Daniele Del Fabbro

Hepatectomy for Stage B and Stage C Hepatocellular Carcinoma in the Barcelona Clinic Liver Cancer Classification: Results of a Prospective Analysis

HYPOTHESIS Using an algorithm for selection of patients with hepatocellular carcinoma (HCC) for surgery, Barcelona Clinic Liver Cancer (BCLC) classification stage B and stage C disease is not a contraindication. DESIGN Prospective cohort study. SETTING University tertiary care hospital. PATIENTS Among 163 consecutive patients with HCC, 120 (73.6%) underwent surgery; 113 of 120 (94.2%) underwent resection. Of 113 patients, 61 (54.0%) had BCLC stage 0 or A disease, 24 (21.2%) had stage B disease, and 28 (24.8%) had stage C disease. INTERVENTIONS Surgical strategy was based on the relationship of the tumor to the intrahepatic vascular structures on intraoperative ultrasonography. MAIN OUTCOME MEASURES Mortality, morbidity, rate of cut edge local recurrences, and long-term outcome were evaluated. P < .05 was considered statistically significant. RESULTS Hospital mortality was 0.9%. The overall morbidity was 27.4%, and major morbidity was 3.5%. After a median follow-up of 24 months (range, 1-65 months), there was no cut edge recurrence. For patients with BCLC stages 0 or A, B, and C disease, the 3-year overall survival rates were 81%, 67%, and 74%, respectively (P =.24); the 3-year disease-free survival rates were 30%, 35%, and 15%, respectively (P =.85); and the 3-year hepatic disease-free survival rates were 39%, 44%, and 17%, respectively (P =.79). CONCLUSIONS Patients with BCLC stage B and stage C HCC can tolerate hepatic resection with low mortality, acceptable morbidity, and survival benefits if resection is performed under strict intraoperative ultrasonographic guidance. These results should prompt revision of the BCLC recommendations.

One-stage ultrasonographically guided hepatectomy for multiple bilobar colorectal metastases: A feasible and effective alternative to the 2-stage approach

BACKGROUND Two-stage hepatectomy with or without portal vein embolization allows treatment of multiple bilobar metastases, thereby expanding operative indications for these patients. Two operations are needed, however, and some patients are not able to complete the treatment strategy because of disease progression. Using experience gained from our policy of ultrasonographically guided resection, we explored the safety and effectiveness of 1-stage operative procedures in patients otherwise recommended for the 2-stage approach. METHODS A total of 29 patients with multiple (>or=4) bilobar colorectal liver metastases (CLM) were selected from 100 consecutive patients submitted to surgical resection. The total number of preoperative CLM was 163 (median, 5; range, 2-20). The operative strategy was based on tumor-vessel relationships at intraoperative ultrasonography (IOUS) and on findings at color Doppler IOUS. RESULTS There was no in-hospital mortality. Tumor removal was feasible with 1-stage operative procedures in all but 3 patients who underwent laparotomy. The overall morbidity rate was 23% (6/26); none of the patients required reoperation. Major morbidity occurred in 1 patient (4%). Blood transfusions were administered in 4 patients (15%). After a mean follow-up of 17 months (median, 14; range, 6-54), 3 patients had died from systemic recurrence, 12 patients were alive without disease, and 11 were alive with disease. No local recurrences were observed at the resection margin. CONCLUSION IOUS-guided resection based on strict criteria allows a 1-stage operative treatment in selected patients with multiple bilobar CLM. This strategy decreases the need for a two-stage hepatectomy, thereby avoiding the disadvantages of a 2-stage approach.

Contrast-enhanced intraoperative ultrasonography during hepatectomies for colorectal cancer liver metastases

Preliminary reports showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) provides information on primary or metastatic tumors of the liver that is not obtainable with conventional intraoperative ultrasonography (IOUS). This study validates the impact of CEIOUS, focusing on resective surgery for colorectal cancer (CRC) liver metastases. Twenty-four consecutive patients underwent liver resection using IOUS and CEIOUS for CRC liver metastases. CEIOUS was accomplished with intravenous injection of 4.8 mL of sulphur-hexafluoride microbubbles. CEIOUS found lesions missed at preoperative imaging and at IOUS in four patients and confirmed all of the new findings of IOUS in four patients. In addition, CEIOUS helped to define the tumor margins of the main lesion in 29% of patients with CRC liver metastases. No adverse effects were observed in relation with CEIOUS. In conclusion, CEIOUS improves IOUS accuracy with a significant impact on surgical strategy and radicality in patients who undergo surgery for CRC liver metastases.

