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Sg4b-5 anatomical bi-segmentectomy with regional lymphadenectomy (Sg4b5) is a surgical option for gallbladder cancer (GBC) treatment. The laparoscopic approach to this challenging operation is still controversial. Aim of this study was to compare short- and long-term outcomes of laparoscopic versus open Sg4b5 in a single institution series of patients. All consecutive patients who underwent Sg4b5 for GBC from January 2000 to September 2021 were retrospectively reviewed. Inverse probability of treatment weighting (IPTW) analysis was performed. 75 patients were analyzed, 18 in the laparoscopic and 57 in the open group. After IPTW, laparoscopic approach was associated with a significantly decreased median intraoperative blood loss (100 vs 237.09 ml, p = 0.001), shorter median length of hospital stay (4 vs 8 days, p = < 0.001) and a higher median number of harvested nodes (9 vs 7, p = 0.026). Operation time was shorter in the open group (355 vs 259 min, p < 0.001). No significant differences were found regarding clear resection margins, overall and major (Clavien-Dindo ≥ 3) morbidity, bile leakage rate, 90 days post-operative mortality, overall and disease-free survival. Laparoscopic Sg4b-5 anatomical bi-segmentectomy and regional lymphadenectomy is feasible and safe with long term outcome comparable to open approach at least in early stages. Laparoscopic approach confirms its well-known short-term benefits with less intraoperative bleeding and shorter length of stay. Moreover, it might allow a better lymphadenectomy., (© 2023. Italian Society of Surgery (SIC).)

Standard imaging cannot assess the pathology details of intrahepatic cholangiocarcinoma (ICC). We investigated whether CT-based radiomics may improve the prediction of tumor characteristics. All consecutive patients undergoing liver resection for ICC (2009-2019) in six high-volume centers were evaluated for inclusion. On the preoperative CT, we segmented the ICC (Tumor-VOI, i.e., volume-of-interest) and a 5-mm parenchyma rim around the tumor (Margin-VOI). We considered two types of pathology data: tumor grading (G) and microvascular invasion (MVI). The predictive models were internally validated. Overall, 244 patients were analyzed: 82 (34%) had G3 tumors and 139 (57%) had MVI. For G3 prediction, the clinical model had an AUC = 0.69 and an Accuracy = 0.68 at internal cross-validation. The addition of radiomic features extracted from the portal phase of CT improved the model performance (Clinical data+Tumor-VOI: AUC = 0.73/Accuracy = 0.72; +Tumor-/Margin-VOI: AUC = 0.77/Accuracy = 0.77). Also for MVI prediction, the addition of portal phase radiomics improved the model performance (Clinical data: AUC = 0.75/Accuracy = 0.70; +Tumor-VOI: AUC = 0.82/Accuracy = 0.73; +Tumor-/Margin-VOI: AUC = 0.82/Accuracy = 0.75). The permutation tests confirmed that a combined clinical-radiomic model outperforms a purely clinical one ( p < 0.05). The addition of the textural features extracted from the arterial phase had no impact. In conclusion, the radiomic features of the tumor and peritumoral tissue extracted from the portal phase of preoperative CT improve the prediction of ICC grading and MVI.

