Yoshihiro Mise

Cohort study of the survival benefit of resection for recurrent hepatic and/or pulmonary metastases after primary hepatectomy for colorectal metastases.

Objective:To evaluate resection for hepatic and/or pulmonary recurrences in a cohort that underwent initial hepatectomy for colorectal liver metastases. Summary Background Data:The survival benefit of repeated resections for hepatic and/or pulmonary recurrences after initial hepatectomy for colorectal liver metastases has remained unclear. Methods:Recurrence occurred in 166 of the 216 patients after the first hepatectomy. Repeated resections were performed in 98 patients. We investigated the pattern of recurrence, the proportion of patients who underwent repeated resection, and the surgical outcome. Results:Of the 166 patients with recurrence, 71 had isolated hepatic recurrence, 25 had isolated pulmonary recurrence, 13 had hepatic plus pulmonary recurrence, and 57 had recurrence in other organs. Repeated resections were conducted in 60 (85%) patients with isolated hepatic recurrence, 21 (84%) with isolated pulmonary recurrence, and 9 (69%) with both hepatic and pulmonary recurrence. The 5-year survival rates after repeated resection were 39%, 37%, and 20% for isolated hepatic recurrence, isolated pulmonary recurrence, and hepatic plus pulmonary recurrence, respectively. Multivariate analysis revealed that the following variables contributed to poor prognosis (hazard ratio [95% confidence interval]): number of recurrent tumors (1.20 [1.11–1.29]), maximum size of recurrent tumors (1.26 [1.02–1.48]), pulmonary recurrence (2.36 [1.41–3.20]), and hepatic plus pulmonary recurrence (4.01 [2.86–.17]). Conclusions:Patients with pulmonary or hepatic plus pulmonary recurrence had poorer prognoses than those with isolated hepatic recurrence. Reresection is the only potentially curative treatment. Stricter indication criteria, especially regarding the number of tumor nodules, can lead to comparable long-term outcomes.

Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant

Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion.

The intersegmental plane of the liver is not always flat--tricks for anatomical liver resection.

Objective:To investigate the actual three-dimensional (3D) anatomy of the intersegmental plane of the liver to enable safe and precise anatomic resections of the portal territories. Summary of Background Data:Anatomic resection of the liver requires the precise detection of the intersegmental plane. However, we have sometimes encountered a dissociation between conventional understanding of the anatomy of the intersegmental plane and its actual 3D shape. Methods:3D simulations of the livers of 81 healthy donors for living donor liver transplantation were reviewed. Several key angles formed between the plane of each venous trunk and the actual intersegmental plane on 3D simulation images were measured. The relation between these angles and the volume ratio of the liver segments located on both sides of the intersegmental plane were also investigated. Results:The dissociation between the plane of the venous trunks and the actual intersegmental plane was remarkable, especially in the subphrenic region of the right lobe. The volume ratio of segment VIII compared with segment VII was correlated with the degree of cranio-lateral protrusion of segment VIII (r = 0.35, P = 0.001); this finding was attributed to the intricate surface of the right portal scissura. The same tendency was observed in the left portal scissura between the angle and the volume ratio of segment III/II (r = 0.23, P = 0.049), whereas the main portal scissura exhibited a relatively flat surface compared with the other longitudinal scissurae. Conclusions:The intersegmental plane of the liver has an uneven and curved surface, especially in the right and left portal scissurae. The identification and exposure of the landmark vein on the cut surface is an important technique for avoiding disorientation during anatomic liver resection.

Virtual liver resection: computer-assisted operation planning using a three-dimensional liver representation

In liver surgery, understanding the complicated liver structures and a detailed evaluation of the functional liver remnant volume are essential to perform safe surgical procedures. Recent advances in imaging technology have enabled operation planning using three-dimensional (3D) image–processing software. Virtual liver resection systems provide (1) 3D imaging of liver structures, (2) detailed volumetric analyses based on portal perfusion, and (3) quantitative estimates of the venous drainage area, enabling the investigation of uncharted fields that cannot be examined using a conventional two-dimensional modality. The next step in computer-assisted liver surgery is the application of a virtual hepatectomy to real-time operations. However, the need for a precise alignment between the preoperative imaging data and the intraoperative situation remains to be adequately addressed, since the liver is subject to deformation and respiratory movements during the surgical procedures. We expect that the practical application of a navigation system for transferring the preoperative planning to real-time operations could make liver surgery safer and more standardized in the near future.

