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BackgroundResection of colorectal liver metastasis (CLM) is beneficial when feasible. However, the benefit of second hepatectomy for hepatic recurrence in CLM remains unclear.MethodsThe Colorectal Liver Operative Metastasis International Collaborative retrospectively examined 1004 CLM cases from 2000 to 2018 from a total of 953 patients. Hepatic recurrence after initial hepatectomy was identified in 218 patients. Kaplan-Meier analysis was performed for overall survival (OS) and recurrence-free survival (RFS). Propensity score matching (PSM) was performed to offset selection bias. Cox proportional-hazards regression was performed to identify risk factors associated with OS.ResultsA total of 51 patients underwent second hepatectomy. Unadjusted median OS was 60.1 months in repeat-hepatectomy versus 38.3 months in the single-hepatectomy group (p = 0.015). In the PSM population, median OS remained significantly better in the repeat-hepatectomy group (60.1 vs. 33.1 months; p = 0.0023); median RFS was 12.4 months for the repeat-hepatectomy group, versus 9.8 months in the single-hepatectomy group (p = 0.0050). Repeat hepatectomy was associated with lower risk of death (hazard ratio: 0.283; p = 0.000012). Obesity, tobacco use, and high intraoperative blood loss were associated with significant risk of death (p

Background and Aim The aims of this study were to determine whether a postoperative decrease in skeletal muscle mass (SMM) after hepatic resection can predict long‐term outcomes in patients with hepatocellular carcinoma (HCC) and identify risk factors for SMM loss in patients who undergo hepatic resection. Methods This was a large retrospective study of 400 patients who underwent hepatic resection for HCC and pre‐ and postoperative computed tomography (CT) scans. SMM was measured at the third lumbar vertebrae, and the postoperative change in SMM compared with preoperative values was calculated as Δ SMM. The cutoff value for the post‐/preoperative ratio was set at 0.9. Results Sixty patients (15.0%) developed SMM loss. These patients had a significantly prolonged prothrombin time (P = 0.0092), longer duration of surgery (P = 0.0021), more blood loss (P = 0.0040), and higher rate of postoperative complications (P = 0.0037) than those without SMM loss. Multivariate analysis revealed that prolonged prothrombin time and postoperative complications were independent risk factors for SMM loss after hepatic resection. Patients with SMM loss had significantly shorter overall survival (P = 0.0018) than the other patients had. SMM loss was an independent prognostic factor for overall survival (hazard ratio 1.551, 95% confidential interval 1.028–2.340, P = 0.0363). Conclusions We demonstrated an association of SMM loss with postoperative complications and long‐term prognosis in patients with HCC. Patients with prolonged prothrombin time, or postoperative complications, may need to maintain their SMM. Further prospective studies are needed to investigate whether nutritional support can improve SMM loss., The aims of this study were to determine whether a postoperative decrease in skeletal muscle mass (SMM) after hepatic resection can predict long‐term outcomes in patients with hepatocellular carcinoma (HCC) and identify risk factors for SMM loss in patients who undergo hepatic resection. We demonstrated an association of SMM loss with postoperative complications and long‐term prognosis in patients with HCC. Patients with prolonged prothrombin time, or postoperative complications, may need to maintain their SMM.

[Background/Purpose]To investigate the long‐term outcome and entire treatment course of patients with technically unresectable CRLM who underwent conversion hepatectomy and to examine factors associated with conversion to hepatectomy. [Methods]Recurrence and survival data with long‐term follow‐up were analyzed in the cohort of a multi‐institutional phase II trial for technically unresectable colorectal liver metastases (the BECK study). [Results]A total of 22/12 patients with K‐RAS wild‐type/mutant tumors were treated with mFOLFOX6 + cetuximab/bevacizumab. The conversion R0/1 hepatectomy rate was significantly higher in left‐sided primary tumors than in right‐sided tumors (75.0% vs 30.0%, P = .022). The median follow‐up was 72.6 months. The 5‐year overall survival (OS) rate in the entire cohort was 48.1%. In patients who underwent R0/1 hepatectomy (n = 21), the 5‐year RFS rate and OS rate were 19.1% and 66.3%, respectively. At the final follow‐up, seven patients had no evidence of disease, five were alive with disease, and 20 had died from their original cancer. All 16 patients who achieved 5‐year survival underwent conversion hepatectomy, and 11 of them underwent further resection for other recurrences (median: 2, range: 1‐4). [Conclusions]Conversion hepatectomy achieved a similar long‐term survival to the results of previous studies in initially resectable patients, although many of them experienced several post‐hepatectomy recurrences. Left‐sided primary was found to be the predictor for conversion hepatectomy.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide but with an approximate 5-year survival of greater than 50% in patients after surgical resection. Survival estimates have limited utility for patients who have survived several years after initial treatment. We analyzed how conditional survival (CS) after curative-intent surgery for HCC predicts survival estimates over time. METHODS: NCDB(2004–2014) was queried for patients undergoing definitive surgical resection for HCC. Cumulative overall survival (OS) was calculated using the Kaplan-Meier method, and conditional survival (CS) at x years after diagnosis was calculated as CS(1) = OS ((X+5)) / OS ((X)). RESULTS: Final analysis encompassed 11,357 patients. Age, negative margin status, grade severity and radiation prior to surgery were statistically significant predictors of cumulative overall conditional survival (p≤0.0001). Overall unconditional 5-year survival was 65.7%, but CS estimates were higher. A patient who has already survived 3 years has an additional 2-year, or 5-year CS, estimate of 86.96%. CONCLUSION: Survival estimates following hepatic resection in HCC patients change according to survival time accrued since surgery. CS estimates are improved relative to unconditional OS. The impact of different variables influencing OS is likewise non-linear over the course of time after surgery.

