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Background: Resection of perihilar cholangiocarcinoma (pCCA) is a complex procedure with a high risk of postoperative mortality and early disease recurrence. The objective of this study was to compare patient characteristics and overall survival (OS) between pCCA patients who underwent an R1 resection and patients with localized pCCA who received palliative systemic chemotherapy. Methods: Patients with a diagnosis of pCCA between 1997–2021 were identified from the European Network for the Study of Cholangiocarcinoma (ENS-CCA) registry. pCCA patients who underwent an R1 resection were compared with patients with localized pCCA (i.e., nonmetastatic) who were ineligible for surgical resection and received palliative systemic chemotherapy. The primary outcome was OS. Results: Overall, 146 patients in the R1 resection group and 92 patients in the palliative chemotherapy group were included. The palliative chemotherapy group more often underwent biliary drainage (95% vs. 66%, p < 0.001) and had more vascular encasement on imaging (70% vs. 49%, p = 0.012) and CA 19.9 was more frequently >200 IU/L (64 vs. 45%, p = 0.046). Median OS was comparable between both groups (17.1 vs. 16 months, p = 0.06). Overall survival at 5 years after diagnosis was 20.0% with R1 resection and 2.2% with chemotherapy. Type of treatment (i.e., R1 resection or palliative chemotherapy) was not an independent predictor of OS (hazard ratio 0.76, 95% confidence interval 0.55–1.07). Conclusions: Palliative systemic chemotherapy should be considered instead of resection in patients with a high risk of both R1 resection and postoperative mortality. [ABSTRACT FROM AUTHOR]

Purpose: Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume. Methods: This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added. Results: 6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively). Conclusions: High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight. [ABSTRACT FROM AUTHOR]

Background: Preoperative nutritional status and body structure affect short-term prognosis in patients undergoing major oncologic surgery. Bioimpedance vectorial analysis (BIVA) is a reliable tool to assess body composition. Low BIVA-derived phase angle (PA) indicates a decline of cell membrane integrity and function. The aim was to study the association between perioperative PA variations and postoperative morbidity following major oncologic upper-GI surgery. Patients and Methods: Between 2019 and 2022 we prospectively performed BIVA in patients undergoing surgical resection for pancreatic, hepatic, and gastric malignancies on the day before surgery and on postoperative day (POD) 1. Malnutrition was defined as per the Global Leadership Initiative on Malnutrition criteria. The PA variation (ΔPA) between POD1 and preoperatively was considered as a marker for morbidity. Uni and multivariable logistic regression models were applied. Results: Overall, 542 patients with a mean age of 64.6 years were analyzed, 279 (51.5%) underwent pancreatic, 201 (37.1%) underwent hepatobiliary, and 62 (11.4%) underwent gastric resections. The prevalence of preoperative malnutrition was 16.6%. The overall morbidity rate was 53.3%, 59% in those with ΔPA < −0.5 versus 46% when ΔPA ≥ −0.5. Age [odds ratio (OR) 1.11; 95% confidence interval (CI) (1.00; 1.22)], pancreatic resections [OR 2.27; 95% CI (1.24; 4.18)], estimated blood loss (OR 1.20; 95% CI (1.03; 1.39)], malnutrition [OR 1.77; 95% CI (1.27; 2.45)], and ΔPA [OR 1.59; 95% CI (1.54; 1.65)] were independently associated with postoperative complications in the multivariate analysis. Conclusions: Patients with preoperative malnutrition were significantly more likely to develop postoperative morbidity. Moreover, a decrease in PA on POD1 was independently associated with a 13% increase in the absolute risk of complications. Whether proactive interventions may reduce the downward shift of PA and the complication rate need further investigation. [ABSTRACT FROM AUTHOR]

