• Humans
• Hepatectomy/mortality
• Hepatectomy/methods
• Hepatectomy/adverse effects
• Male
• Female
• Longitudinal Studies
• Middle Aged
• Liver Neoplasms/mortality
• Liver Neoplasms/surgery
• Liver Neoplasms/therapy
• Liver Neoplasms/pathology
• Aged
• Embolization, Therapeutic/methods
• Embolization, Therapeutic/adverse effects
• Embolization, Therapeutic/mortality
• Disease Progression
• Portal Vein
• Risk Factors
• Treatment Failure
• Time Factors
• Adult

• Humans
• Hepatectomy/methods
• Hepatectomy/adverse effects
• Hepatectomy/mortality
• Laparoscopy/adverse effects
• Male
• Female
• Retrospective Studies
• Middle Aged
• Treatment Outcome
• Aged
• Time Factors
• Liver Neoplasms/surgery
• Liver Neoplasms/mortality
• Liver Neoplasms/secondary
• Postoperative Complications/etiology
• Operative Time
• Risk Factors
• Databases, Factual
• Length of Stay
• Blood Loss, Surgical
• Adult
• Blood Transfusion/statistics & numerical data

• Hilar cholangiocarcinoma
• Klatskin tumor
• Resectability
• Transplant
• Unresectability
• Vascular invasion

• Humans
• Klatskin Tumor/surgery
• Cholangiocarcinoma/surgery
• Cholangiocarcinoma/pathology
• Bile Ducts, Intrahepatic/pathology
• Hepatectomy
• Bile Duct Neoplasms/surgery
• Bile Duct Neoplasms/pathology

• LiverMultiScan
• colorectal liver metastasis
• hepatectomy
• magnetic resonance imaging
• post-hepatectomy liver failure
• prehabilitation
• quality of future liver remnant

• MR/P008887/1 Medical Research Council

• cancer
• gastrointestinal
• hepato-pancreatico-biliary
• postoperative complications
• sarcopenia
• surgery

• Humans
• Sarcopenia/complications
• Sarcopenia/diagnostic imaging
• Muscle, Skeletal
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Morbidity
• Biliary Tract Neoplasms/surgery
• Risk Factors
• Retrospective Studies

• Hepatocellular carcinoma (HCC)
• Hong Kong
• consensus
• guidelines

• Humans
• Retrospective Studies
• Liver Neoplasms/diagnostic imaging
• Liver Neoplasms/surgery
• Liver Neoplasms/etiology
• Liver Function Tests
• Liver/surgery
• Hepatocytes/pathology
• Liver Failure/diagnosis
• Liver Failure/etiology
• Hepatectomy/adverse effects
• Indocyanine Green
• Albumins
• Magnetic Resonance Imaging/methods
• Risk Assessment

• bile leak
• extended hepatectomy
• liver volume augmentation
• portal vein embolization
• post hepatectomy liver failure

Hepatopancreaticoduodenectomy (HPD) is one of the most complex procedures, and it is very rarely reported. Laparoscopic HPD (LHPD) is even rarer. To date, there are only 3 reports of LHPD for locally advanced gallbladder cancer (GBC) or extrahepatic cholangiocarcinoma (ECC). This is the first report of LHPD for synchronous GBC and ECC.

A 75-year-old female patient complained of jaundice for 2 weeks without fever or abdominal pain. She was diagnosed with synchronous GBC and ECC. After a comprehensive preparation, she underwent a laparoscopic pancreaticoduodenectomy and resection of hepatic segments of IVb and V, and her digestive tract reconstruction followed Child’s methods. She was discharged on the 12th day postoperatively without pancreatic leakage, biliary leakage, or liver failure.

LHPD is safe and feasible for selected cases of GBCs or ECCs.

