Guido Costa

Safe hepatectomy selection criteria for hepatocellular carcinoma patients: a validation of 336 consecutive hepatectomies. The BILCHE score.

BackgroundSelection criteria for hepatectomy for hepatocellular carcinoma (HCC) are object of debate. We presented our criteria for safe hepatectomy for HCC, and we compared the results with those obtainable using the most common scores for HCC.MethodsAll patients submitted to hepatectomy for HCC based on the same criteria were reviewed from our prospectively maintained database. Such criteria included bilirubin (BIL), cholinesterases (CHE), ascites, esophageal varices, and residual liver volume.ResultsA total of 336 patients were analyzed. One hundred fifteen patients (33xa0%) had thoracoabdominal approach, but only 39 (12xa0%) had major or extended resections. The median tumor number was 1 (range 1–33), while the median tumor size was 3.6xa0cm (range 1.1–28). Of those, 94 (29xa0%) had postoperative complications, of which 6xa0% were graded as major (Dindo III–IV). The 90-days mortality was 2xa0%. The MELD, APRI, and CPT scores were not found to be statistically significant for complications, while combining BIL and CHE we defined four classes of risk. The association of BIL >1xa0mg/dl (>17.1xa0µmol/l) and CHE ≤5,900 U/l was the best to detect complications (ORxa0=xa04.45; Pxa0=xa00.007).ConclusionsThis study shows that our selection criteria that count mainly on two commonly available, and inexpensive parameters, BIL and CHE, lead to identify patients potentially at risk of postoperative complications after hepatic resection for HCC. Registration number: NCT02056041 (http://www.clinicaltrials.gov).

Conservative Hepatectomy for Tumors Involving the Middle Hepatic Vein and Segment 1: The Liver Tunnel

BackgroundFor lesions invading the middle hepatic vein (MHV) at caval confluence (CC) the mini-mesohepatectomy(MMH) was proposed.1 If the lesion is extended to the paracaval portion of segment 1(S1) in contact or invading the MHV a new procedure is proposed.MethodsCase-1: mass forming cholangiocarcinoma (MFCCC) 4cm in size invading the MHV and in contact with right (RHV) and left hepatic vein (LHV) at the CC. In Case-2, two colorectal liver metastases (CLM) both 2cm in size occupied S1 (T1) and S8 (T2): T1 was located between RHV and the inferior vena cava (IVC), T2 was in contact with MHV at CC. According to tumor-vessel intraoperative-ultrasound classification2 and color-flow analysis3 parenchyma-sparing procedure was performed.ResultsIn Case-1 a communicating vein (CV) between RHV and MHV was detected at color-flow-IOUS. Contacts between MFCCC with RHV and LHV were confirmed at IOUS as detachable. In Case-2 contact between T1 with MHV was confirmed at IOUS as detachable. Liver-tunnel with IVC and main portal vein bifurcation exposure was performed resecting the MHV in Case-1 and preserving it in Case-2. Both patients had ad an uneventful postoperative course and were discharged on the 8th postoperative day.ConclusionFor tumors involving S1, S4s and/or S8 and infiltrating or in contact with the MHV at the CC, can be removed in a conservative manner by means of the herein described ‘‘Liver Tunnel’’ approach. The latter introduces a further step in favour of parenchyma-sparing policy for centrally located lesions with complex tumor-vessel relationship.

