Right Hepatectomy In Patients Research Articles

Pure laparoscopic donor right hepatectomy in patients over 50years old: Why age should not be a barrier.

Given the global aging population, the average age of liver donors is increasing. This study aimed to evaluate the surgical outcomes of grafts from pure laparoscopic donor right hepatectomy (PLDRH) in liver donors aged>50years. The medical records of liver donors were retrospectively reviewed. The donors underwent conventional donor right hepatectomy (CDRH) from January 2011 to May 2019 or PLDRH from March 2016 to May 2019. We divided the donors into three groups: PLDRH donors aged ≥50 (n=26; Group 1) and aged<50 (n=257; Group 2), and CDRH donors aged ≥50years (n=66; Group 3). Operation time (p<.01) and hospital stay (p<.01) were significantly lower in Group 1 than in Group 3. Other postoperative outcomes of donors including graft anatomical variation, graft weight, graft-to-recipient weight ratio, and hepatic steatosis were similar among the three groups. Although no postoperative complications occurred in Groups 1 and 3, they were detected in 17 cases (6.6%) in Group 2. No postoperative complications were detected among the recipients. PLDRH was feasible and safe in donors aged over 50years, with outcomes similar to those for donors aged <50years. PLDRH should not be avoided solely based on the donor's age ≥50years.

Pure laparoscopic vs open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis.

Since minimally invasive surgery has been incorporated in overall surgery, pure laparoscopic technology is involved in most hepatectomies, including right hepatectomy, in patients with hepatocellular carcinoma (HCC). However, its feasibility and safety in right hepatectomy are still controversial owing to the limited literature. This study aimed to compare the short- and long-term outcomes of pure laparoscopic right hepatectomy (PLRH) with those of open right hepatectomy (ORH) in patients with HCC. The prospectively collected medical records of 327 patients with HCC who underwent right hepatectomy between January 2010 and April 2020 at Seoul National University Hospital were retrospectively reviewed. We performed 1:1 propensity score matching between the PLRH and ORH groups. The primary end point was short-term outcomes, including hospital stay, blood loss, and morbidity; the secondary end point was long-term outcomes, including overall and recurrence-free survival. Forty-nine patients were included in each group. Patients who underwent PLRH had a shorter postoperative hospital stay than those who underwent ORH (12.2 vs 8.9 days; P < .001). The requirement for blood transfusion was significantly lower in the PLRH group than in the ORH group (10.2% vs 2.0%; P=.010). The operative time (P=.479) and proportion of major complications (P=.487) were comparable between the groups. There were no significant differences in overall survival (P=.524) and the recurrence-free survival rate (P=.576) between the groups. Postoperative outcomes, including oncological outcomes, were comparable between PLRH and ORH, showing that PLRH can be a safe and feasible option to replace ORH in patients with HCC.

Pure laparoscopic versus open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis

Yi-yeon NAM, Suk Kyun HONG*, Sola LEE, Sanggyun SUH, Su Young HONG, Eui Soo HAN, YoungRok CHOI, Nam-Joon YI, Kwang-Woong LEE, Kyung-Suk SUH. Ann Hepatobiliary Pancreat Surg 2022;26:S94. https://doi.org/10.14701/ahbps.2022S1.OP-5-6

Prediction of Remnant Liver Regeneration after Right Hepatectomy in Patients with Hepatocellular Carcinoma Using Preoperative CT Texture Analysis and Clinical Features.

Objectives To predict the regenerative rate of liver in patients with HCCs after right hepatectomy using texture analysis on preoperative CT combined with clinical features. Materials and Methods 88 patients with 90 HCCs who underwent right hepatectomy were retrospectively included. The future remnant liver was semiautomatically segmented, and the volume of future remnant liver on preoperative CT (LVpre) and the volume of remnant liver on following-up CT (LVfu) were measured. We calculated the regeneration index (RI) by the following equation: (LVfu – LVpre)/LVpre) × 100 (%). The support vector machine recursive method was used for the feature selection. The Naive Bayes classifier was used to predict liver RI, and 5-fold cross-validation was performed to adjust the parameters. Sensitivity, specificity, and accuracy were calculated to evaluate the diagnostic efficiency of the model. Results The mean RI was 142.99 ± 92.17%. Of all clinical parameters and texture features, the AST, ALB, PT-INR, Perc.10%, and S(5, −5)Correlat were found to be statistically significant with RI. The diagnostic sensitivity, specificity, and accuracy of the model in the training group were 0.902, 0.634, and 0.768, and the AUC value of the obtained model was 0.841. In the test group, the sensitivity, specificity, and accuracy of the model were 1.0, 0.429, and 0.778, respectively, and the AUC value was 0.844. Conclusion The use of texture analysis on preoperative CT combined with clinical features can be helpful in predicting the liver regeneration rate in patients with HCCs after right hepatectomy.