• Extrahepatic cholangiocarcinoma
• Gallbladder cancer
• Hepatopancreaticoduodenectom
• Hepatopancreatoduodenectomy laparoscopy

Over the past few years, liver surgery has been in constant evolution and gained many improvements that helped surgeons push limits further. A complex procedure such as left extended trisectionectomy, as described by Makuuchi in 1987, may be performed in selected cases.

Describe a case of successful resection of a huge bilobar liver sarcoma involving all hepatic veins from a young female patient, in which the blood outflow was preserved through an inferior right hepatic vein, leaving only segment 6 as liver remnant. Case Report. A 19-year-old female with a 3-month history of abdominal pain, vomiting, and weight loss was referred for our evaluation. CT scan and MRI revealed a heterogeneous and bulky expansive hepatic lesion, sparing only segment 6, with an estimated volume of 530 cm³, corresponding to a 1.2 FLR/BW ratio. The tumor involved the three major hepatic veins, but an inferior right hepatic vein was present, draining the spared segment 6. She was submitted to a left trisectionectomy extended to the caudate lobe and segment 7, including resection of all hepatic veins and lymphadenectomy of the hepatic pedicle. She was discharged on the 7th postoperative day without complications. The histopathological and immunohistochemical analysis demonstrated an undifferentiated embryonal sarcoma of the liver.

Inferior right hepatic vein-preserving left extended trisectionectomy is a safe and feasible procedure that should be performed by a hepatobiliary team experienced in major complex hepatectomies.

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare type of primary liver malignancy. Among the risk factors, hepatitis B and hepatitis C virus infections, cirrhosis, and male gender are widely reported. The clinical appearance of cHCC-CCA is similar to that of HCC and iCCA and it is usually silent until advanced states, causing a delay of diagnosis. Diagnosis is mainly based on histology from biopsies or surgical specimens. Correct pre-surgical diagnosis during imaging studies is very problematic and is due to the heterogeneous characteristics of the lesion in imaging, with overlapping features of HCC and CCA. The predominant histological subtype within the lesion establishes the predominant imaging findings. Therefore, in this scenario, the radiological findings characteristic of HCC show an overlap with those of CCA. Since cHCC-CCAs are prevalent in patients at high risk of HCC and there is a risk that these may mimic HCC, it is currently difficult to see a non-invasive diagnosis of HCC. Surgery is the only curative treatment of HCC-CCA. The role of liver transplantation (LT) in the treatment of cHCC-CCA remains controversial, as is the role of ablative or systemic therapies in the treatment of this tumour. These lesions still remain challenging, both in diagnosis and in the treatment phase. Therefore, a pre-treatment imaging diagnosis is essential, as well as the identification of prognostic factors that could stratify the risk of recurrence and the most adequate therapy according to patient characteristics.

• Future liver remnant
• Liver resection
• Small-for-size syndrome

While minimizing intraoperative blood loss during liver resection is one of the most important tasks, it is more difficult to control the refractory bleeding during laparoscopic liver resection than with an open approach. We herein provide a modification of the two-surgeon technique that enables laparoscopic liver parenchymal transection to be performed as quickly and securely as open liver resection. To achieve proper "role sharing," the "transection mode" and the "hemostatic mode" are independent sets in place in this procedure, and these modes are switched rigidly according to the surgical field condition. By thoroughly sharing the roles, rapid laparoscopic liver parenchymal transection comparable to open liver resection can be accomplished. The present modified approach achieves satisfactory transection and hemostasis of the liver parenchyma and is also advantageous for teaching young surgeons and the entire surgical team.

Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival.

• Cirrhosis
• Hepatectomy
• Hepatocellular carcinoma
• Liver transplantation
• Recurrence
• Survival

Despite the recent advances in surgical techniques and perioperative care, liver resection (especially extended hepatectomy) is still a high-risk procedure with considerable morbidity and mortality. Experimental large animal models are the best option for studies in this regard. The present study was performed to present an easy-to-learn, fast, and multipurpose model of liver resection in a porcine model.

