Assessment of hepatic reserve for the indication of hepatic resection

The main goal of liver resection in patients with liver tumor is to cure the patients with the lowest operative risk. Based on our experiences, we report herein, indications of liver resection according to the nature of underlying liver parenchyma. In patients with normal underlying liver parenchyma, major resection does not require specific preoperative assessment. Non-tumorous biopsy is indicated in cases of massive steatosis and/or in patients in whom a complex technical procedure is anticipated. Portal vein embolization (PVE) is considered if the future liver remnant (FLR) is <30%. In patients with chronic liver disease, major hepatectomy is a risky situation, requiring specific preoperative assessment, including non-tumorous biopsy and PVE which could be associated with transarterial chemoembolization. Absence of hypertrophy of the FLR after PVE is a contraindication to a major hepatectomy. Intraoperative procedures in patients at risk require specific techniques, including intermittent clamping, anterior approach with hanging maneuver, and fixation on anatomical position of the remnant liver.     

Assessment of hepatic reserve for indication of hepatic resection: how I do it

Background/purpose Hepatic resection may result in liver failure in patients with cirrhotic livers. Preoperative evaluation of liver function in cirrhotic patients, to prevent postoperative liver failure, is very important.Methods Sixteen patients with hepatocellular carcinoma in cirrhotic livers were enrolled in this study. Liver function was determined quantitatively by monoethylglycinexylidide (MEGX) formation from the metabolism of lidocaine. The whole liver volume and tumor volume were measured by computed tomographic volumetry. The volume of resected liver was recorded by water displacement. The relationship between liver function and remnant liver volume was determined.Results A relationship between the percentage remnant liver volume and ratio of MEGX formation after hepatectomy was found. The regression equation was: (postoperative MEGX formation/preoperative MEGX formation) × 100% = (0.688 × percentage remnant liver volume + 0.179) × 100% (r ² = 0.49). A relationship between MEGX formation after hepatectomy and the international ratio (INR) of prothrombin time was also found. The regression equation was INR = 1.99 – 0.01 × MEGX (r ² = 0.30).Conclusions Post-hepatectomy liver function can be estimated for an individual patient by the appropriate regression equations. Prevention of post-hepatectomy liver failure for patients with cirrhotic livers is feasible.     

Assessment of hepatic reserve for the indication of hepatic resection: how I do it

This author has personally carried out in excess of 700 major hepatic resections for tumor, and runs a unit with a current resection rate of 200 per year, yet uses no scientific tests designed to judge hepatic reserve. In our unit, we have an advantage in that we deal with a northern European population, with a low rate of viral hepatitis, although alcoholism is becoming an increasing feature within our practice and we are dealing with more elderly patients that in the past, and more who have undergone neoadjuvant chemotherapy. In these patients, there appear to be greater risks of postoperative sepsis and slower regeneration. Approximately 65% of our current resection practice is hemihepatectomy or more and the majority is trisectionectomy (extended hepatectomy) and bilateral resection work. Preoperative, operative, and postoperative factors affect the occurrence of postoperative hepatic failure and these aspects are considered. Case series studies are presented to illustrate the incidence of significant hepatic failure we have encountered.     

Assessment of hepatic reserve for indication of hepatic resection: decision tree incorporating indocyanine green test

Preoperative assessment of liver function and prediction of postoperative remaining functional liver parenchymal mass and reserve is of paramount importance to minimize surgical risk, especially in patients with hepatocellular carcinoma (HCC), the majority of whom have liver cirrhosis as a complication. We have established a decision tree for deciding the safe limit of hepatectomy based on three variables: whether ascites is present, the serum total bilirubin level, and the indocyanine green retention rate at 15 minutes (ICGR-15), an indicator of sinusoidal capillarization. In patients who show a sign of decompensated cirrhosis as reflected by an elevated bilirubin value or uncontrollable ascites, hepatectomy is not indicated. In patients without ascites and with normal bilirubin level, the ICGR-15 value becomes the main determinant for the resectability and hepatectomy procedure. Incorporation of ICGR-15 into the decision tree enables patients conventionally classified into Child–Turcotte–Pugh class A or score 5–6 to be subdivided into several groups in which various hepatectomy procedures are feasible: enucleation, limited resection, segmentectomy, mono- to bisectoriectomy, and trisectriectomy. During strict application of this decision tree to 1429 consecutive hepatectomies, of which 685 were performed on HCC patients, during the last 10 years, we encountered only a single mortality.     

