Ultrasound-guided anatomical liver resection using a compression technique combined with indocyanine green fluorescence imaging.

BACKGROUND: Anatomical resection (AR) is a recommended surgical treatment for hepatocellular carcinoma (HCC). However, the conventional procedure (dye injection) for AR is difficult to reproduce. As an alternative, the tumour-feeding portal pedicle compression technique (finger-compression technique) has been proposed as an easy and reversible procedure. Here, we propose a new method combining indocyanine green (ICG) imaging with the finger-compression technique. METHODS: Eligible patients were prospectively enrolled to undergo ICG compression (ICG-C) anatomical hepatectomy for HCC. RESULTS: Fifteen patients underwent AR using the ICG-C technique. Overall, the surgical procedures included six segmentectomies, seven subsegmentectomies, and two right posterior sectionectomies. The median tumour size was 5.8 cm (range 2-7 cm). All procedures had an R0 margin. There were no major complications among patients, and minor morbidity occurred in three patients. CONCLUSIONS: ICG-C is a safe, feasible and effective technique for patients eligible for AR.

Prediction of remnant liver volume using 3D simulation software in patients undergoing R1vasc parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases: reliability, clinical impact, and learning curve.

BACKGROUND: Assessment of the future liver remnant (FLR) is routinely performed before major hepatectomy. In R1-vascular one-stage hepatectomy (R1vasc-OSH), given the multiplanar dissection paths, the FLR is not easily predictable. Preoperative 3D-virtual casts may help. We evaluated the predictability of the FLR using the 3D-virtual cast in the R1vasc-OSH for multiple bilobar colorectal liver metastases (CLM). METHODS: Thirty consecutive patients with multiple bilobar CLMs scheduled for R1vasc-OSH were included. Predicted and real-FLRs were compared. Propensity score-matched analysis was used to determine the impact of 3D-virtual cast on postoperative complications. RESULTS: Median number of CLM and resection areas were 12 (4-33) and 3 (1-8). Median predicted-FLR was 899 ml (558-1157) and 60% (42-85), while for the real-FLR 915 ml (566-1777) and 63% (43-87). Median discrepancy between predicted and real-FLR was -0.6% (p = 0.504), indicating a slight tendency to underestimate the FLR. The difference was more evident in more than 12 CLMs (p = 0.013). A discrepancy was not evident according to the number of resection areas (p = 0.316). No mortality occurred. Patients in virtual-group had lower major complications compared to nonvirtual-group (0% vs 18%, p-value 0.014). CONCLUSION: FLR estimation based on 3D-analysis is feasible, provides a safe surgery and represents a promising method in planning R1vasc-OSH for patients with multiple bilobar CLMs.

Oncological outcome of R1 vascular margin for mass-forming cholangiocarcinoma. A single center observational cohort analysis.

BACKGROUND: Recent studies validated the possibility to detach colorectal liver metastases from vessels (R1vasc) featuring R1vasc equivalent to R0 and superior to tumor exposure along the transection plane (R1par). To clarify the outcome of R1 surgery (margin <1 mm) in patients with intrahepatic cholangiocarcinoma (MFCCC), distinguishing R1par and R1vasc resections. METHODS: Patients undergoing resection for MFCCC between 2008 and 2016 were considered. Tumor detachment from 1st/2nd-order Glissonean pedicles or hepatic veins was performed in advanced diseases. R0, R1par, and R1vasc were compared. RESULTS: The study included 84 resection areas in 59 patients (17 R1vasc). R1vasc group had local recurrence risk similar to R1par group (per-patient analysis 29% vs. 36%; per-resection area analysis 29% vs. 32%), higher than R0 group (3% and 2%, p = 0.003 and p = 0.0003). R1vasc and R1par groups had similar overall and recurrence-free survival (median OS 30 vs. 30 months; RFS 10 vs. 8 months), lower than R0 group (70 and 39 months, p = 0.066 and p = 0.007). CONCLUSION: In MFCCC patients, R1vasc resection is not an adequate treatment. Local disease control and survival after R1vasc resection are lower than after R0 resection and similar to R1par resection. R1vasc resection could be exclusively considered to achieve resectability in otherwise unresectable patients.

The Liver Tunnel: Intention-to-treat Validation of a New Type of Hepatectomy.

