Extended hepatectomy,or liver transplantation of reduced-size graft,can lead to a pattern of clinical manifestations,namely"post-hepatectomy liver failure"and"small-for-size syndrome"respectively,t...Extended hepatectomy,or liver transplantation of reduced-size graft,can lead to a pattern of clinical manifestations,namely"post-hepatectomy liver failure"and"small-for-size syndrome"respectively,that can range from mild cholestasis to irreversible organ non-function and death of the patient.Many mechanisms are involved in their occurrence but in the recent past,high portal blood flow through a relatively small liver vascular bed has taken a central role.Therefore,several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation,such as portocaval shunt,mesocaval shunt,splenorenal shunt,splenectomy or ligation of the splenic artery.However,high portal flow is not the only factor responsible,and before major liver resections,preoperative assessment of the residual liver function is necessary.Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume,preventing posthepatectomy liver failure.More recently,a new surgical procedure,that combines in situ splitting of the liver and portal vein ligation,has gradually come to light,inducing remarkable hypertrophy of the healthy liver in just a few days.Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.展开更多
Background:Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins,especially in the case of up-front resections,but it is important to know the limits of surgica...Background:Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins,especially in the case of up-front resections,but it is important to know the limits of surgical therapy in this disease.This study aimed to investigate the impact of extent of pancreatic and venous resection on short-and long-term outcomes in patients with pancreatic adenocarcinoma(PDAC).Methods:This was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC.Short-and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy(TP)or pancreaticoduodenectomy(PD)with simultaneous portal vein(PV)and/or superior mesenteric vein(SMV)resection.Venous resections were carried out as tangential venous resection(TVR)or segmental venous resection(SVR).Patients were divided into 4 groups:(1)PD+TVR,(2)PD+SVR,(3)TP+TVR,(4)TP+SVR.Uni-and multivariate Cox regression analysis were performed to identify factors associated with survival.Results:Ninety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC.Among them,25 were submitted to PD+TVR(25.3%),12 to PD+SVR(12.1%),23 to TP+TVR(23.2%),and 39 to TP+SVR(39.4%).Overall,major morbidity(Clavien-Dindo grade≥IIIA)was 26.3%.Thirty-and 90-day mortality were 3%and 11.1%,respectively.There were no significant differences among groups in terms of short-term outcomes.Median overall survival of patients submitted to PD+TVR was significantly higher than those to TP+SVR(29.5 vs 7.9 months,P=0.001).Multivariate analysis identified TP(HR=2.11;95%CI:1.31–3.44;P=0.002)and SVR(HR=2.01;95%CI:1.27–3.15;P=0.003)as the only independent prognostic factors for overall survival.Conclusions:Up-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC.Perioperative treatments in high-risk surgical groups may improve such poor outcomes.展开更多
BACKGROUND Two-stage hepatectomy(TSH)is a well-established surgical technique,used to treat bilateral colorectal liver metastases(CRLM)with a small future liver remnant(FLR).However,in classical TSH,drop-out is report...BACKGROUND Two-stage hepatectomy(TSH)is a well-established surgical technique,used to treat bilateral colorectal liver metastases(CRLM)with a small future liver remnant(FLR).However,in classical TSH,drop-out is reported to be around 25%-40%,due to insufficient FLR increase or progression of disease.Trans-arterial radioembolization(TARE)has been described to control locally tumor growth of liver malignancies such as hepatocellular carcinoma,but it has been also reported to induce a certain degree of contralateral liver hypertrophy,even if at a lower rate compared to portal vein embolization or ligation.CASE SUMMARY Herein we report the case of a 75-year-old female patient,where TSH and TARE were combined to treat bilateral CRLM.According to computed tomography(CT)-scan,the patient had a hepatic lesion in segment VI-VII and two other confluent lesions in segment II-III.Therefore,one-stage posterior right sectionectomy plus left lateral sectionectomy(LLS)was planned.The liver volumetry estimated a FLR of 38%(segments I-IV-V-VIII).However,due to a more than initially planned,extended right resection,simultaneous LLS was not performed and the patient underwent selective TARE to segments II-III after the first surgery.The CT-scan performed after TARE showed a reduction of the treated lesion and a FLR increase of 55%.Carcinoembryonic antigen and CA 19.9 decreased significantly.Nearly three months later after the first surgery,LLS was performed and the patient was discharged without any postoperative complications.CONCLUSION According to this specific experience,TARE was used to induce liver hypertrophy and simultaneously control cancer progression in TSH settings for bilateral CRLM.展开更多
Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with prima...Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.展开更多
Radiofrequency ablation(RFA)currently represents a potentially curative treatment for hepatocellular carcinoma(HCC)in its early stages(1,2).Providing higher rates of complete necrosis of target tumor than other loco-r...Radiofrequency ablation(RFA)currently represents a potentially curative treatment for hepatocellular carcinoma(HCC)in its early stages(1,2).Providing higher rates of complete necrosis of target tumor than other loco-regional therapies(LRTs),RFA plays an important role as bridge therapy to liver transplantation(LT)(3).In the study from Lee and colleagues of the UCLA medical center,published in issue of June 2017 of Hepatology,Authors analyzed the outcome of 121 patients with 156 de-novo HCC treated with RFA as initial stand-alone therapy(4).The study is a fair attempt to analyze the efficacy of RFA as bridge therapy to LT,considering all potential outcome measures.Nevertheless,some results passed unnoticed,while instead deserve further discussion.展开更多
Liver transplantation(LT)for hepatocellular carcinoma(HCC)was characterized in its early experience by high recurrence rates due to extensive tumor burden(1).Only after the adoption of Milan criteria(2),LT was recogni...Liver transplantation(LT)for hepatocellular carcinoma(HCC)was characterized in its early experience by high recurrence rates due to extensive tumor burden(1).Only after the adoption of Milan criteria(2),LT was recognized as a standard treatment for HCC(3).Besides HCC,other hepatic malignancies were proposed to be treated in the past with LT but due to the poor results observed(4),these indications were abandoned.Among them,colorectal liver metastases(CRLM)were considered an absolute contraindication until recently.展开更多
The recurrence rate after primary resection for hepatocellular carcinoma(HCC)has been reported to be up to 80%.There is no consensus or guideline about the best treatment option for such recurrent HCC(rHCC).It is ther...The recurrence rate after primary resection for hepatocellular carcinoma(HCC)has been reported to be up to 80%.There is no consensus or guideline about the best treatment option for such recurrent HCC(rHCC).It is therefore of paramount importance to select patients for suitable treatment due to the high risk of associated morbidity and mortality.In this paper,we review the literature on treatment for rHCC and propose a strategy based on the best evidence available.Even in rHCC,it is still possible to achieve cure and good survival rates through careful patient selection.Repeat hepatectomy is recognized as a feasible and safe procedure even in cirrhotic patients and should be considered as the best option with curative intent when the patient is fit enough.Greater adoption of minimally-invasive liver surgery could have the potential to increase the number of candidate patients with rHCC for repeat resection in the next few years.Liver transplantation offers longer disease-free survival compared to repeat resection,curing the underlying cirrhosis,but is not widely available due to organ shortage.When surgery is not feasible,locoregional treatments such as radiofrequency ablation and transarterial chemoembolization have an important role for patients who cannot tolerate repeat hepatectomy and are not suitable for transplantation.For advanced cases,systemic therapy could be considered.展开更多
Intrahepatic cholangiocarcinoma(ICCA)incidence has been rising in the last few decades.Currently,hepatic resection is the only curative treatment for ICCA,and there is a lack of evidence supporting the use of preopera...Intrahepatic cholangiocarcinoma(ICCA)incidence has been rising in the last few decades.Currently,hepatic resection is the only curative treatment for ICCA,and there is a lack of evidence supporting the use of preoperative treatment.A narrative review was conducted to analyze the available literature published on the role of neoadjuvant chemotherapy(CHT),either alone or combined with intra-arterial therapies(IAT),for downstaging unresectable ICCA to surgical resection.Most of the studies included in this review showed that secondary resection was associated with improvement in overall survival.In particular,studies analyzing CHT alone reported the highest conversion rate ranging from 20%to 57.1%,confirming that systemic treatment may yield the best results,and therefore,it should always be included as part of the neoadjuvant protocol.Among all the IATs,the longest overall survival reported was after CHT plus hepatic artery infusion,25 months.Downsizing neoadjuvant multimodal approach,including combined systemic therapy with IAT,might improve the long-term outcomes of unresectable patients and expand surgical indications.However,randomized controlled trials are necessary to confirm their effectiveness.展开更多