Background/purpose Right hepatic vein (RHV) drainage area resection is performed for intrahepatic tumors. However, borders of RHV drainage areas are difficult to identify. We evaluated the usefulness of indocyanine green (ICG) fluorescent images to identify the borders for RHV drainage area resection. Methods From January 2016 to May 2019, we included 12 patients who underwent hepatic resection of the RHV drainage area, which was evaluated using ICG fluorescence images after clamping the RHV and with or without clamping the proper hepatic artery (PHA). The resected liver volume was compared with the preoperative simulated resected liver volume by 3-dimensional computed tomography. Results Eleven borders of the RHV drainage area between the middle hepatic vein (MHV) or inferior RHV drainage area were confirmed using ICG fluorescent images in 12 patients. The borders were observable by only clamping the RHV. In one patient, the border could not be identified because there was a shunt between the RHV and MHV at the peripheral area. Resected liver volume was significantly correlated with the results of preoperative simulation. Conclusion The RHV drainage area resection could be one of the options of hepatic resection for the tumor involving the root of the RHV. ICG fluorescent imaging in hepatic resection of the RHV drainage area is useful for determining areas of liver congestion and clamping the PHA is not always necessary.

During portal vein embolization (PVE) prior to hepatectomy, the viability of the future liver remnant (FLR) is a critical determinant associated with the risk of post-operative liver failure and death.1 Care is taken to prevent embolization of viable liver and to prevent spread of embolization material. Alongside a review of the literature, we present a potentially devastating case of pulmonary embolization of material following PVE and liver resection.

Background Most prognostic scoring systems for colorectal liver metastases (CRLMs) account for factors related to tumour biology. Little is known about the effects of the host phenotype to the tumour. Our objective was to delineate the relationship of systemic inflammation and body composition features [i.e. low skeletal muscle mass (sarcopenia) and low visceral adipose tissue (VAT)], two well-described host phenotypes in cancer. Methods Clinical data and pre-operative blood samples were collected from 99 patients who underwent resection of CRLM. Pre-operative computed tomography scans were available for 97 patients; body composition was analysed at the L3 level, stratified for sex and age. Clinicopathological variables, serum C-reactive protein (CRP), and various body composition variables were evaluated. Overall survival was evaluated as a function of these same variables in multivariate Cox regression analysis. Results Skeletal muscle was significantly correlated with VAT (r = 0.46, P = 5 mg/mL) in 42 patients (43.3%). Elevated CRP was more common in patients with sarcopenia (73.8% vs. 51.1%, P = 0.029). The most significant prognostic factors were the coincidence of elevated CRP and adverse body composition features (sarcopenia and/or low VAT; hazard ratio 4.3, 95% confidence interval 1.5-13.0, P = 0.008), as well as Fong clinical prognostic score (hazard ratio 2.9, 95% confidence interval 1.5-5.5, P = 0.002). Conclusions Body composition in patients with CRLM is not directly linked to the presence of systemic inflammation. However, when systemic inflammation coincides with sarcopenia and/or low VAT, prognosis is adversely affected, independent of the Fong clinical prognostic score.

Hepatocellular carcinoma (HCC) is the fifth most common malignant tumor and constitutes a major health threat globally. Intermediate HCC (Barcelona Clinic Liver Cancer Staging, stage B) encompasses a wide range of patients and is characterized by substantial heterogeneity with varying tumor burdens and liver functions. Therefore, it is paramount to evaluate the patient's overall conditions and to select the most appropriate therapy based on available evidence. Transarterial chemoembolization is the recommended first-line therapy for intermediate HCC patients. However, in clinical practice, other treatment options are also used as alternative therapies, such as hepatic resection, percutaneous thermal ablation, radiotherapy (RT), systemic treatment, immunotherapy, and so forth. In this review, we will introduce current treatment strategies for intermediate HCC, discuss their advantages and disadvantages, and propose future directions.

BACKGROUND The survival outcomes of recurrent hepatocellular carcinoma (HCC) after curative resection remain unclear due to lack of clear basis for the selection of treatment option. We investigated overall survival (OS) after intrahepatic recurrence and re-recurrence free survival (rRFS) of the patients with recurrent HCC, and whether Milan criteria (MC) status at resection and recurrence impacts on OS and rRFS. METHOD We enrolled 959 patients who experienced recurrence after primary hepatic resection for HCC. We divided the cohort into four groups according to MC at two periods: IN-rIN MC (HCC within MC at the time of resection-recurrence within MC), IN-rOUT MC (HCC within MC at the time of resection-recurrence outside MC), OUT-rIN MC (HCC outside MC at the time of resection-recurrence within MC), and OUT-rOUT MC (HCC outside MC at the time of resection-recurrence outside MC). RESULTS In the entire cohort, 1-, 3-, and 5-year OS after recurrence was 81.0%, 55.7%, and 45.8%, respectively, while rRFS was 63.7%, 46.1%, and 42.0%, respectively. The IN-rIN MC group had the best outcomes (5-year OS and rRFS, 54.5% and 45.7%, respectively). The IN-rOUT and OUT-rIN MC groups had better 5-year OS outcomes than the OUT-rOUT MC group (46.5%, 38.6%, and 24.8%, respectively; P 0.05). CONCLUSION Survival after first recurrence following curative primary resection for HCC was affected by MC at both time of resection and recurrence. Both the IN-rOUT and OUT-rIN MC groups with similar survival outcomes can be saved via curative treatment.

