Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant.

BACKGROUND: Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion. METHODS: A volumetric analysis using image-processing software was performed in selected patients with liver tumours suspected on preoperative imaging of major HV invasion. The size of the non-congested liver remnant (NCLR) was calculated by subtracting the congested area from the liver remnant. Venous reconstruction was scheduled in patients who met the following criteria: normal liver function (indocyanine green retention rate at 15 min (ICGR(15) ) of less than 10 per cent) with a NCLR smaller than 40 per cent of total liver volume (TLV), or liver dysfunction (ICGR(15) 10-20 per cent) with a NCLR smaller than 50 per cent of TLV. Surgical outcomes and liver regeneration were investigated. RESULTS: A total of 55 patients with suspected HV invasion were enrolled. Sacrifice of one or more HVs was deemed possible in 37 patients. Venous reconstruction was scheduled in 18 patients. At operation, there was seen to be no venous involvement in 11 patients. The HV was sacrificed in 29 patients, and preserved or reconstructed in 24. Volume restoration ratios at 3 months were similar in the sacrifice (88 per cent) and preserve (87 per cent) groups. Operating time was shorter (465 min) and blood loss was lower (580 ml) in the sacrifice than in the preserve group (523 min and 815 ml respectively). CONCLUSION: The HV can be sacrificed safely according to the proposed criteria, reducing surgical invasiveness without influencing the postoperative course.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion.

BACKGROUND: Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival. METHODS: This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high-volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures. RESULTS: A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence-free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004). CONCLUSION: RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

ANTECEDENTES: La duodenopancreatectomía (pancreaticoduodenectomy, PD) con resección de la vena porta (portal vein resection, PVR) es una operación estándar para el adenocarcinoma ductal pancreático (pancreatic ductal adenocarcinoma, PDAC) con invasión de la vena porta (portal vein, PV); sin embargo, las tasas de margen positivo siguen siendo altas. Nuestra hipótesis fue que la duodenopancreatectomía regional (regional pancreaticoduodenectomy, RPD) en la que el tejido blando alrededor de la PV se reseca en bloque podría mejorar el resultado oncológico y la supervivencia. MÉTODOS: Este estudio retrospectivo incluyó pacientes consecutivos que se sometieron a PD con PVR entre enero de 2005 y diciembre de 2016 en un solo centro de alto volumen. En la PD estándar (SPD) con PVR, la PV se esqueletizó disecando el tejido blando circundante. En la RPD, el segmento retropancreático de la PV se resecó en bloque con el tejido blando circundante. La extensión de la linfadenectomía fue similar en ambos procedimientos. RESULTADOS: Se incluyeron un total de 268 pacientes (177 sometidos a SPD y 91 a RPD). Los pacientes sometidos a SPD presentaron con mayor frecuencia tumores resecables (35 (38%) versus 107 (61%), P = 0,014)) y recibieron con mayor frecuencia terapia neoadyuvante (23 (25%) versus 14 (8%), P < 0,001)) que los pacientes sometidos a RPD. La resección R0 se logró en 73 (80%) pacientes pertenecientes al grupo RPD, en comparación con 117 (66%) pacientes sometidos a SPD (P = 0.011), aunque los resultados perioperatorios fueron comparables entre los grupos. La mediana de supervivencia libre de recidiva (recurrence-free survival, RFS) y de supervivencia global (overall survival, OS) fueron 17 meses y 31 meses, respectivamente, en pacientes sometidos a RPD, en comparación con 11 meses y 21 meses en pacientes sometidos a SPD, (P = 0,003 para RFS y P = 0,004 para la OS). CONCLUSIÓN: La RPD es tan segura y factible como la SPD y puede aumentar la supervivencia de pacientes con PDAC con invasión de la PV.

Possible underestimation of blood loss during laparoscopic hepatectomy.

Background: Previous studies have documented potential advantages of laparoscopic hepatectomy in decreasing blood loss compared with open surgery. This study aimed to compare intraoperative blood loss estimated using four different methods in open versus laparoscopic hepatectomy. Methods: Patients undergoing liver resection between 2014 and 2017 were evaluated prospectively, differentiating between the laparoscopic and open approach. Groups were compared using univariable and multivariable analyses. Intraoperative blood loss was estimated using three formulas based on the postoperative decreases in haematocrit, haemoglobin or red blood cell volume, and using the conventional method of the sum of suction fluid amounts and gauze weight. In addition, blood loss per hepatic transection area was calculated to compare groups. Results: Some 125 patients who underwent hepatectomy were selected, including 56 open hepatectomies and 69 laparoscopic liver resections. Intraoperative blood loss per hepatic transection area estimated by the conventional method was significantly less in the laparoscopic than the open group (3·6 (range 0·2-50·0) versus 6·6 (1·2-82·5) ml/cm2 respectively; P < 0·001). In contrast, there were no significant differences between groups in blood loss estimated based on the decrease in haematocrit (12·9 (0-65·2) versus 8·1 (0-123·7) ml/cm2; P = 0·818), haemoglobin or red blood cell volume. Blood loss estimation using three formulas showed significant linear correlations with the blood loss estimated by the conventional method in the open group (r s = 0·758 to 0·762), but not in the laparoscopic group (r s = -0·019 to 0·031). Conclusion: The conventional method of calculating blood loss in laparoscopic hepatectomy can underestimate losses.

Indocyanine green fluorescence imaging in the surgical management of liver cancers: current facts and future implications.

Imaging detection of liver cancers and identification of the bile ducts during surgery, based on the fluorescence properties of indocyanine green, has recently been developed in liver surgery. The principle of this imaging technique relies on the intravenous administration of indocyanine green before surgery and the illumination of the surface of the liver by an infrared camera that simultaneously induces and collects the fluorescence. Detection by fluorescence is based on the contrast between the (fluorescent) tumoral or peri-tumoral tissues and the healthy (non-fluorescent) liver. Results suggest that indocyanine green fluorescence imaging is capable of identification of new liver cancers and enables the characterization of known hepatic lesions in real time during liver resection. The purpose of this paper is to present the fundamental principles of fluorescence imaging detection, to describe successively the practical and technical aspects of its use and the appearance of hepatic lesions in fluorescence, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver surgery.