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BACKGROUND: Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is not always reliable with currently available scores, particularly in patients with primary liver tumor. This study aims to (I) to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and (II) to create a score predicting 90-day mortality preoperatively. METHODS: Thirteen high-volume centers participated in this retrospective multicentric study. A risk analysis based on patient characteristics, underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score. A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index (CCI), the age-adjusted CCI (aCCI), the ALPPS risk score before Stage 1 (ALPPS-RS1) and Stage 2 (ALPPS-RS2). The model was internally validated applying bootstrapping. RESULTS: A total of 451 patients were included. Mortality was 14.4%. The CAPRA score is calculated based on the following formula: (0.1 × age) − (2 × BSA) + 1 (in the presence of primary liver tumor) + 1 (in the presence of severe cardiovascular disease) + 2 (in the presence of moderate or severe diabetes) + 2 (in the presence of renal disease) + 2 (if classic ALPPS is planned). The predictive ability was 0.837 for the CAPRA score, 0.443 for CCI, 0.519 for aCCI, 0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2. After 1,000 cycles of bootstrapping the C statistic was 0.793. The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70. CONCLUSIONS: Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure. By assessing the patient’s preoperative condition in relation to ALPPS, the CAPRA score has a very good ability to predict postoperative mortality.

BACKGROUND Laparoscopic liver resection of tumors located in segments 7 and 8 are considered a complex resection. The aim of this study was to compare the intraoperative and early postoperative outcomes of patients operated by pure laparoscopic (PLS) vs hand-assisted laparoscopic surgery (HALS). METHODS From January 2003 to January 2021, we included patients with minimally invasive surgery for lesions located in segments 7 and 8. To overcome selection bias, we performed 1:1 propensity score matching (PSM) between HALS and PLS cohorts, including 30 patients in each of the groups. Of the 60 patients who underwent PSM, we compared the first 30 patients with the following 30 patients. RESULTS A total of 79 LLRs were performed, 46 by HALS and 33 by PLS. After PSM, in the PLS cohort, cirrhosis was more frequent (33.3% vs. 13.3%, p = 0.02). The surgical time, blood loss, Pringle maneuver, clamping time, and morbidity were similar between both groups, but with a lower hospital stay in the PLS group (3 days vs. 4 days, p

BACKGROUND The potential benefit related to laparoscopic liver surgery (LLS) for colorectal liver metastases outcomes is not well known. MATERIALS AND METHODS Serum cytokines associated with Th1 (tumor necrosis factor-α) and Th2 [interleukin (IL)-10 and IL-6] phenotypes were measured in 36 patients operated on for colorectal liver metastases by open liver surgery (OLS) and LLS. Measurements were performed at 3 time points: 1 day before surgery, day 3 postoperative, and 1 month postoperative. We compared the postoperative inflammatory response influence between LLS and OLS on long-term outcomes. RESULTS In both groups, only IL-6 levels on day 3 postoperative were higher than those measured preoperatively and at 1 month. Comparing the tumor necrosis factor-α levels between the LLS and OLS groups, preoperative (7.28 vs. 2.36), day 3 (7.99 vs. 4.08) and 1 month (7.39 vs. 1.99) postoperative levels were higher in the OLS group (P

In this multimedia article, we demonstrate an extreme in situ liver surgery under total vascular exclusion with right hepatic vein and inferior vena cava grafts for an intrahepatic cholangiocarcinoma in a centre with experience in highly complex hepatobiliary surgery and liver transplantation. This surgical approach after neoadjuvant chemotherapy provides an opportunity for surgical salvage in patients with large tumors invading the hepatocaval confluence. This patient was considered unresectable at another hospital and referred to our unit. We performed an accurate preoperative assessment with new generation 3D modelling to plan the type of vascular reconstruction that would allow adequate hepatic venous outflow and the volume of the future liver remnant sufficient to avoid postoperative liver failure. For hemodynamic management of the patient, we performed a total hepatic vascular exclusion with veno-venous bypass without intraoperative adverse events. We used a cryopreserved carotid artery graft after previously planning the most appropriate diameter and length for right hepatic vein reconstruction. The inferior vena cava was reconstructed with gore-tex graft. During the hospital stay there were no postoperative complications. The patient is free of disease. We conclude that patients with advanced malignant liver disease should always be referred to highly specialized liver surgery centers to assess the most appropriate oncological management and the possibility of surgical resectability.