Objective This study aimed to evaluate the safety and efficacy of three‐dimensional conformal radiotherapy (3D‐CRT) and hepatic resection for patients with hepatocellular carcinoma (HCC) involving portal vein tumor thrombus (PVTT). Methods We retrospectively analyzed 323 HCC patients involving PVTT. Among them, 134 patients underwent 3D‐CRT, while 189 controls treated with hepatic resection (HR). Survival rate and prognostic analysis were performed using Kaplan‐Meier method and Cox regression analyses. Results The 1‐, 2‐, and 3‐year overall survival (OS) of RT group and HR group was 54% vs 62%, 33% vs 47%, and 18% vs 43%, respectively (P = 0.003). In the subgroup of PVTT type analysis, the 1‐, 2‐, and 3‐year OS in RT group was 65%, 39%, and 19%, respectively, while that in HR group was 83%, 53%, and 42%, respectively, in type I PVTT (P

BACKGROUND Age-related events, such as cardiopulmonary complications, delirium, transfer to a rehabilitation facility, and dependency are a major problem after hepatic resection in the elderly. This prospective multicenter study aimed to preoperatively evaluate frailty in the elderly according to a phenotypic frail index, named the "Kihon Checklist (KCL)," to predict "age-related events" after hepatic resection. METHODS Between May 2016 and September 2017, 217 independently living patients who consented among all patients aged ≥65 years who planned to undergo hepatic resection were included in the study. Preoperative frailty was defined as a total KCL score ≥8. We analyzed clinical characteristics and outcomes, including age-related events (major respiratory and cardiac complications, delirium medication needed, transfer to rehabilitation facility, and dependency) between patients with and without frailty. RESULTS Of the 217 patients, 63 and 154 were classified into the frail and non-frail groups, respectively. The incidences of age-related events (31.7% vs. 7.8%, P

Background Hepatic resection is a relatively young and complex specialized procedure. A strong relationship between volume and perioperative mortality has been reported internationally. However, there has been no multicentre study into hepatic resection in Australia. This retrospective, population-based cohort study was conducted to determine national, state and territory based volume and perioperative mortality rates (POMRs). Methods Australian Institute of Health and Welfare data was interrogated for the Australian Classification of Health Intervention codes for hepatic resection defined as extended hemi-hepatectomy (30421), hemi-hepatectomy (30418), segmental hepatic resection (30415) and sub-segmental hepatic resection (30414). Logistic regression analysis was performed using the de-identified data to investigate trends and differences between states/territories. Mortality rates were risk adjusted for age, gender and public or private admission. The data set included patients who underwent hepatic resection in the financial years 2005/2006 to 2012/2013. Results The overall POMR for all types of hepatic resection was 1.6% (201/12 562). There was no significant change in POMR over time. However, there was significant variation between the states and territories with two states having significantly higher POMR for major hepatic resections (regional range: 1.3-3.8%). POMRs increased with age with the highest mortality seen in the 75-79 year age group. The POMR was lower in private than in public hospitals. Conclusion The results of this study confirm that the overall Australian POMR for major hepatic resection is similar to results reported internationally. National and state/territory POMR has not varied significantly over time. The significant variation between states/territories warrants further investigation.

Background Accurate assessment of liver functional reserve preoperatively is vital for safe hepatic resection. The ALBI score is a new model for assessing liver function. This study aimed to evaluate the value of combining ALBI score with sFLR in predicting postoperative morbidity and PHLF in HCC patients who underwent hepatectomy. Methods Patients undergoing three-dimensional CT reconstruction prior to hepatectomy for HCC between January 2015 and January 2017 were enrolled. The values of the CP score, ALBI score and sFLR in predicting postoperative outcomes were evaluated. Results A total of 229 HCC patients were enrolled; 24 (10.5%) experienced major complications and 21 (9.2%) developed PHLF. The incidence of major complications and PHLF increased with increasing ALBI grade. The ALBI grade classified patients with CP grade A into two subgroups with different incidences of PHLF (P=0.029). sFLR and ALBI score were identified as independent predictors of PHLF. The AUC values for the CP score, ALBI score, sFLR and sFLR×ALBI for predicting major complications were 0.600, 0.756, 0.660 and 0.790, respectively. The AUC values of the CP score, ALBI score, sFLR and sFLR×ALBI for predicting PHLF were 0.646, 0.738, 0.758 and 0.884, respectively. Conclusion The ALBI score showed superior predictive value of postoperative outcomes over CP score, and the combination of sFLR and ALBI score was identified as a stronger predictor of postoperative outcomes than the sFLR or ALBI score alone. This article is protected by copyright. All rights reserved.

Transarterial chemoembolization (TACE) is recommended for patients with intermediate-stage (Barcelona Clinic Liver Cancer criteria B [BCLC-B]) hepatocellular carcinoma (HCC). However, patients with BCLC-B HCC can differ in background factors related to hepatic function, as well as tumor size and number. In the present study, we clarified the role of hepatic resection in patients with BCLC-B HCC. A total of 489 BCLC-B HCC patients with Child-Pugh class A disease initially treated with hepatic resection or TACE were included. After propensity score matching (n = 264), hepatic resection (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.35-0.91) was independently associated with survival in the multivariate analysis. We then divided patients into two groups based on the results of statistical analysis. There were 170 patients treated with resection and 319 with TACE. Child-Pugh score and number of tumors (cut-off, three tumors) were independently associated with type of HCC treatment in the multivariate analysis. We then divided patients in Group A (Child-Pugh score of 5 and ≤3 tumors; n = 186) and Group B (Child-Pugh score of 6 or ≥4 tumors; n = 303). In Group A, cumulative survival was significantly higher in the hepatic resection group than in the TACE group (P = 0.014). In Cox proportional hazards models, hepatic resection (HR, 0.38; 95% CI, 0.23-0.64) was independently associated with survival in Group A patients. In Group B, treatment status was not associated with overall survival. Hepatic resection should be considered in patients with a Child-Pugh score of 5 and ≤3 tumors, despite having BCLC-B HCC.

