic impact of peritumoral imaging features.

Parenchymal-sparing hepatectomy (PSH) is recommended in patients with colorectal liver metastases (CRLM). Based on the principle of PSH, to investigate the impact of anatomical resection (AR) and non-anatomic resection (NAR) on the outcome of CRLM and to evaluate the potential prognostic impact of three peritumoral imaging features. Fifty-six patients who had abdominal gadoxetic acid-enhanced magnetic resonance imaging (MRI) before CRLM surgery were included in this retrospective research. Peritumoral early enhancement, peritumoral hypointensity on hepatobiliary phase (HBP), and biliary dilatation to the CRLM at MRI were evaluated. Survival estimates were calculated using the Kaplan-Meier method, and multivariate analysis was conducted to identify independent predictors of liver recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS). NAR had a lower 3-year LRFS compared with AR (36.6% vs. 78.6%, p = 0.012). No significant differences were found in 3-year RFS (34.1% vs. 41.7%) and OS (61.7% vs. 81.3%) (p > 0.05). In NAR group, peritumoral early enhancement was associated with poor LRFS (p = < 0.001, hazard ratio [HR] = 6.260; 95% confidence interval [CI], 2.322,16.876]) and poor RFS (p = 0.035, HR =2.516; 95% CI, 1.069,5.919). No independent predictors of CRLM were identified in the AR group. In patients with CRLM, peritumoral early enhancement was a predictor of LRFS and RFS after NAR according to the principle of PSH.

Locoregional treatment for colorectal liver metastases aiming for precision medicine.

In patients with colorectal liver metastases (CLM), surgery is potentially curative. The use of novel surgical techniques and complementary percutaneous ablation allows for curative-intent treatment even in marginally resectable cases. Resection is used as part of a multidisciplinary approach, which for nearly all patients will include perioperative chemotherapy. Small CLM can be treated with parenchymal-sparing hepatectomy (PSH) and/or ablation. For small CLM, PSH results in better survival and higher rates of resectability of recurrent CLM than non-PSH. For patients with extensive bilateral distribution of CLM, two-stage hepatectomy or fast-track two-stage hepatectomy is effective. Our increasing knowledge of genetic alterations allows us to use them as prognostic factors alongside traditional risk factors (e.g. tumor diameter and tumor number) to select patients with CLM for resection and guide surveillance after resection. Alteration in RAS family genes (hereafter referred to as "RAS alteration") is an important negative prognostic factor, as are alterations in the TP53, SMAD4, FBXW7, and BRAF genes. However, APC alteration appears to improve prognosis. RAS alteration, increased number and diameter of CLM, and primary lymph node metastasis are well-known risk factors for recurrence after CLM resection. In patients free of recurrence 2 y after CLM resection, only RAS alteration is associated with recurrence. Thus, surveillance intensity can be stratified by RAS alteration status after 2 y. Novel diagnostic instruments and tools, such as circulating tumor DNA, may lead to further evolution of patient selection, prognostication, and treatment algorithms for CLM.

Safety and Feasibility of Laparoscopic Parenchymal-Sparing Hepatectomy for Lesions with Proximity to Major Vessels in Posterosuperior Liver Segments 7 and 8

Laparoscopic parenchymal-sparing hepatectomy (PSH) for lesions with proximity to major vessels (PMV) in posterosuperior segments (PSS) has not yet been sufficiently examined. The aim of this study is to examine the safety and feasibility of laparoscopic PSH for lesions with PMV in PSS 7 and 8. We retrospectively reviewed the outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for PSS lesions and focused on patients who underwent laparoscopic PSH for lesions with PMV in PSS. Blood loss was lower in the LLR group (n = 110) than the OLR group (n = 16) (p = 0.009), and no other short-term outcomes were significantly different. Compared to the pure LLR group (n = 93), there were no positive surgical margins or complications in hand-assisted laparoscopic surgery (HALS) (n = 17), despite more tumors with PMV (p = 0.009). Regarding pure LLR for one tumor lesion, any short-term outcomes in addition to the operative time were not significantly different between the PMV (n = 23) and no-PMV (n = 48) groups. The present findings indicate that laparoscopic PSH for lesions with PMV in PSS is safe and feasible in a matured team, and the HALS technique still plays an important role.

