Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis.

OBJECTIVE: To stratify major hepatectomies (MajHs) according to their outcomes. SUMMARY OF BACKGROUND DATA: MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections. METHODS: We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center. RESULTS: We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31). CONCLUSIONS: The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.

Laparoscopic Liver Resection for Hepatocellular Carcinoma in Child-Pugh A Patients With and Without Portal Hypertension: A Multicentre Study.

BACKGROUND: Laparoscopic liver resection (LLR) may improve outcomes for cirrhotic patients with hepatocellular carcinoma (HCC) and portal hypertension (PHT). The aim of this study was to compare the short-term outcomes after LLR for HCC in cirrhotic patients with and without PHT. METHODS: This multicentric study included 96 HCC patients who underwent LLR. Clinically significant portal hypertension (CSPH) was defined by a hepatic venous pressure gradient ≥10 mmHg. Short-term outcomes and liver-specific complications including post-hepatectomy liver failure (PHLF), ascites and encephalopathy were compared between patients with and without CSPH. RESULTS: Thirty-one patients (32%) had CSPH. The CSPH group had higher post-operative morbidity (52% vs. 15%; p < 0.001), PHLF (10% vs. 0%; p = 0.03) and encephalopathy (10% vs. 0%; p = 0.03). There was no difference in terms of post-operative ascites between the two groups (CSPH: 16% vs. no CPSH: 8%, p = 0.28). The length of stay was longer in patients with CSPH than in those without CSPH (6 vs. 4 days; p < 0.001). CONCLUSIONS: The laparoscopic approach is feasible in selected HCC patients with CSPH, at the price of significant increases in liver-specific complications and length of stay.

Impact on Oncological Outcomes and Intent-to-Treat Survival of Resection Margin for Transplantable Hepatocellular Carcinoma in All-Comers and in Patients with Cirrhosis: A Multicenter Study.

BACKGROUND: The outcomes of liver resection (LR) with a narrow margin in patients with transplantable hepatocellular carcinoma (HCC) have not been studied. The aim was to assess whether narrow margin following up-front LR impacts the incidence, timing, pattern, and transplantability of tumor recurrence in patients with initially transplantable HCC. METHODS: All initially transplantable HCC patients undergoing hepatectomy with either narrow (<10 mm) or wide (≥10 mm) margins from 2007 to 2016 at four Western university centers were compared in terms of recurrence, transplantability of recurrence, recurrence-free survival (RFS), and intention-to-treat overall survival (ITT-OS). Independent predictors of non-transplantability of recurrence were assessed. RESULTS: This study included 187 patients (narrow group, n = 107 vs. wide group, n = 80). Recurrence was significantly more frequent in the narrow margin group (44% vs. 26%; p = 0.01) with a shorter RFS (p = 0.03). The transplantability of recurrence and ITT-OS were, however, not different between the two groups. The presence of satellite nodules on the resected specimens emerged as the sole independent predictor of non-transplantability of tumor recurrence. The stratification of the analysis according to the presence of cirrhosis achieved essentially the same results as in the whole study population. CONCLUSIONS: Narrow margin was associated with a higher tumor recurrence rate and a shorter RFS for patients with initially transplantable HCC. However, transplantability of recurrence and long-term ITT-OS were not impaired.

Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis.

OBJECTIVE: To elucidate minor hepatectomy (MiH) outcomes. SUMMARY BACKGROUND DATA: Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures. METHODS: We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers. EXCLUSION CRITERIA: cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders. RESULTS: Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02). CONCLUSIONS: MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.

Prospective evaluation of the International Study Group for Liver Surgery definition of post hepatectomy liver failure after liver resection: an international multicentre study.

BACKGROUND: The International Study Group for Liver Surgery (ISGLS) definition of post hepatectomy liver failure (PHLF) was developed to be consistent, widely applicable, and to include severity stratification. This international multicentre collaborative study aimed to prospectively validate the ISGLS definition of PHLF. METHODS: 11 HPB centres from 7 countries developed a standardised reporting form. Prospectively acquired anonymised data on liver resections performed between 01 July 2010 and 30 June 2011 was collected. A multivariate analysis was undertaken of clinically important variables. RESULTS: Of the 949 patients included, 86 (9%) met PHLF requirements. On multivariate analyses, age ≥70 years, pre-operative chemotherapy, steatosis, resection of >3 segments, vascular reconstruction and intraoperative blood loss >300 ml significantly increased the risk of PHLF. Receiver operator curve (ROC) analysis of INR and serum bilirubin relationship with PHLF demonstrated post-operative day 3 and 5 INR performed equally in predicting PHLF, and day 5 bilirubin was the strongest predictor of PHLF. Combining ISGLS grades B and C groups resulted in a high sensitivity for predicting mortality compared to the 50-50 rule and Peak bilirubin >7 mg/dl. CONCLUSIONS: The ISGLS definition performed well in this prospective validation study, and may be the optimal definition for PHLF in future research to allow for comparability of data.

