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BACKGROUND: Liver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.METHODS: In this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.RESULTS: In total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02-1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.CONCLUSION: Thirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.

Background Laparoscopic redo resections for colorectal metastases are poorly investigated. This study aims to explore long-term results after second, third, and fourth resections. Material and methods Prospectively updated databases of primary and redo laparoscopic liver resections in six European HPB centers were analyzed. Procedure-related overall survival after first, second, third, and fourth resections were evaluated. Furthermore, patients without liver recurrence after first liver resection were compared to those with one redo, two or three redo, and patients with palliative treatment for liver recurrence after first laparoscopic liver surgery. Survival was calculated both from the date of the first liver resection and from the date of the actual liver resection. In total, 837 laparoscopic primary and redo liver resections performed in 762 patients were included (630 primary, 172 first redo, 29 second redo, and 6 third redo). Patients were bunched into four groups: Group 1—without hepatic recurrence after primary liver resection (n = 441); Group 2—with liver recurrence who underwent only one laparoscopic redo resection (n = 154); Group 3—with liver recurrence who underwent two laparoscopic redo resections (n = 29); Group 4—with liver recurrence who have not been found suitable for redo resections (n = 138). Results No significant difference has been found between the groups in terms of baseline characteristics and surgical outcomes. Rate of positive resection margin was higher in the group with palliative recurrence (group 4). Five-year survival calculated from the first liver resection was 67%, 62%, 84%, and 7% for group 1, 2, 3, and 4, respectively. Procedure-specific 5-year overall survival was 50% after primary laparoscopic liver resection, 52% after the 1st reoperation, 52% after the 2nd, and 40% after the 3rd reoperation made laparoscopic. Conclusions Multiple redo recurrences can be performed laparoscopically with good long-term results. Liver recurrence does not aggravate prognosis as long as the patient is suitable for reoperation.

Background Complex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery. Methods AKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality. Results Overall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS. Conclusion Following extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.

The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs).The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations.Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.

BACKGROUND This study aims to compare the short- and long-term outcomes of patients undergoing minimally invasive liver resection (MILR) versus open liver resection (OLR) for nonrecurrent hepatocellular carcinoma (HCC). METHODS Review of 204 MILR and 755 OLR without previous LR performed between 2005 and 2018. 1:1 coarsened exact matching (CEM) and 1:1 propensity-score matching (PSM) were performed. RESULTS Overall, 190 MILR were well-matched with 190 OLR by PSM and 86 MILR with 86 OLR by CEM according to patient baseline characteristics. After PSM and CEM, MILR was associated with a significantly longer operation time [230 min (interquartile range [IQR], 145-330) vs. 160 min (IQR, 125-210), p

Aim. To analyze the safety and advantages of central resection in comparison with extended hepatectomies. Methods. From June 2017 to May 2020 29 central and extended liver resections for children were performed. Central hepatic resections were carried out in 8, extended hepatectomies – in 21 patients. Preoperative investigations, intraoperative and postoperative data in both groups were analyzed.Results. The main indication for surgery was hepatoblastoma. Future liver remnant volume was significantly higher in central resections group (р = 0.003). No difference in median operative time (р = 0.94), intraoperative blood loss (р = 0.078) and blood transfusion rate (р = 0.057) were found between groups. There were no postoperative complications difference. Also no difference in hospital stay length (р = 0.3) were found.Conclusion. In comparison with extended procedures, central liver resection has similar complication rate. Central hepatectomy is a safe procedure in children with liver tumors, which allows to preserve more healthy parenchyma.

BACKGROUND Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging. METHODS There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases. RESULTS Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited. DISCUSSION The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.

Zusammenfassung Hintergrund Das hepatozelluläre Karzinom (HCC) ist der häufigste maligne Lebertumor in einer Leberzirrhose. Neben der Lebertransplantation stellt die Leberresektion in kompensierter Zirrhose eine kurative Therapieoption dar, die jedoch mit einer höheren postoperativen Morbidität und Mortalität einhergeht. Patienten Es wurden 108 Patienten identifiziert, die mit einer Leberzirrhose im Zeitraum von Januar 2008 bis Dezember 2019 an der Universitätsmedizin Mainz eine Leberresektion erhalten haben. Im gleichen Zeitraum wurden 185 Resektionen wegen eines HCC in nicht zirrhotischer Leber durchgeführt. Als weitere Kontrollgruppe dienten 167 Resektionen wegen kolorektaler Lebermetastasen (CRLM), die dem Ausmaß der Resektionen in Leberzirrhose entsprachen. Neben den generellen Patientencharakteristika wurde bei allen Patienten präoperativ der Charlson Comorbidity Index (CCI) erhoben und der MELD-/Child-Score bestimmt. Die perioperative Morbidität wurde nach der Clavien-Dindo-Klassifikation erfasst. Resektionen eines HCC in Zirrhose und kolorektaler Lebermetastasen wurden zudem in einer Match-Pair-Analyse verglichen. Ergebnisse Die 3 Gruppen waren hinsichtlich des Alters zum Operationszeitpunkt vergleichbar. Die präoperative Leberfunktion war bei Patienten mit CRLM signifikant besser (p Schlussfolgerung Resektionen in einer Leberzirrhose sind bei einer Begrenzung des Resektionsausmaßes und entsprechender Patientenselektion mit einem vertretbaren Risiko möglich. Komorbiditäten erhöhen zusätzlich zu einer Einschränkung der Leberfunktion die postoperative Mortalität, weshalb diese unbedingt in die Patientenselektion integriert werden sollten.

Background Laparoscopic anatomic hepatectomy (LAH) has gradually become a routine surgical procedure. However, how to expose the whole hepatic vein and avoid the hepatic vein laceration is still a challenge because of the caudate lobe, particularly in right hepatectomy. We adopted a dorsal approach combined with Glissionian appraoch to perform laparoscopic right anatomic hepatectomy (LRAH). Methods Twenty patients who underwent LRAH from January 2017 to November 2018 were retrospectively analysed. Of these patients, seven patients underwent laparoscopic right hemihepatectomy (LRH group), seven patients who underwent laparoscopic right posterior hepatectomy (LRPH group), and six patients who underwent laparoscopic hepatectomy for segment 7 (LS7 group). The paracaval portion of caudate lobe could be transected firstly through dorsal approach and the corresponding major hepatic vein could be exposed from its root to the peripheral branches safely. Due to exposure along the major hepatic vein trunk, the remaining liver parenchyma could be quickly transected from dorsal to cranial side. Results The mean age of the patients was 53.8 years and the male: female ratio was 8:12. The median operation time was 306.0 ± 58.2 min and the mean estimated volume of blood loss was 412.5 ± 255.4 mL. The mean duration of postoperative hospital stay was 10.2 days. The mean Pringle maneuver time was 64.8 ± 27.7 min. Five patients received transfusion of 2–4 U of red blood cells. Two patients suffered from transient hepatic dysfunction and one suffered from pleural effusion. None of the patients underwent conversion to an open procedure. The operative duration, volume of the blood loss, Pringle maneuver time, and postoperative hospital stay duration did not differ significantly among the LRH, LRPH, and LS7 groups (P > 0.05). Conclusions Dorsal approach combined with Glissonian approach for right lobe is feasible and effective in laparoscopic right anatomic liver resections.