Diagnostic laparoscopy prior to planned hepatic resection for colorectal metastases

HYPOTHESES: (1) A clinical risk score (CRS) is useful in selecting patients for diagnostic laparoscopy prior to planned resection of colorectal metastasis. (2) Preventing unnecessary celiotomy in these patients undergoing laparoscopy is associated with shorter hospital stays and earlier administration of systemic chemotherapy. DESIGN: Retrospective analysis of data collected in a prospective database. SETTING: Tertiary cancer hospital. PATIENTS: Two hundred seventy-six patients who underwent laparoscopy prior to planned partial hepatic resection (n = 264) for colorectal metastases or prior to hepatic artery infusion pump placement for colorectal metastases (n = 12). MAIN OUTCOME MEASURES: The yield of laparoscopy for patients with potentially resectable tumors was analyzed in the context of a CRS, calculated by assigning 1 point for each of the following adverse, disease-related factors: lymph node-positive primary tumor, disease-free interval less than 12 months, more than 1 hepatic tumor, hepatic tumor greater than 5 cm, and cardio embryonic antigen level less than 200 ng/mL. The CRS represents the sum for each patient. Length of hospital stay and time to initiation of chemotherapy were compared in those patients determined to be unresectable. RESULTS: Staging laparoscopy prevented nontherapeutic celiotomy in 10% of patients submitted to operation for a potentially curative partial hepatectomy (26 of 264) and in 33% of patients scheduled for pump placement only (4/12). The CRS correlated closely with the likelihood of identifying radiographically occult unresectable disease: 0 or 1, 4%; 2 or 3, 21%; and 4 or 5, 38%. Likewise, the percentage of patients avoiding an unnecessary celiotomy increased progressively with increasing CRS: 0 or 1, 0%; 2 or 3, 11%; and 4 or 5, 24%. Preventing an unnecessary celiotomy with laparoscopy was associated with a decreased length of hospital stay (P<.01) and earlier initiation of chemotherapy (P = .045). CONCLUSIONS: Diagnostic laparoscopy does not need to be performed routinely in all patients prior to hepatic resection for colorectal cancer metastasis. Laparoscopy has a very low yield in patients with a CRS of 1 or less and is unnecessary. The yield of laparoscopy increases with increasing CRS. Preventing celiotomy with laparoscopy is associated with a decreased length of hospital stay and earlier initiation of postoperative chemotherapy.     

肝癌切除围手术期肝脏贮备功能的研究

绝大部分肝细胞性肝癌病人合并肝硬化。常规肝功能检查对估计肝硬化病人肝切除时围手术期肝脏贮备功能存在明显不足。我们通过动物实验和临床观察，研究嘴哚氰绿５分钟潴留率（ＩＣＧＲ１５）、精氮酸清除率（Ａｒｇ－ＣＲ）、利多卡因代谢（ＬＩＤ）、肝实持切除率（ＰＨＲＲ）和动脉血酮体幽会在反映肝功能状态上的实际价值，并根据临床结果进行了综合评定。结果表明上述指标有助于及时地准确了解病人的肝脏功能状态、并提出了术前     

How I do it: assessment of hepatic functional reserve for indication of hepatic resection

Liver resection of up to 75% of the total liver volume (TLV) has been regarded as safe in normal livers, but this concept was challenged by the results of living donor hepatectomies. In normal livers or livers with resolved jaundice, hepatectomy of 65% of TLV may be safe, except for patients with an indocyanine green retention rate at 15min (ICG R15) of over 15%, excessive hepatic steatosis, and age of over 70 years. However, the permissible extent of hepatectomy has been much restricted in cirrhotic livers because most post-hepatectomy liver failure (PHLF) has occurred in cirrhotic livers. Our routine protocols for the assessment of functional hepatic reserve (FHR) include biochemical liver function tests, ICG R15, Doppler ultrasonography, and triphasic liver computed tomogram (CT) with volumetry. Blood cell count and gastroesophageal endoscopic findings are taken into consideration for cirrhotic livers, as well as age, diabetes, cardiopulmonary function, and general performance. Preoperative portal vein embolization has been used for safe hepatectomy even in cirrhotic livers. We think that any cirrhotic liver showing optimal FHR should have a remnant liver of 40% of TLV to prevent PHLF. ICG R15 and triphasic CT with volumetry have been the most useful methods for assessment of FHR and determination of hepatecomy extent in our institution.     

