Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer

Background and aims The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection. Materials and methods Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival. Results Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection. Conclusion Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.     

Hepatic resection for benign non-cystic liver lesions

BackgroundHepatic resection is indicated for a variety of benign conditions because of persistent symptoms, uncertainty regarding the diagnosis or the risk of malignant transformation. The aim of this study was to assess the indications for and outcome of hepatic resection for benign non-cystic liver lesions in a specialist hepatobiliary unit.Patients and methodsAll patients who had undergone hepatic resection for benign non-cystic hepatic lesions between 1989 and 2001 were identified from a prospective database for analysis.ResultsA total of 49 patients (40 women, 9 men) with a mean age of 43 years (range 21–75 years) underwent resection of non-cystic benign lesions. Indications for operation included suspected liver cell adenoma (n=11), suspicion of malignancy (11), persistent symptoms attributable to the lesion (20) or chronic sepsis (7). The final diagnosis was focal nodular hyperplasia (n=12), haemangioma (12), adenoma (8), sclerosing cholangitis (5), inflammatory pseudotumour (4), intrahepatic cholelithiasis (3), chronic hepatic abscess (3), benign biliary fibrosis (I) and leiomyoma (I). Major anatomical hepatic resections were performed in 44 patients, and 5 patients underwent a segmentectomy or minor atypical resection. Median operating time was 215 min (range 45–450 min) and median blood loss was 875 ml (range 200–4000 ml). Ten patients (20%) required a median blood transfusion of 2 units (range 2–8 units). The median postoperative stay was 10 days (range 4–33 days). There were no deaths, but complications occurred in 15 patients (27%).ConclusionsHepatic resection can be safely recommended for selected patients with a variety of benign non-cystic hepatic lesions. A small group of patients undergo resection as a result of inability to rule out a malignant process, but the large majority will be operated on because of either their malignant potential or related symptoms.     

Early postoperative outcomes following hepatic resection for benign liver disease in 79 consecutive patients

Background:

Liver resection is an accepted treatment modality for malignant disease of the liver. However, because of its potential morbidity and mortality, the practice of liver resection in benign disease is more controversial. This study was designed to assess the early outcomes of 79 consecutive liver resections for benign disease over a 12-year period and compare these with early outcomes of 390 consecutive liver resections for metastatic colorectal cancer (MCRC) during the same period.

Methods:

Consecutive liver resections were carried out in a single hepatopancreatobiliary (HPB) centre between 1996 and 2008. Patient demographics and early outcomes were recorded. Statistical analyses were performed using spss (Version 15). P < 0.05 was considered to be significant.

Results:

There was no difference in median age between the benign group vs. the MCRC group (P = 0.181). However, there was a significant trend towards a lower ASA grade in the benign group (P < 0.001). There was no difference in median blood loss (P = 0.139) or hospital stay (P = 0.262). Morbidity rates were 8.9% in the benign group and 20.5% in the MCRC group (P = 0.002). The rate of serious complications was 1.3% in the benign group compared with 4.4% in the MCRC group (P = 0.041). There were no postoperative deaths in the benign group and eight (2%) in the MCRC group (P = 0.004).

Conclusions:

Liver resection for benign liver tumours can be undertaken with a mortality rate approaching zero and minimal morbidity in specialist HPB units.     

Laparoscopic anatomic liver resection

BackgroundLiver resection is reputed to be one of the most difficult procedures embraced in laparoscopy. This report shows that with adequate training, anatomical liver resection including major hepatectomies can be performed.MethodsThis is a retrospective study.ResultsFrom 1995 to 2004, among 84 laparoscopic liver resections, 46 (54%) anatomical laparoscopic hepatectomies were performed in our institution by laparoscopy. Nine (20%) patients had benign disease while 37 (80%) had malignant lesions. Among those with malignant lesions, 14 patients had hepatocellular carcinoma (HCC), 18 had colorectal metastasis (CRM), while 5 had miscellaneous tumours. For benign disease, minor (two Couinaud''s segments or less) and major anatomic hepatectomies were performed in five and four patients, respectively. For malignant lesions, minor and major anatomic hepatectomies were performed in 15 and 22 patients, respectively. Overall, conversion to laparotomy was necessary in 7 (15%) patients. Blood transfusion was required in five (10%) patients. One patient died of cerebral infarction 8 days after a massive peroperative haemorrhage. The overall morbidity rate was 34% whatever the type of resection. Three patients required reoperation, either for haemorrhage (n=1) and/or biliary leak (n=2). For CRM (n=18), overall and disease-free survival at 24 months (mean follow-up of 17 months) were 100% and 56%, respectively. For HCC (n=14), overall and disease-free survival at 36 months (mean follow-up of 29 months) were 91% and 65%, respectively. No port site metastasis occurred in patients with malignancy.ConclusionsAfter a long training with limited liver resection in superficial segments, laparoscopic anatomical minor and major resections are feasible. Short-term carcinological results seem to be similar to those obtained with laparotomy.     

