Safe Hepatic Resection Research Articles

Portal Vein Embolization: Indications, Outcomes, and Complications

AbstractPortal vein embolization (PVE) is performed with the goal of causing hypertrophy of the future liver remnant (FLR) in patients prior to partial liver resections for either hepatocellular carcinoma or metastatic liver tumors. Since its earliest description in 1984, PVE has evolved technically and has proven to be a safe and effective means of causing predictable FLR hypertrophy. PVE allows patients who would have otherwise not been candidates to proceed with safe hepatic resection, particularly extended hepatic resections. Despite advances in equipment and techniques, complications do occur with PVE. This article discusses the indications, outcomes, and complications of PVE while providing historical perspective and technical insights.

A Clinical-Radiomic Model for Predicting Indocyanine Green Retention Rate at 15 Min in Patients With Hepatocellular Carcinoma.

Purpose:The indocyanine green retention rate at 15 min (ICG-R15) is of great importance in the accurate assessment of hepatic functional reserve for safe hepatic resection. To assist clinicians to evaluate hepatic functional reserve in medical institutions that lack expensive equipment, we aimed to explore a novel approach to predict ICG-R15 based on CT images and clinical data in patients with hepatocellular carcinoma (HCC).MethodsIn this retrospective study, 350 eligible patients were enrolled and randomly assigned to the training cohort (245 patients) and test cohort (105 patients). Radiomics features and clinical factors were analyzed to pick out the key variables, and based on which, we developed the random forest regression, extreme gradient boosting regression (XGBR), and artificial neural network models for predicting ICG-R15, respectively. Pearson's correlation coefficient (R) was adopted to evaluate the performance of the models.ResultsWe extracted 660 CT image features in total from each patient. Fourteen variables significantly associated with ICG-R15 were picked out for model development. Compared to the other two models, the XGBR achieved the best performance in predicting ICG-R15, with a mean difference of 1.59% (median, 1.53%) and an R-value of 0.90. Delong test result showed no significant difference in the area under the receiver operating characteristic (AUROCs) for predicting post hepatectomy liver failure between actual and estimated ICG-R15.ConclusionThe proposed approach that incorporates the optimal radiomics features and clinical factors can allow for individualized prediction of ICG-R15 value of patients with HCC, regardless of the specific equipment and detection reagent (NO. ChiCTR2100053042; URL, http://www.chictr.org.cn).

Assessment of Safety and Applicability of Laparoscopic vs Open Non Anatomical Resection of Hepatocellular Carcinoma in Cirrhotic Patients

Abstract Background Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Liver surgery was one of the last frontiers reached by minimally invasive surgery. Surgical technique and equipment evolved to overcome technical limitations, making laparoscopic liver resections (LLR) safe and feasible. Surgeons developed skills in a stepwise approach, beginning with low complexity operations for benign diseases and reaching high-complexity surgeries for malignant cases and living donor organ harvesting. Objective s: The aim of the study is to compare short term results of laparoscopic versus open hepatectomy regarding to intra operative details and post-operative management and complications for achieving a safe hepatic resection for treatment of HCC in cirrhotic patients. Patients and Methods In this prospective study, a comparison between laparoscopic resection and open resection was done to compare short-term results between laparoscopic and open liver resection. This study was conducted on 30 patients with hepatocellular carcinoma. 15 patients (50%) were treated by laparoscopic liver resection (Group A) while the other 15 patients (50%) were treated by open liver resection (Group B). Results Regarding the demographic data, the presence of past history of medical condition and the preoperative laboratory results, no statistical significance was found. The mean operative time has statistically significant difference between the 2 groups, with decreased operative time in the laparoscopic group (P < 0.001). The mean blood loss has no statistically significant difference relations between the 2 groups, (P = 0.866) with conversion rate of (13.3%) happened in two cases. Conclusion Laparoscopic liver resection is a safe and feasible treatment option for HCC in cirrhotic patient needing minor resection at laparoscopic segments (II, III, IVa,V,VI). Laparoscopic liver resection for HCC has superior short- term and comparable oncological outcomes to open liver resection. LLR should be performed for carefully selected patients and by an expert surgical team.