To explore potential sex differences in outcomes and regenerative parameters post major hepatectomies.Although controversial, sex differences in liver regeneration have been reported for animals. Whether sex disparity exists in human liver regeneration is unknown.Data from consecutive hepatectomy patients (55 females, 67 males) and from the international ALPPS (Associating-Liver-Partition-and-Portal-vein-ligation-for-Staged-hepatectomy, a two stage hepatectomy) registry (449 females, 729 males) were analyzed. Endpoints were severe morbidity (≥3b Clavien-Dindo grades), Model for End-stage Liver Disease (MELD) scores, and ALPPS interstage intervals. For validation and mechanistic insight, female-male ALPSS mouse models were established. t , χ 2 , or Mann-Whitney tests were used for comparisons. Univariate/multivariate analyses were performed with sensitivity inclusion.Following major hepatectomy (Hx), males had more severe complications ( P =0.03) and higher liver dysfunction (MELD) P =0.0001) than females. Multivariate analysis established male sex as a predictor of complications after ALPPS stage 1 (odds ratio=1.78; 95% confidence interval: 1.126-2.89; P =0.01), and of enhanced liver dysfunction after stage 2 (odds ratio=1.93; 95% confidence interval: 1.01-3.69; P =0.045). Female patients displayed shorter interstage intervals (2 weeks, 64% females versus 56% males, P =0.01), however, not in postmenopausal subgroups. In mice, females regenerated faster than males after ALPPS stage 1, an effect that was lost upon estrogen antagonism.Poorer outcomes after major surgery in males and shorter ALPPS interstage intervals in females not necessarily suggest a superior regenerative capacity of female liver. The loss of interstage advantages in postmenopausal women and the mouse experiments point to estrogen as the driver behind these sex disparities. Estrogen's benefits call for an assessment in postmenopausal women, and perhaps men, undergoing major liver surgery.

Background Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. Methods This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. Results We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p p p Discussion Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210–490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129–234). This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.

BACKGROUND: Liver tumors that invade the hepatic vein are surgically challenging, especially in patients with liver dysfunction. Preservation of as much of the parenchyma as possible is important; thus, when feasible, we perform hepatectomy with hepatic vein reconstruction (HVR) using an external iliac vein (EIV) graft. We conducted a retrospective study to investigate the benefit of HVR and to evaluate our procedure. METHODS: The study included patients treated by hepatectomy with HVR using EIV grafts and vascular clips. We reviewed the surgical outcomes, including total operation and HVR times, postoperative complications, and postoperative liver function. RESULTS: The surgeries included right HVR (n=13), left HVR (n=3), and middle HVR (n=1). The total operation time was 277±72 minutes (155–400 minutes), and the HVR time was 27±5 minutes (19–40 minutes). Graft patency was confirmed in 14 (82%) of the patients. One patient who underwent HVR with running sutures required emergency surgery due to graft thrombosis. Clavien-Dindo > grade IIIa postoperative complications occurred in 4 (23.5%) patients, but there were no treatment-related deaths. CONCLUSIONS: In conclusion, our hepatic resections with HVR using the same techniques and graft materials showed acceptable surgical outcomes. From our experience, we believe that preparatory hepatic resection with HVR is an effective treatment, especially for patients with decreased liver function or with a small residual liver parenchyma.

Background: While ALPPS triggers a fast liver hypertrophy, it is still unclear which factors matter most to achieve accelerated hypertrophy within a short period of time. The aim of the study was to identify patient-intrinsic factors related to the growth of the future liver remnant (FLR). Methods: This cohort study is composed of data derived from the International ALPPS Registry from November 2011 and October 2018. We analyse the influence of demographic, tumour type and perioperative data on the growth of the FLR. The volume of the FLR was calculated in millilitre and percentage using computed-tomography (CT) scans before and after stage 1, both according to Vauthey formula. Results: A total of 734 patients were included from 99 centres. The median sFLR at stage 1 and stage 2 was 0.23 (IQR, 0.18–0.28) and 0.39 (IQR: 0.31–0.46), respectively. The variables associated with a lower increase from sFLR1 to sFLR2 were age˃68 years (p =.02), height ˃1.76 m (p ˂.01), weight ˃83 kg (p ˂.01), BMI˃28 (p ˂.01), male gender (p ˂.01), antihypertensive therapy (p ˂.01), operation time ˃370 minutes (p ˂.01) and hospital stay˃14 days (p ˂.01). The time required to reach sufficient volume for stage 2, male gender accounts 40.3% in group ˂7 days, compared with 50% of female, and female present 15.3% in group ˃14 days compared with 20.6% of male. Conclusions: Height, weight, FLR size and gender could be the variables that most constantly influence both daily growths, the interstage increase and the standardized FLR before the second stage.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.; METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.; RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P= .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ? .001). The need for vascular reconstruction was associated with higher mortality (P= .04). Two of the 4 patients transplanted died.; CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results. Copyright © 2022 Elsevier Inc. All rights reserved.

