Sander Dinant

Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

BackgroundTreatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors.MethodsA total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988–1993; n = 45), 2 (1993–1998; n = 25), and 3 (1998–2003; n = 29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival.ResultsThe proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P < .05). Two-year survival increased significantly from 33% ± 7% and 39% ± 10% in periods 1 and 2 to 60% ± 11% in period 3 (P < .05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis.ConclusionsMainly in the last 5-year period (1998–2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.

Assessment of Future Remnant Liver Function Using Hepatobiliary Scintigraphy in Patients Undergoing Major Liver Resection

Background99mTc-mebrofenin hepatobiliary scintigraphy (HBS) was used as a quantitative method to evaluate liver function. The aim of this study was to compare future remnant liver function assessed by 99mTc-mebrofenin hepatobiliary scintigraphy with future remnant liver volume in the prediction of liver failure after major liver resection.MethodsComputed tomography (CT) volumetry and 99mTc-mebrofenin hepatobiliary scintigraphy were performed prior to major resection in 55 high-risk patients, including 30 patients with parenchymal liver disease. Liver volume was expressed as percentage of total liver volume or as standardized future remnant liver volume. Receiver operating characteristic (ROC) curve analysis was performed to identify a cutoff value for future remnant liver function in predicting postoperative liver failure.ResultsPostoperative liver failure occurred in nine patients. A liver function cutoff value of 2.69%/min/m2 was calculated by ROC curve analysis. 99mTc-mebrofenin hepatobiliary scintigraphy demonstrated better sensitivity, specificity, and positive and negative predictive value compared to future remnant liver volume. Using 99mTc-mebrofenin hepatobiliary scintigraphy, one cutoff value suffices in both compromised and noncompromised patients.ConclusionPreoperative 99mTc-mebrofenin hepatobiliary scintigraphy is a valuable technique to estimate the risk of postoperative liver failure. Especially in patients with uncertain quality of the liver parenchyma, 99mTc-mebrofenin HBS proved of more value than CT volumetry.

Risk Assessment of Posthepatectomy Liver Failure Using Hepatobiliary Scintigraphy and CT Volumetry

A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection–related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. Methods: Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate 99mTc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operating-characteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. Results: Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure–related mortality developed (P = 0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure–related mortality were 2.5%/min/body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. Conclusion: Preoperative measurement of 99mTc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure–related mortality after partial liver resection.

Preoperative assessment of liver function: a comparison of 99mTc-Mebrofenin scintigraphy with indocyanine green clearance test.

Background/aims: The indocyanine green (ICG) clearance test is the most frequently used test for preoperative assessment of liver parenchymal function but has its limitations. The aim of this study was to investigate the correlation between ICG clearance test and the liver uptake of 99‐Technetium‐labelled (99mTc)‐Mebrofenin (99mTc‐Mebrofenin) as measured with hepatobiliary scintigraphy.

Vascular Occlusion Techniques during Liver Resection

Control of bleeding from the transected liver basically consists of vascular inflow occlusion and control of hepatic venous backflow from the caval vein. Central venous pressure determines the pressure in the hepatic veins and is an extremely important factor in controlling blood loss through venous backflow. Vascular inflow occlusion (Pringle maneuver) involves clamping of the portal vein and the hepatic artery in the hepatic pedicle and gives rise to postischemic, reperfusion injury. Several strategies have been devised to reduce reperfusion injury (pharmacological interventions) or to increase ischemic tolerance of the liver (ischemic preconditioning). Intermittent clamping is recommended in complex liver resections or in patients with diseased livers. The combination of occlusion of vascular inflow and outflow of the liver results in total hepatic vascular exclusion (THVE) and is mainly used in tumors invading the caval vein. During THVE the liver can be cooled by hypothermic perfusion allowing for extended ischemia times. Selective THVE entails clamping of the main hepatic veins in their extrahepatic course, thus preserving caval flow. Safe liver surgery requires knowledge of the regular techniques of vascular occlusion for ‘on demand’ use when necessitated to reduce blood loss.

Portal vein ligation is as effective as sequential portal vein and hepatic artery ligation in inducing contralateral liver hypertrophy in a rat model

PURPOSE Dual embolization of the hepatic artery and portal vein (PV) has been proposed to enhance contralateral liver regeneration before resection. The aim of this study was to evaluate the effect of PV ligation compared with simultaneous or sequential dual ligation on regeneration, proinflammatory response, and liver damage. MATERIALS AND METHODS Single hepatic artery ligation (HAL), PV ligation (70%), or dual ligation of the hepatic artery and PV (70%) simultaneously or sequentially within a 48-hour interval was performed in a rat model. Liver regeneration, proinflammatory mediators, hepatocellular synthetic function and injury, histopathology, and apoptosis were assessed at a maximum of 14 days after surgery. RESULTS Sequential dual ligation resulted in a faster increase in hepatocyte proliferation at 24 hours without additional increase in liver mass compared with PV ligation after 14 days. Both dual ligations significantly increased proinflammatory response in plasma and in the regenerating liver compared with PV ligation alone. Fourteen days after PV ligation, the hepatic parenchyma was completely restored, whereas fibronecrosis was seen in the sequentially dual-ligated groups and complete necrosis was seen in simultaneously ligated groups. Increased apoptosis in the regenerating liver and prolonged hepatic dysfunction were observed after both dual ligations. CONCLUSIONS PV ligation is as effective as dual ligation in inducing liver regeneration. No additional benefit of arterial ligation was observed.

Liver protection by hypothermic perfusion at different temperatures during total vascular exclusion

Abstract: Introduction: In situ hypothermic perfusion (HP) can be applied to attenuate ischemia and reperfusion (I/R) injury during liver resection under total vascular exclusion (TVE). This study examines the protective effect of cooling by HP at 20 and 28°C as compared with no HP during TVE in a porcine liver I/R model.

Original article: new surgical approaches to the Klatskin tumour

Background Surgical treatment of hilar cholangiocarcinoma (Klatskin tumours) is difficult because of its central location in the liver hilum. Recent developments in surgical techniques have improved the outcome after resection.

In vitro function of porcine carotid arteries preserved in UW, HTK and Celsior solutions

We compared the efficacy of histidine‐tryptophan‐ketoglutarate (HTK) and University of Wisconsin (UW) solution with Celsior solution using hypothermically‐preserved porcine carotid arteries and studied the importance of different components of these solutions by preserving carotid arteries in modified HTK solutions.