RESUMEN
In Italy, 20 minutes of continuous, flat-line electrocardiogram are required for death declaration, which significantly increases the risks of donation after circulatory death (DCD) LT. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death LT by combining normothermic regional and end-ischemic machine perfusion. However, data on uncontrolled DCD (uDCD) LT performed by this approach are lacking. This was a multicenter, retrospective study performed at 3 large-volume centers comparing clinical outcomes of uncontrolled versus controlled DCD LT. The aim of the study was to assess outcomes of sequential normothermic regional perfusion and end-ischemic machine perfusion in uncontrolled DCD liver transplantation (LT). Of 153 DCD donors evaluated during the study period, 40 uDCD and 59 donation after circulatory death grafts were transplanted (utilization rate 52% vs. 78%, p = 0.004). Recipients of uDCD grafts had higher MEAF (4.9 vs. 3.5, p < 0.001) and CCI scores at discharge (24.4 vs. 8.7, p = 0.026), longer ICU stay (5 vs. 4 d, p = 0.047), and a trend toward more severe AKI. At multivariate analysis, 90-day graft loss was associated with recipient BMI and lactate downtrend during normothermic regional perfusion. One-year graft survival was lower in uDCD (75% vs. 90%, p = 0.007) but became comparable when non-liver-related graft losses were treated as censors (77% vs. 90%, p = 0.100). The incidence of ischemic cholangiopathy was 10% in uDCD versus 3% in donation after circulatory death, p = 0.356. uDCD LT with prolonged warm ischemia is feasible by the sequential use of normothermic regional perfusion and end-ischemic machine perfusion. Proper donor and recipient selection are key to achieving good outcomes in this setting.
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Trasplante de Hígado , Obtención de Tejidos y Órganos , Humanos , Trasplante de Hígado/efectos adversos , Estudios Retrospectivos , Perfusión/efectos adversos , Donantes de Tejidos , Supervivencia de Injerto , Ácido Láctico , Preservación de Órganos/efectos adversosRESUMEN
OBJECTIVES: To evaluate the inter-observer reliability of modified Response Evaluation Criteria In Solid Tumours (mRECIST) of patients with hepatocellular carcinoma (HCC) undergoing neo-adjuvant treatments before liver transplant (LT). The agreement of tumor number, size, transplant criteria, and the radiological-pathological concordance were also assessed. METHODS: A total of 180 radiological studies before/after neo-adjuvant therapies performed on 90 patients prior to LT were reviewed from three expert centers. Kappa-statistic and intraclass correlation (ICC) were evaluated on mRECIST and on tumoral features. Complete radiological response (CR) was compared with complete pathological response (CPR). RESULTS: Before neo-adjuvant therapies, the agreement on tumor number, size, and transplant criteria ranged from moderate (defined as ICC of 0.41-0.60) to almost perfect (ICC of 0.81-0.99), being higher with magnetic resonance imaging (MRI) than CT (0.657-0.899 and 0.422-0.776, respectively). After neo-adjuvant therapies, the agreement decreased, as ICCs ranged between 0.518 and 0.663 with MRI and between 0.508 and 0.677 with CT. Concordant mRECIST pairs were 201 of 270 reviews (76.3%) with a kappa of 0.648 indicating substantial agreement. When the three observers completely agreed on CR, the positive predictive value for CPR was 51.6%. The negative predictive value was 94.2% with a kappa of 0.512 indicating fair agreement between radiology and pathology. CONCLUSIONS: mRECIST agreement was substantial among the three observers involved. The agreement on tumor number, size, and transplant criteria ranged from moderate to almost perfect, with the highest ICCs obtained with MRI before neo-adjuvant therapies. Finally, the predictive value of mRECIST in the diagnosis of CPR was only fair. KEY POINTS: ⢠The review of 180 radiological exams of patients with hepatocellular carcinoma before and after neo-adjuvant therapies showed that the concordance among three different raters on mRECIST diagnosis was substantial. ⢠The inter-observer reliability on fulfilment of transplant criteria slightly decreased when evaluated through CT and after loco-regional therapies. ⢠The radiological diagnosis of complete response after neo-adjuvant therapies was predictive of complete pathological response in only 51.6% of cases.
