1,721,176 research outputs found
Minimally invasive liver surgery in a hepato-biliary unit: learning curve and indications
No full textOperative indications and type of resection represent a crucial issue of minimally invasive liver surgery (MILS), and they should not be modified by the increased experience of laparoscopic liver surgeons. The aim of this study was to define the indications for MILS and the learning curve in a high-volume hepatobiliary surgery Unit. Between 2009 and 2014, 993 liver resections were performed in our unit, and MILS was performed in 81 of these (8.2 %). The proportion of MILS significantly increased over the study period of time and was significantly higher during the last 2 years than during the first 2 years (10.8 vs. 6.4 %; p = 0.042). Rate of liver resections for benign disease between the first 2 years and the last 2 years of the study period was not significantly different (14.7 vs. 10.5 %; p = 0.098). Rate of MILS for malignant disease significantly increased from the first 2 years to the last 2 years: 3.2 vs. 7.5 % (p < 0.001). Indication for left lateral sectionectomy in the whole series was rare. It was performed in 37 cases as the only liver surgical procedure, on 993 liver resections (3.7 %). In 25 (67.6 %) of these, a minimally invasive approach was used. Rate of left lateral sectionectomies between the first 2 years and the last 2 years of the study period was not significantly different: 4.5 vs. 3.8 % (p = 0.645). This study shows that the proportion of MILS significantly increased over the study period of time in our high-volume hepatobiliary surgery Unit without changing surgical indications for benign disease and type of resections
Indications for Surgery in Cirrhotic Patients
Full text linkLiver resection (LR) still remains one of the main curative options for hepatocellular carcinoma (HCC). When HCC is diagnosed in the cirrhotic liver, the indication for LR should be carefully established. The assessment of such patients should not consider only tumor burden, but must also necessarily include an accurate evaluation of the preoperative liver function to reduce the risk of the most feared complication following LR, that is, post-hepatectomy liver failure (PHLF). PHLF represents the most important cause of postoperative 90-day mortality and is the most commonly used measure to assess the early postoperative outcome. The evaluation of liver function includes assessment of functional reserve of the cirrhotic liver, presence of portal hypertension, extent of LR, volume of functional remnant liver (FRLV), patient performance status and comorbidities. Furthermore, LR should be carefully evaluated against liver transplantation, when this can be a chance of cure, and other potentially curative therapies such as ablation
The impact of intraoperative ultrasonography on the management of disappearing colorectal liver metastases
No full textHepatic resection for colorectal liver metastases (CRLM) is currently the only treatment option that can offer a chance of long-term survival, with 5-year survival rates of 40% [1–3], and exceeding 50% in selected patients [4–6]. However, resectability is the limiting factor; indeed, only 10–25% of patients with CRLM are candidates for surgical resection at the time of presentation [7].
More recently, the introduction of new and more effective chemotherapy regimens combined with targeted agents have improved the response rate over that of standard chemotherapy alone, from 30 to 60% [8–10]. For this reason preoperative chemotherapy for CRLM has been widely used and an increasing number of patients receive chemotherapy prior to liver resection, either as neoadjuvant strategy for initially resectable CRLM [11], or as conversion chemotherapy in patients with initially unresectable CRLM in attempt to convert them into surgical candidates [12,13].
The extensive use of chemotherapy may cause the shrinkage of CRLM and sometimes makes such lesions impossible to identify in radiological imaging studies. These lesions are called ‘missing’ or ‘disappearing’ CRLM [14]. Disappearing liver metastases (DLM) are defined as a disappearance of liver metastases on cross-sectional imaging after administration of preoperative chemotherapy, which means a complete radiological response or complete clinical response (CCR). This phenomenon has been reported by several centers and can occur in 5–25% of patients who undergo preoperative systemic chemotherapy [15–21]. Patients with multiple CRLM, with size <1 cm and those undergoing prolonged preoperative chemotherapy, presented significantly higher risk of developing DLM [18]. Different reported rates of DLM may depend on the quality and type of cross-sectional imaging [22]. Indeed preoperative chemotherapy can induce parenchymal changes to the liver by increasing fatty content, defined as steatosis or steatohepatitis. In that setting the background liver appears less dense, with lower contrast between the parenchyma and the hypovascular metastases, hindering their detection [14,22]. Compared with computed tomography (CT), magnetic resonance imaging (MRI) with liver-specific contrast agents, presents higher sensitivity and better specificity to detect and differentiate CRLM, and can be considered as the best modality to image CRLM missing on CT scan, especially in case of chemotherapy-induced steatosis or steatohepatitis [14,22,23]
ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases
No full textN
Liver resections for hilar cholangiocarcinoma
No full textHilar cholangiocarcinoma (HC) is a rare tumor which has to be distinguished by intrahepatic cholagiocarcinoma invading hepatic hilum because the former has better prognosis then the latter. Patients with HC are difficult to manage because many challenging issues remain in the treatment of this tumour regarding correct diagnosis and therapeutic strategy. HC is resectable in about 30% of cases, but operative risk is highly influenced by septic complications of preoperative biliary drainage and by the need of major liver resection associated with biliary resection. We report the results of 43 resected patients (28 M/15 F; mean age 60 years, range 33-78), accounting for 29% of 149 patients with HC. Symptomless jaundice was the most common clinical presentation (87%; 130 patients). Biliary stricture was classified according to the Bismuth-Corlette classification as type 1 in 3 patients (7%); type 2 in 12 patients (28%); type 3 in 28 patients (65%). Ten patients underwent preoperative right portal vein embolization. Main biliary confluence excision associated with major hepatectomy was performed in 40 patients (93%), with R0 resection rate by 77%. Postoperative mortality rate was 6.9% (3 patients). Morbidity rate was 52.5% (21 patients), being biliary fistula (38%) and liver failure (19%) the most frequent complications. Five-year overall and disease-free survival rate were 36.1% and 28.2, respectively.
