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Background: Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion., Patients and Methods: The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range)., Results: Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero., Conclusions: This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass., (© 2024. Society of Surgical Oncology.)

Background: Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients., Methods: From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible., Results: There were 6 male and 5 female patients (median age, 58 years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90 days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29 months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37 months (median, 15 months)., Conclusion: In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The recent development of 3D vision in laparoscopic and robotic surgical systems raises the question of whether these two procedures are equivalent. The aim of this study was to evaluate the surgical and long-term oncological outcomes of 3D laparoscopic (3D-LLR) and robotic liver resection (RLR) for hepatocellular carcinoma (HCC)., Methods: The data for operative time, morbidity, margins, and survival were reviewed for 3D-LLR and compared with RLR., Results: From 2011 to 2017, 93 patients with HCC, including 58 (62%) with cirrhosis, underwent 3D-LLR [49 (53%)] or RLR [44 (47%)]. No difference was observed in operative time (269 vs. 252 min; p = 0.52), overall (27% vs. RLR: 16%; p = 0.49) and severe morbidity (4% vs. 2%; p = 0.77) or in the surgical margin width (9 vs. 11 mm; p = 0.30) between the 3D-LLR and RLR groups. The 3-year overall and recurrence-free survival rates after 3D-LLR and RLR were 82% and 24% and 91% (p = 0.16) and 48% (p = 0.18), respectively., Conclusions: The 3D-LLR and RLR systems provide comparable surgical margins with similar short- and long-term oncological outcomes.

Introduction: Although a positive surgical margin is a known prognostic factor for recurrence, the optimal surgical margin width in the context of an R0 resection for early-stage hepatocellular carcinoma (HCC) is still debated. The aim of the current study was to examine the impact of wide (> 1 cm) versus narrow (< 1 cm) surgical margin status on the incidence and recurrence patterns among patients with T1 HCC undergoing an R0 hepatectomy., Methods: Between 1998 and 2017, patients with T1 HCC who underwent R0 hepatectomy for stage T1 HCC were identified using an international multi-institutional database. Recurrence-free survival (RFS) was estimated, and recurrence patterns were examined based on whether patients had a wide versus narrow resection margins., Results: Among 404 patients, median patient age was 66 years (IQR: 58-73). Most patients (n = 326, 80.7%) had surgical margin < 1 cm, while 78 (19.3%) patients had a > 1 cm margin. The majority of patients had early recurrences (< 24 months) in both margin width groups (< 1 cm: 70.3% vs > 1 cm: 85.7%, p = 0.141); recurrence site was mostly intrahepatic (< 1 cm: 77% vs > 1 cm: 61.9%, p = 0.169). The 1-, 3-, and 5-year RFS among patients with margin < 1 cm were 77%, 48.9%, and 35.3% versus 81.7%, 65.8%, and 60.7% for patients with margin > 1 cm, respectively (p = 0.02). Among patients undergoing anatomic resection, resection margin did not impact RFS (3-year RFS: < 1 cm: 49.2% vs > 1 cm: 58.9%, p = 0.169), whereas in the non-anatomic resection group, margin width > 1 cm was associated with a better 3-year RFS compared to margin < 1 cm (86.7% vs 47.3%, p = 0.017). On multivariable analysis, margin > 1 cm remained protective against recurrence (HR = 0.50, 95%CI 0.28-0.89), whereas Child-Pugh B (HR = 2.13, 95%CI 1.09-4.15), AFP > 20 ng/mL (HR = 1.71, 95%CI 1.18-2.48), and presence of microscopic lymphovascular invasion (HR = 1.48, 95%CI 1.01-2.18) were associated with a higher hazard of recurrence., Conclusion: Resection margins > 1 cm predicted better RFS among patients undergoing R0 hepatectomy for T1 HCC, especially small (< 5 cm) HCC. Although resection margin width did not influence outcomes after anatomic resection, wider margins were more important among patients undergoing non-anatomic liver resections.

