Parenchyma-sparing Resection Research Articles

Impact of major hepatectomy on recurrence after resection of hepatocellular carcinoma at CNLC Ib stage: a propensity score matching study.

Patients with hepatocellular carcinoma (HCC) who undergo curative hepatectomy may experience varying remnant liver volumes. Our study aimed to evaluate whether the extent of liver resection has an effect on postoperative recurrence in HCC patients at China Liver Cancer Staging (CNLC) Ib stage. A retrospective analysis was conducted on 197 patients who underwent hepatectomy for a solitary HCC lesion measuring ≥5cm (CNLC Ιb stage) between January 2019 and June 2022. Patients were divided into major hepatectomy (MAH) group (n=70) and minor hepatectomy (MIH) group (n=127) based on the extent of liver resection. Recurrence-free survival (RFS) was compared between the two groups. Propensity score matching (PSM) was employed to minimize bias in the retrospective analysis. Patients who underwent MAH had a greater total complication rate than did those who underwent MIH (35.7% vs. 11.8%, P<0.001). The median RFS was 14.6 months (95% CI: 11.1-18.1) for MAH group and 24.1 months (95% CI 21.2-27.1) for MIH group (P<0.001). After PSM, patients who underwent MAH still had a greater total complication rate than those who underwent MIH (36.7% vs. 16.3%, P=0.037). The median RFS was 13.2 months (95% CI: 15.1-21.7) for MAH group and 22.3 months (95% CI 18.1-26.5) for MIH group (P=0.0013). The Cox regression model identified MAH as an independent poor predictor for HCC recurrence (hazard ratios of 1.826 and 2.062 before and after PSM, respectively; both P<0.05). MIH can be performed with fewer postoperative complications and contributes to improved RFS in patients with HCC at CNLC Ιb stage compared to MAH. Parenchyma-sparing resection should be considered the first choice for these HCCs.

Reappraisal of the Parenchyma-Sparing Resections for Pancreatic Neuroendocrine Tumors: A Chinese High-volume Center Experience

Background: Parenchyma-sparing resections (PSRs) are increasingly used for small pancreatic neuroendocrine neoplasms (PNENs) to preserve the function of the gland. However, the data are extremely limited due to the rarity of this tumor. Aims: This study sought to describe the indications, operative technique, short and long-term outcomes of PSRs for PNENs, with a focus on postoperative pancreatic fistula (POPF) and oncologic outcomes. Methods: From 2008 to 2018, data collected retrospectively from 113 PNENs that underwent PSRs (113/421, 27%) were reviewed. A comparison was conducted of PSRs of PNENs without (group1, n=101) or with pancreatic transection (group 2, n=12). Results: Of the 113 patients, the most common indication for PSRs was insulinoma (80%), followed by NF-PNEN (20%). The majority of lesions were WHO G1 grade (80/113, 71%). The mean maximum diameter of the tumors was 19 mm. Patients who underwent PSRs had a low rate of severe postoperative morbidity (7/113, 6%). Pancreatic endocrine and exocrine insufficiency occurred in only 1% and 7% of patients respectively. And there was no evidence of tumor recurrence after PSRs detected during follow-up. Age was identified as the only independent positive risk factor of POPF in group 1. Patients in group 2 had significantly higher rates of POPF (p=0.002), overall morbidity (p=0.002), severe morbidity (p=0.026) and readmission (p=0.004). Conclusions: PSRs of PNENs appear to be feasible and safe, preserving the endocrine and exocrine function of the gland with no increased risk of recurrence or metastasis. In contrast, PSRs involving transection of the pancreas should be performed more cautiously.

Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis

BackgroundPancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications.Materials and MethodsPubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD.ResultsConcordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15–1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28–0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178–5.34); p = 0.96].ConclusionsDPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.

Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?

Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is amultiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure anew onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, amortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.

The association between KRAS and histopathological growth patterns and the impact on resection margins around vasculature and bile ducts in colorectal liver metastases.

