Matteo Cimino

Intraoperative ultrasonographic detection of communicating veins between adjacent hepatic veins during hepatectomy for tumours at the hepatocaval confluence

The presence of communicating veins between adjacent hepatic veins may allow parenchyma‐sparing hepatectomy. Taking advantage of improvements in ultrasound technology, such as e‐flow modality, a study of the presence of communicating veins was conducted in patients with hepatic tumours at the caval confluence.

Upper Transversal Hepatectomy

BackgroundFor tumors involving hepatic veins (HV) at hepato-caval confluence (HC), major hepatectomy or vascular reconstruction, are recommended. Detection of communicating veins (CV) between adjacent HVs allows conservative hepatectomies.MethodsA 61 year-old man was operated for multiple colorectal liver metastases (CLM). The 2 main CLM (14 and 3.5xa0cm in size) were adjacent, separated by the middle HV (MHV) at HC, and involved segments 1(paracaval portion), 7, and 8, and segments 4-superior(S4sup) and 1(paracaval portion), respectively. At HC the larger CLM invaded the right HV (RHV), and the smaller was in contact with the left HV (LHV). A thick inferior RHV (IRHV), and 2 CVs connecting IRHV-MHV and MHV-LHV, were evident.ResultsAfter J-shaped thoracophrenolaparotomy, intraoperative ultrasound (IOUS) confirmed the CVs. Liver was detached from the inferior vena cava preserving the IRHV: RHV was divided, and common trunk of MHV-LHV was taped, and, once clamped, hepato-petal flow in S4inf, S5, and S6 portal branches was confirmed at IOUS. Upper-transverse IOUS-guided resection, comprehensive of S7, S8, S4sup, and S1 (paracaval portion) with preservation of the CVs was performed. MHV at HC was divided once detachment of the LHV from the tumor was ultimate. No congestive areas remained. No postoperative mortality and major morbidity occurred: patient was discharge on 17th postoperative day, and is disease-free at 7 months after surgery.ConclusionsDetection of CVs between adjacent HVs enables new conservative hepatectomies for tumors at HC. The herein described upper transversal hepatectomy despite two HVs are resected, allows adequate liver outflow and remaining functional liver parenchyma.

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).

New technique for defining the right anterior section intraoperatively using ultrasound-guided finger counter-compression.

v A i n F P m u P a t e t is generally considered that for delimitation of the hepatic rea to be resected, once anatomic sectionectomy is planned, reventive division of the sectional vascular pedicles by an xtrahepatic approach is required. But all proposed techiques are technically demanding and time consuming, ith associated drawbacks, although these are not numercally defined. We have shown that intraoperative ultraound (IOUS)-targeted bimanual liver compression can be n effective method for disclosing subsegmental and segental areas of the liver and removing them in an anatomic ashion. We describe a new technique based on IOUSuided liver compression for accomplishing a right anterior ectionectomy (RAS).

Potential role of cholinesterases to predict short-term outcome after hepatic resection for hepatocellular carcinoma

Estimation of functional liver reserve in patients with hepatocellular carcinoma (HCC) is of paramount importance to properly select candidates for surgical resection. Together with the value of bilirubin, the presence/absence of ascites and esophageal varices, and the rate of residual liver volume, which are our current parameters to measure functional liver reserve, we sought to investigate the value of preoperative cholinesterases (CHE) in predicting postoperative outcome after hepatic resection for HCC. We reviewed the records of 279 consecutive patients who underwent hepatic resection for HCC in our Unit between 2001 and 2011. The value of preoperative CHE was analyzed against the occurrence of postoperative events. Receiver–operator characteristic curve analysis was used to identify cut-off values of CHE that predicted adverse outcomes. Univariate and multivariate analyses on clinically relevant variables, which included the MELD score among others, were performed. Pxa0<xa00.05 was considered statistically significant. Eighty (29xa0%) of 279 patients had complications, of which 60 (21.5xa0%) were liver-related. Major morbidity occurred in 16 (6xa0%) patients. The 30-day postoperative mortality was 1xa0%. A value of CHExa0≤xa05,900xa0UI/L had a sensitivity of 73xa0% and a specificity of 67xa0% in predicting liver-related postoperative complications (Pxa0=xa00.001). The multivariate analysis revealed that only blood transfusion, major resections, and a value of CHExa0≤xa05,900xa0UI/L independently predicted the risk of morbidity. The results indicated that CHE contributed important information in predicting postoperative outcome after hepatic resection for HCC. Thus, it should be included in the selection process of candidates to surgery for such disease.

Systematic Subsegmentectomy by Ultrasound-Guided Finger Compression for Hepatocellular Carcinoma in Cirrhosis

BackgroundSystematic and extensive use of intraoperative ultrasound (IOUS) allows us to perform new conservative surgical procedures in liver surgery. This video shows systematic subsegmentectomy by IOUS-guided finger compression for a case of hepatocellular carcinoma (HCC) in cirrhosis.MethodsThe case of a 69-year-old woman with a single 3.5-cm HCC in segment 3 is presented. The patient has hepatitis C virus (HCV)-related well-compensated cirrhosis. After performing a T-inverted laparotomy, the IOUS is carried out for staging. Then, the area of resection is anatomically marked by IOUS-guided finger compression of the subsegmental portal branch feeding the tumor in segment 3. Thus, the resection is performed under intermittent Pringle maneuver using Pean-clasia and bipolar forceps.ResultsNinety-day mortality and morbidity for this patient were nil. No blood transfusions were required. The patient was discharged 8xa0days after surgery.ConclusionsSystematic subsegmentectomy by IOUS-guided finger compression is a feasible and effective technique, especially for HCC in cirrhosis. It may be potentially applied in each segment of liver as long as the thickness of the parenchyma and the anatomy of liver are suitable. We believe that this technique should be part of the modern liver surgeon’s armamentarium.

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

BACKGROUNDnContrast-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.nnnMETHODSnOne-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.nnnRESULTSnUsing 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.nnnCONCLUSIONSnCompared with IOUS, CE-IOUS improved detection and resection guidance. These additions are significant and demand its use in cases with multiple and isoechoic CLMs.

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.

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.