Evolution of laparoscopic surgery in a high volume hepatobiliary unit: 150 consecutive pure laparoscopic hepatectomies. / Evolución de la cirugía laparoscópica en una unidad hepatobiliar de alto volumen: 150 hepatectomías laparoscópicas consecutivas.

INTRODUCTION: Compared to other surgical areas, laparoscopic liver resection (LLR) has not been widely implemented and currently less than 20% of hepatectomies are performed laparoscopically worldwide. The aim of our study was to evaluate the feasibility, and the ratio of implementation of LLR in our department. METHODS: We analyzed a prospectively maintained database of 749 liver resections performed during the last 10-year period in a single centre. RESULTS: A total of 150 (20%) consecutive pure LLR were performed between 2005 and 2015. In 87% of patients the indication was the presence ofprimary or metastatic liver malignancy. We performed 30 major hepatectomies (20%) and (80%) were minor resections, performed in all liver segments. Twelve patients were operated twice and 2 patients underwent a third LLR. The proportion of LLR increased from 12% in 2011 to 62% in the last year. Conversion rate was 9%. Overall morbidity rate was 36% but only one third were classified as severe. The 90-day mortality rate was 1%. Median hospital stay was 4 days and the rate of readmissions was 6%. CONCLUSIONS: The implementation of LLR has been fast with morbidity and mortality comparable to other published series. In the last 2 years more than half of the hepatectomies are performed laparoscopically in our centre.

Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis.

BACKGROUND: The value of temporary intraoperative porto-caval shunts (TPCS) in cava-sparing liver transplantation is discussed controversially. Aim of this meta-analysis was to analyze the impact of temporary intraoperative porto-caval shunts on liver injury, primary non-function, time of surgery, transfusion of blood products and length of hospital stay in cava-sparing liver transplantation. METHODS: A systematic search of MEDLINE/PubMed, EMBASE and PsycINFO retrieved a total of 909 articles, of which six articles were included. The combined effect size and 95 % confidence interval were calculated for each outcome by applying the inverse variance weighting method. Tests for heterogeneity (I 2) were also utilized. RESULTS: Usage of a TPCS was associated with significantly decreased AST values, significantly fewer transfusions of packed red blood cells and improved postoperative renal function. There were no statistically significant differences in primary graft non-function, length of hospital stay or duration of surgery. CONCLUSION: This meta-analysis found that temporary intraoperative porto-caval shunts in cava-sparing liver transplantation reduce blood loss as well as hepatic injury and enhance postoperative renal function without prolonging operative time. Randomized controlled trials investigating the use of temporary intraoperative porto-caval shunts are needed to confirm these findings.

Prospective evaluation of the International Study Group for Liver Surgery definition of bile leak after a liver resection and the role of routine operative drainage: an international multicentre study.

BACKGROUND: The International Study Group for Liver Surgery (ISGLS) proposed a definition for bile leak after liver surgery. A multicentre international prospective study was designed to evaluate this definition. METHODS: Data collected prospectively from 949 consecutive patients on specific datasheets from 11 international centres were collated centrally. RESULTS: Bile leak occurred in 69 (7.3%) of patients, with 31 (3.3%), 32 (3.4%) and 6 (0.6%) classified as grade A, B and C, respectively. The grading system of severity correlated with the Dindo complication classification system (P < 0.001). Hospital length of stay was increased when bile leak occurred, from a median of 7 to 15 days (P < 0.001), as was intensive care stay (P < 0.001), and both correlated with increased severity grading of bile leak (P < 0.001). 96% of bile leaks occurred in patients with intra-operative drains. Drain placement did not prevent subsequent intervention in the bile leak group with a 5-15 times greater risk of intervention required in this group (P < 0.001). CONCLUSION: The ISGLS definition of bile leak after liver surgery appears robust and intra-operative drain usage did not prevent the need for subsequent drain placement.

