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Purposes: We sought to investigate the accuracy of abdominal CT scanning for anastomotic leakage and the effect of false-negative scans on the delay in therapeutic intervention and clinical outcome. Method: Data from a prospectively bi-institutionally maintained database of all patients who underwent elective colorectal surgery with primary anastomosis for malignant or benign disease between 2010 and 2017 were reviewed. Patients with confirmed anastomotic dehiscence at reintervention who underwent a postoperative CT scan for suspected leakage were identified and radiological reports were retrieved. Results: Seventy-six patients with anastomotic dehiscence were included in the study. American Society of Anesthesiologists score, sex, type of surgical procedure, malignancy, and type of anastomosis do not correlate with postoperative false-negative CT imaging. Postoperative false-negative CT scan, however, led to delayed reintervention (3 vs. 6h, p = 0.023) and increased mortality (five deaths vs. no deaths, p = 0.043). Free abdominal air (p = 0.001) and extraluminal contrast extravasation (p = 0.001) were found to be predictive of accuracy in anastomotic leakage diagnosis. Conclusion: The suboptimal specificity of a postoperative CT scan in suspected anastomotic leakage after colorectal surgery can delay reintervention and increase mortality.

Background: We aimed to assess the ability of comprehensive complication index (CCI) and Clavien-Dindo complication (CDC) scale to predict excessive length of hospital stay (e-LOS) in patients undergoing liver resection for hepatocellular carcinoma. Methods: Patients were identified from an Italian multi-institutional database and randomly selected to be included in either a derivation or validation set. Multivariate logistic regression models and ROC curve analysis including either CCI or CDC as predictors of e-LOS were fitted to compare predictive performance. E-LOS was defined as a LOS longer than the 75th percentile among patients with at least one complication. Results: A total of 2669 patients were analyzed (1345 for derivation and 1324 for validation). The odds ratio (OR) was 5.590 (95%CI 4.201, 7.438) for CCI and 5.507 (4.152, 7.304) for CDC. The AUC was 0.964 for CCI and 0.893 for CDC in the derivation set and 0.962 vs. 0.890 in the validation set, respectively. In patients with at least two complications, the OR was 2.793 (1.896, 4.115) for CCI and 2.439 (1.666, 3.570) for CDC with an AUC of 0.850 and 0.673, respectively in the derivation cohort. The AUC was 0.806 for CCI and 0.658 for CDC in the validation set. Conclusions: When reporting postoperative morbidity in liver surgery, CCI is a preferable scale.

Objectives Baseline body composition has been associated with dismal outcomes in patients undergoing a variety of major abdominal operations. Whether specific anthropometric indexes can predict morbidity after rectal resection has been poorly investigated. The aims of this study were to assess whether there is a relationship between body mass index and the different computed tomography–assessed body composition indexes, and whether the analysis of different body compartments could be predictive of short-term outcomes in patients undergoing curative surgery for rectal cancer. Methods Computed tomography–derived measures of skeletal muscle and adipose tissue areas of patients undergoing surgery for rectal cancer between January 2009 and December 2016 were used to calculate population-specific thresholds of sarcopenia, subcutaneous adiposity, visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. Association between the aforementioned body composition features were related with overall complication, infection, and anastomotic leak. Results During the study period, 311 patients received surgery and 173 were eligible for an accessible preoperative computed tomography imaging. After surgery, 59 (34.1%) patients experienced a complication, 29 an infection, and 10 an anastomotic failure. The overall morbidity rate was observed more frequently in patients with sarcopenia than in those without sarcopenia (39% versus 17.5%; P = 0.002) and infections (41.4% versus 21.5% respectively; P = 0.024). The presence of myosteatosis also was associated with a higher incidence of overall morbidity (33.9% versus 20.2% in patients without myoteatosis; P = 0.048). Anastomotic failure occurred in 6 of 10 patients with visceral obesity and in 24 of 112 (21.4%) patients without this condition (P = 0.007). Conclusions Some anthropometric indexes are accurate predictors of specific types of morbidity. These findings may allow a more accurate preoperative risk stratification.

