Contribution of peroperative ultrasonography in the surgery of liver tumors

Intraoperative echography helps both in the detection of the tumor and in the assessment of the vascular and biliary anatomy. The experience reported here was gained with 114 carcinomas in cirrhotic livers, 46 carcinomas in normal livers, 330 cases of metastases to the liver and 55 benign tumors. Ultrasound has modified the surgical prediction in 10 to 30% of all cases, according to the group.     

Intraoperative ultrasonography in resection of small hepatocellular carcinoma associated with cirrhosis

Preoperative detectability rates of hepatocellular carcinoma smaller than 5 cm in 113 cirrhotic patients were 91 percent by ultrasonography, 93 percent by computed tomography, and 92 percent by selective angiography. The combination of two methods produced detectability rates of 97 to 99 percent. One hundred three patients underwent various types of hepatic resection with the aid of intraoperative ultrasonography. Forty-four tumors (43 percent) were embedded in the liver, and these tumors were not detected by conventional surgical exploration. The detectability rates were 38 percent for hepatocellular carcinomas smaller than 2 cm, 57 percent for 2 to 3.5 cm tumors, and 71 percent for 3.5 to 5 cm tumors. All undetectable hepatocellular carcinomas were identified by intraoperative echography. The overall detection rate by this method was 98 percent, which was substantially higher than the preoperative rate. Intraoperative ultrasonography is a useful and indispensable method for performing atypical minor hepatectomy for the treatment of small hepatocellular carcinomas associated with liver cirrhosis.     

Value of intraoperative ultrasonography in the surgical treatment of malignant tumors of the liver]

This retrospective study was designed to assess the specific contribution of intraoperative ultrasonography (IOU) in a series of 50 surgical procedures for malignant tumors of the liver (including 27 hepato-cellular carcinomas (HCC) secondary to cirrhosis and 18 metastases). Compared to conventional pre- and intra-operative investigations, IOU was more sensitive (81%) but less specific (27%) for detection of tumor nodules, but was inaccurate in detection of daughter nodules in hepato-cellular carcinomas (HCC) secondary to cirrhosis. The main specific contribution of IOU was assistance in performing surgery. In 14 cases (52%) of HCC secondary to cirrhosis, IOU provided one or several additional pieces of information which resulted in changes of the planned surgical procedure in 11 cases (41%) mainly enabling limited resection of small deep impalpable tumors. In 10 cases (37%), IOU directly guided resection (echo-guided segmentectomy or tumorectomy). Contribution of IOU was poor in primary carcinoma in non-cirrhotic liver, but in 8 cases of metastasis (44%) IOU provided additional information which resulted in changes of the intended surgical procedure in 5 cases (28%) mainly leading to a more extensive resection. Finally IOU was considered to be indispensable in 15 cases of HCC cirrhosis (56%) and in 5 cases of metastasis (28%).     

Segmental liver resection using ultrasound-guided selective portal venous occlusion

Anatomical segmental resection of small hepatic lesions using operative ultrasonography is improved by selective intrahepatic portal venous occlusion. The technique was successfully performed in 15 of the 18 patients in whom it was attempted. The lesions resected included 7 hepatocellular carcinomas in cirrhotic patients, 5 hepatic metastases, 2 benign tumors and 1 gallbladder carcinoma. The mean duration of local vascular exclusion was 47 minutes (range, 22 to 80 minutes) and mean blood transfusion requirement was 1.3 units (range, 0 to 7 units). Five patients sustained postoperative complications and these included chest infection (2 patients), ascites (2 patients), pleural effusion (1 patient) and hemorrhage (1 patient) from the site of hepatic resection. There were no postoperative deaths. One patient required further resection of a recurrent colonic metastasis and two patients have died of disseminated disease. This technique has allowed limited anatomical resection of lesions that would have otherwise required extensive classical hepatic resections or would have not been amenable to resection.     