Glisson’s sheath was discovered by Johannis Walaeus in 1640. Francis Glisson published his book entitled Anatomia Hepatis in 1654 and accurately portrayed the essential anatomy of the major vessels of the liver, The Glisson’s capsule wraps the portal vein, hepatic artery and bile duct and these three structures are therefore regarded as forming one morphological system, which since then has been referred to as the Glissonean system.

Backgrounds/Aims Laparoscopic major liver resections are still considered innovative procedures despite the recent development of laparoscopic liver surgery. Robotic surgery has been introduced as an innovative system for laparoscopic surgery. In this study, we investigated surgical outcomes after major liver resections using robotic systems. Methods From January 2009 to October 2018, 70 patients underwent robotic major liver resections, which included conventional major liver resections and right sectionectomy. The short-term and long-term outcomes were compared with 252 open major resections performed during the same period. Results Operative time was longer in the robotic group (472 min vs. 349 min, p

BACKGROUND Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited. MATERIALS AND METHODS We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma. RESULTS No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203). CONCLUSIONS The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

The aim of this study was to evaluate the short- and long-term results and risk factors of liver surgery in patients over the age of 70 following liver resection for colorectal liver metastases. A total of 650 patients with an average age of 63.8 ± 9.3 years were evaluated. We compared groups of patients younger and older than 70 years of age. Time of hospitalisation, 30-day postoperative morbidity and mortality, overall and recurrence-free survival, the number and largest diameter of metastases, small and large liver resections, and the interval between primary colorectal and liver surgery were evaluated according to the results of liver resections. Length of hospitalisation, 30-day postoperative morbidity and mortality, and long-term results did not differ between groups of patients. Pulmonary embolism and confusion had a higher incidence in patients ≥70 years old (p

Background In patients with colorectal liver metastases, the possibility for radical liver resection can be limited by oxaliplatin-induced sinusoidal obstruction syndrome (SOS). This study investigates the potential of mesenchymal stem cells (MSC) to improve the outcome of liver resections in pigs with SOS. Materials and methods SOS was induced in all animals (n=20) on day 0. Animals in the experimental group (n=8) received allogeneic MSC on day 7. Liver resection was performed in all animals on day 14 and the animals were observed until day 28. Ultrasound volumetry, biochemical analysis and histological examination of liver parenchyma was performed during the follow-up period. Results Six animals from the control group died prematurely, while all animals survived in the experimental group. According to histology, biochemical analysis and ultrasound volumetry, there were no significant differences between the groups documenting the effect of MSC. Conclusion Single dose allogeneic MSC administration improved survival of animals with SOS undergoing partial liver resection. Further experiments with different timing of liver resection and MSC administration should be performed to investigate the effect of MSC in more detail.

Background The aim of the study was to determine the value of synchronous liver resection in patients with oligo-metastatic gastric cancer and the prognostic factors in these patients. Patients and methods We compared the results of 21 gastric patients with liver metastases and synchronous liver resection (LMR) to 21 propensity score-matched patients with gastric cancer and liver metastases in whom liver resection was not performed (LM0) and to a propensity score-matched control group of 21 patients without liver metastases and stage III and IV resectable gastric cancer (CG). Results The overall 5-year survival of LMR, LM0 and CG were 14.3%, 0%, and 19%, respectively (p = 0.002). Five-year survival was 47.5% for well-differentiated tumour compared to 0% in patients with moderate or poor tumour differentiation (p = 0.006). In addition, patients with R0 resection and TNM stage N0–1 had a significantly better survival compared to patients with TNM N stage N2–3 (5-year survival: 60% for N0–1 vs. 7.7% for N2–3; p = 0.007). Conclusions The results presented in the study support synchronous liver resections in gastric patients and provide additional criteria for patient selection.

The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process. Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients. Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p

Laparoscopic segment 7 segmentectomy and segment 6–7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach. The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally. Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days. The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.

Background The debate over the surgical strategy optimization in colorectal cancer patients with liver metastases (mCRC) has been ongoing in the last 20 years. However, parenchyma sparing surgery (PPS) in cases of hard to reach liver cites (HTRLC) remain to be controversial. Methods A prospective analysis of 185 mCRC patients performed who were devided in two groups depending by predominant liver cite localization. Peripherally localized metastases (PLM) (n = 107) (S2, S3, S6, S7, Spiegel lobe and subcapsular area 1–2 cm below the liver surface). Group 2 included those with metastases localized in HTRLC (n = 78) - metastatic lesions of the “right venous core”, portal and caval hilum, paracaval part of S1, “deep” parenchyma cites of S5, S8 and S4. Results In 26 (33,3%) and 32 (29,9%) patients of HTRLC and PLM, respectively, performed one liver re-resection (0,62). In HTRLC group 2 and more re-resection were performed in 7 (8,9%) cases while in PLM in 11 (10,3%), p = 0,76. Postoperative major morbidity was 24,4%, 21,8% (p = 0,15) and mortality 8,9%, 4,6% for HTRLC and PLM groups, respectively. R1v principles were implemented in 24 (30,7%) cases with centrally located metastases and in only 6 cases (5.6%) with peripheral localized metastases (p = 0,001). Cumulative 3-year disease-free survival (DSF) for PLM and HTRLC groups was 63% and 41% (p = 0,008). DFS for R1v (n = 24) and R0 (54) cochorts in HTRLC group was 33% and 43%, respeсtively (p = 0,44). Conclusions Principles of the PPS tactic provides an adequate removal of metastatic lesions in hard to reach liver cites allowing to maintain organ functions and increases the feasibility of the repeated liver resections in case of the initial disease progression., Highlights • The parenchymal preserving surgery allows to remove adequately metastatic lesions in “hard to reach liver cites”. • Сumulative 3-year disease-free survival between groups PLM and HTRLC was was in total 63% and 41%, respectively (p=0,008). • R1v detachment in combination with modern chemotherapy may be an effective method to reduce the cohort of unresectable cases.