The liver is the most frequent and often the only site of distant disease in colorectal cancer and, of all treatment protocols currently in use, resection is the most likely to result in long-term cure. Within the liver, tumour proximity to major vasculature and biliary structures poses a resection challenge, requiring a balance of achieving negative margins while preserving adequate vascular circulation and biliary drainage. The focus on parenchymal sparing resections are important but just as important may be the 'biological' behaviour of the tumour. In colorectal liver metastases (CRLM), biomarkers such as the Kirsten rat sarcoma oncogene homologue (KRAS) gene and histological growth patterns (HGPs) further improve the prognostication after resection. However, to date, the association between the KRAS status and HGPs in CRLM and their impact on resection margins around major vasculature or biliary structures in terms of overall survival and recurrence rates are unclear. The aim of this review was to explore the available evidence for the association between KRAS and HGPs in CRLM and attempt to define their impact on resection margins near major structures.

When Should Lymphadenectomy Be Performed in Non-Metastatic Pancreatic Neuroendocrine Tumors? A Population-Based Analysis of the German Clinical Cancer Registry Group.

Patient selection for lymphadenectomy remains a controversial aspect in the treatment of pancreatic neuroendocrine tumors (pNETs), given the growing importance of parenchyma-sparing resections and minimally invasive procedures. This population-based analysis was derived from the German Cancer Registry Group during the period from 2000 to 2021. Patients with upfront resected non-functional non-metastatic pNETs were included. Out of 5520 patients with pNET, 1006 patients met the inclusion criteria. Fifty-three percent of the patients were male. The median age was 64 ± 17 years. G1, G2, and G3 pNETs were found in 57%, 37%, and 7% of the patients, respectively. Lymph node metastasis (LNM) was present in 253 (24%) of all patients. LNM was an independent prognostic factor (HR 1.79, CI 95% 1.21-2.64, p = 0.001) for disease-free survival (DFS). The 3-, 5-, and 10-year disease-free survival in nodal negative tumors compared to nodal positive was 82% vs. 53%, 75% vs. 38%, and 48% vs. 16%. LNM was present in 5% of T1 tumors, 25% of T2 tumors, and 49% of T3-T4 tumors. In T1 tumors, G1 was the most predominant tumor grade (80%). However, in T2 tumors, G2 and G3 represented 44% and 5% of all tumors. LNM was associated with tumors located in the pancreatic head (p < 0.001), positive resection margin (p < 0.001), tumors larger than 2 cm (p < 0.001), and higher tumor grade (p < 0.001). The multivariable analysis showed that tumor size, tumor grade, and location were independent prognostic factors associated with LNM that could potentially be used to predict LNM preoperatively. LNM is an independent negative prognostic factor for DFS in pNETs. Due to the low incidence of LNM in T1 tumors (5%), parenchyma-sparing surgery seems oncologically adequate in small G1 pNETs, while regional lymphadenectomy should be recommended in T2 or G2/G3 pNETs.

The Sling Technique for Laparoscopic Liver Mobilization.

As liver surgery continues to evolve, be it open, laparoscopic or robotic, it remains a procedure that can deteriorate in the blink of an eye. Liver surgery in patients with hepatoma is further complicated, as the vast majority have significant fibrosis, if not cirrhosis. Thus, parenchymal sparing resection is increasingly necessary. Effective and safe intracorporeal mobilization of the liver is essential for minimal access parenchymal-sparing and conventional resection. This retrospective review of over 150 cases performed provides a hands-on approach to laparoscopic hepatic mobilization with the use of an inexpensive technique using a 1" packing tape to "Sling" the liver in-order to divide the ligaments holding the liver in place and optimally position the liver for parenchymal transection. Use of a 1" packing tape to "Sling" the liver intracorporeally is demonstrated to enable mobilization of the liver for tissue sparing non-anatomic, anatomic and major resections. Use of a 1" packing tape to "Sling" the liver intracorporeally can facilitate mobilization for resection. Surgeons hoping to master minimal access resection should also be well versed in the use of laparoscopic ultrasound and liver transplant "Piggyback" technique.