Totally laparoscopic central bisectionectomy for colorectal cancer liver metastasis using indocyanine green fluorescence imaging

Laparoscopic central bisectionectomy is still an area of great challenge and technically requiring surgery due to high incidence of surgical complication and poor intraoperative outcomes. We report our experience totally laparoscopic central bisectionectomy for colorectal cancer liver metastasis (CRLM) using indocyanine green (ICG) fluorescence imaging. The patient was 77-years-old man and was performed laparoscopic low anterior resection with ileostomy, cholecystectomy for rectal cancer 3 years before admission. He diagnosed metachronous CRLM and on magnetic resonance imaging, 5 cm sized hepatic mass was shown between segment 4 and 8 with middle hepatic vein (MHV) involvement. During operation, the Cavitron Ultra Sonic Aspirator® and Sonicision™ (Medtronic) was applied for hepatic parenchyma dissection. For resection of major glissonian pedicle and MHV, Signia™ staple (Medtronic) was used. After right anterior glissonian pedicle was isolated and temporary clamping, 2.5 mg ICG was injected intravenously. The ICG stained area could be recognized, and subsequent parenchyma dissection was completed successfully under Pringled maneuver. Specimen was retieved via extended umbilical port site. The operation time was 205 minutes and the estimated blood loss was 300 mL. No transfusion was done intraoperatively and postoperatively. There was no significant complication after surgery. Computed tomography was checked on postoperative day 5, showed no abnormal pathologic findings. On pathologic findings, metastatic adenocarcinoma sized 5.4 cm with clear resection margin was diagnosed. The patient discharged on postoperative day 7. Laparoscopic central bisectionectomy is safe and feasible compared with conventional open surgery. ICG imaging system is effective and helpful for safe hepatic resection.

Combining albumin-bilirubin score with future liver remnant predicts post-hepatectomy liver failure in HBV-associated HCC patients.

Accurate assessment of liver functional reserve pre-operatively is vital for safe hepatic resection. The ALBI score is a new model for assessing liver function. This study aimed to evaluate the value of combining ALBI score with sFLR in predicting post-operative morbidity and PHLF in HCC patients who underwent hepatectomy. Patients undergoing three-dimensional CT reconstruction prior to hepatectomy for HCC between January 2015 and January 2017 were enrolled. The values of the CP score, ALBI score and sFLR in predicting post-operative outcomes were evaluated. A total of 229 HCC patients were enrolled; 24 (10.5%) experienced major complications and 21 (9.2%) developed PHLF. The incidence of major complications and PHLF increased with increasing ALBI grade. The ALBI grade classified patients with CP grade A into two subgroups with different incidences of PHLF (P=.029). sFLR and ALBI scores were identified as independent predictors of PHLF. The AUC values for the CP score, ALBI score, sFLR and sFLR×ALBI for predicting major complications were 0.600, 0.756, 0.660 and 0.790 respectively. The AUC values of the CP score, ALBI score, sFLR and sFLR×ALBI for predicting PHLF were 0.646, 0.738, 0.758 and 0.884 respectively. The ALBI score showed superior predictive value of post-operative outcomes over CP score, and the combination of sFLR and ALBI score was identified as a stronger predictor of post-operative outcomes than the sFLR or ALBI score alone.

Integration of Child-Pugh score with future liver remnant yields improved prediction of liver dysfunction risk for HBV-related hepatocellular carcinoma following hepatic resection.

