Quantitative Assessment of the Accuracy of Real-Time Virtual Sonography for Liver Surgery.

Background. Real-time virtual sonography (RVS) is a navigation system for liver surgery. In this study, the degree of misalignment of intraoperative RVS images with computed tomographic (CT) images was measured. Methods. Between December 2014 and July 2015, intraoperative RVS was performed in a total of 33 patients undergoing liver surgery. Reconstructed CT images, rendered like intraoperative ultrasonographic (IOUS) images, were adjusted with the IOUS images and visualized side by side. The degree of misalignment between the reconstructed CT images and IOUS images was measured at anterior section, posterior section, and left liver in each patient. Furthermore, the time required for the adjustment was measured as the "adjustment time." Results. The degree of misalignment between the images could potentially be measured for a total of 96 points in the 33 patients. Of these, the actual measurement could not be conducted for 35 points due to poor visualization of the intrahepatic vasculature (n = 20) or to a large misalignment that hampered continuation of further adjustment (n = 15). The median degree of misalignment was 9.8 mm (range = 2.4-37.6 mm) in the right anterior section, 9.8 mm (range = 2.7-71.5 mm) in the right posterior section, and 9.5 mm (range = 0.9-37.6 mm) in the left liver. The median adjustment time was 105 seconds (range = 51-245 seconds). Conclusions. Although some misalignment occurred, it might be acceptable for selected situations. Further investigation is needed to reduce the frequency of adjustment failure.

Assessment of Preoperative Liver Function for Surgical Decision Making in Patients with Hepatocellular Carcinoma.

BACKGROUND: Most patients with hepatocellular carcinoma (HCC) have underlying liver disease and a preoperative liver function evaluation is important to avoid postoperative liver failure and death. In Western guidelines, portal hypertension (PH) is listed as a contraindication for liver resection. On the other hand, the indocyanine green retention rate at 15 min (ICG R15) has been widely used in Asian countries for surgical decision making. However, these criteria are based on reports published in the 20th century that included only a small number of patients and were developed empirically. SUMMARY: The number of published case series concerning liver resection in HCC patients with PH has been rapidly increasing since 2011, indicating that liver resection in HCC patients with PH is now routinely performed in specialized centers worldwide. Although PH certainly has an impact and should be considered as a contraindication for major liver resection, it is no longer considered to be a contraindication for minor liver resection, especially laparoscopic liver resection. In addition, new biomarkers and imaging tools to assess preoperative liver function have been extensively reported. The combination of these new factors to well-known risk factors, such as PH and ICG R15, might strengthen the ability to stratify the risk of postoperative liver failure. KEY MESSAGES: The present review covers recent topics regarding the assessment of preoperative liver function for surgical decision making in patients with HCC.

Assessment of Preoperative Liver Function in Patients with Hepatocellular Carcinoma - The Albumin-Indocyanine Green Evaluation (ALICE) Grade.

BACKGROUND: Most patients with hepatocellular carcinoma (HCC) have underlying liver disease, therefore, precise preoperative evaluation of the patient's liver function is essential for surgical decision making. METHODS: We developed a grading system incorporating only two variables, namely, the serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), to assess the preoperative liver function, based on the overall survival of 1868 patients with HCC who underwent liver resection. We then tested the model in a European cohort (n = 70) and analyzed the predictive power for the postoperative short-term outcome. RESULTS: The Albumin-Indocyanine Green Evaluation (ALICE) grading system was developed in a randomly assigned training cohort: linear predictor = 0.663 × log10ICG R15 (%)-0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). This new grading system showed a predictive power for the overall survival similar to the Child-Pugh grading system in the validation cohort. Determination of the ALICE grade in Child-Pugh A patients allowed further stratification of the postoperative prognosis. This result was reproducible in the European cohort. Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure and mortality (ascites: grade 1, 2.1%; grade 2, 6.5%; grade 3, 16.0%; mortality: grade 1, 0%; grade 2, 1.3%; grade 3, 5.3%) than the previously reported model based on the presence/absence of portal hypertension. CONCLUSIONS: This new grading system is a simple method for prediction of the postoperative long-term and short-term outcomes.