Resected Liver Volume Research Articles

Italian experience in minimally invasive liver surgery: a national survey.

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5 days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.

PTH-326 Cytoreductive surgery and heated intraperitoneal chemotherapy with synchronous liver resection for metastases of colorectal origin

Introduction The combination of peritoneal metastases (PMCR) and liver metastases in colorectal cancer (CRLM) has been considered a relative contra-indication to surgical treatment of either lesion. In the UK joint resection has not been widely undertaken and there is no published UK data. We present a cohort of eight synchronous liver resections with cytoreduction and heated intraperitoneal chemotherapy (CRS+HIPEC) at a single UK centre. Method All patients undergoing CRS+HIPEC with a hepatobiliary surgeon were identified from the prospectively kept PTS database. Patients who had only liver mobilisation were excluded. Outcome data was gathered from the electronic patient record and the PTS database. Post-hepatectomy liver failure was defined using International Study Group of Liver Surgery criteria. Results Seven patients underwent eight CRS+HIPEC procedures with synchronous liver resection for metastasis of colorectal origin over 5 years. Median PCI was 9 (range 3–17), with CC-0/1 resection in all patients. The median volume of resected liver was 90.6 cm 3 (2760 cm 3 – 15 cm 3 ). Median CCU stay was 2 (1–3) days and hospital stay 11 (8–20) days. Two patients experienced grade 3–4 complications: one grade-A post-hepatectomy liver failure and one sepsis. There was no 30 day mortality. Median CCU stay, inpatient stay, and grade 3–4 complication rate for patients undergoing CRS+HIPEC without liver resection for PMCR (n = 85) in our unit is 2 (0–16) days 12 (4–141) days and 21% respectively. Three patients are alive at a median follow-up of 59.2(39–61) months. All surviving patients had CC0 resections and PCI Conclusion In selected patients with metastatic colorectal cancer, synchronous liver resection with CRS+HIPEC is safe, with inpatient stay, CCU stay and complication rates comparable to CRS+HIPEC without liver resection in our unit. Our outcomes and survival figures are consistent with published data which suggests improved overall survival compared to modern systemic chemotherapy. Disclosure of interest None Declared.

Intraoperative simulation of remnant liver function during anatomic liver resection with indocyanine green clearance (LiMON) measurements

ObjectivePost-hepatectomy liver failure (PHLF) is the major cause of death following liver resection. The aim of this study was to evaluate the feasibility of an intraoperative simulation of post-resection liver function. MethodsIntraoperative liver function was measured by indocyanine green (ICG) clearance using the LiMON™ technology. In 20 patients undergoing anatomic liver resection, ICG plasma disappearance rate (PDR (%/min) and ICG retention at 15 min (R15) (%) were measured immediately after the induction of anaesthesia (t0), after selective arterial and portovenous inflow trial clamping (TC) of the resected liver segments (t1), after the completion of resection (t2) and before the closure of the abdominal cavity (t3). ResultsThe median baseline (t0) PDR was 16.5%/min. Trial clamping of the inflow (t1) resulted in a significant reduction in PDR to 10.5%/min. Results under TC were similar to those obtained after resection (t2) (median PDR: 10.5%/min). Linear regression modelling showed that post-resection liver volume could be accurately predicted by TC of liver inflow (P < 0.0001), but not by determining the resected liver volume. Simulated post-resection liver function under TC correlated well with PHLF and length of hospital stay. ConclusionsIntraoperative ICG clearance measurements allow real-time monitoring of intraoperative liver function during surgery. Trial clamping of arterial and portovenous inflow accurately predicts immediate post-resection liver function. The intraoperative measurement of liver function and simulation of post-resection liver function may help to avoid PHLF.

Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer.

Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD. Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r. The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery. While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.