Technical Feasibility and Surgical Outcomes of Modified Right Hepatectomy in Patients with Gall Bladder Neck Cancer with Jaundice : A Study of 22 Patients

Technical Feasibility and Surgical Outcomes of Modified Right Hepatectomy in Patients with Gall Bladder Neck Cancer with Jaundice : A Study of 22 Patients

Right Hepatectomy In Patient with Absent Portal Vein Bifurcation

Introduction: Understanding of hepatic vascular anatomy and its variations are crucial for performing liver resection and transplantation. Here we present a case of successful right hepatectomy in the patient with absent portal vein bifurcation. Case presentation: 34 years old female presented for elective right hepatectomy. Preoperative CT scan demonstrated absence of portal vein bifurcation. Right hepatectomy was safely achieved by parenchymal division under ultrasound guidance with preservation of intrahepatic portal branches to left hemiliver and without postoperative complications. Discussion: Normal portal vein anatomy is observed in 65-86% of all cases [1, 2]. Of all portal vein anatomy variations, absence of the portal vein bifurcation is rarest among reported with incidence as low as 0.03% [1]. Conclusion: Preoperative recognition of aberrant portal vein anatomy is important for prevention of life-threatening complications after elective hepatectomy and transplantation.

Effects of liver cirrhosis on portal vein embolization prior to right hepatectomy in patients with primary liver cancer.

Preoperative portal vein embolization (PVE) induces compensatory hyperplasia of the future liver remnants (FLR), thus increasing resectability in the non-cirrhotic patients with primary liver cancer (PLC). However, it is unclear if it is similar in patients with liver cirrhosis. Therefore, the present study investigated the PVE value prior to liver resection in patients with PLC, and the liver cirrhotic effects on the compensatory hypertrophy of FLRs following PVE. In the present study, 21 patients with PLC who successfully underwent hepatic resection subsequent to PVE, were retrospectively examined. The patients were divided into a non-cirrhosis group and a cirrhosis group according to the absence or presence of cirrhosis, respectively. The FLR volume between the two groups of patients was compared. There was a significant difference in the FLR volume for all patients prior to, and 4–6 weeks following, PVE (P<0.001). PVE induced significant compensatory hypertrophy in the FLRs whether in the non-cirrhosis group (P=0.002) or cirrhosis group (P<0.001). However, no significant difference was identified between the two groups with respect to FLR volume enlargement 4–6 weeks following PVE (P=0.373). In conclusion, PVE prior to hepatectomy may promote FLR compensatory hypertrophy and an increase in the resectability of PLC tumors. No significant effects of liver cirrhosis were identified on liver lobe hyperplasia following PVE.

Comparison of Clinical Outcomes following Glue versus Polyvinyl Alcohol Portal Vein Embolization for Hypertrophy of the Future Liver Remnant prior to Right Hepatectomy

PurposeTo report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group). Materials and MethodsBetween March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ2 tests. ResultsTechnical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE. ConclusionsPVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.

The anterior hanging-approach improves postoperative course after right hepatectomy in patients with colorectal liver metastases. Results of a prospective study with propensity-score matching comparison

