F. Procopio

Is Tumor Detachment from Vascular Structures Equivalent to R0 Resection in Surgery for Colorectal Liver Metastases? An Observational Cohort

BackgroundR0 resection is the standard for colorectal liver metastases (CLMs). Adequacy of R1 resections is debated. Detachment of CLMs from vessels has been proposed to prioritize parenchyma sparing and increase resectability, but outcomes are still to be elucidated. The present study aimed to clarify the outcomes of R1 surgery (margin <1xa0mm) in patients with CLMs, distinguishing standard R1 resection (parenchymal margin, R1Par) and R1 resection with detachment of CLMs from major intrahepatic vessels (R1Vasc).MethodsAll patients undergoing first resection between 2004 and June 2013 were prospectively considered. R0, R1Par, and R1Vasc were compared in per-patient and per-resection area analyses.ResultsThe study included 627 resection areas in 226 consecutive patients. Fifty-one (8.1xa0%) resections in 46 (20.4xa0%) patients were R1Vasc, and 177 (28.2xa0%) resections in 107 (47.3xa0%) patients were R1Par. Thirty-two (5.1xa0%) surgical margin recurrences occurred in 28 (12.4xa0%) patients. Local recurrence risk was similar between the R0 and R1Vasc groups (per-patient analysis 5.3 vs. 4.3xa0%; per-resection area analysis 1.5 vs. 3.9xa0%, pxa0=xa0n.s.) but increased in the R1Par group (19.6 and 13.6xa0%, pxa0<xa00.05 for both). The R1Par group had a higher rate of hepatic-only recurrences (49.5 vs. 36.1xa0%, pxa0=xa00.042). On multivariate analysis, R1Par was an independent negative prognostic factor of overall survival (pxa0=xa00.034, median follow-up 33xa0months); conversely R1Vasc versus R0 had no significant differences.ConclusionsR1Par resection is not adequate for CLMs. R1Vasc surgery achieves outcomes equivalent to R0 resection. CLM detachment from intrahepatic vessels can be pursued to increase patient resectability and resection safety (parenchymal sparing).

Twelve-year experience of “radical but conservative” liver surgery for colorectal metastases: impact on surgical practice and oncologic efficacy

BACKGROUNDnLiver surgery for colorectal metastases (CLM) is moving toward parenchyma-sparing approaches. The authors reported the technical feasibility of parenchyma-sparing hepatectomy for deeply located tumors, but its impact on daily practice and long-term outcomes remain unclear.nnnMETHODSnThe patients undergoing liver resection (LR) for CLM with vascular contact (first-/second-order pedicle or hepatic vein (HV) trunk) were considered. Those undergoing major hepatectomy were excluded. The authors technique included tumor-vessel detachment, partial resection of marginally infiltrated HVs, and detection of communicating vessels (CVs) among HVs to preserve outflow after HV resection.nnnRESULTSnAmong 169 patients with major vascular contact, parenchyma-sparing LR was feasible in 146 (86%). Twenty-eight SERPS, 13 transversal hepatectomies, 6 mini-mesohepatectomies, and 4 liver tunnels were performed. Sixty-six (45%) patients underwent CLM-vessel detachment, 25 (17%) underwent partial HV resection, and 30 (21%) achieved outflow preservation by CV identification. The mortality and severe morbidity rates were 1.4% and 8.2%, respectively. The 5-year survival rate was 30.7%. The parenchyma-sparing strategy failed in 14 (7%) patients because of recurrence in the spared parenchyma or cut edge; 13 were radically retreated.nnnCONCLUSIONnUltrasound-guided parenchyma-sparing surgery is feasible in most patients with ill-located CLMs. This procedure is safe and achieves adequate oncologic outcomes.

Progression of Colorectal Liver Metastases from the End of Chemotherapy to Resection: A New Contraindication to Surgery?

BackgroundNot all patients with resectable colorectal liver metastases (CLM) benefit from liver resection (LR); only patients with disease progression during chemotherapy are excluded from surgery.ObjectiveThis study was performed to determine whether tumor behavior (stable disease/progression) from the end of chemotherapy to LR impacts prognosis.MethodsPatients undergoing LR after tumor response or stabilization during chemotherapy were considered. Overall, 128 patients who underwent examination by two imaging modalities (computed tomography/magnetic resonance imaging) after chemotherapy with axa0>xa03-week interval between the two imaging modalities were analyzed. Any variation in CLM size was registered. Tumor progression was defined according to the response evaluation criteria in solid tumors (RECIST) criteria.ResultsAmong 128 patients with stable disease or partial response to preoperative chemotherapy, 32 (25%) developed disease progression in the chemotherapy to LR interval, with a disease progression rate of 17% when this interval wasxa0<xa08xa0weeks. Survival was lower among patients with progression than those with stable disease [3-year overall survival (OS) 23.0 vs. 52.4%, and recurrence-free survival (RFS) 6.3% vs. 21.6%; pxa0<xa00.001]. Survival was extremely poor in patients with early progression (<xa08xa0weeks) (0.0% 2-year OS, 12.5% 6-month RFS). Disease progression in the chemotherapy to LR interval was an independent negative prognostic factor for OS and RFS [hazard ratio 3.144 and 2.350, respectively; pxa0<xa00.001].ConclusionsEarly disease progression in the chemotherapy to LR interval occurred in approximately 15% of patients and was associated with extremely poor survival. Even if these data require validation, the risk for early disease progression after chemotherapy should be considered, and, if progression is evident, the indication for surgery should be cautiously evaluated.