Background The Barcelona Clinic Liver Cancer (BCLC) classification is the most widely used staging system for hepatocellular carcinoma (HCC), but its prognostic ability in patients after resection has not been yet validated. The aim of this study was to evaluate the BCLC classification among patients after resection. Methods The subjects were 196 patients who underwent hepatic resection for HCC between April 2003 and December 2014 at Jikei University Hospital. All patients were classified into a tumor stage according to the BCLC classification. Overall survival rate was calculated according to stages defined by the BCLC classification. Results Overall survival rates at 1, 3 and 5-year were 100%, 95.2% and 95.2% in BCLC 0, 96.7%, 90.0% and 78.4% in BCLC A solitary, 86.2%, 86.2% and 86.2% in BCLC A multiple, 100.0%, 78.8% and 78.8% in BCLC B and 86.5%, 63.3% and 57.6% in BCLC C, respectively. Postoperative complications and mortality rates in relation to BCLC stage were comparable. Conclusion The BCLC treatment algorithm should consider the role of resection also for multiple early, intermediate and advanced stages.

Background In recent years, the establishment of new staging systems for hepatocellular carcinoma (HCC) has been reported worldwide. The system combining albumin–bilirubin (ALBI) with tumor–node–metastasis stage, developed by the Liver Cancer Study Group of Japan, was called the ALBI-T score. Methods Patient data were retrospectively collected for 357 consecutive patients who had undergone hepatic resection for HCC with curative intent between January 2004 and December 2015. The overall survival and recurrence-free survival were compared by the Kaplan–Meier method, using different staging systems: the Japan integrated staging (JIS), modified JIS, and ALBI-T. Results Multivariate analysis identified five poor prognostic factors (higher age, poor differentiation, the presence of microvascular invasion, the presence of intrahepatic metastasis, and blood transfusion) that influenced overall survival, and four poor prognostic factors (the presence of intrahepatic metastasis, serum α-fetoprotein level, blood transfusion, and each staging system (JIS, modified JIS, and ALBI-T score)) that influenced recurrence-free survival. Patients for each these three staging system had a significantly worse prognosis regarding recurrence-free survival, but not with overall survival. The modified JIS score showed the lowest Akaike information criteria statistic value, indicating it had the best ability to predict overall survival compared with the other staging systems. Conclusions This retrospective analysis showed that, in post-hepatectomy patients with HCC, the ALBI-T score is predictive of worse recurrence-free survival, even when adjustments are made for other known predictors. However, modified JIS is better than ALBI-T in predicting overall survival.

Introduction Laparoscopic hepatectomy is difficult because surgeons must perform the transection using many (four and more) energy devices and without direct manual maneuvers. Here we introduce hepatic transection by the classical method with a few (two or three) energy devices. Materials and surgical technique We performed laparoscopic hepatectomy for 40 patients with hepatic tumor and liver dysfunction. For parenchymal transection, we used bipolar radiofrequency coagulation forceps connected to a voltage-controlled electrosurgical generator and ultrasonic dissector. The demarcation of the liver surface was made by an ultrasonic dissector. Along the demarcation line, the blades of a BiClamp were opened slightly and inserted into the hepatic parenchyma. We clamped slowly, softly, and gradually, and a small amount of hepatic parenchyma was consequently coagulated and fractured. After the crush, the small vessels and intrahepatic bile duct that were sealed were left as atrophic strings, and the strings were divided by an ultrasonic dissector. Large vessels and Glisson's sheaths were left because of the small clamp. Large Glisson's sheaths and hepatic veins were ligated with a titanium clip or autosutures, and cut without bile leakage or bleeding. The mean operation time of the procedure was 196.9 min, mean blood loss was 69.9 mL, and mean postoperative hospitalization was 9.5 days. No blood transfusions were needed. Two cases had perioperative complications-one involving right shoulder pain and the other involving ascites due to liver dysfunction-but there were no serious postoperative complications. Discussion The present results appear to demonstrate that this simple and safe method helps decrease intraoperative bleeding and shorten hospital stay.

BACKGROUND Waitemata District Health Board has New Zealand's largest catchment and busiest colorectal unit. The upper gastrointestinal unit was established in 2005, in part to provide a hepatic resection service for patients with colorectal carcinoma metastatic to the liver. The aim of this investigation was to report on quality indicators for the hepatic resection of colorectal carcinoma in the development of a regional resection service. METHODS Prospectively collected data on patients undergoing hepatic resection for colorectal carcinoma between 2005 and 2014 was reviewed and correlated with costing data and national hepatic resection rates. RESULTS A total of 123 patients underwent 138 hepatic resections for metastatic colorectal cancer with a median hospital stay of 8 days (range 4-37 days), a zero 30-day mortality and a median cost of NZ$21 374 for minor hepatectomy and NZ$43 133 for major hepatectomy. Actuarial 5-year disease-free survival was 44%, with 28 patients alive and disease free at 5 years post-resection. Median overall survival was not reached. Review of national hepatic resection rates indicate that Waitemata District Health Board performs one sixth of all hepatic resections in New Zealand and that this treatment modality may be underutilized in the management of patients with metastatic colorectal cancer. CONCLUSION A regional hepatic resection centre for colorectal metastases can be established in areas of population need and can provide a high-quality, cost-effective service.

BACKGROUND Hepatic resectional surgery remains a highly specialized area of general surgery usually reserved for completion at tertiary metropolitan referral centres. Port Macquarie, on the Mid North Coast of New South Wales, is the only regionally based hospital offering surgery of this nature in mainland Australia. The purpose of this study is to review the data for patients undergoing hepatic resectional surgery in this non-metropolitan centre in order to illustrate that these operations can be carried out safely in a regional setting with comparable results to tertiary-level centres. METHODS A retrospective review of consecutive patients undergoing elective hepatic resections at Port Macquarie from February 2008 to 31 October 2015 was completed. Pre-morbid patient clinical and demographic factors, histopathological details, post-operative complications, survival and mortality data were all noted. RESULTS A total of 66 consecutive elective liver resections were performed during the study period. Metastatic colorectal cancer was the most commonly observed pathology (n = 33, 50.0%). The 90-day mortality was 4.5% (n = 3) whilst 17 patients (n = 17, 25.8%) experienced major complications (Clavien-Dindo grade 3 or 4). The median overall survival following hepatectomy for colorectal metastases was 48 months (95% confidence interval 37-59 months). CONCLUSION Our study shows excellent morbidity, mortality and survival for hepatic resectional surgery performed in a regional centre and is comparable data to major metropolitan centres. Our study confirms that major hepatic resectional surgery in this setting is safe and effective.

