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Objective: The aim of the study was to evaluate the survival benefits of liver resection (LR) compared with transarterial chemoembolization (TACE) for patients with multiple hepatocellular carcinomas (HCCs)., Background: Despite significant improvements in diagnostic imaging and the widespread application of screening programs, some patients with HCC continue to present with multiple tumors. The surgical indications for multiple HCCs remain controversial., Methods: Among 77,268 patients with HCC reported in a Japanese nationwide survey, 27,164 patients had multiple HCCs. The exclusion criteria were Child-Pugh B/C, treatment other than LR and TACE, >3 tumors, and insufficient available data. Ultimately, 3246 patients (LR: n = 1944, TACE: n = 1302) were included. The survival benefit of LR for patients multiple HCCs was evaluated by using propensity score matching analysis., Results: The study group of 2178 patients (LR: n = 1089, TACE: n = 1089) seemed to be well matched. The overall survival rate in the LR group was 60.0% at 5 years, which was higher than that in the TACE group (41.6%, P < 0.001). Among patients with a tumor size of 30 mm or more, LR showed a survival benefit over TACE at 5 years (53.0% vs 32.7%, P < 0.001). The multivariate analysis indicated that age, serum albumin level, serum alpha-fetoprotein (AFP) level, macrovascular invasion, tumor size, and TACE were independent predictors of poor prognosis in multiple HCCs., Conclusions: LR could offer better long-term survival than TACE for patients with multiple HCCs (up to 3 tumors). If patients have good liver function (Child-Pugh A), LR is recommended, even for those with multiple HCCs with tumor sizes of 30 mm or more.

Purposes: Postoperative complications are associated with poor overall and cancer-specific survival after resection of various types of cancer, including primary colorectal cancer. However, the oncological impact of surgical site infection (SSI) after liver resection for colorectal liver metastases (CLM) is unclear. The aim of this study was to investigate the oncological impact of SSI after liver resection for CLM., Methods: We reviewed data from 367 consecutive patients treated by curative liver resection for CLM between 1994 and 2015. Patients who underwent simultaneous resection of colorectal cancer and synchronous liver metastases (n = 86) were excluded from the analysis. Short- and long-term outcomes were analyzed., Results: SSI developed in 18 (6.4%) of the 281 patients in the analytic cohort (SSI group). The remaining 93.6% (n = 263) did not suffer this complication (no-SSI group). The operative duration was significantly longer in the SSI group than in the No-SSI group (p = 0.002). The overall survival rates 5 years after liver resection for CLM were 33.3% in the SSI group vs. 50.7% in the No-SSI group (p = 0.043). Multivariate analysis indicated that a liver tumor size ≥ 5 cm, R1 resection, and SSI were independently associated with overall survival after liver resection., Conclusions: SSI after liver resection for CLM is associated with adverse oncological outcomes.

Background: The most frequent pattern of recurrence is remnant liver after hepatectomy for gastric cancer liver metastases (GLM). The evidence of adjuvant hepatic artery infusion chemotherapy (HAIC) after hepatectomy for GLM is lacking. The aim of this study was to evaluate the efficacy of adjuvant HAIC after hemihepatectomy for GLM., Methods: Between 2001 and 2012, 14 patients who underwent hemihepatectomy for GLM were included in this study. Adjuvant HAIC to the remnant hemiliver was the FEM regimen (333 mg/m 2 5-fluorouracil each week, 30 mg/m 2 epirubicin once every 4 weeks, and 2.7 mg/m 2 mitomycin-C once every 2 weeks) and was administered for 6 months after hemihepatectomy. Clinicopathological prognostic factors for survival were analyzed using a prospectively collected database., Results: Nine patients had solitary GLM, and 5 patients had multiple GLM before surgery. The median period from hemihepatectomy to HAIC was 30 days. The 6-month HAIC completion rate was 79% (n = 11/14). Reasons of HAIC failure included liver dysfunction (n = 1), catheter infection (n = 1), and development of multiple recurrence (n = 1). The median follow-up was 29 (range 8-166) months. Recurrences were detected in 8 patients (57%). The site of recurrences included lung (n = 1), lymph nodes (n = 1), peritoneal dissemination (n = 1), brain (n = 1), pleural (n = 1), and multiple sites (n = 3). The overall 5-year survival rate was 43%. The pathological T4 classification and the preoperative CEA ≥5 ng/mL were significant prognostic factors for overall survival., Conclusions: Adjuvant HAIC after hemihepatectomy for GLM prevents remnant liver recurrence and may contribute to long-term survival., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long-term outcomes and recurrence patterns after one-stage resection in patients with bilobar versus unilobar MCLM., Methods: The records of patients undergoing parenchymal-sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching., Results: The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short-term outcomes did not differ between the two groups. Five-year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence-free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver-only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns., Conclusions: The clearance of bilobar MCLM by one-stage resection of parenchymal-sparing intent provided comparable long-term survival to unilobar MCLM., (© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Purposes: Repeat hepatectomy remains the only curative treatment for recurrent colorectal liver metastasis (CLM) after primary hepatectomy. However, the repeat resection rate is still low, and there is insufficient data on the outcomes after repeat hepatectomy. The aim of this study was to investigate the feasibility and prognostic benefit of aggressive repeat hepatectomy for recurrent CLM., Methods: Data were reviewed from 282 consecutive patients who underwent primary curative hepatectomy for CLM between January 1994 and March 2015. The short- and long-term outcomes were analyzed., Results: One hundred ninety-three patients (68 %) developed recurrence, and repeat hepatectomy was conducted in 62 patients. Overall, 62 s, 11 third, 4 fourth, and 1 fifth hepatectomies were performed. The postoperative morbidity and mortality rates were low (11.5 and 1.3 %, respectively). The overall survival rates at 3 and 5 years after primary hepatectomy for CLM in the repeat hepatectomy group were 79.5 and 57.4 %, respectively. A multivariate analysis indicated that postoperative complications were independently associated with overall survival after repeat hepatectomy., Conclusions: Repeat hepatectomy for CLM is feasible, with acceptable rates of perioperative morbidity and mortality, and the potential for long-term survival. However, postoperative complications following aggressive repeat hepatectomy for CLM are associated with adverse oncological outcomes.