Application of three-dimensional visualization system combined with choledochofiberscope for the treatment of hepatolithiasis

Objective To investigate the clinical value of three-dimensional visualization system combined with choledochofiberscope in the treatment of hepatolithiasis.Methods The clinical data of 30 patients with hepatolithiasis who were admitted to the Chenggong Hospital of Xiamen University from January 2012 to January 2013 were retrospectively analyzed.The preoperative two-dimensional images of computed tomography (CT) was converted to the three-dimensional images by IQQA-Liver system.The location of the stones and their relationship with adjacent organs were learned.The surgical plan was made based on the three-dimensional images,and the liver volume and liver volume planed to be excised were measured.Bile duct exploration,washing,lithotripsy and lithotomy were performed using the traditional method combined with choledochofiberscopy.The rate of residual stones and actual volume of liver resected were calculated.The correlation between the volume of actual liver resected and predicted liver resection volume was analyzed by calculating the Pearson correlation coefficient.Results The three-dimensional reconstruction of the CT data of the 30 patients clearly displayed the size,location of the tumor,as well as its relationship with adjacent blood vessels and bile ducts.Surgical plan was made according to the result of three-dimensional reconstruction,including 24 cases of choledochotomy,15 cases of partial liver resection,and 16 cases of bile duct stricture repairment + cholangioenterostomy.The volume of liver of the 15 patients who were planed to receive partial liver resection was (1 390 ± 148) mL,and the volume of liver planed to be resected was (275 ± 156) mL.Preoperative evaluation of the anatomy of blood vessels,stones and bile ducts based on three-dimensional images was confirmed with operative findings.In actual practice,there were 24 patients received choledochotomy,6 received liver parenchyma cutting,15 received partial liver resection and 16 received cholangioenterostomy.The agreement rate of the surgical plan and the actual practice was 100.0％ (30/30).The actual volume of liver resected was (261 ± 148)mL.The mean error rate of the volume of liver planed to be resected was 5.4％.The predicted liver resection volume was positively correlated with the actual liver resection volume (r =0.902,P ＜ 0.05).Exploration with choledochoscope was routinely performed,including 23 cases of lithotomy through choledochofiberscope.The operation time was (121 ± 65)minutes,and the volume of intraoperative blood loss was (158 ± 78) mL.No bile leakage was detected,and the incidence of incisional infection was 3.3％ (1/30).The results of CT or choledochoscopy showed that the rate of residual stones after surgery was 10.0％ (3/30).Conclusion Three-dimensional visualization system combined with choledochofiberscopy is helpful in the treatment of hepatolithisis. Key words: Hepatolithiasis ; Three-dimensional visualization system ; Choledochofiberscope

Extensive liver resection with preoperative chemotherapy for colorectal metastases with high risk of complications

Objective: to study influence of preoperative chemotherapy on postoperative complications rate. Material and methods: an analysis of 455 cases of extensive liver resection. 229 (56%) patients didn’t receive neoadjuvant chemotherapy, 176 (44%) - received preoperative chemotherapy. 216 (53%) patients had bilobar lesions, 156 (39%) - had multiple metastases, 168 (42%) - had synchronous metastases, 237 (58%) - had metachronous metastases. 60 (15%) patients in addition to liver lesions, had been resected for extrahepatic metastases. Results: bevacizumab inckusion to preoperative regional chemotherapy did not lead to increase of postoperative complication rate. Conclusion: Postoperative complication rate didn’t significantly differ in all groups of treatment, regardless of liver resection volume. Extension of liver resection from standard hepatectomy to extensive, leads to statistically significant increase of acute hepatic failure. Acute hepatic failure takes the first place among complications (21%).

The critical value of remnant liver volume-to-body weight ratio to estimate posthepatectomy liver failure in cirrhotic patients

