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Background & Aims Despite improvements in medical and surgical techniques, post-hepatectomy liver failure (PHLF) remains the leading cause of postoperative death. High postoperative portal vein pressure (PPV) and portocaval gradient (PCG), which cannot be predicted by current tools, are the most important determinants of PHLF. Therefore, we aimed to evaluate a digital twin to predict the risk of postoperative portal hypertension (PHT). Methods We prospectively included 47 patients undergoing major hepatectomy. A mathematical (0D) model of the entire blood circulation was assessed and automatically calibrated from patient characteristics. Hepatic flows were obtained from preoperative flow MRI (n = 9), intraoperative flowmetry (n = 16), or estimated from cardiac output (n = 47). Resection was then simulated in these 3 groups and the computed PPV and PCG were compared to intraoperative data. Results Simulated post-hepatectomy pressures did not differ between the 3 groups, comparing well with collected data (no significant differences). In the entire cohort, the correlation between measured and simulated PPV values was good (r = 0.66, no adjustment to intraoperative events) or excellent (r = 0.75) after adjustment, as well as for PCG (respectively r = 0.59 and r = 0.80). The difference between simulated and measured post-hepatectomy PCG was ≤3 mmHg in 96% of cases. Four patients suffered from lethal PHLF for whom the model satisfactorily predicted their postoperative pressures. Conclusions We demonstrated that a 0D model could correctly anticipate postoperative PHT, even using estimated hepatic flow rates as input data. If this major conceptual step is confirmed, this algorithm could change our practice toward more tailor-made procedures, while ensuring satisfactory outcomes. Lay summary Post-hepatectomy portal hypertension is a major cause of liver failure and death, but no tool is available to accurately anticipate this potentially lethal complication for a given patient. Herein, we propose using a mathematical model to predict the portocaval gradient at the end of liver resection. We tested this model on a cohort of 47 patients undergoing major hepatectomy and demonstrated that it could modify current surgical decision-making algorithms.

Background and aims LR and LT are the standard curative options for early HCC. LT provides best long-term survival but is limited by organ shortage. LR, readily available, is hampered by high recurrence rates. Salvage liver transplantation is an efficient treatment of recurrences within criteria. The aim of the study was to identify preoperative predictors of non transplantable recurrence (NTR) to improve patient selection for upfront LR or LT at initial diagnosis. Study design Consecutive LR for transplantable HCC between 2000 and 2015 were studied. A prediction model for NTR based on preoperative variables was developed using sub-distribution hazard ratio after multiple imputation and internal validation by bootstrapping. Model performance was evaluated by the concordance index after correction for optimism. Results A total of 148 patients were included. Five-year overall survival and recurrence free survival were 73.6% and 29.3%, respectively (median follow-up 45.8 months). Recurrence rate was 54.8%. NTR rate was 38.2%. Preoperative model for NTR identified >1 nodule [sub-distribution hazard ratio 2.35 95% confidence interval (CI) 1.35-4.09], AFP >100 ng/mL (2.14 95% CI 1.17-3.93), and F4 fibrosis (1.93 95% CI 1.03-3.62). The apparent concordance index of the model was 0.664 after correction for optimism. In the presence of 0, 1, and ≥2 factors, NTR rates were 2.6%, 22.7%, and 40.9%, respectively. The number of prognostic factors was significantly associated with the pattern of recurrence (P = 0.001) and 5-year recurrence free survival (P Conclusions Cirrhosis, >1 nodule, and AFP >100 ng/mL were identified as preoperative predictors of NTR. In the presence of 2 factors or more upfront transplantation should be probably preferred to resection in regard of organ availability. Other patients are good candidates for LR and salvage liver transplantation should be encouraged in eligible patients with recurrence.