Background: Tumor size (TS) represents a critical parameter in the risk assessment of laparoscopic liver resections (LLR). Moreover, TS has been rarely related to the extent of liver resection. The aim of this study was to study the relationship between tumor size and difficulty of laparoscopic left lateral sectionectomy (L-LLS)., Methods: The impact of TS cutoffs was investigated by stratifying tumor size at each 10 mm-interval. The optimal cutoffs were chosen taking into consideration the number of endpoints which show a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors., Results: A total of 1910 L-LLS were included. Overall, open conversion and intraoperative blood transfusion were 3.1 and 3.3%, respectively. The major morbidity rate was 2.7% and 90-days mortality 0.6%. Three optimal TS cutoffs were identified: 40-, 70-, and 100-mm. All the selected cutoffs showed a significant discriminative power for the prediction of open conversion, operative time, blood transfusion and need of Pringle maneuver. Moreover, 70- and 100-mm cutoffs were both discriminative for estimated blood loss and major complications. A stepwise increase in rates of open conversion rate (Z = 3.90, P < .001), operative time (Z = 3.84, P < .001), blood loss (Z = 6.50, P < .001), intraoperative blood transfusion rate (Z = 5.15, P < .001), Pringle maneuver use (Z = 6.48, P < .001), major morbidity(Z = 2.17, P = .030) and 30-days readmission (Z = 1.99, P = .047) was registered as the size increased., Conclusion: L-LLS for tumors of increasing size was associated with poorer intraoperative and early postoperative outcomes suggesting increasing difficulty of the procedure. We determined three optimal TS cutoffs (40-, 70- and 100-mm) to accurately stratify surgical difficulty after L-LLS., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: Major hepatectomy in cirrhotic patients still represents a great challenge for liver surgeons. Hence, the aim in the present study is to investigate the clinical impact of major hepatectomy and to assess whether the surgical approach influences the outcome of cirrhotic patients., Methods: Multicenter retrospective study including cirrhotic patients undergoing major laparoscopic (mjLLR) and open liver resection (mjOLR) in 14 Western liver centers was performed (2009-2020). Clinical, demographic, and perioperative data were compared using propensity score matching (PSM). Long-term outcome after resection for hepatocellular carcinoma was analyzed., Results: Overall, 352 patients were included; 108 after mjLLR and 244 after mjOLR. After PSM, 88 patients were matched in each group. In the mjLLR group, compared to mjOLR, less blood loss (P = .042), lower overall and severe complication (P < .001, .020), such as surgical site infection, acute kidney injury and liver failure were observed, parallel to a shorter length of hospital stay. Stratifying patients based on the type of resection, less severe complications was observed only after laparoscopic left hepatectomy (P = .044), while the advantages of laparoscopy tend to decrease during right hepatectomy. Subgroup analysis of long-term survivals following liver resection for hepatocellular carcinoma showed no difference between mjLLR and mjOLR., Conclusions: This multicenter experience suggests potential short-term benefits of mjLLR in cirrhotic patients compared to mjOLR, without compromising long-term outcome. These findings might have interesting clinical implications for the management of patients with chronic liver disease., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Despite the worldwide increase of both obesity and the use of minimally invasive liver surgery (MILS), evidence regarding the safety and eventual benefits of MILS in obese patients is scarce. The aim of this study was therefore to compare the outcomes of non-obese and obese patients (BMI 18.5-29.9 and BMI≥30, respectively) undergoing MILS and OLS, and to assess trends in MILS use among obese patients., Methods: In this retrospective cohort study, patients operated at 20 hospitals in eight countries (2009-2019) were included and the characteristics and outcomes of non-obese and obese patients were compared. Thereafter, the outcomes of MILS and OLS were compared in both groups after propensity-score matching (PSM). Changes in the adoption of MILS during the study period were investigated., Results: Overall, 9963 patients were included (MILS: n = 4687; OLS: n = 5276). Compared to non-obese patients (n = 7986), obese patients(n = 1977) were more often comorbid, less often received