Total Liver Volume Research Articles

Early experience of pure minimally invasive donor hepatectomy by junior surgeon

Although the pure minimally invasive donor hepatectomy (PMIDH) has been increasingly performed, it is still reported by experienced surgeons. Here we reported the early experience of PMIDM by junior surgeon. From April 2019 to November 2020, PMIDHs were performed for 19 patients by single novice surgeon (H.D.H) at Yonsei University College of Medicine. Clinical characteristics, perioperative outcomes of donors and clinical features of recipients were analyzed. Eighteen of 19 donors had pure laparoscopic liver resection. Right, left hemihepatectomies and left lateral sectionectomies were performed for 15, 1 and 3 donors, respectively. Mean total operation time was 460.63 ± 70.89 minutes and median operative bleeding was 200 mL (50-1,600 mL). Median hospital stay was 8 (7-11) days. In terms of laparoscopic donor right hemihepatectomy, mean total operation time was 464.21 ± 43.52 minutes. Median amount of bleeding during operation was 225 mL (50-1,600 mL). Mean estimated total liver volume was 1,228.26 ± 217.01 (935.80-1,584.90) and mean real graft weight was 764.86 ± 153.46 (529.00-1,077.00). The robotic donor right hemihepatectomy was performed for one donor. Total operation time was 663 minutes with 550 mL of operative bleeding. There was no conversion to open surgery. Only the first donor had transfusion during operation. There was no severe perioperative complication more than grade III according to classification of Clavien-Dindo surgical complication. Although the PMIDH may need high level of surgical skill, it appears to be a safe and feasible procedure by junior surgeon in properly selected donors.

Identifying enhancement-based staging markers on baseline MRI in patients with colorectal cancer liver metastases undergoing intra-arterial tumor therapy.

To determine if three-dimensional whole liver and baseline tumor enhancement features on MRI can serve as staging biomarkers and help predict survival of patients with colorectal cancer liver metastases (CRCLM) more accurately than one-dimensional and non-enhancement-based features. This retrospective study included 88 patients with CRCLM, treated with transarterial chemoembolization or Y90 transarterial radioembolization between 2001 and 2014. Semi-automated segmentations of up to three dominant lesions were performed on pre-treatment MRI to calculate total tumor volume (TTV) and total liver volumes (TLV). Quantitative 3D analysis was performed to calculate enhancing tumor volume (ETV), enhancing tumor burden (ETB, calculated as ETV/TLV), enhancing liver volume (ELV), and enhancing liver burden (ELB, calculated as ELV/TLV). Overall and enhancing tumor diameters were also measured. A modified Kaplan-Meier method was used to determine appropriate cutoff values for each metric. The predictive value of each parameter was assessed by Kaplan-Meier survival curves and univariable and multivariable cox proportional hazard models. All methods except whole liver (ELB, ELV) and one-dimensional/non-enhancement-based methods were independent predictors of survival. Multivariable analysis showed a HR of 2.1 (95% CI 1.3-3.4, p = 0.004) for enhancing tumor diameter, HR 1.7 (95% CI 1.1-2.8, p = 0.04) for TTV, HR 2.3 (95% CI 1.4-3.9, p < 0.001) for ETV, and HR 2.4 (95% CI 1.4-4.0, p = 0.001) for ETB. Tumor enhancement of CRCLM on baseline MRI is strongly associated with patient survival after intra-arterial therapy, suggesting that enhancing tumor volume and enhancing tumor burden are better prognostic indicators than non-enhancement-based and one-dimensional-based markers. • Tumor enhancement of colorectal cancer liver metastases on MRI prior to treatment with intra-arterial therapies is strongly associated with patient survival. • Three-dimensional, enhancement-based imaging biomarkers such as enhancing tumor volume and enhancing tumor burden may serve as the basis of a novel prognostic staging system for patients with liver-dominant colorectal cancer metastases.

Parenchymal-sparing approaches for resection of tumors located in the paracaval portion of the caudate lobe of the liver-utility of limited resection and central hepatectomy.

