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Surgical resection remains the best therapeutic option for the long-term survival of patients with perihilar cholangiocarcinoma (PCC).1 For patients presenting with Bismuth type 3 or 4 tumors, left or right extended liver resection has been shown to be feasible.2 The Achilles heel of the procedure remains biliary reconstruction due to multiple small-diameter remnant liver bile ducts.3 This study showed how a Kasai-like portoenterostomy allows circumvention of this difficulty.A 57-year-old woman with a type 3a PCC invading the main portal vein bifurcation underwent a right hepatectomy with en bloc resection of segment 4b, the caudate lobe, and the extrahepatic common bile duct; hepatic pedicle lymphadenectomy; and main portal vein bifurcation reconstruction.4 The cross-section of the left biliary plate was tumor-free at frozen section analysis but involved three small biliary ducts originating from segments 2, 3, and 4a. The biliary plate and the distance between each duct were too large to allow unification. A Roux-en-Y portoenterostomy, inspired by the Kasai procedure,5 was performed between the umbilical plate and the extramucosal wall of an efferent Roux-en-Y jejunal limb. Two temporary external trans-portoenterostomy drains were placed according to the Voelker technique.The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The two trans-portoenterostomy drains were removed after 6 weeks, and patient was disease-free at the 2-year follow-up evaluation.In extended PCC, Kasai-like portoenterostomy may facilitate complex biliodigestive reconstructions when multiple biliary ducts are involved.

Backgrounds/Aims Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD. Methods During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients. Results Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 ＞0

(1) Background: colorectal liver metastases (CRLM) are the most common extra-lymphatic metastases in colorectal cancer; however, few patients are fit for curative surgery. Microwave ablation (MWA) showed promising outcomes in this cohort of patients. This systematic review and pooled analysis aimed to analyze the oncological results of MWA for CRLM. (2) Methods: Following PRISMA guidelines, PubMed, Scopus, EMBASE, Google Scholar, Science Direct, and the Wiley Online Library databases were searched for reports published before January 2021. We included papers assessing MWA, treating resectable CRLM with curative intention. We evaluated the reported MWA-related complications and oncological outcomes as being recurrence-free (RF), free from local recurrence (FFLR), and overall survival rates (OS). (3) Results: Twelve out of 4822 papers (395 patients) were finally included. Global RF rates at 1, 3, and 5 years were 65.1%, 44.6%, and 34.3%, respectively. Global FFLR rates at 3, 6, and 12 months were 96.3%, 89.6%, and 83.7%, respectively. Global OS at 1, 3, and 5 years were 86.7%, 59.6%, and 44.8%, respectively. A better FFLR was reached using the MWA surgical approach at 3, 6, and 12 months, with reported rates of 97.1%, 92.7%, and 88.6%, respectively. (4) Conclusions: Surgical MWA treatment for CRLM smaller than 3 cm is a safe and valid option. This approach can be safely included for selected patients in the curative intent approaches to treating CRLM.

Background: Patients with numerous colorectal liver metastases (CLM) have high risk of early recurrence after liver resection (LR). The presence of intrahepatic occult microscopic metastases missed by imaging has been hypothesized, but it has never been assessed by pathology analyses. Methods: All patients with > 10 CLM who underwent LR between September 2015 and September 2016 were considered. A large sample of liver without evidence of disease (“healthy liver”) was taken from the resected specimen and sent to the pathologist. One mm-thick sections were analyzed. Any metastasis, undetected by preoperative and intraoperative imaging, but identified by the pathologist was classified as occult microscopic metastasis. Results: Ten patients were prospectively enrolled (median number of CLM n = 15). In a per-lesion analysis, the sensitivity of computed tomography and magnetic resonance imaging was 91 and 98% respectively. The pathology examination confirmed all the CLM. All patients had an adequate sample of “healthy liver” (median number of examined blocks per sample n = 14 [5–33]). No occult microscopic metastases were detected. After a median follow-up of 15 months, 5 patients were disease-free. Recurrence was hepatic and bilobar in all patients. Conclusions: Clinically relevant occult microscopic disease in patients with numerous CLM is excluded. These results support the indication to resection in such patients and exclude the need for de principe major hepatectomy to increase the completeness of surgery.