Laparoscopic approach to liver hydatidosis: initial experience.

INTRODUCTION: Hepatic hydatidosis is a pathology that has a worldwide distribution, and is frequent in some rural areas in Argentina. Surgical treatment still offers the best results. The laparoscopic approach is controversial because of lack of experience with this technique. OBJECTIVE: To evaluate the feasibility and efficacy of the laparoscopic approach in this pathology and to present the experience obtained in a medical center in Argentina. MATERIAL AND METHODS: We prospectively evaluated patients with a diagnosis of non complicatedhydatidosis, over 15 years of age whose cyst had the following characteristics: unique cyst, size less than 5 centimeters, located in the anterior segments or easy access. Analyzed data were: sex, age, cyst localization, treatment, operating time, morbidity and mortality and recurrence. RESULTS: Nine patients were operated using a laparoscopic approach. The cysts were localized in the segments iii, iv, v and vi. Six patients were operated with pneumoperitoneum and 3 with a parietal traction device, in all the patients the first approach was a laparoscopic PAIR (punction, aspiration, injection and reaspiration). Seven Mabit-Lagrot procedures were performed and 2pericystectomies. The operative time was a mean of 89.7min and a hospital stay of 52h. The morbidity was 22.2% and the mortality was 0%.Mean follow-up of 19 months showed no recurrences. CONCLUSION: A higher number of patients and a longer follow-up are necessary to evaluate the efficacy of approach; the laparoscopic approach seems to be safe. Our results coincide with the majority of other publications.

Pure laparoscopic liver resection reduces surgical site infections and hospital stay. Results of a case-matched control study in 50 patients.

BACKGROUND: Laparoscopic resection is an emerging tool in surgical oncology, but its role in liver tumors is far from being universally accepted. METHODS: We designed a case-matched control study, comparing laparoscopic (LAP) vs. open hepatectomies (OP) performed in the same center during the same period of time. Fifty LAP were performed (34 liver metastases, 7 hepatocellular carcinomas, 2 hydatid cysts, and 5 benign tumors). Cases were compared with 100 OP matched according to: diagnosis, number of lesions, type of resection, age, ASA score, and ECOG performance status. We evaluated intraoperative and postoperative parameters, focusing on morbidity and mortality. RESULTS: Preoperative data were comparable in both groups. Operative features were similar in terms of overall morbidity 18 (36 %) vs. 36 (36 %), p = 1; intraoperative bleeding, 401 (18-2192) vs. 475 (20-2000) mL, p = 0.89; pedicle clamping, 37 (74 %) vs. 88 (88 %), p = 0.55; margin, 0.6 (0-5) vs. 0.65 (0-5) cm, p = 0.94, and mortality p = 0.65 for the LAP and OP groups, respectively. There was a significant decrease in surgical site infections 1 (2 %) vs. 18 (18 %) p = 0.007 in the LAP group. Operative time was longer: 295 (120-600) vs. 200 (70-450) min (p = 0.0001), and hospital stay significantly shorter: 4 (1-60) vs. 7 (3-44) days, p = 0.0001 with less readmissions (0 vs. 7 %) in the LAP. DISCUSSION: In adequately selected patients, laparoscopic hepatectomy is feasible, safe, shortens hospital stay, and decreases surgical site infections.

[Liver resections as radical surgery for hepatic hydatidosis: results in 50 patients]. / Resultados de las resecciones hepáticas como tratamiento radical de la hidatidosis hepatica en 50 pacientes.