Background: Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal metastases (CLM). As alternative, ultrasound-guided one-stage hepatectomy (E-OSH) has been proposed even for deep-located nodules to compare TSH and E-OSH. Methods: All consecutive TSH at the Paul Brousse Hospital and E-OSH at the Humanitas Research Hospital were considered. The inclusion criteria were ≥6 CLM, ≥3 CLM in the left liver, and ≥1 lesion with vascular contact. A total of 74 TSH and 35 E-OSH were compared. Results: The 2 groups had similar characteristics. Drop-out rate of TSH was 40.5%. In comparison with the cumulated hepatectomies of TSH, E-OSH had lower blood loss (500 vs. 1,100 mL, p = 0.009), overall morbidity (37.1 vs. 70.5%, p = 0.003), severe morbidity (14.3 vs. 36.4%, p = 0.04), and liver-specific morbidity (22.9 vs. 40.9%, p = 0.02). R0 resection rate was similar between groups. E-OSH and completed TSH had similar overall survival (5-year 38.2 vs. 31.8%), recurrence-free survival (3-year 17.6 vs. 17.7%), and recurrence sites. Conclusions: E-OSH is a safe alternative to TSH for multiple bilobar deep-located CLM. Whenever feasible, E-OSH should even be considered the preferred option because it has excellent safety and oncological outcomes equivalent to completed TSH, without the drop-out risk.

Background Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL. Methods In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated. Results A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P < 0·001; 15 versus 3·1 per cent in the validation cohort, P < 0·001). Conclusion The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Background Locoregional extension of intrahepatic cholangiocarcinoma (ICC) at the time of diagnosis results in a low resectability rate and poor prognosis. The aim of this retrospective study was to assess the efficacy of neoadjuvant chemotherapy for locally advanced ICC. Methods All consecutive patients with ICC between 2000 and 2013 were included prospectively in a single-centre database and analysed retrospectively. Patients with locally advanced ICC considered as initially unresectable received primary chemotherapy, followed by surgery in those with secondary resectability. Results of patients who underwent surgery for locally advanced ICC were compared with those of patients with initially resectable ICC treated by surgery alone. Results A total of 186 patients were included in the study. Of 74 patients with locally advanced ICC, 39 (53 per cent) underwent secondary resection after a median of six chemotherapy cycles. Patients in this group were younger (P = 0·030) and had more advanced disease than those who had surgery alone, and presented more frequently with lymphadenopathy (P = 0·010) and vascular invasion (P = 0·010). Postoperative morbidity and mortality were no different between the groups. The median survival of patients who had surgery after chemotherapy was 24·1 months, and that of patients who had surgery alone was 25·7 months (P = 0·391). Conclusion Patients with locally advanced ICC treated by surgery following neoadjuvant chemotherapy had similar short- and long-term results to patients with initially resectable ICC who had surgery alone. Neoadjuvant chemotherapy as a first-line treatment for locally advanced ICC may be an effective downstaging option, facilitating secondary resectability in patients with initially unresectable disease.

Background Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension. Methods This was a retrospective study of all consecutive patients who received portasystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunting were compared with those who had a TIPSS procedure following one-to-one propensity score matching. The primary study endpoints were overall survival and shunt failure, defined as major variceal rebleeding, relapse of refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death. Results A total of 471 patients received either a surgical shunt or TIPSS. Of these, 334 consecutive patients with cirrhosis who underwent elective surgical shunting (34) or TIPSS (300) for repeated variceal bleeding or refractory ascites were evaluated. Propensity score matching yielded 31 pairs of patients. There were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was less frequent after surgical shunting than TIPSS (6 of 31 versus 16 of 31; P = 0·016). The 5-year shunt failure-free survival (77 versus 15 per cent; P = 0·008) and overall survival (93 versus 42 per cent; P = 0·037) rates were higher for patients with surgical shunts. Multivariable analysis revealed that a Model for End-Stage Liver Disease (MELD) score exceeding14 and TIPSS were independently associated with shunt failure. In patients with MELD scores of 14 or less, the 5-year overall survival rate remained higher after surgical shunting than TIPSS (100 versus 40 per cent; P < 0·001). Conclusion Surgical shunting achieved better results than TIPSS in patients with complicated portal hypertension and low MELD scores.