The aim of this study was to report the impact of C-choline PET/CT on the management of patients with hepatocellular carcinoma (HCC) and incorporate into a refined algorithm combining diagnostic imaging and multidisciplinary team (MDT) discussion.From February 2010 to February 2016, the charts of all patients discussed in the liver MDT were revised. Suspected or confirmed HCC lesions or Barcelona Clinic Liver Cancer stages A, B or C with a C-choline PET/CT performed in our hospital were included in the analyses. Overall, 73 patients (male : female=59 : 14; median age: 75 years) were enrolled. Forty-two (57%) patients were newly diagnosed, whereas 31 (43%) came to our attention at disease recurrence. Seven (10%) patients were Barcelona Clinic Liver Cancer stage 0, 31 (42%) patients were stage A, 15 (20%) patients were stage B, and 18 (25%) patients were stage C. The reference standards for ultimate imaging validation were either histology or MDT consensus. A minimum follow-up of 6 months was established.Overall eight (10%) patients were initially referred for chemotherapy (sorafenib), 43 (59%) for surgery, two (3%) for surgery or transarterial embolization, five (7%) for follow-up only, one (1%) for extrahepatic radiotherapy, seven (10%) for stereotactic body radiation therapy of the liver, six (8%) for transarterial embolization, and one (1%) for liver transplant. After C-choline PET/CT and MDT discussion, in seven patients the diagnosis changed, in six patients the treatment was changed, and in nine patients both the diagnosis and the treatment were changed. Overall, in 30% of our patients, the diagnosis or treatment was altered on the basis of our algorithm of management.The incorporation of C-choline PET/CT into the MDT discussion altered the diagnosis/treatment of one-third of HCC patients. We propose a novel diagnostic algorithm to be refined in referral centers for HCC management.

Malnutrition in liver surgery is correlated with higher postoperative complications and longer length of hospital stay (LOHS), the same items that ERAS programs try to optimize. However, to date, standardized dietary protocols have not been defined within ERAS programs. Aim of this study was to evaluate the impact on LOHS and postoperative complications, of a personalized nutritional protocol (NutriCatt) with diet and oral branched-chain amino acid (BCAA) supplementation, adopted within the ERAS program.1960 consecutive liver resections were performed from January 2000 to September 2018.perihilar cholangiocarcinoma, simultaneous colorectal and liver resections. Four groups for analysis: resections before 2009 (1st period); from 2009 to 2016 (2nd period, including laparoscopic resections); between 2016 and September 2017 (ERAS); after September 2017 (ERAS + NutriCatt).LOHS declined (p 0.0001), from a median of 10 days (1st period) to 8, 7 and 6 in 2nd period, ERAS and ERAS + NutriCatt groups, respectively. At multivariable analysis for risk of LOHS 8 days, the 2nd period, ERAS and ERAS + NutriCatt groups showed a protective effect. These results were confirmed for both minor and major resections. LOHS was significantly lower in ERAS + Nutricatt group than in ERAS group, without increasing risk of postoperative complications, although the rate of laparoscopic resections was similar in these two groups and complexity of liver resections was significantly higher in the last period.Adoption of a personalized nutritional protocol with BCAA supplementation within the ERAS program for liver resections was a safe and effective approach that may impact on reducing the LOHS.

Surgical resection remains the best therapeutic option for the long-term survival of patients with perihilar cholangiocarcinoma (PCC).1 For patients presenting with Bismuth type 3 or 4 tumors, left or right extended liver resection has been shown to be feasible.2 The Achilles heel of the procedure remains biliary reconstruction due to multiple small-diameter remnant liver bile ducts.3 This study showed how a Kasai-like portoenterostomy allows circumvention of this difficulty. A 57-year-old woman with a type 3a PCC invading the main portal vein bifurcation underwent a right hepatectomy with en bloc resection of segment 4b, the caudate lobe, and the extrahepatic common bile duct; hepatic pedicle lymphadenectomy; and main portal vein bifurcation reconstruction.4 The cross-section of the left biliary plate was tumor-free at frozen section analysis but involved three small biliary ducts originating from segments 2, 3, and 4a. The biliary plate and the distance between each duct were too large to allow unification. A Roux-en-Y portoenterostomy, inspired by the Kasai procedure,5 was performed between the umbilical plate and the extramucosal wall of an efferent Roux-en-Y jejunal limb. Two temporary external trans-portoenterostomy drains were placed according to the Voelker technique. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The two trans-portoenterostomy drains were removed after 6 weeks, and patient was disease-free at the 2-year follow-up evaluation. In extended PCC, Kasai-like portoenterostomy may facilitate complex biliodigestive reconstructions when multiple biliary ducts are involved.