Severe ischemic changes of the liver remnant after hepatectomy could expedite tumor recurrence on the residual liver. Our study aimed at assessing the effect of warm ischemic/reperfusion (I/R) injuries on surgery-to-local recurrence interval and patient overall survival, during major hepatectomies under inflow and outflow vascular control.One hundred and eighteen patients were subjected to liver resection under total inflow and outflow vascular clamping and were assigned as study group. These individuals were retrospectively matched to 112 counterparts, who underwent liver surgery applying inflow and outflow vascular clamping only of the segment harboring the tumor, sparing the liver remnant from any I/R injury (control group). The two cohorts were compared regarding recurrence-free survival and overall survival.Reversible I/R injuries of the liver remnant subjected to vascular clamping were manifested, with increase of AST values at postoperative day 2 in the study group, as compared to the control group (603 ± 270 U/L vs. 450 ± 290 U/L, p 0.001), reversing to normal by day 7. Recurrence-free survival and overall survival were no significantly different between the two groups (log rank statistic p = 0.298 and 0.639, respectively).Reversible I/R injuries of the liver remnant do not seem to be implicated in the precipitation of local malignant recurrence or in shorter long-term survival, in comparison to a technique sparing the residual liver of I/R injury. This retrospective cohort study was registered at clinicaltrials.gov under unique identifying number: NCT04257240.

Summary Aim of the study Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: “classic”, “combined”, and “liver-first”. The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival. Patients and Methods Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) “classic”: surgery of primary tumor and then surgery of sCRLM; (2) “combined”: combined surgery of primary tumor and sCRLM: and (3) “liver-first”: surgery of sCRLM and then surgery of primary tumor. Results During this period, 170 patients who underwent 209 hepatectomies were included (“classic”: 149, “combined”: 34, “liver-first”: 26). The rate of severe complications was higher in the “combined” group compared to the “classic” group (35% vs. 12%, P = 0.03), and the “liver-first” group (35% vs. 19%, P = 0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups. Conclusion All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The “combined” strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Multidisciplinary tumour clinics represent the modern state-of-the-art cancer care. However, liver tumour clinics are resource exhaustive and establishing them in resource restricted scenarios is a challenge. We present core concepts in establishing a multidisciplinary tumour clinic, followed by our 5-year experience of multidisciplinary liver tumour clinic from Tata Memorial Hospital Mumbai, India, which represents one of the largest hepatobiliary oncology units in the country. This study provides a roadmap for setting up a multidisciplinary liver tumour clinic and explains the stepwise real-time working of the clinic. The account will act as a blueprint for the establishment of such clinics in the country and abroad.

The “Small-for-Size” syndrome is defined as a liver failure after a liver transplant with a reduced graft or after a major hepatectomy. The later coined “Small-for-Flow” syndrome describes the same situation in liver resections but based on hemodynamic intraoperative parameters (portal pressure > 20 mmHg and/or portal flow > 250 ml/min/100 g). This focuses on the damage caused by the portal hyperafflux related to the volume of the remnant. Relevant studies were reviewed using Medline, PubMed, and Springer databases. Portal hypertension after partial hepatectomies also leads to a higher morbidity and mortality. There are plenty of experimental studies focusing on flow rather than size. Some of them also perform different techniques to modulate the portal inflow. The deleterious effect of high posthepatectomy portal venous pressure is known, and that is why the idea of portal flow modulation during major hepatectomies in humans is increasing in everyday clinical practice. Considering the extensive knowledge obtained with the experimental models and good results in clinical studies that analyze the “Small-for-Flow” syndrome, we believe that measuring portal flow and portal pressure during major liver resections should be performed routinely in extended liver resections. Applying these techniques, the knowledge of hepatic hemodynamics would be improved in order to advance against posthepatectomy liver failure.

Radical tumor removal remains the key task in hepatoblastoma surgery. Patients who need extended resection and have a risk of posthepatectomy liver failure are particularly difficult. In cases with insufficient future liver volume, the method of choice is a two-staged hepatectomy or liver transplantation. Despite the wide spread of laparoscopic liver surgery in adults, the minimally invasive approach has not been studied in pediatrics, and the literature on this issue is scarce. In current publication a case of successful partial associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) in a child, firstly accomplished pure laparoscopically. Described experience suggests the feasibility of laparoscopic liver resections in children and effectiveness of partial in situ liver splitting to reach appropriate future liver remnant volume and to avoid liver transplantation and its disadvantages.

Major liver resections are limited by the volume of future liver (FLR) remnant with the risk of subjecting patient to post surgery liver failure. This increases morbidity and mortality of the patients. However, the technique of ipsilateral portal vein embolisation (PVE) has given surgeons extra mileage to consider major liver resections previously thought to be unresectable. Al cases should be discussed in a multidisciplinary setting. A good knowledge of portal anatomy and variations should be known as part of selection procedure for PVE. Base liver functional status should be reviewed before consideration given to PVE. CT volumetry assessment should be made before and after PVE to assess for resectability. Multiple embolic materials are used in current practice, but none have shown superiority. Several complications are related to application of PVE, however it is generally regarded a safe procedure. Atleast four weeks are required to assess for FLR with repeat abdominal cross-sectional imaging. Patients with normal liver function tests achieve maximum hypertrophy in four weeks versus patients with underlying liver disease. Liver surgery is scheduled upto 2 to 6 weeks following embolisation. The aim of this article is to provide an overview of current indications, technique, complications and outcomes following PVE.