The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

Videofluorescence navigation during parenchymal-sparing liver resections using a domestic fluorescence imaging system

Parenchyma- sparing liver resections are aimed at maximizing the possible preservation of parenchyma not affected by the tumor - a current trend in hepatopancreatobiliary surgery. On the other hand, a prerequisite for operations is to ensure their radicality. To effectively solve this problem, all diagnostic imaging methods available in the arsenal are used, which make it possible to comprehensively solve the issues of perioperative planning of the volume and technical features of the planned operation. Diagnostic imaging methods that allow intraoperative navigation through intraoperative, instrumentally based determination of the tumor border and resection plane have additional value. One of the methods of such mapping is ICG video fluorescence intraoperative navigation. An analysis of the clinical use of the domestic video fluorescent navigation system "MARS" for parenchymal-sparing resections of focal liver lesions is presented. An assessment was made of the dynamics of the distribution of the contrast agent during ICG videofluorescent mapping during parenchymal-sparing resection interventions on the liver, with the analysis of materials from histological examination of tissues taking into account three-zonal videofluorescent marking of the resection edge, performed using the domestic videofluorescence imaging system «MARS».

Current status of liver surgery for non-colorectal non-neuroendocrine liver metastases: the NON.LI.MET. Italian Society for Endoscopic Surgery and New Technologies (SICE) and Association of Italian Surgeons in Europe (ACIE) collaborative international survey.

Despite the increasing trend in liver resections for non-colorectal non-neuroendocrine liver metastases (NCNNLM), the role of surgery for these liver malignancies is still debated. Registries are an essential, reliable tool for assessing epidemiology, diagnosis, and therapeutic approach in a single hub, especially when data are dispersive and inconclusive, as in our case. The dissemination of this preliminary survey would allow us to understand if the creation of an International Registry is a viable option, while still offering a snapshot on this issue, investigating clinical practices worldwide. The steering committee designed an online questionnaire with Google Forms, which consisted of 37 questions, and was open from October 5th, 2022, to November 30th, 2022. It was disseminated using social media and mailing lists of the Italian Society of Endoscopic Surgery and New Technologies (SICE), the Association of Italian Surgeons in Europe (ACIE), and the Spanish Chapter of the American College of Surgeons (ACS). Overall, 141 surgeons (approximately 18% of the total invitations sent) from 27 countries on four continents participated in the survey. Most respondents worked in general surgery units (62%), performing less than 50 liver resections/year (57%). A multidisciplinary discussion was currently performed to validate surgical indications for NCNNLM in 96% of respondents. The most commonly adopted selection criteria were liver resectability, RECIST criteria, and absence of extrahepatic disease. Primary tumors were generally of gastrointestinal (42%), breast (31%), and pancreaticobiliary origin (13%). The most common interventions were parenchymal-sparing resections (51% of respondents) of metachronous metastases with an open approach. Major post-operative complications (Clavien-Dindo > 2) occurred in up to 20% of the procedures, according to 44% of respondents. A subset analysis of data from high-volume centers (> 100 cases/year) showed lower post-operative complications and better survival. The present survey shows that NCNNLM patients are frequently treated by surgeons in low-volume hospitals for liver surgery. Selection criteria are usually based on common sense. Liver resections are performed mainly with an open approach, possibly carrying a high burden of major post-operative complications. International guidelines and a specific consensus on this field are desirable, as well as strategies for collaboration between high-volume and low-volume centers. The present study can guide the elaboration of a multi-institutional document on the optimal pathway in the management of patients with NCNNLM.

Single center outcomes from parenchymal-sparing resections and microwave ablations for neuroendocrine tumor liver metastases

BackgroundReported outcomes after surgical debulking in patients with advanced neuroendocrine tumor liver metastases (NETLM) are sparse. MethodsNETLM patients that underwent surgical debulking from 2019 to 2021 were reviewed. Trends in perioperative liver function, complications, symptom response, and progression-free survival were examined. Results1069 liver lesions were debulked from 53 patients using a combination of parenchymal-sparing resections (PSR) and ultrasound-guided microwave ablations (MWA). Post-operative transaminitis and thrombocytopenia were common, and severity correlated with increasing number of lesions. Laboratory markers for synthetic liver function did not differ according to the number of lesions debulked. 13% of patients sustained a Clavien-Dindo grade 3 or 4 complication which was not associated with the number of lesions targeted. All patients with preoperative symptoms had improvement after surgery. Median time to progression was 10.9 months. ConclusionsPSR with MWA for large numbers of NETLM is safe and effective for symptom control and does not affect synthetic liver function.