Portal vein resection and reconstruction prior to hepatic dissection during right hepatectomy and caudate lobectomy for hepatobiliary cancer

BACKGROUND: Hepatobiliary cancer invading the hilar bile duct often involves the portal bifurcation. Portal vein resection and reconstruction is usually performed after completion of the hepatectomy. This retrospective study assessed the safety and usefulness of portal vein reconstruction prior to hepatic dissection in right hepatectomy and caudate lobectomy plus biliary reconstruction, one of the common procedures for radical resection. METHODS: Clinical characteristics and perioperative results were compared in patients who underwent right hepatectomy and caudate lobectomy plus biliary reconstruction with (ten patients) and without (11 patients) portal reconstruction from September 1998 to March 2002. RESULTS: All ten portal vein reconstructions were completed successfully before hepatic dissection; the portal cross-clamp time ranged from 15 to 41 (median 22) min. Blood loss, blood transfusion during the operation, postoperative liver function, morbidity and length of hospital stay were similar in the two groups. No patient suffered postoperative hepatic failure or death. CONCLUSION: This study demonstrates that portal vein reconstruction does not increase the morbidity or mortality associated with right hepatectomy and caudate lobectomy with biliary reconstruction. This approach facilitates portal vein reconstruction for no-touch resection of hepatobiliary cancer invading the hilar bile duct.     

Repeated hepatic resection

Sixteen patients underwent repeated hepatic resections over a 16 year period. The cases were divided into two groups: group A, non-planned repeated resections (14 cases), and group B, planned repeated resections (two cases). Group A is composed of patients requiring re-resection as a result of the hepatic re-recurrence of the neoplasia (three hepatocellular carcinomas, nine metastases from colorectal carcinoma, and two metastases from carcinoid tumor). Group B is composed of two cases (hepatocellular carcinoma and metastases of leiomyosarcoma) where the extent of the disease was incompatible with radical resection in a single time thus making necessary to plan for repeated operations. The need for correct preoperative assessment of hepatic performance using CT, US and Tc 99m HIDA scan, as well as intraoperative ultrasonography is stressed.     

Laparoscopic hepatic resection

Background Although laparoscopy in general surgery is increasingly being performed, only recently has liver surgery been performed with laparoscopy. We critically review our experience with laparoscopic liver resections. Methods From January 2000 to April 2004, we performed laparoscopic hepatic resection in 16 patients with 18 hepatic lesions. Nine lesions were benign in seven patients (five hydatid cysts, three hemangiomas, and one simple cyst), five were malignant in five patients (five hepatocarcinoma), and four patients had an uncertain preoperative diagnosis (one suspected hemangioma and three suspected adenomas). The mean lesion size was 5.2 cm (range, 1–12). Twelve lesions were located in the left lobe, three were in segment VI, one was in segment V, one was in segment IV, and one was in the subcapsular part of segment VIII. Results The conversion rate was 6.2%; intraoperative bleeding requiring blood transfusions occurred in two patients. Mean operative time was 120 min. Mean hospital stay was 4 days (range, 2–7). There were no major postoperative complications and no mortality. Conclusions Hepatic resection with laparoscopy is feasible in malignant and benign hepatic lesions located in the left lobe and anterior inferior right lobe segments (IV, V, and VI). Results are similar to those of the open surgical technique in carefully selected cases, although studies with large numbers of patients are necessary to drawn definite conclusions.     

肝脏切除技术

肝切除是一项需由有经验的外科医生完成的高风险手术.肝切除术在治疗肝恶性疾病中的地位在过去100年里随着并发症、病死率不断地减少及生存率的提高而发生了改变.对肝解剖新的认识,不断提高的围手术期治疗,麻醉技术和技术上的进步已使患者的治疗效果得到改善.随着技术的进步,从前被认为肿块不可切除的患者有了接受根治性手术的机会.该篇综述描述了针对肝切除的不同方法及技巧.文中对肝切除相关解剖、手术命名,解剖肝切除与非解剖肝切除的地位进行了讨论.分析了不同血管控制方法及对不同的肝实质横断策略进行了对比,同时涉及到了微创手术技术.最后,介绍了作者对肝切除的有关技术经验.     