INTRODUCTION: Among several regions in the world hepatic hydatidosis can be considered endemic. Currently there are many available treatments for this disease, been surgery the most effective one. Surgical procedures can be divided in two main groups, radical and non-radical procedures. The goal of this work is to evaluate the morbidity, mortality and percentage of recurrence in patients treated with hepatectomies, comparing them with other publications. MATERIAL AND METHODS: This retrospective study was carried out in a series from Spain and Argentina. We analyzed the following data: sex, age, type of resection, associated surgical gestures, presence of liver disease, operative time, blood transfusion, morbidity, mortality, hospital stay, re-hospitalization, recurrence and follow up. Dindo--Clavien classification was used for complications, and International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane classification for hepatectomies. Mortality was considered until 90 days after surgery. To evaluate the recurence we only included patients followed over 6 months. RESULTS: Indications for liver resections were performed in patients with cysts larger than 5 centimeters, multiple cysts, large cysts, with bile duct communicated or suspicion of this communication. Five patients required blood transfusions (10%) with a median for these 5 patients of 740 ml and 74 ml for the complete series. The median operative time was 186 minutes (range 45 to 1,050 minutes). Median hospital stay was 7.7 days. Monitoring more than 6 months was conducted in 38 patients. CONCLUSIONS: We believe that hepatic hydatid disease is a multifaceted disease and requires more than one therapeutic approach. Hepatectomy with complete resection of the parasite offers the possibility of doing so in a controlled and safe way by experienced hands, ensuring good results in the treatment of this disease.

[Disconnected panreatic duct syndrome]. / Síndrome del ducto pancreático desconectado.

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.

Surgical management of acute cholecystitis. Results of a nation-wide survey among Spanish surgeons.

There is a wide variability in the management of acute cholecystitis. A survey among the members of the Spanish Association of Surgeons (AEC) analyzed the preferences of Spanish surgeons for its surgical management. The majority of the 771 responders didn't declare any subspecialty (41.6%), 21% were HPB surgeons, followed by colorectal and upper-GI specialities. Early cholecystectomy during the first admission is the preferred method of management of 92.3% of surgeons, but only 42.7% succeed in adopting this practice. The most frequent reasons for changing their preferred practice were: Patients not fit for surgery (43.6%) and lack of availability of emergency operating room (35.2%). A total of 88.9% perform surgery laparoscopically. The majority of AEC surgeons advise index admission cholecystectomy for acute cholecystitis, although only half of them succeed in its actual implementation. There is room for improvement in the management of acute cholecystitis in Spanish hospitals.

[Hilar cholangiocarcinoma: The number of positive nodes and positive node/total node ratio is a significant prognostic factor for survival]. / Colangiocarcinoma hiliar: el número de ganglios positivos y la relación ganglios positivos/ganglios totales son un factor pronóstico importante de supervivencia.

INTRODUCTION: Surgical treatment of hilar cholangiocarcinoma remains a challenge. Multiple prognostic factors have been proposed. The number of positive nodes and the ratio between positive lymph node and total lymph node (G+/Gt) are considered by some authors as the most important factor. MATERIAL AND METHODS: We analyzed a series of 58 patients with Klatskin tumors. We evaluated the prognostic factors and survival with emphasis on the prognostic impact of the number of positive nodes and its relation to total lymph nodes. RESULTS: Resectability was 78% with a 5-year survival of 32%. The median number of nodes examined was 9.5. No significant differences were found in several of the proposed prognostic factors. The presence of 2 or more positive nodes or a ratio G+/Gt ≥ 0.2 were found to be poor prognostic factors. CONCLUSION: The relationship between positive lymph nodes and total lymph nodes and the number of positive lymph nodes are important prognostic factors.

[Multicentre study on hepatic adenomas]. / Estudio multicéntrico sobre adenomas hepáticos.

INTRODUCTION: Hepatic adenomas (HA) are benign tumours which can present serious complications, and as such, in the past all were resected. It has now been shown that those smaller than 3 cm not expressing ß-catenin only result in complications in exceptional cases and therefore the therapeutic strategy has been changed. MATERIAL AND METHOD: Retrospective study in 14 HPB units. INCLUSION CRITERIA: patients with resected and histologically confirmed HA. STUDY PERIOD: 1995-2011. RESULTS: 81 patients underwent surgery. Age: 39.5 years (range: 14-75). Sex: female (75%). Consumption of oestrogen in women: 33%. Size: 8.8 cm (range, 1-20 cm). Only 6 HA (7.4%) were smaller than 3 cm. The HA median was 1 (range: 1-12). Nine patients had adenomatosis (>10HA). A total of 51% of patients displayed symptoms, the most frequent (77%) being abdominal pain. Eight patients (10%) began with acute abdomen due to rupture and/or haemorrhage. A total of 67% of the preoperative diagnoses were correct. Surgery was scheduled for 90% of patients. The techniques employed were: major hepatectomy (22%), minor hepatectomy (77%) and one liver transplantation. A total of 20% were performed laparoscopically. The morbidity rate was 28%. There were no cases of mortality. Three patients had malignisation (3.7%). The follow-up period was 43 months (range 1-192). Two recurrences were detected and resected. DISCUSSION: Patients with resected HA are normally women with large lesions and oestrogen consumption was lower than expected. Its correct preoperative diagnosis is acceptable (70%). The major hepatectomy rate is 25% and the laparoscopy rate is 20%. There was a low morbidity rate and no mortality.