Assessment of hepatic functional reserve is important to enable the selection of appropriate treatment methods and safe hepatic resection in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). In the present study, an evaluation was made of the clinical value of combining the Child-Pugh score (CPS) with the standardized future liver remnant (sFLR) measurement to predict postoperative liver dysfunction (PLD). A total of 61 HBV-related HCC patients undergoing liver volumetry prior to hepatectomy were enrolled in the study. The sFLR was calculated as the ratio of FLR volume to standardized liver volume. PLD was defined as a prothrombin time of >18 sec or a peak serum bilirubin level of >51.3 µmol/l for 7 days after surgery. Univariate analysis and multivariate logistic regression analysis were performed to identify risk factors associated with PLD. The correlation between PLD and the combination of sFLR and CPS was analyzed. In total, 18 out of 61 patients developed PLD (29.5%), with a significantly higher PLD incidence for a CPS of 6 than a CPS of 5 (P<0.05). Multivariate logistic regression analysis revealed that a prothrombin time of <13.3 sec and an sFLR of <0.55 were independent risk factors for PLD. Receiver operating characteristic (ROC) curve analysis revealed that the cut-off values of sFLR and sFLR/CPS for predicting PLD were 54.5% and 0.0916, respectively, with areas under the ROC curve of 0.820 and 0.860, respectively. The combination of CPS and sFLR appears to yield improved prediction of the occurrence of PLD compared with either CPS or sFLR alone.

Quantitative Assessment of the Portal Pressure for the Liver Surgery Using Serological Tests

Objective:To establish a reliable equation to predict hepatic venous pressure gradient (HVPG) using serological tests for surgical patients with hepatocellular carcinoma (HCC).Background:Accurate assessment of portal pressure for surgical patients with HCC is important for safe hepatic resection (HR). The HVPG is regarded as the most reliable method to detect portal hypertension. However, HVPG is not utilized in many medical centers due to invasiveness of procedure.Methods:Between 2006 and 2008, 171 patients (Correlation cohort), who underwent liver surgery in a tertiary hospital, were enrolled. Preoperative measurements of the HVPG and serological tests were performed simultaneously. Correlation between the HVPG and serological tests were analyzed to establish an equation for calculated HVPG (cHVPG). Between 2008 and 2013, 510 surgical patients (Application cohort) were evaluated, and HR recommended when cHVPG < 10 mm Hg. The outcomes of HR were analyzed to evaluate reliability of the cHVPG for HR.Results:In the correlation cohort, the equation for cHVPG was established using multivariate linear regression analysis; cHVPG (mm Hg) = 0.209 × [ICG-R15 (%)] − 1.646 × [albumin (g/dL)] − 0.01×[platelet count (103)] + 1.669 × [PT-INR] + 8.911. In the application cohort, 425 patients with cHVPG < 10 mm Hg underwent HR. Among them, 357 had favorable value of ICG-R15 < 20% (group A), and 68 had unfavorable value of ICG-R15 ≥ 20% (group B). There was no significant difference in patient demographics, tumor characteristics, operative outcome, and survival rates between group A and B.Conclusions:The equation for cHVPG of this study was established on statistical reliability. The cHVPG could be useful to predict portal pressure quantitatively for surgical patients with HCC using serological tests.

The Feasibility of Hepatic Resections Using a Bipolar Radiofrequency Device (Habib®)

The bipolar radiofrequency device (Habib®) has been recently introduced in order to reduce intraoperative bleeding for a safe hepatic resection as an alternative to the conventional tools. However, indications, perioperative findings, and outcome of the device for hepatic resections remain and deserve to be analyzed. The current study aims to analyze the feasibility of the bipolar radiofrequency device (Habib®) for hepatic resections. Information of the patients that underwent hepatic resection using with the Habib® device between 2007 and 2011 was abstracted. Patient, disease, and operation-related findings and perioperative data were investigated. A total of 71 cases (38 [53.5%] males, mean age was 56.8 ± 11.9) were analyzed. Metastatic disease (n = 55; 77.5%) was the leading indication followed by primary liver and biliary malignancies (n = 7; 9.9%), hemangioma (n = 5; 7%), hydatid disease (n = 3; 2.8%), and hepatic gunshot trauma (n = 1; 1.4%). Metastasectomy was the most commonly performed procedure (n = 31; 56.3%), but in 24 (77.4%) cases, it was performed in addition to extended resections. Other procedures in the study patients include segmentectomy in 17, bisegmentectomy in 19, trisegmentectomy in 17, right or left hepatectomy in 8, and extended right/left hepatectomy in 3. The mean (±SD) operation time was 241.7 ± 78.2min. The median amount of bleeding was 300cc (range 25-2500), and 23 (32.4%) cases required perioperative transfusion. The median hospitalization period was 5days (range 1-47). Lengthened drainage (n = 9, 12.7%) and intraabdominal abscess (n = 8, 11.23%) were the most common problems. Hepatic resections using the Habib® device seem to be feasible in cases with primary and metastatic hepatic lesions and benign liver masses and even those with hepatic trauma. It may lessen the amount of intraoperative hemorrhage, although lengthened drainage and intraabdominal abscess were the major postoperative problems in these cases.