Peroperative exploration of the liver in hepatic tumor surgery

Intraoperative exploration of the liver and complete abdominal examination are essential before hepatic resection for patients with liver tumors. The surgeon's eye and hand, traditional methods of exploration, are still accurate for abdominal exploration, screening of small superficial liver tumors and evaluation of non-tumoral liver parenchyma. Intraoperative ultrasonography is often superior to preoperative screening methods in diagnosing small liver tumors. Intraoperative ultrasonography identifies variations of intrahepatic vascular structures and reveals exact location of tumors according to functional anatomy. The surgeon's eye and hand and intraoperative ultrasound are complementary for a complete exploration, and may affect operative decision making. Laparoscopy and laparoscopic ultrasonography, when diagnosing non resectable tumors, reduce the number of unnecessary laparotomies. However, the effectiveness of exploration by laparoscopy and laparoscopic ultrasonography is lower than that of laparotomy, which remains indispensable before hepatic resection for malignant tumors.     

深部微小肝癌术中超声导引下经肝穿刺美蓝定位与切除

目的探讨术中超声引导下美兰染色在深部微小肝癌的手术定位及切除方法。方法对2011年8月~2014年2月入住我院临床确诊的肝深部微小肝癌患者13例,术中应用Aloka 5000型超声仪,探头(频率5 MHz)直接置于肝脏表面进行超声检查,确定微小肝癌的大小、形态,并在超声导引下经肝穿刺注射美兰于肿瘤表面,并实施距肿瘤边缘1~2cm的不规则肝部分切除术。结果 13例患者均合并有肝硬化,均无法通过触诊发现病灶。术中超声均准确的定位病灶的位置、大小及形态,并成功的经肝穿刺注射美兰至肿瘤表面,并根据美蓝定位顺利找到肿瘤,实施手术切除,术后恢复良好。结论合并有肝硬化的肝实质深部微小肝癌行术中超声引导下经皮肝穿刺美蓝染色,定位准确;保证切缘阴性的不规则肝部分切除能保留更多的正常肝组织,减少手术时间及出血量,减轻对肝功能的损害。     

Intrahepatic Glissonian access for segmental liver resection in cirrhotic patients

The main goal of segmental technique is to preserve the maximum amount of liver parenchyma. Liver-preserving techniques are especially important for patients with hepatocellular carcinoma and cirrhosis. We report the technique for segmental liver resection in cirrhotic patients and detail technical difficulties and immediate surgical outcome. For right segmental liver resections the intrahepatic access is performed through small incisions around the hilar plate. Left segmental resection technique also consists of small incisions following specific anatomic landmarks. Nineteen cirrhotic patients underwent segmental liver resections. A blood transfusion was required in 2 patients. No patient experienced major bleeding from the liver incisions made for intrahepatic access. The median hospital stay was 5 days. No surgical mortality occurred. The intrahepatic access technique allows individual resections of liver segments and is feasible even in cirrhotic patients. Knowledge of segmental liver resection techniques is an essential armamentarium in the modern era of liver surgery.     

Isolated resection of segment 8 for liver tumors: a new approach for anatomical segmentectomy

HYPOTHESIS: Isolated resection of segment 8 (the right anterosuperior liver segment) is one of the most difficult hepatectomies to perform because of the location of segment 8, the relation between section 8 and the main intrahepatic vessels, and the absence of any anatomical landmarks. The few reports that deal with isolated resection of section 8 generally describe the use of a deep wedge transparenchymal transection. DESIGN: Original surgical technique. PATIENTS AND METHODS: The proposed technique is based on the extraparenchymal isolation and temporary clamping of the right anterior artery and portal branches, causing ischemic demarcation on the liver surface, which corresponds to the anatomical borders of the right paramedian segments (5 and 8). The liver is widely transected along the main hepatic fissure; then the pedicles of segment 8 are selectively ligated inside the parenchyma, and the resection is accomplished. This technique was used in 10 patients: 5 with hepatocellular carcinoma on cirrhosis and 5 with liver metastases. RESULTS: The mean operation time was 253 minutes. Intraoperative blood loss was minimal in all cases, and 7 patients did not require blood transfusion. Slight complications developed in 3 patients, and there was no operative death. The mean hospital stay was 9.3 days. CONCLUSIONS: This operative procedure is safe and ensures a complete anatomical resection of segment 8. The wide opening of the liver parenchyma facilitates hemostasis and makes it possible to obtain a correct resection margin. This technique is recommended for limited metastatic lesions located in segment 8 or for hepatocellular carcinoma arising in a cirrhotic liver.     