Modern trends in minimally invasive versus open hepatectomy for colorectal liver metastasis: an analysis of ACS-NSQIP.

Surgical resection of colorectal liver metastasis (CRLM) provides the best opportunity for prolonged survival. Eligibility for metastasectomy has expanded with technical advancements including parenchymal-sparing hepatectomy (PSH). Meanwhile, enthusiasm for minimally invasive surgery (MIS) has increased, though this approach may be preferentially utilized for technically straightforward cases. The purpose of this study is to characterize modern trends in open versus MIS approaches to partial hepatectomy and anatomic hepatectomy for CRLM within a nationwide cohort. The American College of Surgeons' National SurgicalQuality Improvement Program (ACS-NSQIP) was used to investigate trends in MIS versus open hepatectomy for CRLM from 2015 to 2019. We examined baseline clinicopathologic and disease-related characteristics and compared trends in treatments over the study period. A total of 7457 patients undergoing hepatectomy for CRLM were identified (1367 MIS, 6090 open). Patients had similar clinicopathologic features between the two groups. Patients undergoing MIS resection less frequently received neoadjuvant therapy (51.1% vs 64.0%, p < 0.001) or concurrent intraoperative ablation (15.0% vs 21.3%, p < 0.001). Patients with tumors < 2cm (34.9% vs 26.8%, p < 0.001) or only one to two tumors (82.8% vs 65.0%, p < 0.001) more commonly underwent MIS. MIS and open partial hepatectomies both significantly increased over the study period, but open partial hepatectomy increased at a greater rate than MIS (p < 0.001). Rates of anatomic resections have remained the same, with a greater proportionperformed using an open approach (34.9% vs 16.4%, p < 0.001). Rates ofoperations consisting of > 1 concurrent partial hepatectomy are stable, but significantly more likely to be performed open (p < 0.001). Hepatectomy for CRLM has increased from arisein partial hepatectomy, potentially translating to increased use of PSH. Current trends suggest MIS approaches appear to be increasing, but selectively implemented for patients with less technically demanding disease characteristics. Educational efforts should be directed towards increased dissemination of parenchymal-sparing MIS techniques for more complex resections.

Parenchymal-sparing hepatectomy for colorectal liver metastases reduces postoperative morbidity while maintaining equivalent oncologic outcomes compared to non-parenchymal-sparing resection

BackgroundModern chemotherapy and repeat hepatectomy allow to tailor the surgical strategies for the treatment of colorectal liver metastases (CRLM). This study addresses the hypothesis that parenchymal-sparing hepatectomy reduces postoperative complications while ensuring similar oncologic outcomes compared to the standardized non-parenchymal-sparing procedures. MethodsClinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2019 at a hepatobiliary center in Switzerland were assessed. Patients were stratified according to the tumor burden score [TBS2 = (maximum tumor diameter in cm)2 + (number of lesions)2)] and were dichotomized in a lower and a higher tumor burden cohort according to the median TBS. Postoperative outcomes, overall survival (OS) and recurrence-free survival (RFS) of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing non-PSR. ResultsDuring the study period, 153 patients underwent liver resection for CRLM with curative intent. PSR was performed in 79 patients with TBS <4.5, and in 42 patients with TBS ≥4.5. Perioperative chemotherapy was administered in equal rates in both groups (PSR vs. non-PSR) both in TBS ≥4.5 and TBS <4.5. In patients with lower tumor burden (TBS <4.5), PSR was associated with lower overall complication rate (15.2% vs. 46.2%, p = 0.009), a trend for lower major complication rate (8.9% vs. 23.1%, p = 0.123), and shorter length of hospital stay (5 vs. 9 days, p = 0.006) in comparison to non-PSR. For TBS <4.5, PSR resulted in equivalent 5-year OS (48% vs. 39%, p = 0.479) and equivalent 5-year RFS rates (44% vs. 29%, p = 0.184) compared to non-PSR. For TBS ≥4.5, PSR resulted in lower postoperative complication rate (33.3% vs. 63.2%, p = 0.031), a trend for lower major complication rate (23.8% vs. 42.2%, p = 0.150), lower length of hospital stay (6 vs. 9 days, p = 0.005), equivalent 5-year OS (29% vs. 22%, p = 0.314), and equivalent 5-year RFS rates (29% vs. 18%, p = 0.156) compared to non-PSR. Among all patients treated with PSR, patients undergoing minimal-invasive hepatectomy had equivalent 5-year OS (42% vs. 37%, p = 0.261) and equivalent 5-year RFS (34% vs. 34%, p = 0.613) rates compared to patients undergoing open hepatectomy. ConclusionsPSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay, and equivalent oncologic outcomes compared to non-PSR, independently of tumor burden. Our findings suggest that minimal-invasive PSR should be considered as the preferred method for the treatment of curatively resectable CRLM, if allowed by tumor size and location.