Left bisegmentectomy for liver cirrhosis associated primary hepatic carcinoma with preoperative chemoembolization

Abstract Introduction: Hepatocellular carcinoma is the most frequent primary malignant tumor of the liver, being linked in 80% of cases with viral hepatitis ”B” or “C”. Treatment remains a challenge especially in cases with associated hepatic cirrhosis, where preoperative arterial chemoembolization followed by liver resection is recommended. Case report: We discuss the case of a 64 years old cirrhotic patient, diagnosed by echography, computed tomography, magnetic resonance cholangiography with hepatocellular carcinoma (64x52x46 mm). Preoperative chemoembolization was performed with Lipiodol and 5-FU by supra-selective catheterization of left hepatic artery, followed by favorable radiologic response. Two weeks after embolization, the patient was admitted in Surgical Clinic No. 1 Targu Mures where an atypical resection of the left hepatic lobe (bisegmentectomy II-III) was performed with Harmonic Scalpel. Early and late postoperative evolution was favorable. Discussions: The principle of arterial chemoembolization is based on the fact that vasculature of primary hepatic tumors is predominantly arterial. Arterial obstruction may lead to ischemic necrosis while tumor embolization combination with a chemotherapeutic agent significantly improves its local concentration. Decrease in tumor size and its vasculature allows for safe hepatic resection especially in the cirrhotic liver. Conclusion: In case of tumoral cirrhotic liver preoperative chemoembolization decreases intra and postoperative bleeding risk, providing a safe and oncological resection.

Hepatic Resection for the Carcinoid Syndrome in Patients with Severe Carcinoid Heart Disease: Does Valve Replacement Permit Safe Hepatic Resection?

Hepatic resection of metastatic carcinoid cancer can prolong survival and control symptomatic endocrinopathy. Decompensated carcinoid heart disease (CHD) can develop in some patients with metastatic carcinoid cancers, which can preclude operation for resectable hepatic metastases. We hypothesized that outcomes after hepatic resection for patients with the carcinoid syndrome after valve replacement for CHD would be similar to carcinoid patients without CHD. We compared the survival and symptom control after hepatic resection for patients undergoing valve replacement for CHD to carcinoid patients without CHD matched for age, sex, and extent of hepatectomy. Fourteen patients with earlier valve replacement for CHD were compared with 28 carcinoid patients without CHD. All patients had hepatic resection for metastatic carcinoid disease and carcinoid syndrome. Mean age, sex distribution, and extent of hepatectomy (major hepatectomy, 78%) was similar between groups. Mean interval from valve replacement to hepatectomy was 101 days. There was no operative mortality. Major operative morbidity, inclusive of operative blood loss and cardiorespiratory events, occurred in 28.5% and 14.2% for CHD and non-CHD groups, respectively (p = 0.16). Symptom-free survival for CHD and non-CHD groups was 69% and 81% at 1 year (p = 0.22) and 61% and 44% (p = 0.17) at 5 years, respectively. Octreotide-free survival after hepatectomy 69% and 84% (p = 0.15) at 1 year and 62% and 52% (p = 0.29) 5 years, respectively. Overall survival CHD and non-CHD groups 100% at 1 year and 100% and 70% (p = 0.002) 5 years. Valve replacement for severe CHD is safe and hepatic resection is associated with similar outcomes as patients without CHD undergoing hepatic resection for carcinoid syndrome. Identifying resectable hepatic metastases from carcinoids in patients with severe CHD should prompt valve replacement and interval hepatic resection.

Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry.

