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Alveolar echinococcosis is a chronically progressive and potentially fatal disease. Patients with multiple giant alveolar echinococcosis have a poor prognosis when radical resection cannot be achieved, but curative resection can be limited by low future remnant liver volumes. In these cases, 2-stage liver resection may be a better choice: after a first-stage hepatectomy with partial resection, liver regeneration is allowed in the residual liver before proceeding to the second-stage hepatectomy. In this study, we therefore retrospectively reviewed and evaluated the safety and feasibility of two-stage hepatectomy in patients with multiple giant alveolar echinococcosis. We reviewed the data for all patients who underwent 2-stage hepatectomy for multiple giant alveolar echinococcosis between August 2013 and December 2015 at either the West China Hospital of Sichuan University or the Hospital of Ganzi Tibetan Autonomous Prefecture. We identified 7 patients in whom 2-stage hepatectomy was completed. During the first-stage hepatectomy, 4 patients underwent right-sided hepatectomy and the other 3 underwent left-sided hepatectomy. The second-stage hepatectomies were successfully performed 3 months after the first-stage procedures. All patients had follow-up durations of >1 year; there were no cases of operation-related mortality, and no patients experienced disease recurrence. Two-stage hepatectomy is safe and feasible for patients with multiple giant alveolar echinococcosis.

351 Background: A significant number of patients with colorectal liver metastases (CRLM) present with unresectable bilobar disease. Two-stage hepatectomy with portal vein embolization (PVE) have been described as a treatment for CRLM allowing for volume regeneration of a functional liver remnant. No large-scale multi-institutional studies exist. The aim of this project was to describe outcomes following two-stage hepatectomy, including overall survival (OS), recurrence-free survival (RFS), and complications. Methods: Patients completing two-stage hepatectomy for CRLM at five US institutions were identified and retrospectively analyzed (2000-2015). Overall survival and recurrence-free survival following second-stage surgery, short-term mortality, Clavien-Dindo complications, and readmission rates were examined. Results: A total of 209 patients were identified. Mean age was 52 (SD +/-11.4), 59.8% were male, and 87.0% had synchronous disease. A total of 65.1% of patients underwent PVE, and 27.3% underwent hepatic artery infusion pump placement. 88.3% of cases underwent neoadjuvant chemotherapy. Following the first stage, 30-day morbidity was 24.4%, with 4.8% major (Clavien-Dindo grade ≥3) complications, and 30-day readmission was 6.7%. Mean time between first and second stage was 4.1 months (S.D. +/-3.1), and 57.5% received systemic chemotherapy between the two resections. Following the second stage, overall complications were 47.4% with 23.9% major complications, and 30-day readmission was 9.7%. Mortality following second stage was 3.8% at 30 days, and 5.3% at 90-days. Following the second stage, RFS at 1-, 3-, and 5-years was 80%, 46%, and 29% respectively. OS at 1-, 3-, and 5-years was 87%, 64%, and 45% respectively. Conclusions: Two-stage hepatectomy for CRLM provides acceptable recurrence-free and overall survival in the context of advanced bilobar disease. Major complications and readmission following the first stage are rare. Following the second stage, short-term major morbidity, mortality, and readmissions are also acceptable. For well-selected patients, two-stage hepatectomy remains a safe and effective treatment for CRLM, with potential for more widespread adoption.

Laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) is a new technique with a first laparoscopic step available in cases of unresectable right liver masses and inadequate future liver remnant (FLR).In Step 1, laparoscopic right portal vein occlusion is performed with microwave ablation on the future transection plane and in the FLR. Step 2 consists of a totally laparoscopic right trisectionectomy.Duration of the Step 1 operation was 170 min, without the need for blood transfusions and intensive care unit admission. The postoperative liver volumetric computed tomography scan was performed on postoperative day 9 and revealed a satisfactory left hepatic hypertrophy (FLR 666 cm(3); FLR to body weight ratio 0.96; FLR increase 90.4 %; daily FLR hypertrophy 35 cm(3)/day). Duration of the Step 2 operation was 630 min (liver transection time 240 min). Blood loss was 700 cc, with no need for transfusion. The specimen was extracted through a 10-cm Pfannenstiel incision, and pathology revealed a tumor-free resection margin (R0). The patient was discharged on postoperative day 7 without complications (total hospital stay for Step 1 + Step 2: 10 days).Totally LAPS is a technically feasible and safe procedure. It could provide benefit in selected patients with primarily non-resectable liver cancer, making extreme liver surgery easy and safe in well-selected patients.