BackgroundThe extensive use of major hepatectomy for liver malignancies with cirrhosis increases the risk of posthepatectomy liver failure (PHLF), which is associated with a high frequency of postoperative complications, mortality, and an increased length of hospital stay. Remnant liver volume-to-body weight ratio (RLV-BWR) is more specific than the ratio of RLV-to-total liver volume (RLV-TLV) in predicting postoperative course after major hepatectomy in normal liver. Patients having normal liver with an anticipated RLV-BWR ≤0.5% are at considerable risk for hepatic dysfunction and postoperative mortality. In the present study, the critical value of RLV-BWR after liver resection in cirrhotic liver was investigated. Patients and methodsThirty one patients who underwent hepatectomy for hepatocellular carcinoma in one medical treatment unit of West China Hospital from September 2012 to December 2012 were retrospectively enrolled in study. Volumetric measurements of TLV using computed tomography were obtained before hepatectomy. PHLF was diagnosed by the “50–50 criteria.” The influence of RLV-TLV and RLV-BWR on the occurrence of PHLF was investigated, and the critical value of RLV-BWR was concluded. ResultsAccording to the occurrence of PHLF, the patients were retrospectively divided into PHLF group and non-PHLF group. There were no statistical differences of preoperative indicators between the two groups. The intraoperative indicators including the resected liver volume, RLV-TLV, and RLV-BWR were statistically significant (P < 0.05) between the two groups. The postoperative indicators including total bilirubin (TBIL), international normalized ratio, and peritoneal drainage fluid at the third and the fifth day after surgery were statistically significant (P < 0.05) between the two groups. Area under the receiver operating characteristic curve (ROC curve) predicted by RLV-BWR to the incidence of PHLF was 0.864 (P = 0.019) with 95% confidence interval (95% CI = 0.608–0.819), and the sensitivity and specialty rate were 70% and 95%, which were more than 50% and 70%, respectively. It suggested that the critical value of RLV-BWR (1.4%) had a certain predictive value on PHLF. Area under the receiver operating characteristic curve predicted by RLV-TLV to the incidence of PHLF was 0.568 (P = 0.628) with 95% confidence interval (95% CI = 0.376–0.747), and the sensitivity and specialty rate were 42.9% and 82.6%, respectively. The sensitivity (42.9%) <50% suggested that the critical value of RLV-TLR (51%) had a poor predictive value on PHLF. According to the curve critical value 1.4% of RLV-BWR, the patients were divided into RLV-BWR ≥1.4% group and RLV-BWR <1.4% group, and the incidence of PHLF between the two groups was statistically significant (P = 0.006). ConclusionsRLV-BWR was more specific than RLV-TLV in predicting PHLF after major hepatectomy of cirrhotic liver. Patients with an anticipated RLV-BWR <1.4% are at considerable risk for PHLF.

Factors Influencing Liver and Spleen Volume Changes after Donor Hepatectomy for Living Donor Liver Transplantation

Purpose: To define the changes in liver and spleen volumes in the early postoperative period after partial liver donation for living-donor liver transplantation (LDLT) and to determine factors that influence liver and spleen volume changes. Materials and Methods: 27 donors who underwent partial hepatectomy for LDLT were included in this study. The rates of liver and spleen volume change, measured with CT volumetry, were correlated with several factors. The analyzed factors included the indocyanine green (ICG) retention rate at 15 minutes after ICG administration, preoperative platelet count, preoperative liver and splenic volumes, resected liver volume, resected-to-whole liver volume ratio (LVR/LVW), resected liver volume to the sum of whole liver and spleen volume ratio [LVR/(LVW + SV0)], and pre and post hepatectomy portal venous pressures. Results: In all hepatectomy donors, the volumes of the remnant liver and spleen were increased (increased rates, 59.5 ± 50.5%, 47.9 ± 22.6%). The increment rate of the remnant liver volume revealed a positive correlation with LVR/LVW (r = 0.759, p < 0.01). The other analyzed factors showed no correlation with changes in liver and spleen volumes. Conclusion: The spleen and remnant liver volumes were increased at CT volumetry performed 2 weeks after partial liver donation. Among the various analyzed factors, LVR/LVW influences the increment rate of the remnant liver volume. Index terms Hepatectomy Transplantation Liver Spleen

Computer-assisted surgical planning system in liver resection for hepatocellular carcinoma

Objective To evaluate the role of computer-assisted surgical planning system in liver resection for patients with hepatocellular carcinoma (HCC).Methods Between January 2010 and January 2012,21 patients with HCC who underwent liver resection were included in this study.Computer assisted operative planning was performed before surgery.Results Computer-assisted surgical planning was performed successfully in all the 21 patients.The three dimensional anatomic evaluation was precise and quantitative.The predicted liver resection volume showed a significant correlation with the actual volume,with a mean difference of 3.5％.The types of liver resection included anatomic liver resection (15 patients) and local resection (6 patients).There was a 0％ mortality and a 14.3％ morbidity (3/21).Conclusions The computer-assisted surgical planning system reliably analyzed the 3D vascular structures and predicted accurately liver resection volumes.It can help to promote precise and safe liver resection. Key words: Hepatectomy; Computer-aided design; Three-dimensional reconstruction; Liver neoplasms; Liver volume

