Segmental Liver Resection Research Articles

Coexistence of common gallstones and sinusoidal obstruction syndrome: Case report and review of the literature

Purpose: The sinusoidal obstruction syndrome (SOS) of the liver is an obliterative vasculitis that involves the terminal branches of the hepatic venules and sinusoids. When it is not treated, it will be a serious risk of mortality. Here, we aim to present our patient who has been associated with recurrent cholangitis attacks due to cholelithiasis and choledocholithiasis and is associated with sinusoidal obstruction syndrome with the literature. Description of the case: A 30 years old male patient had complaints of abdominal pain and nausea for a long time. The patient had a history of choledocholithiasis and cholangitis attacks. Although ERCP was performed and a stent was placed in the biliary tract, his jaundice did not disappear. Liver function tests were high. Tumor markers were negative. Methods: We could not make a definitive diagnosis with imaging methods and biopsy and we planned surgery. We performed segmental liver resection and biliary diversion in the surgery. Histopathological examination of the resected liver tissue was compatible with SOS. Conclusion: Many studies have been done on the etiology of SOS and different causes have been revealed. Accompanied with clinical findings, a definitive diagnosis is made with the exclusion of the presumptions considered. Surgery can be performed for both diagnostic and therapeutic purposes. If patients with elevated liver function tests and bilirubin have long-term abdominal pain, SOS should be bear in mind.

Feasibility and safety of liver resection for huge hepatocellular carcinoma in cirrhotics

Background: With the current high incidence of hepatocellular carcinoma (HCC), more patients even with large and huge HCC are considered for liver resection.Methods: Medical records of consecutive adult cirrhotic patients who underwent partial hepatectomy for huge HCC (≥10 cm, huge HCC group) versus small HCC (<5 cm, small HCC group) at Sohag university hospital (January 2016 to December 2020) were analyzed. Both groups were compared regarding postoperative morbidity and risk of mortality following post hepatectomy liver failure (PHLF) as defined by the 50-50 criteria (50% mortality occurs among patients who developed increased plasma bilirubin >50 μml/l and reduced prothrombin activity <50% on postoperative day 5 (POD-5).Results: Thirty two patients were enrolled (16 per group), with median age of 56 (range 38-81) years, 22 were males. In correlation with resection of more liver segments in the huge HCC group, post hepatectomy alteration of liver functions (bilirubin rise and reduction of albumin and prothrombin concentration) was significantly pronounced among patients who had resection for huge compared with small HCC (p<0.05). Huge HCC group exhibited significantly worse postoperative complication score (p< 0.05) and needed significantly prologed periods of hospital stay (p<0.05). Concurrent persistence of PHLF and thrombocytopenia until POD-5 occurred in 3 patients (2 with huge HCC and 1 with small HCC). Among those patients, only one from huge HCC group died (mortality 6%) postoperatively.Conclusions: Liver resection provides safe and effective treatment strategy for carefully selected cirrhotic patients with huge HCC.

Lap posterosuperior segmentectomy

Surgical resection is one of the curative options for hepatocellular carcinoma (HCC). Posterosuperior segmentectomy is defined as anatomical resection of the liver segments 7 and 8. However, minimally invasive resection of posterosuperior liver segments is considered a difficult and complex operation and is therefore rarely reported. We present a video of laparoscopic posterosuperior segmentectomy of the liver (S7, 8) due to HCC, in a 66-years old male patient. Liver mobilization was performed with exposure of the inferior vena cava. Intraoperative ultrasound was used to locate the tumor and identify its relationship with the portal veins of segments 7 and 8. The liver parenchyma was divided using ultrasonic energy device and the Glissonean pedicles were ligated using hem-o-lock and surgical clips. The surgical specimen was removed through a lower midline incision. Operative time was 162 minutes, and the estimated blood loss was 400 mL. The patient recovered without problems such as admission to the intensive care unit or blood transfusion. Pathology confirmed progressed HCC. Laparoscopic posterosuperior segmentectomy is difficult, but is feasible and safe. This video can help inexperienced surgeons perform this complex procedure.