Resection of liver cancer involving the paracaval portion (PC) of the caudate lobe is challenging because the PC is located deepest in the liver. This study aimed to elucidate the utility of two parenchymal-sparing approaches of limited resection and central hepatectomy for resecting tumors located in the PC. In 2018 and 2020, 12 out of 143 patients underwent hepatectomy for tumors located in the PC of the liver. In six patients, limited resection (LR) of the PC after full mobilization of the liver off the inferior vena cava (IVC) was performed for tumors excluding the hilar plate or large hepatic veins (large HVs), including major hepatic veins or thick short hepatic veins. In six patients, central hepatectomy (CH) using liver tunnel was performed for tumors involving or close to the hilar plate and/or large HVs. During CH, the surgical view of the cranial side of the hilar plate was wide enough to perform combined resection of the large HVs in front of the IVC. Five of the six CHs were performed with resection of the LHVs. No LRs were accompanied with resection of the LHVs. The CH was associated with longer Pringle's time (76 min vs. 29.5 min, p = 0.015) and blood loss (1104 ml vs. 370 ml, p = 0.041). The preserved liver parenchyma volumes were 82% and 95% of the total liver volume after CH and LR, respectively. Our parenchymal-sparing approach for resection of liver cancer located in the PC is feasible for curative resection.

Coil volume embolization ratio for preventing recanalization after portal vein embolization.

The purpose of this study was to evaluate the optimum volume embolization ratio (VER) for the prevention of recanalization after portal vein embolization (PVE) and the influence of recanalization on future liver remnant (FLR) function using technetium-99m galactosyl human serum albumin single-photon emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging. We analyzed procedural data of 18 patients who underwent PVE from 2015 to 2018. A total of 29 portal branches were embolized (12 anterior branch, 11 posterior branch, 4 left branch, 2 right branch) with absolute ethanol and coils. Portal vein recanalization was evaluated three weeks after PVE by contrast-enhanced CT. We classified the treated portal branches as non-recanalized and recanalized. VER was compared between the groups. In addition, for each patient, we calculated and evaluated the ratio of FLR volume to total liver volume (volumetric %FLR), FLR count to total liver count on 99mTc-GSA SPECT/CT fusion imaging (functional %FLR), and functional-volumetric ratio (functional %FLR/ volumetric %FLR). Twenty-six portal branches showed no recanalization (non-recanalized group, n=26, 89.7%), while three portal branches showed recanalization (recanalized group, n=3, 10.3%). The median VER was 4.94% (3.12%-11.1%) in the non-recanalized group and 3.49% (2.76%-4.32%) in the recanalized group, which was significantly different between the groups (p = 0.045, Mann-Whitney U test). The median functional-volumetric ratio was 1.16 (1.03-1.50) in non-recanalized patients (n=15, 83.3%) and 1.01 (0.96-1.13) in recanalized patients (n=3, 16.7%), and it was significantly higher in the non-recanalized patients (p = 0.021, Mann-Whitney U test). The VER for preventing recanalization after PVE was approximately 5% (> 4.94%). 99mTc-GSA SPECT/CT fusion imaging revealed a decrease in FLR function due to recanalization after PVE.

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. .

Bile Salt and FGF19 Signaling in the Early Phase of Human Liver Regeneration.