R0 Liver Resections for Primary Malignant Liver Tumors in the Noncirrhotic Liver: A Diagnosis-Related Analysis

Background Primary liver cancer constitutes an increasingly malignancy in the Western world and one of the leading causes of cancer-related deaths worldwide. The purpose of this study was to evaluate and compare long-term outcomes after R0 resections in noncirrhotic livers for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Methods Between April 1998 and May 2006 a total of 102 patients with either ICC (n = 41, group 1) or HCC (n = 61, group 2) in the absence of cirrhosis underwent curative liver resection in our department. Demographic characteristics, operative details, perioperative complications, pathologic findings, tumor recurrence and survival were analyzed. Results Gender (P = 0.007), extent of liver resection (P = 0.036), additional surgical procedures (P < 0.001) and operative morbidity (P = 0.018) differed among the two groups. Following resection, after a median follow-up of 28 months, the calculated 5-year survival was 44% and 40% for ICC and HCC, respectively (P = 0.38). The corresponding recurrence-free survival was 25% for both ICC and HCC (P = 0.66). UICC stage was found to predict overall and recurrence-free survival in both types of tumors. Multifocality in the case of ICC, and tumor differentiation and vascular invasion in the case of HCC, were predictive factors for overall and recurrence-free survival, respectively. In multivariable analyses, vascular invasion for HCC was predictive for overall and recurrence-free survival, whereas in the case of ICC significant differences were detected in the recurrence analysis for multifocality and UICC stage. Conclusions R0 resections for both ICC and HCC result to similar long-term outcomes, which are characterized by good overall and acceptable recurrence-free survival rates.     

Central hepatectomy versus extended hepatectomy for liver malignancy: a matched cohort comparison

ObjectiveTo compare surgical outcomes between matched central hepatectomy (CH) and extended hepatectomy (EH) groups.BackgroundSurgical choices for centrally located liver tumours are limited. The traditional EH harbours substantial risks, whereas CH is an alternative parenchymal‐sparing resection that may improve peri‐operative morbidity.MethodsA review of 4661 liver resections at a single institution was performed. The cases (CH) were matched in a 1:1 ratio with EH controls.ResultsThe CH group was matched for demographic, tumour and laboratory factors with either right EH or combined (right/left) EH groups (n= 63 per group). Colorectal liver metastases were the most common diagnosis occurring in 70% of the patients. Higher intra‐operative blood loss was observed in the right EH(P = .01) and combined EH groups (P < 0.01) compared with the CH group. There was a trend towards lower 90‐day morbidity in the CH group (43%) compared with the right EH(59%, P = 0.1) and combined EH groups (56%, P = 0.2). The length of hospital stay was significantly longer in the control groups (P < 0.01 for both). The control groups had significantly higher post‐operative bilirubin and International Normalized Ratio (INR) levels compared with the CH group. A post‐operative bilirubin higher than 4 mg/dl was observed in 2% of the CH group compared with 39% of the right EH group (P < 0.01) and 52% of the combined EH group (P < 0.01). No differences in the rates of bile leak/biloma, post‐hepatectomy liver failure or 90‐day mortality were found.ConclusionsCH, as compared with EH, was safe and associated with a shorter hospital stay and less post‐operative liver dysfunction. CH should be considered in patients with centrally located tumours amenable to such a resection.     

Outcome after a liver resection of benign lesions

BackgroundBenign liver tumours represent a challenge in clinical management. There is considerable controversy with respect to the indications for surgery as the evidence for surgical treatment is variable. The aim of this retrospective study was to analyse the indication and outcome after resection of benign, solid liver lesions.MethodsData of 79 patients, who underwent liver resection between 2001 and 2012, were analysed for demographic and outcome parameters.ResultsThirty‐eight patients with focal nodular hyperplasia (48%), 23 patients with haemangioma (29%) and 18 patients with hepatocellular adenoma (23%) underwent a hepatic resection. A major hepatic resection was performed in 23 patients (29%) and a minor resection in 56 patients (71%). The post‐operative mortality rate was zero and the 30‐day morbidity rate 13.9%. After a median follow‐up of 64 months, 75 patients (95%) were alive, and no patient had developed recurrent disease. Fifty‐four patients (68%) were pre‐operatively symptomatic, of which, 87% had complete or partial relief of symptoms after a liver resection. The incidence of symptoms increased with the lesions' size.DiscussionThe management of benign liver lesions necessitates an individualized therapy within a multidisciplinary, evidence‐based, treatment algorithm. Resection of benign liver lesions can be performed safely in well‐selected patients without mortality and low post‐operative morbidity.     