The hippurate ratio as an indicator of functional hepatic reserve for resection of hepatocellular carcinoma in cirrhotic patients

Predicting the ability of the cirrhotic liver to withstand resection remains a challenge for the surgeon. This study evaluates the use of the hippurate ratio, a novel assessment of glycine conjugation of paraaminobenzoic acid by the liver, as a preoperative indicator of functional hepatic reserve. Between 1998 and 2000, sixty-one cirrhotic patients were prospectively assessed for hepatic resection using the hippurate ratio, indocyanine green retention at 15 minutes (ICG R-l5), and other standard measures of liver function. Twenty-six patients were excluded as candidates for resection on the basis of inadequate functional hepatic reserve. Patients excluded from resection had significantly higher ICG R-15 values (29% ±9% vs. 16% ±12%, P = 0.00l), higher Child-Pugh scores (5.9 ± 0.9 vs. 5.3 ± 0.4, P = 0.01), and lower hippurate ratios (30% ±14% vs. 45% ± lS%, P = 0.005). There was a significant correlation between the hippurate ratio and ICG R-l5. Other indicators of liver function such as factor V, factor VII, albumin, bilirubin, protbrombin time, and transaminases were no different between patients who did and those who did not undergo resection. Of the 35 patients resected, there were seven (20%) who developed varying degrees of liver failure with three perioperative deaths (8.5%). Patients who had some degree of liver failure had significantly lower hippurate ratios than patients who had no liver failure (29% ±10% vs. 48% ±14%, P = 0.002). There was no difference in ICG R-15 values between patients who had liver failure and those who did not. The hippurate ratio offers information on hepatocellular reserve that is not provided by other measures of liver function and may allow better selection of cirrhotic patients for liver resection. Supported by a grant from the Physician’s Services Incorporated Foundation, Ontario, Canada. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000.     

Appraisal of surgical resection of gallbladder carcinoma with special reference to hepatic resection

Carcinoma of the gallbladder a gastrointestinal malignancy with an extraordinarily poor prognosis. However, aggressive surgery, with special reference to hepatic resection, may improve survival. To prove this, we performed a retrospective analysis over an 18-year period to investigate the experience of a center that began employing liver resection in patients with gallbladder cancer in 1978. The analysis was based on patients' documentation and regular follow-up to January 1996. The standard procedures were extended cholecystectomy (cholecystectomy with lymphadenectomy and wedge hepatic resection), anatomic segmentectomy of segments IVa and V, and extended hepatectomy. Significance was assessed by the log-rank test. Thirty-nine patients were resected, curatively in 41% (n = 22; group I) and palliatively in 31% (n = 17; group 2). In 28% (n = 15; group 3) a palliative or no operation was performed. Only curatively resected patients were analyzed and followed up to January 1996. No patients in group 1 died postoperatively. The actuarial 5-year survival rate of the patients with curative resection was 55%. Four patients had stage I, two had stage II, four had stage III, and two had stage IV disease according to TNM-classification. Six of the 16 patients without lymph node metastasis survived more than 5 years. A significant difference in long-term survival was recognised between stage II and stage IV patients and between stage (pT1a)- and (look table 1b) (pT1b)-patients (P < 0.01). Diagnostic efforts should focus on detecting early stages I and II gallbladder cancer. In advanced cases, aggressive surgery, particularly with hepatic resection, is the method of choice and is successful even in patients 70 years and older. Received for publication on July 31, 1997; accepted on April 1, 1998     

门静脉动脉化对扩大肝-胆切除术后肝脏储备功能的影响

目的 观察慢性、梗阻性黄疸小型猪肝-胆切除术联合限流性部分门静脉动脉化(PPVA)术后肝脏储备功能的动态变化.方法 利用梗阻性黄疸小型猪模型,模拟进行联合半肝切除的肝门部胆管癌扩大根治性手术.实验分组:无黄疸对照组(A组,n=4)、门静脉动脉化组(B组,n=4)及非门静脉动脉化组(C组,n=4).对照观察根治术中应用限流性PPVA在术后30 d内的吲哚菁绿15 min滞留率(ICG15),从而判断肝脏储备功能的动态变化.结果 术前B、C组高于A组[(0.66±0.07)%、(0.64±0.09)%比(0.09±0.01)%,P＜0.01],术后第1天B组低于C高于A组[(0.59±0.11)%比(0.82±0.09)%、(0.18±0.04)%,P＜0.05、P＜0.01],术后第7天B组高于A组低于C组[(0.34±0.09)比(0.17±0.04)%、(0.69±0.11)%,P均＜0.05].术后第30天B组低于C组、与A组差异无统计学意义[(0.12±0.03)%比(0.22±0.03)%、(0.09±0.003)%,P＜0.01、P＞0.05].B组术后第7天低于术前[(0.34±0.09)%比(0.66±0.07)%,P＜0.01].结论 限流性PPVA可促进慢性梗阻性黄疸小型猪肝-胆切除术后残肝储备功能的恢复.