Parenchymal-sparing hepatectomy with hepatic vein resection and reconstruction

Background Hepatectomy remains the most important treatment modality for most malignant liver tumors. Vascular involvement stays a reason for unresectability or major parenchymal resection. A possible way to avoid this is parenchymal-sparing hepatectomy (PSHX) with vascular resection and reconstruction (HVRR). In this article, we aim to demonstrate the specific role of this technique in avoiding post-hepatectomy liver failure (PHLF). Methods A retrospective analysis of 10 patients who underwent HVRR was conducted. 99mTechnetium-mebrofenin hepatobiliary scintigraphy (HBS) was used to predict the future liver remnant function (FLRF). Calculations were made for each patient to compare HVRR and major hepatectomy (with or without portal vein embolization). Results In our cohort, there was no perioperative mortality. Two patients suffered a Clavien–Dindo grade 3a complication and none had clinically significant PHLF. Estimated FLRF was significantly higher in HVRR compared to major hepatectomy after portal vein embolization (p < .005). Conclusions Instead of focusing on inducing liver remnant hypertrophy, preserving parenchyma through HVRR can be an interesting treatment strategy. It can be performed with an acceptable operative risk. Calculations of FLRF (using HBS) suggest that this approach is able to reduce the risk for PHLF and related morbidity or mortality.

Parenchymal-sparing hepatectomy for colorectal liver metastases reduces postoperative morbidity while maintaining equivalent oncologic outcomes compared to non-parenchymal-sparing resection

Abstract Objective Modern chemotherapy and repeat hepatectomy allow to tailor the surgical strategies for the treatment of colorectal liver metastases (CRLM). This study addresses the hypothesis that parenchymal-sparing hepatectomy reduces postoperative complications while ensuring similar oncologic outcomes compared to the standardized non-parenchymal-sparing procedures. Methods Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2019 at a major hepatobiliary center in Switzerland were assessed. Patients were stratified according to the tumor burden score [TBS2 = (maximum tumor diameter in cm)2 + (number of lesions)2)] and were dichotomized in a lower and a higher tumor burden cohort according to the median TBS. Postoperative outcomes, overall survival (OS) and disease-free survival (DFS) of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing non-PSR. Results During the study period, 153 patients underwent liver resection for CRLM with curative intent. PSR was performed in 79 patients with TBS &amp;lt; 4.5, and in 42 patients with TBS ≥ 4.5. In patients with lower tumor burden (TBS &amp;lt; 4.5), PSR was associated with lower complication rate (15.2% vs. 46.2%, p = 0.009), and shorter length of hospital stay (5 vs. 9 days, p = 0.006) in comparison to non-PSR. For TBS &amp;lt; 4.5, PSR resulted in equivalent 5-year OS (48% vs. 39%, p = 0.479) and equivalent 5-year DFS rates (DFS, 44% vs. 29%, p = 0.184) compared to non-PSR. For TBS ≥ 4.5, PSR resulted in lower postoperative complication rate (33.3% vs. 63.2%, p = 0.031), lower length of hospital stay (6 vs. 9 days, p = 0.005), equivalent 5-year OS (29% vs. 22%, p = 0.314), and equivalent 5-year DFS rates (29% vs. 22%, p = 0.896) compared to non-PSR. Among all patients treated with PSR, patients undergoing minimal-invasive hepatectomy had equivalent 5-year OS (42% vs. 37%, p = 0.261) and equivalent 5-year DFS (34% vs. 34%, p = 0.613) rates compared to patients undergoing open hepatectomy. Conclusion PSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay, and equivalent oncologic outcomes compared to non-PSR independently from tumor burden. Our findings suggest that minimal-invasive PSR should be considered as the preferred method for the treatment of curatively resectable CRLM if allowed by tumor size and location.