To present surgical and oncological outcomes using a prospective and randomized trial (LapOpHuva, NCT02727179) comparing minimally invasive liver resection (LLR) versus open liver resection (OLR) in patients with colorectal liver metastases (CRLM). Between February 2005 and March 2016, 204 selected patients with CRLM were randomized and 193 were included: LLR (n = 96) and OLR (n = 97). The primary endpoint was to compare postoperative morbidity. Other secondary endpoints were oncological outcomes, use of the Pringle maneuver, surgical time, blood losses, transfusions, hospital stay, mortality and OS, and disease-free survival (DFS) at 3, 5, and 7 years. LLR presented with lower global morbidity (11.5% vs. 23.7%, p = 0.025) but with similar severe complications. Long-term survival outcomes were similar in both groups. The cumulative 1-, 3-, 5-, 7-year OS for LLR and OLR were 92.5%, 71.5%, 49.3%, 35.6% versus 93.6%, 69.7%, 47.4%, 35.5%, respectively (log-rank = 0.047, p = 0.82). DFS for LLR and OLR was 72.7%, 33.5%, 22.7%, and 20.8% versus 61.6%, 27.2%, 23.9%, and 17.9%, respectively (log-rank = 1.427, p = 0.23). LLR involved more use of the Pringle maneuver (15.5% vs. 30.2%, p = 0.025) and a shorter hospital stay (4 vs. 6 days, p

Purpose Assessing hepatic vein reconstruction using a left renal vein graft and in situ hypothermic liver perfusion in an extended liver resection. Methods Patients included in this study were those with liver tumors undergoing curative surgery with resection and reconstruction of hepatic veins. Hepatic vein was reconstructed using a left renal vein graft. We describe the technical aspects of liver resection and vascular reconstruction, the key aspects of hemodynamic management, and the use of in situ hypothermic liver preservations during liver transection (prior to and during vascular clamping). Results The right hepatic vein was reconstructed with a median left renal venal graft length of 4.5 cm (IQR, 3.1–5.2). Creatinine levels remained within normal limits in the immediate postoperative phase and during follow-up. Median blood loss was 500 ml (IQR, 300–1500) and in situ perfusion with cold ischemia was 67 min (IQR, 60.5–77.5). The grafts remained patent during the follow-up with no signs of thrombosis. No major postoperative complications were observed. Conclusion Left renal vein graft for the reconstruction of a hepatic vein and in situ hypothermic liver perfusion are feasible during extended liver resection.

Next-generation three-dimensional modelling software for personalized surgery allows spatially accurate depiction of the hepatic and vasculature anatomy based on the complexity and individual variation in each patient, and could facilitate decision-making about preoperative strategy in perihilar cholangiocarcinoma.