The involvement of bile salt–fibroblast growth factor 19 (FGF19) signaling in human liver regeneration (LR) is not well studied. Therefore, we studied aspects of bile salt–FGF19 signaling shortly after liver resection in patients. We compared plasma bile salt and FGF19 levels in arterial, portal and hepatic venous blood, calculated venous‐arterial differences (ΔVA), and determined hepatic transcript levels on two intra‐operative time points: before (< 1 hour) and immediately after (> 2‐3 hours) liver resection (i.e., following surgery). Postoperative bile salt and FGF19 levels were assessed on days 1, 2, and 3. LR was studied by computed tomography (CT)–liver volumetry. Following surgery, the liver, arterial, and portal bile salt levels were elevated (P < 0.05). Furthermore, an increased amount of bile salts was released in portal blood and extracted by the remnant liver (P < 0.05). Postoperatively, bile salt levels were elevated from day 1 onward (P < 0.001). For FGF19, intra‐operative or postoperative changes of ΔVA or plasma levels were not observed. The bile salt–homeostatic regulator farnesoid X receptor (FXR) was markedly up‐regulated following surgery (P < 0.001). Cell‐cycle re‐entry priming factors (interleukin 6 [IL‐6], signal transducer and activator of transcription 3 [STAT3], and cJUN) were up‐regulated following surgery and were positively correlated with FXR expression (P < 0.05). Postoperative hyperbilirubinemia was preceded by postsurgery low FXR and high Na+/Taurocholate cotransporting polypeptide (NTCP) expression in the remnant liver coupled with higher liver bile salt content (P < 0.05). Finally, bile salt levels on postoperative day 1 were an independent predictor of LR (P < 0.05). Conclusion: Systemic, portal, and liver bile salt levels are rapidly elevated after liver resection. Postoperative bile salts were positively associated with liver volume gain. In the studied time frame, FGF19 levels remained unaltered, suggesting that FGF19 plays a minor role in human LR. These findings indicate a more relevant role of bile salts in human LR.

A Quantitative Study on the Protective Effects of Resveratrol against Bisphenol A-induced Hepatotoxicity in Rats: A Stereological Study.

Background: Bisphenol A (BPA) is a widely used chemical with toxic effects on the liver. Resveratrol (RES) is an herbal compound with protective properties. This study aimed to investigate the protective effects of RES on the liver in rats exposed to BPA.Methods:This study was conducted in 2018 in Shiraz, Iran. Thirty Sprague-Dawley male rats were divided into five groups: a control group (distilled water), a sham group (olive oil as a BPA solvent), a BPA group (50 mg/kg), an RES group (100 mg/kg), and a RES+BPA group (50 mg/kg+100 mg/kg). Olive oil, BPA, and RES were administered to the animals via gavage for eight weeks. After eight weeks, the animals’ livers were removed, and stereological measurements were made to obtain the total liver volume, portal triad volumes, hepatocyte nucleus and cytoplasm volumes, hepatocyte numbers, sinusoidal space volumes and lengths, and Kupffer cell (KC) numbers. The data were analyzed using the one-way analysis of variance testResults: The hepatocyte number, the total liver volume, and hepatocyte nucleus and cytoplasm volumes in the BPA group decreased by 41% (P<0.001), 18% (P<0.001), 32% (P=0.030), and 37% (P=0.014), respectively. The number of KCs and the length of sinusoids in the BPA group were increased compared with all the other groups (P<0.001). Our histological study revealed vacuolization, sinusoidal space dilatation, and congestion in the BPA group.Conclusion: In this study, the RES group, compared with the BPA group, exhibited a decrease in the total volume and length of sinusoids and the number of KCs. Additionally, the RES group showed an increase in the total liver volume, hepatocyte nucleus and cytoplasm volumes, portal triad volumes, and hepatocyte numbers after oral administration

Efficacy of Pre-Operative Portal Vein Embolization of Biliary Neoplasm before Major Hepatectomy

