Risk factors for postoperative bile leakage:a retrospective single-center analysis of 411 hepatectomies

BACKGROUND： The primary focus of the study was to ana- lyze the risk factors for bile leakage after hepatectomy for be- nign or malignant tumors. METHODS： A total of 411 patients who had undergone hepa- tectomy between December 2006 and December 2011 were ret- rospectively analyzed. The severity of bile leakage was graded according to the ISGLS classification. Twenty-eight pre- and postoperative parameters were analyzed. RESULTS： The overall bile leakage incidence was 10.2% （42/411）. The severity of the leakage was classified according to the IS- GLS classification. Bile leakage was detected early in case of abdominal drainage （11.4% vs 1.9%, P=0.034）. It prolonged the time of hospitalization （16 vs 9 days, P=0.001）. In all patients, wedge resection was associated with a higher incidence of bile leakage in contrast to anatomical resections （25.6% vs 4.1%, P〈0.0001） regardless of the underlying liver disease. Furthermore, total vascular exclusion increased risk of bile leakage （P=0.008）. CONCLUSIONS： Bile leakage as a major issue after hepatic resection is related to the postoperative morbidity and the hospitalization time. It is associated with non-anatomical re- section and a total vascular exclusion.

Solid,non-skin,post-liver transplant tumors:Key role oflifestyle and immunosuppression management

Liver transplantation has been the treatment of choice for end-stage liver disease since 1983.Cancer has emerged as a major long-term cause of death for liver transplant recipients.Many retrospective studies that have explored standardized incidence ratio have reported increased rates of solid organ cancers postliver transplantation;some have also studied risk factors.Liver transplantation results in a two to five-fold mean increase in the rate of solid organ cancers.Risk of head and neck,lung,esophageal,cervical cancers and Kaposi’s sarcoma is high,but risk of colorectal cancer is not clearly demonstrated.There appears to be no excess risk of developing breast or prostate cancer.Environmental risk factors such as viral infection and tobacco consumption,and personal risk factors such as obesity play a key role,but recent data also implicate the role of calcineurin inhibitors,whose cumulative and dose-dependent effects on cell metabolism might play a direct role in oncogenesis.In this paper,we review the results of studies assessing the incidence of non-skin solid tumors in order to understand the mechanisms underlying solid cancers in post-liver transplant patients and,ultimately,discuss how to prevent these cancers.Immunosuppressive protocol changes,including a calcineurin inhibitor-free regimen,combined with dietary guidelines and smoking cessation,are theoretically the best preventive measures.

Large,multifocal or portal vein-invading hepatocellular carcinoma(HCC)downstaged by Y90 using personalized dosimetry:safety,pathological results and outcomes after surgery

Background:Transarterial radioembolization(TARE)has recently been recognized as a bridging/downstaging therapy to surgery for early hepatocellular carcinomas(HCCs)with high rates of complete pathological necrosis(CPN)on liver explants.In patients with portal vein tumoral thrombus(PVTT),multifocal or large tumors,TARE has mainly a palliative role and surgery remains controversial in this poor-prognosis population.Personalized dosimetry recently proved to outperform standard dosimetry used in prior negative Y90 randomized-controlled trials.Methods:In this retrospective study,we evaluated safety,radiological and pathological response and outcomes in HCC patients with PVTT,multifocal or large tumors,who underwent surgery after downstaging using TARE with Y90-loaded glass microspheres with personalized dosimetry.Results:Between December 2015 and October 2021,18 unresectable patients(14/18 with PVTT)had surgery(16 resections,2 liver transplantations)6.2 months(range,2-14.6 months)after a single Y90 treatment.No 90-day mortality was reported.Objective modified response criteria in solid tumors(mRECIST)response were noted in all but one patient.Complete and extensive(50-99%)necrosis was observed in 36%and 45%of tumors,respectively.The post-treatment tumor-absorbed dose significantly differed depending on the extent of pathological necrosis(P=0.045).Median overall survival and progression-free survival(PFS)were respectively of 61.8 months[95%CI:31.4 months-not reached(NR)]and 49.3 months(95%CI:14 months-NR).PFS was longer in patients with complete imaging response[median NR(none recurred or died)vs.21.5 months(95%CI:10.1 months-NR),P<0.001]and in those with complete pathological response[median NR vs.22.5 months(95%CI:10.1 months-NR),P<0.001].Conclusions:Y90 TARE using personalized dosimetry can provide high rates of imaging and pathological response in patients with PVTT,large or multifocal HCC.Subsequent surgery is safe and leads to outcomes far exceeding expectations in an otherwise poor prognosis population with no chance for cure.