3549Background: The two-stage surgical resection (TSR) of bilobar colorectal liver metastases (CRLM) is widely used and has shown encouraging survival results. The risk of drop-out after the first-...

666 Background: The two-stage surgical resection (TSR) of bilobar colorectal liver metastases (CRLM) is widely used and has shown encouraging survival results. The risk of drop-out after the first-stage hepatectomy remains high and associated with poor survival rates. Our objective was to evaluate the predictive factors of long-term survival, based on the pathologic response to an intensified systemic chemotherapy administered preoperatively. Methods: Data from 899 patients treated for CRLM in our institution were collected prospectively between January 2003 and August 2013. We evaluated the pathologic response to preoperative chemotherapy, and its impact on the second-stage completion and on survival. Results: Sixty-seven patients were eligible for the TSR first stage. All patients underwent an intensified chemotherapy in combination with a biotherapy (Bevacizumab or Cetuximab) in 38cases. The Tumour Regression Grade (TRG), the Blazer grade, and the modified-TRG were used to classify patients as responders (TRG and mTRG 1-3, Blazer 0-1) or non-responders (TRG and mTRG 4-5, Blazer 2) after the first stage. Responders in the three classifications (TRG: p = 0.033; mTRG: p = 0.03, Blazer:p = 0.005), and initial metastases number (p = 0.001) were independent predictive factors for the second-stage completion. Triple chemotherapy were associated with responders in the three classifications (TRG and mTRG: 73.7% versus 26.3% p < 0.0001 ; Blazer : 84.2% versus 15.8% p = 0.001). Median overall survival (OS) of patients who completed TSR was significantly different (44, 84 versus18,39 months; p < 0.0001). There was no statistical difference in OS and recurrence-free survival between the responders and non-responders. Conclusions: A good pathologic response to intensified preoperative chemotherapy is associated with completion of the second stage of TSR, and thus with a longer survival. Knowing this response before the first-stage resection may allow avoiding useless resections for patients who will not benefit from this strategy.

A two-stage hepatectomy procedure is a therapeutic strategy for patients presenting with initially unresectable multiple and bilobar colorectal liver metastases in order to achieve a curative R0 resection. The main goal of this approach is to minimize the risk of postoperative liver failure resulting from a too small remnant liver after completing a curative resection. This procedure combines two sequential liver resections that involve perioperative chemotherapy and portal vein embolization. This article describes our standardized strategy of two-stage hepatectomy combined with portal vein embolization used over the last 15 years and discusses the alternative procedures as well as their respective advantages and drawbacks.

Background The aim of this study was to analyze the feasibility and early outcomes of 2-stage liver resection for bilobar metastases. Methods Data from 39 consecutive patients undergoing 2-stage hepatectomy between 2004 and 2010 were prospectively collected. Results The median age was 59 years (range, 33–79 years), and the ratio of men to women was 1.8:1. Metastases were colorectal carcinoma (n = 33), neuroendocrine tumors (n = 3), gastrointestinal stromal tumor (n = 1), ocular melanoma (n = 1), and salivary gland carcinoma (n = 1). Perioperative chemotherapy was given to 32 patients (82%). Twenty-nine patients (74%) underwent portal venous embolization. Radiofrequency ablation was used in 8 patients (21%). Twenty-seven patients (69%) successfully completed clearance. For the 1st and 2nd stages, the median lengths of stay were 11 days (range, 6–53 days) and 13 days (range, 6–44 days), and morbidity rates were 23% and 56%. Liver insufficiency occurred in 2 (5%) and 6 (22%) patients. Overall mortality was 2.6%. For colorectal metastases, median survival in successes versus failures was 24 versus 10 months (P = .03), and 3-year survival was 30% versus 0%. Conclusions Two-stage hepatectomy is feasible, with 69% of patients achieving clearance with low mortality. Morbidity is significant, particularly transient hepatic insufficiency.