Background: Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer., Methods: We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA., Results: Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001)., Conclusions: Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.

Background: In some cases, hepato-biliary-pancreatic (HBP) surgery requires hepatic artery resection and hepatic artery reconstruction (HAR) for histologically curative resection. We describe our surgical HAR technique, which involves continuous suturing, and we report the results of a study of the surgical outcomes., Methods: Between 2000 and 2014, 380 patients underwent radical surgery for advanced HBP malignancies (118 bile duct cancers, 189 pancreatic head cancers, and 73 gallbladder cancers), 24 of whom (6.3 %) underwent HAR (for complete cure of 16 bile duct cancers, 5 pancreatic cancers, and 3 gallbladder cancers). The 24 surgical procedures included 8 hepato-pancreatoduodenectomies, 10 hepatectomies, and 6 pancreatoduodenectomies. The ends of the 2 arteries were spatulated, and the reconstruction was performed with a continuous 7-0 polypropylene suture under loupe magnification., Results: Eighteen right hepatic arteries, 4 left hepatic arteries, and 2 proper hepatic arteries were resected and reconstructed. Median HAR time was 18 min (range 9-31 min). End-to-end anastomosis was performed in 7 patients, and heterogeneous reconstruction was performed in 17 patients (with 9 colic arteries, 4 gastroduodenal arteries, and 4 others). Doppler ultrasonography performed upon vessel reconstruction depicted pulsatile flow within the intrahepatic arteries in all cases, and patency of the reconstructed vessel was confirmed postoperatively by contrast-enhanced CT in 19 patients (82.6 %). Morbidity occurred in 10 patients (42 %), including 4 HAR-related complications: 3 bile leakages and 1 hepatic abscess., Conclusion: Our HAR method can be performed safely and easily by general surgeons. It may be a time-saving procedure that yields acceptable patency and morbidity rates.