Complete removal of the tumor-bearing portal territory decreases local tumor recurrence and improves disease-specific survival of patients with hepatocellular carcinoma

BACKGROUND & AIMS Anatomic resection (AR) of the tumor-bearing portal territory has been reported to be associated with a decreased recurrence of hepatocellular carcinoma (HCC). However, because of the heterogeneity of the study populations, its oncologic advantage remains controversial. The objective of the present study was to determine the clinical advantage of AR for primary HCC, based on the data from a large prospective cohort treated under a constant surgical policy. METHODS In 209 Child-Pugh class A patients with primary, solitary HCC measuring ⩽5.0cm in diameter, which was resectable either by AR or limited resection (non-AR), the overall survival (OS) and disease-free survival (DFS) were compared with patients in whom complete AR was achieved and those who eventually ended up with non-AR after adjustment for the propensity scores to select AR. Advantages of AR in disease-specific survival and local recurrence were also evaluated by competing-risks regression to clarify the true oncologic impact of AR. RESULTS The AR group showed better DFS than the non-AR group (HR, 0.67; 95% CI, 0.45-0.99; p=0.046), while no significant difference was observed in OS (hazard ratio [HR], 0.82; 95% CI, 0.46-1.48; p=0.511). Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.12; 95% CI, 0.05-0.30; p<0.001) and improves disease-specific survival (HR, 0.50; 95% CI, 0.28-0.90; p=0.020), while the other cause of death was highly influenced by patient age (>65years) (HR, 7.51; 95% CI, 2.16-26.04; p=0.002) and not associated with AR. CONCLUSION Complete removal of tumor-bearing portal territory decreases the risk of local recurrence and death from HCC.

The Feasibility of Third or More Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma.

OBJECTIVES To investigate the feasibility and prognostic benefits of third or more hepatectomy (third or more Hx) for recurrent hepatocellular carcinoma. BACKGROUND Second hepatectomy (second Hx) has been accepted as an effective treatment of recurrent hepatocellular carcinoma after first hepatectomy (first Hx). However, the feasibility and efficacy of third or more Hx have not been adequately assessed. METHODS Data were reviewed from 1340 patients with hepatocellular carcinoma who underwent curative hepatectomy. Among them, 941, 289, and 110 underwent first Hx, second Hx, and third or more Hx, respectively. Surgical outcomes and long-term survival were compared among the groups. RESULTS Surgical duration was significantly longer in third or more Hx (median, 6.4 hours) than in second Hx (median, 5.9 hours). Postoperative bile leakage and wound infection were more frequently observed in third or more Hx versus second Hx (12.5% vs 6.2%, [P = 0.04] and 2.9% vs 0.4% [P = 0.03], respectively). Three and 5-year disease-free survival rates were 36.8% and 27.1% in first Hx, 24.4% and 17.9 % in second Hx, and 26.1% and 12.8% in third or more Hx, respectively (P < 0.01 [first Hx vs third Hx], P = 0.95 [second Hx vs third or more Hx]). The 5-year overall survival rates from each resection were similar among the groups (65.3%, 60.5%, 68.2%, respectively). The 5- and 10-year overall survival rates from initial hepatectomy in patients who received third or more Hx were 91.4% and 75.5%, respectively. CONCLUSIONS Third or more Hx is technically demanding in terms of surgical duration and morbidity compared with second Hx. However, aggressive repeat resection offers a survival similar to second Hx, leading to cumulative long-term survival from initial resection.