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM: To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.METHODS: A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.RESULTS: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.CONCLUSION: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.     

Improved liver function after portal vein embolization and an elective right hepatectomy

BackgroundPortal vein embolization (PVE) is used before extensive hepatic resections to increase the volume of the future remnant liver within acceptable safety margins (conventionally >0.6% of the patient's weight). The objective was to determine whether pre‐operative PVE impacts on post‐operative liver function independently from the increase in liver volume.MethodsThe post‐operative liver function of patients who underwent an anatomical right liver resection with (n = 28) and without (n = 53) PVE were retrospectively analysed. Donors of the right liver were also analysed (LD) (n = 17).ResultsPatient characteristics were similar, except for age, weight and American Society of Anesthesiologists (ASA) score that were lower in LD. Post‐operative factor V and bilirubin levels were, respectively, higher and lower in patients with PVE compared with patients without PVE or LD (P < 0.05). Patients with PVE had an increased blood loss, blood transfusions and sinusoidal obstruction syndrome. The day‐3 bilirubin level was 40% lower in the PVE group compared with the no‐PVE group after adjustment for body weight, chemotherapy, operating time, Pringle time, blood transfusions, remnant liver volume, pre‐operative bilirubin level and pre‐operative prothrombin ratio (P = 0.001).ConclusionsFor equivalent volumes, the immediate post‐operative hepatic function appears to be better in livers prepared with PVE than in unprepared livers. Future studies should analyse whether the conventional inferior volume limit that allows a safe liver resection may be lowered when a PVE is performed.     

Successful management and technical aspects of major liver resection in children: A retrospective cohort study

Optimal treatment of patients with various types of liver tumors or certain liver diseases frequently demands major liver resection, which remains a clinical challenge especially in children.Eighty seven consecutive pediatric liver resections including 51 (59%) major resections (resection of 3 or more hepatic segments) and 36 (41%) minor resections (resection of 1 or 2 segments) were analyzed. All patients were treated between January 2010 and March 2018. Perioperative outcomes were compared between major and minor hepatic resections.The male to female ratio was 1.72:1. The median age at operation was 20 months (range, 0.33–150 months). There was no significant difference in demographics including age, weight, ASA class, and underlying pathology. The surgical management included functional assessment of the future liver remnant, critical perioperative management, enhanced understanding of hepatic segmental anatomy, and bleeding control, as well as refined surgical techniques. The median estimated blood loss was 40 ml in the minor liver resection group, and 90 ml in major liver resection group (P < .001). Children undergoing major liver resection had a significantly longer median operative time (80 vs 140 minutes), anesthesia time (140 vs 205 minutes), as well as higher median intraoperative total fluid input (255 vs 450 ml) (P < .001 for all). Fourteen (16.1%) patients had postoperative complications. By Clavien-Dindo classification, there were 8 grade I, 4 grade II, and 2 grade III-a complications. There were no significant differences in complication rates between groups (P = .902). Time to clear liquid diet (P = .381) and general diet (P = .473) was not significantly different. There was no difference in hospital length of stay (7 vs 7 days, P = .450). There were no 90-day readmissions or mortalities.Major liver resection in children is not associated with an increased incidence of postoperative complications or prolonged postoperative hospital stay compared to minor liver resection. Techniques employed in this study offered good perioperative outcomes for children undergoing major liver resections.     

Liver resection with bipolar radiofrequency device: Habib 4X

Background. Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib^TM 4X, a new bipolar RF device designed specifically for liver resection is described here. Methods. Habib^TM 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak. Results. Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringle''s manoeuvre). Mean intraoperative blood loss was 305 ml (range 0–4300) ml, with less than 5% (n=18) rate of transfusion. Conclusion. Habib^TM 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.     