Background: The laparoscopic approach might increase the number of cirrhotic patients with hepatocellular carcinoma (HCC) indicated for liver resection, otherwise contraindicated due to portal hypertension. The goal of this study was to confirm the safety of laparoscopic liver resection (LLR) in patients with portal hypertension., Methods: This prospective, single-center, open study (ClinicalTrials.gov ID: NCT02145013) included all consecutive cirrhotic patients who underwent LLR for HCC from 2014 to 2017. Short-term outcomes were compared between patients with and without clinically significant portal hypertension (CSPH, defined by hepatic venous pressure gradient ≥ 10 mmHg)., Results: The study population included 45 patients, comprising 27 patients (60%) in the no CSPH group and 18 patients (40%) in the CSPH group. All planned procedures could be performed. The two groups did not differ in the extent of resection, transfusion, duration of clamping, and need for conversion. Overall, the 90-day mortality and severe morbidity rates were nil. Moderate morbidity was significantly higher in the CSPH group (39 vs. 4%, p = 0.01); however, the two groups did not differ in the rate of unresolved liver decompensation. Intensive care unit and hospital stays were significantly longer in the CSPH group. At 2 years, overall survival was 77% in the no CSPH group and 100% in the CSPH group (p = 0.17), and recurrence-free survival was 55% in the no CSPH group and 79% in the CSPH group (p = 0.10)., Conclusion: LLR is safe in BCLC 0-A patients with CSPH, with no mortality and good short-term outcomes. Re-evaluation of the BCLC guidelines is needed.

The original version of this article unfortunately contained a mistake. There was an error in the last sentence of the summary and the last sentence of the discussion. It should read as "On HBP, all FNH appeared hyper- or iso-intense compared to adjacent liver while close to 97% of HCA appeared hypointense".

Purpose: To assess the value of Hepatobiliary phase MRI (HPB-MRI) to differentiate FNH and HCA, and evaluate its impact on diagnostic accuracy, diagnostic confidence, inter-observer variability, and patient clinical management., Methods: Forty-nine patients referred for Gd-BOPTA-enhanced MRI were retrospectively included in this IRB-approved study, with a total of 119 lesions-90 FNH and 29 HCA. Two observers separately assessed in 2 distinct randomized reading sessions the performance of MRI with (HBP-MRI) or without (conventional MRI) the use of HBP images. Each lesion was ranked with a 5-point scale (from 1 Typical FNH to 5 Certainly not a FNH). Sensitivity, specificity, overall accuracy, and inter-observer agreement for the differentiation of FNH from HCA were calculated and compared between conventional and HBP-MRI., Results: Both sensitivity (respective values of 38.9% and 97.8%), overall accuracy (respective values of 53.8% and 98.3%), and inter-observer agreement (respective values of Kappa 0.56 and 0.88) were significantly higher using HBP-MRI than with conventional MRI, with unchanged specificity (100%). The sensitivity of conventional MRI for the diagnosis of FNH was significantly lower in lesions ≤ 3 cm (20% vs. 88%). Overall, HBP could have changed lesion management in 59/119 cases (49.5%), including 53 FNH and 6 HCA with no impact in 60/119 lesions (50.5%) including all 35 lesions classified as scores 1 and 2 for the diagnosis of FNH., Conclusions: The clinical impact of HBP-MRI is mostly important for smaller than 3-cm FNH, and more limited in larger FNH lesions as well as for HCA diagnosis for which conventional MRI is already accurate. The use of extracellular contrast agents upfront could limit the required use of linear HBP contrast agents for benign hepatocellular lesion characterization. On HBP, all FNH appeared hypointense compared to adjacent liver while close to 97% of HCA appeared hypointense.