The aim — to determine the role and effectiveness of various surgical treatment methods for liver echinococcosis, depending on the type of echinococcal cyst, its location and size.Materials and methods. A treatment results analysis of 56 patients with liver echinococcosis who were treated in the clinic from 2008 to 2018 was performed. There were 42.9 % of men and 57.1 % of women. The mean age of the patients was 48 ± 2.3 years. The standard examination algorithm included mandatory contrast enhanced CT and the detection of antibodies to echinococcus in blood serum in addition to routine laboratory and instrumental tests. CL type of cysts were detected in 3 patients (5.4 %), type CE1 in 27 patients (48.2 %), type CE2 in 10 cases (17.9 %), type CE3 in 12 cases (21.4 %), type CE4 — 5 — in 4 patients (7.2 %). Patients underwent various surgical interventions, depending on the type of echinococcal cyst. PAIR was used in 3 patients (5.4 %), PAIRD was used in 7 patients (12.5 %). Echinococcectomy was performed in 17 patients (30.4 %) The open approach was performed in 8 patients (14.3 %), and laparoscopic approach — in 9 cases (16.1 %). Pericystectomy was performed in 19 patients (33.8 %)/The open approach was used in 16 cases (28.4 %), and laparoscopic approach — in 3 cases (5.4 %). In another 10 cases (17.9 %), liver resections varying from segmentectomy to hemihepatectomy were performed.Results and discussion.Bile leakage via the drainages of the abdominal cavity was observed in 7 cases (12.5 %). Allergic reactions of varying severity were observed in 3 cases (5.6 %). The recurrence of decease was noted in 2 patients (4 %). There was no lethality in this group of patients.Conclusions. The absence of a unified surgical tactics for liver echinococcosis requires the use of an individualized approach. The choice of treatment method depends on the location and size of the cyst, the stage of parasite development. Postoperative therapy with albendazole (mebendazole) in the presence of a live parasite is required. In the presence of a non‑living parasite (cysts of type CE4 — CE5) it is advisable to use observant tactics., Цель работы — определить роль и эффективность разных способов хирургического лечения эхинококкоза печени в зависимости от типа эхинококковых кист, их локализации и размера.Материалы и методы. Проанализированы результаты лечения в клинике Института общей и неотложной хирургии имени В. Т. Зайцева НАМН Украины в период с 2008 по 2018 г. 56 больных с эхинококкозом печени. Среди них мужчин было 42,9 %, женщин — 57,1 %. Средний возраст пациентов составил (48,0 ± 2,3) года. Стандартный алгоритм исследования, кроме рутинных лабораторных и инструментальных исследований, предусматривал обязательное выполнение компьютерной томографии с контрастным усилением и выявление антител к эхинококку в сыворотке крови. Кисты типа CL диагностированы у 3 (5,4 %) больных, типа CE1 — у 27 (48,2 %), типа СЕ2 — у 10 (17,9 %), типа СЕ3 — у 12 (21,4 %), типа СЕ4 и СЕ5 — у 4 (7,2 %). Пациентам были выполнены разные оперативные вмешательства в зависимости от типа эхинококковой кисты. Методика PAIR применена у 3 (5,4 %) больных, PAIRD — у 7 (12,5 %). Эхинококкэктомия выполнена у 17 (30,4 %) пациентов, в частности в открытом варианте — у 8 (14,3 %), в лапароскопическом — у 9 (16,1 %), перицистэктомия — у 19 (33,8 %), в частности в открытом варианте — у 16 (28,4 %), с использованием лапароскопического доступа — у 3 (5,4 %). Еще в 10 (17,9 %) наблюдениях проведены разные по объему резекции печени (от сегментэктомии до гемигепатэктомии).Результаты и обсуждение. Желчеистечение по дренажам брюшной полости отмечено в 7 (12,5 %) наблюдениях, аллергические реакции разной степени выраженности — в 3 (5,6 %), рецидив — в 2 (4,0 %). Случаев летального исхода не было.Выводы. Отсутствие единой хирургической тактики при эхинококкозе печени требует использования индивидуального подхода. Выбор метода лечения зависит от локализации и размера кисты, стадии развития паразита. Послеоперационная терапия альбендазолом (мебендазолом) при наличии живого паразита обязательна. В случае неживого паразита (кисты типа СЕ4 — СЕ5) целесообразно использовать выжидательную тактику., Мета роботи — визначити роль та ефективність різних способів хірургічного лікування ехінококозу печінки залежно від типу ехінококових кіст, їх локалізації та розміру.Матеріали і методи. Проаналізовано результати лікування в клініці Інституту загальної та невідкладної хірургії імені В. Т. Зайцева НАМН України в період з 2008 до 2018 р. 56 хворих з ехінококозом печінки. Серед них чоловіків було 42,9 %, жінок — 57,1 %. Середній вік пацієнтів становив (48,0 ± 2,3) року. Стандартний алгоритм дослідження, крім рутинних лабораторних та інструментальних досліджень, передбачав обов’язкове виконання комп’ютерної томографії з контрастним посиленням і виявлення антитіл до ехінококу в сироватці крові. Кісти типу CL діагностовано у 3 (5,4 %) хворих, типу CE1 — у 27 (48,2 %), типу СЕ2 — у 10 (17,9 %), типу СЕ3 — у 12 (21,4 %), типу СЕ4 та СЕ5 — у 4 (7,2 %). Пацієнтам були виконані різні оперативні втручання залежно від типу кісти. Методику PAIR застосовано у 3 (5,4 %) хворих, PAIRD — у 7 (12,5 %). Ехінококектомію виконано у 17 (30,4 %) пацієнтів, зокрема у відкритому варіанті — у 8 (14,3 %), в лапароскопічному — у 9 (16,1 %), перицистектомію — у 19 (33,8 %), зокрема у відкритому варіанті — у 16 (28,4 %), з використанням лапароскопічного доступу — у 3 (5,4 %). Ще в 10 (17,9 %) спостереженнях проведено різні за обсягом резекції печінки (від сегментектомії до гемігепатектомії).Результати та обговорення. Жовчовитікання по дренажах черевної порожнини відзначено в 7 (12,5 %) спостереженнях, алергічні реакції різного ступеня вираження — в 3 (5,6 %), рецидив — у 2 (4,0 %). Випадків летального наслідку не було.Висновки. Відсутність єдиної хірургічної тактики при ехінококозі печінки потребує використання індивідуального підходу. Вибір методу лікування залежить від локалізації та розміру кісти, стадії розвитку паразита. Післяопераційна терапія альбендазолом (мебендазолом) за наявності живого паразита обов’язкова. У разі неживого паразита (кісти типу СЕ4 — СЕ5) доцільно використовувати вичікувальну тактику.

