Disease-Free Interval and Tumor Stage Complementarily Predict the Biological Behavior of Recurrent Hepatocellular Carcinoma.

BACKGROUND: Currently used treatment algorithms were originally established based on the clinical outcomes of the initial treatment for primary hepatocellular carcinoma (HCC), and no strong evidence exists yet to suggest if these algorithms could also be applicable to patients with recurrent HCC after surgery. As such, this study sought to explore an optimal risk stratification method for cases of recurrent HCC for better clinical management. METHODS: Among the 1616 patients who underwent curative resection for HCC, the clinical features and survival outcomes of 983 patients who developed recurrence were examined in detail. RESULTS: Multivariate analysis confirmed that both the disease-free interval (DFI) from the previous surgery and tumor stage at recurrence were significant prognostic factors. However, the prognostic impact of DFI seemed different according to the tumor stages at recurrence. While curative-intent treatment showed strong influence on survival [hazard ratio (HR), 0.61; P < 0.001] regardless of the DFI in patients with stage 0 or stage A disease at recurrence, early recurrence (< 6 months) was a poor prognostic marker in patients with stage B disease. The prognosis of patients with stage C disease was exclusively influenced by the tumor distribution or choice of treatment than by the DFI. CONCLUSIONS: The DFI complementarily predicts the oncological behavior of recurrent HCC, with its predictive value differing depending on the tumor stage at recurrence. These factors should be considered for selection of the optimal treatment in patients with recurrent HCC after curative-intent surgery.

The Impact of Lenvatinib on Tumor Blood Vessel Shrinkage of Hepatocellular Carcinoma during Treatment: An Imaging-Based Analysis.

INTRODUCTION: When lenvatinib is administered to people with hepatocellular carcinoma (HCC), tumor blood flow is reduced due to the inhibition of the vascular endothelial growth factor receptor (VEGFR) and fibroblast growth factor receptor (FGFR). Few studies have examined the decrease in tumor blood flow with respect to changes in tumor blood vessels (TBVs) in clinical practice. We investigated the mechanism of tumor blood flow control by investigating changes in the diameter of relatively large TBVs in large-sized lesions with high blood flow. METHODS: From January 2011 to October 2021, patients receiving lenvatinib for unresectable intrahepatic HCC at Toranomon Hospital, Tokyo, Japan, were considered for inclusion. We investigated the TBV diameter in the arterial phase of dynamic computed tomography before treatment and its change over time (2-12 weeks after lenvatinib initiation). The relationship between changes in TBV diameter and prognosis was also examined. RESULTS: Of 114 patients treated with lenvatinib for HCC, 26 patients who had intrahepatic lesions with a tumor diameter of 30 mm or more enrolled in the study. The median tumor and TBV diameters before treatment were 58 mm and 2.55 mm, respectively. Twenty-five patients (96%) had a shrinkage in TBV diameter 2-12 weeks after lenvatinib administration. The maximum TBV diameter shrinkage of 20% or more was observed in 19 patients (73%), and progression-free survival was prolonged in these patients compared to the group with less than 20% TBV diameter shrinkage (p = 0.039). DISCUSSION/CONCLUSION: Due to the antiangiogenic effect of lenvatinib, a shrinkage in the TBV diameter of HCC was observed. The shrinkage of TBV may be regarded as a process of normalization of TBVs. The shrinkage of TBVs in imaging analysis may be associated with improved prognosis; however, additional studies are still required.

Risk Stratification of Patients with Marginal Hepatic Functional Reserve Using the Remnant Hepatocyte Uptake Index in Gadoxetic Acid-Enhanced Magnetic Resonance Imaging for Safe Liver Surgery.