Background: Malignant biliary neoplasm is relatively common in Southeast Asia. Portal vein embolization (PVE) is a preoperative procedure to induce hypertrophy of future liver remnants. PVE can decrease the rate of post hepatectomy liver failure (PHLF). Objective: To evaluate the efficacy of preoperative PVE of biliary neoplasm patient prior to major hepatic resection. Materials and Methods: The study included 53 patients with biliary neoplasm planned for major hepatic resection and that underwent PVE between July 2013 and August 2019. Liver volumetry before and after PVE was analyzed. Operative procedure and post hepatectomy outcome were evaluated. Results: Peri-hilar type cholangiocarcinoma, Bismuth-Corlette classification IIIA was the most frequent tumor. The technical success rate of PVE is 100%. Future liver remnant (FLR) volume after PVE was significantly increased from 379.1 to 460 mL (p&lt;0.001). Post PVE FLR over total functional liver volume (TFLV) ratio was significantly increased from 27.8% to 34.6%(p&lt;0.001). The mean kinetic growth rate (KGR) per week was 7.1%. Twenty-four patients underwent subsequent hepatectomy, and two patients presented with PHLF. Twenty-nine patients (54.7%) did not undergo subsequent hepatectomy as planned due to advanced disease with 21 (72.4%) because of locally advanced cancer, peritoneal carcinomatosis, and N2 lymph nodes metastasis), four (13.8%) that refused surgical treatment, and three (10.3%) that were loss to follow-up. Conclusion: Preoperative PVE before major hepatic resection in biliary neoplasm patients is an effective procedure to increase FLR, FLR/TFLV ratio, and provide good KGR. However, more than half of post preoperative PVE could not be obtained hepatectomy because of the progression to advanced stage of disease. Keywords: Biliary neoplasm, Portal vein embolization, Future liver remnant, Major hepatic resection, Post hepatectomy liver failure

Safe use of right lobe living donor livers with moderate steatosis in adult-to-adult living donor liver transplantation: a retrospective study.

Hepatic steatosis (HS) beyond a certain degree can jeopardize living donor (LD) safety, particularly in right lobe (RL) donors, making it a major obstacle for donor pool expansion in adult-to-adult living donor liver transplantation (ALDLT). From July 2004 to June 2016, 58 LDs donated their RLs despite having moderate HS (30%-50% steatosis) determined by intraoperative biopsy at a single center. We performed greedy matching to compare the outcomes of the donors and recipients of this group with those of LDs with no HS. The mean left lobe (LL) HS value in the 58 cases was 20.9±12.4%, which was significantly lower than the mean RL HS value (38.8±6.7%, P<0.001). The mean ratio of the remnant LL to the total liver volume was 37.8±2.2. No differences were observed in the postoperative liver function and donor and recipient morbidity and mortality rates. The liver regeneration rates in recipients and donors at 1month, 6months, and 1year postoperatively did not differ significantly. The patient and graft survival rates of the recipients showed no differences. The use of well-selected RL grafts with moderate steatosis does not impair graft function, recipient outcomes, or donor safety.

Quantitative Liver Volumetric Parameters on Computed Tomography May Be Used for Identifying Severe Esophageal Varices and the Risk of First Variceal Hemorrhage

Background: To assess whether the quantitative parameters of liver lobe volume (LLV) based on computed tomography (CT) can identify severity of esophageal varices (EV) and the risk of first variceal hemorrhage (FVH) in patients with liver cirrhosis. Methods: A total of 217 endoscopically confirmed EV patients were enrolled in this study and were divided into a non-conspicuous EV group (mild-to-moderate EV, n=83) and a conspicuous EV group (severe EV, n=134), a FVH group(n=17) and a non-FVH group (n=27), patients’ clinical finding were recorded. The left, right, caudate lobe volume and the corresponding functional volume (LV, RV, CV, LFV, RFV, CFV), total liver volume and the functional volume (TV, TFV) were measured respectively, and the ratio of CV/TV, CFV/TFV were calculated. Univariate and multivariate logistic analysis were used to determine the independent factors and the receiver operating characteristic(ROC) curves were performed to evaluate the diagnostic performance. Results: CV, CFV, CV/TV and CFV/TFV were significantly different in the conspicuous EV study and the FVH study (p <0.05). Multivariate analysis indicated that CV/TV and ascites were independent predictive factors for severe EV. A nomogram combing CV/TV and presence of ascites revealed a satisfactory diagnostic performance for severe EV(area under the curve (AUC)=0.853, 95%CI 0.797, 0.905). Furthermore, CV/TV and the presence of red color sign (RC) were found to be independent predictive factors for the risk of FVH, CV/TV showed a superior discriminative performance (AUC=0.851,95%CI 0.714-0.987) when compared with RC sign under endoscopy (AUC=0.779, 95%CI 0.649-0.91). Conclusions: Quantitative parameters of LLV have great potential be used as an alternative to identify EV severity and the risk of FVH. Funding Information: Not applicable. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study had approval from the Institutional Review Board of West China Hospital, and informed consent requirement was waved.