OBJECTIVE: This prospective intention-to-treat validation study evaluated the liver tunnel (LT) technique for patients having ≥1 deep centrally located liver tumor, with or without middle hepatic vein (MHV) invasion. BACKGROUND: Conservative surgery has been proposed for patients with deep liver tumors having complex relationships. LT is one such novel technique. METHODS: Eligible patients were prospectively enrolled for LT. LT relies on tumor-vessel detachment, and the presence of communicating veins if MHV resection is necessary. RESULTS: Twenty consecutive patients met the inclusion criteria: 17 had colorectal liver metastases, 1 had hepatocellular carcinoma, 1 had mass-forming cholangiocarcinoma, and 1 had mixed hepatocellular carcinoma-mass-forming cholangiocarcinoma. Nineteen patients underwent LT. The MHV was resected in 6 patients, always sparing segments 4i and 5. Overall, 180 lesions were removed (median 7; range 1-37): 79 lesions were included in the LT specimen (median 3; range 1-13). There was no in-hospital 90-day mortality. Overall morbidity occurred in 10 (50%) patients: major in 2 (10%). All complications were managed conservatively. After a median 15-month follow-up (range 6-48), 2 instances of cut-edge local recurrences were observed. CONCLUSIONS: This study shows that LT is technically feasible and safe. Further studies are needed for standardizing its use.

Progression of Colorectal Liver Metastases from the End of Chemotherapy to Resection: A New Contraindication to Surgery?

BACKGROUND: Not all patients with resectable colorectal liver metastases (CLM) benefit from liver resection (LR); only patients with disease progression during chemotherapy are excluded from surgery. OBJECTIVE: This study was performed to determine whether tumor behavior (stable disease/progression) from the end of chemotherapy to LR impacts prognosis. METHODS: Patients undergoing LR after tumor response or stabilization during chemotherapy were considered. Overall, 128 patients who underwent examination by two imaging modalities (computed tomography/magnetic resonance imaging) after chemotherapy with a > 3-week interval between the two imaging modalities were analyzed. Any variation in CLM size was registered. Tumor progression was defined according to the response evaluation criteria in solid tumors (RECIST) criteria. RESULTS: Among 128 patients with stable disease or partial response to preoperative chemotherapy, 32 (25%) developed disease progression in the chemotherapy to LR interval, with a disease progression rate of 17% when this interval was < 8 weeks. Survival was lower among patients with progression than those with stable disease [3-year overall survival (OS) 23.0 vs. 52.4%, and recurrence-free survival (RFS) 6.3% vs. 21.6%; p < 0.001]. Survival was extremely poor in patients with early progression (< 8 weeks) (0.0% 2-year OS, 12.5% 6-month RFS). Disease progression in the chemotherapy to LR interval was an independent negative prognostic factor for OS and RFS [hazard ratio 3.144 and 2.350, respectively; p < 0.001]. CONCLUSIONS: Early disease progression in the chemotherapy to LR interval occurred in approximately 15% of patients and was associated with extremely poor survival. Even if these data require validation, the risk for early disease progression after chemotherapy should be considered, and, if progression is evident, the indication for surgery should be cautiously evaluated.

Aggressive and Multidisciplinary Local Approach to Iterative Recurrences of Colorectal Liver Metastases.

BACKGROUND: Liver resection (LR) of colorectal metastases is associated with high recurrence risk. Aggressive local retreatment is advocated, but further recurrences may occur. Poor is known about presentation, treatment, and outcome of iterative recurrences. METHODS: A series of 323 consecutive patients undergoing first LR in the period 2004-2013 was reviewed. Patients with recurrence were included. Any local treatment (surgery, radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT)) was analyzed. If first recurrence (1st Rec) was treated, further recurrences and treatments were considered. RESULTS: Overall, 206 (63.8%) patients had 1st Rec; 105 (51.0%) were treated (72 surgery, 19 RFA, 14 SBRT). Among treated patients, 78.1% had 2nd Rec, 74.4% 3rd Rec, 72.2% 4th Rec. Liver involvement progressively decreased (from 81.6 to 30.8%), and pulmonary one increased (from 23.3 to 53.8%). The proportion of treated patients remained stable (1st Rec = 51%, 2nd Rec = 55%, 3rd Rec = 56.3%, 4th Rec = 69.2%): surgery and RFA decreased (from 35.4 to 23.1%; from 9.2 to 0%) and SBRT increased (from 6.8 to 46.2%). Overall, 105 patients received 205 treatments (133 operations in 80 patients). Surgery had the best local disease control: at 2 years 93.4% versus RFA 56.4% (p = 0.0008) and SBRT 74.0% (p = 0.051). In comparison with chemotherapy, recurrence treatment improved survival after 1st Rec (3-year survival 62.9 vs. 13.4%, p < 0.0001), 2nd Rec (61.3 vs. 22.5%, p < 0.0001), and 3rd Rec (2-year survival 88.9 vs. 30.8%, p = 0.005). CONCLUSIONS: Aggressive local treatment of recurrent metastases may improve survival, even in the case of iterative recurrences and extrahepatic lesions. Surgery is the standard, but a multidisciplinary approach should be adopted to enlarge the pool of treatable patients.