This study aimed to determine the effect of preoperative liver volumetry on postoperative outcomes after extended right hepatectomy. Primary end point was to evaluate whether future liver remnant (FLR)/standardized liver volume ratio (sFLR) >20% is sufficient for a safe hepatic resection. Secondary end point was to assess whether preoperative portal vein embolization (PVE) is associated with improved outcome in patients with initial sFLR ≤ 20%. An sFLR >20% of the total liver volume has been proposed as sufficient for safe hepatic resection, but this concept has not been validated in a large series. In addition, recent reports suggest preoperative PVE is indicated for sFLR <30%. The impact of sFLR and PVE on short-term outcomes (postoperative complications, liver insufficiency, and 90-day mortality) was analyzed in 301 consecutive patients after extended right hepatectomy. Liver volumetry accounted for partial resection of segment IV. Liver insufficiency was defined as peak postoperative serum bilirubin >7 mg/dL. Predictors of liver insufficiency were identified by multivariate logistic regression. Postoperative liver insufficiency occurred in 45 patients (15%) and accounted for 61% of deaths. Among 290 patients who underwent liver volumetry, sFLR was <20% in 38 patients, 20.1% to 30% in 144, and ≥ 30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with sFLR 20.1% to 30% and sFLR ≥ 30% but higher in patients with sFLR ≤ 20% (P 0.05). Postoperative outcomes were similar between patients with increase in sFLR from ≤ 20% to >20% after PVE and patients with initial sFLR >20%. Multivariate analysis revealed that body mass index >25 kg/m2, intraoperative blood transfusion, and sFLR ≤ 20% (odds ratio = 3.18; 95% CI, 1.34-7.54) independently predicted postoperative liver insufficiency. Systematic measurement of FLR volume is important to select patients for PVE and extended right hepatectomy. A sFLR >20% is sufficient for safe hepatic resection and sFLR 20.1% to 30% is not an indication for preoperative PVE.

Synchronous Colorectal Liver Metastases: Triumph Of Prospective Randomized Trials Over Observational Bias Leads To Paradigm Shift

The last one and a half decade has witnessed an exciting era for the management of advanced colorectal cancer, with emergence of effective combination chemotherapy, potent biologic agents, surgical techniques for safe hepatic resection and ancillary procedures such as portal vein embolization and radiofrequency ablation. Integration of these various interventions within the context of a multidisciplinary approach has fostered an aggressive stance amongst oncologists. This approach continues to be pushed forward with attempts to ‘‘tease out’’ additional patients who may become candidate for curative hepatic resection and hence alter the natural history of their disease. In this issue, Reddy et al comprehensively review the current evidence for outcomes in the management of synchronous colorectal liver metastases (CRLM) and inquire whether a paradigm shift is necessary. Let us examine some of the controversial issues that the authors raise in this review and then determine whether a paradigm change is justified. The traditional approach to the management of the asymptomatic primary tumor with synchronous CRLM has been to resect it to avoid future obstruction, perforation or bleeding. This notion is particularly evident for rectal primaries where surgeons believe that at minimum a diverting colostomy is necessary to prevent eventual obstruction during systemic chemotherapy/chemoradiation. Given that even primary tumors are now commonly considered quite responsive to current multiagent chemotherapy, potential complications are an unlikely event as evidenced by the report from the BRiTE registry. Additional evidence will hopefully become available from the National Surgical Adjuvant Breast and Bowel Project (NSABP) C-10, a phase II trial evaluating FOLFOX6 with bevacizumab in patients who present with untreated primary colon cancer and concomitant metastatic disease not considered surgically resectable for cure. Downsizing to resectable disease has been extensively investigated by the Paul Brousse group in France. Adam et al reported their experience of a multimodality approach where patients received multiple cycles of chemotherapy and, if deemed resectable, then integrating a combination of hepatic resection, resection of extrahepatic disease, portal vein embolization, radiofrequency ablation, cryotherapy, two-stage hepatectomy, and repeat hepatectomy to achieve cure. When one critically examines this most aggressive approach for CRLM with an intention-to-treat analysis, the percentage of long-term survivors at a mean follow-up of 48.7 months was very low (3.5% alive and 2.2% alive without disease). This appears to be a long run for a short slide. When the same data are used to claim that chemotherapy will nullify the biologic effects of portal lymph node metastases, the reservations expressed by Wagman have to be echoed. Inoperable colorectal metastases may be considered a declining entity, but when one examines the published series on ‘‘conversion chemotherapy’’, patient selection is an important variable and it is clear that, the criteria for non-resectability not only differed between the studies but were often poorly defined. Until the report of the multi-institutional phase III trial by Portier et al, there had been no clear evidence from a randomized trial that adjuvant chemotherapy, either systemic or by hepatic artery infusion, added benefit over surgery alone. This trial was marred by slow accrual and inadequate sample size (173 of the planned 200 patients over a period of 10 years) but nonetheless did show The Author(s) 2009. This article is published with open access at Springerlink.com