Background The purpose of this study was to determine the optimal definition and elucidate the predictive factors of early recurrence after surgery for colorectal liver metastases (CRLM). Methods Among 987 patients who underwent curative surgery for CRLM from 1990 to 2012, 846 with a minimum follow-up period of 24 months were eligible for this study. The minimum p value approach of survival after initial recurrence was used to determine the optimal cutoff for the definition of early recurrence. The predictive factors of early recurrence and prognostic factors of survival were analyzed. Results For 667 patients (79%) who developed recurrence, the optimal cutoff point of early recurrence was determined to be 8 months after surgery. The impact of early recurrence on survival was demonstrated mainly in patients who received preoperative chemotherapy. Among the 691 patients who received preoperative chemotherapy, recurrence was observed in 562 (81%), and survival in patients with early recurrence was significantly worse than in those with late recurrence (5-year survival 18.5% vs. 53.4%, p 1 chemotherapy line (p = .03), disease progression during last-line chemotherapy (p = .024), >3 tumors (p = .0014), and carbohydrate antigen 19-9 >60 U/mL (p = .0003) as independent predictors of early recurrence. Salvage surgery for recurrence significantly improved survival, even in patients with early recurrence. Conclusion The optimal cutoff point of early recurrence was determined to be 8 months. The preoperative prediction of early recurrence is possible and crucial for designing effective perioperative chemotherapy regimens. Implications for practice In this study, the optimal cutoff point of early recurrence was determined to be 8 months after surgery based on the minimum p value approach, and its prognostic impact was demonstrated mainly in patients who received preoperative chemotherapy. Five factors, including age, number of preoperative chemotherapy lines, response to last-line chemotherapy, number of tumors, and carbohydrate antigen 19-9 concentrations, were identified as predictors of early recurrence. Salvage surgery for recurrence significantly improved survival, even in patients with early recurrence. For better selection of patients who could truly benefit from surgery and should also receive strong postoperative chemotherapy, the accurate preoperative prediction of early recurrence is crucial.

The partial liver's ability to regenerate both as a graft and remnant justifies right lobe (RL) living donor liver transplantation. We studied (using biochemical and radiological parameters) the rate, extent of, and predictors of functional and volumetric recovery of the remnant left liver (RLL) during the first year in 91 consecutive RL donors. Recovery of normal liver function (prothrombin time [PT] ≥70% of normal and total bilirubin [TB] ≤20 µmol/L), liver volumetric recovery, and percentage RLL growth were analyzed. Normal liver function was regained by postoperative day's 7, 30, and 365 in 52%, 86%, and 96% donors, respectively. Similarly, mean liver volumetric recovery was 64%, 71%, and 85%; whereas the percentage liver growth was 85%, 105%, and 146%, respectively. Preoperative PT value (p = 0.01), RLL/total liver volume (TLV) ratio (p = 0.03), middle hepatic vein harvesting (p = 0.02), and postoperative peak TB (p

To investigate the prognostic significance of pathologic response (PR) after transarterial chemoembolization (TACE) in cirrhotic patients resected or transplanted for hepatocellular carcinoma (HCC), and to identify predictors of complete pathologic response (CPR).Between 1990 and 2010, 373 consecutive cirrhotic patients with HCC were treated by TACE followed by either liver resection (LR:184 patients) or liver transplantation (LT:189 patients). The PR was evaluated as the mean percentage of non-viable tumor area within each tumor. CPR was defined as the absence of any viable tumor area in all the present nodules.A total of 59 (32%) and 37 (20%) patients had CPR after LR and LT, respectively. Five-year overall survival (OS) was higher in patients with CPR compared to those without, after LR (58% vs. 34%; p=0.0006) and tends to be higher after LT (84% vs. 65%; p=0.09). The 5-year recurrence-free survival (RFS) rates were significantly higher in both groups (24% vs. 13% after LR; p=0.008 and 94% vs. 73% after LT, p=0.007). A cut-off value of90% necrosis emerged as an impacting factor on patient survival after LR or LT. On multivariate analysis stratified on the type of procedure (LR or LT), PR90% remained an independent factor of better OS and RFS. Independent factors associated with CPR were: a maximal tumor size30 mm (RR 2.17 [1.27-3.74]), a single tumor (RR 6.08 [3.29-12.07]), and an preoperative AFP100 ng/ml (see results section) (RR 3.99 [1.63-11.98]). The probability to achieve a CPR ranged from 2% in the absence of any factors to 48% in the presence of all factors.In cirrhotic patients with HCC, a complete or nearly complete PR improves long-term survival after LR and LT independently of other pathological factors. This underlines the importance of neoadjuvant treatment to obtain a significant decrease of active tumor load.