Objective: The authors present outcomes of robotic liver resections in comparison with open technique questioning the need to have experience of laparoscopy for such procedures before transition to robotic assisted. Materials and methods: Retrospective review of liver resections done robotically from February 2015 to June 2017 compared to matched control cohort of open cases from January 2012 to December 2016. Results: Twenty-one patients in the study group were compared with matched control of 42 open cases (1:2 ratio). The types of procedure were similar in both the groups. There were 4 left lateral hepatectomy, 3 left hepatectomy, and 1 left hepatectomy with hepatico-jejunostomy, 3 right hepatectomy, 3 right posterior sectorectomy, 4 bisegmentectomy and 4 mono-segmentectomy. There were 9 patients with primary liver cancer, 2 each with liver metastasis and carcinoma gall bladder and 8 patients had benign liver disease. Mean blood loss was 370 ± 311 ml in the robotic group compared to 451 ± 330 ml in control group (p = 0.06). Minor complications developed in 19.0% of robotic cases compared to 40.5% in open surgery, while major complications occurred in 4.7% of robotic cases compared to 7.1% of open cases. Mean hospital stay was 5.3 ± 0.8 days for the robotic group and 7.7 ± 4.2 days for open group (p = 0.02). Local tumor recurrence occurred in 1 out of 13 resections done for malignancy in the robotic group and 7 out of 26 in the open group. Conclusion: This study highlights the utility of surgical robots for segmental and complex liver resections with equivalent outcomes and decreased length of hospital stay compared to open surgery without having experience of same with the laparoscopy. Keywords: Robotic, Liver resection, Open surgery

BACKGROUND In April 2018, a dedicated hepatobiliary unit was established in a tertiary hospital in North Queensland. Changes included the employment of a hepatobiliary-trained surgeon, centralized referrals, and formalized multidisciplinary team meetings. This study aimed to evaluate the impact of establishing a hepatobiliary unit on outcomes after liver resection, in a regional centre where such procedures were previously performed by non-specialist general surgeons. METHODS Adult patients who underwent elective liver resection in Townsville from 2013 to 2020 were included in the study. Outcomes after liver resection were collected across two study periods - before and after the hepatobiliary unit was established. The primary end points were a before and after comparison of the 90-day morbidity and mortality and the R1 margin rates. RESULTS Across the two study periods, 76 and 77 patients, respectively, underwent liver resection. Rates of R1 resection, 90-day mortality and major complications were not significantly different between the two study periods. Primary tumours (14.5% before versus 50.6% after) and cirrhosis (1.3% before versus 14.3% after) were significantly higher in the latter period, as was the median length of stay (4 days before versus 6 days after). Annual surgical volume increased by 75% in the period after 2018 compared to the 5 years preceding it. CONCLUSION Establishing a centralized hepatobiliary unit in a tertiary regional centre resulted in increased surgical volume and case complexity, with no change in early outcomes after liver resection. Overall, this dedicated unit improved the accessibility of a subspecialty surgical service in regional Australia.

Introduction Simultaneous robot assisted colon and liver resections are being performed more frequently at present due to the expanded adoption of the robotic platform for surgical management of metastatic colon cancer. However, this approach has not been studied in detail with only case series available in the literature. The aim of this systematic review was to evaluate the current body of evidence on the feasibility of performing simultaneous robotic colon and liver resections. Methods A systematic review was performed through PubMed to identify relevant articles describing simultaneous colon and liver resections for metastatic colon cancer. Results A total of 28 patients underwent simultaneous resections robotically with an average operative time of 420.3 minutes and average blood loss of 275.6 ml. Postoperative stay was 8.6 days on average with all cases achieving negative surgical margins. Conclusions Robotic simultaneous resection of colorectal cancer with liver metastases is technically feasible and seems oncologically equivalent to open or laparoscopic surgery. Further studies are urgently needed to assess benefits of robotic surgery in the patient population.

The use of the Pringle maneuver (PM) varies widely among surgical departments. Its use depends on the operator and type of liver resection. The aim of this study was to determine the impact of the PM on patient outcomes when undergoing major liver resections. This retrospective study comprised 179 colorectal liver metastasis patients from two liver centers from Leeds and Warsaw. Only right or right extended hepatectomies with negative oncological margins were included. The primary outcome measure was the 5-year overall survival (OS). The PM was applied during 60 (33.5%) major hepatectomies included in the study and was associated with a higher peak 3-day postoperative bilirubin concentration (p = 0.002), yet not with the peak 3-day alanine aminotransferase activity (p = 0.415). The 5-year OS after liver resections with the PM and without the PM were 55.0% and 33.4%, respectively (p = 0.019). Following stratification by the Tumor Burden Score, after resections with the use of the PM, superior survival was particularly found in the subgroup of patients at intermediate risk of recurrence (p = 0.004). However, the use of the PM had no significant effect on the 5-year overall survival following adjustment for the confounding effect of the carcinoembryonic antigen concentration (p = 0.265). The use of the PM had no negative effects on the long-term outcomes in patients undergoing major, oncologically radical liver resections for colorectal metastases.

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. At first diagnosis, HCC is multifocal in about 35–40% of patients (1,2). According to Western guidelines, the treatment of multifocal (non-metastatic) HCC is well codified: transplantation is indicated for HCCs within Milan criteria (2–3 nodules ≤30 mm), ablation for non-transplantable HCCs within Milan criteria, and chemoembolization for the remaining patients (3). Liver resection has no role. Daily practice is much more complex. The term multinodular HCC encompasses a wide range of scenarios, from oligonodular to diffuse disease, from multicentric to metastatic tumors, that require a case-by-case tailored treatment. We are still far from a real solution and several issues deserve further investigations, including the role of surgery, as highlighted by the recently published Japanese series of liver resections for multiple HCCs (1).

Background In recent years, laparoscopic liver resection has elicited growing attention as a safe procedure for various forms of hepatic resection. In the context of an aging population, this study aims to evaluate outcomes in elderly patients (>70 y) compared with younger patients (≤70 y). Methods All consecutive patients undergoing minimally invasive liver resections between December 2013 and January 2018 at the Department of Surgery, Charite–Universitatsmedizin Berlin, were included in this analysis. Patients’ characteristics, such as body mass index, American Society of Anesthesiologists classification, as well as underlying liver disease and function, were examined and the perioperative outcomes of patients aged >70 y (group 1; G1) contrasted with patients aged ≤ 70 y (group 2; G2). Results Of 250 patients, 67 were >70 y old (G1) and 183 were ≤70 y old (G2). Patients in G1 were characterized by a higher body mass index (27.6 kg/m2 versus 24.9 kg/m2; P = 0.004) and impaired physical states (American Society of Anesthesiologists score III/IV; 60% versus 37%; P = 0.002) when compared with group 2. G1 also exhibited higher rates of primary and secondary hepatic malignancies (G1: n = 62; 92.5%; G2: n = 115, 62.8%; P = 0.031) in addition to higher rates of cirrhosis (G1: n = 30, 44.8%; G2: n = 38, 20.8%; P = Conclusions Minimally invasive liver resection is a feasible and safe procedure in elderly patients despite this age group exhibiting a higher rate of primary and secondary malignancy and cirrhosis, as well as an overall more severely compromised physical health when compared with patients under the age of 70 y. Therefore, it stands to reason that patients in poorer general health might particularly benefit from a minimally invasive approach.