HPB further education – Fluorescence Imaging in Liver Tumor Resection

Hepatocellular carcinoma (HCC), cholangiocarcinoma, and colorectal liver metastasis (CRLM) are the most common indications for liver resection. Historically, anatomic liver resection (ALR) was the standard of care, causing many patients with small, segmental tumors to undergo larger resections; however, in recent decades, there has been a shift towards parenchymal-sparing resection (PSR) which allows sparing of a larger volume of normal liver. With the increase in PSR and the improvement in intra-operative technology, use of fluorescence imaging to guide liver resection has been explored.

Changes in diagnosis and operative treatment of insulinoma over two decades

PurposeMost insulinomas are small solitary, benign neoplasms. Imaging and surgical techniques improved over the last 20 years. Thus, the aim of the present study was to analyze changes in diagnosis and surgery of insulinoma patients in a referral center over two decades.MethodsOperated patients with a histologically proven insulinoma were retrieved from a prospective database. Clinico-pathological characteristics and outcomes were retrospectively analyzed with regard to the time periods 2000–2010 (group 1) and 2011–2020 (group 2).ResultsSixty-one of 202 operated patients with pNEN had an insulinoma, 37 (61%) in group 1 and 24 (39%) in group 2. Of those 61 insulinomas, 49 (80%) were sporadic benign, 8 (13%) benign MEN1-associated insulinomas, and 4 (7%) sporadic malignant insulinomas. In 35 of 37 (95%) patients of group 1 and all patients of group 2, the insulinoma was preoperatively identified by imaging. The most sensitive imaging modality was endoscopic ultrasound (EUS) with correctly diagnosed and localized insulinomas in 89% of patients in group 1 and 100% in group 2. In group 1, significantly less patients were operated via minimally invasive approach compared to group 2 (19% (7/37) vs. 50% (12/24), p = 0.022). Enucleation was the most frequently performed operation (31 of 61, 51%), followed by distal resection (15 of 61, 25%) without significant differences between groups 1 and 2. The rate of relevant postoperative complications was not different between groups 1 and 2 (24% vs. 21%, p = 0.99). Two patients with benign insulinoma (1 out of each group) experienced disease recurrence and underwent a second resection. After a median follow-up of 134 (1–249) months, however, all 57 (100%) patients with benign insulinoma and 3 out of 4 patients with malignant insulinoma had no evidence of disease.ConclusionInsulinoma can be preoperatively localized in almost all patients, allowing for a minimally invasive, parenchyma-sparing resection in selected patients. The long-term cure rate is excellent.

Laparoscopic parenchyma-sparing resections for solid pseudopapillary tumors located in the head of pancreas

BackgroundSolid pseudopapillary tumor (SPT) of the pancreas is a rare low-grade malignant tumor. Here, we aimed to determine the safety and feasibility of laparoscopic parenchyma-sparing pancreatectomy for SPT located in the pancreatic head.MethodsFrom July 2014 to February 2022, 62 patients with SPT located in the pancreatic head were operated laparoscopically in two institutions. These patients were divided into two groups according to the operative strategy: laparoscopic parenchyma-sparing pancreatectomy (27 patients, group 1) and laparoscopic pancreaticoduodenectomy (35 patients, group 2). The clinical data were retrospectively collected and analyzed in terms of demographic characteristics, perioperative variables, and long-term follow-up outcomes.ResultsThe demographic characteristics of the patients in the two groups were comparable. Compared to the patients in group 2, those in group 1 required less operative time (263.4 ± 37.2 min vs. 332.7 ± 55.6 min, p < 0.001) and experienced less blood loss (105.1 ± 36.5mL vs. 188.3 ± 150.7 mL, p < 0.001). None of the patients in group 1 had tumor recurrence or metastasis. However, 1 (2.5%) patient in group 2 showed liver metastasis.ConclusionLaparoscopic parenchyma-sparing pancreatectomy is a safe and feasible approach for SPT located in the pancreatic head, with favorable long-term functional and oncological results.

Comment on: Are Parenchyma-Sparing Resections Really Appropriate for Small (

Comment on: Are Parenchyma-Sparing Resections Really Appropriate for Small (<3 cm) Nonfunctional Pancreatic Neuroendocrine Tumors?

Robotic hepatectomy: current evidence and future directions.