Liver transplantation (LT) is the best curative treatment for early hepatocellular carcinoma (HCC) in patients with cirrhosis. However, the current shortage of organs causes prolonged waiting times and poorer intention-to-treat (ITT) survival (i.e., after listing) owing to tumor progression and dropout. Portal hypertension (PH) is a recognized risk factor of HCC development in patients with cirrhosis and its recurrence after resection. The aim of this study was to evaluate the potential impact of PHT on the results of LT on an ITT basis. Patients with cirrhosis listed for LT for HCC were included and their outcomes after listing were compared according to the presence or absence of PH defined as presence of esophageal varices or ascites or low platelet count and splenomegaly. Among 243 consecutively listed patients, 70% were affected by PH, which was associated with a significantly higher risk of tumor progression (38% vs. 22%; P = 0.017) and a higher risk of dropout (22% vs. 8%; P = 0.01). Transarterial chemoembolization (TACE) was similarly applied to the two groups (60% vs. 67%; P = 0.325). An absence of TACE was the only other independent risk factor of dropout owing to tumor progression. Under an ITT analysis, PH reduced overall survival (OS), but there was no difference in OS and time to recurrence post-LT. The only pathological feature that could potentially explain this observation was the lower complete response to TACE in the PHT group (12% vs. 36%; P = 0.001). Conclusion: PH should be regarded as a major risk factor of dropout owing to tumor progression and should be taken into consideration when managing patients with HCC who are waiting for LT. (Hepatology 2015;62:179-187)

Background The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort. Methods Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo–Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality. Results Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09). Conclusion This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.

Ischemic cholangiopathy (IC) has a known poor prognosis. However, the risks and outcomes of this complication after transcatheter arterial chemoembolization (TACE) in hepatectomized patients are poorly documented. This study aimed to evaluate the incidence of and to identify the predictive factors for IC following TACE for recurrent hepatocellular carcinoma (HCC) after hepatectomy.From a cohort with a total of 486 patients who underwent resection for HCC, we included all consecutive patients who were treated with TACE for recurrent HCC after hepatectomy between 2000 and 2017. IC was defined by the coexistence of biological cholestasis and morphological lesions.A total of 156 patients underwent TACE for the treatment of HCC recurrence after hepatectomy. Of them, eight (5.1%) developed IC. Their prognosis was poor compared with patients without IC (3-year survival 23.4% vs 76.2%; P = 0.008). Two factors, namely, time between hepatectomy and TACE (4.8 months vs. 16.0 months, P = 0.001) and TACE for a remnant liver mobilized during hepatectomy (P = 0.001), were associated with IC. Receiver operating characteristic (ROC) curve analysis showed that 7 months was the more discriminant cutoff for the time period. IC occurred in 33.3% of the patients with the two factors, in 5.0% of those with one factor, and 0% in the absence of any factors.TACE for treating HCC recurrence carries a high risk of IC when performed early after hepatectomy in a previously mobilized liver. Our results might aid in identifying candidates for TACE for recurrent HCC, considering the major effect on patient outcomes.

L’impact des evenements indesirables (EI), lors d’un prelevement de greffon hepatique sont inconnus. Les objectifs de ce travail etaient d’identifier leurs facteurs favorisants et d’en evaluer l’impact. Methodes Tous les EI survenus au cours des prelevements de greffons hepatiques sur des donneurs en etat de mort encephalique de fevrier 2015 a fevrier 2018, ont ete colliges de maniere prospective. Les EI ont ete classes en majeurs (section d’une artere, erreur d’evaluation du greffon, probleme de cannulation, decapsulation majeure), et EI mineurs (plaie veineuse, plaie digestive, decapsulation mineure, autres). Resultats Parmi les 424 greffons preleves et transplantes, un EI a ete rencontres chez 40 patients (EI majeures, n = 13 [3 %] et EI mineurs, n = 27 [6 %]). Au contraire d’un EI mineur, la survenue d’un EI majeur etait associee a une diminution de la survie greffon (69 % vs 96 % a 1 an, p = 0,01). En analyse multivariee, la presence d’une steatose > 30 %, le nombre de culots peroperatoire, l’existence d’un EI grave et le statut hospitalise du receveur etaient des facteurs independant de la survie du greffon. Conclusion Bien que rare, la survenue d’un EI majeur compromet la survie du greffon. Une meilleure connaissance des EI pourrait permettre d’en diminuer la gravite

