Antonio Ceriello

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.

Short- and Long-Term Follow-Up

Laparoscopic liver surgery (LLS) is now a widely accepted procedure. It is no longer questionable whether short-terms results after liver resection are better for LLS than for open surgery. Postoperative morbidity and mortality rates, hospital stay, abdominal-wall complications, and intraoperative bleeding are reduced with LLS in both benign and malignant conditions [1–6]. In the absence of general contraindications, a laparoscopic approach should be indicated for the majority of benign liver nodules located in the anterior segments [7–9]. Many investigators in the early 2000s felt there were no benefits in long-term oncological outcomes for patients with hepatocellular carcinoma (HCC) and colorectal metastasis (CRM) undergoing LLS. In very early experiences with general laparoscopic surgery, there was evidence of an unusually high tumor recurrence rate, especially at port sites. This condition was not found following LLS, probably because this surgery became widely diffused among surgeons following technical refinements to reduce tumor manipulation and avoid tumor-cell seeding. Another early issue was the adequacy of surgical margins [10]. More recent series show that this condition is not sustained by evidence [2, 3, 7, 11], even if there are no controlled trials comparing open and LLS approaches.

Hepatitis B Prophylaxis in Hepatitis B–Negative Recipients Transplanted With Donor Grafts Positive for Hepatitis B Core Antibodies

BACKGROUND AND AIMS Use of grafts from hepatitis B (HBV) core antibody (HBcAb(+)) individuals is a routine transplant practice. Herein, we have reported the results of 20 HBV-negative patients transplanted with a HBcAb-positive liver grafts in order to access the efficacy of HBV prophylaxis using immunoglobulin (IE) and antiviral drugs. METHODS From January 2004 to December 2009, we performed 168 liver transplantations including 38 HBcAb-positive grafts (22.6%) in 18 cases of HBV-positive recipients and 20 HBV-negative recipients. Histological data obtained from these last 20 grafts during retrieval showed an Ishak 1 score in three and no fibrosis in the other cases. HBV prophylaxis included infusion of 10,000 UI IG during the anhepatic phase and every 24 hours for the first 7 days irrespective of the antibody titer as well as lamivudin (100 mg) administered daily. Once discharged, outpatient management provided modulated IG infusions according to when the antibody titer was lower than 400 UI. RESULTS No patient displayed an HBV infection. The overall survival was 80%. Two patients died within the first month after transplantation due to septic complications; one patient succumbed at 24 months after transplantation because of a lymphoproliferative malignancy and another died due to an aggressive hepatitis C virus recurrence at 6 months post transplant. CONCLUSION By using appropriate anti-HBV prophylaxis, HBcAb-positive grafts can be used safely for HBcAb-negative recipients.

Hepatic Angiomyolipoma and Intramural Small Intestinal Schwannoma: A Coincidence or a Relationship?

We report a case of hepatic angiomyolipoma associated to a small bowel schwannoma in a 40-years old woman. Both lesions were asyntomatic. Histologically, hepatic angiomyolipoma showed oncocytic features and scanty adipose tissue, the tumor cells expressed desmin, smooth muscle actin, S-100 protein and HMB45. The tumor cells of intramural small intestinal mass were positive for S-100 protein and GFAP and negative for CD117, CD34 and desmin. To the best of our knowledge, no case of hepatic angiomyolipoma has been previously reported in association with intestinal schwannoma.

Our experience of liver Epithelioid Hemangioendothelioma: From a misdiagnosis to liver transplantation with long term follow-up

Abstract Malignant Hepatic Epithelioid hemangioendothelioma (HEHE) is an uncommon vascular tumor of intermediate malignant potential. HEHE is a rare tumor and it is difficult to diagnose for surgeons, hepatologists, radiologists and pathologists. So, misdiagnosis with a delay of the treatment is not uncommon. We describe a case of a young woman with a diagnosis of HEHE made 6 years after the first evidence of liver mass with a very long term follow-up after surgical treatment. She had two diagnoses of Hepatocellurar carcinoma (HCC) and a diagnosis of Cholangiocarcinoma after three different fine needle biopsies. After clinical observation, a new laparoscopic core biopsy was performed. In a first time approach, considering clinical and radiological patterns, a diagnosis of Budd-Chiari Syndrome was finally made. For that the patient underwent an orthotopicliver transplantation (OLTx). The surgical sample histological analysis allowed a definitive diagnosis of HEHE. At last, at follow up 7 years after three OLTx the patient is still alive and in good health with no evidence of recurrence.

A New Anatomical Vision: Liver Surgery on the Screen

Shall we see through a camera better than with our eyes? The question, still appropriate at the present time, dates back to the seventeenth century. It seemsthat Vermeer, and then Canaletto some decades later, introduced in their paintings the use of the camera obscura, or optic camera (Figs. 14.1, 14.2). The simplest arrangement, with a lens fastened in the pinhole, projected an inversed and reversed image on a vertical screen opposite the aperture. A variation on this employed a translucent screen, allowing the viewer to see the image from the other side, thereby correcting the left-to-right reversal. These two types of cameras projected the image directly and could be combined in one device. The optical camera obscura ushered in a new approach to optics, opening up new views of the visible world and shaping a new understanding of vision itself.

Portal Vein Ligation

Portal vein ligation (PVL) is a standard procedure for achieving resectability in patients with an inadequate future remnant liver (FRL) prior to planning subsequent major hepatectomy. Its role in inducing FRL hypertrophy prior to major liver resection is clear [1]. Actually, PVL is the first step in a two-stage hepatectomy for treating initially unresectable liver metastases [1]. As reported in the literature, this procedure can be achieved safely without causing mortality [2]. Capussotti et al. showed how PVL is as effective as PV embolization in inducing hypertrophy of the remnant liver volume [2]. The possibility of using a laparoscopic approach seems to be favorable, even for achieving lower patient morbidity rates, particularly in the case of synchronous colorectal metastasis, avoiding the need to perform a further procedure (laparotomy/portal embolisation) [3,4]. Finally, in a planned two-stage hepatectomy, laparoscopic PVL (LPVL) greatly reduces the presence of adhesions when it is time to perform the second surgical step [5].

Encircling the Pedicle for the Pringle Maneuver

Although some liver resections may now be safely performed without vascular clamping, blood saving remains an important concern in hepatobiliary surgery, especially in patients with liver tumors, as blood loss seems to directly affect early and late outcome.

Treating the Resected Surface

Postoperative complications directly due to liver resection are hepatic failure and abdominal fluid collections due to bleeding or biliary leaks from the resection plane. The decrease in complication rates is due to technological advances and the widespread use of anatomically oriented resection techniques that significantly minimize liver-tissue necrosis. Hepatic parenchyma has in fact a complex, high-density framework of vascular and biliary structures, and even the most meticulous and appropriate approach to resection does not exclude the risk of postoperative bleeding and/or biliary leaks.