Liver surgery can only be offered to approximately 20% of patients with colorectal liver metastases, provided that the primary tumor is controlled. Currently, a selected subgroup of the remaining 80% of the patients, who were initially considered as unresectable and were assigned to receive palliative chemotherapy, may benefit from liver surgery and often require a multidisciplinary approach in order to achieve a curative liver resection. This multidisciplinary approach may also use additional methods such as radiofrequency, portal vein embolization, and downsizing or conversion chemotherapy. The combination of these different therapies resulted in the development of nontraditional liver resection techniques including the so-called two-stage hepatectomy procedure. The aim of these strategies is to achieve a complete tumoral resection in a curative intent, to increase safely the indications of liver resection for patients presenting with initially unresectable liver metastases, and to offer to them similar results in term of short- and long-term outcome to that observed in patients with initially resectable liver metastases.

Background As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long-term outcome, safety and efficacy of two-stage hepatectomy (TSH) for CLM in a large cohort of patients. Methods Patients undergoing surgery between December 1996 and December 2009 were reviewed. The early postoperative and long-term outcomes as well as the patterns of failure to complete TSH and its clinical implications were analysed. Results Eighty patients were scheduled to undergo TSH. Sixty-one patients had completion of TSH combined with (58 patients), or without (3) portal vein embolization/ligation (PVE/PVL). Five patients were excluded after first-stage hepatectomy and 14 after PVE/PVL. The 5-year overall survival rate and median survival in patients who completed TSH were 32 per cent and 39·6 months respectively, and corresponding recurrence-free values were 11 per cent and 9·4 months respectively. Six patients were alive beyond 5 years after TSH. Multivariable logistic regression analysis showed that failure to complete TSH was driven by two independent prognostic scenarios: three or more CLM in the future remnant liver (FRL) combined with age over 70 years predicted tumour progression after first-stage hepatectomy, and three or more CLM in the FRL combined with carcinomatosis at the time of first-stage hepatectomy predicted the development of additional FRL metastases after PVE/PVL. Conclusion A therapeutic strategy using TSH provided acceptable long-term survival with no postoperative mortality. Further efforts are needed to increase the number of patients who undergo TSH successfully.

Introducción: La hepatectomía en dos etapas utiliza la regeneración compensatoria del hígado tras una primera hepatectomía no curativa para lograr una resección curativa en una segunda intervención. Objetivo: Presentar nuestra experiencia inicial aprovechando esta propiedad, en la estrategia de manejo de pacientes previamente declarados irresecables. Material y Método: Entre Marzo de 2006 y Marzo de 2010, fueron tratados 8 casos. Resultados: De 64 pacientes en los que se realizó hepatectomía, 8 de ellos, con enfermedad metastásica bilateral, confinada al hígado, fueron sometidos a ligadura portal del lado derecho; en la mitad se realizó resección simultánea de enfermedad del futuro remanente hepático izquierdo. Cuatro a 8 semanas más tarde, cinco fueron sometidos a hepatectomía derecha extendida o hepatectomía derecha (con segmento IV previamente resecado), y otro que era recurrente de previa hepatectomía central más colectomía, fue explorado, ligado y luego sometido a cirugía combinada con radiofrecuencia (RFA). Con seguimiento promedio para el grupo resecado RO (n = 6) de 18 meses (3-39), una paciente fallece por recurrencia pulmonar masiva a los 18 meses del diagnóstico, dos se someten a tercera cirugía y RFA con intención curativa, sin evidencia actual de enfermedad, dos no presentan recurrencia y una presenta recurrencia costal, sin evidencia de enfermedad intraabdominal. Otros dos están esperando la hepatectomía post resección del primario y ligadura portal. Conclusión: En nuestro medio, la colectomía y hepatectomía en múltiples etapas en pacientes con enfermedad hepática bilateral metastásica de origen colorrectal es una estrategia factible y razonable para lograr una resección con intención curativa.

