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Background: Local hemostatic agents have a role in limiting bleeding complications associated with liver resection.Methods: In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10.Results: The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%).Conclusions: FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures. [ABSTRACT FROM AUTHOR]

Abstract: Caroli''s disease (including Caroli''s syndrome) is a rare autosomal recessive disorder of the liver characterized by diffuse cystic dilatation of the intrahepatic bile ducts. The disease may present at any age and is characterized by recurrent episodes of biliary obstruction, cholangitis, hepaticolithiasis, and liver abscesses. Caroli''s syndrome is further associated with congenital hepatic fibrosis and portal hypertension. Patients with recurrent complications or cirrhosis may die because of recurrent infection, portal hypertension, liver failure, or cholangiocarcinoma. Liver transplantation is the treatment of choice for these complicated patients. Here we describe the youngest reported patient with Caroli''s syndrome treated successfully using liver transplantation and review the recent literature. [Copyright &y& Elsevier]

Background: Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma. Study design: We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival. Results: Forty-three patients (24 men) aged 63.7 ± 11.4 years (standard deviation) were followed for a mean of 23.9months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival. Conclusions: Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question. [Copyright &y& Elsevier]

Management of hepatocellular carcinoma in the early cirrhotic remains controversial. The exact role of liver transplantation versus resection remains to be determined. The following short review attempts to present the evidence for the respective roles of liver transplantation versus liver resection in early stage HCC. [ABSTRACT FROM AUTHOR]

Background: Involvement of the IVC has traditionally been considered a relative contraindication to resection for advanced tumors of the liver. Combined resection of the liver and IVC for malignancy can be performed safely and results in long-term survival in select patients. Study Design: Sixty patients undergoing hepatic and IVC resection by the primary author from 1996 to 2012 were reviewed. Median age was 52 years. Resections were carried out for cholangiocarcinoma (n = 26), hepatocellular carcinoma (n = 16), colorectal metastases (n = 13), gastrointestinal stromal tumor (n = 2), hepatoblastoma (n = 2), and squamous cell carcinoma (n = 1). Resections performed included 27 right and 5 left trisegmentectomies and 25 right and 3 left lobectomies, including the caudate lobe. Ex vivo procedures were performed in 6 patients using veno–venous bypass and the other 54 procedures were performed using varying degrees of vascular isolation. In situ cold perfusion of the liver was used in 8 patients. The IVC was reconstructed using a tube graft (n = 38) primarily (n = 8) or with patches (n = 14). Results: There were 5 perioperative deaths (8%). Three patients died of liver failure, 1 patient died of pulmonary hemorrhage, and 1 patient died of massive pulmonary embolism. Nine patients had evidence of postoperative liver failure that resolved with supportive management. Three patients required temporary dialysis. With a median follow-up of 31 months, 14 patients have died of recurrent malignancy between 22 and 44 months, and an additional 4 patients are alive with disease at 16 to 33 months. Actuarial 1- and 5-year survival rates were 89% and 35%, respectively. Conclusions: Inferior vena cava involvement by malignancy does not obviate liver resection. The procedure's increased risk is balanced by the possible benefits, given the lack of alternative curative approaches. [Copyright &y& Elsevier]

Background: Vascular reconstruction along with major liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased risk. The purpose of this report is to assess the role of portal vein resection and reconstruction in the surgical management of hilar cholangiocarcinoma. Study Design: Ninety-five patients with hilar cholangiocarcinoma who underwent resection between 1999 and 2010 were reviewed. Liver resections performed along with biliary resection included 84 trisegmentectomies (63 right, 21 left) and 11 lobectomies (8 left, 3 right). Thirteen patients also had simultaneous pancreaticoduodenectomy performed. Forty-two patients underwent portal vein resection and reconstruction. Five patients required reconstruction of the hepatic artery. Preoperative portal vein embolization was used in 38 patients. Results: Patients undergoing resection had a 5% mortality rate, with an overall morbidity rate of 36%. Patients who underwent portal vein resection had perioperative mortality and morbidity similar to those who did not have portal vein resection. Median survival was 38 months (95% CI, 29–51 months), with a 5-year survival rate of 43%. There was no difference in long-term survival between those patients who had portal vein resection and those that did not. Negative margins were achieved in 84% of cases and were associated with improved survival (p < 0.01). Five-year survival rate in patients undergoing R0 resection was 50%. Patients with positive lymph nodes appeared to have a worse 5-year survival rate than patients with node-negative status (23% versus 49%); however, only negative margin status was associated with improved survival by multivariate analysis. Conclusions: Surgical resection of hilar cholangiocarcinoma that requires resection of the portal vein can be performed safely and should not be a contraindication to resection. [ABSTRACT FROM AUTHOR]

Background: Combined resection of both the liver and pancreas for malignancy remains a controversial procedure. To many, the need for such an extended procedure implies an extent of disease that is usually not amenable to surgical control, and the extent of the procedure exposes the patients to substantial operative risks. The purpose of this study was to assess our results with combined resection of the liver and pancreas. Study Design: Forty patients underwent combined liver and pancreas resection from 1996 to 2009. Patient ages ranged from 39 to 69 years (mean 53 years). Underlying diagnoses were neuroendocrine tumor (13), cholangiocarcinoma (13), gallbladder carcinoma (9), gastrointestinal stromal tumor (3), colorectal cancer (1), and metastatic ocular melanoma (1). Pancreatic resections included 26 pancreaticoduodenectomies (PD) and 14 distal pancreatic resections. Liver resections included 18 trisectionectomies (13 right, 5 left), 10 lobectomies (8 right, 2 left), and 12 segmental resections. Results: There was no perioperative mortality. One patient who underwent PD with right trisegmentectomy for gallbladder cancer developed postoperative liver failure that improved with supportive management. Two patients developed bile leaks that resolved with conservative management. One patient developed a pancreatic leak/hemorrhage and required a completion pancreatectomy. Mean hospital stay was 14 days (range 7 to 42 days). Median follow-up was 30 months (range 3 to 76 months). Patients undergoing resection for neuroendocrine tumors had a better 5-year survival than those with hepatobiliary malignancies (100% vs 37% p = 0.01). Conclusions: Combined resection of the liver and pancreas can be performed safely. The need for combined partial hepatectomy and pancreatectomy to remove malignancy should not be considered a contraindication to resection in selected patients. [Copyright &y& Elsevier]