Novel virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy

The novel technique of virtual hepatectomy is useful for evaluation of the portal territory of the liver, since this software program includes functions for liver surgery planning. We evaluated the accuracy of virtual hepatectomy for anatomical hepatectomy. Between 2010 and 2011, 92 patients with liver tumors underwent virtual hepatectomy preoperatively. The predicted liver volume was compared with the actual liver volume among patients who underwent anatomical sectionectomy, segmentectomy, and hemihepatectomy. Ninety of 92 patients underwent anatomical hepatectomy on the basis of virtual hepatectomy. According to the surgical procedure, the predicted liver resection volume showed a strong correlation with the actual liver volume in patients who underwent sectionectomy (r = 0.985, p < 0.0001, n = 44, median error rate 9 %), segmentectomy (r = 0.949, p < 0.0001, n = 17, median error rate 12 %), and hemihepatectomy (r = 0.967, p < 0.0001, n = 29, median error rate 7 %). The novel technique of virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy.

Relationship between hospital volume and operative mortality for liver resection: Data from the Japanese Diagnosis Procedure Combination database

The present study aimed to conduct a nationwide investigation on the relationship between hospital volume and outcomes following liver resection in Japan. We also discuss health policy implications of the results. Using the Japanese Diagnosis Procedure Combination database, we identified 18 046 patients who underwent hepatic resection between July and December 2007-2009. Patients were subdivided into hospital-volume quartiles: very low- (<18/year), low- (18-35), high- (36-70) and very high-volume groups (>70). Multivariate logistic regression analysis for in-hospital mortality within 30 days of surgery was performed to analyze adjusted effects of various factors. Patients in the very high-volume group had a higher Charlson Comorbidity Index (P < 0.001) than those in the very low-volume group. Very low-volume hospitals were significantly less likely to perform extended lobectomy than very high-volume hospitals (5.4% vs 17.6%, P < 0.001). Crude in-hospital mortality within 30 days of surgery was 1.1% (0.6%, 0.8%, 1.9% and 3.0% for limited resection, segmentectomy, lobectomy and extended lobectomy, respectively). With reference to the very low-volume group, risk-adjusted odds ratios (95% confidence intervals) of low-, high- and very high-volume groups for overall mortality were 0.70 (0.48-1.02; P = 0.060), 0.52 (0.34-0.81; P = 0.004) and 0.16 (0.09-0.30; P < 0.001), respectively. There is a linear trend between higher hospital volume and lower in-hospital mortality of liver resection in Japan, particularly for lobectomy and extended lobectomy. Based on these results, regionalization of lobectomy and extended lobectomy in high-volume centers could be effective for reducing postoperative mortality.

Application of a computer-assisted operation planning system in curative hepatectomy for complex hilar cholangiocarcinoma

