Completion of a Liver Surgery Complexity Score and Classification Based on an International Survey of Experts.

BACKGROUND: Liver resections have classically been distinguished as "minor" or "major," based on number of segments removed. This is flawed because the number of segments resected alone does not convey the complexity of a resection. We recently developed a 3-tiered classification for the complexity of liver resections based on utility weighting by experts. This study aims to complete the earlier classification and to illustrate its application. STUDY DESIGN: Two surveys were administered to expert liver surgeons. Experts were asked to rate the difficulty of various open liver resections on a scale of 1 to 10. Statistical methods were then used to develop a complexity score for each procedure. RESULTS: Sixty-six of 135 (48.9%) surgeons responded to the earlier survey, and 66 of 122 (54.1%) responded to the current survey. In all, 19 procedures were rated. The lowest mean score of 1.36 (indicating least difficult) was given to peripheral wedge resection. Right hepatectomy with IVC reconstruction was deemed most difficult, with a score of 9.35. Complexity scores were similar for 9 procedures present in both surveys. Caudate resection, hepaticojejunostomy, and vascular reconstruction all increased the complexity of standard resections significantly. CONCLUSIONS: These data permit quantitative assessment of the difficulty of a variety of liver resections. The complexity scores generated allow for separation of liver resections into 3 categories of complexity (low complexity, medium complexity, and high complexity) on a quantitative basis. This provides a more accurate representation of the complexity of procedures in comparative studies.

Perceived complexity of various liver resections: results of a survey of experts with development of a complexity score and classification.

BACKGROUND: Liver resections have classically been distinguished as "minor" or "major" based on the number of segments removed. However, it is clear that the number of segments alone does not convey the complexity of a resection. To date, no study has formally assessed the complexity of various anatomic liver resections. STUDY DESIGN: A 4-question survey was administered to 135 expert liver surgeons in 14 countries. The first 3 questions related to the country in which the surgeon was practicing and the surgeon's experience. In the fourth question, the experts were asked to rate the difficulty of various open, anatomic liver resections on a scale of 1 to 10. RESULTS: Sixty-six of 135 (48.9%) surgeons responded to the survey. Twelve procedures were rated. The lowest mean score of 1.37-indicating least difficulty-was given to peripheral wedge resection. Left trisectionectomy with caudate resection was deemed most difficult, with a score of 8.28. The mean scores for the 2 procedures perceived as least difficult-peripheral wedge resection and left lateral sectionectomy-were lower than the mean scores of all the rest of the procedures at a highly statistically significant level (p < 0.0001). The 4 procedures with the highest scores shared the common attribute that they involved the right intersectional plane. CONCLUSIONS: These data represent the first quantitative assessment of the perceived difficulty of a variety of liver resections. The complexity scores generated allow for separation of liver resections into 3 categories of complexity (low complexity, medium complexity, and high complexity) on a quantitative basis.

Left lateral segmentectomy for pediatric live-donor liver transplantation: special attention to segment IV complications.

BACKGROUND: During left lateral segmentectomy for live-donor liver transplant, the vascular inflow to segment IV can be compromised. An area of ischemia can be seen intraoperatively and further segment IV resection may be needed to prevent necrosis and abscess formation. METHODS: From July 1995 to February 2007, 324 consecutive living donor liver transplantations were performed at Hospital A. C. Camargo and Hospital Sirio-Libanes, Sao Paulo, Brazil. Two hundred eleven left lateral segments were transplanted in this period. Data on 204 left lateral segments donors were available for this analysis. RESULTS: There were 108 female and 96 male donors. Median age was 29 years (range, 16-48 years). Median follow-up time was 2.2 years (range, 2 months-11.8 years). Median intensive care unit stay was 1 day (range, 1-3 days), and median hospital stay was 5 days (range, 4-47 days). Postoperative complications were encountered in 39 donors (19.1%). Partial segment IV resection on the course of the primary surgery due to parenchyma discoloration was required in 107 cases (52.5%). Ten patients (4.9%) developed segment IV necrosis or abscesses, although four of them had had segment IVB resection intraoperatively. Segment IV necrosis or abscess significantly increased hospital stay and the number of readmissions, from 5.5+/-3.5 days to 8.4+/-3.7 days (P=0.012) and from 6 of 194 (3%) to 5 of 10 (50%) (P=0.001), respectively. CONCLUSIONS: Middle hepatic segment abscess or necrosis was the most frequent complication after left lateral segmentectomy (4.9%). Objective intraoperative strategies need to be developed to evaluate middle hepatic segment ischemia to identify and treat patients at higher risk.