preoperative chemotherapy or had a history of previous hepatectomy, had longer operation durations and more intraoperative blood loss (IOBL), paralleling significantly higher rates of wound- and respiratory-related complications. After PSM, MILS, compared to OLS, was associated, among both non-obese and obese patients, with less IOBL (200 ml vs 320 ml, 200 ml vs 400 ml, respectively), lower rates of transfusions (6.6% vs 12.8%, 4.7% vs 14.7%), complications (26.1% vs 35%, 24.9% vs 34%), bile leaks(4% vs 7%, 1.8% vs 4.9%), liver failure (0.7% vs 2.3%, 0.2% vs 2.1%), and a shorter length of stay(5 vs 7 and 4 vs 7 days). A cautious implementation of MILS over time in obese patients (42.1%-53%, p < .001) was paralleled by stable severe morbidity (p = .433) and mortality (p = .423) rates, despite an accompanying gradual increase in surgical complexity., Conclusions: MILS is increasingly adopted and associated with perioperative benefits in both non-obese and obese patients., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The difficulty of laparoscopic right liver resections (LRLR) is mainly associated with their poor accessibility. Anthropometric data rather than BMI was reported to predict transection time and blood loss. Aim of the study was to evaluate the correlation between anthropometric data and preparatory manoeuvres difficulties during LRLR., Methods: All patients who underwent LRLR requiring full right liver mobilization from November 2019 to March 2021 were prospectively included in the study. Data on surgeons' difficulty perceptions on liver mobilization (LM), isolation of right hepatic vein (RHVI), liver manageability and visibility were rated with a 5-point scale. Data on cranio-caudal liver diameters (CCliv), CHALLENGE Index (CCliv/latero-lateral abdomen diameter), times needed to LM and RHVI were collected., Results: Sixty-five patients (29 wedge and 36 anatomical resections) with a median BMI of 25.5 were analysed. One patient required open conversion due to oncological reason. No correlations between BMI and CCliv or CHALLENGE Index were found. Larger CCliv diameter correlated with longer time for both RHVI (r = 0.589, p = 0.002) and LM (r = 0.222, p = 0.049). Higher CHALLENGE index correlated with longer time for RHVI (r = 0.589, p = 0.002). The CHALLENGE index showed a linear correlation with difficulty to the isolation of RHV (r = 0.327, p = 0.045), whilst the liver manipulation difficulty increased with latero-lateral liver diameter (r = 0.244, p = 0.033). BMI had no correlation with the duration of preparatory maneuvers neither with surgeons' difficulties., Conclusions: Anthropometric data can help to anticipate the difficulty of preparatory maneuvers during laparoscopic right liver resections., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Tumors involving the hepatic veins at the hepatocaval confluence often require major or extended hepatectomies. Color Doppler intraoperative ultrasonography (CD-IOUS) evaluation of liver hemodynamics to assess congestion in the veno-occlusive parenchyma provides real-time information helpful in parenchyma-sparing surgery (PSS). This study evaluated the feasibility of CD-IOUS in patients undergoing laparoscopic liver resections for such tumors and its capacity to allow PSS., Methods: Consecutive patients undergoing laparoscopic liver resection for tumors at the hepatocaval confluence requiring resection of at least one hepatic vein between January 2010 and August 2020 were included. Patients were divided in 3 groups: (A) patients not assessed with CD-IOUS because it would not change the scheduled operation; patients assessed with CD-IOUS and treated with (B) PSS and (C) no-PSS. Portal blood flow in the veno-occlusive parenchyma was assessed using CD-IOUS at baseline and after clamping the concerned hepatic vein., Results: The study included 43 out of 47 patients with tumors at the hepatocaval confluence. There were 19 patients in group A. Among patients assessed with CD-IOUS, the resection of 26 hepatic veins was planned: 25 were resected, and 1 was spared. Group B included 22 patients treated with PSS, whereas group C included 2 patients with resection of all veno-occlusive parenchyma. No postoperative mortality or major morbidity was observed. The median length of hospital stay was 5 days., Conclusions: Selected patients with tumors involving the hepatocaval confluence can be safely approached using laparoscopy. CD-IOUS evaluation of the veno-occlusive area can increase the success rate of PSS., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: and purpose: FDG-PET/CT has gained acceptance for tumours staging. Few and conflicting data exist on the sensitivity of FDG-PET/CT in identifying colorectal mucinous liver metastases (mucCRLM). The aim of this study was to evaluate the diagnostic performance of the FDG-PET/CT in patients with mucCRLM who underwent liver surgery., Methods: All patients affected by mucCRLM scheduled for liver resection who had undergone preoperative FDG-PET/CT between 2005 and 2018 were analyzed. Diagnostic performance of FDG-PET/CT was assessed in organ and lesion-based analysis., Results: 58 patients out of 131 (44.2%) affected by mucCRLM fulfilled the inclusion criteria. 