Stepwise liver resections (resection of segments II/III, IVa/IVb, and VIII/IV) were performed in eight pigs with intraoperative monitoring of hemodynamic parameters. The technical aspects, tips, and tricks of this method are explained in detail.

Based on the specific anatomical characteristics of the porcine liver, all resection types including segmental resection, hemihepatectomy, and extended hepatectomy could be performed in one animal in an easy-to-learn and fast technique. All animals were hemodynamically stable following stepwise liver resection.

Stepwise liver resection using stapler in a porcine model is a fast and easy-to-learn method with which junior staff and research fellows can perform liver resection up to extended hepatectomy under stable conditions.

• Anatomy
• extended hepatectomy
• liver resection
• porcine
• resection technique
• stapler

• hepatocellular carcinoma
• oncological benefit
• portal vein embolization
• portal vein ligation

Use of steatotic livers is a known risk factor for increased primary nonfunction after liver transplantation. This study investigated the efficacy and clinical outcome of simple weight reduction of steatosis for donors undergoing living-donor liver transplantation (LDLT).

We defined two groups: the reduction group, which included donors with >30% macrovesicular steatosis and body mass index (BMI) >25 kg/m², and the conventional group, which included donors with <30% macrovesicular steatosis. Donors in the reduction group were educated about the goal of voluntary weight reduction to lose 5% of body weight, not exceeding 1.6 kg/week, and attempted to maintain weight reduction for at least 8 weeks.

Weight reduction significantly improved steatosis (40.71±14.56 vs. 7.867±2.67, p=0.000). Body weight and BMI were reduced in the weight reduction group (85.40±8.254 kg vs. 76.27±7.556 kg, p=0.052; and 28.89±2.303 kg/m²vs. 26.16±1.629 kg/m², p=0.025, respectively). The transplanted grafts of recipients and remnant livers of donors showed intact liver function, and there was no difference in liver function tests between the conventional and reduction groups. No significant difference in graft survival was observed.

Simple weight reduction improves steatosis and contributes to safer LDLT for both recipient and donor. Importantly, according to our results, even steatotic livers can be used for LDLT after patients follow a simple weight reduction protocol.

Despite the ongoing decades-long controversy, Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (EH) (≥5 segment resection). The association of PM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10–0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18–0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06–0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. PM is associated with lower intraoperative bleeding, PHH, and major morbidity risk after EH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH.

• Colorectal neoplasms
• Hepatic veins
• Hypertrophy
• Portal vein
• Therapeutic embolization

• Adult
• Aged
• Aged, 80 and over
• Bilirubin/blood
• Colorectal Neoplasms/pathology
• Coloring Agents/pharmacokinetics
• Female
• Hepatectomy
• Hepatic Insufficiency/diagnosis
• Hepatic Insufficiency/etiology
• Hepatic Insufficiency/metabolism
• Humans
• Indocyanine Green/pharmacokinetics
• Liver Function Tests
• Liver Neoplasms/metabolism
• Liver Neoplasms/secondary
• Liver Neoplasms/surgery
• Male
• Metastasectomy
• Middle Aged
• Postoperative Complications/diagnosis
• Postoperative Complications/etiology
• Postoperative Complications/metabolism
• Predictive Value of Tests
• ROC Curve
• Retrospective Studies

Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear.

All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database.

Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively.

This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

•

LHT is an extended resection reported to have higher incidences of morbidity and mortality compared with less extensive hepatic resections.