Introduction. Synchronous metastases of gastric cancer to the liver occur in 3–14% of patients with this cancer, and metachronous lesions in 37% of patients after radical gastrectomy. Liver resections due to metastases of gastric carcinomas represent only 5–9% of resections due to metastases other than colorectal cancer. Until recently, patients with gastric carcinoma metastases to the liver were classified in the IV stage of cancer and the therapy was limited to chemotherapy or palliative treatment only. Material and methods. The paper presents a current review of literature and the authors’ own experience with liver resection due to gastric cancer metastases into this organ. During 34 months, 488 patients with liver metastases were treated in the Department of General, Transplant and Liver Surgery, of the Medical University of Warsaw, in whom 426 surgical procedures were performed (87.3%). The types of surgical procedures are as follows: minor liver resections in 204 patients (47.9%), hemihepatectomies in 102 patients (23.9%), thermoablations in 86 patients (20.2%) and laparotomies in 34 patients (8.0%). Among patients treated for liver metastases there were 4 patients with metastases from gastric cancer (0.8%), which constituted 1% of patients operated on, but 6.8% of patients with liver metastases from organs other than colorectal cancer. The postoperative course and direct results in all patients operated because of gastric cancer metastases into the liver were very good. Conclusions. In some patients (single metachronous metastasis, no extrahepatic lesions, no peritoneal lesions, with subsequent chemotherapy) liver resection due to metastases from gastric cancer provides a chance for a longer survival.

Rural surgeons are performing operations typically performed by “specialists.” This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = “well prepared”). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), para-thyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.

Objectives: To compare King Saud University Medical City experience in laparoscopic liver resection with our previously established database for open resections. Methods: A retrospective study was conducted at King Saud University Medical City, Riyadh, Saudi Arabia. All adult patients who underwent liver resection from 2006 to 2017 were included. Patients who had their procedure converted to open were excluded. Results: Among the 111 liver resections included, 22 (19.8%) were performed laparoscopically and 89 (80.1%) were performed using the open technique. Malignancy was the most common indication in both groups (78.5%). The mean operative time was 275 min (SD 92.2) in the laparoscopic group versus 315 min (SD 104.3) in the open group. Intraoperative blood transfusion was required in the laparoscopic (9%) and open groups (31.4%). The morbidity rate was 13.6% in the laparoscopic group and 31.4% in the open group, and the mortality rate was 0% in the laparoscopic group and 5.6% in the open group. Conclusion: Laparoscopic liver resection appears to be a safe technique and can be performed in various benign and malignant cases. Saudi Med J 2019; Vol. 40 (5): 452-457 doi: 10.15537/smj.2019.5.24086 How to cite this article: Al-Saif FA, Aldekhayel MK, Al-Alem F, Hassanain MM, Mattar RE, Alsharabi A. Comparison study between open and laparoscopic liver resection in a Saudi tertiary center. Saudi Med J . 2019 May;40(5):452-457. doi: 10.15537/smj.2019.5.24086.

BACKGROUND: Intrahepatic cholangiocarcinoma (IHC) is a malignancy with an increasing incidence. Surgery is the only treatment modality associated with long term survival. The objective of this study is to utilize a nationwide representative database to quantify the trends in incidence, and surgery for IHC in the United States from 2004–2014, as well as identify any disparities in the receipt of surgery. METHODS: All patients admitted with a diagnosis of IHC between 2005 and 2014 were identified from the Nationwide Inpatient Sample (NIS) database. Trends in the number of IHC admissions and surgery procedures as well as outcomes were examined, and a multivariate analysis was used to determine the effects of demographic and clinical co-variables on resection rates. RESULTS: An estimated total of 104,045 IHC related admissions occurred between 2005 and 2014. The hospitalization rate for IHC increased by nearly 2-fold in 2014 [38.9 per 100,000 (95% CI, 35.7–42.2)] from 18.1 per 100,000 (95% CI, 15.8–20.3) in 2005. Liver resections increased 248% (P80 years (OR =0.45; 95% CI, 0.33–0.60), Black race (OR =0.50; 95% CI, 0.39–063), Hispanic race (OR =0.59; 95% CI, 0.45–0.79), Medicaid insurance (OR =0.58; 95% CI, 0.42–0.79) and Elixhauser comorbidity score >3 (OR =0.58; 95% CI, 0.47–0.73) were associated with decreased rates of resection. CONCLUSIONS: Overall hospitalization and volume of surgery for IHC has increased dramatically over the past decade. There has been an increase in cost, decrease in LOS and inpatient mortality during the period. Socioeconomic and racial disparities were observed in the receipt of surgery for IHC. Additional work is needed to understand the complex interplay between socioeconomic status and race in in the treatment of IHC.

Highlights • The volume of the liver that can be resected is limited by the need to leave behind liver tissue of sufficient volume to carry our normal liver functions and allow regeneration. • Two staged hepatectomy and portal vein embolization/ligation allow hypertrophy of the future liver remnant, but the long period required may allow tumor progression. • ALPPS combines portal vein ligation with transection of the liver tissue, inducing rapid hypertrophy of the future remnant liver. • Despite high morbidity and mortality initially, the procedure is now safe due to better technique and the selection criteria. • Future efforts are directed towards better evaluation of liver function, refinements in the technique, and more accurate patient selection., Introduction Associating Liver Partition and Portal Vein Ligation for Staged -hepatectomy (ALPPS) is an evolving procedure that allows rapid hypertrophy of the future liver remnant (FLR). We describe the first two cases performed in Qatar. Case presentations Case 1: A 53 -year old male with sarcoma metastases to the liver 8 years after resection of an abdominal wall tumor, requiring an extended right hepatectomy but with in an inadequate FLR. ALPPS was done and he achieved 147% increase in the volume of the FLR within 6 days (from 15.9%–34.2%). The second stage was completed successfully on day 7. Case 2: A 59-year old male patient had colorectal liver metastases that required an extended right liver resection and had inadequate FLR of 19.8%. Seven days after the first stage, the FLR hypertrophied to 37.7% (90.2% increase in volume) and the second stage was completed successfully on day 8. Both patients had uneventful recovery and no recurrence or complications on follow up. Discussion ALPPS allows large liver resections while circumventing the long delay in the conventional two staged hepatectomy and portal vein ligation/embolization. The reported morbidity and mortality in earlier series was high, but recent selection criteria and technique refinements reduce this morbidity. Many variations are still being reported. Conclusion ALPPS is an evolving technique that adds to the armamentarium of the liver surgeon to allow larger liver resections in a timely manner. It is feasible and safe to be performed with careful selection.