Hepatectomy with or without the thoraco-abdominal approach: impact on perioperative outcome.

BACKGROUND: Hepatectomy using the thoraco-abdominal approach (TAA) compared to the abdominal approach (AA) remains under debate. This study assessed the perioperative outcomes of patients operated with or without TAA. METHODS: 1:1 propensity score-matched analysis was applied in 744 patients operated between 2007 and 2013, identifying 246 patients who underwent hepatectomy with TAA compared to 246 patients with AA. These groups were matched for demographics, liver disease, comorbidity, tumor features, and extent of resection. Rates of morbidity and mortality were the study endpoints. RESULTS: The rates of morbidity or mortality were not different. With the TAA length of the operations (P = 0.002), length of the Pringle maneuver (P = 0.012), and rate of blood transfusions (P = 0.041) were significantly different. Hospital stay was similar. Independent significant prognostic factors for adverse perioperative outcome were: renal comorbidity (OR = 2.7; P = 0.001), extent of the resection (OR = 3.7; P = 0.001), and increased BILCHE score (OR = 2.4; P = 0.002). CONCLUSIONS: Hepatectomy using the TAA was not associated with adverse perioperative outcome. The associations with length of operation, Pringle maneuver and blood transfusions may have reflected the complexity of the tumor presentation rather than the technical approach.

Individualized risk estimation for postoperative morbidity after hepatectomy: the Humanitas score.

BACKGROUND: Estimation of postoperative morbidity after hepatectomy remains challenging. The aim of this prospective study was to develop a surgical score to predict an individual risk of post-hepatectomy complications. METHODS: All consecutive patients scheduled for hepatectomy from February 2012 to September 2015 were included and randomly assigned into a derivation or validation cohort. We developed a score based on preoperative variables, and we tested them using multivariate analyses. Odds-ratio (OR) values were used to build the score. RESULTS: 340 patients were included, 240 in the derivation and 100 in the validation cohort. Multivariate analysis showed that major hepatectomy (OR = 1.62; 95% CI 1.39-3.51), liver stiffness ≥9.7 kPa (OR = 2.46; 95% CI 1.16-5.28), BILCHE score (combination of serum bilirubin and cholinesterase) ≥2 (OR = 2.76; 95% CI 0.82-4.28) and esophageal varices (OR = 1.59; 95% CI 1.51-3.61) were independent complications predictors. A 10-point scoring system was introduced. Patients with a score ≤4 did not experience complications, whereas patients with ≥7 points experienced up to 54% of complications (P < 0.001). CONCLUSIONS: A new, easy and clinically reliable surgical score based on the liver stiffness, BILCHE score, type of hepatectomy, and presence of varices may be used to predict post-hepatectomy morbidity. CLINICAL TRIAL NUMBER: NCT02454686 (https://www.clinicaltrials.gov/).

Twelve-year experience of "radical but conservative" liver surgery for colorectal metastases: impact on surgical practice and oncologic efficacy.