SWI/SNF-deficient undifferentiated/rhabdoid carcinoma of the gallbladder carrying a POLE mutation in a 30-year-old woman: a case report

BackgroundUndifferentiated carcinoma of the biliary tract are highly aggressive malignancies. In other organs, a subgroup of undifferentiated carcinoma related to SWI/SNF complex–deficiency have been described.Case presentationA 30-year-old woman presented with rising inflammatory markers (C-reactive protein (CRP)). Ultrasound examination revealed a large tumor of the liver. A computed tomography scan was performed and was primarily interpreted as a tumor-forming liver abscess, possibly caused by gallbladder perforation. Subsequent liver segment resection was performed. Microscopic examination showed an undifferentiated carcinoma with rhabdoid morphology and prominent inflammatory infiltrate in the gallbladder base. With SWI/SNF immunohistochemistry, intact expression of SMARCB1, SMARCA4, ARID1A, but loss of SMARCA2 and PBRM1 was detected. Next-generation-sequencing detected KRAS, PBRM1 and ARID1B mutations, a deleterious splice-site mutation in the POLE-gene and a mutation in the TP53-gene.ConclusionsWe were able to demonstrate loss of SMARCA2 expression and mutations characteristic of an SWI/SNF-deficient carcinoma in a tumor derived from the gallbladder. This is the first reported case of an undifferentiated carcinoma with rhabdoid features in the gallbladder carrying a POLE mutation and SWI/SNF-deficiency of PBRM1 and SMARCA2.

Increase of Portal Vein Pressure Gradient After Hepatectomy Predicts Post-operative Liver Dysfunction.

Background. Post-hepatectomy liver failure (PHLF) is an important cause of mortality and morbidity. Whether Child-Pugh A patients with varying degrees of cirrhosis are good candidates for hepatectomy is disputed. The purpose of this study was to analyze the impact of portal venous pressure gradient (PVPG) variation during surgery on PHLF. Methods. PVPG, the pressure gradient between the portal vein and central vein, was measured in consecutive patients before and after liver resection. The optimal cutoff of PVPG to predict PHLF was determined by receiver operating characteristic curve analysis. Risk factors for PHLF were subjected to univariate and multivariable analysis. Results. Sixty Child-Pugh A patients were recruited. The mean PVPG was increased from 5.17 ± 4.78mm of mercury (mmHg) to 6.37 ± 4.44mmHg after liver resection. The optimal cutoff value of PVPG increments to predict PHLF was 1.5mmHg. Multivariable analysis showed prothrombin time (PT), post-hepatectomy PVPG increments of 1.5mmHg or greater, and resected liver segments of 3 or more to be independent predictors of PHLF. Conclusions. Acute PVPG increase after hepatectomy is associated with a higher risk of PHLF in Child-Pugh A patients.

Safety and efficacy of right portal vein embolization in patients with prior left lateral liver resection.

In patients with bilobar metastatic liver disease, surgical clearance of both liver lobes may be achieved through multiple-stage liver resections. For patients with extensive disease, a major two-staged hepatectomy consisting of resection of liver segments II and III before right-sided portal vein embolization (PVE) and resection of segments V-VIII may be performed, leaving only segments IV ± I as the liver remnant. To describe the outcome following right-sided PVE after prior complete resection of liver segments II and III. In this retrospective study, 15 patients (mean age = 60.4 ± 9.3 years) with liver metastases from colorectal cancer (n = 14) and uveal melanoma (n = 1) who were scheduled to undergo a major two-stage hepatectomy, were included. Total liver volume (TLV) and volume of the future liver remnant (FLR) were measured on pre- and postinterventional computed tomography (CT) scans, and standardized FLR volumes (ratio FLR/TLV) were calculated. Patient data were retrospectively analyzed regarding peri- and postinterventional complications, with special emphasis on liver function tests. The mean standardized post-PVE FLR volume was 26.9% ± 6.4% and no patient developed hepatic insufficiency after the PVE. Based on FLR hypertrophy and liver function tests, all but one patient were considered eligible for the subsequent right-sided hepatectomy. However, due to local tumor progression, only 9/15 patients eventually proceeded to the second stage of surgery. . Right-sided PVE was safe and efficacious in this cohort of patients who had previously undergone a complete resection of liver segments II and III as part of a major staged hepatectomy pathway leaving only segments IV(±I) as the FLR. .

