Risk Of Hepatic Insufficiency Research Articles

Laparoscopic Anatomical Combined Segment 3 and Segment 4 Liver Resection

Background: In 1992, Kawasaki et al. reported the first combined segments 3 and 4 liver resection through an open procedure.1 As opposed to a major hepatectomy, this type of liver resection reduces the risk of postoperative hepatic insufficiency, especially in cirrhotic patients. Presently, various types of laparoscopic liver resections are performed in numerous surgical centers. To our knowledge, a combined segments 3 and 4 liver resection through a laparoscopic procedure has not been reported.2–9 This video describes the technical aspects of a totally laparoscopic anatomical combined segments 3 and 4 liver resection using the Glissonian approach. Methods: A 63-year-old woman was referred for a 2.1 cm tumor in segment 4. The tumor was suspected to be a hepatocellular carcinoma and was located deep in segment 4 and adjacent to the Glissonian pedicle of segment 3. The patient had viral hepatitis C, and based on her liver enzymes she was a Child–Pugh class A. Although a left hemihepatectomy could be performed in this case, an anatomical combined segments 3 and 4 liver resection was planned to preserve segment 2 to maximize the remnant liver volume. Technically, the most important aspects of this case included an oncologic resection while preserving the vascular structures to the remnant liver to avoid ischemia in segment 2. Operatively, Glissonian pedicles to segments 2, 3, and 4 (G2, G3, and G4) were dissected proximally. To avoid damaging G2 pedicle, G3 and G4 pedicles were ligated separately with a laparoscopic stapler. A flexible endoscope was used to maximize visualization intra-operatively. After ligating the pedicles, a line of parenchymal demarcation was established along segment 3. Meticulous dissection along the precise ischemic line was performed to prevent injury to the vascular structure of the remnant liver. Ultrasonic shears was used to transect the superficial liver parenchyma, and the deep portion was transected using both laparoscopic cavitron ultrasonic aspirator and electrocautery. After transecting segment 3, segment 4 was dissected along the middle hepatic vein. After ligating the left medial vein from the left hepatic vein, segments 3 and 4 were resected. The specimen was inserted into a vinyl bag and the operative field was irrigated and fibrin glue was applied along the parenchyma. Results: The operation took ~290 minutes and the estimated intraoperative blood loss was 400 mL. No intraoperative transfusion was necessary. On postoperative day 5, a postoperative computed tomogram scan showed no evidence of complications, and the patient recovered with no problems. The final pathology analysis confirmed a cholangiocarcinoma, with a negative resection margin. The patient is alive without adjuvant treatment at 1 year. Conclusion: Laparoscopic anatomical combined segments 3 and 4 liver resection is a feasible operative procedure in patients at risk of hepatic insufficiency. A laparoscopic resection of these segments may be performed without sacrificing large amounts of hepatic parenchyma. No competing financial interests exist. Runtime of video: 6 mins 39 secs This video was presented at the SAGES 2016 annual meeting, held at the Hynes Veterans Memorial Convention Center in Boston, MA.

Hilar Cholangiocarcinoma: Resection or Transplantation?

This is a review of the current status of surgical resection and liver transplantation in the treatment of hilar cholangiocarcinoma (CCA). For patients with hilar CCA and underlying parenchymal disease, specifically those with primary sclerosing cholangitis, liver transplantation is generally favored as there is risk of hepatic insufficiency and multicentric disease with extended resection. For de novo patients with no underlying liver disease, the decision between resection and transplantation proves to be more difficult. Results have shown that when margin- and node-negative resections are achieved, survival outcomes between patients undergoing resection and liver transplantation are comparable, though at baseline the patients selected for transplant were unresectable and, thus, had no other curative option and potentially more advanced disease than those selected for resection. Difficulty lies, however, in accurately predicting which patients are resectable as commitment to surgical resection precludes liver transplantation and vice versa. Recent work has focused on improving surgical resection outcomes as liver transplantation continues to be limited by the extreme organ shortage. Hilar lesions previously considered unresectable as a result of vascular involvement are now being resected using en bloc surgical techniques with vascular reconstruction. Additionally, the application of portal vein embolization to CCA has allowed for safer extended hepatic resections in a select group of patients. At present, surgical resection and liver transplantation remain as the only potentially curative treatment options for perihilar CCA. The presence of underlying parenchymal liver disease, ability to obtain margin- and node-negative resection, and overall candidacy for transplantation should guide decision making.

«SAVING» A TWO-STAGE LIVER RESECTION BY THE ALPPS TYPE

A gold standard for the treatment of metastases of colorectal cancer in the liver is combined treatment with postoperative or perioperative chemotherapy. Despite the improvement of antitumor drugs, the main condition for the successful treatment of patients with metastatic colorectal cancer is the operation in a radical volume, implying a macroscopic and microscopic absence of a residual tumor. The main contraindications to anatomic resections of the liver include a marked decrease in liver function, insufficient volume of the remaining parenchyma of the liver, and for a long time, bilobar liver damage was considered, which excludes the possibility of simultaneous removal of all foci. The traditional variant of the surgical solution of the problem of bilobar metastatic liver injury is the implementation of two-stage anatomical resections. It has been proved that the reduction of liver and FLR functional reserves of less than 20% at normal and 40% in the case of compromised liver parenchyma, the implementation of surgical interventions is associated with a high risk of hepatic insufficiency. One of the promising ways to overcome this obstacle is to perform various modifications of ALPPS liver resections. In the present work, we present a clinical case of performing a two-stage liver resection according to the type of ALPPS in a patient with metastatic colorectal liver cancer who had previously undergone PVL with unrealized vicar hypertrophy. The described observation testifies to the justification of performing repeated liver resections in patients with metastatic colorectal cancer and demonstrates the possibilities of ALPPS technique.