118 mucCRLM were detected. FDG-PET/CT confirmed 71 (60.2%) CRLM in 51 patients. The sensitivity and specificity of FDG-PET/CT were 89.4% and 100% in the organ-based analysis and 60.7% and 100% in lesion-based analysis. Absence of micro-vascular invasion (100% vs. 23%, p < 0.001) and median percentage of viable tumour cells were associated with FDG-PET/CT false negative (15% vs. 60%, p = 0.007). At ROC analysis viable tumour cells percentage >25% was associated with low risk of false negative (AUC 0.848; p = 0.006)., Conclusions: FDG-PET/CT had a significant rate of false negative results in patients with mucinous colorectal liver metastases. Negative FDG-PET/CT in patients with low percentage of viable tumour cells after chemotherapy should be considered with caution., Competing Interests: Declaration of competing interest No potential conflict of interest was reported by the authors. All authors have approved the final article. Data for the current study is owned by the department where the study was conducted. Authors have full control of all primary data. Data may be requested to the corresponding author., (Copyright © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes., Study Design: All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes., Results: Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes., Conclusion: Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries., (© 2021. Italian Society of Surgery (SIC).)

Background: Preoperative biliary drainage may be essential to reduce the risk of postoperative liver failure after hepatectomy for perihilar cholangiocarcinoma. However, infectious complications related to preoperative biliary drainage may increase the risk of postoperative mortality. The strategy and optimal drainage method continues to be controversial., Methods: This is a retrospective multicenter study including patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2016 at 14 Italian referral hepatobiliary centers. The primary end point was to evaluate independent predictors for postoperative outcome in patients undergoing liver resection for perihilar cholangiocarcinoma after preoperative biliary drainage., Results: Of the 639 enrolled patients, 441 (69.0%) underwent preoperative biliary drainage. Postoperative mortality was 8.9% (12.5% after right-side hepatectomy versus 5.7% after left-side hepatectomy; P = .003). Of the patients, 40.5% underwent preoperative biliary drainage at the first admitting hospital, before evaluation at referral centers. Use of percutaneous preoperative biliary drainage was significantly more frequent at referral centers than at community hospitals where endoscopic preoperative biliary drainage was the most frequent type. The overall failure rate after preoperative biliary drainage was 43.3%, significantly higher at community hospitals than that at referral centers (52.7% v 36.9%; P = .002). Failure of the first preoperative biliary drainage was one of the strongest predictors for postoperative complications after right-side and left-side hepatectomies and for mortality after right-side hepatectomy. Type of preoperative biliary drainage (percutaneous versus endoscopic) was not associated with significantly different risk of mortality., Conclusion: Failure of preoperative biliary drainage was significantly more frequent at community hospitals and it was an independent predictor for postoperative outcome. Centers' experience in preoperative biliary drainage management is crucial to reduce the risk of failure that is closely associated with postoperative morbidity and mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI., Methods: All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results., Results: Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2-10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS)., Conclusions: Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.