BACKGROUND: This study aimed to explore the efficacy of gadoxetic acid-enhanced (Gd-EOB) magnetic resonance imaging (MRI) in surgical risk estimation among patients with marginal hepatic function estimated by indocyanine green (ICG) clearance test. METHODS: This analysis focused on 120 patients with marginal hepatic functional reserve (ICG clearance rate of future liver remnant [ICG-Krem] < 0.10). Preoperative Gd-EOB MRI was retrospectively reviewed, and the remnant hepatocyte uptake index (rHUI) was calculated for quantitative measurement of liver function. The predictive power of rHUI for posthepatectomy liver failure was compared with several clinical measures used in current risk estimation before hepatectomy. RESULTS: Receiver operating curve analysis showed that rHUI had the best predictive power for posthepatectomy liver failure among the tested variables (ICG-R15, ICG-Krem, albumin + bilirubin score, and albumin + ICG-R15 score). Cross-validation showed that a threshold of 925 could be the best cut-off value for estimating the postoperative risk of liver failure with sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.689, 0.884, 5.94, and 0.352, respectively. CONCLUSION: rHUI could be a sensitive substitute measure for posthepatectomy liver failure risk estimation among patients with marginal hepatic functional reserve.

A preoperative risk score based on multifrequency bioelectrical impedance analysis in patients undergoing liver resection.

PURPOSE: To investigate if body composition parameters measured by bioelectrical impedance analysis (BIA) and are reportedly correlated with clinical outcomes of patients undergoing digestive tract surgery could be useful for reliably evaluating the perioperative risk in patients undergoing hepatectomy. METHODS: Consecutive 200 patients who underwent BIA before hepatectomy were retrospectively reviewed. A risk prediction model for postoperative morbidity was created using the initial 100 patients, and its performance was validated using the remaining 100 patients. RESULTS: Based on the correlation with postoperative morbidity, a novel risk prediction model, the protein-edema score, was created using net protein weight and extracellular water/total body water ratio measured through BIA. The protein-edema score (score 0 vs. ≥ 1) showed a reproducible correlation with Clavien-Dindo 2 or greater postoperative morbidity in the validation set (17.7% vs. 46.4%, P = 0.002) as observed in the training set (18.8% vs. 49.0%, P = 0.002) after statistical adjustment. Similar tendency was also confirmed in Clavien-Dindo 3a or greater postoperative morbidity (5.9% vs. 18.2%, P = 0.037) and postoperative refractory ascites (5.5% vs. 17.4%, P = 0.037) in the validation set. CONCLUSIONS: The protein-edema score created based on BIA is significantly correlated with postoperative morbidity in patients undergoing liver resection.

Subserosal vascular density predicts oncological features of T2 gallbladder cancer.

PURPOSE: Tumor sidedness (hepatic side vs. peritoneal side) reportedly predicts microvascular invasion and survival outcomes of T2 gallbladder cancer, although the actual histopathological mechanism is not fully understood. METHODS: The clinical relevance of tumor sidedness was revisited in 84 patients with gallbladder cancer using histopathological analysis of the vascular density of the gallbladder wall. RESULTS: Hepatic-side tumor location was associated with overall survival (OS) (hazard ratio [HR], 13.62; 95% confidence interval [CI], 2.09-88.93) and recurrence-free survival (RFS) (HR, 8.70; 95% CI, 1.36-55.69) in T2 tumors. The Adjusted Kaplan-Meier curve indicated a clear survival difference between T2a (peritoneal side) and T2b (hepatic side) tumors (P = 0.006). A review of 56 pathological specimens with gallbladder cancer and 20 control specimens demonstrated that subserosal vascular density was significantly higher on the hepatic side of the gallbladder, regardless of the presence of cancer (P < 0.001). Multivariate analysis also confirmed that higher subserosal vascular density was significantly associated with poor OS (HR, 1.73; 95% CI, 1.10-2.73 per 10 microscopic fields) and poor RFS (HR, 1.62; 95% CI, 1.06-2.49) in T2  gallbladder cancer. CONCLUSION: Higher subserosal vascular density may account for the higher incidence of cancer spread and the poor prognosis of T2b gallbladder cancer.

Efficacy and safety of postoperative preemptive use of tolvaptan for patients with cirrhosis undergoing hepatectomy for hepatocellular carcinoma.

