Jaime Kruger

High Mortality Rates After ALPPS: the Devil Is the Indication

Surgical resection with R0 margins still remains the ultimate goal for most liver malignancies [1]. In many cases, a complete margin-free resection represents a challenge especially when lesions might present as giant masses (i.e., hepatocellular carcinoma, intrahepatic cholangiocarcinoma), compromising major vessels, or as bilobar multicentric disease (i.e., metastatic colorectal carcinoma), demanding extended resections. In order to obtain complete resection of tumors that are large, multiple, or oddly located, a great amount of parenchyma is sacrificed, with the greatest concern being the future liver remnant (FLR) and posthepatectomy liver failure [2]. Santibañes and Clavien [3] wrote an elegant editorial enumerating important surgical advances that provided the possibility of curative resection for patients with an extensive tumor load in the liver, such as portal vein embolization, staged liver resection, and the association of both procedures. There is no doubt that these techniques provided a significant advance enabling the treatment of patients with large tumor masses, avoiding a small liver remnant and consequently preventing postoperative liver failure. Recently, an innovative operation combining the principles of these aforementioned strategies has become an alternative approach to increase the FLR in major hepatectomies [3]. The associating liver partition and portal vein ligation for staged hepatectomy—termed as ALPPS—has triggered many and heated debates along recent years. The new concept of in situ liver partition associated to portal vein ligation leading to a fast and significant contralateral parenchyma hypertrophy was first performed by Hans Schlitt in 2007, being the first scientific report by Baumgart et al. in 2011 and popularized by Santibañes and his colleagues [4]. Schnitzbauer et al. [5] in a cooperative experience from 5 German centers with 25 patients showed aspects that should be addressed. In this initial experience, a high morbidity rate (68 %) and a concerning mortality rate (12 %) were reported; on the other hand, an impressive volume growth in a short period of time and low rates of postoperative liver failure were observed. ALPPS is still under evaluation in a stage between exploration and assessment [6]. Indeed, the experience with ALPPS is lacking and we still seek the best indications to perform it. Moreover, regarding the surgical technique itself, the procedure is not well standardized. P. Herman : J. A. P. Krüger (*) :M. V. Perini : F. F. Coelho Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 255 9° andar sala 9025, São Paulo, SP CEP 05403-900, Brazil e-mail: jaime.kruger@hc.fm.usp.br

Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol

Colorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.

CENTRAL HEPATECTOMY FOR BILIARY CYSTADENOMA: PARENCHYMA-SPARING APPROACH FOR BENIGN LESIONS

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Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury

AIM To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury. METHODS From a prospective database of patients treated for benign biliary strictures at our hospital, cases that underwent liver resections were reviewed. All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy (open or laparoscopic). Liver resection was indicated in patients with Strasberg E3/E4 (hilar stricture) bile duct lesions associated with vascular damage (arterial and/or portal), ipsilateral liver atrophy/abscess, recurrent attacks of cholangitis, and failure of previous hepaticojejunostomy. RESULTS Of 148 patients treated for benign biliary strictures, nine (6.1%) underwent liver resection; eight women and one man with a mean age of 38.6 years. Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery. The mean number of surgical procedures before definitive treatment was 2.4. All patients had Strasberg E3/E4 injuries, and vascular injury was present in all cases. Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality. Mean time of follow up was 69.1 mo and after long-term follow up, eight patients are asymptomatic. CONCLUSION Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.

Video assisted resections. Increasing access to minimally invasive liver surgery

OBJECTIVE To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. METHODS From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. RESULTS The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. CONCLUSION The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.

Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases

Histomorphological features have been described as prognostic factors after resection of colorectal liver metastases (CLM). The objectives of this study were to assess the prognostic significance of tumor budding (TB) and poorly differentiated clusters (PDC) among CLM, and their association with other prognostic factors.

Laparoscopic transthoracic liver resection

Introduction Minimally invasive laparoscopic liver surgery is being performed with increased frequency. Lesions located on the anterior and lateral liver segments are easier to approach through laparoscopy. On the other hand, laparoscopic access to posterior and superior segments is less frequent and technically demanding. Aim Technical description for laparoscopic transthoracic access employed on hepatic wedge resection. Technique Laparoscopic transthoracic hepatic wedge resection on segment 8. Conclusion Transthoracic approach allows access to the posterior and superior segments of the liver, and should be considered for oddly located tumors and in patients with numerous previous abdominal interventions.