Resecciones hepáticas: nueva terminología y nuestra experiencia en el Hospital Italiano de Rosario / Hepatic resections: new terminology and our experience in Rosario Italian Hospital

Antecedentes: La cirugía hepática ha alcanzado en las últimas dos décadas un desarrollo tal que hoy en día se pueden realizar resecciones hepáticas con una gran seguridad sin pérdida de sangre intraoperatoria, morbilidad aceptable y nula mortalidad. Objetivo: Evaluar retrospectivamente en una base de datos prospectiva iniciada en mayo de 1984 en el Hospital Italiano de Rosario, las resecciones hepáticas, terminología, sus indicaciones, aspectos técnicos y resultados obtenidos. Lugar de aplicación: Servicio de Clínica Quirúrgica "B", Hospital Privado. Población: 110 pacientes fueron sometidos a 117 resecciones primarias y 2 re-resecciones y 1 en dos etapas (120 hepatectomías). Método: Se utilizó la terminología de la "escuela francesa" y se la adaptó a la nueva, llamada de "Brisbane" (IHPBA-2000). Se realizaron 54 hepatectomías mayores (3 o más segmentos) y 66 hepatectomías menores en 110 pacientes y en 113 operaciones. Se utilizaron las 3 técnicas clásicas de resección para las 120 hepatectomías. El tiempo operatorio se sumó en los casos de que las hepatectomías fueron de 2 o más en cada paciente. Resultados: En hepatectomías mayores (n=54) el tiempo operatorio fue de 4,40 hs ñ 2,30 hs, la estadía hospitalaria de 8 ñ 4 días, la morbilidad del 54 por ciento y la mortalidad operatoria del 7,4 por ciento (4 casos desde 1984 a 1991) y nula desde 1992 (p<0,001). La utilización de transfusión de sangre intraoperatoria disminuyó de 6 unidades de promedio en el período 84 a 91 a 3 unidades en el período 92 a 01 (p<0,05) (excepto traumas). En hepatectomías menores (n=66) el tiempo operatorio fue de 3,30 hs ñ 2,10 hs, la estadía hospitalaria fue de 5 ñ 2 días, la morbilidad del 15 por ciento y la mortalidad operatoria del 0 por ciento (AU)

Avaliaçäo da regeneraçäo hepática após esplenectomias total e parcial; estudo experimental em ratos / Informations concerning hepatic regeneration after large splenoctomy; experimental study in rats

A presente investigaçäo foi feita com intuito de se avaliar a influência da ressecçäo parcial do baço sobre regeneraçäo hepática. O estudo foi realizado com ratos da raça Wistar, que foram divididos em quatro grupos a saber: Grupo A - (sham) ratos submetidos à laparotomia e à suave manipulaçäo do fígado e do baço. Grupo B - (controle) ratos submetidos à ressecçäo de 68 por cento do parênquima hepático. Grupo C - ratos submetidos à ressecçäo de 68 por cento do parênquima hepático e à esplenectomia. Grupo D - ratos submetidos à ressecçäo de 68 por cento do parênquema hepático e à hemiesplenectomia. Todos os animais foram sacrificados após 72 horas de observaçäo. O critério utilizado para avaliar a regeneraçäo hepática foi a contagem do número de mitoses, em 20 campos de médio aumento, com objetiva de 25 vezes, ocorridas nos hepatócitos e nas células de Kupffer, durante o primeiro ciclo do processo de regeneraçäo. Os resultados demonstraram aumento do número de mitoses no grupo C e diminuiçäo de mitoses no grupo D (p<0,01). Concluímos, após análise dos grupos do nosso experimento, que a esplenectomia intensifica a regeneraçäo hepática e que apenas a metade do parênquima esplênico é capaz de desencadear um efeito inibidor deste fenômeno no rato

Resecciones hepáticas, aspectos quirúrgicos, morbilidad y mortalidad / Hepatic resections, surgical aspects, morbidity and mortality

Se presenta la experiencia institucional en resecciones hepáticas electivas durante los años 1990 y 1991. De 215 resecciones hepáticas, 87% correspondieron a lesiones malignas y un 13% a lesiones benignas. El tamaño promedio de las lesiones fue de 7,8 cm. En 11 pacientes se constató invasión vascular tumoral. En forma rutinaria se utilizó un disector ultrasónico (Cavitron), y control vascular unilateral previo a la transección del parénquima. El promedio de sanfre trasfundida fue de 2,3 unidades por paciente y se demostró una correlación entre cantidad de sangre trasfundida y cantidad de tejido hepático resecado. Factores determinantes de morbilidad fueron la edad del paciente, malignidad de la lesión, trasfusión de más de 3 uds. de sangre, y extensión de la resección. La mortalidad fue de 2,3% (5 pacientes) y afectó sólo a pacientes con lesiones malignas. No hubo mortalidad operatoria