Abstract：

Objective To investigate the change of hepatic functional reserve (HFR) after flowcontrolled partial portal vein arterialization (PPVA) in hepato-biliary resection (HBR) in miniature pigs with obstructive jaundice. Methods Eight miniature-pig models with chronic gradually obstructive jaundice were divided into 2 groups with 4 pigs each: PPVA group (group B,n =4), non-PPVA group (group C, n = 4), and another 4 pigs without chronic gradually obstructive jaundice served as control group ( group A, n = 4). Approaches of EHBR with or without PPVA were done, then the effects of flow-controlled PPVA on HFR of remnant liver were studied by detecting indocyanine-green retention at 15 min ( ICG15 ) in 30 days post-operation. Results ICG15 in groups B and C was significantly higher than in group A pre-operation[(0.66±0.07)%, (0.64±0.09)% vs (0.09±0.01)%,P＜0.01]. ICG15 in group B was significantly lower than that in group C, and higher than in group A at the first day post-operation[(0. 59 ±0.11)% vs (0.82±0.09)%, (0.59±0.11)% vs (0. 18±0.04)%,P＜0. 05,P＜0. 01]. ICG15 in group B was significantly lower than in group C, and higher than in group A at 7th day post-operation [(0. 34±0.09)% vs (0.69 ±0. 11)%, (0.34±0.09)% vs (0. 17 ±0.04)% ,both P＜0.05]. ICG15 in group B was significantly lower than in group C, but showed no significant difference from group A at 30th day post-operation[(0.12 ±0.03)% vs (0.22 ±0.03)%, (0.12 ±0.03)% vs (0.09 ± 0. 003)% ,P ＜0. 01 ,P ＞ 0. 05]. ICG15 in group B on the 7th day post-operation was significantly lower than that pre-operation[(0. 34 ± 0. 09 ) % vs (0. 66 ± 0. 07 ) %, P ＜ 0. 01]. Conclusion Flow-controlled PPVA in HBR is beneficial to recovery of HFR on miniature pigs with obstructive jaundice.     

Safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection

Accurate tumor localization is critical to performing minimally invasive colorectal resection. This study reviews the safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection. Weretrospectively reviewed 50 consecutive patients with colorectal neoplasms who underwent endoscopic tattooing prior to laparoscopic resection. Data were obtained from medical charts, endoscopy records, and pathology reports. No complications related to endoscopy or tattooing were incurred. Five neoplasms (10%) were in the ascending colon, five (10%) were in the transverse colon, eight (16%) were in the descending colon, 23 (46%) were in the sigmoid colon, and nine (18%) were in the rectum. Tattoos were visualized intraoperatively and accurately localized the neoplasm in 44 patients (88%). Six patients (12%) did not have tattoos visualized laparoscopically and required intraoperative localization. On average, the pathology specimens in this series had a 15 cmproximal margin, a 12 cmdistal margin, and 15 lymph nodes. In the context of laparoscopic colorectal resection, preoperative endoscopic tattooing is a safe and reliable method of tumor localization in most cases. Localizing colon and proximal rectal lesions with tattoos may be preferable to other localization techniques including intraoperative endoscopy.     

Preoperative estimation of operative risk in liver surgery,with special reference to functional reserve of the remnant liver following major hepatic resection

Hepatic functional reserve was evaluated in 76 patients with known liver, biliary tract or pancreas diseases using kinetic analysis of removal of indocyanine green (ICG) with special reference to maximal removal rate (Rmax). In surgery other than hepatectomy, if ICG Rmax is below 0.4 mg/kg/min the operative risk should be considered high. In hepatic surgery, even if ICG Rmax is above 0.4 mg/kg/min the operative risk was high and it should be required to be above 1.0 mg/kg/min for extended lobectomy or hepatectomy. Furthermore, prior to hepatectomy the functional reserve of the remnant liver was estimated from an effective liver volume rate, calculated from the rate of uptake of radioisotope as measured by on-line computer system, and ICG Rmax. The functional reserve of the remnant liver was compared with the operative results, such as morbidity or mortality for each patient. When ICG Rmax of the remnant liver was below 0.4 mg/kg/min the prognosis was poor in hepatic surgery, because of there were three post-operative death and seven complications such as ascites or liver failure in the ten cases. On the other hand, when above 0.4 mg/kg/min, the prognosis was good without any postoperative death or complications in the twelve cases of hepatic surgery, as the completely same results for general surgery, in which it is as well when ICG Rmax of whole liver is above 0.4 mg/kg/min.