Tumor-associated macrophages (TAMs) are key components of the tumor microenvironment (TME). In colorectal liver metastasis (CLM), TAM morphology correlates with prognosis, with smaller TAMs (S-TAMs) conferring a more favorable prognosis than larger TAMs (L-TAMs). However, the metabolic profile of in vivo human TAM populations remains unknown. Multiparametric flow cytometry was used to freshly isolate S- and L-TAMs from surgically resected CLM patients (n = 14S-, 14L-TAMs). Mass spectrometry-based metabolomics analyses were implemented for the metabolic characterization of TAM populations. Gene expression analysis and protein activity were used to support the biochemical effects of the enzyme–substrate link between riboflavin and (lysine-specific demethylase 1A, LSD1) with TAM morphologies. L-TAMs were characterized by a positive correlation and a strong association between riboflavin and TAM morphologies. Riboflavin in both L-TAMs and in-vitro M2 polarized macrophages modulates LSD1 protein expression and activity. The inflammatory stimuli promoted by TNFα induced the increased expression of riboflavin transporter SLC52A3 and LSD1 in M2 macrophages. The modulation of the riboflavin-LSD1 axis represents a potential target for reprogramming TAM subtypes, paving the way for promising anti-tumor therapeutic strategies. [ABSTRACT FROM AUTHOR]

Background: High-quality surgery plays a central role in the delivery of excellent oncologic care. Benchmark values indicate the best achievable results. We aimed to define benchmark values for gallbladder cancer (GBC) surgery across an international population. Patients and Methods: This study included consecutive patients with GBC who underwent curative-intent surgery during 2000–2021 at 13 centers, across seven countries and four continents. Patients operated on at high-volume centers without the need for vascular and/or bile duct reconstruction and without significant comorbidities were chosen as the benchmark group. Results: Of 906 patients who underwent curative-intent GBC surgery during the study period, 245 (27%) were included in the benchmark group. These were predominantly women (n = 174, 71%) and had a median age of 64 years (interquartile range 57–70 years). In the benchmark group, 50 patients (20%) experienced complications within 90 days after surgery, with 20 patients (8%) developing major complications (Clavien–Dindo grade ≥ IIIa). Median length of postoperative hospital stay was 6 days (interquartile range 4–8 days). Benchmark values included ≥ 4 lymph nodes retrieved, estimated intraoperative blood loss ≤ 350 mL, perioperative blood transfusion rate ≤ 13%, operative time ≤ 332 min, length of hospital stay ≤ 8 days, R1 margin rate ≤ 7%, complication rate ≤ 22%, and rate of grade ≥ IIIa complications ≤ 11%. Conclusions: Surgery for GBC remains associated with significant morbidity. The availability of benchmark values may facilitate comparisons in future analyses among GBC patients, GBC surgical approaches, and centers performing GBC surgery. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma (CCA) is a rare cancer characterized by a global increasing incidence. Extracellular vesicles (EV) contribute to many of the hallmarks of cancer through transfer of their cargo molecules. The sphingolipid (SPL) profile of intrahepatic CCA (iCCA)-derived EVs was characterized by liquid chromatography-tandem mass spectrometry analysis. The effect of iCCA-derived EVs as mediators of inflammation was assessed on monocytes by flow cytometry. iCCA-derived EVs showed downregulation of all SPL species. Of note, poorly-differentiated iCCA-derived EVs showed a higher ceramide and dihydroceramide content compared with moderately-differentiated iCCA-derived EVs. Of note, higher dihydroceramide content was associated with vascular invasion. Cancer-derived EVs induced the release of pro-inflammatory cytokines in monocytes. Inhibition of synthesis of ceramide with Myriocin, a specific inhibitor of the serine palmitoyl transferase, reduced the pro-inflammatory activity of iCCA-derived EVs, demonstrating a role for ceramide as mediator of inflammation in iCCA. In conclusion, iCCA-derived EVs may promote iCCA progression by exporting the excess of pro-apoptotic and pro-inflammatory ceramides. [ABSTRACT FROM AUTHOR]

Despite current evidence, the use of drains in liver surgery is still controversial. We conducted an international survey to investigate the clinical use of drains in the E-AHPBA, A-HPBA and A-PHPBA communities. An open survey of 30 questions was prepared on Google-Form and distributed by email to all members. One hundred and ninety-one HPB surgeons responded to the survey. One hundred and twelve surgeons (58.6%) reported routine use of abdominal drains after liver resections. Eighty-eight (46.1%) responded that removal was driven by low volume and low bilirubin levels in the drains. For minor liver resection, 97 (50.8%) surgeons reported using drains selectively; in contrast, 134 (70.2%) surgeons prefer to use a drain always after major procedures. Among patients with cirrhosis, 87 (45.5%) surgeons reported routine drains placement, while 84 (44.0%) considered drains selectively. A no-drain policy was most prevalent among surgeons from North America (80%) versus Asian-Pacific (70.0%), European and African (60.8%), and South American (61.5%) surgeons. Among minimally invasive surgeons, 74.2% reported drain use only in selected cases versus 35.0% among surgeons who performed open surgery. The practice of draining after liver surgery is still highly variable among centers and surgeons around the world, with a high variability according to the underlying liver condition and planned surgical approach. [ABSTRACT FROM AUTHOR]