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Carcinoma Camouflage

Question: A 74-year-old woman with compensated Child-Pugh A cirrhosis (Model for End-Stage Liver Disease score of 8) secondary to autoimmune hepatitis on azathioprine monotherapy was evaluated for abdominal bloating and intermittent right upper quadrant abdominal pain. She endorsed a 5-lb unintentional weight loss over the past 4 months associated with anorexia. On physical examination, she was well-appearing with a soft abdomen and no abdominal tenderness, distension, or ascites. The pertinent serology revealed an aspartate aminotransferase of 76 U/L, a total protein of 8.3 g/dL, albumin of 3.4 g/dL, hemoglobin of 12.2 g/dL, white blood cells of 3.1 × 109/L, platelets of 96,000, lactate dehydrogenase of 290 U/L, and alpha fetoprotein of 4.25 ng/mL. An abdominal ultrasound examination revealed a new hypoechoic lesion measuring 2.5 cm × 2 cm × 1.5 cm with minimal flow by Doppler. Triple phase magnetic resonance imaging (MRI) of the liver revealed a lobular 3.5 cm × 3.0 cm mass in hepatic segments 2 and 3 (Figures A and B, red arrows) as well as a 3.9 cm × 3.1 cm mass in segment 7, each T1 hypointense and T2 hyperintense with peripheral enhancement and washout including marked diffusion restriction favoring multifocal hepatocellular carcinoma with an atypical enhancement pattern. Imaging was negative for extrahepatic disease. Outside of the Milan criteria, the patient was referred to surgical oncology for further evaluation and management. The mass in segment 3 seemed to be larger via intraoperative ultrasound examination (5 cm) and was therefore resected. The mass in segment 7 underwent microwave ablation to preserve the liver parenchyma. Pathology revealed a sheetlike proliferation of large, pleomorphic, atypical vesicular lymphoid cells (Figure C) with mitotic figures and apoptotic bodies (Figure D). Immunohistologic staining was diffusely and strongly positive for CD20 (Figure E), CD10, and BCL6. Workup for viral serologies was negative (hepatitis B virus, hepatitis C virus, HIV, and Epstein–Barr virus stain from liver tissue). What is the next step in evaluation and management? What is the most likely diagnosis? Look on page 1942 for the answer and see the Gastroenterology website (www.gastrojournal.org/) for more information on submitting your favorite image to Clinical Challenges and images in GI. A referral to hematology/oncology was made for the initiation of rituximab-based chemotherapy. This patient has diffuse large B-cell lymphoma (DLBCL), germinal center B-cell type. The pathology from the resected liver segments revealed DLBCL, germinal center B-cell subtype, without double or triple-hit features after fluorescence in situ hybridization analysis. Positron emission tomography with computed tomography scans confirmed no evidence of active disease and final staging was deemed to be stage IEA with a National Comprehensive Cancer Network International Prognostic Index score of 4 (high to intermediate) secondary to age, extranodal disease, and elevated lactate dehydrogenase. Three short cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) was recommended. Echocardiogram revealed a normal ejection fraction. Unfortunately, she developed neutropenic fever during cycle 1 with extended spectrum beta lactamase urinary tract infection, urinary retention, and anasarca requiring granulocyte colony stimulating factor, antibiotics, and adjustment of diuretics. Additional chemotherapy was not advised, and she will follow-up with positron emission tomography with computed tomography scans in 2 months. DLBCL is the most common aggressive non-Hodgkin lymphoma (NHL).1Shibata J. Kurahashi S. Naito T. et al.Diffuse large B cell lymphoma primarily presenting as acute liver failure in a surviving patient.J Community Hosp Intern Med Perspect. 2019; 9: 135-139Crossref PubMed Google Scholar DLBCL may manifest as a primary hepatic lymphoma (PHL) in the late stage of disease. PHL is exceedingly rare, estimated to be present in 0.4% of extranodal NHL and 0.016% of all NHL cases.2Zhang K.J. Chen S. Chen J.L. et al.Complete response to comprehensive treatment of a primary hepatic diffuse large b cell lymphoma: a case report.Oncol Lett. 2015; 9: 1557-1660Crossref PubMed Scopus (3) Google Scholar Contributing factors include chronic viral infections (hepatitis B and C, Epstein–Barr virus, HIV), cirrhosis, autoimmune disease, and chronic use of immunosuppressants. R-CHOP is the gold standard of therapy. Chronic azathioprine use increases the risk of lymphoma; however, the association with PHL has not been reported. Imaging characteristics suggestive of PHL on MRI may consist of signal restriction in the diffusion-weighted imaging and a lower apparent diffusion coefficient.3Colagrande S. Calistri L. Grazzini G. et al.MRI features of primary hepatic lymphoma.Abdom Radiol. 2018; 43: 2277-2287Crossref PubMed Scopus (17) Google Scholar Clinicians should consider hepatic lymphoma in cirrhotic patients if there is a history of autoimmune disease, immunosuppressant use such as azathioprine, atypical enhancement pattern on MRI, and a normal alpha fetoprotein.