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Carcinoma Hepatocelular , Quimioembolización Terapéutica , Neoplasias Hepáticas , Trasplante de Hígado , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/terapia , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/terapia , Reproducibilidad de los Resultados , Criterios de Evaluación de Respuesta en Tumores Sólidos , Estudios RetrospectivosRESUMEN
Mechanical circulatory support (MCS) refers to a range of rescue devices to assist circulation for the treatment of heart failure, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and ventricular assist devices (VADs). This review aims at evaluating the transplant outcome of the livers procured from brain-dead donors on MCS, who are currently considered as having extended criteria. We identified 22 records (17 on VA-ECMO and 5 on VADs), most of which (68.2%) were case reports. We performed a meta-analysis only when the outcome was reported homogeneously among studies; otherwise, we illustrated the results with narrative synthesis. A total of 156 liver transplants (LTs) have been reported, where VA-ECMO was initiated in the donor with resuscitative intent or as a bridge to donation. Early graft survival approached 100% in most studies. The pooled rate of primary nonfunction was 1% (95% CI: 0-3%). Only three successful LTs from VAD donors have been reported. Particular attention should be paid to cardiological history, biochemical tests, and imaging, as well as MCS parameters, to determine graft eligibility for transplantation. Although further analysis is needed in this field, the results of this review advocate a more systematic consideration of brain-dead patients on MCS as potential liver donors.
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Trasplante de Corazón , Corazón Auxiliar , Trasplante de Hígado , Encéfalo , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND & AIMS: In the context of liver transplantation (LT) for hepatocellular carcinoma (HCC), prediction models are used to ensure that the risk of post-LT recurrence is acceptably low. However, the weighting that 'response to neoadjuvant therapies' should have in such models remains unclear. Herein, we aimed to incorporate radiological response into the Metroticket 2.0 model for post-LT prediction of "HCC-related death", to improve its clinical utility. METHODS: Data from 859 transplanted patients (2000-2015) who received neoadjuvant therapies were included. The last radiological assessment before LT was reviewed according to the modified RECIST criteria. Competing-risk analysis was applied. The added value of including radiological response into the Metroticket 2.0 was explored through category-based net reclassification improvement (NRI) analysis. RESULTS: At last radiological assessment prior to LT, complete response (CR) was diagnosed in 41.3%, partial response/stable disease (PR/SD) in 24.9% and progressive disease (PD) in 33.8% of patients. The 5-year rates of "HCC-related death" were 3.1%, 9.6% and 13.4% in those with CR, PR/SD, or PD, respectively (p <0.001). Log10AFP (p <0.001) and the sum of number and diameter of the tumour/s (p <0.05) were determinants of "HCC-related death" for PR/SD and PD patients. To maintain the post-LT 5-year incidence of "HCC-related death" <30%, the Metroticket 2.0 criteria were restricted in some cases of PR/SD and in all cases with PD, correctly reclassifying 9.4% of patients with "HCC-related death", at the expense of 3.5% of patients who did not have the event. The overall/net NRI was 5.8. CONCLUSION: Incorporating the modified RECIST criteria into the Metroticket 2.0 framework can improve its predictive ability. The additional information provided can be used to better judge the suitability of candidates for LT following neoadjuvant therapies. LAY SUMMARY: In the context of liver transplantation for patients with hepatocellular carcinoma, prediction models are used to ensure that the risk of recurrence after transplantation is acceptably low. The Metroticket 2.0 model has been proposed as an accurate predictor of "tumour-related death" after liver transplantation. In the present study, we show that its accuracy can be improved by incorporating information relating to the radiological responses of patients to neoadjuvant therapies.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Trasplante de Hígado/efectos adversos , Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia , Tecnología Radiológica/métodos , Carcinoma Hepatocelular/sangre , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/cirugía , Causas de Muerte , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Hepáticas/sangre , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/métodos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/etiología , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/prevención & control , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/prevención & control , Valor Predictivo de las Pruebas , Pronóstico , Medición de Riesgo/métodos , Carga Tumoral , Ultrasonografía/métodos , alfa-Fetoproteínas/análisisRESUMEN