We describe a case of complex parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases. A 66-years-old male, who previously received a diagnosis of a stenosing adenocarcinoma of the hepatic flexure and synchronous bilobar liver metastases, was referred to our hospital. At the time of the presentation of the disease, a contrast-enhanced CT scan showed 24 liver lesions, with a bilobar distribution and two major cluster of lesions in segment 6 and 7. After neoadjuvant chemotherapy, global partial response, with complete response for most lesions, was detected: seven lesions were visible after re-staging. Surgical strategy was planned by means of three-dimensional reconstruction and simulation software. A unique transection plane comprising partial resection of segments 2, 3, 4, 5 and 8 and complete resection of segments 6 and 7 was performed. Left, middle and right hepatic veins were exposed on the cut surface. Accurate preoperative planning and intraoperative ultrasound for resection guidance allowed us to follow complex transection planes and treat a patient with a high burden of bilobar deeply located disease in a parenchymal-sparing perspective. [ABSTRACT FROM AUTHOR]

We describe a complex case of extended hepatectomy with venous outflow reconstruction for the treatment of advanced mass-forming cholangiocarcinoma (MFCCC) invading the three main hepatic veins (HVs). A 50-year-old woman who received a diagnosis of MFCCC and judged unresectable, was referred to our hospital. After multidisciplinary team evaluation, the patient underwent abdominal computed tomography, gadoxetic acid-enhanced magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography. The radiological examinations showed a large mass located in S4s-8 and S1, in contact with the right hepatic vein (RHV), the inferior right hepatic vein, the anterior wall of the inferior vena cava (IVC), infiltrating the middle and left hepatic veins (MHV, LHV). Several communicating veins between the RHV, MHV and LHV were detected. The case was further investigated, and the surgical strategy planned by means of using three-dimensional simulation software. A total upper transversal hepatectomy with resection of the main HVs and outflow reconstruction was performed. The outflow of the remnant liver was restored performing a vascular anastomosis between the parenchymal stump of the RHV and the IVC. Meticulous review of pre-operative imaging techniques with three-dimensional simulation of hepatectomy together with advanced use of intra-operative ultrasound allowed us to offer the chance of cure to a patient otherwise considered unresectable. [ABSTRACT FROM AUTHOR]

Hepatocholangiocarcinoma (HCC-CC) is a rare malignancy containing features of both hepatocellular carcinoma (HCC) and mass-forming cholangiocarcinoma (MFCCC), of which the outcome after hepatectomy remains to be clarified. The aim of this study was to analyze the characteristics and outcomes of patients with transitional HCC-CC and compare them with those of patients with HCC and MFCCC. Our prospectively maintained database was queried, and 14 transitional HCC-CC patients were identified over a total of 406 consecutive hepatic resections. A 1:1:1 match was performed with HCC and MFCCC patients operated in the same period. A total of 42 patients were matched according to tumor stage (T1-2-3, N0, M0), number of tumors, R0 resection, no 90-day mortality, and follow-up. Primary endpoints were disease-free survival (DFS) and overall survival (OS). Disease-free survival rates at 1-, 3-, and 5-year were 71.4%, 57.1%, 35.7% for transitional HCC-CC patients; 85.7%, 40.4%, 10.1% for HCC patients; 85.1%, 34.0%, 22.7% for MFCCC patients (5-year DFS: HCC-CC vs. HCC, p = 0.575; HCC-CC vs. MFCCC, p = 0.766, respectively). Similarly, OS rates at 1-, 3-, and 5-year were 92.9%, 71.4%, 64.3% for transitional HCC-CC patients; 100%, 64.3%, 41.7% for HCC patients; 100%, 54.5%, 43.6% for MFCCC patients (5-year OS: HCC-CC vs. HCC, p = 0.891; HCC-CC vs. MFCCC, p = 0.673, respectively). When accurately matched with respect to tumor burden, transitional HCC-CC patients show similar outcomes to those of HCC and MFCCC patients. Further evaluations of differences in tumor biology are necessary to better characterize the prognosis of transitional HCC-CC patients. [ABSTRACT FROM AUTHOR]

Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63–75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5 years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power. [ABSTRACT FROM AUTHOR]

Whether hepatic resection for multinodular hepatocellular carcinoma (HCC) is indicated remains to be demonstrated. We investigated the prognostic factors in a large series of patients treated with hepatic resection at a reference cancer center. All consecutive patients resected for multinodular HCC from January 2004 to April 2015 were reviewed. The study endpoints were the survival analysis and the definition of resection criteria. Among 380 patients resected for HCC, 116 (31%) were affected by multinodular HCC without macrovascular invasion. The median tumor number was 2 (range 2–30), while the median tumor size was 3.5 cm (range 1.1–28). The 90-day mortality was 2.6%. Morbidity was 31%. After a median follow-up of 31 months (range 3.1–149.7), the 1-, 3-, and 5-year overall survival rates were 85, 52, and 35%, respectively. At the multivariate analysis, tumor number more than 4 (HR = 2.15; 95% CI 1.8–4.18; P = 0.001), tumor size more than 6 cm (HR = 2.78; 95% CI 2.08–4.91; P = 0.001), esophageal varices (HR = 3.01; 95% CI 1.98–5.61; P = 0.002), and major hepatectomy (HR = 2.91; 95% CI 1.97–4.54; P = 0.001) were independently significant for survival. Median survival shifted from 20 to 52 months based on these factors. Hepatic resection for multinodular HCC may result in survival benefit for patients up to four tumors, none more than 6 cm, without varices, and eventually treated by conservative surgery. [ABSTRACT FROM AUTHOR]

Background: Not all patients with resectable colorectal liver metastases (CLM) benefit from liver resection (LR); only patients with disease progression during chemotherapy are excluded from surgery.Objective: This study was performed to determine whether tumor behavior (stable disease/progression) from the end of chemotherapy to LR impacts prognosis.Methods: Patients undergoing LR after tumor response or stabilization during chemotherapy were considered. Overall, 128 patients who underwent examination by two imaging modalities (computed tomography/magnetic resonance imaging) after chemotherapy with a > 3-week interval between the two imaging modalities were analyzed. Any variation in CLM size was registered. Tumor progression was defined according to the response evaluation criteria in solid tumors (RECIST) criteria.Results: Among 128 patients with stable disease or partial response to preoperative chemotherapy, 32 (25%) developed disease progression in the chemotherapy to LR interval, with a disease progression rate of 17% when this interval was < 8 weeks. Survival was lower among patients with progression than those with stable disease [3-year overall survival (OS) 23.0 vs. 52.4%, and recurrence-free survival (RFS) 6.3% vs. 21.6%; p < 0.001]. Survival was extremely poor in patients with early progression (< 8 weeks) (0.0% 2-year OS, 12.5% 6-month RFS). Disease progression in the chemotherapy to LR interval was an independent negative prognostic factor for OS and RFS [hazard ratio 3.144 and 2.350, respectively; p < 0.001].Conclusions: Early disease progression in the chemotherapy to LR interval occurred in approximately 15% of patients and was associated with extremely poor survival. Even if these data require validation, the risk for early disease progression after chemotherapy should be considered, and, if progression is evident, the indication for surgery should be cautiously evaluated. [ABSTRACT FROM AUTHOR]