A cohort study of hepatectomy-related complications and prediction model for postoperative liver failure after major liver resection in 1,441 patients without obstructive jaundice.

BackgroundThis cohort study, based on a large sample of extensive hepatectomy cases, aimed to analyze the distribution of hepatectomy-related complications and to develop a predictive model of posthepatectomy liver failure (PHLF).MethodsData of patients who underwent hepatectomy of ≥3 liver segments at the Eastern Hepatobiliary Surgery Hospital from 2000 to 2016 were collected and analyzed. Information on hepatectomy-related complications was collected and risk factors were analyzed. A total of 1,441 eligible patients were randomly assigned at 3:1 ratio into the derivation (n=1,080) and validation (n=361) cohorts. The multivariable logistic regression model was used to establish the prediction model of PHLF in the derivation cohort.ResultsThe incidence rates of PHLF, ascites, bile leakage, intra-abdominal bleeding, and abscesses were 58.22%, 10.76%, 11.17%, 9.71%, and 4.16%, respectively. The 90-day perioperative mortality rate was 1.32%. Multivariate analyses found that age, gender, platelet, creatinine, gamma-glutamyltransferase, thrombin time, fibrinogen, hepatitis B e (HBe) antigen positive, and number of resected liver segments were independent prognostic factors of PHLF in the derivation cohort and included in the nomogram. The prediction model demonstrated good discrimination [area under the curve =0.726, 95% confidence interval (CI), 0.696–0.760, P<0.0001] and calibration.ConclusionsOur study showed a high perioperative safety and a low risk of serious complications in patients who underwent major liver resection (MLR) at a large hepatobiliary surgery center. Routine preoperative clinical information can be used to develop a postoperative liver failure risk prediction model for rational planning of surgery.

Resection of liver segments VII-VIII: is right hepatic vein reconstruction advisable?

To improve the treatment outcomes in patients with primary and metastatic liver tumors localized in segments VII-VIII involving the right hepatic vein and its branches. There were 16 surgical interventions including resection of liver segment VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction. All procedures were carried out at the Department of Liver and Pancreatic Tumors of the Blokhin National Medical Cancer Research Center for the period 2016-2020. The cause of surgery was colorectal cancer liver metastases in 8 patients, hepatocellular carcinoma in 2 cases, angiomyolipoma in 1 case and metastases of uterine cancer in 1 patient. Minor liver resection was additionally performed in 5 cases. Median surgery time was 150 (80-220) min, intraoperative blood loss - 400 (100-2000) ml. Afferent blood flow was blocked in 4 patients for 14 (12-25) min. None patient had intraoperative signs of impaired venous outflow. Biliary fistula in postoperative period occurred in 1 patient. No complications were noted in other cases. Median postoperative hospital-stay was 13 (9-19) days. There were no specific complications in long-term postoperative period that could be associated with venous outflow blockade through the right hepatic vein. Existing vessels and intrahepatic collaterals de novo can provide adequate venous outflow into the middle hepatic vein and short hepatic veins during resection of liver segments VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction and the absence of inferior right hepatic vein.

Application of Indocyanine Green Fluorescence Imaging in Laparoscopic Liver Surgery