The oncosurgery approach to managing liver metastases from colorectal cancer: a multidisciplinary international consensus.

An international panel of multidisciplinary experts convened to develop recommendations for the management of patients with liver metastases from colorectal cancer (CRC). The aim was to address the main issues facing the CRC hepatobiliary multidisciplinary team (MDT) when managing such patients and to standardize the treatment patients receive in different centers. Based on current evidence, the group agreed on a number of issues including the following: (a) the primary aim of treatment is achieving a long disease-free survival (DFS) interval following resection; (b) assessment of resectability should be performed with high-quality cross-sectional imaging, staging the liver with magnetic resonance imaging and/or abdominal computed tomography (CT), depending on local expertise, staging extrahepatic disease with thoracic and pelvic CT, and, in selected cases, fluorodeoxyglucose positron emission tomography with ultrasound (preferably contrast-enhanced ultrasound) for intraoperative staging; (c) optimal first-line chemotherapy-doublet or triplet chemotherapy regimens combined with targeted therapy-is advisable in potentially resectable patients; (d) in this situation, at least four courses of first-line chemotherapy should be given, with assessment of tumor response every 2 months; (e) response assessed by the Response Evaluation Criteria in Solid Tumors (conventional chemotherapy) or nonsize-based morphological changes (antiangiogenic agents) is clearly correlated with outcome; no imaging technique is currently able to accurately diagnose complete pathological response but high-quality imaging is crucial for patient management; (f) the duration of chemotherapy should be as short as possible and resection achieved as soon as technically possible in the absence of tumor progression; (g) the number of metastases or patient age should not be an absolute contraindication to surgery combined with chemotherapy; (h) for synchronous metastases, it is not advisable to undertake major hepatic surgery during surgery for removal of the primary CRC; the reverse surgical approach (liver first) produces as good an outcome as the conventional approach in selected cases; (i) for patients with resectable liver metastases from CRC, perioperative chemotherapy may be associated with a modestly better DFS outcome; and (j) whether initially resectable or unresectable, cure or at least a long survival duration is possible after complete resection of the metastases, and MDT treatment is essential for improving clinical and survival outcomes. The group proposed a new system to classify initial unresectability based on technical and oncological contraindications.

Progression while receiving preoperative chemotherapy should not be an absolute contraindication to liver resection for colorectal metastases.

PURPOSE: Tumor progression while receiving neoadjuvant chemotherapy (PD) has been associated with poor outcome and is commonly considered a contraindication to liver resection (LR). This study aims to clarify in a large multicenter setting whether PD is always a contraindication to LR. METHODS: Data from the LiverMetSurvey international registry were analyzed. Patients undergoing LR for colorectal metastases without extrahepatic disease after neoadjuvant chemotherapy between 1990 and 2009 were reviewed. RESULTS: Among 2143 patients, PD occurred in 176 (8.2 %). Risk of progression was increased after 5-FU or irinotecan (22.7 % vs. 6.8 % after other regimens, p < 0.0001; 14.9 % vs. 7.2 %, p < 0.0001), while it was reduced after oxaliplatin (5.6 % vs. 12.0 %, p < 0.0001) and still diminished among patients receiving targeted therapies (2.6 %). PD was an independent prognostic factor of survival at multivariate analysis (35 % vs. 49 %, p = 0.0006). In the PD group, 3 independent prognostic factors were identified: carcinoembryonic antigen (CEA) ≥ 200 ng/mL (p = 0.003), >3 metastases (p = 0.028), and tumor diameter ≥ 5 0 mm (p = 0.002). A survival predictive model showed that patients without any risk factors had 5-year survival rates of 53.3 %; good survival results were still observed if metastases were >3 or ≥ 50 mm (29.9 and 19.1 %, respectively). On the contrary, survival was less than 10 % at 3 years in the presence of >1 prognostic factor or CEA of ≥ 200 ng/mL. CONCLUSIONS: PD is a negative prognostic factor, but it is not an absolute contraindication to LR. Patients with PD could be scheduled for LR except for those with >3 metastases and ≥ 50 mm, or CEA ≥ 200 ng/mL in whom further chemotherapy is recommended.