PurposeTo establish the role of the anterior approach with liver hanging maneuver for right hepatectomy in patients with colorectal liver metastases (CRLM). Summary background dataThe indications for hepatectomy in patients with CRLM are expanding. The liver remnant must be protected to avoid morbidity. MethodsWe prospectively enrolled all patients with the diagnosis of CRLM requiring right hepatectomy from 2009 to 2012. In all cases right hepatectomy with an anterior-hanging maneuver approach was attempted. We compared the group of patients who underwent this procedure with a group of patients who had previously undergone a conventional right hepatectomy. To minimize selection bias, propensity score matching was performed, based on baseline patient characteristics. ResultsA right hepatectomy was planned in 57 cases. The anterior-hanging approach was feasible in 85% of cases. Overall morbidity was similar. In-hospital mortality due to hepatic insufficiency was 2.3% in anterior-hanging group compared to 9% in the conventional group (p = 0.30). The incidence of ascites was significantly greater in the conventional group (AH: 18% vs Conv: 54%; p = 0.002), and hospital stay was longer (AH: 10.9 ± 5.7 vs Conv: 14.4 ± 8.1 days; p = 0.05). Bilirubin levels were significantly lower in anterior-hanging group in day 1 and 3. There were no differences on recurrence nor survival. ConclusionsThe anterior-hanging approach for right hepatectomy in patients with CRLM can be used safely with a high feasibility rate. Its use contributes to improve postoperative course.

Prognostic effect of preoperative sequential transcatheter arterial chemoembolization and portal vein embolization for right hepatectomy in patients with solitary hepatocellular carcinoma.

Backgrounds/AimsBoth preoperative transcatheter arterial chemoembolization (TACE) alone and portal vein embolization (PVE) alone have a detrimental prognostic effect on the post-resection outcomes in patients with hepatocellular carcinoma (HCC). The main objective of this study was to assess the prognostic impact of preoperative TACE on the long-term survival outcomes in patients undergoing preoperative PVE and right liver resection for solitary HCC.MethodsPatients who underwent macroscopic curative right liver resection of solitary HCC that lied between 3.0 and 7.0 cm (n=113) with or without preoperative TACE and PVE were selected for the study, making these subjects were divided into three groups; the TACE-PVE group (n=27), the PVE-alone group (n=13), and the control group (n=73). The subjects in the three groups were followed up for ≥36 months or until death.ResultsThe 1-, 3-, 5-, and 10-year overall patient survival rates of all 113 patients were 96.5%, 88.2%, 81.3% and 65.0%, respectively. The 1-, 3-, 5-, and 10-year overall patient survival rates were 96.3%, 83.4%, 83.4% and 47.6% respectively in the TACE-PVE group; 84.6%, 76.9%, 57.7% and 19.2% respectively in the PVE-alone group; and 98.6%, 91.7%, 85.1% and 81.7% respectively in the control group (p=0.047). Patients were also sub-grouped according to tumor size, and those with a tumor of up to cutoff at 5 cm showed no prognostic difference (p=0.774), but tumor size >5 cm was associated with inferior patient survival only in the TACE-PVE group (p=0.018).ConclusionsPreoperative sequential TACE and PVE appear to be compliant to the conventional oncological concept in addition to induction of the future remnant liver regeneration. Therefore, we suggest that preoperative TACE should be come first whenever preoperative PVE for major hepatectomy is planned, especially in patients with hypervascular HCC tumors.

2:06 PM Abstract No. 262 - Procedural and clinical outcomes following portal vein embolization prior to right hepatectomy: a comparison between n-butyl-cyanoacrylate and polyvinyl alcohol particles

There is a lack of clinical data comparing the use of different embolic agents in portal vein embolization (PVE) prior to right hepatectomy to induce hypertrophy of the future liver remnant (FLR). Here we compare the procedural and surgical outcomes following PVE and right hepatectomy in patients embolized with n-butyl-cyanoacrylate (NCBA) or polyvinyl alcohol (PVA) particles.

Preoperative portal vein embolization with a combination of trisacryl microspheres, gelfoam and coils

