Alessandro Ferrero

Portal Vein Ligation as an Efficient Method of Increasing the Future Liver Remnant Volume in the Surgical Treatment of Colorectal Metastases

OBJECTIVE To compare the volumetric increase of segments 2 and 3, segment 4, and the caudate lobe after portal vein ligation (PVL) and portal vein embolization (PVE). The small size of the remnant liver and chemotherapy-induced liver injury increase the risk of postoperative hepatic insufficiency after major hepatic resection for colorectal liver metastases. Portal vein ligation has been suggested to be less effective than embolization in inducing hypertrophy of the remnant liver. DESIGN, SETTING, AND PATIENTS We retrospectively reviewed 48 patients with colorectal liver metastases who underwent PVL (n = 17) or PVE (n = 31) at the Istituto per la Ricerca e la Cura del Cancro or the Institut Paoli-Calmette from March 1, 2000, through August 31, 2006. MAIN OUTCOME MEASURES To compare the volume increase of segments 2 and 3, segment 4, and of the caudate lobe in patients who have undergone PVL or PVE in preparation for a major hepatic resection. RESULTS There were no deaths related to PVE or PVL. Portal vein ligation was associated with resection of synchronous colorectal cancer in 16 patients. Resection of a liver metastasis in the remnant liver was performed in 11 patients. The median estimated baseline volume of segments 2 and 3 was 17.7% in the PVL group and 17.5% in the PVE group (P = .72). After PVL or PVE, it increased to 26.9% and 24.7%, respectively (P = .95), for volumetric increases of 43.1% and 53.4%, respectively (P = .39). The volumetric increases of segment 4 and the caudate lobe were similar. CONCLUSION Portal vein ligation is as effective as PVE in inducing hypertrophy of the remnant liver volume.

Portal hypertension: contraindication to liver surgery?

IntroductionIn recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients.MethodsBetween 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it.ResultsPatients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P < 0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P = 0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P = 0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P = 0.004; 77.8% vs. 57.6%, P = 0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P = 0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival.ConclusionsPortal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Randomized clinical trial of liver resection with and without hepatic pedicle clamping

The purpose of this study was to compare the perioperative outcome of liver resection with and without intermittent hepatic pedicle clamping.

Combined first‐stage hepatectomy and colorectal resection in a two‐stage hepatectomy strategy for bilobar synchronous liver metastases

This study assessed the feasibility and outcomes of combined colorectal and hepatic resection as the first step of two‐stage hepatectomy in patients with bilobar synchronous colorectal liver metastases.

Liver dysfunction and sepsis determine operative mortality after liver resection

Liver failure is the principal cause of death after hepatectomy. Its progression towards death and its relationship with sepsis are unclear. This study analysed predictors of mortality in patients with liver dysfunction and the role of sepsis in the death of these patients.

Prospective randomized study of steroids in the prevention of ischaemic injury during hepatic resection with pedicle clamping

The major drawback of hepatic pedicle clamping is ischaemia–reperfusion injury with impairment of liver function. Perioperative steroid administration has been advocated to reduce liver damage. The aim of this prospective, randomized study was to determine whether steroid administration can reduce liver injury and improve short‐term outcome.

Bile leak after hepatectomy: Predictive factors of spontaneous healing

BACKGROUND Bile leakage after hepatectomy usually has spontaneous healing, but some patients require interventional procedures. To identify early predictive factors of conservative management failure. METHODS This study focused on patients with bile leak after hepatectomy without extrahepatic biliary resection from 1996 through 2006. RESULTS Bile leakage occurred in 34 of 593 patients (5.7%). Conservative management was successful in 26 patients (76.5%). At univariate analysis overall associated resections, vascular associated resections, and drainage output on days 1, 3, and 10 from leak onset were significant negative predictors of spontaneous healing. At multivariate analysis drainage output greater than 100 mL on day 10 was the only independent prognostic factor of conservative management failure (relative risk, 55.985; P = .008) with 80% sensitivity, 93.3% specificity, and 90% accuracy. CONCLUSIONS Wait-and-see treatment is successful in most cases. Patients with drainage output greater than 100 mL 10 days after bile leakage diagnosis should be scheduled for interventional treatments.

Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma.