• Colorectal liver metastases
• Extended left hepatectomy
• Hepatobiliary
• Left hepatic trisectionectomy

The aim of this study was to assess and compare the discriminatory performance of well-known risk assessment scores in predicting mortality risk after extended hepatectomy (EH). A series of 250 patients who underwent EH (≥5 segments resection) were evaluated. Aspartate aminotransferase-to-platelet ratio index (APRI), albumin to bilirubin (ALBI) grade, predictive score developed by Breitenstein et al., liver fibrosis (FIB-4) index, and Heidelberg reference lines charting were used to compute cut-off values, and the sensitivity and specificity of each risk assessment score for predicting mortality were also calculated. Major morbidity and 90-day mortality after EH increased with increasing risk scores. APRI (86%), ALBI (86%), Heidelberg score (81%), and FIB-4 index (79%) had the highest sensitivity for 90-day mortality. However, only the FIB-4 index and Heidelberg score had an acceptable specificity (70% and 65%, respectively). A two-stage risk assessment strategy (Heidelberg–FIB-4 model) with a sensitivity of 70% and a specificity 86% for 90-day mortality was proposed. There is no single specific risk assessment score for patients who undergo EH. A two-stage screening strategy using Heidelberg score and FIB-4 index was proposed to predict mortality after major liver resection.

• Cholangiocarcinoma
• Hepatocellular carcinoma
• Hepatocholangiocarcinoma
• Liver neoplasms

• Cholangiocarcinoma
• chemoradiation
• chemotherapy
• hilar
• intrahepatic
• perihilar
• radiation therapy
• surgery

• Cholangiocarcinoma
• Extended resection
• Intrahepatic cholangiocarcinoma
• Liver resection
• Liver surgery
• Morbidity
• Mortality
• Survival

• Aged
• Female
• Hepatectomy/methods
• Hepatectomy/mortality
• Humans
• Liver Diseases/blood
• Liver Diseases/complications
• Liver Diseases/surgery
• Liver Failure/etiology
• Liver Failure/mortality
• Male
• Middle Aged
• Multivariate Analysis
• Odds Ratio
• Platelet Count/statistics & numerical data
• Postoperative Complications/etiology
• Postoperative Complications/mortality
• Predictive Value of Tests
• Preoperative Period
• Retrospective Studies
• Thrombocytopenia/blood
• Thrombocytopenia/etiology
• Thrombocytopenia/surgery
• Treatment Outcome

• Imaging
• Liver resection
• Post-hepatectomy liver failure
• Risk factors
• Scoring system

• Extended hepatectomy
• Laparoscopic liver resection
• Trisectionectomy

• Adult
• Aged
• Aged, 80 and over
• Blood Loss, Surgical/statistics & numerical data
• Female
• Hepatectomy/methods
• Humans
• Laparoscopy
• Length of Stay/statistics & numerical data
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Postoperative Complications
• Retrospective Studies
• Young Adult

• Hepatocellular carcinoma
• Liver resection
• Liver transplantation

• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/surgery
• Female
• Hepatectomy/adverse effects
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/surgery
• Liver Neoplasms/complications
• Liver Neoplasms/surgery
• Liver Transplantation/adverse effects
• Male
• Middle Aged
• Postoperative Period
• Retrospective Studies
• Survival Rate/trends

Preoperative portal vein embolization (PVE) induces compensatory hyperplasia of the future liver remnants (FLR), thus increasing resectability in the non-cirrhotic patients with primary liver cancer (PLC). However, it is unclear if it is similar in patients with liver cirrhosis. Therefore, the present study investigated the PVE value prior to liver resection in patients with PLC, and the liver cirrhotic effects on the compensatory hypertrophy of FLRs following PVE. In the present study, 21 patients with PLC who successfully underwent hepatic resection subsequent to PVE, were retrospectively examined. The patients were divided into a non-cirrhosis group and a cirrhosis group according to the absence or presence of cirrhosis, respectively. The FLR volume between the two groups of patients was compared. There was a significant difference in the FLR volume for all patients prior to, and 4–6 weeks following, PVE (P<0.001). PVE induced significant compensatory hypertrophy in the FLRs whether in the non-cirrhosis group (P=0.002) or cirrhosis group (P<0.001). However, no significant difference was identified between the two groups with respect to FLR volume enlargement 4–6 weeks following PVE (P=0.373). In conclusion, PVE prior to hepatectomy may promote FLR compensatory hypertrophy and an increase in the resectability of PLC tumors. No significant effects of liver cirrhosis were identified on liver lobe hyperplasia following PVE.