Background: The impact of postoperative complications (POCs) on long-term outcomes following hepatocellular carcinoma (HCC) resection remains to be ascertained., Methods: All consecutive HCC resected at a single center were analyzed. Patients with POCs, classified according to Clavien classification, were compared to those without in terms of demographics, pathology, management, overall survival (OS), and disease-free survival (DFS). Independent prognostic factors of POCs were identified using multivariable regression models., Results: Among 341 patients, overall POCs rate was 34% (n = 116) and grade III-IV POCs rate was 14.4% (n = 49). POCs were an independent negative factor for OS [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.12-2.26, p = 0.009] with BCLC stage, the need for combined procedure, intraoperative transfusion, and the METAVIR score of the underlying parenchyma. Similarly, occurrence of POCs was associated independently with DFS (HR 1.59, 95% CI 1.18-2.15, p = 0.002), together with the presence of portal hypertension, BCLC stage, the need for combined procedure, intraoperative transfusion, and the presence of satellite nodules. After stratification, the negative impact of morbidity on OS and DFS reached statistical significance in the BCLC stage A subset only (p = 0.026, and p < 0.001, respectively). Open resection, intraoperative transfusion, and the existence of underlying liver injury were independent predictors of POCs., Conclusions: POCs should be considered as a long-term prognostic factor. Careful patient selection requiring underlying liver assessment and appropriate strategy, such as mini-invasive surgery and restricted transfusion policy, might be promoted to prevent POCs.

Purpose: To compare the added values of hepatobiliary phase (HBP) MRI and contrast-enhanced ultrasound (CEUS) in addition to inconclusive extracellular gadolinium-based contrast-enhanced MRI (CE-MRI) to characterize benign hepatocellular tumors (BHT)., Methods: Eighty-three BHT-46 focal nodular hyperplasia (FNH) and 37 hepatocellular adenomas (HCA)-with inconclusive CE-MRI in 54 patients (43 women and 11 men, mean age 42 years old ± 14.8) were retrospectively analyzed. All patients underwent both HBP-MRI and CEUS. Two radiologists independently reviewed 2 sets of images, SET-1: CE-MRI and HBP-MRI; SET-2: CE-MRI and CEUS, and classified lesions as "definite FNH," "possible FNH," or "definitely not FNH." Sensitivity (Se) and specificity (Spe) were compared between the two sets; subgroup analyses according to the lesion's size were performed., Results: Regardless of lesion size, the respective Se and Spe of both datasets were not statistically different (95.7 and 100% vs. 76.1 and 94.6% for set-1 and -2 respectively; p = 0.18). For lesions larger than 35 mm, although both sets had similar specificity (100%), sensitivity was higher for SET-1 (100% vs. 40%); p = 0.04. Tumor classifications using SET-1 and SET-2 could have changed patient management in 35/54 (64.8%) and 33/54 (61.1%) of all patients, respectively., Conclusions: HBP-MRI or CEUS should be performed after an inconclusive CE-MRI. Both can change patient management by avoiding unnecessary biopsy or surveillance. The use of HBP-MRI should be advocated over CEUS in larger (>35 mm) lesions.

Introduction: Data evaluating trends in hospital volume are lacking. The current study sought to examine trends in outcomes relative to hospital volume following liver surgery., Methods: A total of 14,296 patients >18 years undergoing an elective liver resection (LR) for cancer were identified using the National Inpatient Sample from 2001 to 2011. Multivariable logistic regression analysis was performed to compare postoperative morbidity and mortality relative to hospital volume over time., Results: Over time, the proportion of patients undergoing a LR at a high-volume hospital (HVH) increased from 24.4 to 45.0 %, while the proportion of patients undergoing a LR at a low-volume hospital (LVH) decreased from 40.4 to 22.7 %. On multivariable analysis, patients undergoing a LR at high-volume hospitals demonstrated a 29 % lower odds of mortality (OR = 0.71, 95 % CI = 0.59-0.86, p < 0.001) compared with patients undergoing a LR at a LVH. The rate of regionalization, however, was not equal among all patients as older patients, patients belonging to a racial minority, and those presenting with substantial comorbidity were less likely to undergo a LR at a HVH., Conclusion: An increase in the regionalization of liver surgery was observed over time. Trends in regionalization were, however, associated with discrepancies in access to HVH among specific patient populations.

