Resection Of Hepatic Tumors Research Articles

Hepatic resection for metastatic liver tumor after lung cancer resection in a chronic renal failure patient with long-term survival

症例は83歳男性で，2012年1月に肺癌に対し左肺上葉切除術を行った．術後病理診断はstage IIBであったが，高齢でありまた維持透析中であったため術後補助化学療法は行わず画像検査のみを行っていた．術後11ヵ月目の胸腹部CT検査で肝S8に径1.5 cmの腫瘤が認められ，肺癌孤立性肝転移再発の診断となり，肝部分切除術を行った．術後病理検査は転移性扁平上皮癌で肺癌肝転移の診断となった．肝切除後5年を経過しているが現在無再発生存中である．肺癌の肝転移症例は切除の対象となることは少ないが，他に非治癒因子がなく肝転移巣が完全に切除できるのであれば肝切除により予後の改善が見込める症例が存在すると思われた．

Sex-determining region on Y chromosome is a key mediator of sexual dimorphism in hepatic ischemia/reperfusion injury

Introduction: Females seem be more tolerant to liver ischemia/reperfusion (I/R) injury than males, the mechanisms of which remains unknown. The objective of the current study was to identify the role of sex-determining region on Y chromosome (SRY) on hepatic I/R-induced liver damage. Method: 771 patients who underwent hepatic resection (HR) for hepatic tumors were included, and the postoperative outcome was compared between female and male patients by using propensity score matching (PSM) analysis. Hepatocyte-specific SRY transgenic mice were generated and subjected to an I/R model in vivo. In vitro experiments were performed by treating primary hepatocytes from these mice with hypoxia/reoxygenation stimulation. The function of SRY in I/R-induced liver damage and the potential underlying mechanisms were investigated through various phenotypic analyses and biological approaches. Result: The incidence of overall postoperative complications, mortality and liver failure was significantly higher among male versus female patients (all p<0.05). SRY expression was significantly upregulated after hepatic I/R injury. Overexpression of SRY in male or female (SRY TG) mice promoted hepatic I/R injury as manifested by increased inflammatory reaction, oxidative stress and cell death versus age- and gender matched littermates. Direct binding and activation of GSK3β by SRY and subsequent inhibition of Wnt/β-catenin signaling accounted for the susceptibility of SRY TG mice to hepatic I/R injury. Activation of β-catenin by LiCl abrogated SRY-initiated I/R injury. Conclusion: SRY is a novel mediator inducing sex specific hepatic I/R via inactivation of Wnt/β-catenin signaling. Modulation of SRY in males is a unique mode of regulating Wnt/ β-catenin signaling, and provides novel opportunities in devising therapeutics in specific hepatic injury.

Hepatic vein reconstruction for parenchema-sparing resection of advanced hepatic tumors

Hepatic vein reconstruction for parenchema-sparing resection of advanced hepatic tumors

Major vascular resection and reconstruction combined with liver resection for primary and metastatic hepatic tumors

Major vascular resection and reconstruction combined with liver resection for primary and metastatic hepatic tumors

Comparetive analysis of laparoscopic-assisted and open liver resection for large hepatic tumors

Background: This study aimed to assess outcomes of Laparoscopic-Assisted Resection(LAR) and Open Liver Resection(OLR) for large (≥ 8 cm) liver tumors. Methods: A prospectively collected database of 350 liver resection was reviewed from January of 2015 to August 2017. The data for patients undergoing LAR comparing with OLR for large liver tumors were analyzed. Results: During the period studied, 30 LARs and 43 OLR were performed (females, 54 %; mean age, 55.4 years) for large tumors. Patients with benign tumors were 20 in LAR and 27 in OLR group. Patients with malignant tumors were 10 in LAR and 16 in OLR group. The mean diameter of tumor in LAR group was 126 mm and in OLR - 120 mm (p>0,05). The median operative time was 382 min in LAR and 350 min in OLR group(p>0,05), and the blood loss was 310 ml for LAR and 790 ml for OLR group(p< 0,05). The Clavien-Dindo complications IIIa-b were 10% in LAR and 11,6% in OLR (p>0,05), and no mortality occurred during a 90-day period. Conclusion: The findings showed that LAR is feasible and safe for large liver tumors, has less blood loss and can be performed with acceptable morbidity.