Background: R0 resection is the standard for colorectal liver metastases (CLMs). Adequacy of R1 resections is debated. Detachment of CLMs from vessels has been proposed to prioritize parenchyma sparing and increase resectability, but outcomes are still to be elucidated. The present study aimed to clarify the outcomes of R1 surgery (margin <1 mm) in patients with CLMs, distinguishing standard R1 resection (parenchymal margin, R1Par) and R1 resection with detachment of CLMs from major intrahepatic vessels (R1Vasc). Methods: All patients undergoing first resection between 2004 and June 2013 were prospectively considered. R0, R1Par, and R1Vasc were compared in per-patient and per-resection area analyses. Results: The study included 627 resection areas in 226 consecutive patients. Fifty-one (8.1 %) resections in 46 (20.4 %) patients were R1Vasc, and 177 (28.2 %) resections in 107 (47.3 %) patients were R1Par. Thirty-two (5.1 %) surgical margin recurrences occurred in 28 (12.4 %) patients. Local recurrence risk was similar between the R0 and R1Vasc groups (per-patient analysis 5.3 vs. 4.3 %; per-resection area analysis 1.5 vs. 3.9 %, p = n.s.) but increased in the R1Par group (19.6 and 13.6 %, p < 0.05 for both). The R1Par group had a higher rate of hepatic-only recurrences (49.5 vs. 36.1 %, p = 0.042). On multivariate analysis, R1Par was an independent negative prognostic factor of overall survival ( p = 0.034, median follow-up 33 months); conversely R1Vasc versus R0 had no significant differences. Conclusions: R1Par resection is not adequate for CLMs. R1Vasc surgery achieves outcomes equivalent to R0 resection. CLM detachment from intrahepatic vessels can be pursued to increase patient resectability and resection safety (parenchymal sparing). [ABSTRACT FROM AUTHOR]

Purpose: In recent decades, the use of radiopharmaceuticals in the assessment of hepatocellular carcinoma (HCC) has become established, and new findings indicate that radiolabelled choline has considerable potential in this setting. Therefore, in this study we aimed to assess the diagnostic role of C-choline positron emission tomography (PET)/CT, compared with conventional imaging with CT/MRI, in patients with HCC. Methods: The study population comprised 45 patients (male to female ratio = 37:8, median age 70.5 years) referred to our institution owing to HCC: 27 at initial diagnosis and 18 for restaging after recurrence. In all cases we performed whole-body C-choline PET/CT and compared its findings with contrast-enhanced CT ( n = 35) or MRI ( n = 29) or both ( n = 15) for a total of 50 paired scans. The reference standard was either histological proof (21 patients) or a multidisciplinary consensus. Diagnostic accuracy was then determined in a scan-based (SBA) and a lesion-based analysis (LBA). Results: On SBA the sensitivity and specificity for PET were 88 and 90 %, respectively, whereas for CT/MRI they were 90 and 73 %, respectively ( p > 0.05). On LBA the overall sensitivity and specificity were 78 and 86 %, respectively, for PET vs 65 and 55 % for CT/MRI. Overall we investigated 168 disease sites, of which 100 were in the liver and 68 were extrahepatic. When considering only liver lesions, C-choline PET and CT/MRI showed an accuracy of 66 and 85 %, respectively, while for extrahepatic lesions PET showed an accuracy of 99 %, while the accuracy of CT/MRI was 32 %. In both cases, there was a statistically significant difference in accuracy between the two modalities ( p < 0.01). Combination of the PET results with those of CT/MRI resulted in the highest diagnostic accuracy in both analyses, at 92 % for SBA and 96 % for LBA. In 11 patients (24 %) the PET findings modified the therapeutic strategy, the modification proving appropriate in 10 of them. Conclusion: C-Choline PET showed good accuracy in investigating patients with HCC and prompted a change in treatment planning in almost one fourth of patients. The main strength of C-choline PET/CT resides in its ability to detect extrahepatic HCC localizations, but the combination with conventional imaging modalities allowed for the highest diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Background: Statistical cure is achieved when a patient population has the same mortality as cancer-free individuals; however, data regarding the probability of cure after hepatectomy of colorectal liver metastases (CLM) have never been provided. We aimed to assess the probability of being statistically cured from CLM by hepatic resection. Methods: Data from 1,012 consecutive patients undergoing curative resection for CLM (2001-2012) were used to fit a nonmixture cure model to compare mortality after surgery to that expected for the general population matched by sex and age. Results: The 5- and 10-year disease-free survival was 18.9 and 15.8 %; the corresponding overall survival was 44.3 and 32.7 %. In the entire study population, the probability of being cured from CLM was 20 % (95 % confidence interval 16.5-23.5). After the first year, the mortality excess of resected patients, in comparison to the general population, starts to decline until it approaches zero 6 years after surgery. After 6.48 years, patients alive without tumor recurrence can be considered cured with 99 % certainty. Multivariate analysis showed that cure probabilities range from 40.9 % in patients with node-negative primary tumors and metachronous presentation of a single lesion <3 cm, to 1.5 % in patients with node positivity, and synchronous presentation of multiple, large CLMs. A model for the calculation of a cure fraction for each possible clinical scenario is provided. Conclusions: Using a cure model, the present results indicate that statistical cure of CLM is possible after hepatectomy; providing this information can help clinicians give more precise answer to patients' questions. [ABSTRACT FROM AUTHOR]