Background: Recurrence remains frequent after curative-intent hepatectomy for colorectal liver metastases (CRLM). We sought to define short- and long-term outcomes, and identify prehepatectomy factors associated with survival, following rehepatectomy (RH) for recurrence., Methods: We conducted a multi-institutional cohort study of hepatectomy for CRLM over 2006-2013. Second-stage resections were excluded. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS) assessed using Kaplan-Meier methods. Secondary outcomes included 30-day overall morbidity and mortality, and survival from recurrence. Outcomes of RH and initial hepatectomy (IH) were compared., Results: Of 2771 hepatectomies included in the study, 447 were RH. Median operative time, 30-day morbidity, mortality, and median length of stay did not differ for RH and IH. Five-year OS did not statistically differ, i.e. 56.5 % from RH and 67.6 % from IH [adjusted hazard ratio (HR) 0.9, 95 % confidence interval (CI) 0.5-1.7], and 5-year RFS was inferior after RH (18.5 vs. 28.8 %; adjusted HR 1.3, 95 % CI 1.0-1.7). In patients who eventually recurred, 5-year survival from the time of recurrence did not differ whether it was after RH (46.5 %) or after IH (60.3 %) (adjusted HR 1.1, 95  % CI 0.8-1.8). Rectal primary tumor (HR 1.4, 95 % CI 1.0-2.1) and metastasis ≥3 cm (HR 1.3, 95 % CI 1.1-2.7) were independently associated with RFS, but not OS, after RH., Conclusion: Short-term outcomes of RH did not differ from IH. While recurrence was more frequent after RH than IH, it did not impact OS. Survival from the time of recurrence did not differ whether recurrence occurred after RH or after IH. CRLM recurrence can be treated with curative intent with excellent long-term outcomes.

Background: The optimal strategy in patients with stage IVA colorectal cancer remains debated. This study was designed to compare the long-term outcomes and the pattern of recurrence following classical (CS) versus reverse (RS) strategy., Methods: Data from all consecutive patients, who have completed the CS and RS, were retrospectively reviewed. A propensity score matching (PSM) was performed on 1:2 (RS:CS) ratio to obtain two groups matched for tumor characteristics. Survival and recurrence pattern were investigated before and after matching., Results: The study population included 161 patients: 145 treated with CS versus 16 with RS. Five-year overall survival (OS, 51.5 vs. 42.7 %, p = 0.91) and recurrence-free survival (RFS, 20.5 vs. 20.6 %, p = 0.15) were not different between the two strategies. The median time to recurrence (TTR) whatever the site was significantly shorter in the RS group than in the CS group (3.5 vs. 13 months, p = 0.02). Extrahepatic recurrence was significantly more frequent (37.5 vs. 16.6 %; p = 0.04) and occurred earlier after treatment completion in the RS group than in the CS group (3.4 vs. 16.4 months, p = 0.009). Similar findings in terms of OS, RFS, median TTR whatever the site and proportion of extrahepatic recurrence were observed after PSM., Conclusions: Stage IVA colorectal cancer patients who have completed the CS or RS had similar OS. Extrahepatic recurrence is more frequent and occurs earlier after RS. Postoperative locoregional therapy and active follow-up strategies should be considered in RS patients.