OBJECTIVE: The aim of this study was to evaluate correlation between centers' volume and incidence of failure to rescue (FTR) following liver resection for hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: FTR, defined as the probability of postoperative death among patients with major complication, has been proposed to assess quality of care during hospitalization. Perioperative management is challenging in cirrhotic patients and the ability to recognize and treat a complication may be fundamental to rescue patients from the risk of death. METHODS: Patients undergoing liver resection for HCC between 2008 and 2018 in 18 Centers enrolled in the He.Rc.O.Le.S. Italian register. Early results included major complications (Clavien ≥3), 90-day mortality, and FTR and were analyzed according to center's volume. RESULTS: Among 1935 included patients, major complication rate was 9.4% (8.6%, 12.3%, and 7.0% for low-, intermediate- and high-volume centers, respectively, P = 0.001). Ninety-day mortality rate was 2.6% (3.7%, 4.2% and 0.9% for low-, intermediate- and high-volume centers, respectively, P < 0.001). FTR was significantly higher at low- and intermediate-volume centers (28.6% and 26.5%, respectively) than at high-volume centers (6.1%, P = 0.002). Independent predictors for major complications were American Society of Anesthesiologists (ASA) >2, portal hypertension, intraoperative blood transfusions, and center's volume. Independent predictors for 90-day mortality were ASA >2, Child-Pugh score B, BCLC stage B-C, and center's volume. Center's volume and BCLC stage were strongly associated with FTR. CONCLUSIONS: Risk of major complications and mortality was related with comorbidities, cirrhosis severity, and complexity of surgery. These factors were not correlated with FTR. Center's volume was the only independent predictor related with severe complications, mortality, and FTR.

Purpose A preoperative risk score (PRS) to predict outcome of patients with intrahepatic cholangiocarcinoma treated by liver surgery could be clinically relevant.To assess accuracy for broadly adoption, external validation of predictive models on independent datasets is crucial. The objective of this study was to externally validate the score for prediction of long-term outcomes after liver surgery for intrahepatic cholangiocarcinoma proposed by Sasaki et al. and based on preoperative albumin, neutrophil-to-lymphocytes-ratio, CA19-9 and tumor size. Methods Patients treated by liver surgery for intrahepatic cholangiocarcinoma at 11 international HPB centers from 2001 to 2018 were included in the external validation cohort. Harrell's c-index and Hosmer-Lemeshow analyses were used to test PRS discrimination and calibration. Kaplan–Meier curve for risk groups as described in the original study were displayed. Results A total of 355 patients with 174 deaths during the follow-up period (median = 41.7 months, IQR 32.8–50.6) were included. The median PRS value was 14.7 (IQR 10.7–20.6), with normal distribution across the cohort. A Cox regression on PRS covariates found coefficients similar to those of the derivation cohort, except for tumor size. Measures of discrimination estimated by Harrell's c-index was 0.61(95%CI:0.56–0.67) and Hosmer-Lemeshow p = 0.175. The Kaplan-Meyer estimation showed reasonable discrimination across risk groups, with 5years survival rate ranging from 20.1% to 0%. Conclusion In this external validation cohort, the PRS had mild discrimination and poor calibration performance, similarly to the original publication. Nevertheless, its ability to identify different classes of risk is clinically useful, for a better tailoring of a therapeutic strategy.