Assessment of liver function for safe hepatic resection

The preoperative assessment of liver function is extremely important for preventing postoperative liver failure and mortality after hepatic resection. Liver function tests may be divided into three types; conventional liver function tests, general scores, and quantitative liver function tests. General scores are based on selected clinical symptoms and conventional test results. Child-Turcotte-Pugh score has been the gold standard for four decades, but the Child-Turcotte-Pugh score has difficulty discriminating a good risk from a poor risk in patients with mild to moderate liver dysfunction. The model for end-stage liver disease score has also been applied to predict short-term outcome after hepatectomy, but it is only useful in patients with advanced cirrhosis. Quantitative liver function tests overcome the drawbacks of general scores. The indocyanine green retention rate at 15 minutes (ICG R15) has been reported to be a significant predictor of postoperative liver failure and mortality. The safety limit of the hepatic parenchymal resection rate can be estimated using the ICG R15, and a decision tree (known as the Makuuchi criteria) for selecting patients and hepatectomy procedures has been proposed. Hepatic resection can be performed with a mortality rate of nearly zero using this decision tree. If the future remnant liver volume does not fulfill the Makuuchi criteria, preoperative portal vein embolization should be performed to prevent postoperative liver failure. Galactosyl human serum albumin-diethylenetriamine-pentaacetic acid scintigraphy also provides data that complement the ICG test. Other quantitative liver function tests, however, require further validation and simplification.

Comparison of Two Methods of Future Liver Remnant Volume Measurement

BackgroundIn liver transplantation, a minimum graft to patient body weight (BW) ratio is required for graft survival; in liver resection, total liver volume (TLV) calculated from body surface area (BSA) is used to determine the future liver remnant (FLR) volume needed for safe hepatic resection. These two methods of estimating liver volume have not previously been compared. The purpose of this study was to compare FLR volumes standardized to BW versus BSA and to assess their utility in predicting postoperative hepatic dysfunction after hepatic resection. MethodsRecords were reviewed of 68 consecutive noncirrhotic patients who underwent major hepatectomy after portal vein embolization between 1998 and 2006. FLR (cubic centimeter) was measured preoperatively with three-dimensional helical computed tomography; TLV (cubic centimeter) was calculated from the patients’ BSA. The relationship between FLR/TLV and FLR/BW (cubic centimeter per kilogram) was examined using linear regression analysis. Receiver operating characteristic (ROC) curve analysis was used to determine FLR/TLV and FLR/BW cutoff values for predicting postoperative hepatic dysfunction (defined as peak bilirubin level > 3 mg/dl or prothrombin time > 18 s). ResultsRegression analysis revealed that the FLR/TLV and FLR/BW ratios were highly correlated (Pearson correlation coefficient, 0.98). The area under the ROC curve was 0.85 for FLR/TLV and 0.84 for FLR/BW (95% confidence interval, 0.71–0.97). Sixteen of the 68 patients developed postoperative hepatic dysfunction. The ROC curve analysis yielded a cutoff FLR/BW value of ≤0.4, which had a positive predictive value (PPV) of 78% and a negative predictive value (NPV) of 85%. The corresponding FLR/TLV cutoff value of ≤20% had a PPV of 80% and a NPV of 86%. ConclusionsBased on the strong correlation between the FLR measurements standardized to BW and BSA and their similar ability to predict postoperative hepatic dysfunction, both methods are appropriate for assessing liver volume. In noncirrhotic patients, a FLR/BW ratio of ≤0.4 and FLR/TLV of ≤20% provide equivalent thresholds for performing safe hepatic resection.