Background Hepatic resection (HR) in cirrhotic patients with Hepatocellular carcinoma (HCC) and portal hypertension (PHT) is not recommended according to the international guidelines. The aim of this work is to study the outcome of HR for HCC in cirrhotic patients with PHT. Methods It is a single institutional retrospective study of 170 Child-Pugh class A cirrhotic patients underwent HR for HCC from 2011 to July 2015. The patients were divided into two groups according to the presence and absence of PHT. Results PHT was present in 91 patients (53.5%). The postoperative morbidity was non-significantly higher in patients with PHT than patients without PHT (31.9% vs 25.3% respectively, P=0.36). Patients with PHT showed 90-day perioperative mortality (3.3%) similar to patients without PHT (2.5%). In subgroup analysis, The 1-, 3-, and 5-year overall survival (OS) for patients with limited HR was 90.3%, 74.3%, and 66.2%, respectively for patients with PHT, and 93.9%, 80.9%, and 73.6%, respectively for patients without PHT, without significant difference (P=0.38). Conclusion HR in Child-Pugh class A cirrhotic patients with PHT is safe and effective procedure with good short and long-term outcomes in comparison to patients without PHT especially with limited liver resection.

BACKGROUND To assess the changes in blood loss during hepatic resection with improved haemostatic devices such as a bipolar sealing device and a topical haemostatic agent. METHODS This retrospective clinical study of prospectively collected data will assess hepatic resections performed by a single surgeon between 2005 and 2013, with the introduction of the two haemostatic techniques in 2009. RESULTS A total of 371 hepatic resections (214 from 2005 to 2008 and 157 from 2009 to 2013) were included in this study. Compared with the conventional hepatic resection (2005-2008), the use of haemostatic techniques (2009-2013) significantly reduced the need for inflow occlusion (OR: 0.37, 95% CI: 0.24-0.57, P < 0.001), overall occlusion time (20.8 min versus 25.9 min, P = 0.04) and transfusion requirement (4.6% versus 12%, OR: 0.35, 95% CI: 0.14-0.90, P = 0.02). Mean overall blood loss was reduced post-2009; however, the decrease was not statistically different (401.3 mL versus 470.8 mL, P = 0.27). Subgroup analysis revealed that blood loss was more than halved post-2009 compared with pre-2009 for patients who received pre-operative chemotherapy (324.6 mL versus 738.5 mL, P = 0.005). CONCLUSION The use of a bipolar sealing device and a topical haemostatic agent reduces the need for inflow occlusion, overall occlusion time and transfusions in all patients compared with conventional hepatic resections.

Background Liver metastasis is common in patients with oesophageal cancer. The effect of operative intervention for post-operative solitary liver metastasis from oesophageal squamous cell carcinoma (ESCC) has not previously been examined. This research was to compare the effect of surgery and non-surgical therapy in patients with post-operative solitary liver metastasis from ESCC. Methods We retrospectively analysed the clinical data of 69 consecutive patients with solitary hepatic metastasis who had undergone oesophagectomy for ESCC and were subsequently referred to the First Affiliated Hospital of Zhengzhou University from January 2005 to December 2013. The survival rates of the surgical and non-surgical groups were compared. Results There were 26 patients in the surgical group and 43 patients in the non-surgical group. There was no operative death in the surgical group. Post-operative complications were observed in six patients, and all of these patients recovered after additional treatments. Patients in the surgical group had 1- and 2-year cumulative survival rates of 50.8 and 21.2%, respectively, which were significantly higher than the 31.0 and 7.1% survival rates of patients in the non-surgical group (P 12 months had a better survival rate than those with a DFI lasting ≤12 months (all P Conclusions Operative intervention is a better treatment choice for patients with post-operative solitary liver metastasis from ESCC, especially for patients with a DFI lasting >12 months. Patients selected for hepatic resection should be considered on an individual basis through a multidisciplinary team of specialists.

AIM The suitability of hepatic resection for older patients remains controversial. This study aimed to investigate whether age influences overall survival of patients with hepatocellular carcinoma (HCC) after resection. METHODS Records of 1,132 patients with HCC after hepatic resection were retrospectively reviewed. Overall survival (OS) was compared between younger and older patients based on five cut-off ages (30, 40, 50, 60, and 70 years). RESULTS Across all patients, OS was 89.7% at 1 year, 67.7% at 3 years, and 47.7% at 5 years. OS was similar between younger and older patients at all cut-off ages (all P > 0.1), but OS was marginally lower among patients >70 years old than those ≤70 (P = 0.090). Multivariate analyses identified several risk factors for lower OS: preoperative serum albumin 80 U/L, α-fetoprotein ≥400 ng/ml, presence of esophagogastric varices or macrovascular invasion, incomplete/absent tumor capsule, tumor size >10 cm, tumor number ≥3, and major hepatectomy. CONCLUSION Age does not influence the prognosis of patients with HCC after hepatic resection. Older patients should be considered for curative resection if remnant liver volume and liver function are adequate. J. Surg. Oncol. 2016;114:966-970. © 2016 Wiley Periodicals, Inc.