Although immunosuppressed patients may be more prone to SARS-CoV-2 infection with atypical presentation, long-term immunosuppression therapy may provide some sort of protection for severe clinical complications of COVID-19. The interaction between immunosuppression and new antiviral drugs in the treatment of transplanted patients contracting COVID-19 has not yet been fully investigated. Moreover, data regarding the optimal management of these patients are still very limited. We report a case of the successful recovery from severe COVID-19 of a kidney-transplanted patient treated with hydroxychloroquine, lopinavir/ritonavir, steroid, and tocilizumab.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , COVID-19/terapia , Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , SARS-CoV-2/inmunología , Antivirales/uso terapéutico , COVID-19/diagnóstico , COVID-19/inmunología , COVID-19/virología , Quimioterapia Combinada/métodos , Femenino , Rechazo de Injerto/inmunología , Rechazo de Injerto/prevención & control , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Hidroxicloroquina/uso terapéutico , Terapia de Inmunosupresión/efectos adversos , Lopinavir/uso terapéutico , Pulmón/diagnóstico por imagen , Persona de Mediana Edad , Prednisolona/uso terapéutico , Respiración Artificial , Ritonavir/uso terapéutico , SARS-CoV-2/aislamiento & purificación , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: The optimal surgical strategy to lessen the risk of hepatocarcinoma (HCC) recurrence is debated. This study aimed to investigate the role of anatomic resection (AR) and parenchyma-sparing resection (PSR) in HCC recurrence patterns. METHODS: The study analyzed 384 cirrhotic patients with a first diagnosis of HCC. Of these patients, 142 underwent AR, and 242 underwent PSR. The two groups were unbalanced at the univariate analysis. To minimize this bias, a 1:1 propensity score-matching analysis (PSA) was used. Disease-free survival (DFS) curves were analyzed by the Kaplan-Maier method. RESULTS: The PSA allowed pairing of 200 patients (100 for AR and 100 for PSR). In this study, 59 patients (62.8%) had recurrence after AR compared with 58 patients (63.7%) after PSR (p = 0.891). The rates of local recurrence were respectively 15.3% and 15.5% (p = 0.968). When microvascular invasion was considered, the median DFS was 10.7 months for AR and 9.4 months for PSR (p = 0.607). In comparisons of AR and PSR, DFS did not differ significantly between subgroups with high histologic grading (p = 0.520), multiple nodules (p = 0.307), and Child-Pugh B (p = 0.679). CONCLUSION: Excision of the anatomic segment did not seem to reduce the rate of relapse or recurrence patterns significantly, even in high-risk subgroups.
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Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/cirugía , Hepatectomía/métodos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Recurrencia Local de Neoplasia , Tratamientos Conservadores del Órgano , Anciano , Supervivencia sin Enfermedad , Femenino , Humanos , Italia , Estimación de Kaplan-Meier , Cirrosis Hepática/complicaciones , Masculino , Microvasos/patología , Persona de Mediana Edad , Clasificación del Tumor , Invasividad Neoplásica , Puntaje de Propensión , Factores de Riesgo , Factores Sexuales , Carga TumoralRESUMEN
The main goal of allocation system is to guarantee an equal access to the limited resource of liver grafts for every class of patients on the waiting list, balancing between the ethical principles of equity, utility, benefit, need, and fairness. The aim of this review was to analyze liver allocation policies among these organizations, focusing on HCC. The European area considered for this analysis included 6 macro-areas or countries, which are congregated from the same policy of liver sharing and allocation. By this definition, the 6 areas identified are: Centro Nazionale Trapianti (CNT) in Italy; Eurotransplant (Germany, the Netherlands, Belgium, Luxembourg, Austria, Hungary, Slovenia, and Croatia); Organizacion Nacional de Transplantes (ONT) in Spain; Etablissement francais des Greffes (EfG) in France; NHS Blood Transplant (NHSBT) in the United Kingdom and Ireland; Scandiatransplant (Sweden, Norway, Finland, Denmark, and Iceland); Romanian National Policy. Each identified area, as network for organ sharing in Europe, adopts a basic allocation system that consider a policy center oriented or patient oriented. Priorization of patients affected by HCC in the waiting list for deceased donors liver transplant worldwide is dominated by 2 main principles: urgency and utility. The main message of this review is the absence of a common organs allocation policy over the Eurpean countries. Despite that, long-term survival of the community of patients listed for transplant due to HCC results, however, highly acceptable in Europe and comparable to the long-term survial reported in the UNOS register.