Indocyanine green fluorescence imaging in the surgical management of liver cancers: Current facts and future implications

Imaging detection of liver cancers and identification of the bile ducts during surgery, based on the fluorescence properties of indocyanine green, has recently been developed in liver surgery. The principle of this imaging technique relies on the intravenous administration of indocyanine green before surgery and the illumination of the surface of the liver by an infrared camera that simultaneously induces and collects the fluorescence. Detection by fluorescence is based on the contrast between the (fluorescent) tumoral or peri-tumoral tissues and the healthy (non-fluorescent) liver. Results suggest that indocyanine green fluorescence imaging is capable of identification of new liver cancers and enables the characterization of known hepatic lesions in real time during liver resection. The purpose of this paper is to present the fundamental principles of fluorescence imaging detection, to describe successively the practical and technical aspects of its use and the appearance of hepatic lesions in fluorescence, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver surgery.

Three-dimensional volumetry in 107 normal livers reveals clinically relevant inter-segment variation in size

BACKGROUND The anatomic resection of Couinauds segments is one of the key techniques in liver surgery. However, the territories and volumes of the eight segments are not adequately assessed based on portal branching. METHODS Three-dimensional (3D) perfusion-based volumetry was performed in 107 normal livers. Based on Couinaud classification, the portal branches were identified and the volumes of each segment were calculated. The relationships between branching patterns of the portal veins and segmental volumes were assessed. RESULTS In descending order of volume, median volumes of segments VIII, VII, IV, V, III, VI, II and I were recorded. Segment VIII was the largest, accounting for a median of 26.1% (range: 11.1-38.0%) of total liver volume (TLV), whereas segments II and III each represented <10% of TLV. In 69.2% of subjects, the portal branches of segment V diverged from the trunk of the branches of segment VIII. No relationship was found between branching type and segment volume. CONCLUSIONS The territories and volumes of Couinauds segments vary among segments, as well as among individuals. Detailed 3D volumetry is useful for preoperative evaluations of the dissection line and of future liver remnant volume in anatomic segmentectomy.

Evaluation of the safety and efficacy of simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases

BACKGROUND It remains unclear whether primary colorectal cancer and synchronous liver metastases (SLMs) should be resected simultaneously or with a staged procedure. METHODS We reviewed the short-term outcomes of 127 patients who underwent simultaneous resection of primary colorectal cancer and SLM at our institution from January 1993 to December 2011. RESULTS The proportion of simultaneous resections was 84.7% (127 of 150 patients). There was no postoperative mortality, and the postoperative complication rate was 61.4%. Major complications occurred in 23 (18.2%) patients, and anastomotic failure occurred in 2 (1.6%). The 3-, 5-, and 10-year overall survival rates were 74%, 64%, and 52%, respectively. The median recurrence-free survival period was 7.0 months (95% confidence interval, 4.5-9.5 months) and the 5-year recurrence-free survival rate was 17%. CONCLUSION Simultaneous resection can be performed safely in patients with colorectal cancer and SLM.

Colorectal Liver Metastases: A Critical Review of State of the Art

Background: Over 50% of patients with colorectal cancer will develop liver metastases. Only a minority of patients present with technically resectable disease. Around 40% of those undergoing surgical resection are alive five years after their diagnosis compared with less than 1% for those with disseminated disease treated with systemic chemotherapy. Surgical resection remains the only possibility for long-term survival for these patients and great efforts have been made to increase the rates of resection whilst improving long-term outcomes. Summary: This review considers current technical and oncological criteria for resection, as well as targeted approaches to stratify underlying tumor biology in order to better predict long-term benefit. The role of neoadjuvant and perioperative systemic chemotherapy is critically reviewed, with suggestions for patient stratification in order to identify those who are likely to derive the greatest benefit. The key role of multidisciplinary assessment and decision making for these complex patients is also discussed. Key Messages: Surgery remains the optimal treatment for colorectal liver metastases (CRLM). Despite the curative intent of surgical resection, the majority of patients develop recurrence. Surgical strategies should therefore be adopted to maximize the potential for repeat resections in the event of recurrence. Although a number of preoperative prognostic markers have been identified, none are absolute contraindications to resection. In order to reduce postoperative recurrence, neo-adjuvant chemotherapy is now the standard of care in a number of countries. The evidence base for this approach is contentious, and the potential benefit of such a strategy is likely to be greatest in patients with high oncological risk disease. Multidisciplinary care is essential to ensure the optimal management of these complex patients. In addition, all patients with CRLM should be discussed with specialist hepatobiliary surgeons.