Background: The benefit of anatomic (AR) versus parenchyma-sparing resection (PSR) in hepatocarcinoma (HCC) is still debated. The aim of the study was to compare AR vs. PSR in terms of overall survival (OS) and disease-free survival (DFS). Methods: A systematic review was conducted using Medline and Google Scholar. To reduce intra- and inter-study heterogeneity, only propensity-matched studies and randomized clinical trials (RCT) were evaluated and a generic inverse variance meta-analysis was run. A sub-analysis was performed in case of tumor microvascular invasion (MVI). Results: Eleven propensity-matched and one RCT were evaluated, with a total of 3445 patients (AR = 1776 and PSR = 1669). Tumor burden and liver function were comparable among studies (I2< 50%, p > 0.5). OS was similar between AR and PSR (HR 0.93; 95%CI, 0.75–1.15; p = 0.50, I2= 41%). DFS was improved in AR at 1year (RR 0.84; 95%CI, 0.72–0.97; p = 0.02; I2= 36%) and 3years (RR 0.90; 95%CI, 0.83–0.98; p= 0.02; I2= 40%) but not at 5years (RR 0.94; 95%CI, 0.87–1.01; p = 0.07; I2= 41%). Furthermore, in the presence of MVI, no difference in OS and DFS was observed between AR and PSR. Conclusion: When liver function and tumor burden are comparable, AR and PSR achieved similar overall survival. AR improved local control in the early period after surgery. Furthermore, in the presence of MVI, the extension of surgery was not associated with better OS and DFS.

Background: Optimal treatment of hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR). Method: between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan–Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort. Results: 226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1–5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8–9) for TACE, and 11 months (95%CI:9–12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1–2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05). Conclusion: Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.

Introduction Increasingly, patients with multiple colorectal liver metastases (CRLM) are surgically treated. R1par surgery remains one of the negative prognostic factors for overall survival (OS). According to our data on R1 in main intrahepatic vascular contact (MVC), we investigate the oncological outcome of patients with multiple bilobar disease with bilateral MVC (BC), compared to patients with unilateral MVC (UC) and patients with disease and no MVC (NC). Methods This single-institution study included patients who underwent hepatectomy for multiple (≥ 4) bilobar CRLM lesions from 2004-2019. Three-hundred-fifty-five patients meet the inclusion criteria. One-hundred-thirty-two patients with R1par resection were excluded. Three groups were defined: NC, UC, BC. After pairwise propensity score match 145 patients were analyzed. Results No differences between groups were observed in the preoperative variables. Increased surgical time, hilar clamping, and blood loss were reported in the BC group. Postoperative minor morbidity, liver failure rate, overall and local recurrences were higher in the BC group. BC patients were more likely to be re-resected. Cumulative OS 3-5 years survival in NC, UC, BC were 54%-40%, 49%-35%, 57%-24% (p < 0.91). At multivariate analysis, factors influencing OS, were N status of the primitive lesions, RAS status, and repeated hepatectomy. Conclusions Patients with BC and lesions ≥ 4 are generally considered unresectable or suitable for staged hepatectomy. This retrospective study shows that these patients can be submitted to the so called enhanced-one-staged hepatectomy with the same oncological results, however surgical complexity, postoperative minor morbidity and postoperative liver failure are increased.

Background.Primary splenic angiosarcoma is a very rare mesenchymal malignant tumor associated with a poor prognosis due to its high metastatic potential. This disease can be easily neglected and spontaneous splenic rupture is a frequent manifestation at the time of diagnosis leading to a poor outcome because of peritoneal dissemination.Case Presentation.We describe the case of a 49-year-old man who presented with asthenia, left upper quadrant abdominal pain, and anemia. Computerized tomography scan showed an enlarged spleen with no nodules and a nontraumatic rupture of the splenic capsule. Splenectomy was performed on account of the severe anemia and histopathology examination showed a primary angiosarcoma.Conclusions.Splenic angiosarcoma should be considered as one of the differential diagnoses in patients with nontraumatic spleen rupture and a specific previous medical history. Regrettably, splenectomy allows for a definitive diagnosis but not a curative treatment.