BACKGROUND: Liver surgery for colorectal metastases (CLM) is moving toward parenchyma-sparing approaches. The authors reported the technical feasibility of parenchyma-sparing hepatectomy for deeply located tumors, but its impact on daily practice and long-term outcomes remain unclear. METHODS: The patients undergoing liver resection (LR) for CLM with vascular contact (first-/second-order pedicle or hepatic vein (HV) trunk) were considered. Those undergoing major hepatectomy were excluded. The authors' technique included tumor-vessel detachment, partial resection of marginally infiltrated HVs, and detection of communicating vessels (CVs) among HVs to preserve outflow after HV resection. RESULTS: Among 169 patients with major vascular contact, parenchyma-sparing LR was feasible in 146 (86%). Twenty-eight SERPS, 13 transversal hepatectomies, 6 mini-mesohepatectomies, and 4 liver tunnels were performed. Sixty-six (45%) patients underwent CLM-vessel detachment, 25 (17%) underwent partial HV resection, and 30 (21%) achieved outflow preservation by CV identification. The mortality and severe morbidity rates were 1.4% and 8.2%, respectively. The 5-year survival rate was 30.7%. The parenchyma-sparing strategy failed in 14 (7%) patients because of recurrence in the spared parenchyma or cut edge; 13 were radically retreated. CONCLUSION: Ultrasound-guided parenchyma-sparing surgery is feasible in most patients with ill-located CLMs. This procedure is safe and achieves adequate oncologic outcomes.

Is Tumor Detachment from Vascular Structures Equivalent to R0 Resection in Surgery for Colorectal Liver Metastases? An Observational Cohort.

BACKGROUND: R0 resection is the standard for colorectal liver metastases (CLMs). Adequacy of R1 resections is debated. Detachment of CLMs from vessels has been proposed to prioritize parenchyma sparing and increase resectability, but outcomes are still to be elucidated. The present study aimed to clarify the outcomes of R1 surgery (margin <1 mm) in patients with CLMs, distinguishing standard R1 resection (parenchymal margin, R1Par) and R1 resection with detachment of CLMs from major intrahepatic vessels (R1Vasc). METHODS: All patients undergoing first resection between 2004 and June 2013 were prospectively considered. R0, R1Par, and R1Vasc were compared in per-patient and per-resection area analyses. RESULTS: The study included 627 resection areas in 226 consecutive patients. Fifty-one (8.1 %) resections in 46 (20.4 %) patients were R1Vasc, and 177 (28.2 %) resections in 107 (47.3 %) patients were R1Par. Thirty-two (5.1 %) surgical margin recurrences occurred in 28 (12.4 %) patients. Local recurrence risk was similar between the R0 and R1Vasc groups (per-patient analysis 5.3 vs. 4.3 %; per-resection area analysis 1.5 vs. 3.9 %, p = n.s.) but increased in the R1Par group (19.6 and 13.6 %, p < 0.05 for both). The R1Par group had a higher rate of hepatic-only recurrences (49.5 vs. 36.1 %, p = 0.042). On multivariate analysis, R1Par was an independent negative prognostic factor of overall survival (p = 0.034, median follow-up 33 months); conversely R1Vasc versus R0 had no significant differences. CONCLUSIONS: R1Par resection is not adequate for CLMs. R1Vasc surgery achieves outcomes equivalent to R0 resection. CLM detachment from intrahepatic vessels can be pursued to increase patient resectability and resection safety (parenchymal sparing).

Diagnosis and Management of Bile Leaks After Hepatectomy: Results of a Prospective Analysis of 475 Hepatectomies.

BACKGROUND: The diagnosis and management of bile leaks after hepatectomy are heterogeneous because there is no agreement on the definition of post-hepatectomy biliary fistula. The aim of this study was to validate our definition and management of biliary fistulas after hepatic resection and to compare our results with those proposed by other authors. METHODS: A prospective series of patients who underwent hepatic resection from 2004 to 2012 were established. Drains were maintained for 7 days, and bilirubin was measured on postoperative days (PODs) 3, 5, and 7. Drains were removed if the bilirubin on POD 7 was less than that on POD 5 and less than 171 µmol/l (10 mg/dl). A statistical analysis of prognostic factors for biliary fistula was performed. RESULTS: Among 475 consecutive patients, 39 (8%) had biliary fistulas. Only 8 (1.7%) patients required postoperative interventions. In comparison with other studies, we observed a higher rate of bile leaks, but at the same time, we observed a lower rate of interventional procedures. The area under the receiver operating characteristic curve on POD 7 had the highest predictive value (0.81; P < 0.001). Pringle maneuvers lasting ≥90 min (OR = 3.4; P < 0.001), extended resections (OR = 6.4; P = 0.007), blood transfusions (OR = 2.4; P = 0.035), and resections including segment I (OR = 1.9; P = 0.033) or segment V (OR = 1.8; P = 0.024) were independently associated with an increased risk of bile leak. CONCLUSIONS: The proposed definition of biliary fistula provides effective recognition of those that are clinically relevant with a reduction of the risk of unrecognized collections and minimal postoperative morbidity. REGISTRATION NUMBER: NCT02056028 ( http://www.clinicaltrials.gov ).