To study the clinical use of indocyanine green(ICG)fluorescence imaging in laparoscopic liver surgery, the clinical and pathological data of 68 patients who underwent laparoscopic hepatectomy using the ICG fluorescence imaging technique during the study period from September 2016 to October 2018 in Zhongnan Hospital of Wuhan University were retrospectively analyzed. Analysis was carried out on the surgical methods, fluorescence navigation methods, ICG injection time and dose, tumor characteristics, and pathological studies of the resected specimens. Of 68 patients, only 3 patients were converted to open surgery. 32 patients underwent ICG fluorescent guided laparoscopic anatomical resection of lower hepatic segment/hepatic hemilivers(positive staining in 17 patients, negative staining in 15 patients), with 19 patients successfully staining with ICG(59.4%). Postoperative histopathology showed primary hepatic solid tumors(n=31), secondary liver tumors(n=12), hepatic cysts(n=4), hepatic hemangiomas(n=5), hepatolithiasis(n=12)and hepatic focal nodular hyperplasia(n=1). These lesions were combined with hepatitis B liver fibrosis in 29 patients. ICG fluorescence imaging positively impacted on laparoscopic liver surgery. Proper preoperative ICG injection was helpful for the identification, localization and intraoperative surgical guidance of tumors, especially for patients with deep-seated and central tumors. As a consequence, oncological and surgical safety of laparoscopic liver surgery was improved. Targeted visualization of liver segments and surgical navigation using intraoperative ICG injections facilitated accurate and precise resection of anatomical liver segments or hemi-hepatectomies. The use of intraoperative ICG fluorescence technology for hepatic hemangioma, hepatic cyst, intrahepatic bile duct stones and other benign liver lesions, helped to improve safety of surgery.

A Single Centre Comparative Study of Total Laparoscopic versus Open Liver Resection of Right Posterior Segments

Purpose: Patients with lesions in the right posterior segments of the liver have been considered technically challenging for laparoscopic liver resection (LLR). The aim of the current study is to compare short-term outcomes of LLR and open liver resections (OLR) of the right posterior segments. Methods: Retrospective review of patients undergoing resection of the right posterior segments of the liver from June 2016 to January 2018 in our tertiary centre. Results: Eighteen patients in each group (LLR and OLR) underwent resection of the right posterior segments. The mean age and gender distribution were comparable between both groups. In four patients (22.2%), conversion to open surgery was indicated. The maximum tumour diameter was comparable between the groups (4.04 ± 2.52cm in LLR versus 3.88± 2.26 in OLR, p=.876). Similar operating times were found in LLR and OLR (244.66 ±79.42 and 220.75 ±102.35 minutes respectively) (p=0.187). There was no difference in intraoperative blood loss (p=0.539), duration of Pringle manoeuvre (p=0.157) and resection margins (p=0.114). Postoperative complications were comparable using Dindo-Clavien classification. Length of stay (LOS) was shorter following LLR (4.8 ± 1.72 versus 9.0 ± 3.9 days in the OLR, p<0.0005). Conclusion: LLR for carefully selected patients with lesions in the right posterior segments is safe and feasible with similar short-term outcomes and shorter LOS compared to the OLR group.

Extended Indications for Laparoscopic Parenchyma-Sparing Resection of Posterosuperior Liver Segments in Patients with Colorectal Metastases. PSM Analysis of Outcomes in Comparison with Open Hepatectomy

Background: Indications for laparoscopic liver resection (LLR) of posterosuperior segments (RSS) for colorectal liver metastases (CRLM) are commonly restricted to small, superficial lesions not adjacent to large vessels. There is no long-term survival comparative estimation after LRR and open liver resection (OLR). We aimed to compare outcomes after parenchyma-sparing LLR with extended indication and open liver resection (OLR) for CRLM located in PSS. Methods: Two Russian centers took part in the study. Patients with hemihepatectomy, extrahepatic tumors were excluded. Logistic regression was used for 1:1 propensity score matching (PSM). Results: PSS were resected in 77 patients. LLR were performed in 51 (66%) patients. Twenty pairs of patients were matched. Demographic and preoperative data are presented in the table. After matching, no differences were found in terms of blood loss, ICU and hospital stay, which were better for LLR group before PSM. No 90-day mortality was observed within both groups. After PSM, no difference was found in 5-year overall survival after LLR and OLR (78% and 63%, respectively) and 4-year disease-free survival (27% in both groups). Conclusions: Expanding indication for laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients if performed in high volume specialized centers expertized in laparoscopic liver surgery.OL01-03Demographic dataFactorsBefore matchingAfter matchingLLR (n=51)OLR (n=26)PLLR (n=20)OLR (n=20)PMedian size of largest metastatic tumor, mm40 (10-98)46 (15-100)0,38450 (15-98)44 (15-100)0,309Rate of metastases >50 mm, n (%)17 (33%)10 (39%)0,6569 (45%)7 (35%)0,519Proximity to the large hepatic vessels, n (%)12 (24%)8 (31%)0,4935 (25%)6 (30%)0,655Anatomical resection, n (%)22 (43%)9 (35%)0,4717 (35%)8 (40%)0,744Difficulty index, point7,0 (4,8-11,1)6,1 (2,9-10,7)0,0917,2 (4,8-11,8)6,4 (2,9-10,7)0,189Positive response to neoadjuvant chemo (RECIST), n (%)27 (53%)16 (62%)0,47313 (65%)12 (60%)0,744Positive response to adjuvant chemo (RECIST), n (%)36 (71%)18 (69%)0,90215 (75%)14 (70%)0,723 Open table in a new tab