Hepatic Vein-Sparing Hepatectomy for Multiple Colorectal Liver Metastases at the Caval Confluence

BackgroundTwo-stage hepatectomies generally are selected for patients with multiple bilobar colorectal liver metastases (CLMs) involving the hepatic veins (HV) at the caval confluence to reduce the risk of postoperative hepatic failure due to insufficient remnant liver.1,2 The use of IOUS based on well-established criteria offers alternative technical solutions to the staged resections.3,4 This report describes a sophisticated IOUS-guided parenchyma-sparing procedure.MethodsA 57-year-old woman with multiple CLMs underwent surgery. One of these CLMs was located in segments 8 to 4 sup involving the middle hepatic vein (MHV) at the caval confluence. A second CLM was between dorsal segment 8 and the paracaval portion of segment 1 involving the right hepatic vein (RHV) at the caval confluence. Neither the inferior RHV nor the communicating veins were evident at preoperative imaging. The left hemiliver represented 27 % of the total liver volume, and segments 2 and 3 represented 16 %.ResultsAfter a J-shaped thoracophrenolaparotomy, liver exploration with IOUS showed tumoral invasion of MHV and RHV at their caval confluence for one third of their circumference. No communicating veins were intraoperatively evident. A partial resection of segments 7, 8, and 4 superior and 1-paracaval sparing both RHV and MHV was performed. The latter were partially resected, and vessel wall reconstruction was obtained by direct running suture. No congested area or vascular thrombosis occurred, and the postoperative course was uneventful. No local recurrence had occurred after 6 months of follow-up evaluation.ConclusionsThe video shows an HV-sparing IOUS-guided hepatectomy as an alternative to conventional staged surgery. This policy represents a safe and effective alternative to major resection performed immediately or in a staged perspective.

Radical but Conservative Liver Resection for Large Centrally Located Hepatocellular Carcinoma: The Mini Upper-Transversal Hepatectomy

BackgroundIn patients with hepatocellular carcinoma (HCC) in a diseased liver, surgery should be offered in a parenchyma-sparing fashion. This approach seems unfeasible for large and deeply located lesions. Ultrasound study of the tumor-vessel relationship and hepatic inflow and outflow opens new technical solutions: herein is described a new operation based on this approach.1–3MethodsA 69-year-old man with a large centrally located HCC (Barcelona Clinic Liver Cancer stage C) underwent surgery. The HCC was located in segments 7, 8, and part of 5, extensively compressing and dislodging the anterior (P5–8) and posterior (P6–7) Glissonean pedicles at their origin. The lesion involved the right hepatic vein (RHV) and was in contact with the middle hepatic vein at the caval confluence. An inferior RHV (IRHV) was preoperatively evident.ResultsAfter a J-shaped thoracophrenolaparotomy, the liver exploration with the aid of intraoperative ultrasound confirmed the tumoral contact without vascular invasion with P5–8 and P6–7 and disclosed multiple communicating veins between the middle hepatic vein and RHV, warranting with the IRHV the segment 5–6 outflows. A resection of segments 7 and 8 with RHV resection, together with complete tumor detachment from P5–8 and P6–7, was performed. The specimen was removed combining the crush-clamping method for the parenchyma division and a peeling-off technique by means of blunt scissor dissection for the tumor vessel detachment. The postoperative course was uneventful. The patient was alive without recurrence at 12xa0months after surgery.ConclusionsThis video is the first live demonstration of the previously reported radical but conservative policy, adding to the latter the technical solutions provided by detection of accessory veins such as the IRHV and communicating veins.1–4

Planning of the Surgical Strategy

IOUS exploration of the liver can have a great impact on surgical strategy. However, more recently the impact of IOUS on operative decision making, when compared with those of preoperative imaging techniques, is reported to be just around 4–7 % [1, 2].

Diagnosis and Staging: Contrast-Enhanced Intraoperative Ultrasound (CEIOUS) Using Intravascular Contrast Agents

Tumor echogenicity and background liver appearance in IOUS (i.e., cirrhotic, steatotic) can affect our ability to recognize tiny lesions. It has been shown that small metastases can be better recognized if they are hypoechoic rather than isoechoic.

Exploring the Liver by Ultrasound Along its Anatomy

Adequate knowledge of liver anatomy, by surgical and ultrasound, is a requirement for performing IOUS: its vascular skeleton composed of the glissonian skeleton with its portal, arterial, and biliary elements and the hepatic veins are landmarks for liver exploration.