Evaluation of Anemia and Nutritional Status on Children Undergoing Resection of Primary Liver Tumors

IntroductionComplete tumor resection of primary malignant liver tumors offers the best chance of survival. However, many of these children may experience anemia and failure to thrive. This study analyzes the association of preoperative anemia and nutritional support with outcomes in children undergoing major resection of primary malignant liver tumors. MethodsUsing the National Surgical Quality Improvement Program Pediatric database from 2012 to 2015, children undergoing major liver resections for primary malignant hepatic tumors were selected. Patient demographics, comorbidities, and 30-d outcomes were compared with respect to the presence of preoperative anemia and the need for nutritional support. Outcomes included 30-d postoperative complications, perioperative blood transfusions, and hospital readmissions. Propensity score matching was performed to control for significant confounders. ResultsOne hundred ten children were included, 76 (69.1%) with preoperative anemia, and 36 (32.7%) receiving nutritional support. Anemia was associated with preoperative chemotherapy (P = 0.02) and steroids (P = 0.03). Nutritional support was associated with cardiac (P = 0.01), respiratory (P < 0.01), neurologic (P < 0.01), and hematologic comorbidities (P = 0.02). There were 20 (18.2%) postoperative complications and 6 (5.5%) hospital readmissions. After propensity score matching, there was no difference in complications between anemic and nonanemic patients (P = 0.13). Preoperative nutritional support was associated with an increased rate of complications (P < 0.01). Neither anemia (P = 1.00) nor nutritional support (P = 0.49) were associated with readmissions. ConclusionsThe need for nutritional support is common in children undergoing resection of primary malignant hepatic tumors. Anemia was not significantly associated with postoperative complications. In this study, nutritional support was associated with an increased risk of postoperative complications. The need for nutritional support may warrant special attention to the patient's overall conditioning during operative planning.

Comparison of resection site of standardized laparoscopic hepatic tumor resection.

IntroductionThe degree of difficulty in laparoscopic hepatic resection (LHR) was higher in tumors involving the suprahepatic segments than other sites. However, thanks to surgical instruments and procedures being improved and standardized, LHR can be performed safely in all regions.AimWe report our standardized surgical techniques and outcomes in a series of patients undergoing LHR in our hospital and analyze the surgical outcomes, particularly with regard to the site of resection.Material and methodsWe retrospectively analyzed data from 238 patients who underwent standardized laparoscopic partial hepatic resection between 2010 and 2017. In standardized LHR, the operator formed a triangle with the laparoscope in the center, maintaining a co-axial position by changing the port where the laparoscope was inserted.ResultsOperative time for the resection of tumors of the right hepatic lobe was 202 ±92 min and 140 ±104 min for tumors of the left hepatic lobe (p = 0.0024); intraoperative blood loss was 80 ±170 ml and 19 ±127 ml, respectively (p = 0.0016). No differences were found in the surgical outcomes between the various segments of the right hepatic lobe. In the left hepatic lobe, operative time was significantly shorter with laparoscopic tumor resection in segment III (p = 0.0023).ConclusionsDuring standardized LHR, a better field of vision with the greater ease can be established during resection of the left hepatic lobe compared to that of the right hepatic lobe. Nonetheless, LHR of the right lobe can be performed safely using various surgical instruments and techniques.

Perioperative liver and spleen elastography in patients without chronic liver disease.

AIMTo investigate changes in hepatic and splenic stiffness in patients without chronic liver disease during liver resection for hepatic tumors.METHODSPatients scheduled for liver resection for hepatic tumors were considered for enrollment. Tissue stiffness measurements on liver and spleen were conducted before and two days after liver resection using point shear-wave elastography. Histological analysis of the resected liver specimen was conducted in all patients and patients with marked liver fibrosis were excluded from further study analysis. Patients were divided into groups depending on size of resection and whether they had received preoperative chemotherapy or not. The relation between tissue stiffness and postoperative biochemistry was investigated.RESULTSResults are presented as median (interquartile range). 35 patients were included. The liver stiffness increased in patients undergoing a major resection from 1.41 (1.24-1.63) m/s to 2.20 (1.72-2.44) m/s (P = 0.001). No change in liver stiffness in patients undergoing a minor resection was found [1.31 (1.15-1.52) m/s vs 1.37 (1.12-1.77) m/s, P = 0.438]. A major resection resulted in a 16% (7%-33%) increase in spleen stiffness, more (P = 0.047) than after a minor resection [2 (-1-13) %]. Patients who underwent preoperative chemotherapy (n = 20) did not differ from others in preoperative right liver lobe [1.31 (1.16-1.50) vs 1.38 (1.12-1.56) m/s, P = 0.569] or spleen [2.79 (2.33-3.11) vs 2.71 (2.37-2.86) m/s, P = 0.515] stiffness. Remnant liver stiffness on the second postoperative day did not show strong correlations with maximum postoperative increase in bilirubin (R2 = 0.154, Pearson’s r = 0.392, P = 0.032) and international normalized ratio (R2 = 0.285, Pearson’s r = 0.534, P = 0.003).CONCLUSIONLiver and spleen stiffness increase after a major liver resection for hepatic tumors in patients without chronic liver disease.