Aims The discovery of unexpected peritoneal carcinomatosis (PC) at the time of hepatectomy for colorectal liver metastases (CLM) is usually considered a contraindication for continuing resection. The first aim of this study was to assess the long-term outcome of patients operated for CLM, and who presented unexpected PC during laparotomy. The second aim was to identify preoperative predictors of PC. Methods All patients at a single center between 1985 and 2010 who had unexpected PC, discovered during planed resection of CLM, and negative preoperative imaging for PC were selected. Clinicopathological data were retrospectively analyzed to assess survival outcomes and to identify predictors of unexpected PC. Results Out of the 1340 operated patients for CLM, 42 (3%) had unexpected PC. Only patients (n = 30; 71%) who had PC limited to two abdominal regions (Median peritoneal cancer index (PCI): 2 (1–6)) were resected. Twelve patients were not resected due to the extent of peritoneal disease. The overall survival of the 30 patients resected for CLM who had limited PC was 18% at 5 years (median: 42 months). On multivariate analysis, a previous history of PC, a pT4 stage and bilobar CLM were independent predictors of unexpected PC. Conclusion Unexpected PC should not be a contraindication for resection provided that the PCI is low and complete resection of all peritoneal and hepatic lesions can be achieved. Previous history of PC, a pT4 primary tumor and bilobar CLM are associated with increased risk of unexpected PC.

Background The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear. Methods This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo–Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis. Results A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity. Conclusion Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

Background Combining radiofrequency ablation (RFA) with hepatectomy may enable treatment with curative intent for patients with colorectal liver metastasis (CRLM). However, the oncological outcomes in comparison with resection alone remain to be clarified. Methods Patients who underwent a first hepatectomy between 2001 and 2012 for CRLM were enrolled. Short- and long-term outcomes of patients who underwent hepatectomy plus RFA were compared with those of patients who had hepatectomy alone using propensity score matching. Results Of a total of 553 patients, hepatectomy + RFA and hepatectomy alone were performed in 37 and 516 respectively. Before matching, patients in the hepatectomy + RFA group were characterized primarily by a larger tumour burden. After matching of 31 patients who underwent hepatectomy + RFA with 93 who had hepatectomy alone, background characteristics were well balanced. In the matched cohort, overall and disease-free survival in the hepatectomy + RFA group were no different from those among patients who had hepatectomy alone (5-year overall survival rate 57 versus 61 per cent, P = 0·649; 5-year disease-free survival rate 19 versus 17 per cent, P = 0·865). Local recurrence at the ablated site was observed in four of 31 patients (13 per cent). Although overall local recurrence (ablated site and/or cut surface) was more frequent in the hepatectomy + RFA group (9 of 31 (29 per cent) versus 11 of 93 (12 per cent); P = 0·032), there was no difference in intrahepatic disease-free survival between the two groups (P = 0·705). Conclusion Hepatectomy + RFA achieved outcomes comparable to hepatectomy alone. Combining RFA with hepatectomy should be considered as an option to achieve cure.