Objective To evaluate a computer-assisted operation planning system in curative hepatectomy for complex hilar cholangiocarcinoma.Methods The clinical data of 15 patients with complex hilar cholangiocarcinoma who were admitted to the Chinese PLA General Hospital from January 2008 to December 2009 were retrospectively analyzed.Based on triple-phase contrast-enhanced computed tomography inages,a computer-assisted operative planning system was used to evaluate the anatomic relationship between the tumor and its adjacent vessels,liver volume,operative feasibility,and the potential surgical approaches.The accuracy of three-dimensional reconstruction was tested by comparison to actual intraoperative findings.The correlation between actual liver resection volumes and predicted liver resection volumes was analyzed by calculating a Pearson correlation coefficient.Differences in liver volumes calculated by two-dimensional techniques versus three-dimensional reconstruction were analyzed using the paired t test,and the error rate was compared using the chi-squarc test. Results Fifteen patients received curative hepatectomy,including extended hemihepatectomy in 8 patients and trisectionectony in 7 patients.Preoperative evaluation of the hepatic anatomy based on three-dimensional reconstruction imaging was confirmed with operative findings.The sensitivity,specificity and accuracy rates were 100.0％,72.7％ and 72.7％ for patients with portal invasion and 100.0％,78.6％ and 78.6％ for patients with hepatic arterial invasion,respectively.The actual liver resection volume was positively correlated with the predicted liver resection volume ( r =0.974,P ＜ 0.05 ).The mean liver volumes calculated by the three-dimensional reconstruction and the two-dimen-sional techniques were (458 ±86)ml and (491 ± 103 )ml,respectively,with no significant difference (t =-1.911,P ＞0.05 ).The error rates of the three-dimensional reconstruction and the two-dimensional techniques were 4.7％ and 7.2％,respectively,with no significant differnece ( x2 =2.381,P ＞ 0.05 ).Five patients had postoperative complications,and each was cured with conservative or interventional management. Conclusion The application of a computer-assisted operation planning system may improve the safety and accuracy of curative resection for complex hilar cholangiocarcinoma. Key words: Cholangioearcinoma, hilar; Thrce-dimensional reconstruction; Surgical planning; Hepatectomy

Value of a virtual liver surgery planning system in predicting hepatic dysfunction after hepatectomy for liver cancer

Objective To calculate the residoal liver volume using a virtaal liver surgery planning system,and to investigate the value of standardized estimated liver remnant volume ratio (STELR) in prcdicting hepatic dysfunction after hepatectomy.Methods The clinical data of 76 patients with primary liver cancer who were admitted to the First Affiliated Hospital of Fujian Medical University from April 2007 to October 2011 were retrospectivcly analyzed.The virtual resection and residual liver volume measurements were carried out using Liv 1.0 software.The value of STELR in predicting hepatic dysfunction was assessed using receiver operator characteristic (ROC) curves.Effects of different risk factors on postoperative hepatic dysfunction were analyzed using univariate analysis of variance and multivariate Logistic regression models. Results The mean residual liver volumes predicted by the software and resected during operation were (489 ± 206)ml and (459 ± 199 )ml,respectively,with a positive correlation between predicted and actual resection volumes (r =0.916,P ＜ 0.05).Of the 76 patients,48 had mild hepatic dysfunction,19 had moderate hepatic dysfunction and 9 had severe hepatic dysfunction.A critical STELR of 53％ was associated with severe hepatic dysfunction.Severe hepatic dysfunction was detected in 2 out of 59 (3％) patients with STELR ≥ 53％ and 7 out of 17 (41％) patients with STELR ＜ 53％,which represented a significant difference ( x2 =5.085,P ＜ 0.05 ).The result of univariate analysis revealed that STEL,R,operating time,intraoperative blood loss were significant prognostic indicators for severe hepatic dysfunction ( F =7.227,8.630,13.809,P ＜0.05).Multivariate Logistic regession revealed that STELR was a significant independent predictor of severe hepatic dysfunction ( Wald =6.675,P ＜ 0.05 ).Conclusion The likelihood of severe hepatic dysfunction after hepatectomy can be predicted by STELR. Key words: Liver neoplasms; Surgical planning; Liver volume

Equivalent Outcomes After Anatomical and Non-anatomical Resection of Small Hepatocellular Carcinoma in Patients with Preserved Liver Function

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument. The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function. The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups. There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival. AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.

Impact of preoperative targeted therapy on postoperative complications after resection of colorectal liver metastases