Quantitative CT assessment by histogram and volume ratio in pyrrolizidines alkaloids-induced hepatic sinusoidal obstruction syndrome

ObjectiveTo quantitatively assess hypoattenuation volume ratio and hepatic parenchymal hypoattenuation on contrast enhanced computed tomography (CECT) in patients with pyrrolizidines alkaloids (PAs)-induced hepatic sinusoidal obstruction syndrome (HSOS), and evaluate the correlations of the CT-based quantitative values with clinical factors. MethodsThirty-five patients with PAs-induced HSOS who underwent CECT were retrospectively enrolled. The ratio of hypoattenuation volume to total liver volume, and changes in damaged area-to-normal liver density ratio (ΔDR) derived from histogram on portal venous phase were quantitatively measured. Heterogeneous hypoattenuation (CT score) scored by hypoattenuation volume ratio and ΔDR were calculated. The correlation between imaging findings and clinical factors was analyzed using Pearson correlation test. ResultsLiver function tests were abnormal in most patients, the mean Hounsfield unit (HU) of damaged area (58.68 ± 17.3) was significantly lower (P < 0.001) than the corresponding normal liver (82.27 ± 23.97). Heterogeneous hypoattenuation were mild in 13 patients (37 %), moderate in 16 patients (46 %), and severe in 6 patients (17 %). ΔDR derived from histogram was positively correlated (weakly to moderately) with total bilirubin (r = 0.341, P = 0.045), direct bilirubin (r = 0.385, P = 0.022), and alkaline phosphatase (r = 0.491, P = 0.003), while such correlation was not observed in hypoattenuation volume ratio. The severity of heterogeneous hypoattenuation scored by hypoattenuation volume ratio and ΔDR was positively correlated (weakly) with prothrombin time (r = 0.357, P = 0.035), international normalized ratio (r = 0.363, P = 0.032), alkaline phosphatase (r = 0.359, P = 0.034), and model for end-stage liver disease (MELD) score (r = 0.347, P = 0.041). ConclusionHeterogeneous hypoattenuation scored by volume ratio and ΔDR on CECT provides a non-invasive approach in evaluating the severity of PAs-induced HSOS.

Functional transition: Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization.

BACKGROUNDPreoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear.AIMTo investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and 99mTc-galactosyl-human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images. METHODSThirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and 99mTc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D 99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D 99mTc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV.RESULTSFFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE (P < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% (P < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% (P < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure.CONCLUSIONThe functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.

Can Beaver Tail Liver be the Cause of Preference in Living Liver Transplantation Donors?

This study aims to investigate whether there was a difference between the levels of safety in terms of the postoperative residual liver volume in living transplant donors with normal liver anatomy and beaver tail liver. Contrast-enhanced abdominal computed tomography (CT) images of 158 volunteers were retrospectively scanned. They were divided into 2 groups; with and without beaver tail liver. The total and left lobe volumes of the liver in all the candidates were calculated. The data were evaluated using the Mann-Whitney U test. Statistical values of p<0.05 were considered significant. The median value of the total liver volume was 1.252 mL and that of the left lobe percentage was 38% in the beaver tail group and 1.375 mL and 35%, respectively, in the normal liver group. A significant difference was observed in terms of the total liver volume and left lobe volume percentages of the 2 groups (p=0.012 and p<0.001, respectively). The percentage of the left lobe in the beaver tail group was significantly higher, which indicates that liver transplantation donors with the beaver tail feature may be safer in terms of residual liver volume.