Aim We aimed to evaluate whether functional assessment of the future remnant liver is a predictor of postoperative morbidity after hepatic resection in patients with hepatocellular carcinoma (HCC). Methods One hundred forty-six patients who underwent hepatic resection for HCC were enrolled in this study. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid enhanced MRI (EOB-MRI) analysis for functional liver assessment was carried out before hepatic resection. The signal intensity in the remnant liver was measured and divided by the signal intensity of the major psoas muscle (the liver to major psoas muscle ratio, LMR) for standardization. The remnant liver function was calculated using the formula (LMR on the hepatobiliary phase/LMR on the precontrast image). Computed tomography liver volumetry was also carried out. The remnant functional liver was calculated as the remnant liver volume or volumetric rate × remnant liver function by EOB-MRI. Results Morbidities developed in 19 (13.0%) patients. Morbidities associated with the liver occurred in 7 patients (4.7%). There was no mortality during surgery. Median remnant liver function scores using EOB-MRI and remnant functional liver using volumetric rate or volumetry were 1.82 (range, 1.25–2.96), 155.9 (range, 64.7–285.3), and 1027 (range, 369–2148), respectively. Logistic regression analysis identified the remnant functional liver volume as the only independent predictor for liver-related morbidity. Conclusion Remnant functional liver volume using computed tomography liver volumetry and EOB-MRI was a significantly useful predictor for liver-related morbidity after hepatic resection in patients with HCC.

Aim: The present study investigated the effect of sarcopenia on short- and long-term surgical outcomes and identified potential prognostic factors for hepatocellular carcinoma (HCC) following hepatectomy among patients 70 years of age and older. Methods: Patient data were retrospectively collected for 296 consecutive patients who underwent hepatectomy for HCC with curative intent. Patients were assigned to two groups according to age (younger than 70 years, and 70 years and older), and the presence of sarcopenia. The clinicopathological, surgical outcome, and long-term survival data were analyzed. Results: Sarcopenia was present in 112 of 296 (37.8%) patients with HCC, and 35% of patients aged 70 years and older. Elderly patients had significantly lower serum albumin levels, prognostic nutrition index, percentage of liver cirrhosis, and histological intrahepatic metastasis compared with patients younger than 70 years. Overall survival and disease-free survival rates in patients with sarcopenia correlated with significantly poor prognosis in the group aged 70 years and older. Multivariate analysis revealed that sarcopenia was predictive of an unfavorable prognosis. Conclusion: This retrospective analysis revealed that sarcopenia was predictive of worse overall survival and recurrence-free survival after hepatectomy in patients 70 years of age and older with HCC.

Background The aim of the study was to investigate the therapeutic role of lymphadenectomy (LND) in patients with intrahepatic cholangiocarcinoma. Methods 826 patients who underwent liver resection were identified using the SEER database from 1988 to 2011. Two groups of patients were defined: 201 (24%) undergoing potentially therapeutic LND (group A, >3 lymph nodes (LN) removed), and 625 (76%) not receiving therapeutic LND (group B, ≤3 LNs removed). A propensity score analysis was performed to create a matched cohort of 402 patients (201 in either group). The survival benefit of therapeutic LND was also estimated using multivariate parametric analysis comparing two simulated cohorts of 826 patients. Results 1-, 3-, and 5-year survival rates were 71%, 37%, and 27% for group A patients, and 73%, 37%, and 27% for matched group B patients (P = 0.656). When simulation analysis was performed, a moderate survival benefit of LND of 5.46 months was calculated (95%CI, 4.64–6.29). Considerable differences in LND survival benefit predictions were found according to patient's sex (males, 9.90 vs. females 1.16 months), age (≤60 years, 15 vs. >60 years, −1.34 months), and tumor size (>50 mm, 9.20 vs. ≤50 mm, −0.28). Conclusions LND therapeutic benefit among a subset of patients. Future work is required to investigate the role of routine LND among these patients. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

Background Colorectal cancer is common with half of all patients developing metastases to the liver. The aim of this study was to document the survival for patients undergoing liver resection for colorectal cancer metastases. Method A review of all patients undergoing hepatic resection for colorectal liver metastases at a New Zealand tertiary level public hospital over a 9-year period was performed. Results Primary survival outcomes assessed were overall survival (OS) and disease-free survival (DFS). Of the 116 patients followed-up with a median (range) of 53 (10–116) months, the OS at 5 years was 53%. Median survival was 6.5 years. At end of follow-up, 57% of patients were alive and 49% were alive without recurrence. The overall rate of recurrence was 39%. Conclusion This study confirms that excellent long term survival can be achieved with hepatic resection for colorectal liver metastases.

AIM Percutaneous radiofrequency ablation (P-RFA) therapy is a widely applied treatment for small hepatocellular carcinoma (HCC); however, local recurrence is a major issue of HCC located at the surface of the liver (surface HCC). The aim of this study was to compare the outcome of laparoscopic hepatic resection (LH) and P-RFA for surface HCC in case-control patient groups using the propensity score. METHODS Between 2011 and 2013, 40 and 52 patients underwent LH and P-RFA for surface HCC (≤3 cm, 1-3 nodules). To correct the difference in clinicopathological factors between the two groups, propensity score matching was used at a 1:1 ratio, which resulted in a comparison of 27 patients/group. We compared outcomes between the two groups, with special reference to local recurrence. RESULTS Clinicopathological variables were well balanced between the two groups. One patient in the LH group was converted to open surgery due to adhesion. The incidence of complications was 0% in the P-RFA group and 15% (four patients) in the LH group (P = 0.11); however, none of these four patients in the LH group sustained severe complications. The duration of hospitalization following treatment was longer in the LH group than in the P-RFA group (12.6 vs 7.6 days, P

BACKGROUND A patient can be considered statistically cured from a specific disease when their mortality rate returns to the same level as that of the general population. In the current study, the authors sought to assess the probability of being statistically cured from intrahepatic cholangiocarcinoma (ICC) by hepatic resection. METHODS A total of 584 patients who underwent surgery with curative intent for ICC between 1990 and 2013 at 1 of 12 participating institutions were identified. A nonmixture cure model was adopted to compare mortality after hepatic resection with the mortality expected for the general population matched by sex and age. RESULTS The median, 1-year, 3-year, and 5-year disease-free survival was 10 months, 44%, 18%, and 11%, respectively; the corresponding overall survival was 27 months, 75%, 37%, and 22%, respectively. The probability of being cured of ICC was 9.7% (95% confidence interval, 6.1%-13.4%). The mortality of patients undergoing surgery for ICC was higher than that of the general population until year 10, at which time patients alive without tumor recurrence can be considered cured with 99% certainty. Multivariate analysis demonstrated that cure probabilities ranged from 25.8% (time to cure, 9.8 years) in patients with a single, well-differentiated ICC measuring ≤5 cm that was without vascular/periductal invasion and lymph nodes metastases versus