Background: Patients with single small hepatocellular carcinoma (HCC) can be managed by surgical resection or radio frequency ablation (RFA), with similar recurrence and survival rates. Recently, minimally invasive surgery (MIS) has been introduced in liver surgery, and the advantage/drawback balance between surgery and RFA needs reassessment., Methods: Patients with Child-Pugh class A or B cirrhosis, and with single 1-3 cm HCC, undergoing MIS (laparoscopic or robot-assisted) or RFA from July 1998 to December 2012 were compared., Results: Overall, 45 patients underwent MIS, and 60 underwent RFA. Groups were not statistically different regarding type of underlying liver disease, HCC size, and AFP. However, RFA patients showed worse liver synthetic function with lower albumin and higher bilirubin serum levels, and higher ASA scores. Patients with HCC in segments 2-6 were more often treated by MIS. The incidence of complications was similar between groups (RFA: 6/60, 10 % vs. MIS: 5/45, 11 %, p = 0.854), and there was no measurable difference in the rate of procedure-related blood transfusions (RFA: 1/60, 1.7 % vs. MIS: 3/45, 6.7 %, p = 0.185). Local recurrence was only detected after RFA (11.7 %, p = 0.056, log-rank). Overall survival was higher in the MIS group (p = 0.042), with median survivals of 100 ± 13.5 versus 68 ± 15.9 months., Conclusion: The present data need further validation. Selected patients with single ≤3-cm HCCs can be safely treated by MIS, without increased risk of perioperative complication, and with a lower risk of local recurrence. MIS should be especially favoured in patients with peripheral HCCs in segments 2-6, and/or when a histological assessment is desirable.

Intensive care information systems (ICIS) implemented in intensive care unit (ICU) were shown to improve patient safety, reduce medical errors and increase the time devolved by medical/nursing staff to patients care. Data on the real impact of ICIS on patient outcome are scarce. This study aimed to evaluate the effects of ICIS on the outcome of critically-ill patients. From January 2004 to August 2006, 1,397 patients admitted to our ICU were enrolled in this observational study. This period was divided in two phases: before the implementation of ICIS (BEFORE) and after implementation of ICIS (AFTER). We compared standard ICU patient's outcomes: mortality, length of stay in ICU, hospital stay, and the re-admission rate depending upon BEFORE and AFTER. Although patients admitted AFTER were more severely ill than those of BEFORE (SAPS II: 32.1±17.5 vs. 30.5±18.5, p=0.014, respectively), their ICU length of stay was significantly shorter (8.4±15.2 vs. 6.8±12.9 days; p=0.048) while the re-admission rate and mortality rate were similar (4.4 vs. 4.2%; p=0.86, and 9.6 vs 11.2% p=0.35, respectively) in patients admitted AFTER. We observed that the implementation of ICIS allowed shortening of ICU length of stay without altering other patient outcomes.

Background: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are emerging, minimally invasive techniques. Total mesorectal excision (TME), the gold standard treatment for patients with resectable distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically or via open techniques. A transanal, "down-to-up" TME has already been reported. Our NOTES variant of TME (NOTESTME) is based on a transperineal approach without any form of abdominal assistance. The aim was to reduce further the invasiveness of the procedure while optimizing the anatomical definition of the distal mesorectum. This approach may lead to reduced postoperative pain, decreased hernia formation and improved cosmesis when compared to standard laparoscopy., Methods: NOTESTME was attempted in 16 patients with distal rectal neoplasia (i.e., distal edge of the tumor lower than the pouch of Douglas, between 0 and 12 cm from the dentate line). Additional inclusion criteria consisted of an ASA status ≤III and the absence of previous abdominal surgery., Results: NOTESTME was completed in all patients. Additional abdominal, single-incision laparoscopic assistance was required in 6 (38 %) patients. Mean operative time was 265 min (range 155-440 min). The morbidity rate was 18.8 % (two small bowel obstructions and one pelvic abscess), requiring re-operation in each case. No leaks occurred, and the mortality rate at 30 and 90 days was 0 %. Resection margins were negative in all patients. A median of 17 nodes (range 12-81) was retrieved per specimen. Mean length of hospital stay was 10 days (range 4-29 days). Patients were followed for an average of 7 months (range 3-23 months)., Conclusion: NOTESTME was feasible and safe in this series of patients with mid- or low rectal tumors. The short-term mortality and morbidity rates are acceptable, with no apparent compromise in the oncological quality of the resection. Larger, randomized controlled trials with long-term follow-up are warranted.