Background: To assess whether gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid-enhanced MRI study is useful to estimate liver function in comparison to the presence or absence of cirrhosis, Child Pugh (CP), Model for End-stage Liver Disease (MELD), ALBI scores and biochemical test. Methods: We retrospectively reviewed all consecutive Gd-EOB-DTPA-enhanced-MRI studies performed between 2010 and 2016 in patients with focal liver lesions undergoing clinical evaluation. Patients were divided in study and control group according to the presence of cirrhosis, and then classified by CP, MELD and ALBI. Signal intensity was calculated through the liver-to-muscle ratio in portal- (SI-POR) and hepatobiliary-phase(SI-HEP). Results: Three-hundred-three Gd-EOB-DTPA liver-enhanced-MRI studies were included. One-hundred-ninety-one patients (63%) were cirrhotic. SI-HEP was significantly lower in cirrhotic group (0.55 ± 0.29 vs 0.66 ± 0.40, p = 0.004).The SI-HEP progressively decreased from CP-A to CP-C (0.59 ± 0.28 to 0.25 ± 0.19, p < 0.0001) and a significant difference was found between MELD ≤ 9 and MELD > 9 groups (0.61 ± 0.31 vs 0.49 ± 0.28, p = 0.007). No differences between ALBI grades were evident. Among biochemical parameters a moderate correlation was found among SI-HEP and total bilirubin, AST and albumin. Conclusion: SI-HEP after Gd-EOB-DTPA-enhanced-MRI effectively stratified patients with different Child Pugh grades and MELD scores. This technique could hence be useful as a novel radiological marker to estimate the underlying liver function.

Aim: To assess the efficacy of signal intensity in interstitial and hepatobiliary phase normalized for liver volume, on gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) study, for the evaluation of liver function through the comparison with Child–Pugh (CP), model for end-stage liver disease (MELD), and biochemical tests. Methods: All dynamic Gd-EOB-DTPA MRI studies performed in patients with suspected liver lesions were retrospectively reviewed. The rate of liver-to-muscle ratio on T1 sequence 70 s (interstitial phase) and 20 min (hepatobiliary phase) after injection of Gd-EOB-DTPA was calculated for each MRI study and then normalized for liver volume (irINTnorm and irHEPnorm). Pearson correlation coefficient was computed to assess the correlation among these values and CP and MELD scores, and biochemical tests. Results: A total of 303 MRI studies, performed on 221 patients, were included. Mean age was 63.8 years ± 12.9 with a majority of male patients (186; 61.4%). A total of 186 out of 303 (61.4%) were cirrhotic patients. The irHEPnorm was significantly lower in cirrhotic than non-cirrhotic patients (0.0004 ± 0.0002 to 0.0005 ± 0.0003, p = 0.010). This value had a moderate, significant correlation with Child–Pugh and MELD scores (R = − 0.292, p < 0.0001 and R = − 0.192, p = 0.010, respectively). In particular, irHEPnorm progressively decreased from Child–Pugh A to C (0.0004–0.0002, p < 0.0001) and from MELD ≤ 10 to 19–24 (0.0004–0.0003, p = 0.018). Among biochemical parameters, total bilirubin, GOT, and albumin had the strongest correlation with irHEPnorm (R = − 0.258, − 0.291, and 0.262, p < 0.0001, respectively). No correlations were found between irINTnorm and CP and MELD scores. Conclusion: irHEPnorm value derived from Gd-EOB-DTPA-enhanced MRI is a reliable, non-invasive, useful tool to quantify liver function and to assess the degree of cirrhosis, offering a strict relationship with clinical scores and biochemical parameters. This could help surgeons in clinical decision-making, allowing them to choose the more suitable surgical approach for cirrhotic patients.