Contrast-Enhanced Intraoperative Ultrasonography During Surgery for Hepatocellular Carcinoma in Liver Cirrhosis: Is It Useful or Useless? A Prospective Cohort Study of Our Experience

BackgroundPreliminary results showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) could provide information not obtainable with conventional IOUS during surgery for hepatocellular carcinoma (HCC). The aim of the study was to prospectively validate the role of CEIOUS on the basis of a larger experience and to establish a new classification that takes into account its findings.MethodsEighty-seven consecutive patients underwent hepatecomies for HCC. Those patients with new lesions at IOUS underwent CEIOUS: for that patients received intravenously 4.8 mL sulphurhexafluoride microbubbles. Pattern of enhancement was classified in 4 categories: A1 (full enhancement in the arterial phase and wash-out in the delayed phases), A2 (intralesional signs of neovascularization during all phases), A3 (no nodular enhancement but detectability during the liver enhancement), and B (undetectability during the liver enhancement). Resection was recommended for A1-3 nodules and no treatment for B nodules.ResultsTwenty-nine patients (33%) had 59 new lesions at IOUS and underwent CEIOUS. Twenty-seven nodules showed a B pattern at CEIOUS and were not removed; 32 nodules were classified as A1 in 5 patients, A2 in 11 patients, and A3 in 16 patients. The nodules were removed, and by histology, five A1, nine A2, and six A3 nodules were confirmed to be HCC. CEIOUS modified the operative decision making in 79% of these patients.ConclusionsCEIOUS is useful during surgery for HCC; it complements the accuracy of IOUS and affects the radicalness of the surgical. Specificity of CEIOUS has to be further improved, although intrinsic drawbacks exist in the diagnostic criterion of tumor vascularity.

Anatomical segmental and subsegmental resection of the liver for hepatocellular carcinoma: a new approach by means of ultrasound-guided vessel compression.

Background:Anatomic resection is considered the gold standard approach for liver resection in patients with hepatocellular carcinoma. The use of intraoperative ultrasound (IOUS) as guidance is indispensable in this sense but methods available up to now were rather complex and for that reason of limited use. We herein describe a novel technique for the demarcation of the resection area by means of IOUS-guided finger compression to systematically accomplish anatomic segmental and subsegmental resections. Methods:Thirty-three patients met the eligibility criteria. This technique consisted in the demarcation of the resection area by IOUS-guided finger compression of the vascular pedicle feeding the tumor at the level closest to the tumor but oncologically suitable. Median age was 65 years (range, 36–81). There were 25 men and 8 women. Median tumor number was 1 (range, 1–2); median tumor size was 2 cm (range, 1–10). Twenty-five (76%) patients had cirrhosis or chronic hepatitis, and 8 (24%) had steatosis (ClinicalTrials.Gov ID: NCT00829335). Results:Procedure resulted feasible in all eligible patients, and demarcation area was obtained in all patients within 1 minute of bimanual IOUS-guided compression. There was no mortality or major morbidity: only 7 (21%) patients experienced minor morbidity. No blood transfusions were administered. Conclusions:Systematic segmentectomy and subsegmentectomy by IOUS-guided finger compression is a feasible, safe, and effective technique, which could be considered as a simpler alternative to those up to now proposed.

Systematic extended right posterior sectionectomy: a safe and effective alternative to right hepatectomy.

Background:A surgical approach based on ultrasound-guided hepatectomy might minimize the need for major resection, whose rates of morbidity and mortality are not negligible. Right hepatectomy (RH) is traditionally performed in cases of vascular invasion of the right hepatic vein with multiple tumors in the right posterior section, and/or of the right posterior portal branch (P6-7) with tumor in contact with right anterior portal branch (P5-8). We herein describe an alternative approach to RH consisting in ultrasound-guided systematic extended right posterior hepatic sectionectomy (SERPS). Methods:Among 207 consecutive patients who underwent hepatectomies, 21 (10%) underwent SERPS. Median age was 67 years (range, 48–79). There were 13 men and 8 women. Ten (48%) patients had hepatocellular carcinoma; 11 (52%) had colorectal liver metastases. Median tumor number was 2 (range, 1–15); median tumor size was 4.5 cm (range, 2.5–20). Ten (48%) patients had cirrhosis, 8 (38%) had steatosis, and 3 (16%) had normal liver. Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS. Results:In-hospital and 90-days mortality were nil. Major and minor morbidity occurred in 3 (14%) and 2 (9.5%) patients, respectively. No patients were reoperated because of complications. Blood transfusions were given to 2 (9.5%) patients. After a median follow-up of 21 months, no local recurrence was observed. Conclusions:IOUS-guided SERPS is feasible, safe, and effective. It should be applied whenever possible as alternative resection to RH to maximize liver parenchymal sparing.