Laparoscopic parenchymal-sparing hepatectomy

In their recent meta-analysis, Kalil et al . suggested that laparoscopic parenchymal-sparing hepatectomy (PSH) is associated with acceptable short-term outcomes and oncological efficiency, but they acknowledged that the quality of the available data is poor (1). During open surgery, it has long been recognised that PSH, if feasible, is superior to major hepatectomy due to significantly lower morbidity and mortality, with no differences in long-term survival (2-4).

Laparoscopic Parenchymal-Sparing Hepatectomy for Multiple Colorectal Liver Metastases Improves Outcomes and Salvageability: A Propensity Score-Matched Analysis.

Parenchymal-sparing hepatectomy (PSH) is regarded as the standard of care for colorectal liver metastases (CRLMs) in open surgery. However, the surgical and oncological benefits of laparoscopic PSH compared with laparoscopic major hepatectomy (MH) have not been fully documented. A total of 269 patients who underwent initial laparoscopic liver resections with curative intent for CRLMs between 2004 and 2017 were enrolled. Preoperative patient characteristics and tumor burden were adjusted with propensity score matching, and laparoscopic PSH was compared with laparoscopic MH after matching. PSH was performed in 148 patients, while MH was performed in 121 patients. After propensity score matching, 82 PSH and 82 MH patients showed similar preoperative characteristics. PSH was associated with lower rates of major postoperative complications compared with MH (6.1 vs. 15.9%; p = 0.046). Recurrence-free survival (RFS) and liver-specific RFS rates were comparable between both groups (p = 0.595 and 0.683). Repeat hepatectomy for liver recurrence was more frequently performed in the PSH group (63.9 vs. 36.4%; p = 0.022), and the PSH group also showed a trend toward a higher overall survival (OS) rate (5-year OS 79.4 vs. 64.3%; p = 0.067). Multivariate analyses revealed that initial MH was one of the risk factors to preclude repeat hepatectomy after liver recurrence (hazard ratio 2.39, p = 0.047). Laparoscopic PSH provided surgical and oncological benefits for CRLMs, with less complications, similar recurrence rates, and increased salvageability through repeat hepatectomy, compared with laparoscopic MH. PSH should be the standard approach, even in laparoscopic procedures.

Parenchymal-sparing versus extended hepatectomy for colorectal liver metastases: A systematic review and meta-analysis.