Background: 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., Methods: 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., Results: 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., Conclusions: 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: Difficulty scores (DSs) have been proposed to rate laparoscopic liver resection (LLR) technical difficulty increasing surgical safety. The aim of the study was to validate three DSs (Hasegawa, Halls and Kawaguchi) and compare their ability to predict technical difficulty and postoperative outcomes., Materials and Methods: All patients who underwent LLR from January 2006 to January 2019 were analyzed. Exclusion criteria were cyst fenestrations, thermal ablation, missing data for the computation of the DS and a follow-up < 90 days., Results: The population comprised 300 patients. The DS distribution in the study population was: Halls low 55 (18.3%), moderate 82 (27.3%), high 111 (37%) and extremely high 52 (17.3%); Hasegawa low 130 (43.3%), medium 105 (35%) and high 65 (21.7%); Kawaguchi Grade I 194 (64.7%), Grade II 47 (15.7%) and Grade III 59 (19.7%). Hasegawa and Kawaguchi showed the strongest correlation (r = 0.798, p < 0.001). Technical complexity, evaluated using the Pringle maneuver, Pringle time, blood loss and operative time, increased significantly with Hasegawa and Kawaguchi score classes (p < 0.001 for all comparisons). None of the scores properly stratified postoperative complications. The highest Kawaguchi (23.7% grade III vs. 13.7% grades I and II, p = 0.057) and Hasegawa (24.6% high vs. 13.2% low/medium, p = 0.025) classes had a higher overall morbidity rate than medium-low ones., Conclusions: Kawaguchi and Hasegawa scores predicted LLR's technical difficulty. None of the scores discriminated the postoperative complication risk of low classes compared with medium ones.

Background: To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies., Methods: Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed., Results: Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270-960). Blood loss was a median 300 cc (range 40-1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22)., Conclusions: Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.

Background: Laparoscopic liver resection (LLR) is reported as a safe procedure with potential advantages over open surgery albeit with inherent limitations, such as loss of haptic perception and spatial orientation. Ultrasound is considered the best tool to identify anatomic landmarks and the transection plane during liver surgery. The aim of this study was to analyse the outcomes of LLR performed with a standardized US guidance technique., Methods: We have standardized a 4-step technique for ultrasound-guided LLR: (1) compose a 3-D mind map by studying relationships among lesions and surrounding anatomic structures, (2) sketch the map on the liver surface, (3) check, and (4) correct the transection plane in real time., Results: Between 01/2006 and 12/2016, 190 consecutive patients treated with US-guided LLR were analysed. The indications for LLR included malignant tumours in 148 patients (81.8%). The procedures were classified according to a difficulty scale. There were 18 major hepatectomies (9.9%), 80 anatomic bi- and monosegmentectomies (44.2%), and 101 non-anatomic resections (55.8%). Redo resection was performed in 17 patients (9.4%), and multiple liver resections were performed in 25 patients (24.7%). Median intraoperative blood loss was 100 ± 154 mL. Overall and major morbidity rates were 14.9% and 1.6%, respectively. Mortality was nil., Conclusions: Ultrasound liver map technique enables planning and real-time guidance during laparoscopic liver resections.

Early hospital readmission for dehydration represents a relevant problem among patients with diverting or terminal ileostomy. The aim of the study was to evaluate the efficacy of a new multidisciplinary individualized multistep protocol in terms of reduction of hospital readmission for dehydration. Since January 2016, our institution adopted a new protocol for patients with ileostomy. Protocol key points were: preoperative personalized education in stoma management; early recognition of dehydration symptoms; multidisciplinary counseling; patient autonomy in stoma management through post-operative recall schedule. The study compared a series of consecutive patients treated before (2014-2015) and after (2016-2017) the protocol application. The primary endpoint was hospital readmission rate after protocol use. The secondary endpoint was the identification of possible risk factors for readmission. The entire cohort was composed of 296 patients, 129 in the protocol group and 167 in the control one. The two groups were homogeneous for baseline characteristics. Hospital readmission rate within 30 days post-discharge for dehydration dropped from 9 to 3.9% after protocol application. Specifically, the number of avoided potential readmissions was 29/129 (22.4%). The number needed to treat (NNT) was 20. Univariate analysis identified three relevant variables: patient comorbidities, diuretics use as risk factors and protocol application as the protective one. The multivariate analysis confirmed patient comorbidity as the risk factor. Dehydration related to ileostomy is a potentially avoidable problem, by employing preventive strategies, especially in high-risk patients. Our new protocol could be a simple and cost-saving method, effective in preventing hospital readmissions.