Liver resection without hilus preparation and with selective intrahepatic hilus stapling for benign tumors and liver metastasis

Background Nowadays, liver resection is a routine operative procedure in surgical centers, and strategies must be aimed at avoiding additional risk factors. Extrahepatic isolation of portal vein, hepatic artery and hepatic duct, as well as lymphadenectomy of the liver hilum are generally accepted steps of liver resection, even for metastatic and benign indications. Our primary aim was to analyze the feasibility, blood loss, blood transfusion requirements, incidence of complications, and outcome using the approach for intrahepatic devascularization leaving the extrahepatic hilus untouched. Materials and methods Thirty-eight consecutive patients with resection for metastases and benign liver tumors were selected. After hilar examination, the extrahepatic structures remain intact, and during parenchyma dissection, the whole right or left or the appropriate bi-segmental pedicle is isolated intrahepatically and then transected using a stapler device. Results The used technique was feasible in all cases, and no intra- or postoperative surgical complications were observed. To date, no tumor recurrence was found in the hilum during the follow-up period. Conclusion The intrahepatic pedicle stapling technique appears to be feasible and safe in liver resection. Hilar dissection can, thus, be avoided in liver metastasis and benign liver tumors.     

Laparoscopic liver resections: a feasibility study in 30 patients

OBJECTIVE: To assess the feasibility and safety of laparoscopic liver resections. SUMMARY BACKGROUND DATA: The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. METHODS: A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. RESULTS: From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. CONCLUSION: Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.     

Intraoperative ultrasonographic detection of occult liver metastases in colorectal cancer

Summary The efficacy of intraoperative ultrasonographic detection of colorectal cancer liver metastases was evaluated in 85 patients undergoing operation for primary colorectal tumors or liver secondaries. The results of intraoperative ultrasonography were compared with those of preoperative ultrasonography and computed tomography, as well as the intraoperative appearances of the liver. Additional information about the number of metastases was obtained in 12 cases (14.1%); 17 (24.3%) out of 70 metastases could only be detected by intraoperative ultrasonography. In 4 cases (4.7%) these lesions were solitary. As a result, the operative procedure of choice was changed in 15.3% of the patients. We conclude that intraoperative ultrasonography has a significantly higher ability to detect colorectal cancer liver metastases than preoperative methods or intraoperative inspection and palpation. Intraoperative ultrasonography should be performed in patients without preoperative evidence of liver metastases and in all patients with planned resection of metastases.     

Power Doppler ultrasonographic diagnosis of small hepatocellular carcinomas

BACKGROUND/AIMS: Power Doppler ultrasonography can evaluate the hemodynamics of intrahepatic tumors. The ability of power Doppler ultrasonography to detect small hepatocellular carcinomas and estimate the differentiation of the tumor by the patterns of intranodular waves was assessed. METHODS: We used conventional B-mode ultrasonography, power Doppler ultrasonography, and dynamic computed tomography to examine 71 hepatocellular carcinomas (相似文献   