Truncoumbilical bypass of the portal vein in radical resection of biliary tract tumour involving the hepatic duct confluence

Before combined resection of the right hepatic lobe and the hepatoduodenal ligament, an autogenous external iliac vein was interposed between the root of the portal vein trunk and the umbilical portion of the vein in four patients with biliary tract tumour. The left hepatic arterial pathway was preserved, except in one case in whom resection of this artery was followed by reconstruction. This procedure allowed successful and safe extended right hepatic lobe resection and combined en bloc resection of the hepatoduodenal ligament while preserving hepatic blood perfusion.

Preoperative Regional Maximal Removal Rate of Technetium-99m-galactosyl Human Serum Albumin (GSA-Rmax) Is Useful for Making a Final Decision on Surgical Procedure

Purpose: For safe hepatic resection, the preoperative estimation of hepatic functional reserve in the predicted remnant liver may be more important than that in the entire liver. The purpose of this study was to find the minimal GSA-Rmax in the predicted remnant liver (GSA-RL) using functional imaging that predicts postoperative hepatic failure and, by so doing, avoid this complication. Methods: One hundred and seventy-eight patients were admitted for elective hepatectomy. Conventional liver function, and 15 min retention rate of indocyanine green (ICGR15) were carried out preoperatively. The GSA-Rmax was calculated according to a radiopharmacokinetic model and then, using the SPECT images, we calculated the regional GSA-Rmax in the predicted residual liver (GSA-RL), depending on the operative procedures. The volume of the predicted residual liver (LV-RL) was calculated on the basis of CT images. Results: Surgical procedures consisted of 98 sub-segmentectomy cases, 41 mono-segmentectomy cases, 31 di-segmentectomy cases and 8 tri-segmentectomy cases. The preoperative LV-RL correlated well with the GSA-RL in patients with normal liver however, there was no such correlation in those with chronic hepatitis or cirrhosis. Postoperative major complications such as hepatic failure, hyperbilirubinemia, bleeding (requiring re-operation), ascites, liver abscess, bile leakage and pleural effusion were recorded for 45 patients after subsegmentectomy, 25 patients after monosegmentectomy and 23 patients after di- and tri-segmentectomies. Fourteen patients had more than one complication. All of 7 postoperative hyperbilirubinemia occurred in the patients with GSA-RL < 0.15. Two patients died of postoperative liver failure one to two months after the operation. These two patients GSA-RL values were 0.078 and 0.090, respectively and severe discrepancies between the GSA-Rmax in the remnant liver and ICGR15. Conclusions: Our data suggest that GSA-RL might be a practical and reliable diagnostic method for estimating the postoperative functioning hepatocyte volume and useful for making a final decision on surgical procedure, regarding the extent of liver resection in order to avoid postoperative hyperbilirubinemia or hepatic failure.

Evaluation of liver function for hepatic resection for hepatocellular carcinoma in the liver with damaged parenchyma

Background Liver functional parameters, including the Child—Pugh score and indocyanine green clearance (ICG), and volumetric parameters influencing postoperative liver function were evaluated with the aim of obtaining standardardized criteria for selecting patients for, and deciding the extent of, hepatectomy for hepatocellular carcinoma (HCC). Materials and methods The study population consisted of 120 patients with HCC undergoing hepatic resection excluding those with more than 3000 ml of intraoperative bleeding. Patients were classified as grades A, B, or C on the basis of, respectively, a Child—Pugh score of 5 or 6, 7–9, or ≥10 and were assigned to group D (postoperative liver dysfunction) or group N (no complication). Postoperative complications included massive ascites, pleural effusion, or hyperbilirubinemia. For each grade, the standardized estimated liver remnant ratio (STELR) was determined as the ratio of the liver remnant volume (estimated by computerized tomography) to the standardized total liver volume (STLV), estimated from the body surface area using the equation: liver volume [cm 3] = 706 × body surface area [m 2] + 2.4. The ICG retention rate at 15 min after injection (ICGR15) was then plotted against the STELR for each grade and a demarcation line separating patients in groups N and D was determined statistically by discriminant analysis. Results For grade A patients, the equation of the demarcation line was ICGR15 = 27.5 × STELR + 1.9 (Wilks’ Lambda: 0.667, P < 0.001), indicating that, for safe hepatic resection in patients with an ICGR15 of 10%, the STELR should be greater than 0.29. In contrast, for grade B patients, the equation was ICGR15 = 72 × STELR − 22.1 (0.589, P < 0.001), indicating that, in patients with a 10% ICGR15, the STELR should be greater than 0.44, a larger value than in grade A patients. The number of grade C patients was too small for analysis. Conclusions By combining the Child—Pugh score, ICG clearance, and liver volumetric parameters, criteria for the selection of patients for hepatic resection for HCC were established.