• cirrhosis
• embolization
• hyperplasia
• liver cancer
• portal vein

The liver is the most common site of metastasis in patients with colorectal cancer due to its anatomical situation regarding its portal circulation. About 14 to 18% of patients with colorectal cancer present metastasis at the first medical consultation, and 10 to 25% at the time of the resection of the primary colorectal cancer. The incidence is higher (35%) when a computed tomography (CT) scan is used.

In the last decades, a significant increase in the life expectancy of patients with colorectal cancer has been achieved with different diagnostic and treatment programs. Despite these improvements, the presence of metastasis, disease recurrence, and advanced local tumors continue to remain poor prognostic factors.

Median survival without treatment is <8 months from the moment of its presentation, and a survival rate at 5 years of 11% is the best prognosis for those who present with local metastasis. Even in patients with limited metastatic disease, 5-year survival is exceptional. Patients with hepatic metastasis of colorectal cancer have a median survival of 5 to 20 months with no treatment. Approximately 20 to 30% of patients with colorectal metastasis have disease confined to the liver, and this can be managed with surgery. Modern surgical strategies at the main hepatobiliary centers have proved that hepatectomy of 70% of the liver can be performed, with a mortality rate of <5%.

It is very important to have knowledge of predisposing factors, diagnostic methods, and treatment of hepatic metastasis. However, the establishment of newer, efficient, preventive screening programs for early diagnosis and adequate treatment is vital.

How to cite this article: Valderrama-Treviño AI, Barrera-Mera B, Ceballos-Villalva JC, Montalvo-Javé EE. Hepatic Metastasis from Colorectal Cancer. Euroasian J Hepato-Gastroenterol 2017;7(2):166-175.

• Hepatic metastasis
• Treatment of metastasis.
• Colorectal cancer

• ALPPS
• chemotherapy
• colorectal cancer
• small-for-size
• staged hepatectomy

Little is known about the prognostic impact of cirrhosis on long-term survival of patients with combined hepatocellular-cholangiocarcinoma (cHCC-CC) after hepatic resection. The aim of this study was to elucidate the long-term outcome of hepatectomy in cHCC-CC patients with cirrhosis.

A total of 144 patients who underwent curative hepatectomy for cHCC-CC were divided into two groups: cirrhotic group (n = 91) and noncirrhotic group (n = 53). Long-term postoperative outcomes were compared between the two groups.

Patients with cirrhosis had worse preoperative liver function, higher frequency of HBV infection, and smaller tumor size in comparison to those without cirrhosis. The 5-year overall survival rate in cirrhotic group was significantly lower than that in non-cirrhotic group (34.5% versus 54.1%, P = 0.032). The cancer recurrence-related death rate was similar between the two groups (46.2% versus 39.6%, P = 0.446), while the hepatic insufficiency-related death rate was higher in cirrhotic group (12.1% versus 1.9%, P = 0.033). Multivariate analysis indicated that cirrhosis was an independent prognostic factor of poor overall survival (hazard ratio 2.072, 95% confidence interval 1.041–4.123; P = 0.038).

The presence of cirrhosis is significantly associated with poor prognosis in cHCC-CC patietns after surgical resection, possibly due to decreased liver function.

• Cirrhosis
• Combined hepatocellular-cholangiocarcinoma
• Long-term survival
• Surgical resection

• Albumin
• Bile leak
• Bilirubin
• Liver failure
• MELD
• Outcomes

• Biomarker panel
• Breast cancer
• Colorectal cancer
• Liver metastasis
• Predictive medicine
• Prostate cancer

• Cholangiocarcinoma
• Embolization
• Liver neoplasms
• Liver regeneration
• Therapeutic