Surgical Approach to “Right Hepatic Core”: Deepest Region Surrounded by Major Portal Pedicles and Right Hepatic Vein

Background/Aims: The resection of hepatic tumors located in the region surrounded by the right hepatic vein (RHV) and the portal pedicles of the right paramedian/lateral sector (the right hepatic core) remains a challenge for liver surgeons. The aim of this study was to demonstrate the surgical techniques and outcomes of our atypical-parenchyma-sparing hepatectomy (atypical-PSH) approach for the removal of tumors in the right hepatic core. Methods: Perioperative records of 1,179 consecutive patients who had undergone hepatectomy for hepatocellular carcinoma or colorectal liver metastases from January 2006 to December 2014 were retrospectively reviewed. Results: Twenty-six patients (2%) had a tumor in the right hepatic core. Among them, 20 patients underwent atypical-PSH, including the anterior approach (resection of the right paramedian hepatic parenchyma, n = 9), posterior approach (resection of the right lateral hepatic parenchyma, n = 10), and transhepatic approach (tumor enucleation from the raw surfaces along the RHV, n = 1). Their postoperative outcomes were similar to the remaining 6 patients who had undergone right hepatectomy. Conclusions: Atypical-PSH can be safely applied for the removal of tumors in the right hepatic core. This technique may have potential advantages in preserving hepatic function for postoperative chemotherapy and repeated hepatectomy for future recurrence.

Resection of hepatic tumors with central venous and right atrial extension using cardiopulmonary bypass

Abstract Background Pediatric liver tumors occasionally present with vascular invasion. Standard anatomic resections usually result in complete resection when tumor is intra-hepatic; however, direct tumor extension into the inferior vena cava (IVC) and right atrium (RA) requires additional considerations. Here we present our surgical approach to resection of primary liver tumors directly extending into the IVC and RA. Methods A retrospective analysis of patients undergoing hepatic resection of primary liver tumors with direct extension into the IVC and RA from 1/2013-4/2015 was performed. Results Three patients were identified with tumors arising from the left hepatic lobe, extending into the suprahepatic IVC and RA. Two underwent in-situ parenchymal division, followed by cardiopulmonary bypass (CPB) for en-bloc resection of the intra-atrial tumor. The third had a congested right lobe due to venous obstruction by tumor, thereby requiring total hepatectomy, en-bloc intra-caval tumor excision, ex-situ left hemihepatectomy, and auto-transplantation of the right lobe. All patients required partial IVC or RA resection and reconstruction. Postoperatively, one patient died from metastatic disease at 5 months and two patients were alive after 50 months and 33 months. Conclusion Cardiopulmonary bypass provides a safe, controlled approach for en-bloc resection of hepatic tumors extending into the IVC and RA. This minimizes the risk of tumor fracture or spillage, allowing for complete gross resection.

Curative Resection of Single Primary Hepatic Malignancy: Liver Imaging Reporting and Data System Category LR-M Portends a Worse Prognosis