影响3cm以下小肝癌患者术后生存因素的观察

目的 总结小肝癌的手术治疗经验,探讨影响其术后生存率的临床、病理因素。方法回顾性分析1986年1月-2003年12月间手术切除并获得随访的105例小肝癌(≤3cm)的临床、病理资料,中位随访时间33个月。对有无结节性肝硬化、肝功能Child分级、术前血清AFP水平、肿瘤大小、有无肿瘤包膜、肿瘤分化程度(Edmondson分级)、有无门静脉癌栓、肿瘤是否多灶性(包括卫星灶)及手术方式等9项临床、病理参数与术后生存率及无瘤生存率的关系进行单因素及Cox模型多因素分析。结果截止2004年5月,手术后1、3、5年生存率分别为86．5%、70．3％、55．2％,无瘤生存率分别为78．0％、58．9％、45．6％。再次手术死亡1例。随访期内36例肝内复发,34例死亡。单因素及多因素分析均提示术前肝功能Child分级、肿瘤大小、门静脉癌栓及肿瘤多灶性是影响手术后生存率的预后因素,多因素分析显示肿瘤大小、门静脉癌栓及多灶性是影响手术后无瘤生存率的预后因素。结论距肿瘤1cm以上切缘的局部切除是治疗小肝癌的合理手术方式,手术后的肝内复发和转移及肝功能不良是导致小肝癌患者术后死亡的主要原因。     

Limited hepatic resection by laparoscopy-assisted mini-laparotomy for the treatment of hepatocellular carcinoma in cirrhotic patients

Surgical resection is standard treatment for hepatocellular carcinoma but is often not possible in the presence of cirrhosis or poor liver function. We present a method of performing limited hepatectomy in patients with hepatocellular carcinoma and cirrhosis. We call this method laparoscopy-assisted mini-laparotomy (LAML). The site of the tumor is localized by ultrasound through a laparoscope, and a small skin incision is made over that site to facilitate removal of the portion of liver containing the tumor. Eleven patients underwent limited hepatic resection by LAML. The tumors were on the margin of the liver. There was no hospital mortality or serious complications. The average length of hospital stay was 6.4 days. LAML can be safely performed for hepatocellular carcinoma in cirrhotic patients. It decreases operating time, length of hospital stay, and blood loss.     

Living donor liver transplant for fibrolamellar hepatocellular carcinoma using a deceased donor graft to reconstruct inferior vena cava.

Liver transplantation is now an acceptable treatment for small hepatocellular carcinomas in the setting of cirrhosis. Larger tumors in cirrhotic livers and unresectable tumors in noncirrhotic livers (including fibrolamellar hepatocellular carcinomas) may also be indications for transplantation. With the limited number of cadaver grafts available, living donor liver transplant is becoming an option for some of these patients. We describe a method of reconstruction of the recipient inferior vena cava with deceased donor graft in right lobe living donation for fibrolamellar hepatocellular carcinoma.     

荧光导航系统联合术中超声在精准腹腔镜肝肿瘤切除术中的应用

目的 探讨荧光导航系统联合术中超声在精准腹腔镜肝肿瘤切除术中的应用价值。方法 回顾性分析2019 年3 月至2019 年5 月期间浙江省人民医院应用荧光导航系统联合术中超声实施腹腔镜肝肿瘤切除术12 例患者的临床资料,其中男5 例,女7 例;原发性肝癌9 例,转移性肝肿瘤3 例。术中荧光导航系统联合腹腔镜超声进行肿瘤定位及精准切除,对术中切除肿瘤数量、肿瘤的荧光显影情况、肿瘤切缘、病理类型数据进行分析。结果 术中共发现病灶20个,术后病检提示恶性肿瘤15个、肝硬化结节5个。术中直接于荧光导航系统下显影病灶13 个,腹腔镜超声下发现病灶14 个,腹腔镜超声引导下定位切开部分肝脏后荧光显影病灶6 个。1 例患者的病灶术中荧光导航未直接显影,且超声未发现,结合术前检查切开部分肝脏组织后于荧光下显影后予以切除。其中荧光导航系统下显影切除病灶中5 个术后病理提示为肝硬化结节,术后所有肿瘤切缘均为阴性。结论 荧光导航联合术中超声技术的应用对于腹腔镜肝肿瘤切除术中的肿瘤定位、精准切除有重要临床价值。     