Background & Aims: Serum tumour markers for hepatocellular carcinoma (HCC) have less prognostic significance in early stage. Serum Wisteria floribunda agglutinin-positive Mac-2-binding protein (WFA(+) -M2BP) levels are reportedly associated with hepatocarcinogenic potential in patients with chronic liver diseases. We investigated the prognostic significance of pretreatment serum WFA(+) -M2BP levels in patients with early-stage HCC., Methods: A total of 240 patients who underwent hepatic resection for naïve Barcelona Clinic Liver Cancer (BCLC) class 0 or A HCC were analysed. WFA(+) -M2BP and tumour markers for HCC were measured from serum obtained just prior to treatment. Post-operative recurrence and survival rates were compared according to these serum markers, tumour stage and Child-Pugh class., Results: There was an association between serum WFA(+) -M2BP levels and the fibrosis grade of resected noncancerous liver tissue, whereas no association was found between WFA(+) -M2BP levels and tumour progression or liver function. In a multivariate analysis, pretreatment serum WFA(+) -M2BP level was associated with recurrence and survival, respectively, independent of HCC progression or fibrosis grade of resected noncancerous liver tissue. Recurrence rates after hepatic resection were significantly higher in patients with a pretreatment serum WFA(+) -M2BP ≥ 3.00 than those with a pretreatment serum WFA(+) -M2BP < 3.00 (P = 0.0038). Survival rates were lower in patients with a pretreatment serum WFA(+) -M2BP ≥ 3.00 than those with a pretreatment serum WFA(+) -M2BP < 3.00 (P = 0.0187)., Conclusions: Serum WFA(+) -M2BP level is a prognostic factor for recurrence and survival, in addition to tumour progression and liver function, in patients with early-stage HCC treated with curative hepatic resection., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The results of surgical treatment for T2 gallbladder carcinoma are equivocal, while the precise preoperative TNM staging and localization of gallbladder carcinoma are difficult. The aim of this study was to report the validity of segment 4b and 5 (S4b+5) hepatectomy with extrahepatic bile duct resection for these tumors. We reviewed 30 patients with pT2 gallbladder cancer who underwent S4b+5 hepatectomy with extrahepatic bile duct resection. The median number of lymph nodes retrieved in the S4b+5 hepatectomy group was 11 (0-23) nodes, and lymph node metastasis was observed in 9 of 30 (30%) cases. Although all surgical margins were macroscopically negative, 4 of the 30 patients (13%) had pathologically positive margins. The overall survival rate of patients was 85.1% at 5 years. Of the 30 patients with S4b+5 hepatectomy, surgical margin alone was analyzed as a prognostic factor in univariate and multivariate analysis. The survival rate was comparable between the tumor on the hepatic side and peritoneal side (P = 0.856). Nine patients with additional S4b+5 hepatectomy after simple cholecystectomy because of incidental diagnosis of gallbladder cancer also had comparable survival compared to the remaining 21 patients with simultaneous S4b+5 hepatectomy (P = 0.624). S4b+5 hepatectomy with extrahepatic bile duct resection could be good treatment modality for T2 gallbladder cancers because precise preoperative diagnosis of tumor depth, location, and lymph node metastasis for these tumors is difficult.