Avoiding early postoperative complications in liver surgery. A multivariate analysis of 254 patients consecutively observed

BACKGROUND: The number of hepatic resections for benign and malignant lesions has constantly increased over the past 20 years, as a consequence, surgical experience acquired over the past few years has decreased post-operative morbidity and mortality rates. AIMS: Analysing the relation between potential preoperative risk factors and the occurrence of severe post-operative complications, an attempt is made to identify the variables determining surgical risk in elective hepatic surgery both in normal and cirrhotic liver. PATIENTS AND METHODS: The hospital records of 254 patients who underwent elective liver surgical procedures for hepatic lesions in our department, between 1984 and 1999, were reviewed. The following variables were entered into univariate and multivariate analysis: age, sex, nature of liver lesion (benign or malignant), presence of cirrhosis or cholestasis, synchronous resection of other organs, disorders of blood coagulation, intraoperative blood requirement, the extent of surgical procedures and Pringle's manoeuvre. RESULTS AND CONCLUSIONS: The multivariate analysis of the 254 surgical operations on the liver indicates that the most powerful independent predictors favouring a serious adverse effect includes intra-operative blood transfusions, advanced age and cirrhosis. Scrupulous preoperative clinical evaluation and expert surgical skills minimize intra-operative bleeding and proved to be the most significant factors influencing morbidity and mortality rates.     

Bile duct surgery in the treatment of hepatobiliary and gallbladder malignancies: effects of hepatic and vascular resection on outcomes

BackgroundResection of the bile duct is required for the treatment of cholangiocarcinoma and is sometimes indicated in resections of liver and gallbladder malignancies. The goal of this retrospective review was to characterize surgical outcomes in patients submitted to bile duct resection for malignancy when additional procedures, specifically hepatic or vascular resections, were performed.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was searched to identify a total of 747 patients who underwent: (i) biliary‐enteric anastomosis (BEA) only (Group 1, n= 266); (ii) BEA with hepatic resection (Group 2, n= 439), or (iii) BEA with hepatic and vascular resection (Group 3, n = 42). Postoperative outcomes were compared and regression‐adjusted risk factors were analysed to produce observed and expected (O/E) morbidity and mortality ratios.ResultsThe performance of hepatic and vascular resections significantly increased rates of overall morbidity (P < 0.001) and mortality (P = 0.021). Risk‐adjusted O/E mortality ratios in Groups 1, 2 and 3 were 1.44 [95% confidence interval (CI) 0.84–2.30], 2.16 (95% CI 1.51–2.98) and 5.92 (95% CI 2.54–11.66), respectively. Multivariate analysis identified Group 2 (P < 0.001) and Group 3 (P= 0.001) status as independent predictors of morbidity, and Group 3 status (P= 0.008) as independently associated with mortality. More than 30% of deaths were associated with pulmonary complications and septic shock.ConclusionsThe addition of hepatic and vascular resections to bile duct resection significantly increased morbidity and mortality. The high O/E mortality ratios for patients in Groups 2 and 3 suggest these outcomes can be improved.     

Inferior vena cava resection with hepatectomy: challenging but justified

ObjectiveThe aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours.MethodsFrom February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database.ResultsResections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients.ConclusionsAggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.     

Indication for treatment and long-term outcome of focal nodular hyperplasia

Introduction. Unlike malignant liver tumours, the indications for hepatic resection for benign disease are not well defined. This is particularly true for focal nodular hyperplasia (FNH). Here we summarize a single-centre experience of the diagnosis and management of FNH. Materials and methods. Using a prospectively collected database, a retrospective analysis of consecutive patients who were managed at our centre for FNH between January 1997 and December 2006 was performed. Results. The cohort was divided into two groups of patients: those who were managed surgically (n=15) and those managed conservatively (n=37). There was no correlation between tumour size and number of lesions with oral contraceptive use (p=0.07 and 0.90, respectively) and pregnancy (p=0.45 and 0.60, respectively). However, tumour size (p=0.006) and number of lesions (p=0.02) were associated with the occurrence of pain in these patients. Pain was the commonest symptom of patients (13/15) who were managed surgically. All patients underwent radiological imaging before diagnosis. The sensitivities of ultrasound, CT scanning and MRI scanning in characterizing these lesions were 30%, 70% and 87%, respectively. There were no postoperative deaths and three postoperative complications that were successfully managed non-operatively. With a median follow-up of 24 months in the surgically treated group, one patient has developed recurrent symptoms of pain. Conclusion. In this series, there was no mortality directly due to the surgical procedure and a modest morbidity, justifying surgical resections in selected patients.     

Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120–480 min. The average blood loss was 325 ml (range 50–600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia–reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.     