PURPOSE: Optimal choice of diuretics in perioperative management remains unclear in enhanced recovery after liver surgery. This study investigated the efficacy and safety of tolvaptan (oral vasopressin V2-receptor antagonist) in postoperative management of patients with liver injury and hepatocellular carcinoma. METHODS: The patients clinically diagnosed with liver cirrhosis were included in this study. Clinical outcomes of 51 prospective cohort managed with a modified postoperative protocol using tolvaptan (validation group) were compared with 83 patients treated with a conventional management protocol (control group). RESULTS: Postoperative urine output were significantly larger and excessive body weight increase were reduced with no impairment in renal function or serum sodium levels in the validation group. Although the total amount of discharge and trend of serum albumin level were not significantly different among the groups, global incidence of postoperative morbidity was less frequent (19.6% vs. 44.6%, P=0.005) and postoperative stay was significantly shorter (8 days vs.10 days, P=0.008) in the validation group compared with the control group. CONCLUSIONS: Tolvaptan could be safely used for the patients with injured liver in postoperative management after hepatectomy and potentially advantageous in the era of enhanced recovery after surgery with its strong diuretic effect and better fluid management.

Pretreatment Positron Emission Tomography with 18F-Fluorodeoxyglucose May Be a Useful New Predictor of Early Progressive Disease following Atezolizumab plus Bevacizumab in Patients with Unresectable Hepatocellular Carcinoma.

BACKGROUND AND AIMS: The aim of this study was to identify the utility of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) as a predictor of early progressive disease (e-PD) in patients with hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab (Atezo/Bev). METHODS: Twenty consecutive patients with measurable intrahepatic target nodules who received Atezo/Bev treatment were reviewed. The oncological aggressiveness of tumors estimated by 18F-FDG-PET/CT was analyzed using the rate of e-PD within 12 weeks and early progression-free survival (e-PFS) and overall survival (OS). Multivariate analysis was used to identify potential confounders for PD during Atezo/Bev therapy. RESULTS: Using the Response Evaluation Criteria in Solid Tumors version 1.1, a tumor-to-normal liver ratio (TLR) ≥2, indicating higher oncological aggressiveness in HCCs, was associated with lower objective response rates compared with TLR values <2 (18% vs. 33%, respectively). Moreover, TLR values ≥2 were significantly associated with higher e-PD rates compared with TLR values <2 (64% vs. 11%, respectively) and worse e-PFS (p = 0.021). In multivariate analysis, TLR ≥2 showed marginal significance as a predictor of e-PD (p = 0.053), and utility as a predictor for worse e-PFS (hazard ratio, 7.153; 95% confidence interval, 1.258-40.689; p = 0.027). In contrast, no significant differences in OS with/without e-PD were observed during the treatment course. In this study, 8 patients experienced e-PD and almost 40% of patients experienced acceptable disease control following subsequent lenvatinib treatment. CONCLUSION: Pretreatment 18F-FDG-PET/CT may be a useful new predictor of e-PD and may enable early decision-making based on early treatment changes following Atezo/Bev treatment of HCC.

A randomized controlled trial of surgery and postoperative modified FOLFOX6 versus surgery and perioperative modified FOLFOX6 plus cetuximab in patients with KRAS wild-type resectable colorectal liver metastases: EXPERT study.

PURPOSE: To clarify the efficacy of perioperative chemotherapy for the patients with resectable colorectal liver metastases (CLM), we conducted a multicenter randomized phase III trial to compare surgery followed by postoperative FOLFOX regimen with perioperative FOLFOX regimen plus cetuximab in patients with KRAS wild-type resectable CLM. METHODS: Patients who had KRAS wild-type resectable CLM having one to eight liver nodules without extrahepatic disease were randomly assigned to the postoperative chemotherapy group, wherein up-front hepatectomy was performed followed by 12 cycles of postoperative modified FOLFOX6, and the perioperative chemotherapy group (experimental), wherein six cycles of preoperative modified FOLFOX6 plus cetuximab were performed followed by hepatectomy and six cycles of postoperative modified FOLFOX6 plus cetuximab. The primary endpoint was progression-free survival (PFS). RESULTS: There were 37 patients in postoperative chemotherapy group and 40 patients in the perioperative chemotherapy group who were analyzed. Baseline characteristics were well-balanced between groups. The PFS and overall survival (OS) showed no significant difference (PFS, hazard ratio 1.18 [95% confidence interval 0.69-2.01], P = 0.539: OS, 1.03 [0.46-2.29], P = 0.950). In the postoperative chemotherapy group, 35.1% had a 3-year PFS, and 86.5% had a 3-year OS. Meanwhile, in the perioperative chemotherapy group, 30.0% had a 3-year PFS, and 74.4% had a 3-year OS. CONCLUSION: There was no difference in survival found between the group of the perioperative chemotherapy plus cetuximab and that of the postoperative chemotherapy in the cohort of our study. The study was registered in the University Hospital Medical Information Network (UMIN000007787).