Background: Liver fibrosis is associated with the prognosis of patients with hepatocellular carcinoma (HCC) after treatment. The laboratory marker for liver fibrosis, the FIB-4 index, is reportedly correlated with the degree of liver fibrosis. We evaluated the predictive value of FIB-4 index on the recurrence and survival of HCC patients who underwent curative hepatectomy., Methods: A total of 431 consecutive patients who underwent hepatectomy for primary, nonrecurrent HCC were analyzed. The FIB-4 index was calculated from the patient's age, serum alanine aminotransferase and aspartate aminotransferase levels, and platelet count at the time of HCC diagnosis. Postoperative recurrence and survival rates were compared according to tumor characteristics, tumor markers, Child-Pugh class, and the FIB-4 index., Results: The pretreatment FIB-4 index was associated with recurrence and survival rates, independent of HCC progression or tumor marker levels in a multivariate analysis. Recurrence rates after hepatectomy were higher in patients with a FIB-4 index >3.25 versus ≤3.25 (5-year recurrence rates 69.6% vs 54.8%; P = .0049). Survival was also worse in patients with a FIB-4 index >3.25 than those with a FIB-4 index ≤3.25 (5-year survival rates 67.1% vs 72.2%; P = .0030)., Conclusion: The FIB-4 index is a predictive marker for long-term outcomes in patients with HCC treated with curative hepatic resection., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We investigated changes in highly sensitive lens culinaris agglutinin A-reactive fraction of alpha-fetoprotein (hsAFP-L3) measured using a novel method and its predictive ability for prognosis in patients with hepatocellular carcinoma (HCC) who underwent curative hepatectomy, comparing to other HCC tumor markers, that is, AFP, des-gamma-carboxy prothrombin (DCP), and AFP-L3 measured with conventional method (cAFP-L3). AFP, DCP, and AFP-L3 including both cAFP-L3 and hsAFP-L3 were measured before and after curative hepatectomy in 187 patients. The percentage of patients with elevated tumor marker levels pre- and postoperatively was compared, and recurrence-free and overall survival rates were analyzed based on changes in tumor markers. The percentages of patients with elevated AFP, DCP, and cAFP-L3 decreased postoperatively. In contrast, the percentage of patients with elevated hsAFP-L3 did not decrease postoperatively. Both recurrence-free and overall survival rates were significantly lower in patients whose tumor marker levels remained elevated postoperatively than patients without tumor marker elevation postoperatively. Recurrence-free and overall survival rates of patients in whom hsAFP-L3 became elevated postoperatively despite normal preoperative hsAFP-L3 levels were significantly lower than those of patients with normal hsAFP-L3 postoperatively, and were similar to those of patients with persistent elevation. Preoperative elevations of AFP, DCP, and cAFP normalized in many patients postoperatively, but not for hsAFP-L3. The elevation of hsAFP-L3 identifies patients with poor prognosis despite the normalization of AFP and DCP., (© 2014 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background & Aims: The gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) often depicts non-hypervascular hypointense hepatic nodules during the hepatobiliary phase in patients with hepatocellular carcinoma (HCC). It is unclear whether the presence of these nodules is associated with HCC recurrence after hepatectomy. We conducted a prospective observational study to investigate the impact of the presence of non-hypervascular hypointense hepatic nodules on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI on the recurrence of HCC after hepatectomy., Methods: A total of 77 patients who underwent hepatectomy for primary, non-recurrent, hypervascular HCC were prospectively followed up after hepatectomy. Post-operative recurrence rates were compared according to the presence of non-hypervascular hypointense nodules on preoperative Gd-EOB-DTPA-enhanced MRI., Results: Recurrence rates after hepatectomy were higher in patients with non-hypervascular hypointense nodules (risk ratio 1.9396 [1.3615-2.7222]) and the presence of non-hypervascular hypointense nodules was an independent factor associated with postoperative recurrence (risk ratio 2.1767 [1.5089-3.1105]) along with HCC differentiation and portal vein invasion. While no differences were found in the rate of intrahepatic metastasis recurrence based on the preoperative presence of non-hypervascular hypointense hepatic nodules, the rate of multicentric recurrence was significantly higher in patients with preoperative non-hypervascular hypointense hepatic nodules., Conclusions: Patients with preoperative non-hypervascular hypointense hepatic nodules detected during the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI are at higher risk of HCC recurrence after hepatectomy, mainly due to multicentric recurrence., (Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background & Aims: Previous studies reported that the combination of three tumor markers for hepatocellular carcinoma (HCC), alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive AFP (AFP-L3), and des-gamma-carboxy prothrombin (DCP), has the ability to discriminate survival among patients with HCC. In those studies, however, the study population included all patients with various treatment modalities, and tumor markers were measured only before treatment. We investigated the prognostic value of a combination of these tumor markers for HCC, measured before and after treatment, on survival and recurrence in patients treated with hepatectomy., Methods: A total of 173 patients who underwent hepatectomy for primary, non-recurrent HCC were analyzed. Tumor characteristics, postoperative survival, and recurrence rates were compared according to the number of elevated tumor markers measured before and after treatment., Results: The correlation between the number of elevated tumor markers before treatment and tumor size, rate of portal vein invasion, and tumor differentiation, respectively, was stronger than that between the number of elevated tumor markers after treatment. In contrast, the number of elevated tumor markers after treatment displayed an excellent ability to discriminate post-treatment survival and recurrence rates compared to that before treatment, and was an independent factor associated with survival and recurrence in multivariate analysis., Conclusions: The combination of tumor markers measured after hepatectomy has a better discriminatory ability for postoperative survival and recurrence in HCC patients treated with hepatectomy in comparison to the combination of tumor markers measured before treatment., (Copyright © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objective: To establish the indications of the liver hanging maneuver for major hepatectomy., Summary Background Data: The liver hanging maneuver, which is a technique of passing a tape along the retrohepatic avascular space and suspending the liver during parenchymal transection, facilitates anterior approach of major hepatectomy. However, the feasibility and limits of this maneuver have never been established in patients with different clinical backgrounds., Methods: Medical records of 242 consecutive patients considered for major hepatectomy using the hanging maneuver were reviewed., Results: Among 242 patients, 14 patients (6%) were considered to have contraindication for this maneuver preoperatively because of tumor infiltration to anterior surface of retrohepatic inferior vena cava (IVC). It was successful in 201 patients with overall feasibility of 88%. The feasibility increased significantly in the recent years as compared with the initial years (94% in 2003-2005 vs. 76% in 2000-2002, P < 0.0001). Bleeding during the retrohepatic dissection occurred in 5 patients (2%), which was minor due to injury of hepatic capsule in 3 (1%) and major due to injury of short hepatic vein in 2 (1%). In all cases, bleeding stopped spontaneously. The maneuver was abandoned in 27 patients, including 15 related to severe adhesion between liver and IVC. Univariate analysis showed that adhesion between IVC and liver was the only significant negative predictor affecting the feasibility. Cirrhosis, large tumor, preoperative radiologic treatments did not influence on the feasibility., Conclusions: The liver hanging maneuver has 94% feasibility in recent years. Absolute contraindication is tumor infiltration to the retrohepatic avascular space. Adhesion between the IVC and liver has a negative impact of the feasibility. According to this indication, the hanging maneuver is easily achievable without risk of the major bleeding during the retrohepatic dissection.