International audience; no abstract

For patients who have cirrhosis with hepatocellular carcinoma (HCC), living donor liver transplantation (LDLT) reduces waiting time and dropout rates. We performed a comparative intention-to-treat analysis of recurrence rates and survival outcomes after LDLT and deceased donor liver transplantation (DDLT) in HCC patients. Our study included 183 consecutive patients with HCC who were listed for liver transplantation over a 9-year period at our institution. Tumor recurrence was the primary endpoint. At listing, patient and tumor characteristics were comparable in the two groups (LDLT, n = 36; DDLT, n = 147). Twenty-seven (18.4%) patients dropped out, all from the DDLT waiting list, mainly due to tumor progression (19/27 [70%] patients). The mean waiting time was shorter in the LDLT group (2.6 months versus 7.9 months; P = 0.001). The recurrence rates in the two groups were similar (12.9% and 12.7%, P = 0.78), and there was a trend toward a longer time to recurrence after LDLT (38 ± 27 months versus 16 ± 13 months, P = 0.06). Tumors exceeding the University of California, San Francisco (UCSF) criteria, tumor grade, and microvascular invasion were independent predictive factors for recurrence. On an intention-to-treat basis, the overall survival (OS) in the two groups was comparable. Patients beyond the Milan and UCSF criteria showed a trend toward worse outcomes with LDLT compared with DDLT (P = 0.06). Conclusion: The recurrence and survival outcomes after LDLT and DDLT were comparable on an intent-to-treat analysis. Shorter waiting time preventing dropouts is an additional advantage with LDLT. LDLT for HCC patients beyond validated criteria should be proposed with caution. (HEPATOLOGY 2011;)

Esistono tre regole da rispettare quando si realizza un’epatectomia: adattare l’exeresi alla lesione e non al chirurgo, evitare le complicanze tecniche dell’epatectomia, vale a dire l’emorragia, le perdite biliari e la necrosi a livello del parenchima residuo, e lasciare abbastanza parenchima per evitare l’insufficienza epatica postoperatoria. Una chirurgia efficace e sicura puo essere realizzata solo con una conoscenza perfetta dell’anatomia chirurgica. Questa anatomia corrisponde a un’anatomia funzionale vascolare epatica basata sul concetto della divisione anatomica vascolare del fegato di Claude Couinaud, Thon That Tung e Henri Bismuth, che suddivide il fegato in porzioni indipendenti che possono essere trattate separatamente senza compromettere il funzionamento del fegato residuo. Le epatectomie tipiche sono quelle realizzate lungo delle scissure anatomiche. Esse possono essere maggiori, allargate, superallargate, limitate, segmentarie o sottosegmentarie, a seconda dei segmenti di fegato asportati. Esse sono anche classificate secondo la modalita del controllo vascolare: controllo vascolare primario, sezione parenchimale primaria o combinazione delle due tecniche. Il controllo vascolare puo essere peduncolare, selettivo, soprailare, intraepatico o, per esclusione, vascolare. La condotta generale delle epatectomie comprende, nel preoperatorio, uno studio preciso delle lesioni e dell’anatomia vascolare reale del fegato. Questo studio e eseguito mediante alcuni studi morfologici: ecografia, TC, risonanza magnetica e arteriografia. Puo essere anche necessario valutare la riserva funzionale postoperatoria del fegato con una volumetria e una valutazione funzionale (clearance del verde di indocianina, scintigrafia). L’anestesia e la rianimazione intraoperatoria sono codificate. Sono possibili parecchie vie di accesso: laparotomia sottocostale destra, piu o meno estesa, laparotomia mediana, incisione a J di Makuuchi e accesso laparoscopico. Il fegato deve essere liberato per realizzare un’esplorazione completa (manuale e mediante ecografia intraoperatoria). La sezione parenchimale e condotta in modo da scoprire i peduncoli vasculobiliari nel fegato e da legarli elettivamente. Le epatectomie anatomiche permettono di realizzare l’exeresi di uno o piu segmenti senza compromettere la vascolarizzazione (portale e arteriosa) e il drenaggio (venoso e biliare) dei segmenti del fegato residui. Al termine dell’intervento, la buona legatura dei vasi e delle vie biliari e verificata a livello della sezione. Questo insieme di regole di condotta delle epatectomie deve permettere di realizzare in sicurezza e con delle complicanze minime.