Background Defining reference intervals in experimental animal models plays a crucial role in pre-clinical studies. The hepatic parameters in healthy animals provide useful information about type and extension of hepatic damage. However, in the majority of the cases, to obtain them require an invasive techniques. Our study combines these determinations with dynamic functional test and imaging techniques to implement a non-invasive protocol for liver evaluation. The aim of the study was to determine reference intervals for hepatic function, perfusion and parenchyma attenuation with analytical and biochemical blood parameters, indocyanine green, ultrasound and computed tomography in six healthy SD rats. Methods Six males healthy SD rats were followed for 4 weeks. To determine hepatic function, perfusion and parenchyma attenuation analytical and biochemical blood parameters, indocyanine green, ultrasound and computed tomography were studied. Results were expressed as Means ± standard error of mean (SEM). The significance of differences was calculated by using student t-test, p < 0.05 was considered statistically significant. Results Indocyanine green clearance 5 and 10 minutes after its injection was 80.12% and 96.59%, respectively. Approximate rate of decay during the first 5 minutes after injection was 38% per minute. Hepatic perfusion evaluation with the high-frequency ultrasound was related to cardiovascular hemodynamic and renal perfusion. Portal area, hepatic artery resistance index, hepatic artery and portal peak systolic velocity and average between hepatic artery and porta was 3.41 ± 0.62 mm2, 0.57 ± 0.04 mm2/s, 693.24±102.53 mm2/s, 150.72 ± 17.80 mm2/s and 4.82 ± 0.96 mm2/s, respectively. Heart rate, cardiac output, left renal artery diammetre and renal blood flow were 331.01 ± 22.22 bpm, 75.58 ± 8.72 mL/min, 0.88 ± 0.04 mm2 and 13.65 ± 1.95 mm2/s. CT-scan hepatic average volume for each rat were 21.08±3.32, 17.57±2.76, 14.87±2.83 and 13.67±2.45 cm3 with an average attenuation coefficient of 113.51±18.08, 129,19±7.18, 141,47±1.95 y 151,67±1.2 HU. Conclusion Indocyanine green and high-frequency ultrasound could be used in rats as a suitable marker of liver function. Computed tomography, through the study of raw data, help to characterize liver parenchyma, and could be a potential tool for early detection of liver parenchymal alterations and linear follow-up of patients. Further studies in rats with liver disease are necessary to verify the usefulness of these parameters.

Objectives: To analyze long-term oncological outcome along with prognostic risk factors in a large cohort of patients with colorectal liver metastases (CRLM) undergoing ALPPS. Background: ALPPS is a two-stage hepatectomy variant that increases resection rates and R0 resection rates in patients with primarily unresectable CRLM as evidenced in a recent randomized controlled trial. Long-term oncologic results, however, are lacking. Methods: Cases in- and outside the International ALPPS Registry were collected and completed by direct contacts to ALPPS centers to secure a comprehensive cohort. Overall, cancer-specific (CSS), and recurrence-free (RFS) survivals were analyzed along with independent risk factors using Cox-regression analysis. Results: The cohort included 510 patients from 22 ALPPS centers over a 10-year period. Ninety-day mortality was 4.9% and median overall survival, CSS, and RFS were 39, 42, and 15 months, respectively. The median follow-up time was 38 months (95% confidence interval 32-43 months). Multivariate analysis identified tumor-characteristics (primary T4, right colon), biological features (K/N-RAS status), and response to chemotherapy (Response Evaluation Criteria in Solid Tumors) as independent predictors of CSS. Traditional factors such as size of metastases, uni versus bilobar involvement, and liver-first approach were not predictive. When hepatic recurrences after ALPPS was amenable to surgical/ablative treatment, median CSS was significantly superior compared to chemotherapy alone (56 vs 30 months, P < 0.001). Conclusions: This large cohort provides the first evidence that patients with primarily unresectable CRLM treated by ALPPS have not only low perioperative mortality, but achieve appealing long-term oncologic outcome especially those with favorable tumor biology and good response to chemotherapy.

OBJECTIVE We present a new variant of partial-ALPPS (p-ALPPS) "Tourniquet partial-ALPPS (Tp-ALPPS)", with the aim of reducing aggressiveness during stage 1. SUMMARY BACKGROUND DATA Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) results in liver regeneration in only 9 days. Due to its high initial morbidity and mortality, less aggressive variants were designed. METHODS A new surgical variant of ALPPS was designed consisting in introducing a Kelly forceps from the base of the liver, crossing the liver parenchyma through an avascular area. A 3-mm Vicryl (V152; Ethicon, Somerville, New Jersey, USA) tape is passed, and the tourniquet is then knotted. Six patients operated on by this new Tp-ALPPS surgical technique were compared to 6 patients operated on by Tourniquet ALPPS (T-ALPPS). RESULTS There were no differences in volume increase at 10 days. During stage 1, blood losses and transfusion rates tended to be lower in the Tp-ALPPS group, without statistical differences. Surgical time was shorter in the Tp-ALPPS group than in T-ALPPS (90 min versus 135 min) (p < 0.023). In stage 2, blood losses and transfusion were similar in both groups, but surgical time tended to be higher in the Tp-ALPPS group, which could be related to the surgical technique performed. There were no differences in morbidity and mortality. CONCLUSIONS Tp-ALPPS achieved a similar increase in volume as T-ALPPS but with a shorter stage 1 surgical and similar morbidity and mortality.