Accuracy of Modern Clinical Risk Score Including RAS Status Changes Based on Whether Patients Received Perioperative Chemotherapy for Colorectal Liver Metastases.

BACKGROUND: A modified Fong clinical score (m-Fong CS) that includes the RAS mutation status has recently been proposed and offered an improved survival stratification of patients who undergo surgery and systemic chemotherapy for colorectal liver metastases (CLM). The aim of this study is to assess whether a CS that includes RAS status is influenced by whether patients receive perioperative chemotherapy. METHODS: We created a new CS using multivariate analysis of data of patients who underwent hepatectomy for CLM for the first time between 2010 and 2016 at a single hospital (n = 341, 79% received perioperative chemotherapy). The resulting CS and m-Fong CS were then validated in the patient cohort at three other hospitals (n = 309). Furthermore, the applicability of the two CS in the total cohort (n = 650) was tested according to whether the patients received perioperative chemotherapy. RESULTS: The new CS comprised mutant RAS status, ≥4 CLMs, and a CA19-9 level ≥100 U/mL (1 point per factor). Both the new CS and m-Fong CS failed to stratify the survival of the 309 patients in the validation cohort, including those who did not receive perioperative chemotherapy (29%). Both of the CS accurately stratified the survival of patients who underwent perioperative chemotherapy but not of those who underwent surgery alone. CONCLUSION: A CS that includes the RAS mutation status can stratify the survival of patients who undergo hepatectomy combined with perioperative chemotherapy, but it has limited value for patients who undergo surgery alone.

Identification of liver lesions using fluorescence imaging: comparison of methods for administering indocyanine green.

BACKGROUND: Fluorescence imaging using indocyanine green (ICG) enables intraoperatively visualizing liver tumors as fluorescent. This study evaluated the doses and timing of ICG administration for visualizing tumors via fluorescence using near-infrared light camera systems. METHODS: Consecutive patients who underwent open liver resection for liver tumors from 2016 to 2017 were included. ICG was intravenously injected one-day before surgery at 0.25 mg-intravenous injection (IV), 1.25 mg-IV, 2.5 mg-IV, or 3.75 mg-IV. No additional ICG was administered when patients underwent ICG (0.5 mg/kg) retention test within 10 preoperative days. The ability of fluorescence imaging to enable identifying liver tumors was compared using the PDE-NEO and PINPOINT. RESULTS: 154 lesions in 82 patients were assessed. The tumor identification rate of PDE-NEO did not differ significantly among dosages. The positive predictive values of PDE-NEO were significantly lower at 3.75 mg-IV (69.0%) than in the control group (92.0%) (p = 0.036) and at 1.25 mg-IV (88.9%) (p = 0.033). The tumor identification rate of PINPOINT was significantly higher at 3.75 mg-IV (82.4%) than at 1.25 mg-IV (60.0%) (p = 0.035). The positive predictive values of PINPOINT did not significantly differ among dosages. CONCLUSION: Administering 2.5 mg of ICG one-day before surgery can enable identifying tumors via fluorescence imaging when the ICG test was not performed within 10 preoperative days.

[Clinical Significance of Total Pancreatectomy for Multiple Pancreatic Metastases from Renal Cancer].