BACKGROUND: nowadays laparoscopic liver resection (LapLR) in contrast to traditional open approach is more preferable because of reduction of intraoperative blood loss and postop morbidity, decrease of postop hospital stay. Unfortunately, the place of LapLR in surgery for colorectal liver metastases is still controversial because of small number of comparative studies. PATIENTS AND METHODS: between November 2017 and December 2018 fifty two patients with resectable colorectal liver metastases were included in our pilot study - 35 in the prospective group for laparoscopic liver resection and 17 patients in retrospective group of open-approach liver resections (selected group of historical control) (OLR). RESULTS: one patient was excluded from LapLR group because of absence of intraoperative evidence for metastatic disease (in spite of preop MRI). Two patients had lap-to-open conversion (in one case because of technical difficulties due to the location of the permanent ileostomy in the right mesogastric region; in the other case due to intraoperative bleeding). These patients were included into open group. Atypical liver resections were the most often procedures in both groups - 79% (23/32) and 76% (13/19), p=0.3 (LapLR and OLR, respectively). Duration of the procedure was shorter in the OLR group: 218+71 min vs. 237+101min in LapLR, p=0.6. The mediana for blood loss in LapLR was 100 ml (quartile 100; 200) vs. 320 ml (quartile 200;600) in OLR, p=0.0001. The rate of R0 resections was comparable in both groups (p=1.0). The patients of OLR group more often had >1 complication (16 vs. 13, p=0.01) and had higher frequency of bile fistulas, abscesses in the liver resection area and clostridial colitis. Postoperative hospital stay was shorter in the LapLR group: 11+3 vs. 14+5 days, p=0.008. CONCLUSION: laparoscopic liver resections for metastases of colorectal cancer were associated with less intraoperative blood loss, morbidity, and shorter postoperative hospital stay, with comparable rate of R0 resections.

Neuroendocrine tumors (NETs) are a relatively rare category of cancers that arise in the gastrointestinal (GI) tract and other organs. Extended hepatectomies including resection of multiple organs are often necessary to achieve negative margins.We performed a review of patients undergoing liver resection for NET liver metastases from 2005 to 2015 using National Surgical Quality Improvement Program. We compared patients undergoing hepatectomy alone (HA) versus hepatectomy and a concomitant GI surgery procedure (colorectal, small bowel, and pancreatic) to evaluate postoperative infectious complications.During the study period, 354 patients underwent liver resection for metastatic NET. Hepatectomy alone was performed in 98 patients, and concomitant GI surgery was performed in 256 patients, including 83 colorectal resections (HCCR), 68 small bowel resections, 75 distal pancreatectomies, and 35 pancreaticoduodenectomies (HCPD). Infectious complications were more likely to occur in those undergoing HCPD (60%, P 0.001), and HCCR (32.5%, P 0.05) than in those undergoing HA (16.3%). Patients undergoing HCPD and HCCR had a 7.69-fold and 2.52-fold increased risk of infectious complication, respectively, compared with HA after adjustment for other infection risk factors.Neuroendocrine liver metastases requiring liver resection with concomitant colorectal resection or pancreaticoduodenectomy are at significantly increased risk of developing infectious complications.

Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection.Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected.There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001).Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

Background Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. Liver resections and transplantations have increasingly become feasible options for potential cure. These complex surgeries are inherently associated with increased rates of readmission. In the meanwhile, hospital readmission rates are rapidly becoming an important quality of care metric. Therefore, it is very important to understand the effect of 30-day readmission on mortality and the factors associated with increased 30- and 90-day mortality rates. Methods This is a retrospective cohort study utilizing data from the National Cancer Database. Patients included were 18 years or older who underwent liver resection or liver transplantation for HCC between 2003 and 2011. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission. Results 16 658 patients underwent either a liver resection or transplantation for HCC between 2003 and 2011. For patients with liver transplantations, increased readmission rates were associated with lower risks of 30-day mortality ( P = .012) but a trend toward higher 90-day mortality ( P = .057). Patients who underwent liver resection for HCC also demonstrated increased readmission rates to be associated with lower risk of 30-day mortality ( P = .014) but higher 90-day mortality ( P ≤ .001). Conclusion This is the only study to utilize a national database to investigate the association between readmission rates and mortality rates of both liver transplantations and resections for patients with HCC. We demonstrate 30-day readmission to show no increase in 30-day mortality, but rather higher 90-day mortality.

Introduction Major hepatectomies are utilized to manage primary hepatic malignancies. Reports from high-volume centers (HVCs) with minimal perioperative mortality focus on multiple aspects of perioperative care, although patient-specific factors remain unelucidated. We identified patient factors associated with outcomes and examined whether these contribute to survival differences. Methods We queried the National Cancer Database (2006-2015) for patients with primary liver malignancies managed with major hepatectomy. Facilities were dichotomized by volume (high volume: >15 hepatectomies/year). Perioperative outcomes were compared based on patient demographic and clinical characteristics as well as center volume. Results 4263 patients were included with 78.5% receiving care in low-volume centers (LVCs). 90-day postoperative mortality was higher in LVCs vs. HVCs (12% vs. 7.5%; P < .001). Factors associated with undergoing surgery in LVCs included: living in areas with lower income ( P = .006) and education ( P < .001), having nonprivate insurance ( P < .001), residing near the care center ( P < .001), and having a comorbidity score (CDS) >1 ( P = .014). Patients with CDS ≤ 1 had higher 90-day mortality in LVCs (11.3% vs. 6.6%; P < .001) and had similar outcomes in LVCs and HVCs (15.6% vs. 13.7% P = .6). Patients with CDS > 1 were more likely to receive care in LVCs (16.3% vs. 12.7%; P < .001). Conclusion Reduced perioperative mortality following major hepatectomy in HVCs is driven by optimal management of patients with low CDS. However, nearly 1 in 5 patients who undergo major hepatectomies have a high CDS and approximately 15% of them succumb in the perioperative period irrespective of the treating centers’ experience.