Surgical treatment of synchronous colorectal liver and lung metastases: the usefulness of thoracophrenolaparotomy for single stage resection.

When suitable, surgery still remains the therapeutic option to be preferred for patients carrier of colorectal liver and lung metastases. Since thoracophrenolaparotomy should be helpful during liver resection for some of these patients, simultaneous removal of right lung metastases can be proposed through this approach. Eleven consecutive patients (median age of 53 years) carrier of colorectal liver and lung metastases, underwent single session surgical resection of both liver and right lung lesions by means of J-shaped thoracophrenolaparotomy. The median number of liver metastases removed was 5 (range 2-30) and of lung metastases removed was 2 (range 1-3). Lung metastases were located in the upper lobe in 1 patient, in the middle lobe in 2, in the lower lobe in 6, and in the upper and lower lobe in 2. Mortality and major morbidity were nil. Two patients had a minor morbidity: one had wound infection and bile leakage treated conservatively and the other had transient fever. Mean overall survival was 24.4 months. An aggressive surgical approach should be undertaken for colorectal metastases: in case of multifocal liver disease with complex presentations, J-shaped thoracophrenolaparotomy could be considered as safe approach for combined liver and right lung metastasectomies.

Conservative hepatectomy for tumors involving the middle hepatic vein and segment 1: the liver tunnel.

BACKGROUND: For lesions invading the middle hepatic vein (MHV) at caval confluence (CC) the mini-mesohepatectomy(MMH) was proposed.1 If the lesion is extended to the paracaval portion of segment 1(S1) in contact or invading the MHV a new procedure is proposed. METHODS: Case-1: mass forming cholangiocarcinoma (MFCCC) 4cm in size invading the MHV and in contact with right (RHV) and left hepatic vein (LHV) at the CC. In Case-2, two colorectal liver metastases (CLM) both 2cm in size occupied S1 (T1) and S8 (T2): T1 was located between RHV and the inferior vena cava (IVC), T2 was in contact with MHV at CC. According to tumor-vessel intraoperative-ultrasound classification2 and color-flow analysis3 parenchyma-sparing procedure was performed. RESULTS: In Case-1 a communicating vein (CV) between RHV and MHV was detected at color-flow-IOUS. Contacts between MFCCC with RHV and LHV were confirmed at IOUS as detachable. In Case-2 contact between T1 with MHV was confirmed at IOUS as detachable. Liver-tunnel with IVC and main portal vein bifurcation exposure was performed resecting the MHV in Case-1 and preserving it in Case-2. Both patients had ad an uneventful postoperative course and were discharged on the 8th postoperative day. CONCLUSION: For tumors involving S1, S4s and/or S8 and infiltrating or in contact with the MHV at the CC, can be removed in a conservative manner by means of the herein described ''Liver Tunnel'' approach. The latter introduces a further step in favour of parenchyma-sparing policy for centrally located lesions with complex tumor-vessel relationship.

Radical but conservative liver resection for large centrally located hepatocellular carcinoma: the mini upper-transversal hepatectomy.