Liver resection for hepatocellular carcinoma in cirrhotic patients

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis. Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. From 1998 to 2005, 6 patients (5 males, 1 female, age 52-70 years, mean age 64.1 years) with HCC associated severe, but well compensated liver cirrhosis (Child A-- 4 patients, Child B--2 patients) underwent 9 hepatic resection in our department. Mean tumor size was 56 mm (range 23-86 mm). Two of these lesions were in the left liver and four in the right lobe. Doppler ultrasonography was performed in all cases and CT in 3 cases to confirm the extension of the lesions. Laparoscopy was performed in 3 patients under CO2 pneumoperitoneum. The Pringle maneuver was not used. The transection of the liver parenchyma was obtained by the use of Ligasure and harmonic scalpel. Nine hepatic resections were performed: 7 segmentectomy and 2 non-anatomical resections. The resection margin was 1 cm. The mean operative time was 90 minutes (range 60-120). Mean blood loss was 250 ml and 2 patients required blood transfusion. One patient died on the tenth postoperative day from a severe respiratory distress syndrome and hepatic failure. Major morbidities occurred in three patients who developed moderate postoperative ascites, which resolved successfully with conservative treatment in two patients. Limited liver resection in cirrhotic patients with HCC is feasible with a low complication rate when careful selection criteria are followed (tumor size smaller than 8 cm, Child-Pugh A class and the good general conditions of the patients). Other medical and interventional treatments (chemoembolization, chemotherapy) can only slow the progress of HCC.     

Small liver cancer

We report eight cirrhotic patients with liver cancer of less than 2 cm in diameter, and who were successfully treated by surgery. The sensitivities of diagnostic procedures for small lesions showed that alpha-fetoprotein (AFP) was 75 per cent, radionuclide scanning 25 per cent, CT 33 per cent, ultrasonography 40 per cent and angiography 88 per cent. Serial measurement of AFP appears to be the most helpful for detection of hepatocellular carcinoma at the early stage, particularly in cirrhotic patients. Although hepatic imagings are of limited value for small hepatic tumors, those tools are often useful as a back-up for the routine tests but not for initial procedures. It should also be kept in mind that hepatic arteriography performed in the high risk group often leads to detection of small cancers. In cirrhotic patients with small hepatocellular carcinoma, surgical resection should be done, providing the clinical status and hepatocellular reserve are adequate.     

Diagnostic Approach to Hepatic Mass Lesions and Role of Immunohistochemistry

This review provides an overview of various hepatic mass lesions and a practical diagnostic approach, including most recent immunohistochemical stains used in clinical practice. A wide variety of benign and malignant lesions present as hepatic masses, and the differential diagnosis varies. In cirrhotic liver, the commonest malignant tumor is hepatocellular carcinoma (HCC), which needs to be differentiated from macroregenerative nodules, dysplastic nodules, and other tumors. The differential diagnosis of lesions in noncirrhotic liver in younger patients includes hepatic adenoma (HA), focal nodular hyperplasia (FNH), HCC, and other primary hepatic neoplasms and metastases. In older populations, metastases remain the most common mass lesions.     

Hepatocellular carcinoma: resection versus transplantation

For decision of adequate surgical therapy and comparison of results differentiation of hepatocellular carcinomas (HCC) in cirrhotic and noncirrhotic livers is important. Liver resection is the treatment of choice for HCC in noncirrhotic liver. Between 4/94 and 8/99 we treated 54 patients with hepatocellular carcinoma (HCC) by subtotal hepatic resection (n = 40) and orthotopic liver transplantation (n = 14). Overall 1- and 3-year survival rates of the resection group were 45 and 25% (median follow up: 3.5 years). One-year survival in the transplantation group was 72% (median follow up: 2.2 years). In patients with HCC in cirrhosis in UICC stage I to III the optimal therapy is a controversial issue. In these patients the results after liver resection are poor due to high operative mortality and recurrence (3-year recurrence-free survival: 30%). Regarding the literature, liver transplantation is the treatment of choice in small (< 3-5 cm, < or = 2 tumors) HCCs arising in cirrhosis with better outcome compared to resection. The data in the literature report 3-year-survival rates after liver transplantation of 60-80%. However, consequent patient selection is necessary for this treatment modality. Due to the limited donor resources liver transplantation is rarely justified in advanced tumors.