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Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Selección de Paciente , Donantes de Tejidos , Obtención de Tejidos y Órganos , Listas de Espera , Carcinoma Hepatocelular/mortalidad , Europa (Continente) , Unión Europea , Humanos , Neoplasias Hepáticas/mortalidad , Resultado del TratamientoRESUMEN
Background: Intraoperative blood loss has an unfavorable impact on the outcome of patients undergoing liver surgery. Today, the use of devices capable of minimizing this risk with high technical performance becomes mandatory. Into this scenario fits the CUSA® Clarity Ultrasonic Surgical Aspirator System. This prospective survey involving five liver surgery centers had the objective of investigating whether this innovative ultrasonic surgical aspirator is safe and effective in the transection of the liver parenchyma. Materials and Methods: This clinical study was a prospective, multicenter, single-arm Post-Market Clinical Follow-up study investigating 100 subjects who underwent liver surgery using the CUSA Clarity Ultrasonic Surgical Aspirator System at five centers during a period of 1 year and 8 months. After collecting all the patient's clinical information and instrument usage details, surgeons completed a brief survey giving their opinions on the performance of CUSA. Therefore, safety and efficacy outcomes were evaluated. Results: Surgeons had a 95% success rate in complete removal of the mass with an average overall operative time of 4 hours and 34 minutes. Overall, there were no complications or device deficiencies. Conclusion: The CUSA Clarity Ultrasonic Surgical Aspirator System performs well during liver surgery with a low complication rate. ClinicalTrials.gov Identifier: NCT04298268.
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Hepatectomía , Ultrasonido , Humanos , Estudios de Seguimiento , Hepatectomía/efectos adversos , Hígado/cirugía , Estudios ProspectivosRESUMEN
BACKGROUND: Split liver transplantation is a valuable means of mitigating organ scarcity but requires significant surgical and logistical effort. Ex vivo splitting is associated with prolonged cold ischemia, with potentially negative effects on organ viability. Machine perfusion can mitigate the effects of ischemia-reperfusion injury by restoring cellular energy and improving outcomes. METHODS: We describe a novel technique of full-left/full-right liver splitting, with splitting and reconstruction of the vena cava and middle hepatic vein, with dual arterial and portal hypothermic oxygenated machine perfusion. The accompanying video depicts the main surgical passages, notably the splitting of the vena cava and middle hepatic vein, the parenchymal transection, and the venous reconstruction. RESULTS: The left graft was allocated to a pediatric patient having methylmalonic aciduria, whereas the right graft was allocated to an adult patient affected by hepatocellular carcinoma and cirrhosis. CONCLUSIONS: This technique allows ex situ splitting, counterbalancing prolonged ischemia with the positive effects of hypothermic oxygenated machine perfusion on graft viability. The venous outflow is preserved, safeguarding both grafts from venous congestion; all reconstructions can be performed ex situ, minimizing warm ischemia. Moreover, there is no need for highly skilled surgeons to reach the donor hospital, thereby simplifying logistical aspects.
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Venas Hepáticas , Trasplante de Hígado , Perfusión , Humanos , Venas Hepáticas/cirugía , Trasplante de Hígado/métodos , Perfusión/métodos , Perfusión/instrumentación , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/patología , Hígado/irrigación sanguínea , Hígado/cirugía , Preservación de Órganos/métodos , Preservación de Órganos/instrumentación , Carcinoma Hepatocelular/cirugía , Masculino , Resultado del Tratamiento , Isquemia Fría , Daño por Reperfusión/prevención & control , Daño por Reperfusión/etiología , Adulto , Cirrosis Hepática/cirugía , Hipotermia InducidaRESUMEN
BACKGROUND: Normothermic regional perfusion (NRP) and machine perfusion (MP) are variously used in many European centers to improve the outcomes after liver transplantation from donation after circulatory death (DCD). In Italy, a combination of NRP and subsequent MP has been used since the start of the activity. While NRP is mandatory for every DCD recovery, the subsequent use of MP is left to each center. METHODS: We have designed a national survey to investigate practices and policies of these techniques. The questionnaire included 46 questions and was distributed to all the 21 Italian centers using an online form between June and July 2021. RESULTS: The overall response rate was 100%. A local NRP program for controlled Maastricht type 3 DCD was active in 11/21 (52.4%) centers. Organization and availability of personnel were perceived as the main difficulties in starting such a program. Between 2015 and 2020, 119 DCD livers were transplanted, with an overall utilization rate of 69.2%. Pump flow and gross aspect were considered the most reliable parameters in liver selection during NRP. Eight (72.7%) centers adopted subsequent hypothermic MP, 1 (9.1%) center normothermic MP, and the remaining 2 (18.2%) used both MP types. CONCLUSION: This first snapshot survey shows that NRP with subsequent MP is the most used protocol in Italy for DCD livers, although some heterogeneity exists in the type and purpose of MP between centers. Overall, this policy ensures a high utilization rate, considering the high risk of the DCD donor population in Italy.