Acute appendicitis is commonly encountered in daily practice. The perforation of a retrocecal appendix can result in retroperitoneal abscess a condition that is still recognized as life-threatening. This emphasizes the importance of early diagnosis and prompt management for this uncommon complication. We present a case of unusual presentation of retroperitoneal abscess from perforated appendicitis and a review of the Literature. a 44-year-old woman arrived to our observation for the appearance by about 3 days of abdominal pain on the right quadrants irradiated to the lower limb. at the opening, we drained abscess cavity buffered on the caecum and its mesentery, which deepened in the back-peritoneum, affecting the ipsilateral ileo-psoas muscle and limbing the vertebral plane. appendix stump was perforated. We performed appendectomy with multiple washings of the peritoneal cavity. The patient was discharged at 19th postoperative day. The development of a retroperitoneal abscess, however rare, remains one of the most serious complications of acute appendicitis and is always associated with the perforation of a retrocecal appendix. its insidious onset may delay diagnosis and treatment making this clinical entity a challenge for the surgeon who will have to distinguish between primary and secondary psoas abscess when some combination symptoms such as fever, flank pain and limitation of hip movement arise. acute perforated appendicitis can occasionally manifest as complicated retroperitoneal abscess. it has to be taken into account in the differential diagnosis of a primary psoas abscess. The surgeon’s experience is a key point in therapeutic strategy.

OBJECTIVE: To evaluate whether perioperative bioimpedance vector analysis (BIVA) predicts the occurrence of surgery-related morbidity. SUMMARY BACKGROUND DATA: BIVA is a reliable tool to assess hydration status and compartimentalized fluid distribution. METHODS: The BIVA of patients undergoing resection for pancreatic malignancies was prospectively measured on the day prior to surgery and on postoperative day (POD)1. Postoperative morbidity was scored per the Clavien-Dindo classification (CDC), and the Comprehensive Complication Index (CCI). RESULTS: Out of 249 patients, the overall and major complication rates were 61% and 16.5% respectively. The median CCI was 24 (IQR 0.0-24.2), and 24 patients (9.6%) had a complication burden with CCI≥40. At baseline the impedance vectors of severe complicated patients were shorter compared to the vectors of uncomplicated patients only for the female subgroup (P=0.016). The preoperative extracellular water (ECW) was significantly higher in patients who experienced severe morbidity according to the CDC or not [19.4L (17.5-22.0) vs. 18.2L (15.6-20.6), P=0.009, respectively] and CCI≥40, or not [20.3L (18.5-22.7) vs. 18.3L (15.6-20.6), P=0.002, respectively]. The hydration index on POD1 was significantly higher in patients who experienced major complications than in uncomplicated patients (P=0.020 and P=0.025 for CDC and CCI, respectively).At a linear regression model, age (β=0.14, P=0.035), sex female (β=0.40, P

Background: Management of malignancy in elderly patients is challenging. We aimed to assess the impact of age and ageing on overall survival (OS), recurrence-free survival (RFS), tumour-specific survival (TSS) and potential years of life lost (PYLL) after surgery for hepatocarcinoma (HCC). Methods: Consecutive patients treated for HCC between 2005 and 2015 were evaluated. Patients were divided according to age-decade. Afterwards, elderly patients (≥75years) were compared with patients

Background: The optimal surgical strategy to lessen the risk of hepatocarcinoma (HCC) recurrence is debated. This study aimed to investigate the role of anatomic resection (AR) and parenchyma-sparing resection (PSR) in HCC recurrence patterns. Methods: The study analyzed 384 cirrhotic patients with a first diagnosis of HCC. Of these patients, 142 underwent AR, and 242 underwent PSR. The two groups were unbalanced at the univariate analysis. To minimize this bias, a 1:1 propensity score-matching analysis (PSA) was used. Disease-free survival (DFS) curves were analyzed by the Kaplan-Maier method. Results: The PSA allowed pairing of 200 patients (100 for AR and 100 for PSR). In this study, 59 patients (62.8%) had recurrence after AR compared with 58 patients (63.7%) after PSR (p = 0.891). The rates of local recurrence were respectively 15.3% and 15.5% (p = 0.968). When microvascular invasion was considered, the median DFS was 10.7 months for AR and 9.4 months for PSR (p = 0.607). In comparisons of AR and PSR, DFS did not differ significantly between subgroups with high histologic grading (p = 0.520), multiple nodules (p = 0.307), and Child–Pugh B (p = 0.679). Conclusion: Excision of the anatomic segment did not seem to reduce the rate of relapse or recurrence patterns significantly, even in high-risk subgroups