Postoperative acute multiple organ failure after hepatectomy in a Nigerian male with sickle cell trait: a case report

BackgroundSickle cell disease (SCD) is a monogenic disease characterized by sickle hemoglobin (HbS). Patients homozygous for HbS experience symptoms resulting from sickled erythrocytes no later than adolescence. However, heterozygous HbS carriers, or those with the so-called sickle cell trait (SCT), may undergo surgery without their hemoglobinopathy being known.Case presentationA 53-year-old Nigerian male with hepatitis C infection underwent radiofrequency ablation therapy for multiple hepatocellular carcinomas (HCCs) 17 months prior. Follow-up computed tomography (CT) revealed a solitary tumor (3.2 cm) in the medial section of the cirrhotic liver. The Child–Pugh score was five, and the indocyanine green retention rate at 15 min was 17.4%. The nontumorous liver of the medial section accounted for 10% of the total liver volume according to CT volumetry. With the diagnosis of recurrent HCC, left medial sectionectomy was performed under intermittent blood flow occlusion by Pringle’s maneuver. Intraoperative ultrasonography confirmed that hepatic blood flow had been preserved after hepatectomy. However, laboratory tests on postoperative day (POD) 1 revealed severe liver damage: aspartate aminotransferase 9250 IU/L, alanine aminotransferase 6120 IU/L, total bilirubin 2.8 mg/dL, and prothrombin time% 20.9%. The patient’s renal and respiratory functions also deteriorated; therefore, continuous hemodiafiltration and plasma exchange were initiated under mechanical ventilation. Whole-body contrast-enhanced CT showed no apparent ischemia of the remnant liver, but diffuse cerebral infarction was detected. Despite intensive treatments, he died of multiple organ failure on POD 20. The pathological examination of the resected specimen revealed that the intrahepatic peripheral vessels were occluded by sickled erythrocytes. Additionally, chromatographic analysis of hemoglobin detected the presence of abnormal hemoglobin, although microscopic examination of the peripheral blood erythrocytes did not show morphological abnormalities. Based on these findings, we determined that he had SCT and developed vaso-occlusive crisis involving multiple organs just after hepatectomy.ConclusionSCD is a rare disease in eastern Asia, but its prevalence is increasing globally. Surgeons should pay increased attention to this disease, especially when performing hepatectomy under blood flow occlusion.

Effects of laparoscopy, laparotomy, and respiratory phase on liver volume in a live porcine model for liver resection

BackgroundHepatectomy, living donor liver transplantations and other major hepatic interventions rely on precise calculation of the total, remnant and graft liver volume. However, liver volume might differ between the pre- and intraoperative situation. To model liver volume changes and develop and validate such pre- and intraoperative assistance systems, exact information about the influence of lung ventilation and intraoperative surgical state on liver volume is essential.MethodsThis study assessed the effects of respiratory phase, pneumoperitoneum for laparoscopy, and laparotomy on liver volume in a live porcine model. Nine CT scans were conducted per pig (N = 10), each for all possible combinations of the three operative (native, pneumoperitoneum and laparotomy) and respiratory states (expiration, middle inspiration and deep inspiration). Manual segmentations of the liver were generated and converted to a mesh model, and the corresponding liver volumes were calculated.ResultsWith pneumoperitoneum the liver volume decreased on average by 13.2% (112.7 ml ± 63.8 ml, p < 0.0001) and after laparotomy by 7.3% (62.0 ml ± 65.7 ml, p = 0.0001) compared to native state. From expiration to middle inspiration the liver volume increased on average by 4.1% (31.1 ml ± 55.8 ml, p = 0.166) and from expiration to deep inspiration by 7.2% (54.7 ml ± 51.8 ml, p = 0.007).ConclusionsConsiderable changes in liver volume change were caused by pneumoperitoneum, laparotomy and respiration. These findings provide knowledge for the refinement of available preoperative simulation and operation planning and help to adjust preoperative imaging parameters to best suit the intraoperative situation.