The impact of chemotherapy (CTx) on morbidity after liver resection for colorectal metastases (CRC-LM) has been increasingly investigated during recent years. Biologic agents like bevacizumab (BEV) or cetuximab (CET) are now added as "targeted therapy" (TT), also in neoadjuvant settings. Initial series could demonstrate the safety of those regimens in liver resection but data are still scarce. We evaluated the impact of CTx with BEV or CET (CTx + TT) on perioperative morbidity and mortality. Two hundred thirty-seven patients who underwent liver resections for CRC-LM after chemotherapy before surgery since 1999 were included. One hundred eighty-five patients (78%) had preoperative CTx regimen without biologic agents (fluoropyrimidine-, oxaliplatin-, or irinotecan-based) and 52 (22%) had CTx + TT (39 BEV, 11 CET, 2 CET/BEV). After preoperative CTx + TT, a time interval of at least 4-6 weeks and a residual liver volume of >35% before surgery were required. Hemihepatectomy or more was performed in about half of the patients. The median amount of intraoperatively transfused blood was 0 ml in both groups (p = 0.34). Overall mortality was 1.7% and slightly elevated in patients with CTx + TT (3.8% vs. 1.1%, p = 0.17). Any complication occurred in (CTx + TT vs. CTx) 52% and 46%, respectively (p = 0.47). The rates of liver failure (9.6% vs. 9.7%, p = 0.98), infectious complications such as wound infection (19% vs. 16%, p = 0.62) and abdominal abscess (8% vs. 6.5%, p = 0.71), as well as the rate of relaparotomies (11.5% vs. 7.0%, p = 0.29) showed no significant differences between the groups with TT or without. In multivariate analyses, neither type nor duration of CTx nor the time interval between CTx and surgery showed any influence on complication rates. Our data confirm the safety of targeted therapy before liver resection for CRC-LM. This effect may in part be due to our treatment policy (time interval to resection and residual liver volume) after intensive preoperative CTx.

Total resection of the right hepatic vein drainage area with the aid of three-dimensional computed tomography

We analyzed the feasibility and safety of our preliminary surgical approach for total hepatic resection of the right hepatic vein drainage area (THR-RHV) with the aid of three-dimensional computed tomography (3D-CT) guidance. Clinical findings and 3D-CT volumetry results were investigated in five patients who underwent THR-RHV for a hepatic malignant tumor close to the right hepatic vein (RHV). The mean estimated remnant liver volume after a conventional right lobectomy was 474 ml, whereas that after THR-RHV was 614 ml, indicating that 140 ml (13.8%) of additional liver volume had been preserved by performing THR-RHV. The median operative time, mean ischemic time, and mean blood loss during surgery were 406 min, 51 min, and 587 ml, respectively. Histological examinations confirmed a negative surgical margin in all five patients. The mean liver volume estimated by 3D-CT was 458 ml, whereas the mean actual resected liver volume was 468 g, resulting in a mean error ratio of 3.1%. THR-RHV allowed for a higher remnant liver volume than that after conventional right lobectomy of the liver, and proved feasible with acceptable perioperative results. This technique thus promotes both safety and curability for patients with a tumor close to the RHV.

Prospective Volumetric Assessment of the Liver on a Personal Computer by Nonradiologists Prior to Partial Hepatectomy

BackgroundA small remnant liver volume is an important risk factor for posthepatectomy liver failure. ImageJ and OsiriX® are both free, open-source image processing software packages. The aim of the present study was to compare ImageJ and OsiriX® in performing prospective computed tomography (CT) volumetric analysis of the liver on a personal computer (PC) in patients undergoing major liver resection.MethodsPatients scheduled for a right hemihepatectomy were eligible for inclusion. Two surgeons and one surgical trainee measured volumes of total liver, tumor, and future resection specimen prospectively with ImageJ and OsiriX®. A radiologist also measured these volumes with CT scanner-linked Aquarius iNtuition® software. Resection volumes were compared with the actual weights of the liver specimens removed during surgery, and differences between the measured liver volumes were analyzed.ResultsA total of 15 patients (8 men, 7 women) with a median age of 63 years (48–79 years) were included. There was a significant correlation between the measured weights of resection specimens and the volumes calculated prospectively with ImageJ and OsiriX® (r = 0.89; r = 0.83, respectively). There was also a significant correlation between the volumes measured with radiological software iNtuition® and the volumes measured with ImageJ and OsiriX® (r = 0.93; r = 0.95, respectively).ConclusionsThere were no major differences in total liver volumes, resection volumes, or tumour volumes for these three software packages. Prospective hepatic CT volumetry with ImageJ or OsiriX® is reliable and can be accurately used on a PC by nonradiologists. ImageJ and OsiriX® yield results comparable to the radiological software iNtuition®.