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) offers better short-term results than open surgery with similar long-term results although it is technically difficult due to the risk of bleeding. This study included patients with HCC in Child A cirrhosis who underwent TACE before LLR between 2009 and 2019. The primary endpoint was to analyze the intraoperative and early results of this technique. We also analyzed the long-term outcomes. Patients with and without clinically significant portal hypertension (CSPH) were compared. A total of 44 cirrhotic patients with HCC were included (24 CSPH and 20 non-CSPH). The Pringle maneuver was used in two cases (4.5%), mean blood losses was 100 ml (range 50–200), and three patients (6.8%) required a blood transfusion. The degree of necrosis achieved was greater than 90% in 27 patients (61.4%). At 1, 3, and 5 years, overall survival was 97.7%, 81.5%, and 63.4%, respectively, and disease-free survival was 85.2%, 52.5%, and 34.5%, respectively. There were no statistically significant differences between non-CSPH and CSPH groups regarding intraoperative, early, and long-term outcomes. In our experience, TACE could be beneficial to perform LLR in HCC Child–Pugh A patients with and without CSPH without serious complications and similar oncological outcomes.

Background Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience. Methods Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018. Results We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality. Conclusion Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.

Background Hepatic adenomatosis is defined as the presence of more than 10 adenomatous lesions seated on a healthy liver. The most frequent complication is bleeding, presenting a risk of malignant neoplasms of less than 10%. Clinical Case We present a case of a 28-year-old woman with polycystic ovary syndrome treated with oral contraceptives for 10 years. Ultrasonography showed benign mass, and biopsy specimen showed adenoma. Nuclear magnetic resonance showed multiple hepatic adenomatosis with a large nodule in the right hepatic lobe of 21 cm and another 10 nodules in segments II, III, IVa, IVb, VIII-VII, and VI. A computed tomography scan with volumetry was performed where a future liver remnant volume (FLRV) of 30% was observed with an FLRV body weight ratio of 0.34%. Surgery was planned in 2 stages. First, the lesions of sections II-III, IVa, and IVb were resected and a ligature of right port vein and a tourniquet in Cantlie line were performed. At 15 days the computed tomography volumetry reported an FLRV of 48% with an FLRV body weight ratio of 0.55%. The second time was completed with a regulated right hepatectomy. The hospital stay was 5 days the first time and 6 days the second time, without complications. At present, the patient follows revisions in consultation without pathologic findings of interest. Conclusion In some extreme cases, surgical resection is limited by the FLRV and the risk of liver failure. Before considering liver transplant, associating liver partition and portal vein ligation for staged hepatectomy may be an effective alternative in the management of these patients.

Background Hepatobiliary resections are challenging due to the complex liver anatomy. Three-dimensional printing (3DP) has gained popularity due to its ability to produce anatomical models based on the characteristics of each patient. Methods A multicenter study was conducted on complex hepatobiliary tumours. The endpoint was to validate 3DP model accuracy from original image sources for application in the teaching, patient-communication, and planning of hepatobiliary surgery. Results Thirty-five patients from eight centers were included. Process testing between 3DP and CT/MRI presented a considerable degree of similarity in vascular calibers (0.22 ± 1.8 mm), and distances between the tumour and vessel (0.31 ± 0.24 mm). The Dice Similarity Coefficient was 0.92, with a variation of 2%. Bland–Altman plots also demonstrated an agreement between 3DP and the surgical specimen with the distance of the resection margin (1.15 ± 1.52 mm). Professionals considered 3DP at a positive rate of 0.89 (95%CI; 0.73–0.95). According to student's distribution a higher success rate was reached with 3DP (median:0.9, IQR: 0.8–1) compared with CT/MRI or 3D digital imaging (P = 0.01). Conclusion 3DP hepatic models present a good correlation compared with CT/MRI and surgical pathology and they are useful for education, understanding, and surgical planning, but does not necessarily affect the surgical outcome.