Intraoperative liver ultrasound has a crucial role to guide open liver surgery. A 4-step ultrasound liver map technique for laparoscopic liver resection (LLR) has been standardized in our center. The aim of this study was to evaluate outcomes of our technique according to the hepatectomy technical complexity. A difficulty scale (DS) ranging from 1 to 10 was applied to each LLR. A cumulative sum control-chart analysis identified 3 periods of gradually increasing DS. Perioperative outcomes of the 3 periods were compared. 300 LLRs performed between 2006 and 2018 were analyzed. Median DS was 3 for first 100 cases (P1), 5 for cases 101-200 (P2) and 6 for cases 201-300 (P3). A significantly greater percentage of postero-superior segments resections (P1 11%, P2 36%, P3 46%, p < 0.001) were performed in P3. P3 LLRs had a significantly longer transection time (p < 0.001) and wider cut surface area (p < 0.001), but median blood losses were similar among the 3 periods (P1 100 cc, P2 100 cc, P3 140 cc). There were no differences among periods in overall morbidity (P1 12%, P2 17%, P3 17%), major morbidity (P1 1%, P2 2%, P3 3%) and length of hospital stay (5 days in all the three groups). Despite the increasing surgical complexity of LLR, ultrasound liver map technique allows good perioperative outcomes.

Background: The albumin-indocyanine green evaluation (ALICE) model based on serum albumin and indocyanine retention rate has been shown to be an effective method for predicting postoperative outcomes in hepatocellular carcinoma patients. Aim of the study was to validate the ALICE model in a large Western cohort of patients by comparing the albumin-bilirubin (ALBI) score and Child-Turcotte-Pugh (CTP) score., Methods: A total of 400 patients who underwent hepatic resection from January 2005 to June 2016 at three centers were enrolled. The ALICE, ALBI, and CTP scores were computed for all patients., Results: The ALICE score correlated better with ALBI (r = 0.428) than with CTP score (r = 0.302). Both the ALICE (grade 1: 49%; grade 2: 51%) and the ALBI (grade 1: 52.5%; grade 2: 47.5%) scores stratified the CTP class A patients into two distinct classes. The incidence of ascites (grades 1-3: ALICE 11%, 20%, 58%; ALBI 11%, 23%, 50%) and severe liver failure (ALICE 8.7%, 10.5%, 41.7%; ALBI 8.6%, 12%, 50%) increased with increasing ALBI and ALICE grade and were similar for the same grade., Conclusions: The ALICE model can assess hepatic functional reserve and predict postoperative outcomes with efficacy comparable with the ALBI grade and better than the CTP score., (© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: The role of liver transplant (LT) for neuroendocrine liver metastasis (NELM) has not been completely defined. While international guidelines included LT as a potential treatment for highly selected patients with advanced NELM, recently, LT has been proposed as an alternative curative treatment for NELM for patients meeting restrictive criteria (Milan criteria)., Methods: Using a multi-institutional cohort of patients undergoing liver resection for NELM, the long-term outcomes of patients meeting Milan criteria (resected NET drained by the portal system, stable disease/response to therapies for at least 6 months, metastatic diffusion to < 50% of the total liver volume, a confirmed histology of low-grade, and ≤ 60 years) were investigated., Results: Among the 238 patients included in the study, 28 (12%) patients met the Milan criteria for LT with a 5-year OS of 83%. Furthermore, among patients meeting Milan criteria, subsets of patients with favorable clinic-pathological characteristics had 5-year OS rates greater than 90% including G1 patients (5-year OS, 92%), patients undergoing minor liver resection (5-year OS, 94%), patients with low number of NELM (1-2 NELM), and small tumor size (< 3 cm) (for both groups of patients, 5-year OS, 100%)., Conclusions: In our series, only 12% of patients met Milan criteria, and the 5-year OS after liver resection for this small selected group of patients was comparable with that reported in the literature for patients undergoing LT for NELM within Milan criteria. While LT might be the optimal treatment for patients with unresectable NELM, surgical resection should be the first option for patients with resectable NELM.

