Florin Botea

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.

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.

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.

A Simple, Effective Technique for Port-Site Closure After Laparoscopy

The authors describe a technique that allows suture of the abdominal fascia at sites using a transcurtaneous approach and standard surgical instruments.

Criteria for the selective use of contrast-enhanced intra-operative ultrasound during surgery for colorectal liver metastases.

BACKGROUND Contrast-enhanced intra-operative ultrasound (CE-IOUS) for colorectal liver metastases (CLMs) has become a part of clinical practice. Whether it should be selectively or routinely applied remains unclear. The aim of this study was to define criteria for the use of CE-IOUS. METHODS One-hundred and twenty-seven patients underwent a hepatectomy for CLMs using IOUS and CE-IOUS. All patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI) within 2 weeks prior to surgery. The reference was histology, and imaging at 6 months after surgery. Univariate and multivariate analyses were performed. Statistical significance was set at P = 0.05. RESULTS Using IOUS an additional 172 lesions in 51 patients were found. CE-IOUS found 14 additional lesions in 6 patients. Seventy-eight CLMs in 38 patients appeared within 6 months after surgery. The sensitivity, specificity, positive- and negative-predictive value were 63%, 98%, 100% and 27% for pre-operative imaging, 87%, 100%, 100% and 52% for IOUS, and 89%, 100%, 100% and 56% for IOUS+CE-IOUS, respectively. CE-IOUS allowed better tumour margin definition in 23 patients (18%), thus assisting resection. Analyses indicated that the presence of multiple (P = 0.014), and isoechoic CLMs (P = 0.049) were independently correlated with new findings at CE-IOUS. CONCLUSIONS Compared with IOUS, CE-IOUS improved detection and resection guidance. These additions are significant and demand its use in cases with multiple and isoechoic CLMs.

Minimesohepatectomy for Colorectal Liver Metastasis Invading the Middle Hepatic Vein at the Hepatocaval Confluence

BackgroundIn case of liver tumors invading the middle hepatic vein (MHV) at the hepatocaval confluence (HC) major resection is recommended. We describe a new ultrasound-guided conservative operation for patients with colorectal liver metastasis (CLM) invading the MHV at the HC.MethodsThe case of a 65-year-old woman with two CLMs is described. One CLM was in segments 4-superior (S4-superior) and 8-ventral (S8-ventral) with invasion of the MHV 2 cm from the HC, while the other was in segment 8-dorsal (cranial portion). J-shaped laparotomy and intraoperative ultrasonography (IOUS) were carried out. Anterior surface of the HC was exposed, and compression using the surgeon’s fingertips was applied at the MHV. Once reversal flow in the peripheral portion of the MHV, and/or shunting collaterals with right or left hepatic vein, and/or hepatopetal flow in portal branches to right paramedian section (P5-8) and/or to segment 4-inferior (P4-inferior) were detected by color Doppler IOUS (CD-IOUS), partial resection of S4-superior and S8-ventral with vascular resection of MHV was performed.ResultsThe disclosure of those three criteria by CD-IOUS enables the performance of minimesohepatectomy. No congestion of the remnant liver was found. Ninety-day mortality and morbidity were nil. The patient was discharged 8 days after surgery. At 11 months of follow-up the patient underwent percutaneous radiofrequency ablation for a new 15-mm CLM in segment-8-dorsal (caudal portion). Currently, the patient is alive and free of disease at 17 months after surgery.ConclusionsThe use of CD-IOUS may allow conservative resection of liver tumors invading the MHV at the HC. This might limit the need for larger resections, and broadens the role of IOUS in optimizing surgical strategy.

Experience With More Than 500 Minimally Invasive Hepatic Procedures: A Serious Note Of Caution