Introduction Whether the resection of the caudate lobe, in association with major hepatectomy, improves outcomes in hilar cholangiocarcinoma is controversial. Evidence acquisition We performed a systematic literature review on all studies published from June 1979 to September 2016. Inclusion criteria for eligibility were the presence of parallel-groups of patients treated with major hepatectomy with either caudate lobe resection (CLR), or not (NCLR), in adult population, reporting data on overall survival (OS). We ran out a random-effect meta-analysis for survival data. Evidence synthesis Six retrospective studies with 969 patients (643 CLR and 326 NCLR) were included. The probability of death was significantly lower in CLR group than in NCLR group (HR 0.65; 95% CI: 0.44-0.97; P=0.035). The median survival time was in favor of CLR (WMD 3.46; 95% CI: 1.02-5.90, P=0.005]. Patients who underwent CLR were more likely to receive a R0 resection than those who did not (OR 8.26; 95% CI: 2.45-27.87; P=0.001). No moderator effects were detected at meta-regression for operative time, postoperative complication rate and pathologic findings. Conclusions Despite the paucity of data and the retrospective nature of the included studies, our results suggest that major hepatectomy plus caudate lobe resection may improve the likelihood of R0 resection and the overall survival in patients with hilar cholangiocarcinoma.

Bioimpedance vector analysis (BIVA) is a reliable tool to assess body composition and hydration status. Perioperative sarcopenia, sarcopenic obesity and hyperhydration have been associated with adverse outcomes after pancreatic surgery. Aim of our study was to evaluate whether perioperative BIVA predicts the occurrence of surgery-related morbidity. We prospectively measured BIVA of patients undergoing pancreatic resection at 3 Italian institutions, prior to surgery and on postoperative day (POD) 1. Morbidity was graded per the Clavien-Dindo Classification (CDC), and the Comprehensive Complication Index (CCI). We analyzed 249 patients. Overall complication rate was 61% and 16.5% had a CDC≥3. The median CCI was 24 (IQR 0.0-24.2), and 24 patients (9.6%) had a CCI≥40 (severe complications). Preoperative extracellular water (ECW) was significantly higher in patients who experienced severe morbidity according to the CDC [19.4 L (17.5-22.0) vs. ECW 18.2 L (15.6-20.6), p=0.009 in complicated and uncomplicated, respectively]; ECW was significantly higher in case of either CCI≥40, or not [ECW 20.3 L (18.5-22.7) vs. 18.3 L (15.6-20.6), p=0.002, respectively]. Hydration status on POD1 was significantly different in patients who either experienced major complications or not [ECW 23.9 L (20.6-22.5) vs. 19.7 L (17.3-23.1), p=0.020 and hydration index HI 80.7% (75.3-85.3) vs. 73.9% (73.6-79.8), p Perioperative hydration status significantly predicts major morbidity after pancreatic surgery. BIVA can be useful for evaluation and monitoring of the hydration status and could be considered in clinical practice.