文摘Extended hepatectomy,or liver transplantation of reduced-size graft,can lead to a pattern of clinical manifestations,namely"post-hepatectomy liver failure"and"small-for-size syndrome"respectively,that can range from mild cholestasis to irreversible organ non-function and death of the patient.Many mechanisms are involved in their occurrence but in the recent past,high portal blood flow through a relatively small liver vascular bed has taken a central role.Therefore,several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation,such as portocaval shunt,mesocaval shunt,splenorenal shunt,splenectomy or ligation of the splenic artery.However,high portal flow is not the only factor responsible,and before major liver resections,preoperative assessment of the residual liver function is necessary.Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume,preventing posthepatectomy liver failure.More recently,a new surgical procedure,that combines in situ splitting of the liver and portal vein ligation,has gradually come to light,inducing remarkable hypertrophy of the healthy liver in just a few days.Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.
文摘Background:Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins,especially in the case of up-front resections,but it is important to know the limits of surgical therapy in this disease.This study aimed to investigate the impact of extent of pancreatic and venous resection on short-and long-term outcomes in patients with pancreatic adenocarcinoma(PDAC).Methods:This was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC.Short-and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy(TP)or pancreaticoduodenectomy(PD)with simultaneous portal vein(PV)and/or superior mesenteric vein(SMV)resection.Venous resections were carried out as tangential venous resection(TVR)or segmental venous resection(SVR).Patients were divided into 4 groups:(1)PD+TVR,(2)PD+SVR,(3)TP+TVR,(4)TP+SVR.Uni-and multivariate Cox regression analysis were performed to identify factors associated with survival.Results:Ninety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC.Among them,25 were submitted to PD+TVR(25.3%),12 to PD+SVR(12.1%),23 to TP+TVR(23.2%),and 39 to TP+SVR(39.4%).Overall,major morbidity(Clavien-Dindo grade≥IIIA)was 26.3%.Thirty-and 90-day mortality were 3%and 11.1%,respectively.There were no significant differences among groups in terms of short-term outcomes.Median overall survival of patients submitted to PD+TVR was significantly higher than those to TP+SVR(29.5 vs 7.9 months,P=0.001).Multivariate analysis identified TP(HR=2.11;95%CI:1.31–3.44;P=0.002)and SVR(HR=2.01;95%CI:1.27–3.15;P=0.003)as the only independent prognostic factors for overall survival.Conclusions:Up-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC.Perioperative treatments in high-risk surgical groups may improve such poor outcomes.
文摘BACKGROUND Two-stage hepatectomy(TSH)is a well-established surgical technique,used to treat bilateral colorectal liver metastases(CRLM)with a small future liver remnant(FLR).However,in classical TSH,drop-out is reported to be around 25%-40%,due to insufficient FLR increase or progression of disease.Trans-arterial radioembolization(TARE)has been described to control locally tumor growth of liver malignancies such as hepatocellular carcinoma,but it has been also reported to induce a certain degree of contralateral liver hypertrophy,even if at a lower rate compared to portal vein embolization or ligation.CASE SUMMARY Herein we report the case of a 75-year-old female patient,where TSH and TARE were combined to treat bilateral CRLM.According to computed tomography(CT)-scan,the patient had a hepatic lesion in segment VI-VII and two other confluent lesions in segment II-III.Therefore,one-stage posterior right sectionectomy plus left lateral sectionectomy(LLS)was planned.The liver volumetry estimated a FLR of 38%(segments I-IV-V-VIII).However,due to a more than initially planned,extended right resection,simultaneous LLS was not performed and the patient underwent selective TARE to segments II-III after the first surgery.The CT-scan performed after TARE showed a reduction of the treated lesion and a FLR increase of 55%.Carcinoembryonic antigen and CA 19.9 decreased significantly.Nearly three months later after the first surgery,LLS was performed and the patient was discharged without any postoperative complications.CONCLUSION According to this specific experience,TARE was used to induce liver hypertrophy and simultaneously control cancer progression in TSH settings for bilateral CRLM.