The purpose of this study was to examine the associations between preoperative Liver Imaging Reporting and Data System (LI-RADS) categories and prognosis after curative resection of single hepatic malignancies in patients with chronic liver disease. Between January 2008 and December 2010, 225 patients with chronic liver disease underwent resection of single hepatic malignant tumors (218 hepatocellular carcinomas, three cholangiocarcinomas, four biphenotypic carcinomas) after undergoing gadoxetic acid-enhanced MRI. Two radiologists retrospectively categorized the tumors into LI-RADS categories. Differences in disease-free survival duration between categories were analyzed by the Kaplan-Meier method with the log-rank test. Reviewer 1 categorized two (0.9%) patients as having LR-3, 53 (23.6%) LR-4, 159 (70.7%) LR-5, and 11 (4.9%) LR-M lesions. The corresponding numbers for reviewer 2 were six (2.7%) LR-3, 30 (13.3%) LR-4, 178 (79.1%) LR-5, and 11 (4.9%) LR-M. The 2-year cumulative recurrence or death rates were 15.1% for lesions categorized LR-3 or LR-4 by reviewer 1, 31.7% for LR-5, and 60% for LR-M. For lesions categorized by reviewer 2 the corresponding rates were 20.6% for LR-3 or LR-4, 29% for LR-5, and 54.5% for LR-M. Disease-free survival was significantly worse among patients with lesions categorized as LR-M than for lesions categorized as LR-3 or LR-4 or as LR-5 (p < 0.01 for both reviewers). Disease-free survival did not significantly differ between patients with LR-3 or LR-4 and those with LR-5 lesions (reviewer 1, p = 0.301; reviewer 2, p = 0.291). Patients with tumors preoperatively categorized as LR-M may have a worse prognosis than those with tumors categorized LR-3, LR-4, or LR-5 after curative resection of single hepatic malignancy.

Application of intercostal transthoracic trocars to laparoscopic hepatectomy

Background: Since Couinaud’s hepatic segment VII and VIII are located at the cranial ends of the liver just beneath the diaphragm, resection of hepatic tumors in these regions is technically difficult even by open surgery. Recently, intercostal transthoracic trocars (ITT) have become widely used in laparoscopic hepatectomy for the tumors located in segment VII and/or VIII. Methods: ITT have been used for laparoscopic hepatectomy, as described below: following pneumoperitoneum and placement of abdominal trocars, one or two balloon-tipped trocars are inserted into the abdominal cavity from intercostal space, through pleural space and the diaphragm. At this moment, lower edge of the right lung should be confirmed by ultrasonography and laparoscopic examination. Following minimal mobilization of the right liver, hepatic parenchyma is transected by using the intercostal trocars as a camera port or for the forceps of surgeon’s left hand. Incisions on the diaphragm are suture closed prior to closure of the abdominal wounds. Results: Among the 121 patients who underwent laparoscopic hepatectomies, ITT was used in 17 patients (14%) for resection of tumors located in segment VII (n=6) or VIII (n=11). Median (range) operation time and amount of blood loss for hepatectomy were 226 [109–565] minutes and 70 [3–680] mL, respectively. No postoperative complications associated with the use of ITT occurred. Conclusions: ITT can be used easily and safely, facilitating laparoscopic hepatectomy for the tumors located in segment VII and/or VIII.

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity.

To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome. ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome. ALPPS centers of the International ALPPS Registry having performed ≥10 cases over a period of ≥3 years were assessed for 90-day mortality and major interstage complications (≥3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies. Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36-1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18-0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers. Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.

Perioperative hepatocyte growth factor (HGF) infusions improve hepatic regeneration following portal branch ligation (PBL) in rodents.

As hepatic surgery has become safer and more commonly performed, the extent of hepatic resections has increased. When there is not enough expected hepatic reserve to facilitate primary resection of hepatic tumors, a clinical adjunct to facilitating primary resection is portal vein embolization (PVE). PVE allows the hepatic remnant to increase to an appropriate size prior to resection via hepatocyte regeneration; however, PVE is not always successful in facilitating adequate regeneration. One of the strongest trophic factors for hepatocyte regeneration is hepatocyte growth factor (HGF). The purpose of this study was to improve hepatic regeneration with perioperative HGF infusions in an animal model that mimics PVE. Portal branch ligation (PBL) in rodents is equivalent to PVE in humans. We performed left-sided PBL in Sprague-Dawley rodents with the experimental group receiving perioperative HGF infusions. Baseline and postoperative liver volumetrics were obtained with CT scanning methods as performed in clinical practice. Baseline and postoperative liver functions were assessed via indocyanine green (ICG) elimination testing. HGF infused rodents had statistically significant increase in all postoperative liver volumetrics. Most clinically relevant were increased right liver volumes (RLV), 14.10 versus 7.85cm3 (p value 0.0001), and increased degree of hypertrophy (DH%), 159.23 versus 47.11% (p value 0.0079). HGF infused rodents also had a quick return to baseline liver function, 2.38days compared to 6.13days (p value 0.0001). Perioperative HGF infusions significantly increase hepatic regeneration following PBL in rodents. Perioperative HGF infusions following PVE are a possible adjunct to increase the amount of patients able to successfully undergo primary resection for hepatic tumors. Further basic science is warranted in examining the use of HGF infusions to increase hepatic regeneration and translating that basic science work to clinical practice.