Liver resection can be performed with different surgical approaches whether abdominal or combined thoracoabdominal. This work focuses on the surgical technique for the thoracoabdominal approach in liver surgery, describing the technique, the rationale, and making a review of the current literature on such subject. [ABSTRACT FROM AUTHOR]

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. P < 0.05 was considered statistically significant. Eighty (29 %) of 279 patients had complications, of which 60 (21.5 %) were liver-related. Major morbidity occurred in 16 (6 %) patients. The 30-day postoperative mortality was 1 %. A value of CHE ≤ 5,900 UI/L had a sensitivity of 73 % and a specificity of 67 % in predicting liver-related postoperative complications ( P = 0.001). The multivariate analysis revealed that only blood transfusion, major resections, and a value of CHE ≤ 5,900 UI/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. [ABSTRACT FROM AUTHOR]

Dissection or encirclement of the sectional pedicles for resection area demarcation is generally required for anatomical right posterior sectionectomy (RPS). These maneuvers are sometime unfeasible and potentially dangerous. A new technique for performing an RPS is herein described. Among the last 289 consecutive patients who underwent hepatic resection, 15 met the eligibility criteria for anatomical RPS by ultrasound-guided finger compression. This technique consists in demarcating the resection area by ultrasound-guided finger compression of the right posterior portal pedicle at the level closest to the tumor but oncologically suitable. Five patients had HCC; 11 had colorectal liver metastases. Median tumor number was 2 (range 1-46); median tumor size was 2.4 cm (range 0.4-13). Six patients had cirrhosis or chronic hepatitis, and ten had steatosis. Results show that the procedure resulted feasible in all eligible patients, and demarcation area was obtained in all patients within 1 min of bimanual IOUS guided compression. There was no mortality or major morbidity: only 2 (12%) patients experienced postoperative morbidity. Blood transfusions were not given. Ultrasound-guided finger compression of sectional portal pedicle feeding the right posterior section is a feasible, safe, and effective method, and introduces a new modality for performing RPS. [ABSTRACT FROM AUTHOR]

Preliminary results showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) could provide information not obtainable with conventional IOUS during surgery for hepatocellular carcinoma (HCC). The aim of the study was to prospectively validate the role of CEIOUS on the basis of a larger experience and to establish a new classification that takes into account its findings. Eighty-seven consecutive patients underwent hepatecomies for HCC. Those patients with new lesions at IOUS underwent CEIOUS: for that patients received intravenously 4.8 mL sulphurhexafluoride microbubbles. Pattern of enhancement was classified in 4 categories: A1 (full enhancement in the arterial phase and wash-out in the delayed phases), A2 (intralesional signs of neovascularization during all phases), A3 (no nodular enhancement but detectability during the liver enhancement), and B (undetectability during the liver enhancement). Resection was recommended for A1-3 nodules and no treatment for B nodules. Twenty-nine patients (33%) had 59 new lesions at IOUS and underwent CEIOUS. Twenty-seven nodules showed a B pattern at CEIOUS and were not removed; 32 nodules were classified as A1 in 5 patients, A2 in 11 patients, and A3 in 16 patients. The nodules were removed, and by histology, five A1, nine A2, and six A3 nodules were confirmed to be HCC. CEIOUS modified the operative decision making in 79% of these patients. CEIOUS is useful during surgery for HCC; it complements the accuracy of IOUS and affects the radicalness of the surgical. Specificity of CEIOUS has to be further improved, although intrinsic drawbacks exist in the diagnostic criterion of tumor vascularity. [ABSTRACT FROM AUTHOR]

