• Annals of Hepato-Biliary-Pancreatic Surgery
• /
• v.28 no.1
• /
• pp.25-33
• /
• 2024

Backgrounds/Aims: Parenchymal-sparing anatomical hepatectomy (Ps-AH) based on portal ramification of the right anterior section (RAS) is a new technique to avoid unnecessarily transecting too much liver parenchyma, especially in cases of major anatomical hepatectomy. Methods: We prospectively assessed 26 patients with primary hepatic malignancies having undergone major Ps-AH based on portal ramification of the RAS from August 2018 to August 2022 (48 months). The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: Among the 26 patients analyzed, there was just one case that had intrahepatic cholangiocarcinoma The preoperative level of α-Fetoprotein was 25.2 ng/mL. All cases (100%) had Child-Pugh A liver function preoperatively. The ventral/dorsal RAS was preserved in 19 and 7 patients, respectively. The mean surgical margin was 6.2 mm. The mean surgical time was 228.5 minutes, while the mean blood loss was 255 mL. In pathology, 5 cases (19.2%) had microvascular invasion, and in the group of HCC patients, 92% of all cases had moderate or poor tumor differentiation. Six cases (23.1%) of postoperative complications were graded over III according to the Clavien-Dindo system, including in three patients resistant ascites or intra-abdominal abscess that required intervention. Conclusions: Parenchymal-sparing anatomical hepatectomy based on portal ramification of the RAS to achieve R0-resection was safe and effective, with favorable short-term outcomes. This technique can be used widely in clinical practice.

• Annals of Hepato-Biliary-Pancreatic Surgery
• /
• v.26 no.3
• /
• pp.257-262
• /
• 2022

Backgrounds/Aims: Middle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy. Methods: Patients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation. Results: A total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52). Conclusions: Resection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.

• Annals of Hepato-Biliary-Pancreatic Surgery
• /
• v.28 no.1
• /
• pp.109-113
• /
• 2024

Cholangiocarcinoma is a heterogeneous group of aggressive tumors that correspond to the second most common primary liver tumor. They can be classified according to their anatomical position concerning the biliary tree, and each subtype demonstrates different behavior and treatment. A 38-year-old male patient presenting solely right lumbar pain was diagnosed with a 7 cm hepatic tumor involving segments I, Iva, and VIII associated with involvement of the hepatic veins. He underwent a bloc resection of hepatic segments I, II, III, IV, partial V, partial VII, and VIII; right, middle, and left hepatic veins; and inferior vena cava segment, with perfusion of the remaining liver in situ with a preservation solution. As the patient had a large accessory inferior right hepatic vein draining the remaining liver, no reimplantation of hepatic veins was necessary. He remained clinically stable in outpatient follow-up, with excellent performance status-current survival of 2 years 6 months after surgical treatment.

• Annals of Hepato-Biliary-Pancreatic Surgery
• /
• v.26 no.2
• /
• pp.125-132
• /
• 2022

Backgrounds/Aims: It is generally accepted that non-anatomical resection (NAR) in colorectal liver metastasis (CRLM) has comparable safety and efficacy compared to anatomical resection (AR); however, there are reports that AR may have better outcomes in KRAS mutated CRLM. This study aimed to determine the effects of KRAS mutations and surgical techniques on survival outcomes in CRLM patients. Methods: Two hundred fifty patients who underwent hepatic resection of CRLM with known KRAS mutational status between 2007 and 2018 were analyzed. A total of 94 KRAS mutated CRLM and 156 KRAS wild-type CRLM were subdivided by surgical approach and compared for short- and long-term outcomes. Results: In both KRAS wild-type and mutated type, there was no difference in estimated blood loss, postoperative complications, and 30-day mortality. There was no difference in disease-free survival (DFS) between AR and NAR in both groups (p = 0.326, p = 0.954, respectively). Finally, there was no difference in intrahepatic DFS between AR and NAR groups in both the KRAS groups (p = 0.165, p = 0.516, respectively). Conclusions: The presence of KRAS mutation may not be a significant factor when deciding the approach in simultaneous resection of CRLM.

• Asian Pacific Journal of Cancer Prevention
• /
• v.14 no.5
• /
• pp.3045-3050
• /
• 2013

Purpose: Hepatic resection is arguably the preferred treatment for huge hepatocellular carcinoma (H-HCC). Estimating the remnant liver volume is therefore essential. This study aimed to evaluate the feasibility of using computer-assisted volumetric analysis for this purpose. Methods: The study involved 40 patients with H-HCC. Laboratory examinations were conducted, and a contrast CT-scan revealed that 30 cases out of the participating 40 had single-lesion tumors. The remaining 10 had less than three satellite tumors. With the consensus of the team, two physicians conducted computer-assisted 3D segmentation of the liver, tumor, and vessels in each case. Volume was automatically computed from each segmented/labeled anatomical field. To estimate the resection volume, virtual lobectomy was applied to the main tumor. A margin greater than 1 cm was applied to the satellite tumors. Resectability was predicted by computing a ratio of functional liver resection (R) as (Vresected-Vtumor)/(Vtotal-Vtumor) x 100%, applying a threshold of 50% and 60% for cirrhotic and non-cirrhotic cases, respectively. This estimation was then compared with surgical findings. Results: Out of the 22 patients who had undergone hepatectomies, only one had an R that exceeded the threshold. Among the remaining 18 patients with non-resectable H-HCC, 12 had Rs that exceeded the specified ratio and the remaining 6 had Rs that were < 50%. Four of the patients who had Rs less than 50% underwent incomplete surgery due to operative findings of more extensive satellite tumors, vascular invasion, or metastasis. The other two cases did not undergo surgery because of the high risk involved in removing the tumor. Overall, the ratio of functional liver resection for estimating resectability correlated well with the other surgical findings. Conclusion: Efficient pre-operative resectability assessment of H-HCC using computer-assisted volumetric analysis is feasible.

• Annals of Hepato-Biliary-Pancreatic Surgery
• /
• v.28 no.3
• /
• pp.271-282
• /
• 2024

The history of liver surgery is a tale of progressive resolution of issues presenting one after another from ancient times to the present days when dealing with liver ailments. The perfect knowledge of human liver anatomy and physiology and the development of a proper liver resective surgery require time and huge efforts and, mostly, the study and research of giants of their own times, whose names are forever associated with anatomical landmarks, thorough descriptions, and surgical approaches. The control of parenchymal bleeding after trauma and during resection is the second issue that surgeons have to resolve. A good knowledge of intra and extrahepatic vascular anatomy is a necessary condition to develop techniques of vascular control, paving the way to liver transplantation. Last but not least, the issue of residual liver function after resection requires advanced techniques of volume redistribution through redirection of blood inflow. These are the same problems any young surgeon would face when approaching liver surgery for the first time. Therefore, obtaining a wide picture of historical evolution of liver surgery could be a great starting point to serve as an example and a guide.