Robotic atypical resection of liver segment II for hepatocellular carcinoma (HCC) on a fibrotic (F3) liver

Purpose: We present the case of a 78 years-old patient affected by HCV cirrhosis with a diagnosis of a single resectable 2cm HCC of the upper and lateral border of the segment II. Methods: Pre-operative work-up included liver MRI, thoracic CT-scan and blood exams. Child-Pugh score A5, MELD score 8, Platelet count normal, AFP within normal values. Gastroscopy was zithin limits. After multidisciplinary discussion a liver resection was indicated using a robotic minimally invasive approach. Results: Intraoperative ultrasound was performed to exlude other missed lesions. Parenchymal transection is then realized by the kelly clamp crushing technique under intermittent vascular clamping (extracorporeal control). There were no intraoperative complications, the post-operative course was uneventful with patient discharged at POD 1. Pathological findings: pT1 moderately differentiated hepatocellular carcinoma (Edmonson-Steiner grade 2 to 3), R0 (complete resection). Conclusion: robotic liver resection can be performed safely, with a magnified vision and optimal control of the surgical field.

Redo laparoscopic segment 2/3 hepatocellular carcinoma resection in alcohol-related chronic liver disease

Purpose: Hepatocellular Carcinoma is a leading cause of death in chronic liver disease and cirrhosis. Operative treatment options include surgical resection or liver transplantation. Minimally invasive approaches reduce patient morbidity and improve recovery and return to normal activity, but can be an operative challenge in fibrotic, cirrhotic liver parenchyma. Method: 72-year-old male presented with Hepatocellular Carcinoma in segment 2/3 on a background of alcohol-related Chronic Liver Disease. Multidisciplinary decision to proceed to Laparoscopic Non-anatomical Liver resection. Histology demonstrated mixed HCC, R0 resection with microvascular invasion present. 8/12 follow updemonstrated recurrence in left lateral segments 2/3. Multidisciplinary decision to proceed to Laparoscopic redo Liver resection of segment 2/3 Results: Laparoscopic non-anatomical resection of Segment 2/3 HCC was performed. Histology demonstrated HCC, R0 resection. The patient made an uncomplicated recovery and remains disease free at 4 years. Conclusion: Laparoscopic re-do liver resection for HCC with background chronic liver disease is a feasible and safe approach in selected cases. Careful haemostasis during laparoscopic dissection in cirrhosis is key to avoid intraoperative bleeding, and minimise the risk of losing the visual field and converting to open surgery.

Preoperative Nomogram to Predict Post-Hepatectomy Liver Failure in Patients Undergoing Liver Resection

Background: Post-hepatectomy liver failure (PHLF) is a rare but serious complication after liver resection (LR) and a leading cause of mortality. The aim of the present study was to define preoperative predictors of PHLF and propose a predictive nomogram to be utilized in preoperative planning. Methods: Consecutive patients planned for LR from October 2014 to August 2016 were prospectively recruited. Clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were collected at inclusion and until three months after LR. PHLF was defined by 50-50 criteria and/or postoperative peak total bilirubin >7mg/dL. Results: Four hundred and eighteen LRs were performed in 244 men and 174 women whose median age was 62 years. PHLF was observed in 19 patients (4.6%) after major LR in 17 and minor LR in two. Mortality rate in patients developing PHLF was 21.1% while mortality rate in the entire cohort of 418 patients was 2.2%. Independent predictors of PHLF were diabetes mellitus (odds ratio (OR): 6.6; 95% confidence interval (CI):1.1-39.3), pre-operative chemotherapy cycles ≥8 (OR: 4.1; CI:0.8-20.9), tumor size ≥51mm (OR: 4.8; CI:0.9-26.1), platelet count < 150,000/mL (OR: 8.7; CI:1.3-56.8), ICG-R15 (OR: 10.4; CI:1.9-58.1) and number of resected liver segments ≥3 (OR: 12.9; CI:1.3-125.4). Nomogram built with these six factors had area under receiver operating characteristic curve of 0.92 and goodness-of-fit of p=0.44. Conclusion: Predictive nomogram incorporating ICG-R15 would improve the safety of LR by enabling surgeons to identify high-risk patients and adapt the surgical strategy in them.