How to transect the liver? A history lasting more than a century.

There is a close relationship between blood loss during transection and unfavorable outcome. Many different methods have been used in order to cut the parenchyma, while leaving vital structures intact, coagulate small vessels and seal small biliary ducts. The first method described was the finger-fracture technique and, alternatively, the clamp-crushing method using a small forceps. With this technique, the liver is crushed between the 'jaws', and the vessels and bile ducts are successively ligated and divided. Technological research using different sources of energy developed the water jet dissectors and the ultrasonic dissectors. The CUSA® has been widely adopted for the fascinating way it could selectively destroy and aspirate parenchyma leaving vascular structures almost intact. Several studies have been addressed to clarify these critical points. However, in the majority of cases they are underpowered to demonstrate clear advantages of one method over the others. In conclusion, the evidence suggested no superiority of other techniques over clamp-crushing. But it must be taken into account that it requires strictly hepatic pedicle clamping. The devices available should be used within the limits of each instrument, as well as the surgical skills of the surgeon. Probably the best option should be a combined approach.

[Resection of liver metastases in patients with extrahepatic disease]. / Reseccion de metástasis hepáticas en presencia de enfermedad extrahepática.

Patients who have liver metastasis and extrahepatic metastatic disease (EMD) have been considered as a patient subgroup with a very poor prognosis. Therefore, the presence of EMD was traditionally considered a contraindication for liver resection. But, survivals of around 30% at 5 years, and higher than that achieved with chemotherapy only obtained in some patients with liver metastasis of colorectal origin and EMD who had a resection performed on the hepatic and extrahepatic disease, obliges us to re-think what we must do in these patients. We have carried out an exhaustive review of the literature in an attempt to establish some working guidelines based on current scientific evidence. In summary, we can say that the presence of resectable EMD in patients with liver metastasis must not be considered as an absolute contraindication for liver resection, although the results are inferior to those obtained in patients without EMD. Patients with EMD localised in the ganglia of the coeliac trunk or aorto-cava have a short survival. The use of chemotherapy prior to the surgery is recommended to operate stable patients, or who respond to the chemotherapy and not in progression.

Multicentre study of liver metastases from colorectal cancer in pathological livers.

OBJECTIVES: Resection of colorectal cancer (CRC) liver metastases (LM) in pathological liver (PL) patients (with cirrhosis or hepatopathy) is extremely rare. The aim of this study was to perform a multicentre, retrospective analysis of epidemiology, surgical techniques and outcomes in patients with PL who underwent hepatic resection for CRC-LM. METHODS: A retrospective, multicentre questionnaire was distributed to 15 hepatopancreatobiliary surgical units. RESULTS: Only six of 15 (40%) HPB units reported any experience in the surgical resection of CRC-LM in patients with PL. Of the 20 patients identified, 10 had underlying cirrhosis and 10 had chronic hepatopathy. Their median age was 66 years (range: 49-81 years). Thirteen patients were male. Liver dysfunction was known preoperatively in 18 patients. All patients had Child-Pugh class A disease. Six patients had synchronous disease. There were a total of 38 lesions among the 20 patients, distributed at a median of one lesion per patient (range: 1-4 lesions). The median size of the lesions was 3.0 cm (range: 1.5-9.0 cm). Preoperative median carcinoembryonic antigen (CEA) was 32.3 ng/ml (range: 1-184 ng/ml). The surgical procedures performed included: sub-segmentectomy (n= 12); left lateral sectionectomy (n= 6); segmentectomy (n= 4); radiofrequency ablation (n= 3), and exploratory laparotomy (n= 4). Morbidity occurred in four patients (Clavien grades I [n= 1], II [n= 2] and IVa [n= 1]). Mortality was nil. An R0 resection margin was achieved in 15 of 16 patients. Twelve patients did not receive chemotherapy. In resected patients, 10 presented with relapse. The median disease-free and overall survival periods were 12.2 and 22.3 months, respectively. CONCLUSIONS: When feasible, liver resection is the best option for CRC-LM in PL patients.