Hilar Lymph Node Involvement in Colorectal Cancer Liver Metastases - An Overview

Hepatectomy is the only possible option for cure in any treatment strategy of colorectal liver metastases, and several studies have shown good results, with five-year survival rates ranging from 27 to 56%. Several clinical and pathological predictive factors for survival after liver resection have been studied and the metastatic involvement of the hepatic hilum lymph nodes indicates a poor long-term prognosis. Despite variable results, some authors have reported a not-insignificant improvement in survival rate in liver-metastasis patients with hilar-lymph-node involvement who undergo combined liver resection and lymphadenectomy. Due to the low rates of morbidity and mortality for liverresection surgery, several specialized centers perform liver resections combined with lymphadenectomy in selected cases. It should be noted that the therapeutic value of systemic lymphadenectomy is not yet entirely understood, and only controlled studies comparing groups with and without lymphadenectomy can fully resolve the issue. In any case, hilar lymph node dissection has been shown to be a useful tool for improving the accuracy of extrahepatic disease staging, regardless of its impact on survival. The authors review the incidence and the clinical impact of hilar lymph node metastases, and analyses the possible beneficial role of systematic lymphadenectomy in patients who have undergone liver resection for colorectal-cancer metastases.

Evolution in the surgical management of colorectal liver metastases: Propensity score matching analysis (PSM) on the impact of specialized multidisciplinary care across two institutional eras

Liver metastases are indicators of advanced disease in patients with colorectal cancer. Liver resection offers the best possibility of long‐term survival. Surgical strategies have evolved in complexity in order to offer resection to a greater number of patients, requiring specialized multidisciplinary care. The current paper focused on analyzing outcomes of patients treated after the development of a dedicated cancer center in our institution.

Reply to “Poorly differentiated clusters in colorectal liver metastases: Prognostic significance in synchronous and metachronous metastases”

Dear Dr. Barresi and colleagues, We thank you for your interest in our recently published paper entitled “Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases.” The papers published by Ueno et al and your group 3 about poorly differentiated clusters (PDC) in colorectal cancer inspired us to study PDC in colorectal liver metastasis (CLM). The different results in the studies may be explained by several differences in the methodological approach. For example, we evaluated the largest tumor among patients with more than one metastatic nodule, which was consistent with several previous reports. In contrast, the study by your group analyzed all metastatic nodules and reported the nodulewith the highest number of PDC (80% of patients with PDC versus 49.3% in our study). Another difference was that we identified 11 patients (4.8%) with PDC G3 (ten or more PDC under a microscopic field of ×20) versus only three patients (2%) with PDC G3 identified in your study. In turn, the low number of patients with PDC G3 might explain the lack of a statistical difference in overall survival (OS) and disease-free survival (DFS) in your study. Of note, similarly to your results, patients in our cohort who had PDC in CLMhad aworseOS andDFS (P = 0.019 and P = 0.002) comparedwith patients without PDC. However, we chose to use PDC G3 among patients with CLM because this variable was an independent prognostic factor in the logistic regression. In addition, according the original definition described by Ueno et al, PDC can appear within the tumor and/or at the advancing edge. In our study, we considered the sum of PDC rather than a specific location as in your series. Further studies are needed to validate the PDC location as a prognostic factor. There are different definitions of synchronous/metachronous CLM. We considered metachronous disease when CLM appeared after 12 months from diagnosis of primary tumor as proposed by Fong et al. In an era of multidisciplinary care for CLM that combines surgery and systemic therapy, patients with CLM diagnosed at or before surgery for the primary tumor are usually submitted to neoadjuvant chemotherapy as recommended by the European consensus. In our cohort, 83 patients (36.2%) had CLM diagnosed at or before colorectal resection and 59 of them (71.1%) received chemotherapy before liver resection (unpublished data). The effects of chemotherapy on histopathology are complex 9 and its consequences in CLM associated PDC are unknown. In contrast to the primary colorectal tumor where a pre-treatment biopsy is usually available, pre-chemotherapy pathological evaluation of the CLM was generally not available. In addition, patients with less aggressive disease (eg, small single nodule, metachronous disease, low CEA levels) tend to be operated without preoperative chemotherapy, while patients with more aggressive CLM are usually submitted to neoadjuvant systemic treatment, which may lead to a possible bias. Our understanding of CLM continues to grow and many new pathological prognostic factors have been described in the last years. CLM has increasingly been recognized not only as a secondary metastatic tumor, but also as an independent tumor with its own specific characteristics, behavior, and prognosis. Recently, our group published a proposal regarding standardized pathological reporting of CLM specimens based on described prognostic factors. Such standardize reporting can provide more information beyond margin status and secondary tumor confirmation. In an era where costefficiency is an important concern, the reporting of PDC does not add charges related to immunohistochemical staining, since PDC can be evaluated in routine hematoxilin and eosin staining. We completely agree that further studies are needed to elucidate the role of PDC in CLM. Despite questions about the prognostic impact of PDC grade, presence, or location, both studies indicate that PDC in CLMmay be a promising prognostic factor.