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Trasplante de Hígado , Supervivencia de Injerto , Humanos , Trasplante de Hígado/métodos , Preservación de Órganos/métodos , Perfusión/métodos , Donantes de TejidosRESUMEN
Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.
RESUMEN
Organ shortage is one of the major limitations in the field of liver transplantation, which has led to the consideration of extended criteria donors as a way to expand the donor pool. The use of extended criteria donors in cases of high Model for End-Stage Liver Disease scores or urgent recipients could be complicated by increased postoperative mortality. Donors on left ventricular assist devices could be considered extended criteria donors because of the mechanical circulatory support itself and the potential of chronic liver damage due to right ventricular failure, but experiences in the literature are limited. Here, we report the first case of an urgent liver retransplant procured from a left ventricular assist device donor.
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Enfermedad Hepática en Estado Terminal , Corazón Auxiliar , Trasplante de Hígado , Reoperación , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/cirugía , Humanos , Índice de Severidad de la Enfermedad , Donantes de TejidosRESUMEN
The coronavirus disease 2019 (COVID-19) pandemic has upended healthcare systems worldwide and led to an inevitable decrease in liver transplantation (LT) activity. During the first pandemic wave, administrators and clinicians were obliged to make the difficult decision of whether to suspend or continue a life-saving procedure based on the scarce available evidence regarding the risk of transmission and mortality in immunosuppressed patients. Those centers where the activity continued or was heavily restricted were obliged to screen donors and recipients, design COVID-safe clinical pathways, and promote telehealth to prevent nosocomial transmission. Despite the ever-growing literature on COVID-19, the amount of high-quality literature on LT remains limited. This review will provide an updated view of the impact of the pandemic on LT programs worldwide. Donor and recipient screening, strategies for waitlist prioritization, and posttransplant risk of infection and mortality are discussed. Moreover, a particular focus is given to the possibility of donor-to-recipient transmission and immunosuppression management in COVID-positive recipients.
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COVID-19/epidemiología , Trasplante de Hígado/tendencias , Obtención de Tejidos y Órganos/tendencias , COVID-19/diagnóstico , COVID-19/transmisión , Transmisión de Enfermedad Infecciosa/prevención & control , Enfermedad Injerto contra Huésped/prevención & control , Asignación de Recursos para la Atención de Salud , Humanos , Inmunosupresores/uso terapéutico , Tamizaje Masivo , SARS-CoV-2 , Trasplantes/virologíaRESUMEN
The shortage of organs has pushed transplant surgeons to accept liver grafts with extended criteria, but severe vascular abnormalities may still discourage the use of otherwise acceptable organs. We report herein the case of a liver graft with a 64-mm aneurysm of the proper hepatic artery extended to the origin of the right and left hepatic branches. The graft was deemed unsuitable for transplant by all other centers in the region. However, liver function tests were normal, and there was no evidence of compromised arterial supply. At back table, we resected the aneurysm and anastomosed the right and left hepatic arteries to a vascular graft obtained from the distal tract of the donor's superior mesenteric artery. After portal reperfusion, we anastomosed the mesenteric graft to the recipient's hepatic artery at the origin of the gastroduodenal artery. The postoperative course and the subsequent 6-month follow-up were uneventful. In conclusion, the presence of a hepatic artery aneurysm should not be an absolute contraindication to the use of a liver graft. The present case emphasizes the possibility to utilize an organ that would have been otherwise discarded.