1044P - Incremental cost-effectiveness analysis of hepatic metastasectomy in patients with advanced colon cancer and liver metastasis

Colorectal cancer with liver metastasis is a potentially curable malignancy. Multidisciplinary treatment including hepatic tumor resection provides 20-40% 5 year survival rate. However, the utility of hepatic resection for liver metastases in colorectal cancer is still debatable. Liver metastasectomy requires specialized centers having expertise, resources, and awareness which consume significant amount of hospital budgets. We aimed to evaluate the cost-effectiveness of hepatic metastasectomy in patients with advanced colon cancer with liver metastasis. Medical records of advanced colon cancer patients with liver metastasis only who treated at the King Chulalongkorn Memorial Hospital during January 2007 to 31 December 2010 were reviewed. The study endpoint is to compare the cost per life-year gained in term of incremental cost-effectiveness ratio (ICER) between with or without hepatic metastasectomy by the decision model. Data regarding site of primary tumor, characteristics of liver metastases, treatment strategies, chemotherapy regimens, biologic agents, complications, health coverage and survival data were collected and analyzed. There were 34 patients in liver surgery group and 28 patients in without surgery group. There was significantly longer median survival time in the surgery group vs no surgery, 42.22 vs 18.04 months, respectively (HR = 23.3, P < 0.001). Individual mean cost per patient was higher in the surgery group at 1,975,349 baht (60,446 USD)/case compared to no surgery group at 1,451,028 baht (44,402 USD)/case. The ICER of liver surgery over no surgery was 247,150 baht (7,563 USD) per life-year gained which is lower than the threshold derived from the national gross domestic product per capita. Under the routine clinical service, hepatic metastasectomy is a cost-effective option for patients with colon cancer with liver only metastasis in the tertiary care hospital setting.

Laparoscopic detection and resection of occult liver tumors of multiple cancer types using real-time near-infrared fluorescence guidance

BackgroundTumor recurrence after radical resection of hepatic tumors is not uncommon, suggesting that malignant lesions are missed during surgery. Intraoperative navigation using fluorescence guidance is an innovative technique enabling real-time identification of (sub)capsular liver tumors. The objective of the current study was to compare fluorescence imaging (FI) and conventional imaging modalities for laparoscopic detection of both primary and metastatic tumors in the liver.MethodsPatients undergoing laparoscopic resection of a malignant hepatic tumor were eligible for inclusion. Patients received standard of care, including preoperative CT and/or MRI. In addition, 10 mg indocyanine green was intravenously administered 1 day prior to surgery. After introduction of the laparoscope, inspection, FI, and laparoscopic ultrasonography (LUS) were performed. Histopathological examination of resected suspect tissue was considered the gold standard.ResultsTwenty-two patients suspected of having hepatocellular carcinoma (n = 4), cholangiocarcinoma (n = 2) or liver metastases from colorectal carcinoma (n = 12), uveal melanoma (n = 2), and breast cancer (n = 2) were included. Two patients were excluded because their surgery was unexpectedly postponed several days. Twenty-six malignancies were resected in the remaining 20 patients. Sensitivity for various modalities was 80 % (CT), 84 % (MRI), 62 % (inspection), 86 % (LUS), and 92 % (FI), respectively. Three metastases (12 %) were identified solely by FI. All 26 malignancies could be detected by combining LUS and FI (100 % sensitivity).ConclusionThis study demonstrates added value of FI during laparoscopic resections of several hepatic tumors. Although larger series will be needed to confirm long-term patient outcome, the technology already aids the surgeon by providing real-time fluorescence guidance.