The introduction of robotics into surgery represents progression in the field of minimally invasive surgery. Its use has been reported in coronary artery bypass graft along with repair of other major vascular structures. We report the first case of robot-assisted resection of a large hepatic artery aneurysm. Robotic surgery is safe and feasible and is a significant advance in the field of aneurismal repair. It offers significant advantages in the degrees of freedom of movement compared to laparoscopic surgery.

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in the hands of trained surgeons. The introduction of robotics into surgery represents progression in the field of minimally invasive surgery but has seen a slow uptake in the hepatopancreaticobiliary subspeciality. We report our initial experience in 20 cases of laparoscopic robotic liver resection (LRLR). From March 2011 to April 2013 patients with lesions within the liver were assessed and consented for laparoscopic robotic liver surgery. This is a retrospective analysis of a prospectively kept database on preoperative details and intraoperative and postoperative outcomes. During the time period there were 20 LRLRs. The median age was 62 years (range 39-80 years) with a male to female ratio of 14:6. Ten patients had left lateral sectionectomies, 10 patients had atypical segmental resections; 14 patients had resections for malignancies, 6 patients had resections for benign disease. One case was converted to open resection. The mean operating time was 176.4 ± 74.6 min (range 60-300 min), the mean blood loss was 107 ± 106 ml (range 50-700 ml) and the mean hospital stay was 6.5 ± 3.7 days (range 2-16 days). Two patients required blood transfusions. The incidence of postoperative complications was 10 % (n = 2). LRLR overcomes some of the disadvantages of conventional laparoscopic surgery. It is a technically feasible and safe approach for wedge resections and left lateral sectionectomy of the liver without oncological compromise. However, this surgical technique requires advanced laparoscopic skills and there is an associated steep learning curve. Further studies are needed to determine the potential advantages of this technique for the patient compared to the traditional laparoscopic approach.

The minimally invasive laparoscopic approach for the reversal of Hartmann's procedure (HP) has been shown to be a safe and feasible approach associated with low morbidity and fast recovery. Robotic surgery has not yet been described for HP reversal. We report the case of an 84-year-old man originally operated on in an emergency setting by conventional HP for complicated diverticulitis who underwent a robotic-assisted HP reversal. The surgical procedure and the post-operative follow-up were uneventful, with low post-operative pain, early return to bowel function, and discharge at day 3. The robotic surgery appeared to be a safe, feasible, and valuable approach for HP reversal.

Background: Percutaneous manoeuvres are alternatives to the endoscopic approach in the management of complex biliary disease., Methods: We retrospectively reviewed our experience with 1,014 percutaneous interventions performed between 1980 and 2005 at a tertiary-level hepatobiliary centre. The main outcome measures were the success rate of percutaneous manoeuvres and the procedure-related morbidity and mortality. Eight hundred seventy-two patients who underwent 1,014 percutaneous procedures were divided into four groups according to the indication and goal of therapy: Group A: percutaneous manoeuvres aimed at improving the patient's general condition (worsened by severe jaundice, pruritus, or cholangitis); Group B: cancer patients receiving chemotherapy who required biliary drainage as jaundice was a contraindication for continuing chemotherapy; Group C: manoeuvres performed to confirm diagnosis of biliary obstruction; and Group D: manoeuvres performed with the goal of complete treatment of calculus disease., Results: Interno-external drainage (526 procedures) was the most common intervention and dilatation the most frequently associated manoeuvre (456 procedures). Mean duration of biliary drainage was 159±152 days. Overall success rate (total+partial success) was 86%; the best and worst results were in Groups C (95% success) and A (70% success), respectively. The mortality rate was 7.5%; 29 (37%) deaths were procedure-related (cholangitis being the principal cause). End-stage malignancy was the major cause of mortality (58%). Procedure-related morbidity rate was 17%, and Group C (0%) and Group D (5%) patients had the least number of complications., Conclusions: In complex biliary disease, the percutaneous approach is a feasible and safe therapeutic option and should be added to the armamentarium of experienced hepatobiliary teams. A well-planned strategy consisting of repeated interventions, prolonged biliary drainage, and optimal antibiotic therapy are prerequisites for success with this approach.