BACKGROUND: In patients with hepatocellular carcinoma (HCC) in a diseased liver, surgery should be offered in a parenchyma-sparing fashion. This approach seems unfeasible for large and deeply located lesions. Ultrasound study of the tumor-vessel relationship and hepatic inflow and outflow opens new technical solutions: herein is described a new operation based on this approach.1 (-) 3 METHODS: A 69-year-old man with a large centrally located HCC (Barcelona Clinic Liver Cancer stage C) underwent surgery. The HCC was located in segments 7, 8, and part of 5, extensively compressing and dislodging the anterior (P5-8) and posterior (P6-7) Glissonean pedicles at their origin. The lesion involved the right hepatic vein (RHV) and was in contact with the middle hepatic vein at the caval confluence. An inferior RHV (IRHV) was preoperatively evident. RESULTS: After a J-shaped thoracophrenolaparotomy, the liver exploration with the aid of intraoperative ultrasound confirmed the tumoral contact without vascular invasion with P5-8 and P6-7 and disclosed multiple communicating veins between the middle hepatic vein and RHV, warranting with the IRHV the segment 5-6 outflows. A resection of segments 7 and 8 with RHV resection, together with complete tumor detachment from P5-8 and P6-7, was performed. The specimen was removed combining the crush-clamping method for the parenchyma division and a peeling-off technique by means of blunt scissor dissection for the tumor vessel detachment. The postoperative course was uneventful. The patient was alive without recurrence at 12 months after surgery. CONCLUSIONS: This video is the first live demonstration of the previously reported radical but conservative policy, adding to the latter the technical solutions provided by detection of accessory veins such as the IRHV and communicating veins.1 (-) 4.

State of the art of trauma teams in Italy: A nationwide study.

Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy.

Anatomical resection of segment 8 by means of ultrasound-guided vessel compression.

BACKGROUND: Anatomical resection is the gold standard for liver resection in patients with hepatocellular carcinoma (HCC). Bimanual hepatic vessel compression has been already described, although segmental and subsegmental resection of segment 8 (S8) remain challenging by this technique. We demonstrate how to obtain a S8 demarcation by means of ultrasound-guided vessel compression. METHODS: Two patients with HCC with hepatitis C virus-related cirrhosis partially or fully located in S8 without portal thrombosis underwent liver resection. In the first patient with a HCC fed by subsegmental glissonian pedicles to S4 superior (P4sup) and S8 ventral (P8v), the resection area was disclosed by direct compression of the aforementioned feeding pedicles. A second patient had a HCC located in S8 ventral with a satellite in S8 dorsal; the patient had a pedicle to the right anterior sector originating from the left portal vein. The resection area was obtained by means of direct compression of the P8d and countercompression of the left portal vein (peripherally to the origin of the pedicle to the anterior sector), and P5. Countercompression was needed because of the peculiar trajectory of P8v passing across the middle hepatic vein. RESULTS: In neither case was there a congested area. In the first patient, hepatic veins were not exposed because it was a resection conducted in a subsegmental fashion. There was no morbidity, and no blood transfusions were needed. Patients were both discharged on day 8 after surgery. CONCLUSIONS: Disclosure of subsegmental portions of S8 by means of intraoperative ultrasound-guided compression technique is feasible and confirms the reliability of this approach.

Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection: a further step in favor of the "radical but conservative" policy.

OBJECTIVE: We retrospectively compared the short-term outcome of a consecutive cohort of patients who underwent hepatectomy with intermittent clamping ranging between 60 and 120 minutes with those having a clamping time exceeding 120 minutes. BACKGROUND: Intermittent Pringle maneuver is widely used to minimize blood loss during hepatectomy, without an established time limit. However, many authors claim it is dangerous for patient outcome. MATERIAL AND METHODS: Among 426 consecutive patients who underwent hepatectomy, we retrospectively selected 189 whose intermittent clamping time exceeded 60 minutes: 117 of these had intermittent Pringle maneuver lasting less than 120 minutes (group 1) and 72 clamping time exceeded 120 minutes (group 2). Groups were homogeneous for demographics, preoperative laboratory tests, background liver, and type of tumors. RESULTS: Operation length, and number of lesions removed, was significantly higher in group 2. Conversely, the two groups experienced similar amount of blood loss, rate of blood transfusions, overall and major morbidity, and 30- and 90-day postoperative mortality. In particular, in group 2 there was no mortality at all. Mean serum total bilirubin and alanine aminotransferase level on seventh pod resulted significantly higher in group 2, conversely mean aspartate aminotransferase, cholinesterases, and prothrombin time not differed in 2 groups. CONCLUSIONS: This study shows that hepatectomies done with intermittent clamping exceeding 120 minutes are as safe as those performed with shorter one despite more complex tumor presentations. This seems encouraging the diffusion of procedures done in 1 stage for extensive liver diseases despite the prolonged clamping time.