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Aneurisma/cirugía , Implantación de Prótesis Vascular , Selección de Donante , Arteria Hepática/trasplante , Hepatitis C/complicaciones , Cirrosis Hepática/cirugía , Trasplante de Hígado , Donantes de Tejidos/provisión & distribución , Anciano , Aneurisma/diagnóstico por imagen , Supervivencia de Injerto , Arteria Hepática/diagnóstico por imagen , Hepatitis C/diagnóstico , Hepatitis C/virología , Humanos , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/virología , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
The use of laparoscopic liver resection (LLR) has progressively spread in the last 10 years. Several studies have shown the superiority of LLR to open liver resection (OLR) in term of perioperative outcomes. With this review, we aim to systematically assess short-term and long-term major outcomes in patients who underwent LLR for hepatocellular carcinoma (HCC) in order to illustrate the advantages of minimally invasive liver surgery. Through an advanced PubMed research, we selected all retrospective, prospective, and comparative clinical trials reporting short-term and long-term outcomes of any series of patients with diagnosis of HCC who underwent laparoscopic or robotic resection. Reviews, meta-analyses, or case reports were excluded. None of the patients included in this review has received a previous locoregional treatment for the same tumor nor has undergone a laparoscopic-assisted procedure. We considered morbidity and mortality for evaluation of major short-term outcomes, and overall survival (OS) and disease-free survival (DFS) for evaluation of long-term outcomes. A total of 1,501 patients from 17 retrospective studies were included, 15 studies compare LLR with OLR. Propensity-score matching (PSM) analysis was used in 11 studies (975 patients). The majority of the studies included patients with good liver function and a single HCC. Cirrhosis at pathology ranged from 33% to 100%. Overall mortality and morbidity ranges were 0-2.4% and 4.9-44% respectively, with most of the complications being Clavien-Dindo grade I or II (range: 3.9-23.3% vs. 0-9.52% for Clavien I-II and ≥ III respectively). The median blood loss ranged from 150 to 389 mL; the range of the median duration of surgery was 134-343 minutes. The maximum rate of conversion was 18.2%. The median duration of hospitalization ranged from 4 to 13 days. The ranges of overall survival rates at 1-, 3- and 5-year were 72.8-100%, 60.7-93.5% and 38-89.7% respectively. The ranges of disease free survival rates at 1-, 3- and 5-year were 45.5-91.5%, 20-72.2% and 19-67.8% respectively. The benefits of LLR in term of complication rate, blood loss, and duration of hospital stay make this procedure an advantageous alternative to OLR, especially for cirrhotic patients in whom the use of LLR reduces the risk of post-hepatectomy liver failure. The limits of LLR can be overcome by robotic surgery, which could therefore be preferred. Further benefits of minimally invasive surgery derive from its ability to reduce the formation of adhesions in view of a salvage liver transplant. In conclusion, the results of this review seem to confirm the safety and feasibility of LLR for HCC as well as its superiority to OLR according to perioperative outcomes.
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PURPOSE: The extent of liver resection for the optimal treatment of hepatocellular carcinoma (HCC) is debated. The purpose of this study was to compare the impact of anatomic resection (AR) vs. parenchyma-sparing resection (PSR) on disease recurrence and patient survival. METHODS: We retrospectively analyzed patients with HCC who underwent liver resection from January 2001 to August 2015. Patients receiving AR or PSR were compared by a propensity score analysis (PSA) (caliper = 0.1). The primary outcomes were disease-free survival (DFS) and overall survival (OS) rates, and assessed by the Kaplan-Meier method. RESULTS: 455 consecutive patients were evaluated. After PSA 354 patient were studied (177 pairs for each group). The median follow-up time was 28.2 months. The median OS was 47.5 months (95% CI: 30.0-65.9) for AR and 56.5 months (95% CI 33.2-79.6) for PSR (p = 0.169). The median DFS was 29.2 months (95% CI 17.6-40.8) for AR and 24.8 months (95% CI: 15.2-34.2) for PSR (p = 0.337). The multivariate regression model showed that cirrhosis (HR 2.85, 95% CI: 1.53-5.32; p = 0.001), BCLC grade B (HR 4.15, 95% CI: 1.33-12.95; p = 0.014), microvascular invasion (HR 1.55, 95% CI: 1.03-2.31; p = 0.033), presence of satellitosis (HR 1.94, 95% CI: 1.25-3.01; p = 0.003), severe complications (HR 6.09, 95% CI: 2.26-16.40; p > 0.001) were independently associated with poor long-term oncologic outcomes. CONCLUSIONS: The extent of resection did not significantly affect overall and disease-free survival while tumor characteristics and underlying liver function appeared significant determinants.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía/métodos , Neoplasias Hepáticas/cirugía , Recurrencia Local de Neoplasia/etiología , Neoplasias Primarias Múltiples/cirugía , Tratamientos Conservadores del Órgano/métodos , Anciano , Carcinoma Hepatocelular/fisiopatología , Carcinoma Hepatocelular/secundario , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Cirrosis Hepática/complicaciones , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/fisiopatología , Masculino , Microvasos/patología , Persona de Mediana Edad , Clasificación del Tumor , Invasividad Neoplásica , Neoplasia Residual , Neoplasias Primarias Múltiples/patología , Neoplasias Primarias Múltiples/fisiopatología , Tejido Parenquimatoso/cirugía , Puntaje de Propensión , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Carga TumoralRESUMEN