Small-for-size liver syndrome and posthepatectomy liver failure remain a major challenge for surgeons. Recently, updates in literature points to describe this two syndrome as two face of the same coin. These syndromes are characterized by hyperbilirubinemia, coagulopathy, hyper-GGT, high portal pressure and flow in liver remnant, occurring within the first postoperative week. It can lead to post-operative sepsis and bleeding, increasing mortality and morbidity. Despite the large experience in the field of transplantation, few studies are focused on small-for-size syndrome after major hepatectomy. For years, scientists were focused on the size of liver remnant, supposing a small liver remnant, in relation with the primary liver size, was the cause of the syndrome. The strategies used to prevent it after transplantation, have however shown a predominant role of high portal pressure and flow, leading to an alteration in functional regeneration of liver parenchyma, as the prevalent mechanism. According to these evidences, we suggest adopting another nomenclature for the two syndromes: small-for-flow-liver failure. In this article, we analyze and summarize different experiences, proposing our inward algorithm, including the role of portal flow and pressure measurements. This review seeks to be an operative instrument for surgeons and hepatologists in an effort to find a common point of view regarding small for flow liver failure and its management strategies. Introduction This manuscript would like to be an operative instrument for surgeons and hepatologists. While a lot of opinions, articles, experimental data and suggestive procedures exist on the small-for-size syndrome in the field of living donor transplants, few specific papers are available on small-forsize syndrome (SFFS) after extended hepatectomy. Nowadays, most of physicians consider SFSS and post-hepatectomy liver failure (PHLF) two face of the same coin. Through eight questions, we attempt to roll out every situation in managing oncological patients who underwent extended hepatectomy, trying to translate the transplantation experience in liver oncological surgery's field

Despite surgical resection is the treatment of choice for hepatocellular carcinoma (HCC), long-term prognosis remains unsatisfactory with rate of recurrence of approximately 50% at 3 years and more than 70% at 5 years (1,2).

In oncological surgery, the liver still remain a challenge for surgeons. From the seventies, when liver surgery spread, techniques and strategies to approach parenchymal resection are very changed: from a radical surgery, to the finding of liver regeneration capacity and the concept of minimum remnant size, until now, where new liver regeneration theories and new physiological data are changing our approach. In case of HCC, or in case of metastatic disease, when resection is indicated, there are several diagnostic feature to perform before candidate a patient to surgery. How could be safe a liver resection? Which is the phatophysiological etiology of post-hepatectomy liver failure? How could we expand the safe limits for surgery? All these questions are key-points to better understand liver disease, and, moreover, their treatments. From the first meeting with patient affected by liver cancer, we would like to describe how to manage patients, which kinds of imaging we should prefer, how to assess safe limits for resections, and, in case, how to expand this limit. Then, we will focus on interventional radiologic and surgical strategies to approach liver cancer, and how and why posthepatectomy liver failure could be prevented and diagnosed correctly. Particularly, we would focus on portal vein embolization, two-staged hepatectomy, and ALPPS, always with physiological explanation, from the most up-to-date clinical evidence. Particular attention will be made for liver surgery’s sequel and risks. Comparing the newest data available in literature, we will focus on diagnosing, staging and surgical planning to approach liver resections correctly. In oncological surgery, the liver still remain a challenge for surgeons. From the seventies, when liver surgery spread, techniques and strategies to approach parenchymal resection are very changed: from a radical surgery, to the finding of liver regeneration capacity and the concept of minimum remnant size, until now, where new liver regeneration theories and new physiological data are changing our approach. In case of HCC, or in case of metastatic disease, when resection is indicated, there are several diagnostic feature to perform before candidate a patient to surgery. How could be safe a liver resection? Which is the phatophysiological etiology of post-hepatectomy liver failure? How could we expand the safe limits for surgery? All these questions are key-points to better understand liver disease, and, moreover, their treatments. From the first meeting with patient affected by liver cancer, we would like to describe how to manage patients, which kinds of imaging we should prefer, how to assess safe limits for resections, and, in case, how to expand this limit. Then, we will focus on interventional radiologic and surgical strategies to approach liver cancer, and how and why posthepatectomy liver failure could be prevented and diagnosed correctly. Particularly, we would focus on portal vein embolization, two-staged hepatectomy, and ALPPS, always with physiological explanation, from the most up-to-date clinical evidence. Particular attention will be made for liver surgery’s sequel and risks. Comparing the newest data available in literature, we will focus on diagnosing, staging and surgical planning to approach liver resections correctly