基金The study was approved by Independent Ethics Committee(IEC)of Tübingen University Hospital(No.030/2019A)and informed。
文摘Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.
文摘Radiofrequency ablation(RFA)currently represents a potentially curative treatment for hepatocellular carcinoma(HCC)in its early stages(1,2).Providing higher rates of complete necrosis of target tumor than other loco-regional therapies(LRTs),RFA plays an important role as bridge therapy to liver transplantation(LT)(3).In the study from Lee and colleagues of the UCLA medical center,published in issue of June 2017 of Hepatology,Authors analyzed the outcome of 121 patients with 156 de-novo HCC treated with RFA as initial stand-alone therapy(4).The study is a fair attempt to analyze the efficacy of RFA as bridge therapy to LT,considering all potential outcome measures.Nevertheless,some results passed unnoticed,while instead deserve further discussion.
文摘Liver transplantation(LT)for hepatocellular carcinoma(HCC)was characterized in its early experience by high recurrence rates due to extensive tumor burden(1).Only after the adoption of Milan criteria(2),LT was recognized as a standard treatment for HCC(3).Besides HCC,other hepatic malignancies were proposed to be treated in the past with LT but due to the poor results observed(4),these indications were abandoned.Among them,colorectal liver metastases(CRLM)were considered an absolute contraindication until recently.
文摘The recurrence rate after primary resection for hepatocellular carcinoma(HCC)has been reported to be up to 80%.There is no consensus or guideline about the best treatment option for such recurrent HCC(rHCC).It is therefore of paramount importance to select patients for suitable treatment due to the high risk of associated morbidity and mortality.In this paper,we review the literature on treatment for rHCC and propose a strategy based on the best evidence available.Even in rHCC,it is still possible to achieve cure and good survival rates through careful patient selection.Repeat hepatectomy is recognized as a feasible and safe procedure even in cirrhotic patients and should be considered as the best option with curative intent when the patient is fit enough.Greater adoption of minimally-invasive liver surgery could have the potential to increase the number of candidate patients with rHCC for repeat resection in the next few years.Liver transplantation offers longer disease-free survival compared to repeat resection,curing the underlying cirrhosis,but is not widely available due to organ shortage.When surgery is not feasible,locoregional treatments such as radiofrequency ablation and transarterial chemoembolization have an important role for patients who cannot tolerate repeat hepatectomy and are not suitable for transplantation.For advanced cases,systemic therapy could be considered.
文摘Intrahepatic cholangiocarcinoma(ICCA)incidence has been rising in the last few decades.Currently,hepatic resection is the only curative treatment for ICCA,and there is a lack of evidence supporting the use of preoperative treatment.A narrative review was conducted to analyze the available literature published on the role of neoadjuvant chemotherapy(CHT),either alone or combined with intra-arterial therapies(IAT),for downstaging unresectable ICCA to surgical resection.Most of the studies included in this review showed that secondary resection was associated with improvement in overall survival.In particular,studies analyzing CHT alone reported the highest conversion rate ranging from 20%to 57.1%,confirming that systemic treatment may yield the best results,and therefore,it should always be included as part of the neoadjuvant protocol.Among all the IATs,the longest overall survival reported was after CHT plus hepatic artery infusion,25 months.Downsizing neoadjuvant multimodal approach,including combined systemic therapy with IAT,might improve the long-term outcomes of unresectable patients and expand surgical indications.However,randomized controlled trials are necessary to confirm their effectiveness.