BACKGROUND: Sarcopenia, obesity and sarcopenic obesity have been linked to impaired outcome after liver surgery. Preoperative liver function of sarcopenic, obese and sarcopenic-obese patients might be reduced, possibly leading to more post-operative morbidity. The aim of this study was to explore whether liver function and volume were influenced by body composition in patients undergoing liver resection. METHODS: In 2011 and 2012, all consecutive patients undergoing the methacetin breath liver function test were included. Liver volumetry and muscle mass analysis were performed using preoperative CT scans and Osirix((R)) software. Muscle mass and body-fat% were calculated. Predefined cut-off values for sarcopenia and the top two body-fat% quintiles were used to identify sarcopenia and obesity, respectively. Histologic assessment of the resected liver gave insight in background liver disease. RESULTS: A total number of 80 patients were included. Liver function and volume were comparable in sarcopenic(-obese) and non-sarcopenic(-obese) patients. Obese patients showed significantly reduced liver function [295 (95-508) vs. 358 (96-684) microg/kg/h, P = 0.018] and a trend towards larger liver size [1694 (1116-2685) vs. 1533 (869-2852) mL, P = 0.079] compared with non-obese patients. Weight (r = -0.40), body surface area (r = -0.32), estimated body-fat% (r = -0.43) and body mass index (r = -0.47) showed a weak but significant negative (all P < 0.05) correlation with liver function. Moreover, body-fat% was identified as an independent factor negatively affecting the liver function. CONCLUSION: Sarcopenia and sarcopenic obesity did not seem to influence liver size and function negatively. However, obese patients had larger, although less functional, livers, indicating dissociation of liver function and volume in these patients.

Background Resection of liver metastases from gastric cancer (GC) is rarely performed, and the outcome after hepatic surgery has not been systematically evaluated in the literature. The aim of this study was to perform a systematic review of outcome and prognostic factors for survival after liver metastasectomy for GC. Methods We performed a meta-analysis of published studies that focused on long-term outcomes (5-year overall survival [OS]) after surgical management of liver metastases from GC, and included more than 10 patients each. Pooled hazard ratios (HRs) were calculated for variables considered as potential prognostic factors for OS in at least three publications. Results Twenty-three studies comprising a total of 870 patients were considered in this analysis. The pooled weighted median OS was 22 months (95%CI 17.6–27.2). The pooled 5-year OS after liver resection was 23.8% (95%CI 19–29.3%). The pooled 5-year OS rates for metachronous and synchronous metastases were 30% (95%CI 24.7–35.8%) and 22.6% (95%CI 14–34.4%), respectively. Parameters associated with poor survival were (i) multiple metastases, and (ii) large size of metastases. Conclusions Hepatic resection of GC liver metastases is associated with an acceptable 5-year OS, in particular after surgery of metachronous lesions, and could be offered to selected patients. J. Surg. Oncol. 2015 111:1021–1027. © 2015 Wiley Periodicals, Inc.

Conventional coagulation tests are frequently prolonged after liver surgery, suggesting a post-operative hypocoagulability. However, these tests are unreliable for assessment of the haemostatic status in these patients. In contrast, thrombin generation testing measures the true balance between pro- and anti-coagulant factors.To study the perioperative coagulation status in patients undergoing hemi-hepatectomy using thrombin generation assays.We examined thrombin generation profiles in serial plasma samples taken from seventeen patients undergoing right hemi-hepatectomy. Results were compared to ten patients undergoing pancreatic resection and twenty-four healthy volunteers. In addition, we measured conventional coagulation tests and plasma levels of several haemostatic proteins.Following liver resection, the endogenous thrombin potential (ETP) slightly decreased until post-operative day 7. However, in the presence of thrombomodulin, the ETP increased [from 542 nM*min (417-694) at baseline to 845 nM*min (789-1050) on post-operative day 3] to values higher than that in healthy subjects (558 nM*min (390-680); P 0.001), which contrasts with substantially prolonged PT levels. Normal to decreased thrombin generation was observed following pancreatic resection. Thrombin generation was only slightly affected by thrombomodulin after hemi-hepatectomy, while thrombin generation in healthy subjects decreased profoundly upon addition of thrombomodulin. This hypercoagulability following liver resection may be explained by decreased levels of protein C, S, and antithrombin and by elevated levels of factor VIII.Thrombin generation in the presence of thrombomodulin revealed hypercoagulability in patients following liver resection. These results support the recently advocated restrictive use of plasma during liver resection and the exploration of more extensive use of post-operative thrombosis prophylaxis.

Background and Objectives The purpose of this study was to analyze the patterns of recurrence following intraoperative radiofrequency ablation (RFA) combined with hepatic resection for patients with colorectal liver metastases (CLM). Methods Patients undergoing liver resection (with or without RFA) for CLM were examined. Rates and patterns of disease recurrence, as well as overall survival were assessed using Kaplan–Meier and Cox analyses. Results A total of 174 patients underwent liver resection for CLM (150 without and 24 with intraoperative RFA). RFA was used to treat 41 tumors (median 1.6 cm). The 3-year overall survival was 65.5% and 61.4% (adjusted HR 1.02, 95% CI 0.55–1.88). Median recurrence-free survival was 7.4 versus 12.7 months with RFA versus non-RFA, respectively (adjusted HR 1.51, 95% CI 0.94–4.42). On multivariate analysis, neither survival nor recurrence-free survival was significantly associated with RFA. In total, there were two RFA ablation zone local failures. An ablation site recurrence was the sole site in one patient (4.2%). Conclusion RFA was used as an adjunct to resection in patients with greater disease burden. Despite this, RFA was not significantly associated with a higher risk of local failure and was not associated with worse survival, when compared with liver resection alone. J. Surg. Oncol. 2014 110:734–738. © 2014 Wiley Periodicals, Inc.