With the progress of replacement therapy for pancreatic endocrine and exocrine functions, the indications for a total pancreatectomy are expanding, and reports of multiple pancreatic metastases of renal cancer are on the rise. In the present, we investigated the utility of a total pancreatectomy for multiple pancreatic metastases of renal cancer. The subjects were 8 patients who underwent a total pancreatectomy for multiple pancreatic metastases of renal cancer between 2012 and 2021. The median, postoperative observation period was 31(3-92)months. Six of 8 patients survived without cancer, and one survived with chemotherapy(pazopanib plus axitinib)plus radiation therapy(maintaining stable disease). The one, remaining patient died of hypoglycemia. Of the 8 patients, 4 survived for 2 years or more, and 2 survived for more than 5 years. Postoperative, support for endocrine and exocrine functions is indispensable, but a total pancreatectomy for multiple pancreatic metastases of renal cancer promises to be a viable treatment option owing to its favorable long-term prognosis.

[Multidisciplinary Treatment Aids Long-Term Stage â £ Pancreatic Cancer Survival-A Case Report].

A 56-year-old man presented at a local hospital with nausea, vomiting, epigastric pain, and white stool. CT scan showed hypovascular mass in pancreatic uncinate process and multiple peritoneal nodules. The diagnosis was stage Ⅳ pancreatic cancer(unresectable), and the patient underwent chemotherapy with GEM plus nab-PTX. He also claimed a severe cancer pain at presentation and was prescribed oxycodone 60 mg/day. After 43 months of chemotherapy, the duodenum was obstructed by tumor growth on CT scan, then he underwent duodenal stent placement. He eventually needed a total of 3 duodenal stenting for re-obstruction. He could keep adequate oral intake after the treatment. He also suffered from severe pain by progressed tumor, then underwent celiac plexus block and palliative radiation therapy(20 Gy/5 Fr). Afterwards his cancer pain has been under control. He underwent chemotherapy with FOLFIRINOX for next step. A patient with stage Ⅳ pancreatic cancer may survive for a long period with adequate QOL as a result of multidisciplinary treatment.

[Successful Surgical Resection of Expansive-Growth Acinar Cell Carcinoma-A Case Report].

Here, we report a case of successful surgical resection of expansive-growth acinar cell carcinoma. A 59-year-old man was referred to a local hospital with abdominal distention. CT revealed a large abdominal tumor. Subsequently, he was referred to our hospital. Physical examination showed a large tumor on his left upper abdomen without tenderness. CT revealed an enhanced 18 cm-sized expansive-growth tumor on the left flank, suggesting a primary pancreatic tumor. EUS-FNA yielded a diagnosis of adenocarcinoma. Imaging findings were not typical for pancreatic ductal carcinoma. We performed distal pancreatectomy with splenectomy, transverse colon resection, and proximal gastrectomy. Pathological findings revealed a tumor, measuring 19.5×16.5×15.5 cm, originating from the pancreatic body, positive for trypsin, chymotrypsin, and elastase, consistent with a diagnosis of acinar cell carcinoma, pT3, N0, M0. Four courses of adjuvant chemotherapy with S-1 were provided, and the patient is currently alive without recurrence for 10 months.

[A Case of Pulmonary Metastasis from Hilar Cholangiocarcinoma Treated by Stereotactic Body Radiotherapy].

We report a case of pulmonary metastasis from hilar cholangiocarcinoma successfully treated by stereotactic body radiotherapy. The patient was a 70-year-old woman who underwent extended left hemi-hepatectomy with bile duct reconstruction for hilar cholangiocarcinoma at the age of 67. Pathological diagnosis indicated a well-differentiated adenocarcinoma. We followed up the patient without adjuvant chemotherapy. Nineteen months after the initial resection, a solitary pulmonary metastasis was detected in the right upper lobe. The patient received gemcitabine plus cisplatin(GC)therapy. After 4 courses of GC therapy, the size of the pulmonary metastasis was unchanged. Therefore, we performed a thoracoscopic wedge resection. Pathological diagnosis indicated that the pulmonary metastasis originated from the cholangiocarcinoma. Fifteen months after the pulmonary resection, another solitary pulmonary metastasis was detected in the left lower lobe. As the patient refused further chemotherapy, we performed stereotactic body radiotherapy(SBRT)(50 Gy/4 Fr). An adverse event of Grade 1 radiation pneumonitis was observed. The metastasis disappeared after SBRT. Twenty-eight months after SBRT and 70 months after the initial surgery, the patient is alive without recurrence.