AimsTo assess the safety and efficacy of parenchymal‐sparing hepatectomy (PSH) as a treatment of colorectal liver metastases (CLM).MethodsA comprehensive medical literature search was performed. Perioperative and long‐term survival outcomes were pooled. Subgroup analysis and meta‐regression analysis were performed to identify potential sources of heterogeneity.ResultsA total of 18 studies comprising 7081 CLM patients were eligible for this study. The PSH was performed on 3974 (56.1%) patients. We found that the OS (overall survival; hazard ratio [HR] = 1.01, 95% confidence interval [CI]: 0.94‐1.08) and RFS (recurrence‐free survival; HR = 1.00, 95% CI: 0.94‐1.07) were comparable between non‐PSH and PSH group. The perioperative outcomes were better in PSH than in non‐PSH group. Non‐PSH group was significantly associated with longer operative time (standard mean difference [SMD] = 1.17, 95% CI: 0.33‐2.00), increased estimated blood loss (SMD = 1.36, 95% CI: 0.64‐2.07), higher intraoperative transfusion rate (risk ratio [RR] = 2.27, 95% CI: 1.60‐3.23), and more postoperative complications (RR = 1.39, 95% CI: 1.16‐1.66). Meta‐regression analyses revealed that no variable influenced the association between surgical types and the survival outcomes.ConclusionsThis study shows that PSH is associated with better perioperative outcomes without compromising oncological outcomes. Given the increasing incidence of hepatic parenchyma, the PSH treatment offers a greater opportunity of repeat resection for intrahepatic recurrent tumors. It should be considered as an effective surgical approach for CLM.

Clinical efficacy of parenchymal-sparing hepatectomy for Barcelona clinic liver cancer stage A hepatocellular carcinoma and prognostic factors analysis

Clinical efficacy of parenchymal-sparing hepatectomy for Barcelona clinic liver cancer stage A hepatocellular carcinoma and prognostic factors analysis

Feasibility of laparoscopic parenchymal sparing hepatectomies: a systematic review and meta-analysis

Introduction: Parenchymal sparing hepatectomy (PSH) refers to liver resection with preservation of as much liver parenchyma as possible. PSH may confer oncological advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can be performed laparoscopically, but access to the cranial segments is difficult. The objective of this systematic review is to analyze feasibility, safety, and oncologic outcomes of laparoscopic PSH (LPSH). Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s) and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed. Results: Of 351 studies screened for relevance, 48 studies were selected. After meeting inclusion criteria, ten publications remained reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Of these resections, 132 (21.5%) were in the cranial segments. Median operating time was 190 minutes (range: 125-369 minutes), median estimated blood loss was 200 cc (range: 100-450 cc), median length of hospital stay was 6 days (range: 2-7 days). Conversion rate was 7% and complications occurred in 17% of cases. No perioperative mortality was reported. No standardized reporting format for complications was used across studies. R0 resections were achieved in 91% of cases. Conclusion: Laparoscopic PSH of difficult to reach liver tumors is feasible with acceptable operating times, blood loss, conversion and complication rates. In future studies, data on long term survival and specific tumor type recurrence should be reported.

Outcomes of ALPPS for bilateral colorectal liver metastases compared to those of one-stage parenchymal sparing hepatectomy: a multicenter case-match analysis

Introduction: About 30% of patients with colorectal liver metastases (CRLM) are not initially resectable due to the extent of hepatic disease. When the future liver remnant (FLR) is regarded to be not sufficient, classic two stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be performed to get increase of the FLR. One-stage ultrasound-guided parenchymal-sparing hepatectomy (OSH) may represent an alternative strategy for these patients. Method: A retrospective analysis of patients enrolled within the ALPPS Italian Registry between 2005 and 2017 was performed. Patients undergoing ALPPS for ≥3 bilateral CRLM were matched 1:2 with patients receiving a OSH at Humanitas Research Hospital. Patients were matched according to the Fong Score (1-2/3/4-5); the contact of CRLM with major intrahepatic vessels; the number of CRLM (3-7/≥8); the number of CRLM in the left liver (< /≥3); and the response to preoperative chemotherapy. The main end points of the study were perioperative outcomes, overall (OS) and disease-free survival (DFS). Results: Eighty-one patients were selected (27 ALPPS and 54 OSH) based on matching process. Demographic and tumor characteristics were similar between the two groups. The two treatments differed significantly in major morbidity (29.6% ALPPS vs 7.4% OSH, p=0.017) but with similar mortality rate (7.4% vs 1.8%, p=0.256). Median OS (31.7 vs 31.4 months) and DFS (7.2 vs 7.3 months) were comparable between the two groups. Conclusions: This case-match study demonstrates that ALPPS and OSH for bilateral CRLM achieve comparable OS and DFS, despite higher morbidity rates reported after ALPPS.