To compare the overall survival (OS) and disease-free survival (DFS) of Tourniquet-ALPPS (T-ALPPS) and conventional two-stage hepatectomy (TSH) in patients with colorectal liver metastases (CRLM). A retrospective study from a prospectively collected database was performed between October 2000 and July 2016. TSH was performed before September 2011, after which time T-ALPPS became the technique of choice. A propensity score matching (PSM) was performed based on a 1:1 ratio with consideration of the following variables: number and size of metastases, bilobar disease presence, and chemotherapy received. Thirty-four patients received T-ALPPS; 41 patients received TSH. After PSM, 21 patients remained in each group, with 100% resectability in the T-ALPPS group and 90.5% resectability in the TSH group. The median OS for TSH was 41 months; for T-ALPPS, the median OS was 36 months (P = 0.925). The median DFS was 16 months in the TSH group; the median DFS was 9 months in the T-ALPPS group (P = 0.930). The 1-, 3-, and 5-year OS for TSH was 81%, 66.7%, and 23.8% vs. 76.2%, 57.1%, and 22.9% for T-ALPPS, respectively. The 1-, 3-, and 5-year DFS for TSH was 66.7%, 9.5%, and 5% vs. 44.6%, 11.1%, and 11.1% for T-ALPPS, respectively. The volume increase with T-ALPPS was superior to that with TSH (68% vs. 39%; P = 0.018). There were no differences in morbidity and mortality after stages 1 and 2. T-ALPPS produces a similar outcome to TSH, indicating that it could be a safe and effective alternative for curative hepatectomy for all patients.

Introduction Once liver metastases in pancreatic and periampullary carcinoma are diagnosed, guidelines do not recommend resection of the primary tumor. In this stage of the disease, therapeutic regimes with chemotherapy are the standard treatment. However, it is unclear whether combinations of extensive surgery and novel chemotherapy treatments confer a survival benefit in selected patients. Evidence acquisition We provide a systematic review about liver metastases in pancreatic and periampullary carcinoma treated by surgery utilizing EMBASE, Medline/PubMed, Cochrane and Scopus databases according to PRISMA guidelines. Evidence synthesis In pancreatic and periampullary carcinoma, the number of lesions that can be resected includes a mean or median of 1-3; the size of the lesions should not exceed 3 cm and the most frequent surgical technique used were wedge or atypical resections. Overall morbidity and mortality after liver resection from pancreatic tumors were 0-68% and 0-9.1%, respectively, and from periampullary carcinomas were 0-82% and 0-21%, respectively. Considering both types of carcinomas, the rate of recurrence was up to 91%. Median overall survival ranged from 5.5 to 16.6 months for liver metastases from pancreas carcinoma, and from 5 to 23 months for periampullary carcinoma, with better prognosis for duodenal carcinomas. Conclusions Perioperative chemotherapy is the cornerstone of treatment in patients with liver metastasis from pancreatic and periampullary carcinoma. Liver resection from early liver metastases could be acceptable in selected patients with oligometastatic disease and small single lesions taking into account the individual risk of complications.

Introduction: Obesity represents a risk factor in case of major hepatectomy, because the future liver remnant (FLR) must be proportional with body weight. To avoid post-hepatectomy liver failure, and further increase the ratio between FLR and body weight, we performed a bariatric procedure in the first stage of the ALPPS technique. Patient concerns: Fifty-four-year-old woman, with morbid obesity (BMI 58.5) and type II diabetes mellitus, was scheduled for a major hepatectomy due to multiple colorectal liver metastases Diagnosis: Six months before, the patient was diagnosed with colorectal cancer and synchronous liver metastases. She was initially treated with sigmoidectomy and chemotherapy. After partial response of the liver metastases, we considered a liver resection but the FLR was very low, especially in relation to her BMI. Intervention: We planned a novel approach and, for the first time, we performed a sleeve gastrectomy during the first stage of Tourniquet ALPPS (T-ALPPS). After achieving an adequate FLR, we successfully completed the major hepatectomy during the second stage of T-ALPPS. Outcome: The association between sleeve gastrectomy and T-ALPPS produced an increase of FLR/body weight ratio up to 0.8 that allowed completing a right trisectionectomy in the second stage of ALPPS. The major hepatectomy was performed without severe complications, and several months after surgery the patient is still alive without any recurrence Conclusion: Despite obesity represents a risk factor involved in the carcinogenesis, the role of the bariatric surgery in the oncological setting is not well established. In this clinical case, we benefited from the weight loss produced by bariatric surgery combined with an effective hypertrophy technique and chemotherapy. These findings suggest that bariatric surgery could be useful for obese patients with liver malignancy and need for extended hepatectomy.