Second nationwide surveillance of bacterial pathogens in patients with acute uncomplicated cystitis conducted by Japanese Surveillance Committee from 2015 to 2016: antimicrobial susceptibility of Escherichia coli, Klebsiella pneumoniae, and Staphylococcus saprophyticus.

The Japanese Surveillance Committee conducted a second nationwide surveillance of antimicrobial susceptibility patterns of uropathogens responsible for acute uncomplicated cystitis (AUC) in premenopausal patients aged 16-40 years old at 31 hospitals throughout Japan from March 2015 to February 2016. In this study, the susceptibility of causative bacteria (Escherichia coli, Klebsiella pneumoniae, Staphylococcus saprophyticus) for various antimicrobial agents was investigated by isolation and culturing of organisms obtained from urine samples. In total, 324 strains were isolated from 361 patients, including E. coli (n = 220, 67.9%), S. saprophyticus (n = 36, 11.1%), and K. pneumoniae (n = 7, 2.2%). The minimum inhibitory concentrations (MICs) of 20 antibacterial agents for these strains were determined according to the Clinical and Laboratory Standards Institute (CLSI) manual. At least 93% of the E. coli isolates showed susceptibility to fluoroquinolones and cephalosporins, whereas 100% of the S. saprophyticus isolates showed susceptibility to fluoroquinolones and aminoglycosides. The proportions of fluoroquinolone-resistant and extended-spectrum ß-lactamase (ESBL)-producing E. coli strains were 6.4% (13/220) and 4.1% (9/220), respectively. The antimicrobial susceptibility of K. pneumoniae was retained during the surveillance period, while no multidrug-resistant strains were identified. In summary, antimicrobial susceptibility results of our second nationwide surveillance did not differ significantly from those of the first surveillance. Especially the numbers of fluoroquinolone-resistant and ESBL-producing E. coli strains were not increased in premenopausal patients with AUC in Japan.

[A Case of Subphrenic Lymph Node Metastasis from Gastric Cancer in Which FDG-PET/CT Was Useful for Diagnosis].

A 70-year-old man was admitted for lymph node metastasis detected by FDG-PET/CT showing a mass 10mm in diameter. He had a history of a distal gastrectomy for advanced gastric cancer and was administered postoperative adjuvant chemotherapy consisting of 2 courses of TS-1 with CDDP and TS-1 only for 1 year. Lymph node recurrence was diagnosed and resected 4 years after the initial surgery. Histological examination revealed lymph node metastasis of the gastric cancer. He was administered adjuvant chemotherapy using TS-1 and has been followed-up without recurrences for 17 months after the second operation. We reported a case in which FDG-PET/CT was potentially beneficial for the diagnosis of the postoperative small lymph node metastasis.

Use of intercostal trocars for laparoscopic resection of subphrenic hepatic tumors.

BACKGROUND: The aim of this study was to demonstrate the detailed surgical techniques of laparoscopic hepatectomy using intercostal transthoracic trocars for subcapsular tumors located in segment VII or VIII. METHODS: Intercostal transthoracic trocars were used in patients undergoing laparoscopic hepatectomy for tumors located in segment VII or VIII. Following establishment of pneumoperitoneum and placement of abdominal trocars, balloon-tipped trocars were inserted into the abdominal cavity from the intercostal space and through the pleural space and diaphragm. Upon placement of the intercostal trocars, the lung edge was confirmed by ultrasonography and laparoscopic examination. Following minimal mobilization of the right liver, hemispherical wedge resection of segment VII or VIII was performed using the intercostal trocars as a camera port or for the forceps of the surgeon's left hand. After the hepatectomy, the holes in the diaphragm were sutured closed. RESULTS: Among the 79 patients who underwent laparoscopic hepatectomy, intercostal trocars were used in 14 patients for resection of tumors located in segment VII (4 nodules) or VIII (10 nodules). The median (range) operation time and amount of blood loss for hepatectomy were 225 (109-477) min and 60 (20-310) mL, respectively. No postoperative complications associated with hepatectomy or the use of intercostal trocars occurred. CONCLUSIONS: Use of intercostal transthoracic trocars is safe and effective not only for complicated laparoscopic hepatectomy but also for hemispherical wedge resections of subcapsular hepatic tumors located in segment VII or VIII.