Feasibility of laparoscopic parenchymal sparing hepatectomies: a systematic review

Background: Parenchymal sparing hepatectomy (PSH) refers to liver resection with preservation of as much liver parenchyma as possible. PSH may confer an oncological advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can be performed laparoscopically, but access to the cranial segments is difficult. The objective of this systematic review is to analyze feasibility, safety, and oncologic outcomes of laparoscopic PSH (LPSH). Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s) and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed. Results: Of 351 studies screened for relevance, 48 studies were selected. Because interventions or endpoints were noncontributory, 38 were excluded. Ten publications remained, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Of the resections, 132 (21.5%) were in the cranial segments which previously would have required laparoscopic hemi-hepatectomies or sectionectomies. Median operating time was 190 minutes (range: 125–369 min), median estimated blood loss was 200 cc (range: 100–450 cc), median length of hospital stay was 6 days (range: 2–7 days). Conversion rate was 7%, and complications occurred in 17% of cases. No perioperative mortality was reported. No standardized reporting format for complications was used across studies. R0 resections were achieved in 91% of cases. Conclusion: Laparoscopic PSH of difficult to reach liver tumors is feasible with acceptable operating times, blood loss, conversion and complication rates. In future studies, data on long term survival and specific tumor type recurrence should be reported.

Parenchymal-Sparing Surgery for the Surgical Treatment of Multiple Colorectal Liver Metastases Is a Safer Approach than Major Hepatectomy Not Impairing Patients' Prognosis: A Bi-Institutional Propensity Score-Matched Analysis

Background: The performance of parenchymal-sparing hepatectomy (PSH) versus major hepatectomy (MH) in patients with multiple colorectal liver metastases (CLM) is a matter that is yet debated. We investigated the outcome of patients with multiple CLM undergoing PSH instead of MH. Methods: Databases at 2 institutions were reviewed. A propensity score-matched analysis was applied. Among 554 patients, 110 undergoing PSH and 110 undergoing MH were matched. They were similar in baseline characteristics, comorbidity, and tumor features. Primary outcomes were short- and long-term outcomes. Results: Morbidity was significantly higher in the MH group, while mortality was not significantly different. There were no differences in free-margins width, but a trend of increased survival was seen in the PSH group with a median advantage of 6 months over the MH group. Among the prognostic factors, the T status (hazard ratio [HR] 2.6; p = 0.001), the N status (HR 2.9; p = 0.001), the timing of CLM diagnosis (HR 2.1; p = 0.002), the tumor number (HR 2.0; p = 0.001), the tumor size (HR 2.2; p = 0.015), and the neo-adjuvant chemotherapy (HR 1.7; p = 0.023) were found to be statistically and independently significant for survival. Conclusions: PSH conveys advantage over MH in terms of decreased postoperative morbidity, and a trend of survival benefit. PSH should be considered a suitable alternative to MH whenever it is technically feasible.

Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review

IntroductionColorectal liver metastases develop in 50% of patients diagnosed with colorectal cancer. Surgical resection for colorectal liver metastasis typically involves either anatomical resection (AR) or parenchymal-sparing hepatectomy (PSH). The objective of the current study was to analyze data on parenchymal versus non-parenchymal-sparing hepatic resections for CLM. MethodsA systematic review of the literature regarding parenchymal-sparing hepatectomy was performed. MEDLINE/PubMed, Cochrane, and EMBASE databases were searched for publications containing the following medical subject headings (MeSH): “Colorectal Neoplasms,” “Neoplasm Metastasis,” “Liver Neoplasms” and “Hepatectomy”. Besides, the following keywords were used to complete the literature search: “Hepatectomy,” “liver resection,” “hepatic resection,” “anatomic/anatomical,” “nonanatomic/ nonanatomical,” “major,” “minor,” “limited,” “wedge,” “CRLM/CLM,” and “colorectal liver metastasis.” Data was reviewed, aggregated, and analyzed. ResultsTwo thousand five hundred five patients included in 12 studies who underwent either PSH (n = 1087 patients) or AR (n = 1418 patients) were identified. Most patients had a primary tumor that originated in the colon (PSH 52.2–74.4% vs. AR 53.9–74.3%) (P = 0.289). The majority of studies included a large subset of patients with only a solitary tumor with a reported median tumor number of 1–2 regardless of whether the patient underwent PSH or AR. Median EBL was no different among patients undergoing PSH (100–896 mL) versus AR (200–1489 mL) for CLM (P = 0.248). There was no difference in median length-of-stay following PSH (6–17 days) versus AR (7–15 days) (P = 0.747). While there was considerable inter-study variability regarding margin status, there was no difference in the incidence of R0 resection among patients undergoing PSH (66.7–100%) versus AR (71.6–98.6%) (P = 0.58). When assessing overall survival, there was no difference whether resection of CLM was performed with PSH (5 years OS: mean 44.7%, range 29–62%) or AR (5 years OS: mean 44.6%, range 27–64%) (P = 0.97). ConclusionPSH had a comparable safety and efficacy profile compared with AR and did not compromise oncologic outcomes. PSH should be considered an appropriate surgical approach to treatment for patients with CLM that facilitates preservation of hepatic parenchyma.

Parenchymal-sparing Hepatectomy as the New Doctrine in the Treatment of Liver-metastatic Colorectal Disease: Beyond Oncological Outcomes.

Colorectal cancer is one of the leading causes of mortality in the Western world. Half of patients with colorectal cancer will develop liver-metastatic (CLM) disease, with fewer than 30% having surgically resectable disease at diagnosis. It is well established in the literature that major hepatectomy offers a high rate of R0 resection, however, with concommitant increased rates of mortality and morbidity. Emerging literature during the past two decades has demonstrated the potential superiority of parenchymal-sparing hepatectomy (PSH) in treating CLM disease in terms of oncological outcomes, survival and re-operation in cases of recurrence (salvageability). To date, no data regarding the evaluation of quality of life and cost after PSH have been published. PSH seems to be correlated with less mortality and morbidity, which can be translated in lower re-admission rates, better quality of life and, therefore, reduced relevant cost. Prospective studies and clinical trials evaluating the multiple beneficial role of a PSH surgical strategy in CLM disease are mandatory to support or reject the emerging belief that PSH could be the gold standard of treatment of CLM disease.

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases

The feasibility of parenchymal-sparing hepatectomy has yet to be assessed based on the tumor location, which affects the choice of treatment in patients with colorectal liver metastases. Sixty-three patients underwent first curative hepatectomy for deep-placed colorectal liver metastases whose center was located >30mm from the liver surface. Operative outcomes were compared among patients who underwent parenchymal-sparing hepatectomy or major hepatectomy (≥3 segments). Parenchymal-sparing hepatectomy and major hepatectomy were performed for deep-placed colorectal liver metastases in 40 (63%) and 23 (37%) patients, respectively. Resection time was longer in the parenchymal-sparing hepatectomy than in the major hepatectomy group (57 vs 39minutes) (P=.02) and cut-surface area was wider (120 vs 86cm2)(P<.01). Resected volume was smaller in the parenchymal-sparing hepatectomy than in the major hepatectomy group (251 vs 560g)(P<.01). No differences were found between the 2 groups for total operation time (306 vs 328minutes), amount of blood loss (516 vs 400mL), rate of major complications (10% vs 13%), and positive operative margins (5% vs 4%). Overall, recurrence-free, and liver recurrence-free survivals did not differ between the 2 groups. Direct major hepatectomy without portal venous embolization could not have been performed in 40% of the parenchymal-sparing hepatectomy group (16/40) because of the small liver remnant volume. Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.