Objective:To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BDMarg) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA). Summary Background Data:Intraoperative evidence of invasive cancer at the proximal BDMarg is associated with a dismal survival irrespective of whether a final negative BDMarg is achieved with an additional resection. Methods:Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989–2010) were analyzed. Results:Frozen-section examination of the proximal BDMarg revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 BDMarg resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0-resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection. Conclusions:Additional resection of a positive proximal BDMarg, albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.

Intraoperative Detection of Disappearing Colorectal Liver Metastases as a Predictor of Residual Disease

PurposeThe aim of this study was to evaluate the intraoperative detection rate of residual liver metastases after chemotherapy and to assess the correlation between disappeared liver metastases (DLMs) upon preoperative imaging and complete pathological response.MethodsBetween February 2004 and December 2008 clinicopathological data of 292 consecutive patients who underwent liver resection for colorectal liver metastases were prospectively collected and analyzed in a “per lesion” study. Thirty-three patients with 67 DLMs were included.ResultsDuring laparotomy, we identified 45 out of 67 DLMs (67%). Six DLMs were detected by macroscopic liver examination (9%) and 39 (58%) by intraoperative ultrasound (IOUS). Overall, persistent microscopic residual disease at pathological examination of the resected specimen or recurrence in situ identified during the follow-up were observed in 41 (61.2%) of 67 LMs that had shown a complete response by imaging. At multivariate analysis moderate or severe hepatic steatosis (p = 0.016), subglissonian localization of nodules (p = 0.019) and residual microscopic disease (p = 0.0006) were associated with IOUS detection of residual metastases. Preoperative chemotherapy with more than six cycles (p = 0.022) and intraoperative detection of nodules by IOUS (p = 0.001) were independent predictors of residual disease.ConclusionsSystematic US exploration of the liver leads to increase the intraoperative detection rate of DLMs. Furthermore, the majority of DLMs identified by IOUS presents residual disease at pathological examination and should be treated.

Measured versus estimated total liver volume to preoperatively assess the adequacy of the future liver remnant: Which method should we use?

Objectives:To determine which method of liver volumetry is more accurate in predicting a safe resection. Background:Before major or extended hepatectomy, assessment of the future liver remnant (FLR) is crucial to reduce the risk of postoperative hepatic insufficiency. The FLR volume is usually expressed as the ratio of FLR to nontumorous total liver volume (TLV), which can be measured directly by computed tomography (mTLV) or estimated (eTLV) on the basis of correlation existing with the body surface area. To date, these 2 methods have never been compared. Methods:All consecutive, noncirrhotic patients who underwent resection of 3 or more liver segments between April 2000 and April 2012 and for whom (i) preoperative computed tomographic scans and (ii) body surface area were available entered the study. The mTLV (calculated as TLV − tumor volume) was compared with the eTLV (calculated as −794.41 + 1267.28 × body surface area) using volumetric data (cm3) and clinical outcome measures (specifically, hepatic insufficiency and 90-day mortality). Definition of hepatic insufficiency was peak postoperative serum total bilirubin level of more than 7 mg/dL or, in jaundiced patients, an increasing bilirubin level on day 5 or thereafter. Results:Two-hundred forty-three patients who had undergone major (n = 135) or extended (n = 108) hepatectomies met the inclusion criteria. Twenty-eight patients (11.5%) developed hepatic insufficiency, whereas 7 patients (2.9%) died postoperatively. Compared with the eTLV, the mTLV underestimated the liver volume in 60.1% of the patients (P < 0.01). Forty-seven and 73 patients had an inadequate FLR based on mTLV and eTLV, respectively. Portal vein occlusion (PVO) was used in 44 patients. In patients (n = 162) in whom both methods did not evidence the need for PVO, postoperative hepatic insufficiency and mortality were 4.9% and 0.6%, respectively. Conversely, in patients (n = 27) in whom the eTLV but not the mTLV evidenced the need for PVO, and thus PVO was not performed, hepatic insufficiency (22.2%; P = 0.001) and mortality (3.7%; P = ns) were higher. Conclusions:The use of eTLV identifies a subset of patients (∼11%) in whom liver volumetry with the mTLV underestimates the risk of hepatic insufficiency.