To evaluate the safety and efficiency of preoperative portal vein embolization (PVE) with a combination of trisacryl microspheres, gelfoam and coils for inducing lobar hypertrophy in hepatobiliary malignancy patients. PVE was performed by a percutaneous left approach in 63 patients with hepatic malignancy (hepatocarcinoma=38, colorectal metastasis=14, cholangiocarcinoma=11). The indication of PVE and surgery was evaluated by hepatic tumor board take into consideration to the tumor extension and the hepatic volume on initial and post-embolization CT-scans. The total functional liver volume (TELV) and future liver remnant (FLR) volume were measured before and 24±5days after PVE to assess FLR, TELV and FLR/TELV ratios. Efficiency evaluation was based on FLR increase, the ability to perform the hepatectomy and the hepatic function after surgery. Safety evaluation was determined by clinical and biological follow-up after embolization and surgery. PVE was successful in all the patients. The mean FLR volume increases by 57±56% after embolization (449±180cm(3) to 663±254cm(3)) (P<0.0001). The FLR/TELV ratio increases by 11% after PVE (25±8% to 36±12%). Three minors' complications were registered without impact on surgery, and four patients developed portal hypertension. Forty-nine patients underwent hepatectomy; none of them developed liver failure. Surgery was not performed in 14 patients due to tumor progression (n=9), inadequate hypertrophy of FLR (n=1) and portal hypertension (n=4). Preoperative PVE with a combination of trisacryl microspheres, gelfoam and coils is a safe and effective method for inducing contralateral hypertrophy before right hepatectomy in patients with advanced hepatobiliary malignancy.

Metabolic Disorders, Non-Alcoholic Fatty Liver Disease and Major Liver Resection: An Underestimated Perioperative Risk

IntroductionDespite increasing evidence of an association of metabolic syndrome and liver degeneration, little is known about the results of major hepatic resection in patients with metabolic disorders. Following the observation of some unexplained perioperative deaths following uncomplicated right hepatectomy in patients presenting metabolic disorders, we analyzed the perioperative mortality in such population. Material and MethodsA retrospective analysis of immediate outcome was performed of patients undergoing right hepatectomy and affected by two or more metabolic disorders (diabetes mellitus, hypertension, dyslipidemia, obesity/overweight) without any other known cause of liver disease from January 2001 to May 2010. ResultsAmong 151 patients undergoing right hepatectomy, 30 patients presented two or more metabolic disorders. Perioperative mortality in this group reached 30 % (nine patients). In patients presenting MS (≥3 disorders), mortality reached 54 %. Univariate analysis identified four criteria associated with poor prognosis: MS, perioperative bleeding ≥1,000 mL, middle hepatic vein resection and primary hepatic malignancy. At multivariate analysis, middle hepatic vein resection and underlying primary hepatic malignancy resulted as being related to mortality. ConclusionsPatients presenting with multiple metabolic disorders should be carefully evaluated before major liver resection, especially when the procedure is planned for hepatocellular carcinoma and when a middle hepatic vein resection is required.

Right Hepatectomy in Patients over 70 Years of Age: An Analysis of Liver Function and Outcome

As a consequence of the increase in life expectancy, hepatobiliary surgeons have to deal with an emerging aged population. We aimed to analyze the liver function and outcome after right hepatectomy (RH) in patients over 70 years of age. From January 2006 to December 2009, we prospectively collected data of 207 consecutive elective hepatectomies. In patients who had RH, cardiac risk was assessed by a dedicated preoperative workup. Liver failure (LF) was defined by the "fifty-fifty" criteria at postoperative day 5 (POD) and morbidity by the Clavien-Dindo classification. Liver function tests (LFTs) and short-term outcome were retrospectively analyzed in patients over (elderly group, EG) and younger (young group, YG) than 70 years of age. Eighty-seven consecutive RH were performed during the study period. Indication for surgery included 90 % malignancy in 47 % of patients requiring preoperative chemotherapy. ASA grade > 2 (44 vs. 16 %, p = 0.027), ischemic heart disease (17 vs. 5 %, p = 0.076), and preoperative cardiac failure (26 vs. 2 %, p < 0.001) were more frequent in the EG (n = 23) than in the YG (n = 64). Both groups were similar regarding rates of normal liver parenchyma, chemotherapy and intraoperative parameters. The overall morbidity rates were comparable, but the serious complication (grades III-V) rate was relatively higher in the EG (39 vs. 25 %, p = 0.199), particularly in patients with diabetes mellitus (100 vs. 29 %, p = 0.04) and those who had additional nonhepatic surgery (67 vs. 35 %, p = 0.110) and transfusions (44 vs. 30 %, p = 0.523). The 90-day mortality rate was similar (9 % in the EG vs. 3 % in the YG, p = 0.28) and was related to heart failure in the EG. LFTs showed a similar trend from POD 1 to 8, and patients ≥70 years of age had no liver failure. Age ≥70 years alone is not a contraindication to RH. However, major morbidity is particularly higher in the elderly with diabetes. This high-risk group should be closely monitored in the postoperative course. Liver function is not altered in the elderly patient after RH.