BACKGROUND: Laparoscopic liver resection (LLR) has gained significant popularity over the last 10 years. First experiences of LLR compared to open liver resection (OLR) reported a similar survival and a better safety profile for LLR. MATERIALS AND METHODS: This is a retrospective analysis of prospectively collected data of all consecutive patients treated by liver resection for HCC on liver cirrhosis between January 2005 and March 2017. The choice of procedure (LLR vs OLR) was generally based on tumor localization, history of previous upper abdominal surgery and patient's preference. The type of resection and indication for surgery were unrelated to the adopted technique. Based on pre-operative variables and confirmed cirrhosis, a 1:1 propensity score matching (PSM) model was developed to compare outcomes of LLR and OLR in patients with HCC. Outcomes of interest included morbidity, mortality and long-term cure potential. RESULTS: After-PSM, the LLR group demonstrated better perioperative results including: lower complication rate (50.7% in OLR vs 29.3% in LLR, pâ¯=â¯0.0035), significantly lower intra-operative blood loss (200â¯ml in OLR vs 150â¯ml in LLR, pâ¯=â¯0.007) and shorter hospital length of stay (median 9 days in OLR vs 7 days in LLR, pâ¯=â¯0.0018). Moreover there was no significant difference between the two groups in 3-year survival (76%, CI: 60%-86% in LLR vs 68%, CI: 55%-79% in OLR, pâ¯=â¯0.32) or recurrence-free survival rates (44%, CI: 28%-58%, vs 44%, CI: 31%-57%, pâ¯=â¯0.94). CONCLUSIONS: Minor LLR appeared significantly safer compared to minor OLR for HCC. LLR was associated with fewer post-operative complication, lower operative blood loss and a shorter hospital stay along with similar survival and recurrence-free survival rates.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía/mortalidad , Cirrosis Hepática/cirugía , Neoplasias Hepáticas/cirugía , Complicaciones Posoperatorias , Puntaje de Propensión , Anciano , Carcinoma Hepatocelular/complicaciones , Carcinoma Hepatocelular/patología , Femenino , Estudios de Seguimiento , Humanos , Laparoscopía , Tiempo de Internación , Cirrosis Hepática/complicaciones , Cirrosis Hepática/patología , Neoplasias Hepáticas/complicaciones , Neoplasias Hepáticas/patología , Masculino , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Transplantable hepatocellular carcinoma (HCC) represents a highly debated issue due to the overlap between indications for liver resection (LR) and transplantation (LT) in patients suitable for both. STUDY DESIGN: Between January 2000 and December 2012, five hundred and twenty-four transplantable patients affected by HCC were identified among resected patients. Two regression models were constructed to classify patients into 2 groups pre-low and pre-high risk based on preoperative variables and then to reclassify pre-low-risk patients according to postoperative variables into either post-low or post-high-risk. Additionally, a cohort of patients with comparable baseline characteristics who underwent LT were similarly classified into pre-low and pre-high-risk groups and compared with the resected patients in terms of survival. RESULTS: Cirrhosis, aspartate transaminase, α-fetoprotein, Model for End-Stage Liver Disease score, number of nodules, and diameter of the largest nodule were preoperatively found to be significantly related to overall survival post-LR. Microvascular invasion and satellites were selected to reclassify prognosis in the resulting preoperative low-risk group into post-high risk. The converted group (post-high) demonstrated the same 5-year survival as the pre-high group. Patients undergoing LT had better survival overall than those undergoing LR, with the exception of pre-low LT and post-low LR (confirmed low-risk LR) who had similar outcomes. CONCLUSIONS: The new models were strongly predictive of patients' likelihood of survival after LR for HCC on liver cirrhosis. Liver transplantation offers a survival advantage over LR, except in low-risk groups where both modalities might be comparable.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía/métodos , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/estadística & datos numéricos , Adulto , Anciano , Carcinoma Hepatocelular/mortalidad , Femenino , Hepatectomía/mortalidad , Humanos , Neoplasias Hepáticas/mortalidad , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.