Parenchymal-Sparing Hepatectomy Does Not Increase Intrahepatic Recurrence in Patients with Advanced Colorectal Liver Metastases.

BACKGROUND: Prophylactic impact of major hepatectomy (MH) on liver recurrence has yet to be clarified in patients with advanced colorectal liver metastases (CLMs). METHODS: In our institute, parenchymal-sparing hepatectomy (PSH) is a standard procedure for CLMs consistently throughout initial and repeat resection, and MH is selected only in cases in which CLMs are close to major Glisson's pedicles. We reviewed 145 patients who underwent curative hepatectomy for advanced CLMs (≥4 nodules and ≤50 mm in size) from 1999 to 2012. Surgical outcomes and survival were compared between patients who underwent PSH and MH. RESULTS: PSH was performed in 113 patients (77.9 %) and MH in 32 (22.1 %) patients with advanced CLMs. Tumor characteristics and short-term outcomes did not differ between the 2 groups. Incidence of positive tumor margin (8.8 % in PSH vs 9.4 % in MH; p = .927) and rates of liver-only recurrence (43.4 % in PSH and 50.0 % in MH; p = .505) did not differ. No significant differences were found in 5-year overall survival (37.0 % in PSH vs 29.4 % in MH, p = .473), recurrence-free survival (7.6 vs 6.8 %, p = .597), and liver recurrence-free survival (21.0 vs 21.3 %, p = .691). A total of 65 patients had liver-only recurrence, for which repeat hepatectomy was performed in 81.5 % (53 of 65) following our parenchymal-sparing approach. CONCLUSIONS: In patients with advanced CLM, PSH does not increase positive surgical margin or liver recurrence in comparison with MH. A parenchymal-sparing approach offers a high rate of repeat resection for liver recurrence (salvageability).

High Rate of Organ/Space Surgical Site Infection After Hepatectomy with Preexisting Bilioenteric Anastomosis.

BACKGROUND: The clinical course of hepatectomy in patients with preexisting bilioenteric anastomosis (BEA) is poorly understood. The aim of this study was to evaluate the potential influence of preexisting BEA on organ/space surgical site infection (SSI) after hepatectomy. METHODS: We analyzed consecutive hepatectomies performed between March 2005 and January 2015. Patients' background, operative results, and complications were compared between hepatectomies with and without preexisting BEA. RESULTS: Twenty-two hepatectomies with preexisting BEA were identified among 1745 hepatectomies. The rate of organ/space SSI was much higher in hepatectomies with preexisting BEA than in those without preexisting BEA (40.9 vs. 6.4 %, P < 0.001). Multivariate analyses identified four variables as independent factors associated with organ/space SSI: liver-directed chemotherapy [odds ratio 5.06 (95 % confidence interval 2.29-10.54), P < 0.001], operative time ≥ 300 min [2.40 (1.30-4.54), P = 0.006], estimated blood loss ≥ 500 ml [2.34 (1.26-4.31), P < 0.001], and preexisting BEA [12.08 (4.54-31.32), P < 0.001]. A higher rate of organisms from intestinal flora was detected in organ/space SSI after hepatectomies with preexisting BEA (77.8 vs. 21.3 % without BEA, P = 0.002). Analysis of hepatectomies with preexisting BEA identified selection of antibiotics for prophylaxis as the sole risk factor for organ/space SSI (P = 0.049 for cefazolin versus other antibiotics targeting intestinal flora). CONCLUSIONS: Preexisting BEA is an independent risk factor for the development of organ/space SSI after hepatectomy. Antibiotics targeting intestinal flora are strongly recommended for prophylaxis of infectious complications.