Complex Liver Resections for Intrahepatic Cholangiocarcinoma.

The only curative treatment option for intrahepatic cholangiocarcinoma (iCCA) is liver resection. Due to central tumor localization and vascular invasion, complex liver resections play an important role in curative treatment. However, the long-term outcomes after complex liver resection are not known. Methods: A retrospective cohort study was conducted for all patients undergoing liver surgery for iCCA. Complex liver resections included ante situm resections, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and major liver resection with vascular reconstructions. Results: Forty-nine patients (34%) received complex liver resection, 66 patients (46%) received conventional liver resection and 28 patients (20%) were not resectable during exploration. Preoperative characteristics were not different between the groups, except for Union for International Cancer Control (UICC) stages. The postoperative course for complex liver resections was associated with more complications and perioperative mortality. However, long-term survival was not different between complex and conventional resections. Independent risk factors for survival were R0 resections and UICC stage. Four patients underwent ante situm resection without any mortality. Conclusions: Complex liver resections are justified in selected patients and survival is comparable with conventional liver resections. Survival in iCCA is affected by UICC stage or resections margins and not by the complexity of the case.

Impact of acute kidney injury after extended liver resections.

BACKGROUND: Complex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery. METHODS: AKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality. RESULTS: Overall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS. CONCLUSION: Following extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.

Portal vein arterialization for iatrogenic embolization of the hepatic artery. An old but still useful technique?

INTRODUCTION: Portal Vein Arterialization is a rare procedure for total de-arterialized livers to ensure arterial inflow to the liver. PRESENTATION OF CASE: A 55-year-old male patient underwent pancreatoduodenectomy for chronic pancreatitis. One month after discharge the patient was re-admitted because of bleeding from a pseudoaneurysm of the ligated gastroduodenal artery. During radiological intervention a coil dislocated and a complete occlusion of the hepatic artery occurred. Extraction of the coil was not possible, therefore, the patient was transferred to our hospital for surgical revascularization. We performed a side-to-side running anastomosis between a branch of a mesenteric artery and the corresponding vein to supply arterial blood to the liver. The postoperative course was uneventful. Radiologic examinations showed a patent arterio-portal shunt. DISCUSSION: Portal vein arterialization might be a lifesaving procedure in complication management. CONCLUSION: PVA is an old surgical method, which could be helpful to reduce the failure-to-rescue rate.