Application of modified hand-assisted laparoscopic surgery in the abdominal surgery

Objective To investigate the safety and feasibility of modified hand-assisted laparoscopic surgery (MHALS) in the abdominal surgery. Methods The clinical data of 8 patients who underwent long-sleeved MHALS at the First People's Hospital of Foshan between September 2014 and January 2015 were retrospectively analyzed. Among the 8 patients, right liver cancer with intrahepatic metastasis was found in 2 patients, left liver cancer in 1 patient, hepatic peripheral nerve sheath tumor in 1 patient, left retroperitoneal leiomyosarcoma in 1 patient, extra-and intra-hepatic cholangiolithiasis in 1 patient, choledochocyst in 1 patient and ampulla cancer in 1 patient. Laparoscopic protection sleeve went through the middle of incision-retractor, and then wrapped around it about 10 cm. Incision-retractor was fixed at the abdominal incision firstly, laparoscopic procedures were performed when the wrist of assisted hand was bound and fixed by the distal of sleeve.The patients were followed up by out-patient examination and telephone interview till March 2015. Results All the 8 patients underwent successful MHALS, including 1 of right hemihepatectomy in situ, 1 of ligation of right portal vein+ left liver split (the patient gave up two-stage operation due to intractable ascites and elevated bilirubin), 1 of hepatic left lateral lobectomy (the patient underwent hemostatic sutures in open surgery due to hemorrhage of liver's cutting surface), 1 of hepatic peripheral nerve sheath tumor resection, 1 of left retroperitoneal leiomyosarcoma resection, 1 of choledocholithotomy+ left hepatectomy+ cholecystectomy+ T tube drainage, 1 of choledochocyst+ biliary enteric drainage and 1 of pancreaticoduodenectomy. Four patients had assisted incision of 4 cm, and another 4 patients of 7 cm. Eight patients were followed up for a median time of 3 months (range, 2-7 months). The patient who received ligation of right portal vein+ left liver split died at postoperative month 3, and the others didn't have recurrence of tumor or lithiasis. Conclusion The MHALS is safe and feasible in the abdominal surgery. Key words: Liver neoplasms; Abdominal surgery; Laparoscopy, hand-assisted

Robot-integrated intraoperative ultrasound: Initial experience with hepatic malignancies

Purpose: A new robotic surgery tool allows intraoperative ultrasound to be performed using a fully robotic technique. Herein, we evaluate the feasibility and reliability of robotically integrated ultrasound to guide resection of malignant hepatic tumors. Material and methods: A consecutive series of ultrasound-guided robotic resections of primary and secondary hepatic malignancies was analyzed in terms of perioperative data and specimen evaluation, focusing on the reliability of the new robot-integrated ultrasound probe. Results: Ten consecutive patients underwent 15 robotic liver resections. Two patients were resected to excise primary hepatocellular cancers and eight underwent resections of liver metastases. R0 resections were achieved for all lesions. The median operative time was 247 min, and blood loss was limited. No mortality occurred. Conclusions: Our present analysis confirmed the reliability of fully robotic liver resection guided via robotically integrated ultrasonic assessment. Robotic surgery, particularly hepatic resection, may benefit greatly from better manageability, and the fact that the surgeon can directly manage both the operative and the diagnostic parts of the procedure.

Surgical therapy of neuroendocrine neoplasm with hepatic metastasis: patient selection and prognosis.

Patients with neuroendocrine neoplasms (NEN) develop hepatic metastases in 50-95 %. The aims of this study were to evaluate the outcome/prognosis of patients following hepatic surgery and to identify predictive factors for the selection of patient that benefit from hepatic tumor resection. In a retrospective single-center study (1990 to 2014), 204 patients with hepatic metastasis of NEN were included. Ninety-four were subjected to various forms of liver resection. According to the overall survival, the influence of several prognostic factors like the Ki-67 index, stage of disease, and resection status was evaluated. The primary tumor was located in the small intestine (n = 73), pancreas (n = 58), colon (n = 26), esophagus or stomach (n = 9) and in 38 patients the primary site was unknown. The Ki-67 index was associated with significant different overall survival. Patients with an R0 resection (n = 38) of their hepatic metastasis had a very good 10-year survival of 90.4 %. Patients in whom an R1 (n = 23) or R2 (n = 33) resection of their hepatic metastasis could be achieved had a 10-year survival of 53.4 and 51.4 %, respectively. The majority of the patients (53.9 %) could not be resected and had a poor 10-year survival rate of 19.4 %. Partial or complete control of endocrine-related symptoms was achieved in all patients with functioning tumors following surgery. The overall 5- and 10-year survival rates were 77.9 and 65.2 %, respectively. Surgical resection of hepatic NEN metastases can reduce symptoms and improve the survival in selected patients with a Ki-67 index less than 20 %. The expected outcome has to be compared to the outcome of alternative treatment strategies. An R0 situation should be the aim of hepatic surgery, but also patients with R1 or R2 resection show a good survival benefit.