Minimally invasive hepatectomy continues to gain popularity and acceptance for treatment of benign and malignant liver disease. Robotic hepatectomy offers potential advantages over open and conventional laparoscopic approaches. Review of the literature on robotic hepatectomy was performed. Search terms included "robotic hepatectomy" and "minimally invasive hepatectomy." Search was further customized to include articles related to robotic surgical technology. Across many parameters in liver surgery, robotic liver resection appears to have comparable outcomes with respect to laparoscopic resection. The benefits over open resection are largely related to less morbidity and faster recovery times. There is evidence that the robotic approach may have a shorter learning curve and enable more difficult resections to be performed minimally invasively. The robotic platform may have the potential to achieve superior margin status or parenchymal sparing resection in oncologic resections, but numerous obstacles remain. The robotic platform has not been applied to liver surgery to the same extent as either laparoscopic or open surgery. Robotic surgical technology will need to continue developing to deliver on its potential advantages.

Response to Commentary "Are Parenchyma-Sparing Resections Really Appropriate for Small (

Response to Commentary "Are Parenchyma-Sparing Resections Really Appropriate for Small (<3 cm) Non-Functional Pancreatic Neuroendocrine Tumors?"

Upper Transversal Hepatectomy with Two Hepatic Veins Reconstruction: Combining Parenchymal-Sparing Liver Surgery with Transplantation Techniques for Colorectal Liver Metastases

BackgroundColorectal liver metastases (CRLM) involving two or three main hepatic veins pose a surgical challenge. For these lesions, compelled surgical strategies have usually included major and/or extended liver resections according to the two-stage hepatectomy (TSH) strategy. More recently, a one-stage transversal hepatectomy resecting the posterosuperior liver segment (7,8,4 superior) along with one or more hepatic veins has been described, such as showed herein in a didactical video. MethodsThe patient is a 78-year-old woman with two large CRLMs located into segment 2 and into segment 8. Magnetic resonance imaging and computed tomography showed tumour stability after chemotherapy. The lesion of segment 2 is close to the left hepatic vein while the lesion of segment 8 infiltrates the middle (MHV) and the right hepatic veins (RHV). ResultsUnder intermittent pedicular clamping, resection of the segment 7, 8, 4 superior along with the right and middle hepatic veins is performed. Reconstruction of the veins was performed with 2 cryopreserved autologous saphenous grafts. Postoperative course was uneventful and postoperative CT scan showed patency of the two venous graft reconstructions. ConclusionsSurgery for CRLM has evolved over the last two decades shifting from large anatomical resections to parenchymal-sparing resections. Sparing liver parenchyma allows surgical radicality while reducing the risk of liver failure and allowing repeated liver resection. Associating vascular reconstruction to parenchymal-sparing surgery reduces the risk of venous congestion of the spared liver parenchyma.

Intraoperative indocyanine green clearance in liver surgery: a useful tool to promote parenchymal preservation?

A 66-year-old woman was diagnosed with sigmoid carcinoma with bilobar unresectable liver metastases. Primary tumor resection was performed. Neoadjuvant chemotherapy was administered to downstage liver disease. Following FOLFOX/panitumumab (4 cycles), disease progression was observed within the liver. Therefore, chemotherapy regimen was switched to FOLFIRI/cetuximab (12 cycles). At restaging, 7 out of 10 metastases showed complete radiologic response and 3 showed disease progression. Selective internal radiation therapy (SIRT) with Yttrium-90 was performed on these 3 metastases with very good local radiologic response. Surgical resection with curative intent was attempted. ICG was administered 72 hours before surgery to help localization of liver metastases. Intraoperatively, very poorICG clearance was demonstrated and therefore parenchyma-sparing resections were performed (segment II, III, IV and VII). At final histology, major pathologic response was observed with steatosis of the liver parenchyma. Postoperative course was uneventful and adjuvant capecitabine was administered (8 cycles). No recurrence was demonstrated at 38 months follow-up. However, eighteen months following surgery, she developed impairment of hepatic function and portal hypertension. Conclusion: Preoperative ICG administration could be helpful to intraoperatively detect patients that can develop late post hepatectomy impairment of hepatic function, especially following SIRT2 (REF2), and promote parenchymal preservation.

Robotic ICG-guided Parenchymal-sparing Resections for Liver Metastases Located in the Posterosuperior Segments

Robotic ICG-guided Parenchymal-sparing Resections for Liver Metastases Located in the Posterosuperior Segments