Summary The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri-operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra-abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, ‘hard’ evidence – i.e. high-quality prospective randomised controlled trials – is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.

Purpose To assess the impact of preoperative evaluation by gadoxetic acid-enhanced magnetic resonance imaging (MRI) on early recurrence outcomes after hepatocellular carcinoma (HCC) resection. Materials and Methods The retrospective study included two groups of Child-Pugh class A patients who underwent curative liver resection for a single HCC; in one group the HCC was identified by dynamic computed tomography (CT) and gadoxetic acid-enhanced MRI (n = 174; MRI group); in the other by dynamic CT only (n = 416; non-MRI group). We compared the two groups with respect to recurrence-free survival after propensity score matching (162 pairs). Results In the matched cohorts, disease-free survival rates for overall and intrahepatic recurrence were 92.6% and 91.9% at 1 year and 78.3% and 79.4% at 2 years, respectively, for the MRI group versus 82.7% and 82.7% at 1 year and 67.2% and 70.4% at 2 years, respectively, for the non-MRI group (P

Single-incision laparoscopic hepatic resection has been attracting increased attention from the surgical community in recent years. While there have been reports and studies on this procedure, none has suggested the possibility of doing repeated hepatic resections via a single incision. This report on three such cases aims to determine the feasibility and safety of this approach for such patients. Three patients who had previously had liver resections underwent single-incision laparoscopic hepatic resection in our center. Patient demographics, type of port and instruments used, operating time, complications and incision length were collected. The operating time in each case was less than 230 min. The incision length for the single-port device was 3.5 cm or less. The length of hospital stay was less than 5 days in each case. Intra-operative blood loss was limited to 250 mL in each case. There were no immediate postoperative complications related to hepatic resection. Single-incision laparoscopic hepatic resection is feasible for selected patients who have had previous hepatic resections. Because the port entry site for the single-incision laparoscopic approach is usually slightly larger than that for the conventional approach, it is safer in re-resection cases where there may be adhesions from previous surgery. Other possible benefits, such as cosmesis and reduced port-associated morbidity, are mainly related to the use of only one small incision.

The liver represents a common site for metastasis in colorectal cancer. Improvements in patient selection and surgical techniques has resulted in improved outcomes following hepatic metastasectomy with large series reporting 5- and 10-year overall survival rates of 40% and 20%, respectively. In recent years, criteria for resectability has expanded with the use of forced liver hypertrophy and staged resection. The role of perioperative chemotherapy remains controversial with a slight increase in survival and operative morbidity.

Background The optimal cut-off value of the number of colorectal liver metastases (CRLM) to predict prognosis after hepatic resection remains unclear. This study was conducted to determine a suitable cut-off value. Methods A total of 727 hepatectomized patients with CRLM were evaluated. We proposed the following optimal cut-off values: first, a small P-value for the log-rank test with no overlapping of the 95% confidence interval (CI) for median survival time using the Kaplan–Meier method and the hazard ratio (HR) using the Cox proportional hazards model and, second, the maximum HR value for accurate separation. Results For disease-free survival analysis, of the three group separations, A2 (1, 2–4, and ≥5) showed a small P-value and the largest HR, whereas two group separations, B2, B3 and B4 showed similarly small P-values, but B4 (1–4, ≥5) indicated the largest HR. Regarding the overall survival analysis, of the three group separations, A2 showed the smallest P-value, whereas the two group separations, B4 showed similarly small P-values, with the largest HR. Conclusions Tumor number separation in patients with CRLM after hepatic resection should be performed using the A2 (1, 2–4, and ≥5) or B4 (1–4 and ≥5) classifications.

BACKGROUND This study retrospectively compared the safety and efficacy of percutaneous radiofrequency ablation (RFA) with open hepatic resection (HR) in elderly patients (age > 65 years) with very early or early hepatocellular carcinoma (HCC). METHODS Elderly patients (n = 180) with very early or early HCC were studied. This study was approved by the Ethics Committee of the Cancer Center of Sun Yat-Sen University, Guangzhou, China. Written informed consent was obtained from each patient before treatment. As an initial treatment, 89 patients were treated by RFA and 91 patients by HR. The survival curves were constructed by the Kaplan-Meier method and compared by log-rank test. RESULTS The 1-, 3-, and 5-year overall survivals were 93.2%, 71.1%, and 55.2% for the RFA group and 88.8%, 62.8%, and 51.9% for the HR group, respectively (P = .305). The corresponding recurrence-free survivals for these 2 groups were 84.1%, 62.7%, and 35.5% and 76.7%, 39.3%, and 33.1%, respectively (P = .035). On subgroup analysis for tumor ≤ 3 cm, the 1-, 3-, and 5-year overall survivals were 94.2%, 82.6%, and 67.5% for the RFA group and 90.1%, 65.0%, and 55.1% for the HR group, respectively (P = .038). The corresponding recurrence-free survivals for the 2 groups were 85.5%, 69.1%, and 40.7%, and 82.2%, 40.1%, and 31.8%, respectively (P = .049). For tumor > 3 cm, there was no significant difference between these 2 groups for overall survivals and recurrence-free survivals (P = .543, P = .356, respectively). A multivariate regression analysis showed that treatment type was the only significant prognostic factor for recurrence-free survival (P = .039). CONCLUSIONS There was no difference between the HR and RFA groups for overall survival, but RFA had better efficacy than HR for elderly patients with HCC ≤ 3 cm. Cancer 2013;119:3812–3820. © 2013 American Cancer Society.