Background Bile leaks occurring after complex liver resection and lasting >1 week (grade B) usually are managed by means of invasive cholangiography either endoscopic or percutaneous, with a substantial risk of procedure-related complications. The aim of this study was to investigate the ability of gadoxetic acid disodium–enhanced magnetic resonance cholangiography to detect postoperative biliary leaks and avoid invasive cholangiography in case of peripheral location of the fistula. Methods Patients with grade B biliary leak after complex liver resection from January 2018 to March 2020 underwent magnetic resonance cholangiography to guide the management of the leak (study group). The primary endpoint was the ability of magnetic resonance cholangiography to reduce the need for invasive cholangiography with respect to similar posthepatectomy leaks collected in the previous 2 years and approached with upfront invasive cholangiography (controls). A series of in-hospital outcomes also were compared. Results Out of 533 liver resections, 11 study patients versus 11 control patients with grade B leaks were compared. Magnetic resonance cholangiography achieved 100% accuracy in detection and location of the leak. Five out of 6 peripheral leaks healed without invasive cholangiography. Overall, 50% reduction in the use of invasive cholangiography was observed in the study versus control patients. Median healing time and hospital stay were 38 and 40 days in patients undergoing invasive cholangiography versus 10 and 11 days in patients treated conservatively (P = .007 and 0.012, respectively). Infection rate and other complications rate were 82% vs 20% (P = .01) and 35% vs 40% (P = .5), respectively. Conclusion Magnetic resonance cholangiography is a safe, precise, noninvasive tool to detect posthepatectomy bile leaks that can help clinicians in decision-making on conservative versus invasive treatment of fistulas.

Background The purpose of this study was to establish a preoperative clinical-radiomics prediction model of post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma(HCC) and to predict clinical outcome of HCC patients who suffered PHLF. Methods The study included 555 HCC patients who underwent hepatectomy first time from January 2015 to December 2019 in The First Affiliated Hospital of Sun Yat-sen University and Sun Yat-sen University Cancer Center. Gd-EOB-DTPA-Enhanced MRI was performed within 30 days before surgery. Patients in this study didn’t have other tumors or serious organic diseases and were followed up after liver resections for 90 days. We obtained 60720 MR images from 555 patients (an ROI is shown as figure 1), including 390 cases as training data and 165 cases as independent testing data with the standard of PHLF as ISGLS. Through the multiple-model fusion algorithm, we extracted 1044 features per patient from his MR images, screening out feature sets of high contribution by RFE-SVM algorithm and transforming them to FF scores. Clinical indicators, radiologic features and FF scores were included in our LF scoring model through LDA(Linear discriminant Analysis) algorithms. Results The AUC of LF scoring model reached 0.953 (95%CI 0.953–0.963) and 0.945 (95%CI 0.941–0.980) in the training set and the testing set, respectively (Results are shown in figure 3 and figure 4). The model showed the maximum diameter of nodes, PLT, excision site,iMELD score and FF score were independent risk factors of PHLF in HCC patients (OR=1.258, 0.986, 4.670, 1.237, 320.382; P Conclusions The study indicates that LF scoring model has a good predictive value for the occurrence of PHLF in HCC patients and plays a vital role in predicting the clinical outcome of HCC patients who suffered PHLF.

There is a dearth of information about operative outcomes in patients ≥80 years for hepatocellular carcinoma (HCC) from Western institutions. We compare the result of HCC resections in patients80 years vs. patients ≥80 years from our institution in the UK.We conducted a retrospective review of all patients undergoing liver resections for HCC between 2005 and 2015. Demographics, comorbidities, morbidity, mortality and survival were compared between the two age groups.200 patients underwent resection for HCC in this time period. Nineteen patients were ≥80 years and 181 were80 years. Comorbidities measured by the Charlson Comorbidity Index were significantly higher in the ≥80 group (p 0.0001). There was no significant difference in the extent of resection in the two groups. Morbidity and mortality between the80 years and the ≥80 years group were not significantly different (morbidity 27% vs.16%; p = 0.29) (mortality 7% vs. 0%; p = 0.11). The one-year (83.4% vs. 88.2%; p = 0.83), five-year (56.3% vs. 55.8%; p = 0.83) and the overall survival rate rates (887 days vs. 1035 days; p = 0.66) were not significantly different between the groups.Liver resection should not be precluded based on age alone; with good outcomes in patients ≥80 years justifying surgery.

Background Laparoscopic posterosuperior liver resection is a technically difficult and complex surgery. These patients are seen as poor candidates for laparoscopic surgery. This study aimed to show the safe and effective applicability of the posterosuperior segment resections by experienced surgeons in advanced centers. Materials and methods Patients who underwent laparoscopic posterosuperior liver resection between October 2011 and October 2019 at the Groeninge Hospital were evaluated retrospectively. Demographic and perioperative data were obtained from the prospectively maintained database. Resection of at least 3 consecutive Couinaud segments was accepted as a major surgery (trisegmentectomy). Postoperative complications were registered according to the Clavien-Dindo classification. Results The median age of the 174 patients was 68 years [interquartile range (IQR): 60 to 75]. The semiprone position was used in the majority of operations (82.2%). Nonanatomic resection was performed in more than half of the operations (55.1%). A total of 5 patients underwent major hepatic resection. The median time of surgery was 150 (IQR: 120 to 190) minutes. Median blood loss was determined to be 150 (IQR: 50 to 300) mL. Malignancy was detected in 95% of the cases. The surgical margin was reported to be R0 in 93.3% of the specimens. The median hospitalization time was 4 (IQR: 3 to 6) days. The major complication rate was 1.7%, and only 1 patient died. Overall survival rates for patients who underwent a resection for colorectal liver metastases in the first and fifth years were 97.5% and 62.2%, and disease-free survival rates were 69.8% and 35.5%, respectively. Conclusion Laparoscopic resections in the posterosuperior segments can be performed safely in experienced hands with good short and long term (oncologial) outcomes.

We present the unique case of a young female woman with an infected left liver hematoma as a complication of a previous endoscopic retrograde cholangiopancreatography for a choledocolithiasis. Urgent liver resections are rarely indicated and are usually performed in cases of important liver trauma. To our knowledge this is the first case of an urgent liver resection for the rare indication of late hepatic infected hematoma after an ERCP.