Laparoscopic pancreatic surgery is one of the most difficult procedures, and the adoption of laparoscopic pancreaticoduodenectomy has been limited. The application of laparoscopic surgery has extended to advance cancer, but there have been no reports of laparoscopic pancreaticoduodenectomy after laparoscopic liver resection and distal pancreatectomy. In the present case, a 67‐year‐old woman was diagnosed with remnant pancreatic recurrence of metastatic greater omentum leiomyosarcoma. She had previously undergone laparoscopic distal pancreatectomy and left lateral liver sectionectomy in 2016. We performed laparoscopic subtotal stomach‐preserving pancreaticoduodenectomy in June 2017. The operation time was 274 minutes, and the estimated blood loss was 50 mL. There were no postoperative complications. In summary, laparoscopic pancreaticoduodenectomy is a safe and feasible procedure for a patient who had previously undergone pancreas and liver surgery. [ABSTRACT FROM AUTHOR]

Background: Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long‐term outcomes and recurrence patterns after one‐stage resection in patients with bilobar versus unilobar MCLM. Methods: The records of patients undergoing parenchymal‐sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching. Results: The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short‐term outcomes did not differ between the two groups. Five‐year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence‐free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver‐only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns. Conclusions: The clearance of bilobar MCLM by one‐stage resection of parenchymal‐sparing intent provided comparable long‐term survival to unilobar MCLM. Highlight Fukami and colleagues retrospectively assessed the long‐term outcomes and recurrence patterns after one‐stage resection in patients with bilobar versus unilobar multiple colorectal liver metastases using propensity score matching analysis. No significant differences in overall survival and recurrence patterns after resection were found between bilobar and unilobar multiple colorectal liver metastases. [ABSTRACT FROM AUTHOR]

Purposes: The correct timing of hepatectomy in patients with synchronous colorectal liver metastases is unclear. The aim of this study was to assess the clinical value of simultaneous resection (SR) for patients with colorectal cancer and synchronous liver metastases. Methods: Between January 2006 and December 2013, 158 patients underwent resection of primary colorectal cancer and liver metastases. Sixty-three patients possessed synchronous colorectal liver metastases. Of those with synchronous colorectal liver metastases, 41 patients (65 %) underwent SR, and 22 (35 %) underwent delayed resection (DR). The clinicopathologic and operative data and the surgical outcomes of the patients in the SR and DR groups were retrospectively analyzed. Results: The type of primary/liver resection, liver resection time, total blood loss volume, R0 resection rate, and morbidity rate were similar between the two groups. The SR group was associated with a shorter total postoperative hospital stay (21 vs 32 days, p < 0.001). However, the overall survival rate was similar between the two groups (3-year survival, 65.6 % in the SR group versus 66.8 % in the DR group, p = 0.054). Conclusion: Simultaneous resection of colorectal cancer and synchronous liver metastases is associated with a comparable morbidity rate and shorter hospital stay, even when following rectal resection and major hepatectomy. [ABSTRACT FROM AUTHOR]

Hypothesis: Isolated resection of segment 8 (the right anterosuperior liver segment) is one of the most difficult hepatectomies to perform because of the location of segment 8, the relation between section 8 and the main intrahepatic vessels, and the absence of any anatomical landmarks. The few reports that deal with isolated resection of section 8 generally describe the use of a deep wedge transparenchymal transection. Design: Original surgical technique. Patients and Methods: The proposed technique is based on the extraparenchymal isolation and temporary clamping of the right anterior artery and portal branches, causing ischemic demarcation on the liver surface, which corresponds to the anatomical borders of the right paramedian segments (5 and 8). The liver is widely transected along the main hepatic fissure; then the pedicles of segment 8 are selectively ligated inside the parenchyma, and the resection is accomplished. This technique was used in 10 patients: 5 with hepatocellular carcinoma on cirrhosis and 5 with liver metastases. Results: The mean operation time was 253 minutes. Intraoperative blood loss was minimal in all cases, and 7 patients did not require blood transfusion. Slight complications developed in 3 patients, and there was no operative death. The mean hospital stay was 9.3 days. Conclusions: This operative procedure is safe and ensures a complete anatomical resection of segment 8. The wide opening of the liver parenchyma facilitates hemostasis and makes it possible to obtain a correct resection margin. This technique is recommended for limited metastatic lesions located in segment 8 or for hepatocellular carcinoma arising in a cirrhotic liver. [ABSTRACT FROM AUTHOR]