Preoperative selective portal vein embolization before hepatectomy for liver metastases: Long-term results and impact on survival

Background. Some patients cannot undergo curative surgical procedures for liver metastases because of the risk of severe postoperative hepatic failure, which stems from a too-small future remaining liver (FRL). Preoperative portal vein embolization (PVE) is an effective means of creating hypertrophy of the FRL, thus permitting safe hepatic resection. The aim of this retrospective study was to investigate the long-term results of this technique. Methods. Sixty-eight patients underwent PVE. Of those, 60 (88%) subsequently underwent hepatic resection. Indication for PVE was an estimated FRL ratio (assessed by volumetric computed tomography) of less than 30%. However, if the patient had undergone multiple courses of chemotherapy, the threshold was 40%. The origin of the primary neoplasm was colorectal in 41 patients (68%); in the remaining 19 (32%), the primary neoplasms originated at other sites. Results. Mean growth of the estimated FRL measured by computed tomography 1 month after PVE was 13%. Major complications after hepatectomy occurred in 27% of the patients, and the operative mortality rate was 3%. For the 60 patients who underwent PVE followed by hepatic resection, the 5-year overall survival rate and the disease-free survival rate were 34% and 24%, respectively. The 5-year overall survival rate and the disease-free survival rate of patients with colorectal metastases only were 37% and 21%, respectively. Conclusions. The long-term survival rate after PVE followed by resection is comparable with the survival rate obtained after resection without preoperative PVE. The 5-year survival rate of patients undergoing PVE followed by hepatectomy justifies the use of this technique. This technique thus increases the suitability of resection as a treatment choice for patients with liver metastases. PVE should number among the therapeutic options available to every hepatic surgeon. (Surgery 2002;131:294-9.)

Intraoperative echography for hepatic resection

Basic intraoperative ultrasonographic techniques for safe and accurate hepatic resection are described, with particular reference to understanding the locational relationships between tumors and intrahepatic vascular structures, echo guidance for needle puncture, portal area staining, orientation of the transected hepatic plane, evaluation of all tumors to be removed in the resected specimen, and assessment of blood flow and patency of reconstructed vessels. The use of this approach and the consequent selection of the most appropriate surgical techniques for the removal of multiple metastatic liver tumors are then described in three case reports.

Criteria for safe hepatic resection

To lower morbidity after hepatic resection, the authors examined the influence of predictor variables including: age, sex, preoperative risk factors, serum total bilirubin level, plasma retention rate of indocyanine green at 15 minutes, underlying liver disease, operative blood loss, operation time, amount of whole blood transfused, vascular occlusion time, surgical procedure employed, and extent of hepatic resection. Between January 1990 and December 1992, 172 patients underwent hepatic resection based on our own criteria for hepatectomy, including the presence or absence of ascites, serum total bilirubin level, and the plasma retention rate of indocyanine green at 15 minutes in patients with chronic liver disease. The morbidity rate was 37.2%, and the hospital and operative mortality rates were 2.3% and 0.6%. The multiple logistic model revealed that the risk of morbidity was increased by longer operation time, major hepatic resection, and preoperative cardiovascular disease. Shortening the operation time without increasing operative blood loss and further modalities for making major hepatectomy safer are future problems to be addressed.