Background: The definition of what is unresectable in liver surgery is controversial. Problems that many believe render patients unresectable can currently be resected using advanced techniques of liver surgery. This study assesses liver resection in patients who were unresectable with standard liver resection but were potentially resectable using an aggressive approach to liver surgery. Study Design: From 1997 to 2007, 830 adult patients undergoing hepatectomy were reviewed. Patients were categorized as having unresectable disease by standard resection if the disease could not be resected without resection of the IVC, hepatic vasculature, or because of tumor extent. Results: One hundred sixteen patients were initially believed to have unresectable disease but went on to laparotomy. Eighteen patients were unresectable at operation, although 98 patients were resected. Seventy-eight trisectionectomies; 18 lobectomies; 1 mesohepatectomy; and 1 segment 5, 6 resection, combined with pancreaticoduodenectomy, nephrectomy, and colectomy, were performed. Fourteen patients also had pancreatic resections. Vascular reconstructions were performed on the IVC (n = 35), hepatic veins (n = 21), portal vein (n = 34), and hepatic artery (n = 5). Hypothermic perfusion of the liver was used in 12 patients (4 ex vivo, 8 in situ cold perfusion). Patients undergoing resection had 6% mortality with a morbidity of 35%. Median survival was 37 months (95% CI, 34–42 months). Five-year actuarial survival was 32%. Conclusions: Patients with liver tumors considered “unresectable” by standard liver resection should be considered for resection with an aggressive approach to liver surgery. Five-year survival of approximately one-third of patients can be expected. [Copyright &y& Elsevier]

Background: Patients with hepatic and pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. We examined the longterm outcomes of patients who underwent both lung and liver resections for colorectal metastases over a 10-year period. Study design: Four hundred twenty-three hepatectomies were performed for metastatic CRC between 1992 and 2002 at two university-affiliated hospitals. Patients who underwent both lung and liver resections for metastatic CRC were studied. Demographic, perioperative, and survival data were evaluated by retrospective chart review. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis and survival curves were compared using the log-rank test. Results: Thirty-nine patients underwent both lung and liver resections for metastatic CRC. Eleven patients (28%) underwent staged liver and lung metastasectomy from synchronously identified metastases. Twenty-eight patients (72%) underwent sequential metastasectomy because of recurrent disease. The median disease-free and overall survivals after initial metastasectomy were 19.8 and 87months, respectively. Serial metastasectomy was common in this patient population. The mean number of metastasectomies performed was 2.6 per patient (range 1 to 4). There was no difference in overall survival for patients with synchronous versus metachronous presentation of liver and lung metastases (p=0.45). The site of first recurrence after initial metastasectomy was, most commonly, the lung (n=19, 49%), followed by the liver (n=8, 21%). Nineteen patients (49%) underwent subsequent resections for recurrences. Seven patients (18%) underwent 2 or more liver resections for recurrent disease, and 12 (31%) underwent multiple lung resections. Conclusions: An aggressive multidisciplinary surgical approach should be undertaken for recurrent CRC metastases. In selected patients, serial metastasectomy for recurrent metastatic disease is safe and results in excellent longterm survival after CRC resection. [Copyright &y& Elsevier]

Background: Early recurrence (ER) (<1 year) after liver resection is one of the most important factors that impact the prognosis of patients with hepatocellular carcinoma (HCC). We sought to determine factors associated with ER of HCC and examine the outcomes thereafter. Study design: From March 2001 to June 2003, 56 patients underwent hepatic resection for HCC at University of Toronto and were prospectively followed with median followup of 24 months. Patients with ER were compared with those who remained disease free for more than 1 year. Patient characteristics, tumor stage, and operative procedures were evaluated for their prognostic significance by univariate and multivariable analysis. Time to recurrence and time to death were analyzed using Kaplan-Meier survival curves and compared using log-rank analysis. Results: The initial procedure in all patients was surgical hepatectomy. ER occurred in 21 patients (38%), 31 (55%) remained disease free for more than 1 year, and 4 (7%) were omitted from evaluation because of early (<30 days) death. Median survival after initial hepatic resection for those with ER was 27 months, and 2-year survival was 54%. There were no deaths in the group that remained disease free for more than 1 year (100% 2-year survival, p < 0.05). By multivariate analysis, vascular invasion and positive microscopic margins were significant predictors when all 4 variables were considered in the model (p < 0.05). After ER, 11 of 21 patients (52%) underwent additional therapy with significant improvement in median survival (33 months) compared with those not eligible for conventional therapy (18 months, p = 0.05). Conclusions: ER after liver resection for HCC is the leading cause of death during the first 2 years after potentially curative resection. ER will develop in approximately 75% of patients with either vascular invasion or positive margins. For patients with these predictive factors additional treatment might be advised. [Copyright &y& Elsevier]