Preoperative portal vein embolization (PVE) for patients with hepatocellular carcinoma can improve resectability and may improve disease‐free survival

The aim of this study is to identify the efficacy of portal vein embolization (PVE) before right hepatectomy in patients with hepatocellular carcinoma (HCC) with regard to hepatic function, surgical stress, and survival benefit. Fifty-five patients with HCC underwent right hepatectomy between 1999 and 2009. Preoperative PVE was performed in 19 patients (PVE group) and was not applied in 36 patients (non-PVE group). Changes in liver function and volume were investigated in PVE group. Short and long clinical outcomes after the surgeries were compared between the two groups. The percentage of future liver remnant (%FLR) before PVE was significantly lower (37.8%) in PVE group than in non-PVE group (58.1%) but increased remarkably after PVE (from 37.8% to 55.0%, P < 0.0001). Cumulative disease-free survival and overall survival rates in PVE group were significantly superior to those in non-PVE group (P = 0.010 and 0.049, respectively). Although surgical stress estimated by E-PASS scores and CRP value was not different between the groups, the postoperative value of PT on postoperative day 3 in PVE group was significantly better than in non-PVE group. Preoperative PVE improves resectability and may improve disease-free survival for patients with HCC requiring right hepatectomy.

Pre-hepatectomy portal vein embolization: Single center experience

Aim To evaluate the feasibility and the effectiveness of portal vein embolization (PVE) as preoperative treatment in patients scheduled to undergo right hepatectomy, when the volume of the future remnant liver (FRL) appears to be insufficient to prevent the risk of post-surgical hepatic failure. Materials and Methods Thirty-one consecutive patients (19 men, 12 women; age range: 54–77 years; mean age: 66.2 years) with liver malignancy (7 hepatocellular carcinoma, 13 metastases, 9 cholangiocarcinoma, and 2 gallbladder carcinoma) were selected after clinical–radiological evaluation for PVE. After the embolization changes in volume of FRL, portal pressure, liver enzymes, and complications before and after hepatectomy were assessed. Results PVE was successful in all patients without major complications. The mean volume of FRL, calculated before and 4 weeks after PVE, increased from 319.2 ± 45.1 to 460.2 ± 27.7 cm 3 (+44.2%) in the non-cirrhotic group and from 458.4 ± 38.3 to 605.2 ± 27 cm 3 (+32.1%) in the cirrhotic group. The FRL/TELV ratio increased by 9%. Conclusion In our experience, PVE resulted feasible, safe, with a very low rate of complications, and effective to induce liver regeneration before right hepatectomy in patients with liver malignancy.

Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma

Selective transarterial chemoembolization (TACE) and portal vein embolization (PVE) could improve the rate of hypertrophy of the future liver remnant (FLR) in patients with chronic liver disease. This study evaluated the feasibility and efficacy of this combined procedure. Between November 1998 and October 2004, 36 patients with cirrhosis and hepatocellular carcinoma underwent right hepatectomy after PVE. Additional TACE preceded PVE by 3-4 weeks in 18 patients (TACE+PVE group) and the remaining 18 patients had PVE alone (PVE group). PVE was well tolerated in all patients. The mean increase in percentage FLR volume was significantly higher in the TACE+PVE group than in the PVE group (mean(s.d.) 12(5) versus 8(4) percent; P=0.022). The rate of hypertrophy was more than 10 percent in 12 patients in the TACE+PVE group and in five who had PVE alone (P=0.044). Duration of surgery, blood loss, incidence of liver failure and mortality (two patients in each group) were similar in the two groups. None of the 17 patients with an increase in FLR volume of more than 10 percent died, whereas there were four deaths among 19 patients with a smaller increase. The incidence of complete tumour necrosis was significantly higher in the TACE+PVE group (15 of 18 versus one of 18; P<0.001), with a higher 5-year disease-free survival rate (37 versus 19 percent; P=0.041). Sequential TACE and PVE before operation increases the rate of hypertrophy of the FLR and leads to a high rate of complete tumour necrosis associated with longer recurrence-free survival.