The assessment of liver volume (LV) is important before surgical resection or transplantation to reduce the risk of hepatic insufficiency. LV is usually measured using computed tomography or with some formulas. The aim of this study was to develop a new dynamic formula to predict LV. Using computed tomography, LV was calculated in 101 patients without liver disease. LV was correlated with patient metabolic status, calculated with the Harris–Benedict equation for basal energy expenditure (BEE). Activity energy expenditure (AEE) was also calculated. Using linear regression analysis, a new formula was derived and was compared with Heinmann’s, Urata’s, Emre’s, Vauthey’s, Yoshizumi’s, Yu’s, and Hashimoto’s formulas. A new basal formula was established: LV = (0.789 × BEE) + 272. It was found to be the most accurate (R2 = 0.39, p

Background Hepatocellular carcinoma (HCC) associated with tumor extension in the portal vein, hepatic vein, or inferior vena cava (IVC) is traditionally considered an advanced stage of disease to which palliative radiotherapy or sorafenib chemotherapy is proposed.1,2 Recent studies have shown a significant survival benefit in patients treated with R0 liver resection.3-5 METHODS: We describe the case of a 45-year-old female patient presenting with a voluminous HCC developed in a non-cirrhotic liver with a tumor thrombus obstructing the retrohepatic IVC and the middle hepatic vein termination. Initial treatment included two cycles of selective internal radiation therapy with Yttrium 90 and sorafenib treatment for 1 year. Re-evaluation revealed a significant reduction of the tumor and compensative hypertrophy of the left liver lobe, enabling surgical resection. Results The procedure included anatomic right hepatic trisectionectomy with caudate lobectomy and retrohepatic IVC graft replacement. Total liver vascular exclusion with intrapericardial IVC control enabled en bloc R0 resection of the tumor and the floating tumor thrombus in the cavo-hepatic venous confluence. Total liver vascular exclusion duration was 20 min, for a total warm liver ischemia of 40 min. The duration of the operation was 240 min and blood loss was 700 mL. The patient was discharged on postoperative day 15 and was free of disease 6 months post-surgery. Conclusion Liver surgery with complex vascular resections for HCC with major vascular invasion should be considered a valid therapeutic option in high-volume hepatobiliary centers.

The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound-guided compression of the tumor-feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection.Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1-to-2 with nonanatomic resection cases based on the Child-Pugh class, Model for End-Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/1), and hepatocellular carcinoma size (30, 30-50, and50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90-day mortality (0 compression technique anatomic resection), non-cancer-related death, and follow-up12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases.All patients were Child-Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5-year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2-year local recurrence-free survival (94% vs 78%; P = .012). Nonlocal recurrence-free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3-year survival after recurrence (65% vs 42%; P = .043).Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma-bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.

Background Hepatectomy using the thoraco-abdominal approach (TAA) compared to the abdominal approach (AA) remains under debate. This study assessed the perioperative outcomes of patients operated with or without TAA. Methods 1:1 propensity score-matched analysis was applied in 744 patients operated between 2007 and 2013, identifying 246 patients who underwent hepatectomy with TAA compared to 246 patients with AA. These groups were matched for demographics, liver disease, comorbidity, tumor features, and extent of resection. Rates of morbidity and mortality were the study endpoints. Results The rates of morbidity or mortality were not different. With the TAA length of the operations (P = 0.002), length of the Pringle maneuver (P = 0.012), and rate of blood transfusions (P = 0.041) were significantly different. Hospital stay was similar. Independent significant prognostic factors for adverse perioperative outcome were: renal comorbidity (OR = 2.7; P = 0.001), extent of the resection (OR = 3.7; P = 0.001), and increased BILCHE score (OR = 2.4; P = 0.002). Conclusions Hepatectomy using the TAA was not associated with adverse perioperative outcome. The associations with length of operation, Pringle maneuver and blood transfusions may have reflected the complexity of the tumor presentation rather than the technical approach.

Incisional hernias (IHs) are common complications after liver transplantation (LT) with a reported incidence of 1.7% to 34.3%. The purpose of this retrospective study was to evaluate the risk factors for IH development after LT with a focus on the role of immunosuppressive therapy during the first month after LT. We analyzed 373 patients who underwent LT and divided them into 2 groups according to their postoperative course: an IH group (121 patients or 32.4%) and a no-IH group (252 patients or 67.6%). A univariate analysis demonstrated that the following were risk factors related to IH development: male sex (P = 0.03), a body mass index ≥ 29 kg/m(2) (P = 0.005), LT after 2004 (P = 0.02), a Model for End-Stage Liver Disease (MELD) score ≥ 22 (P = 0.01), and hepatitis B virus infection (P = 0.01). The highest incidence of IHs was found in patients treated with mammalian target of rapamycin (mTOR) inhibitors (54.5%, P = 0.004). A multivariate analysis revealed male sex (P = 0.03), a pretransplant MELD score ≥ 22 (P = 0.04), and the use of mTOR inhibitors (P = 0.001) to be independent risk factors for IHs after LT. In conclusion, immunosuppressive therapy with mTOR inhibitors is an important independent risk factor for IH development after LT. To reduce the incidence of IHs, mTOR inhibitors should be avoided until the fourth month after LT unless their use is deemed to be strictly necessary.