3559 Background: Two-stage hepatectomy (TSH) has been adopted as a treatment strategy for extensive bilateral colorectal liver metastases (CRLM) unable to be resected by a single hepatectomy. Howev...

Aims Two-stage hepatectomy for multiple, bilobar liver metastases from colorectal cancer aimed to minimize liver failure risk by performing the second resection after regeneration, but impact of this strategy on volume of the future liver remnant (FLR) remained to be demonstrated. We compared two-stage hepatectomy with one stage following portal vein embolization (PVE) for multiple, bilobar liver metastases from colorectal cancer as to effects on volume of the FLR. Methods Forty-three patients undergoing major hepatectomy for multiple colorectal cancer metastases were divided retrospectively into patients undergoing hepatectomy following PVE (n = 21) and those undergoing two-stage hepatectomy (n = 22). Increases in FLR volume were compared. Results While the increase in the volume FLR averaged approximately 70 mL (302.6 mL before PVE vs. 370.9 mL after PVE) and the increase in the ratio of FLR to total liver volume averaged approximately 7.5% (30.2% to 37.5%) following PVE, first-stage hepatectomy increased FLR volume by approximately 100 mL (from 259.4 to 361.4), and the ratio, by 15% (26.9% to 41.6%). The FLR hypertrophy ratio relative to pre-procedure volume estimates in the two-stage group (50.2%) was twice that in the PVE group (25.3%). Conclusions Superiority of two-stage hepatectomy in hypertrophy of the FLR was confirmed.

RESULTS: There were 619(55%) cervical and 509(48%) thoracic anastomoses. Cervical anastomosis was associated with a longer median operative time (329min. vs. 316min., p 0.006), greater than 2 units of blood transfusion in a higher proportion of patients (10% vs. 4%, p 0.001), and higher superficial surgical site infections (13% vs. 8%, p 0.01). There were no difference in rates of organ/space infections (6% vs. 7%, p 0.45), overall morbidity (38% vs. 37%, p 0.60), or mortality (3% vs. 4%, p 0.54). Median length of stay was similar (12days cervical vs. 11days thoracic, p 0.20), even among patients with organ/space infections (19days cervical vs. 22 days thoracic, p 0.58). On multivariate analysis, significant predictors for overall morbidity included: diabetes (aOR 1.7: 95%CI 1.092.67) and pre-operative pulmonary infection (aOR 2.26: 95%CI 1.17-4.48).

Hepatectomy is an effective surgical treatment for multiple bilobar liver metastases from colon cancer; however, one of the primary obstacles to completing surgical resection for these cases is an insufficient volume of the future remnant liver, which may cause postoperative liver failure. To induce atrophy of the unilateral lobe and hypertrophy of the future remnant liver, procedures to occlude the portal vein have been conventionally used prior to major hepatectomy. We report a case of a 50-year-old woman in whom two-stage hepatectomy was performed in combination with intraoperative ligation of the portal vein and the bile duct of the right hepatic lobe. This procedure was designed to promote the atrophic effect on the right hepatic lobe more effectively than the conventional technique, and to the best of our knowledge, it was used for the first time in the present case. Despite successful induction of liver volume shift as well as the following procedure, the patient died of subsequent liver failure after developing recurrent tumors. We discuss the first case in which simultaneous ligation of the portal vein and the biliary system was successfully applied as part of the first step of two-stage hepatectomy.

e14674 Background: Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal liver metastases (CLM). Its main drawback is the drop-out risk (25-40% of patients fail to com...