Laparoscopic liver resection after laparoscopic pancreatoduodenectomy for liver metastases of ampulla of Vater adenocarcinoma

BackgroundRepeat laparoscopic surgery has become increasingly common. However, reports of liver resection after pancreatoduodenectomy are scarce, and we report the first successful case of a patient who underwent laparoscopic liver resection after laparoscopic pancreatoduodenectomy.Case presentationA 65-year-old man underwent laparoscopic pancreatoduodenectomy for ampulla of Vater adenocarcinoma. According to the American Joint Committee on Cancer (8th edition) staging guidelines, the tumour was labelled as stage IIIB (fT2N2M0). Twelve months later, a computed tomography (CT) scan revealed liver masses (in segments 3 and 5) and swollen para-aortic lymph nodes. After six chemotherapy courses of gemcitabine with cisplatin, the CT scan showed the disappearance of the para-aortic lymph nodes and progression of liver metastases. Nineteen months after the initial surgery, the patient underwent laparoscopic partial liver resection of segment 5 and left lateral sectionectomy. First, we performed the operation in the left half lateral decubitus position. In this position, the portal vein was isolated safely without hindering the hepato-jejunal anastomosis, although the adhesions around the hepato-jejunal anastomosis were dense. Therefore, we were able to perform liver transection safely with vascular inflow control. The operation duration was 235 min, and the volume of blood loss was 100 g. Macroscopically, the resected margins were negative. The patient was uneventfully discharged 12 days after the second operation. Afterwards, drainage was needed because of an intra-abdominal abscess. Currently, he has been alive for 8 months postoperatively, receives chemotherapy to suppress para-aortic lymph node metastases, and has not had another recurrence.ConclusionsLiver resection after pancreatoduodenectomy can be performed safely with an innovative body position to isolate the portal vein, which is a key point of the surgery. A laparoscopic approach for liver resection after pancreatoduodenectomy is a feasible option.

Robotic minor hepatectomy: optimizing outcomes and cost of care

BackgroundThe advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. MethodsWe queried the medical record and cost data for patients who underwent open or robotic minor (1–2 segment) liver resection from 1/2016–8/2019. Financial data were normalized to Medicare reimbursements. ResultsThere were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p < 0.001) were significantly lower for patients who underwent robotic resection. These factors contributed to minor robotic liver resections costing $534 less than open resections ($3597 ± 1823 vs $4131 ± 1532, p = 0.03). ConclusionPatients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

Impact of anthropometric data on technical difficulty of laparoscopic liver of resections of segments 7 and 8: the CHALLENGE index.

The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes. All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes. Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes. Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight.

Robotic Resection of Postero-Superior Liver Segments (7,8) (with Video)

BackgroundSurgical resection is the standard treatment for colorectal liver metastases. Parenchyma-sparing technique should always be attemptedto prevent postoperative liver failure and increase the opportunity to perform repeated resections in cases of recurrent malignancy. Postero-superior liverresection is defined as the anatomical removal of liver segments 7 and 8, however, minimally invasive resection of postero-superior liver segments isconsidered a difficult and complex operation and thus is rarely reported. MethodsWe present the video of a robotic postero-superior liver resection in a 54-year-old male patient with a synchronous, single, and large colorectal metastasis in the postero-superior liver sector. The Da Vinci Xi system was used. The right liver was mobilized with exposure of the inferior vena cava (IVC), following by intraoperative ultrasound, used to locate the tumor and establish its relationship to the right hepatic vein and portal pedicles fromsegments 7 and 8. A thick hepatic vein draining directly to the IVC was controlled with hem-o-lock and the right hepatic vein was divided using anendoscopic stapler. The surgical specimen was removed through a supra-pubic incision. ResultsOperative time was 205 minutes, and the estimated blood loss was 310 mL. The patient's recovery was uneventful with no need for admission tothe intensive care unit or for blood transfusion. Pathology confirmed colorectal metastasis with free surgical margins.Conclusions: Robotic resection of postero-superior liver segments is feasible and safe and may have some advantages over laparoscopic and openapproaches. This video may help gastrointestinal surgeons perform this complex procedure.