Virtual Liver Resection and Volumetric Analysis of the Future Liver Remnant using Open Source Image Processing Software

BackgroundAfter extended liver resection, a remnant liver that is too small can lead to postresection liver failure. To reduce this risk, preoperative evaluation of the future liver remnant volume (FLRV) is critical. The open-source OsiriX® PAC software system can be downloaded for free and used by nonradiologists to calculate liver volume using a stand-alone Apple computer. The purpose of this study was to assess the accuracy of OsiriX® CT volumetry for predicting liver resection volume and FLVR in patients undergoing partial hepatectomy.MethodsPreoperative contrast-enhanced liver CT scans of patients who underwent partial hepatectomy were analyzed by three observers. Two surgical trainees measured the total liver volume, resection volume, and tumor volume using OsiriX®, and a radiologist measured these volumes using CT scanner-linked Aquarius iNtuition® software. Resection volume was correlated with prospectively determined resection weight, and differences in the measured liver volumes were analyzed. Interobserver variability was assessed using Bland–Altman plots.Results25 patients (M/F ratio: 13/12) with a median age of 61 (range, 34–77) years were included. There were significant correlations between the weight and volume of the resected specimens (Pearson’s correlation coefficient: R2 = 0.95). There were no major differences in total liver volumes, resection volumes, or tumor volumes for observers 1, 2, and 3. Bland–Altman plots showed a small interobserver variability. The mean time to complete liver volumetry for one patient using OsiriX® was 19 ± 3 min.ConclusionsOsiriX® liver volumetry performed by surgeons is an accurate and time-efficient method for predicting resection volume and FLRV.

W1668 The use of Intraoperative Ablation Extends the Limits of Potentially Curative Treatment for Recurrent Colorectal Liver Metastases

S A T A b st ra ct s or 16% of all the patients experienced intraoperative blood loss of more than 1500ml. During operation, 16 patients (7%) received red cell blood transfusion. Two patients (0.9%) were returned to the operating room for postoperative hemorrhage. Univariate analysis identified body mass index (BMI, p=0.001), tumor size (p=0.002), resected liver volume (p<0.001), serum total bilirubin (p¬=0.053), serum prothrombin time (p=0.044), serum glutamate pyruvate transaminase (p=0.041), major hepatectomy (p<0.001), wide incision with right thoracotomy (p=0.085), and additional operative procedure (p=0.034) as risk factors for massive intraoperative blood loss; multivariate analysis identified major hepatectomy (p<0.001) and BMI (p=0.005) as independent risk factors of blood loss of more than 1500 ml. Conclusions: Autologous blood storage might be indicated in patients with these predictive factors. Laparoscopic hepatectomy should not be considered in these patients, because of increased intraoperative blood loss.

Application of computer-assisted operation planning system in precise hepatectomy.

Objective To investigate the clinical value of computer-assisted operation planning system for precise hepatectomy.Methods The clinical data of 45 patients who had undergone precise hepatectomy at General Hospital of PLA from November 2006 to November 2009 were retrospectively analyzed.The 3-dimensional imaging of liver was constructed by computer-assisted operation planning system,and the anatomic relationship between hepatic vasculature and tumor Was analyzed.Volume of hepatic segments,total liver volume,tumor volume,predicted resection volume and the remnant liver volume were calculated before operation.Virtual liver resection was performed in order to select the best operative procedure.The predicted resection volume Was compared with the hepatic segment resected.All data were analyzed by t test,Pearson rank correlation analysis and chi-square test.Results The predicted resection volume calculated based on the 2-dimensional imaging was similar to that calculated based on the 3-dimensional imaging(t=2.125,P>0.05).The three-grade branches of the hepatic artery,portal vein and hepatic vein were clearly shown in the computer-assisted operation planning system.The anatomic relationship between tumor and adjacent vessels was quantitatively analyzed.There was a positive correlation between the predicted resection volume and the resected liver volume(r=0.999,P<0.05),and the error rate Was 5.1%.All patients received anatomical hepatectomy,and the incidence of postoperative complications was 20%(9/45).No liver failure or perioperative mortality was observed.Conclusion Computer-assisted operation planning system may facilitate and promote precise hepatectomy. Key words: Computer-assisted operation planning system; Precise hepatectomy; Liver neoplasms