Las tecnicas de las hepatectomias han evolucionado con el tiempo, sobre todo en lo referente al instrumental quirurgico y a los metodos de pinzamiento vascular, pero las referencias anatomicas se han mantenido fijas. La lobectomia izquierda comienza por una seccion del ligamento redondo y del ligamento triangular izquierdo; los pediculos de los segmentos 3 y 2 se ligan en el borde izquierdo del pediculo portal; una vez realizado este control vascular, se secciona el parenquima hepatico. La intervencion se finaliza con la seccion de la vena hepatica izquierda. Durante la hepatectomia derecha, se realiza la liberacion por seccion del ligamento redondo y del ligamento triangular derecho; los elementos vasculares del pediculo portal derecho pueden disecarse y pinzarse en el pediculo, para ser ligados de manera intraparenquimatosa durante la seccion; una vez logrado este control vascular, se secciona el parenquima hepatico y la intervencion finaliza con la seccion de la vena hepatica derecha. Para una hepatectomia izquierda, se efectua la liberacion por seccion del ligamento redondo y del ligamento triangular izquierdo; los elementos vasculares del pediculo portal izquierdo pueden disecarse y pinzarse en el pediculo, para ser ligados de forma intraparenquimatosa durante la seccion; una vez logrado este control vascular, se secciona el parenquima hepatico y la intervencion finaliza con la seccion de la vena hepatica izquierda. Las hepatectomias derechas ampliadas a los segmentos 4, 1 o 4 y 1, asi como las izquierdas ampliadas a los segmentos 1 o 5 y 8 tambien se describen en este articulo.

Le tecniche delle epatectomie sono progredite con il tempo, in particolare sul piano della strumentazione chirurgica e dei clampaggi vascolari, ma i reperi anatomici sono rimasti fissi. La lobectomia sinistra inizia con la sezione del legamento rotondo e del legamento triangolare sinistro; i peduncoli dei segmenti 3 e 2 sono legati al margine sinistro del peduncolo portale; il parenchima epatico e sezionato sotto questo controllo vascolare. L’intervento termina con la sezione della vena epatica sinistra. Durante l’epatectomia destra si ha una liberazione mediante la sezione del legamento rotondo e del legamento triangolare destro; gli elementi vascolari del peduncolo portale destro possono essere dissecati e clampati nel peduncolo e, poi, possono essere legati in sede intraparenchimale al momento della sezione; sotto questo controllo vascolare, il parenchima epatico e sezionato e l’intervento e completato con la sezione della vena epatica destra. Per un’epatectomia sinistra si ha una liberazione mediante la sezione del legamento rotondo e del legamento triangolare sinistro; gli elementi vascolari del peduncolo portale sinistro possono essere dissecati e clampati nel peduncolo e, poi, possono essere legati in sede intraparenchimale al momento della sezione; sotto questo controllo vascolare, il parenchima epatico e sezionato e l’intervento e completato con la sezione della vena epatica sinistra. Sono descritte le epatectomie destre allargate ai segmenti 4, 1 o 4 e 1 e sinistre allargate ai segmenti 1 o 5 e 8.

Las segmentectomias corresponden a la reseccion de un unico segmento. Las mas utilizadas son las segmentectomias 4, 6 y 7. La reseccion de dos segmentos contiguos de higado se denomina bisegmentectomia; las mas frecuentes (4-5, 6-7 y 5-8) se describen en su totalidad en este articulo. Las trisegmentectomias consisten en la reseccion de tres segmentos hepaticos contiguos, a excepcion de las hepatectomias izquierdas. Se trata de las trisegmentectomias 4-5-6 y 4-5-8. Las cuadrisegmentectomias 1-4-5-8 y 4-5-7-8 constituyen autenticas hepatectomias centrales. Las subsegmentectomias, que son posibles gracias a la ecografia hepatica, permiten conservar el maximo de parenquima hepatico. Las mas utilizadas son las subsegmentectomias 4 anterior y 8 a, b o c.