Validation of CT anatomical volumetry performed using hermes workstation

Purpose: Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden) is increasingly used to assess the hepatic uptake of Technetium Mebrofenate for preoperative liver function assessment. The workstation also allows assessment of anatomical and functional liver volumes on SPECT-CT scan. The aim of the current study is to compare the agreement of the semiautomated liver segmentation for the assessment of total and segmental liver volumes with post resection liver specimen volumes using Hermes workstation. Methods: A retrospective analysis was carried out using a prospectively maintained database. A total of 144 patients underwent standard right or left hepatectomy (Brisbane 2000 nomenclature) between January 2015 and December 2016 were included. Total, resection and remnant anatomical liver volumes were measured retrospectively using Hermes workstation. Postresection volumes measured by assessment of dry weight of pathological specimen were compared with the resection volumes. The Pearson’s correlation coefficient (r) was used to calculate the linear correlation using SPSS. Results: Right hepatectomy was performed in 79% and left hepatectomy in 21% of the included patients. There was no significant inter reader variability (AO,BD) as assessed on 15 initial consecutive scans (+/-15ml). The mean TLV calculated with the Hermes Software was 1688.41±582.86. The mean specimen weight measured during the histopathological analysis was 880.4±469.38. The volume of the resection segments calculated with the Hermes software significantly correlated with the weight of the specimen, with the Pearson correlation coefficient being 0.84 (p<0.001) (Figure 1). Conclusion: Hermes workstation is a reliable, and efficient tool to measure liver anatomical segmental volumes.

Robotic ALPPS for intrahepatic cholangiocarcinoma

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for intrahepatic cholangiocarcinoma (ICC) demonstrated good long-term outcomes and can increase the rate of resectability in locally advanced ICC; however, the rates of postoperative complications (Clavien-Dindo grade III) and mortality range between 13.6 and 44% and 0 and 29%, respectively. Minimally invasive strategies may reduce the risk of postoperative morbidity, with the same oncologic outcomes. We herein report a full robotic ALPPS for advanced ICC. Methods: The patient was a 61-year-old male diagnosed with a 6.5 cm ICC involving segments IV, V, and VIII. The total clean liver volume was 1553 cc, with a future liver remnant (FLR) volume of 21.6% (segments I, II, and III: 337 cc). Results: Computed tomography scan on postoperative day (POD) 9 after stage 1 showed that FLR increased up to 38%. The indocyanine green clearance test showed a plasma disappearance rate of 19.8%/min and a retention rate at 15 min of 5.1%. ALPPS was completed on POD 14, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 5. Final pathology showed a 6 cm ICC, G3, R0 margin (10 mm), T2-N0-M0. The patient started adjuvant capecitabine, and after 16 months he is in good general condition without signs of local or systemic recurrence. Conclusion: Robotic ALPPS combines the opportunity to perform a curative resection in patients presenting with insufficient FLR with the advantages of a minimally invasive approach. It is feasible and oncologically accurate for ICC when performed in fully trained HPB centers.

Increased Estimated Tumour Size to Total Liver Volume Ratio is Associated with Worse Survival in Resectable Hepatocellular Carcinoma

Introduction: Tumour diameter is a known prognostic factor for hepatocellar carcinoma but does not fully reflect tumour burden. In this study we aim to explore the relationship between the estimated tumour volume to total liver volume ratio and overall survival. Method: Patients who were diagnosed of hepatocellular carcinoma with computer tomography (CT) liver volumetry performed during the period of November 2009 to November 2019 were included. Patients underwent hepatic resection were included. Estimated tumour volume (ETV) was defined as 2/3 x π x (largest tumour diameter/2)³ TLV was determined by CT volumetry. Statistical analysis with prospectively collected data was performed. Results: 143 patients was included in the study. The median ETV was 220.9cm3 (0.9—4188.8cm3). The median TLV was 1379.2cm3 (541.6—136524.0) and ETV:TLV ranges 0.0007—7.7341. The hazard ratio was 1.138 for diameter of largest tumour (p< 0.001) and was 1.540 for ETV:TLV (p< 0.001). The optimal cut-off value of ETV:TLV was 0.065 by the ROC curve. Survival analysis showed that patients with ETV:TLV < 0.065 had significantly better 5-year overall survival than those with ETV:TLV >/=0.065 (84.7% vs 45.3%; p< 0.001). 5-year disease free survival was also better in patients with ETV:TLV < 0.065 (50.7% vs 20.5%; p< 0.001). Conclusion: An increase in ETV:TLV to over 0.065 is associated with worse survival outcomes. This can be used as a prognostic tool in the management of HCC.