To the Editor: Although a recent meta-analysis of 29 randomized clinical trials including 8,432 critically ill adult patients admitted to a medical or surgical intensive care unit (ICU) indicates that tight glycemic control with intensive insulin therapy is likely to reduce infection rates for surgical ICU patients but not for those in a medical ICU, the need for insulin drips for patients with hyperglycemia following noncardiac surgery has been poorly investigated. In the current retrospective cohort study by Dr Ramos and colleagues, the authors conclude that blood glucose levels, about 90% of which were determined within 24 hours after general or vascular surgery, are associated with an increased risk of postoperative infections and a longer hospital stay, but not with 30-day mortality. Additionally, the authors revealed that postoperative hyperglycemia increased the risk of infections by 30% with every 40 mg/dL increase from euglycemia ( 110 mg/dL). It appears that these findings support the need of insulin therapy or glucose restriction even for patients with mild to moderate hyperglycemia in response to major noncardiac surgery. However, in a recent study comparing the outcomes of trauma patients treated before institution of an insulin infusion protocol with a blood glucose target of 100–140 mg/dL with those of matched patients who received intensive insulin therapy, there was no difference in infection rates between the groups after adjusting for age, injury severity score, Glasgow Coma Scale scores, and intubation status. In that study, mean patient glucose level did not independently correlate with the development of infections. Another prospective study in a medical ICU failed to show the relationship between blood glucose levels on admission and the outcomes of critically ill patients. I would like to address 2 questions regarding the statistical analysis. The authors mention that Akaike Information Criterion (AIC) was used to determine the best fitting logistic regression model, but the results of AIC are not shown in the article. The AIC is a tool to find the statistical model that best explains the data with a minimum of free parameters. As in the stepwise regression method, before the determination of dependent variables that are to be entered into multiple regression analysis, the correlation between postoperative blood glucose levels and other possible predictive variables such as age, operation status (emergent/elective), operation time, the presence or absence of blood transfusion, and American Society of Anesthesia Classification should be examined. If not so, these methods can be very misleading. The authors stress that postoperative hyperglycemia is associated with postoperative infections, independently of preoperative diabetic status. According to the article, among the patients without postoperative infections 14.1% had overt diabetes, whereas 20.7% had been treated with oral antidiabetic medications or insulin in the infection group. On univariate analysis, the difference in prevalence of diabetes between the groups is marginally significant (P 0.04). I think multivariate analysis including such a marginally significant factor may not be enough for assessing the independency of postoperative hyperglycemia as a predictor for infections. Second, I would like to ask the authors whether subgroup analysis among patients without diabetes mellitus is preferred to clarify the role of postoperative hyperglycemia in the development of postoperative infections.

Resection of Concomitant Hepatic and Extrahepatic Metastases from Colorectal Cancer - A Worthwhile Operation?

Background: The benefit of hepatic resection in case of concomitant colorectal hepatic and extrahepatic metastases (CHEHMs) is still debatable. The purpose of this study is to assess the results of resection of hepatic and extrahepatic metastases in patients with CHEHMs in a high-volume center for both hepatobiliary and colorectal surgery and to identify prognostic factors that correlate with longer survival in these patients. METHOD It was performed a retrospective analysis of 678 consecutive patients with liver resection for colorectal cancer metastases operated in a single Centre between April 1996 and March 2016. Among these, 73 patients presented CHEHMs. Univariate analysis was performed to identify the risk factors for overall survival (OS) in these patients. Results: There were 20 CHMs located at the lymphatic node level, 20 at the peritoneal level, 12 at the ovary and lung level, 12 presenting as local relapses and 9 other sites. 53 curative resections (R0) were performed. The difference in overall survival between the CHEHMs group and the CHMs group is statistically significant for the entire groups (p 0.0001), as well as in patients who underwent R0 resection (p 0.0001). In CHEHMs group, the OS was statistically significant higher in patients who underwent R0 resection vs. those with R1/R2 resection (p=0.004). Three variables were identified as prognostic factors for poor OS following univariate analysis: 4 or more hepatic metastases, major hepatectomy and the performance of operation during first period of the study (1996 - 2004). There was a tendency toward better OS in patients with ovarian or pulmonary location of extrahepatic disease, although the difference was not statistically significant. CONCLUSION In patients with concomitant hepatic and extrahepatic metastases, complete resection of metastatic burden significantly prolong survival. The patients with up to 4 liver metastases, resectable by minor hepatectomy benefit the most from this aggressive onco-surgical management.

Anatomical resection of segment 8 by means of ultrasound-guided vessel compression.

BackgroundAnatomical resection is the gold standard for liver resection in patients with hepatocellular carcinoma (HCC). Bimanual hepatic vessel compression has been already described, although segmental and subsegmental resection of segment 8 (S8) remain challenging by this technique. We demonstrate how to obtain a S8 demarcation by means of ultrasound-guided vessel compression.MethodsTwo patients with HCC with hepatitis C virus-related cirrhosis partially or fully located in S8 without portal thrombosis underwent liver resection. In the first patient with a HCC fed by subsegmental glissonian pedicles to S4 superior (P4sup) and S8 ventral (P8v), the resection area was disclosed by direct compression of the aforementioned feeding pedicles. A second patient had a HCC located in S8 ventral with a satellite in S8 dorsal; the patient had a pedicle to the right anterior sector originating from the left portal vein. The resection area was obtained by means of direct compression of the P8d and countercompression of the left portal vein (peripherally to the origin of the pedicle to the anterior sector), and P5. Countercompression was needed because of the peculiar trajectory of P8v passing across the middle hepatic vein.ResultsIn neither case was there a congested area. In the first patient, hepatic veins were not exposed because it was a resection conducted in a subsegmental fashion. There was no morbidity, and no blood transfusions were needed. Patients were both discharged on day 8 after surgery.ConclusionsDisclosure of subsegmental portions of S8 by means of intraoperative ultrasound-guided compression technique is feasible and confirms the reliability of this approach.