Al hacer una hepatectomia deben respetarse tres reglas: adaptar la exeresis a la lesion y no al cirujano, evitar las complicaciones tecnicas de la hepatectomia (hemorragia, perdida biliar y necrosis del parenquima restante) y dejar suficiente parenquima para evitar la insuficiencia hepatica postoperatoria. Una cirugia eficaz y segura solo puede llevarse a cabo con un conocimiento perfecto de la anatomia quirurgica, la cual corresponde a una anatomia funcional de la irrigacion hepatica basada en el concepto de la division anatomica vascular de Claude Couinaud, Thon That Tung y Henri Bismuth, que divide el higado en porciones independientes que pueden tratarse por separado sin comprometer la funcion del resto del higado. Las hepatectomias tipicas se realizan siguiendo las cisuras anatomicas. Pueden ser mayores, ampliadas, superampliadas, limitadas, segmentarias o subsegmentarias en funcion de los segmentos hepaticos extirpados. Se las clasifica tambien segun el modo de control vascular: control vascular inicial, seccion parenquimatosa inicial o combinacion de ambos. El control vascular puede ser pedicular, selectivo, suprahiliar, intrahepatico o por exclusion vascular. La conducta general en las hepatectomias incluye, en la fase preoperatoria, un estudio preciso de las lesiones y de la anatomia vascular real del higado. Este estudio se lleva a cabo mediante exploraciones morfologicas: ecografia, tomografia computarizada, resonancia magnetica y arteriografia. Tambien puede ser necesario apreciar la reserva funcional hepatica postoperatoria con una volumetria y una valoracion funcional (aclaramiento del verde de indocianina, gammagrafia). La anestesia y la reanimacion peroperatoria estan codificadas. Hay varias vias de acceso posibles: laparotomia subcostal derecha, mas o menos extensa, laparotomia medial, incision en J de Makuuchi, acceso laparoscopico. El higado debe liberarse para realizar una exploracion completa (manual y por ecografia intraoperatoria). La seccion parenquimatosa avanza hasta descubrir los pediculos vasculares y biliares con el fin de ligarlos de forma selectiva. Las hepatectomias anatomicas permiten la exeresis de uno o mas segmentos sin afectar a la vascularizacion (portal y arterial) y al drenaje (venoso y biliar) de los segmentos restantes. Al final de la intervencion, en el corte de seccion se verifica la ligadura correcta de los vasos y de las vias biliares. Este conjunto de reglas de conducta en las hepatectomias deberia proporcionar seguridad y un bajo indice de complicaciones.

Background Portal vein embolization (PVE) increases the resectability of initially unresectable colorectal liver metastases (CLM). This study evaluated long-term survival in patients with CLM who underwent hepatectomy following PVE. Methods In a retrospective analysis patients treated by PVE before major hepatectomy were compared with those who did not have PVE, and with those who had PVE without resection. Results Of 364 patients who underwent hepatectomy, 67 had PVE beforehand and 297 did not. Those who had PVE more often had more than three liver metastases (68 versus 40·9 per cent; P < 0·001) that were more frequently bilobar (78 versus 55·2 per cent; P < 0·001), and a higher proportion underwent extended hepatectomy (63 versus 18·1 per cent; P < 0·001). Postoperative morbidity rates were 55 and 41·1 per cent respectively (P = 0·035), and overall 3-year survival rates were 44 and 61·0 per cent (P = 0·001). Thirty-two other patients who were treated by PVE but did not undergo resection all died within 3 years. Conclusion PVE increased the resectability rate of initially unresectable CLM. Among patients who had PVE, long-term survival was better in those who had resection than in those who did not. PVE is of importance in the multimodal treatment of advanced CLM.

Background The prognostic significance of adrenal metastases (AMs) in patients with colorectal liver metastases (CLMs) remains unknown. The aim of this study was to determine the influence of AMs on long-term outcome and the role of adrenalectomy in patients with CLMs. Methods All patients resected for CLMs who developed AMs at a single institution between 1992 and 2006 were included in the study. Their long-term outcome was compared with that of all other patients resected for CLMs but without AMs. Results Hepatectomy was performed in 796 patients, of whom 14 (1·8 per cent) developed AMs, a median of 28 months after initial diagnosis of CLMs; the remaining 782 patients (98·2 per cent) had no AMs. All 14 patients had chemotherapy, and ten went on to adrenalectomy. Median survival after diagnosis of CLMs was 50 months in patients with AMs versus 68 months in those without (P = 0·020). After diagnosis of AMs, median survival was 23 months, whether or not adrenalectomy was performed. Conclusion The development of AMs after liver resection for colorectal cancer deposits carries a poor prognosis, and adrenalectomy is probably not warranted.