Surgical resection remains the only chance of cure for patients with HC. However, due to the complexity of surgery immediate results remain unsatisfactory with morbidity and mortality rates higher than those reported after liver resection for other malignancies. This is mainly related to septic complications, strictly linked to complications of preoperative biliary drainage. Selective biliary drainage, careful management of biliary drains, drainage of excluded ducts in case of cholangitis, bile culture guided antibiotic use and preoperative portal vein embolizationln are important factors to reduce the risk of cholangitis and of postoperative complications. Because of the significant perioperative risk, the demanding operative management and the rarity of this tumor, patients with HC should be referred to tertiary surgical centers
Primary hepatic leiomyosarcoma in a young male after Hodgkin s disease: diagnostic pitfalls and therapeutic challenge
No full textBackground. Primary leiomyosarcoma of the liver is a rare tumor whose development patterns are unsatisfactorily known.
Patient case. A 26-year-old male patient with a previous history of radiochemotherapy treatment for Hodgkin's lymphoma was referred to our unit with a histological and radiological diagnosis of primary hepatic leiomyosarcoma. Six months before referral, in a workup for hypertension, a CT scan of the abdomen had shown a 2.5-cm lesion in liver segment VII, which was interpreted as an angioma. Shortly before referral the lesion had grown to 7.8 cm associated with two smaller lesions in segments VIII and 111, and a diagnosis of hepatic leiomyosarcoma was made at biopsy. After referral he underwent a right hepatectomy with wedge resection of segment III. This was followed by rapid progression of the disease, in spite of transient stabilization under gemcitabine treatment. Octreotide was also administered after the detection of elevated chromogranin A in serum. The patient died 25 months after liver resection.
Conclusions. The challenges and peculiarities of this case are related to the rarity of the tumor, its accidental discovery without immediate suspicion of its nature, its very aggressive behavior that was only partly controlled by chemotherapy, and the unusual expression of a neuroendocrine phenotypic feature with high serum chromogranin A levels
Graphical display of Model for End-stage Liver Disease (MELD) score (Letter)
No full textNo abstract - Letter with 2 multidimensional figure
Hanging maneuver in right hepatectomy for recurrent metastases with diaphragmatic infiltration after radiofrequency ablation: a new indication
No full textThe liver hanging maneuver is a safe technique to prevent bleeding during transection when a right hepatectomy by an anterior approach, without previous mobilization of the liver, is required. This article proposes a new indication for this technique. The liver hanging maneuver may be useful during right hepatectomy for local recurrence of liver metastases previously treated by radiofrequency ablation (RFA). In these cases, necrosis or fibrosis induced by RFA and local recurrence may cause strong adhesions between liver parenchyma and the diaphragm, thus increasing the risk of bleeding during liver mobilization. Between January 2003 and March 2006, seven patients with recurrent colorectal liver metastases of the right hemiliver, after previous treatment by RFA, underwent right hepatectomy. Liver resection was feasible with the proposed technique in all patients. In four cases, a limited diaphragmatic resection was associated. There was no mortality. Postoperative morbidity was 42.8 per cent. An anterior approach with the liver hanging maneuver for recurrent liver metastases after RFA should be recommended when the metastases are located posteriorly, are not detachable from the diaphragm, and the preliminary mobilization of the right liver may be difficult
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