Background: Regenerative nodular hyperplasia (RNH) represents the end-stage of vascular lesions of the liver induced by chemotherapy. The goal was to evaluate its incidence and impact on the outcome of patients resected for colorectal liver metastases (CLM)., Methods: Patients who underwent hepatectomy for CLM after six cycles or more of first-line chemotherapy, between January 1990 and November 2006, were included. Detailed histopathologic analysis of the nontumoral liver was performed according to a standard format., Results: From a cohort of 856 resected patients at our institution, 771 (90%) received preoperative chemotherapy. Of these, 146 fulfilled the selection criteria and were included: 24 (16%) received 5-fluorouracil (5-FU) and leucovorin (LV) alone, 92 (63%) had 5-FU/LV and oxaliplatin, 18 (12%) had 5-FU/LV and irinotecan, and 12 (8%) were treated by 5-FU/LV, oxaliplatin, and irinotecan. RNH occurred in 22 of 146 patients (15%). Twenty of these patients (91%) received oxaliplatin, of whom six (30%) had chronomodulated therapy. Patients treated by oxaliplatin more often had RNH compared with oxaliplatin-naïve patients (22 vs. 4%). Although operative mortality was nil, the presence of RNH was associated with increased postoperative hepatic morbidity (50 vs. 29%). Elevated preoperative gamma-glutamyltransferase (GGT) (>80 U/L; >1N) and total bilirubin levels (>15 μmol/L; >1N) were independent predictors of RNH., Conclusions: Patients with CLM who receive preoperative oxaliplatin have an increased risk of RNH and associated postoperative morbidity. Increased serum GGT and bilirubin are useful markers to predict the presence of RNH.

Background: As the real clinical significance of carcinoembryonic antigen (CEA) and carbohydrate antigen 19.9 (CA19.9) evolution during preoperative chemotherapy for colorectal liver metastases (CLM) is still unknown, we explored the correlation between biological and radiological response to chemotherapy, and their comparative impact on outcome after hepatectomy., Methods: All patients resected for CLM at our hospital between 1990 and 2004 with the following eligibility criteria were included in the study: (1) preoperative chemotherapy, (2) complete resection of CLM, (3) no extrahepatic disease, and (4) elevated baseline tumor marker values. A 20% change of tumor marker levels while on chemotherapy was used to define biological response (decrease) or progression (increase). Correlation between biological and radiological response at computed tomography (CT) scan, and their impact on overall survival (OS) and progression-free survival (PFS) after hepatectomy were determined., Results: Among 119 of 695 consecutive patients resected for CLM who fulfilled the inclusion criteria, serial CEA and CA19.9 were available in 113 and 68 patients, respectively. Of patients with radiological response or stabilization, 94% had similar biological evolution for CEA and 91% for CA19.9. In patients with radiological progression, similar biological evolution was observed in 95% of cases for CEA and in 64% for CA19.9. On multivariate analysis, radiological response (but not biological evolution) independently predicted OS. However, progression of CA19.9, but not radiological response, was an independent predictor of PFS., Conclusions: In patients with CLM and elevated tumor markers, biological response is as accurate as CT imaging to assess "clinical" response to chemotherapy. With regards to PFS, CA19.9 evolution has even better prognostic value than does radiological response. Assessment of tumor markers could be sufficient to evaluate chemotherapy response in a nonsurgical setting, limiting the need of repeat imaging.