Background: Two-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. The use of IOUS based on well-established criteria offers alternative technical solutions to the staged resections. This report describes a sophisticated IOUS-guided parenchyma-sparing procedure. Methods: A 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 %. Results: After 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. Conclusions: The 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. [ABSTRACT FROM AUTHOR]

Background: For lesions invading the middle hepatic vein (MHV) at caval confluence (CC) the mini-mesohepatectomy(MMH) was proposed. If the lesion is extended to the paracaval portion of segment 1(S1) in contact or invading the MHV a new procedure is proposed. Methods: Case-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 classification and color-flow analysis parenchyma-sparing procedure was performed. Results: In 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. Conclusion: For 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. [ABSTRACT FROM AUTHOR]

Background: In patients with hepatocellular carcinoma (HCC) in a diseased liver, surgery should be offered in a parenchyma-sparing fashion. This approach seems unfeasible for large and deeply located lesions. Ultrasound study of the tumor-vessel relationship and hepatic inflow and outflow opens new technical solutions: herein is described a new operation based on this approach. Methods: A 69-year-old man with a large centrally located HCC (Barcelona Clinic Liver Cancer stage C) underwent surgery. The HCC was located in segments 7, 8, and part of 5, extensively compressing and dislodging the anterior (P5-8) and posterior (P6-7) Glissonean pedicles at their origin. The lesion involved the right hepatic vein (RHV) and was in contact with the middle hepatic vein at the caval confluence. An inferior RHV (IRHV) was preoperatively evident. Results: After a J-shaped thoracophrenolaparotomy, the liver exploration with the aid of intraoperative ultrasound confirmed the tumoral contact without vascular invasion with P5-8 and P6-7 and disclosed multiple communicating veins between the middle hepatic vein and RHV, warranting with the IRHV the segment 5-6 outflows. A resection of segments 7 and 8 with RHV resection, together with complete tumor detachment from P5-8 and P6-7, was performed. The specimen was removed combining the crush-clamping method for the parenchyma division and a peeling-off technique by means of blunt scissor dissection for the tumor vessel detachment. The postoperative course was uneventful. The patient was alive without recurrence at 12 months after surgery. Conclusions: This video is the first live demonstration of the previously reported radical but conservative policy, adding to the latter the technical solutions provided by detection of accessory veins such as the IRHV and communicating veins. [ABSTRACT FROM AUTHOR]

Background: Anatomical resection is the gold standard for liver resection in patients with hepatocellular carcinoma (HCC). Bimanual hepatic vessel compression has been already described, although segmental and subsegmental resection of segment 8 (S8) remain challenging by this technique. We demonstrate how to obtain a S8 demarcation by means of ultrasound-guided vessel compression. Methods: Two patients with HCC with hepatitis C virus-related cirrhosis partially or fully located in S8 without portal thrombosis underwent liver resection. In the first patient with a HCC fed by subsegmental glissonian pedicles to S4 superior (P4sup) and S8 ventral (P8v), the resection area was disclosed by direct compression of the aforementioned feeding pedicles. A second patient had a HCC located in S8 ventral with a satellite in S8 dorsal; the patient had a pedicle to the right anterior sector originating from the left portal vein. The resection area was obtained by means of direct compression of the P8d and countercompression of the left portal vein (peripherally to the origin of the pedicle to the anterior sector), and P5. Countercompression was needed because of the peculiar trajectory of P8v passing across the middle hepatic vein. Results: In neither case was there a congested area. In the first patient, hepatic veins were not exposed because it was a resection conducted in a subsegmental fashion. There was no morbidity, and no blood transfusions were needed. Patients were both discharged on day 8 after surgery. Conclusions: Disclosure of subsegmental portions of S8 by means of intraoperative ultrasound-guided compression technique is feasible and confirms the reliability of this approach. [ABSTRACT FROM AUTHOR]

Background: For 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. Methods: A 61 year-old man was operated for multiple colorectal liver metastases (CLM). The 2 main CLM (14 and 3.5 cm 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. Results: After 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. Conclusions: Detection 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. [ABSTRACT FROM AUTHOR]