Clinical experience of hepatic hemangioma undergoing hepatic resection

The indications for surgery on cavernous hemangiomas, the most common benign tumors of the liver, remain unclear. This study reviewed 43 patients with cavernous hemangioma of the liver who underwent hepatic resection from 1984 to 2000. Patients were divided into three groups based on the reasons for surgery. Group I comprised 13 patients whose lesions presented symptoms and dimensions that were the main indications for operation. Group II consisted of 28 patients diagnosed with malignant tumors or who displayed malignant growth that could not be ruled out preoperatively. Group III comprised 2 patients with tumors found incidentally at laparotomy for other malignancies. No surgical mortality related to hepatectomy was noted. Postoperative bile leak was found in 2 (morbidity rate: 4.7%). Patients were followed up from 6 months to 12 years. Thirteen residual tumors progressed in size. The clinical status or symptoms changed only slightly in 10 patients with recurrence. The results suggest that resection therapy is an effective indicator for patients with symptoms and a questionable diagnosis. Hepatic resection may and should be carried out with no mortality and minimal morbidity risks since the lesion is benign.     

Hospital variation and outcomes of simultaneous resection of primary colorectal tumour and liver metastases: a population-based study

BackgroundThe optimal treatment sequence for patients with synchronous colorectal liver metastases (CRLM) remains uncertain. This study aimed to assess factors associated with the use of simultaneous resections and impact on hospital variation.MethodThis population-based study included all patients who underwent liver surgery for synchronous colorectal liver metastases between 2014 and 2019 in the Netherlands. Factors associated with simultaneous resection were identified. Short-term surgical outcomes of simultaneous resections and factors associated with 30-day major morbidity were evaluated.ResultsOf 2146 patients included, 589 (27%) underwent simultaneous resection in 28 hospitals. Simultaneous resection was associated with age, sex, BMI, number, size and bilobar distribution of CRLM, and administration of preoperative chemotherapy. More minimally invasive and minor resections were performed in the simultaneous group. Hospital variation was present (range 2.4%–83.3%) with several hospitals performing simultaneous procedures more and less frequently than expected. Simultaneous resection resulted in 13% 30-day major morbidity, and 1% mortality. ASA classification ≥3 was independently associated with higher 30-day major morbidity after simultaneous resection (aOR 1.97, CI 1.10–3.42, p = 0.018).ConclusionDistinctive patient and tumour characteristics influence the choice for simultaneous resection. Remarkable hospital variation is present in the Netherlands.     

Laparoscopic management of benign liver diseases: where are we?

BACKGROUND: The role of laparoscopic surgery in the management of benign cystic and solid liver tumours appears to differ according to each tumour type. As regards congenital liver cysts, laparoscopic treatment is now the gold standard for treating selected, huge, accessible, highly symptomatic or complicated cysts. In contrast, the laparoscopic approach is not useful for patients suffering from adult polycystic liver disease (PLD), except for type I PLD with large multiple hepatic cysts. For benign hepatocellular tumours, the surgical management has recently benefited from a better knowledge of the natural history of each type of tumour and from the improvement of imaging techniques in assuring a precise diagnosis of tumour nature. Thus the general tendency has led to a progressive restriction and tailoring of indications for resection in benign liver tumours, selecting only patients with huge, specifically symptomatic or compressive benign tumours or patients suffering from liver cell adenoma. Despite the enthusiastic use of the laparoscopic approach, selective indications for resection of benign liver tumours should indeed remain unchanged. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. Deep, centrally located lesions or tumours in contact with major vascular or biliary trunks are not ideal candidates for laparoscopic liver resections. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resections and is accompanied by the usual postoperative benefits of laparoscopic surgery. When applied in selected patients and tumours, laparoscopic management of benign liver diseases appears to be a promising technique for hepatobiliary surgeons.     

A standard definition of major hepatectomy: resection of four or more liver segments

BackgroundWhile commonly used to describe liver resections at risk for post-operative complications, no standard definition of ‘major hepatectomy’ exists. The objective of the present retrospective study is to specify the extent of hepatic resection that should describe a major hepatectomy.MethodsDemographics, diagnoses, surgical treatments and outcomes from patients who underwent a liver resection at two high-volume centres were reviewed.ResultsFrom 2002 to 2009, 1670 patients underwent a hepatic resection. Post-operative mortality and severe, overall and hepatic-related morbidity occurred in 4.4%, 29.7%, 41.6% and 19.3% of all patients. Mortality (7.4% vs. 2.7% vs. 2.6%) and severe (36.7% vs. 24.7% vs. 24.1%), overall (49.3% vs. 40.6% vs. 35.9%) and hepatic-related (25.6% vs. 16.4% vs. 15.2%) morbidity were more common after resection of four or more liver segments compared with after three or after two or fewer segments (all P < 0.001). There were no significant differences in any post-operative outcome after resection of three and two or fewer segments (all P > 0.05). On multivariable analysis, resection of four or more liver segments was independently associated with post-operative mortality and severe, overall, and hepatic-related morbidity (all P < 0.01).ConclusionsA major hepatectomy should be defined as resection of four or more liver segments.