Prognostication algorithm for non-cirrhotic non-B non-C hepatocellular carcinoma-a multicenter study under the aegis of the French Association of Hepato-Biliary Surgery and liver Transplantation

Background:Liver resection and local ablation are the only curative treatment for non-cirrhotic hepatocellular carcinoma(HCC).Few data exist concerning the prognosis of patients resected for non-cirrhotic HCC.The objectives of this study were to determine the prognostic factors of recurrence-free survival(RFS)and overall survival(OS)and to develop a prognostication algorithm for non-cirrhotic HCC.Methods:French multicenter retrospective study including HCC patients with non-cirrhotic liver without underlying viral hepatitis:F0,F1 or F2 fibrosis.Results:A total of 467 patients were included in 11 centers from 2010 to 2018.Non-cirrhotic liver had a fibrosis score of F0(n=237,50.7%),F1(n=127,27.2%)or F2(n=103,22.1%).OS and RFS at 5 years were 59.2%and 34.5%,respectively.In multivariate analysis,microvascular invasion and HCC differentiation were prognostic factors of OS and RFS and the number and size were prognostic factors of RFS(P<0.005).Stratification based on RFS provided an algorithm based on size(P=0.013)and number(P<0.001):2 HCC with the largest nodule≤10 cm(n=271,Group 1);2 HCC with a nodule>10 cm(n=176,Group 2);>2 HCC regardless of size Conclusions:We developed a prognostication algorithm based on the number(≤or>2)and size(≤or>10 cm),which could be used as a treatment decision support concerning the need for perioperative therapy.In case of bifocal HCC,surgery should not be a contraindication.

The key role of the hepatic veins collaterals in the modern liver surgery

Currently,the terminology for liver anatomy and resection was based on the updates of the Brisbane 2000 system(1).In this setting,Couinaud’s anatomical description serves as the backbone for the classification of resection(2).Based on this classification,an anatomic liver resection was defined as the complete removal of the liver parenchyma confined within the responsible portal territory.Anatomical subsegmentectomy is defined as the removal of the liver parenchyma within the portal territory of less than a Couinaud’s segment.These are also defined as cone units,and their areas can be intraoperatively assessed by using ischemic demarcation,indocyanine green(ICG)staining,or both.

Optimization of the future remnant liver:review of the current strategies in Europe

Liver resection still represent the treatment of choice for liver malignancies,but in some cases inadequate future remnant liver(FRL)can lead to post hepatectomy liver failure(PHLF)that still represents the most common cause of death after hepatectomy.Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL,reducing the risk of post hepatectomy liver failure.Portal vein embolization,portal vein ligation,and ALLPS are the most popular techniques historically adopted up to now.The liver venous deprivation and the radio-embolization are the most recent promising techniques.Despite even more precise tools to calculate the relationship among volume and function,such as scintigraphy with^(99m)Tc-mebrofenin(HBS),no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery,complexity of the pathology and quality of liver parenchyma.The aim of this article is to analyse these different strategies to achieve sufficient FRL.

Indocyanine green fluorescence angiography during liver and pancreas transplantation: a tool to integrate perfusion statement's evaluation

Background: Indocyanine green (ICG) fluorescence imaging is a promising tool for intraoperative decision-making during surgical procedures, in particular to assess organs perfusion. Methods: We used the ICG fluorescence during liver transplantations in six cirrhotic patients to help assessing the graft biliary duct perfusion in order to identify the appropriate level to perform the anastomosis. We also used ICG fluorescence also in five patients receiving kidney-pancreas transplantation to evaluate the perfusion levels of the duodenal stump of the pancreas graft. Results: Follow-up period for the patients was 12 months. The perioperative period was uneventful, no biliary complications such as leaks or stenosis were reported after liver transplantation, no complications of the entero-enteric anastomoses occurred after pancreatic transplantation. Conclusions: ICG fluorescence seems to safely provide important objectifiable perfusion information during organ transplantation procedures that can integrate surgeon's expertise. In fact, detecting intra-operatively perfusion defects, it allows real time modifications on technical strategies potentially useful to reduce the feared risk of anastomotic leakage and consequent severe complications.

Liver venous deprivation:a bright future for liver metastases-but what about hepatocellular carcinoma?

Liver venous deprivation(LVD)refers to the percutaneous procedure aiming to simultaneously abrogate both portal inflow and hepatic venous outflow to accelerate liver regeneration of the future liver remnant(FLR),which limits patient drop-out from resection due either to insufficient FLR or tumor progression.Some authors have designated the exact same technique under the acronym RASPE(Radiological Simultaneous Porto-hepatic Vein Embolization)(1)while others reported on‘double embolization’for designating portal vein embolization(PVE)and proximal embolization of one hepatic vein,keeping patent distal venous branches and veno-venous collaterals(2).

Liver transplantation for irresectable colorectal liver metastases:still a contraindication?

Liver transplantation(LT)for irresectable colorectal cancer liver metastases(i-CRLM)has been considered up to now an absolute contraindication due to unfavorable outcomes,scarcity of grafts and ethical considerations.Recently,promising results of the Norwegian SECA trial raise the question of the utility of LT for i-CRLM with a 5-year survival rate of 60%(1).However,some concerns should be considered as to oncological selection criteria(when to perform the transplantation?)and the source of liver grafts:deceased donor at cost of recipient listed for standard indication or living donor in a population with a higher risk of recurrence.