Introduction: For liver transplant candidates with hepatocellular carcinoma (HCC), the ability of neoadjuvant transarterial chemoembolization (TACE) to improve outcomes remains unproven. The objective of our study was to determine if there was a specific time interval where neoadjuvant TACE would decrease the number of HCC patients removed from the pretransplant waitlist., Materials and Methods: A decision model was developed to simulate a randomized trial of neoadjuvant treatment with TACE vs. no TACE in 600 virtual patients with HCC and cirrhosis. Transition probabilities for TACE morbidity (1 +/- 1%), TACE response rates (30 +/- 20%), and disease progression (7 +/- 7% per month) were assigned by systematic review of the literature (18 reports). Sensitivity analyses were performed to determine time thresholds where TACE would decrease the number of delisted patients., Results: TACE treatment had statistical benefit at waitlist time breakpoints of 4 and 9 months (P < 0.05). When waitlist times were less than 4 months, waitlist attrition was similar (20% vs. 34%, P = 0.08). When waitlist times exceed 9 months, waitlist dropout rates re-equilibrated (33% vs. 46%, P = 0.06). Review of the current literature determined that only those studies reporting on patients with waitlist times between 4 and 9 months found a benefit to neoadjuvant TACE., Conclusions: This analysis indicates that the benefit of neoadjuvant TACE may be limited to those patients transplanted from 4 to 9 months from first TACE. These data may help transplant programs to tailor TACE treatments based on predicted waitlist times to achieve optimal resource utilization and improved organ allocation efficiency.

Background: Liver metastases of malignant renal tumors are regarded as having an ominous prognosis because they are infrequently amenable to radical surgery and respond poorly to chemotherapy. Little is known of the outcome of isolated metastases to the liver for which resection is potentially curative., Methods: Data on 14 patients with liver metastases from renal tumors who underwent a liver resection in a single center between 1982 and 2001 were analyzed retrospectively., Results: There was no operative or postoperative mortality. The median survival was 26 months, with a survival rate of 69% at 1 year and 26% at 3 years. The curative pattern of hepatectomy (2-year survival, 69% vs. 0%; P =.001), an interval between the nephrectomy and the diagnosis of liver metastases in excess of 24 months (2-year survival, 71% vs. 25%; P =.05), tumor size <50 mm (2-year survival, 83% vs. 17%; P =.006), and the possibility of achieving a repeat hepatectomy in the case of recurrence (2-year survival, 100% vs. 21%; P =.02) were associated with a better outcome after the liver resection. Four patients were alive without evidence of disease at 6, 12, 26, and 96 months after the first hepatic resection, and one was alive with hepatic recurrence 18 months after resection., Conclusions: In patients with liver metastases of malignant renal tumors, an aggressive policy for achieving tumor eradication seems to offer a chance for long-term survival, especially after a long disease-free interval from the nephrectomy. However, despite an aggressive policy for achieving tumor eradication, recurrence frequently occurs after liver resection.

Background: Surgical resection is the most effective treatment for colorectal liver metastases but only a minority of patients are candidates for a potentially curative resection. Our experience with neoadjuvant chemotherapy followed by resection and five years survival analysis of the patients treated is presented., Methods: Between February of 1988 and September of 1996, 701 patients with unresectable colorectal liver metastases were treated with neoadjuvant chemotherapy. Four categories of nonresectable disease were defined: large size, ill location, multinodularity, and extrahepatic disease. Liver resection was performed in those patients whose disease became resectable. After resection, the patients were followed up every 3 months. A 5-year survival analysis by the different categories described was performed., Results: Ninety-five patients (13.5%) were found to be resectable on reevaluation and underwent a potentially curative resection. There was no perioperative mortality, and the complication rate was 23%. As of December of 1999, 87 patients have completed 5 years of follow-up. The overall 5-year survival is 35% from the time of resection and 39% from the onset of chemotherapy. Respective 5-year survival rates are 60% for large tumors, 49% for ill-located lesions, 34% for multinodular disease, and 18% for liver metastases with extrahepatic disease. In this latter category, however, a 35% 5-year survival was found when all the patients with extrahepatic disease were analyzed rather than only those for whom extrahepatic disease was the main cause of nonresectability., Conclusions: Neoadjuvant chemotherapy enables liver resection in some patients with initially unresectable colorectal metastases. Long-term survival is similar to that reported for a priori surgical candidates.