Background: Failure of portal vein ligation (PVL) to induce hypertrophy is not uncommon. The aim of the study was to evaluate the impact of intraportal alcohol injection prior to ligation on liver regeneration., Method: Forty-two patients with colorectal liver metastases who underwent PVL between 01/2004 and 06/2014 were analyzed. Beginning in 09/2011, alcohol was injected prior to PVL. Patients treated with PVL alone (Alc- group) were compared with those treated with alcohol injection plus PVL (Alc+ group). Liver regeneration was assessed by volumetric increase (VI)., Results: Alc+ (23 patients) and Alc- (19 patients) groups were similar in terms of age, sex and pre-PVL FLRV. Alc- group had a higher risk of recanalization (12 vs. 1, p < 0.001) and cavernous transformation (7 vs. 2, p = 0.055) of the occluded portal vein. Post-PVL FLRV (43.3 ± 14.3% vs. 34.6 ± 6.4%, p = 0.013) and VI (0.44 ± 0.24 vs. 0.28 ± 0.20, p = 0.029) were higher in Alc+ group. On multivariate analysis male sex (B = -0.149) and alcohol injection (B = 0.143) significantly predicted VI., Conclusions: Alcohol injection prior to PVL may increase the regeneration of the FLRV by reducing the recanalization of the occluded portal vein., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background/aims: Liver surgery for colorectal metastases has moved toward parenchymal sparing strategy with an increasing number of conservative resections. The aim of this study was to elucidate outcomes of bisegmentectomies for right liver metastases., Methodology: The study focuses on 56 patients affected by liver metastases in the right liver with a diameter < or =10 cm undergoing anatomic resections of two or more segments. Patients were divided as follows: 36 right hepatectomies (RH) and 20 bisegmentectomies (BS)., Results: Bisegmentectomies had significantly higher rate of pedicle clamping (80.0% vs 22.2%, p = 0.0001), but intraoperative blood losses were similar. Radical resection rates were similar. Postoperative mortality was nil; morbidity rates were significantly higher after RH (30.6% vs. 5.0%, p = 0.039) with increased rate of liver dysfunction and bile leak (8.3% vs. 0% in both cases). 5-year overall and recurrence-free survival rates were similar into the two groups (RH vs BS): 38.8% vs. 29.1%, p = 0.763; 24.5% vs. 20.5%, p = 0.216. Overall recurrence rates were similar into the two groups. Considering isolated hepatic recurrence, re-resection was feasible more frequently in BS patients (60% vs. 20%)., Conclusions: Bisegmentectomies are a safe alternative to right hepatectomy in right liver metastases treatment, improving postoperative outcomes, offering similar survival results and increasing the opportunity to re-resection in case of recurrence.

In the belief that the advantages stemming from a minimally invasive approach are significant, particularly in cirrhosis patients, we decided to apply this technique in the treatment of a group of patients suffering from HCC associated with cirrhosis. Sixteen patients (10 men, 6 women; mean age 60.1 years) underwent laparoscopic surgery for HCC associated with well compensated HCV-related liver cirrhosis (Child-Pugh class A; mean tumour size 2.9 cm). Seven of these lesions were located in the left liver and 9 in the right lobe. Laparoscopy was performed with a CO2 pneumoperitoneum (12-14 mmHg). The Pringle manoeuvre was not used. There was one conversion to laparotomy due to inadequate exposure. We performed 13 non-anatomical resections, 1 VI segmentectomy and 1 anatomical left lobectomy. None of the patients required blood transfusions. One patient died of severe respiratory distress syndrome on postoperative day 3. Major morbidity included 2 moderate postoperative ascites successfully resolved with conservative treatment. To date (mean follow-up: 18 months) no recurrences at the resection site or port-site metastases have been observed. Limited laparoscopic liver resections for HCC in cirrhotic patients are technically feasible and safe when careful selection criteria are adopted (hepatic involvement limited and located in the left or anterior right segments, tumour size smaller than 5 cm, Child-Pugh class A).