Contrast-Enhanced Intraoperative Ultrasonography in Surgery for Hepatocellular Carcinoma in Cirrhosis

Intraoperative ultrasonography (IOUS) is the most accurate diagnostic technique for staging hepatocellular carcinoma (HCC), but has low accuracy in differentiating the new nodules detected in the cirrhotic liver. The aim of this preliminary report is to evaluate whether contrast‐enhanced intraoperative ultrasonography (CE‐IOUS) could provide additional information to IOUS in patients with HCC. From August 2002 to July 2003, a prospective validation cohort study was conducted. For this purpose, 16 consecutive patients underwent liver resection for HCC using IOUS and CE‐IOUS. Intraoperatively, in all patients 4.8 mL of SonoVue was injected intravenously through a peripheral vein. IOUS depicted 16 new focal liver lesions: 10 with no enhancement peculiar to HCC at CE‐IOUS pattern and at histology (4) or imaging follow‐up (6) proved to be benign; the remaining 6 had enhancement peculiar to HCC and histology confirmed this diagnosis. Two different patterns of enhancement were also recognized at CE‐IOUS in those HCC nodules depicted preoperatively: one had no similarity to that observed at CT. CE‐IOUS added findings to those of unenhanced IOUS in 50% of patients. These results show that IOUS accuracy and specificity is improved by CE‐IOUS, with a great impact on surgical strategy and oncological radicality. Furthermore, a wider experience with vascular enhancement patterns with CE‐IOUS could provide a new classification for HCC nodules. (Liver Transpl 2004;10:S34–S38.)

Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection: a further step in favor of the "radical but conservative" policy.

Objective: We retrospectively compared the short-term outcome of a consecutive cohort of patients who underwent hepatectomy with intermittent clamping ranging between 60 and 120 minutes with those having a clamping time exceeding 120 minutes. Background: Intermittent Pringle maneuver is widely used to minimize blood loss during hepatectomy, without an established time limit. However, many authors claim it is dangerous for patient outcome. Material and Methods: Among 426 consecutive patients who underwent hepatectomy, we retrospectively selected 189 whose intermittent clamping time exceeded 60 minutes: 117 of these had intermittent Pringle maneuver lasting less than 120 minutes (group 1) and 72 clamping time exceeded 120 minutes (group 2). Groups were homogeneous for demographics, preoperative laboratory tests, background liver, and type of tumors. Results: Operation length, and number of lesions removed, was significantly higher in group 2. Conversely, the two groups experienced similar amount of blood loss, rate of blood transfusions, overall and major morbidity, and 30- and 90-day postoperative mortality. In particular, in group 2 there was no mortality at all. Mean serum total bilirubin and alanine aminotransferase level on seventh pod resulted significantly higher in group 2, conversely mean aspartate aminotransferase, cholinesterases, and prothrombin time not differed in 2 groups. Conclusions: This study shows that hepatectomies done with intermittent clamping exceeding 120 minutes are as safe as those performed with shorter one despite more complex tumor presentations. This seems encouraging the diffusion of procedures done in 1 stage for extensive liver diseases despite the prolonged clamping time. ClinicalTrials.gov ID: NCT01237002.

A new systematic small for size resection for liver tumors invading the middle hepatic vein at its caval confluence: mini-mesohepatectomy.

Objective:We describe a new ultrasound guided conservative procedure for patients with liver tumors invading the middle hepatic vein (MHV) at its caval confluence. Summary Background Data:Morbidity and mortality for major hepatectomies are not negligible. However, when tumors invade the MHV at the caval confluence, major surgery is usually recommended. Methods:Patients included in this study were those with tumors invading the MHV at its hepato-caval confluence (within 4 cm). Minimum follow-up was established at 6-months from surgery. Among 284 consecutive hepatectomies, 17 (6%) met the inclusion criteria. Partial sparing of segments 4, 5, and 8 was established intraoperatively, based on color-Doppler IOUS findings (NCT00600522 on ClinicalTrials.gov). Results:In all the 17 patients at least one of the color-Doppler IOUS criteria was disclosed, and limited resections of just segments 4sup and 8 were always feasible. The MHV tract involved was always resected. Seven patients had single tumor removed and 10 multiple: total number of resected tumors was 58 (median: 2; range: 1–18). There were no postoperative mortality and major morbidity. Overall morbidity occurred in 3 (18%) patients. Median blood loss was 250 (range: 50–1000). One patient (6%) received blood transfusion. No local recurrences were observed (median follow-up: 26 months). Conclusions:IOUS assistance systematically allows conservative resection of liver tumor invading the MHV at caval confluence. This drastically limits the need for larger resections, and further broadens the role of IOUS in optimizing the surgical strategy.

Ultrasound-guided reduction of an incarcerated Spigelian hernia

Spigelian hernia is a rare abdominal hernia. We report a case in which its diagnosis proved ultrasonography to be an effective tool, not only to diagnose an incarcerated Spigelian hernia but, moreover, to reduce it by echo-probe palpation. Ultrasound (US) is an aid for therapy of various diseases. In our experience, US-guidance prevented possible damage related to forced and wrongly applied compression during the hernia reduction, and allowed us to perform surgical repair on an elective basis. In conclusion, if an incarcerated Spigelian hernia is suspected, a US examination should be done on an emergency basis to confirm the diagnosis and to attempt US-guided reduction.