Hepatic vein management in a parenchyma-sparing policy for resecting colorectal liver metastases at the caval confluence

Background Patients with tumors involving hepatic vein at the caval‐confluence usually receive major hepatectomies or hepatic vein grafting; however, nonnegligible postoperative mortality and morbidity are associated. Authors introduced the tumor‐vessel detachment for colorectal liver metastases. Then we reviewed our results applying this approach in patients with colorectal liver metastases in contact with hepatic veins at the caval‐confluence. Methods A cohort of consecutive patients with colorectal liver metastases in contact with hepatic veins at the caval‐confluence undergoing liver surgery was reviewed. Relationships were classified as: Type 1: contact/involvement less than a third of hepatic vein circumference; Type 2: contact/involvement in a third to two‐thirds; Type 3: contact/involvement in more than two‐thirds. Hepatic vein‐ colorectal liver metastases detachment, or in case of hepatic vein‐resection, the sparing of the drained parenchyma, were attempted systematically. Results Overall 190 colorectal liver metastases‐hepatic vein contacts in 135 patients were analyzed. Colorectal liver metastases‐hepatic vein detachment was performed in 95 (50%) contacts, partial resection and direct suture in 61 (32%), partial resection and patching in 4 (2%), and hepatic vein complete resection in 30 (16%). Hepatic vein‐sparing resection was possible in 102 patients (76%), and major hepatectomy was needed in 1 (0.7%). Operative mortality, overall and major morbidity rate were 0.7%, 32%, and 4%, respectively. Local recurrence rate was 6% (median follow‐up: 27 months). Preoperative and intraoperative imaging predicted the need for hepatic vein resection in 99% of patients (&kgr; = 0.971). Conclusions Hepatic vein‐sparing or a parenchyma‐sparing policy is feasible in most patients with colorectal liver metastases‐hepatic vein contacts at the caval‐confluence. This approach seems safe, predictable, and oncologically adequate, and, upon further confirmation, could become an alternative to major hepatectomies or hepatic vein replacement.

Individualized risk estimation for postoperative morbidity after hepatectomy: the Humanitas score

BACKGROUNDnEstimation of postoperative morbidity after hepatectomy remains challenging. The aim of this prospective study was to develop a surgical score to predict an individual risk of post-hepatectomy complications.nnnMETHODSnAll consecutive patients scheduled for hepatectomy from February 2012 to September 2015 were included and randomly assigned into a derivation or validation cohort. We developed a score based on preoperative variables, and we tested them using multivariate analyses. Odds-ratio (OR) values were used to build the score.nnnRESULTSn340 patients were included, 240 in the derivation and 100 in the validation cohort. Multivariate analysis showed that major hepatectomy (ORxa0=xa01.62; 95% CI 1.39-3.51), liver stiffness ≥9.7xa0kPa (ORxa0=xa02.46; 95% CI 1.16-5.28), BILCHE score (combination of serum bilirubin and cholinesterase) ≥2 (ORxa0=xa02.76; 95% CI 0.82-4.28) and esophageal varices (ORxa0=xa01.59; 95% CI 1.51-3.61) were independent complications predictors. A 10-point scoring system was introduced. Patients with a score ≤4 did not experience complications, whereas patients with ≥7 points experienced up to 54% of complications (Pxa0<xa00.001).nnnCONCLUSIONSnA new, easy and clinically reliable surgical score based on the liver stiffness, BILCHE score, type of hepatectomy, and presence of varices may be used to predict post-hepatectomy morbidity.nnnCLINICAL TRIAL NUMBERnNCT02454686 (https://www.clinicaltrials.gov/).

Oncologic superiority of anatomic resection of hepatocellular carcinoma by ultrasound-guided compression of the portal tributaries compared with nonanatomic resection: An analysis of patients matched for tumor characteristics and liver function

Background The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound‐guided compression of the tumor‐feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection. Methods Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1‐to‐2 with nonanatomic resection cases based on the Child‐Pugh class, Model for End‐Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/>1), and hepatocellular carcinoma size (>30, 30–50, and >50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90‐day mortality (0 compression technique anatomic resection), non–cancer‐related death, and follow‐up <12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases. Results All patients were Child‐Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5‐year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2‐year local recurrence‐free survival (94% vs 78%; P = .012). Nonlocal recurrence‐free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3‐year survival after recurrence (65% vs 42%; P = .043). Conclusion Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma–bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.

Hepatectomy with or without the thoraco-abdominal approach: impact on perioperative outcome

BACKGROUNDnHepatectomy using the thoraco-abdominal approach (TAA) compared to the abdominal approach (AA) remains under debate. This study assessed the perioperative outcomes of patients operated with or without TAA.nnnMETHODSn1:1 propensity score-matched analysis was appliedxa0in 744 patients operated between 2007 and 2013, identifying 246 patients who underwent hepatectomy with TAA compared to 246 patients with AA.xa0These groups were matched for demographics, liver disease, comorbidity, tumor features, and extent of resection. Rates of morbidity and mortality were the study endpoints.nnnRESULTSnThe rates of morbidity or mortality were not different. With the TAA length of the operations (Pxa0=xa00.002), length of the Pringle maneuver (Pxa0=xa00.012), and rate of blood transfusions (Pxa0=xa00.041) were significantly different. Hospital stay was similar. Independent significant prognostic factors for adverse perioperative outcome were: renal comorbidity (ORxa0=xa02.7; Pxa0=xa00.001), extent of the resection (ORxa0=xa03.7; Pxa0=xa00.001), and increased BILCHE score (ORxa0=xa02.4; Pxa0=xa00.002).nnnCONCLUSIONSnHepatectomy using the TAA was not associated with adverse perioperative outcome. The associations with length of operation, Pringle maneuver and blood transfusions may have reflected the complexity of the tumor presentation rather than the technical approach.