Open right hepatectomy for hepatocellular carcinoma via anterior approach

Introduction: Anterior approach is a well-established technique for large, challenging hepatocellular carcinoma (HCC) in the right liver. Improved oncologic outcomes and disease-free survival is attributed to decreased manipulation of the tumor prior to vascular ligation and parenchymal transection. We present the case of a large HCC safely resected with an anterior approach. Method: A 66-year-old gentleman presented with weight loss, fatigue and right upper quadrant (RUQ) pain. Imaging was consistent with 13.6cm HCC and underlying liver disease. The tumor replaced much of the right liver. Initial future liver remnant (FLR) to total liver volume (TLV) ratio was 30%. Given the underlying liver disease, the patient underwent portal vein embolization with FLR hypertrophy, resulting in FLR/TLV ratio of 44%. The patient proceeded with open right hepatectomy via anterior approach. Results: Abdominal access is obtained through an extended J-shaped thoracoabdominal incision to maximize RUQ exposure. The inferior coronary ligament is opened to isolate the inferior vena cava (IVC). A Rummel tourniquet is placed, to be applied during dissection if necessary. Extrahilar dissection was performed, followed by transection of the right hepatic artery and right portal vein. The latter is closed with continuous suture to avoid stapling across embolization material. Parenchymal transection is performed via anterior approach—with an ultrasonic dissection device for parenchyma, and clips and sutures for structures—using the middle hepatic vein identified on intraoperative ultrasound as the resection margin. The right main pedicle is identified intrahepatically and divided with a stapler. Due to backbleeding, the tourniquet is temporarily applied on the IVC, allowing safe division of the right hepatic vein and branches from the middle hepatic vein. An omental patch is placed at the bed of transection. The patient tolerated procedure well, with estimated blood loss of 200mL. Conclusion: Anterior approach for large HCC is associated with improved perioperative morbidity and mortality as compared to conventional approach with posterior mobilization. IVC clamping is an established technique for controlling hepatic vein backbleeding, particularly in the anterior approach to reduce blood loss.

External Validation of the Use of Tc-99m Mebrofenin Hepatobiliary Scintigraphy to Assess Future Liver Remnant Function before Major Liver Surgery

Purpose: Accurate assessment of future remnant liver function (FRL-F) is paramount before major liver resection to avoid post-hepatectomy liver failure (PHLF), which remain the main perioperative cause of mortality. This study aims to analyse FRL-F using 99mTc-mebrofenin hepatobiliary scintigraphy before major liver surgery. Methods: All consecutive patients who underwent major liver resection between February 2018 and December 2020 and who had a preoperative 99mTc-mebrofenin hepatobiliary scintigraphy to assess FRL-F were included. FRL-V was expressed as percentage of total liver volume and assessed using preoperative computed tomography (CT). Receiver operating characteristic (ROC) curve analysis was performed to evaluate both methods in predicting PHLF. Results: A total of 29 patients were included, with a mean age of 61 years, a mean of BMI 26 kg/m2 and 62% (n=18) were men. PHLF occurred in 6 patients (21%). Scintigraphy showed significant ability to predict PHLF (AUC = 0.7, CI: 0.4-0.9), with cut-off value of 2.62 %/min/m2 showing a true positive (sensitivity) of 0.18, a specificity of 1.00 (false positive rate of 0), and a positive predictive value of 1.00. CT and FRL-V had no capacity to predict the occurrence of PHLF (AUC=0.5, CI: 0.2-0.8). Conclusion: Preoperative 99mTc-mebrofenin hepatobiliary scintigraphy and FRL-F demonstrated better sensitivity, specificity, positive and negative predictive value compared to CT and FRL-V for PHLF prediction. Therefore, where available, scintigraphy should be used systematically preoperatively before major liver surgery to assess FRL-F.