Oncologic superiority of anatomic resection of hepatocellular carcinoma by ultrasound-guided compression of the portal tributaries compared with nonanatomic resection: An analysis of patients matched for tumor characteristics and liver function.

BACKGROUND: The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound-guided compression of the tumor-feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection. METHODS: Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1-to-2 with nonanatomic resection cases based on the Child-Pugh class, Model for End-Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/>1), and hepatocellular carcinoma size (>30, 30-50, and >50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90-day mortality (0 compression technique anatomic resection), non-cancer-related death, and follow-up <12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases. RESULTS: All patients were Child-Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5-year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2-year local recurrence-free survival (94% vs 78%; P = .012). Nonlocal recurrence-free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3-year survival after recurrence (65% vs 42%; P = .043). CONCLUSION: Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma-bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.

Safe hepatectomy selection criteria for hepatocellular carcinoma patients: a validation of 336 consecutive hepatectomies. The BILCHE score.

BACKGROUND: Selection criteria for hepatectomy for hepatocellular carcinoma (HCC) are object of debate. We presented our criteria for safe hepatectomy for HCC, and we compared the results with those obtainable using the most common scores for HCC. METHODS: All patients submitted to hepatectomy for HCC based on the same criteria were reviewed from our prospectively maintained database. Such criteria included bilirubin (BIL), cholinesterases (CHE), ascites, esophageal varices, and residual liver volume. RESULTS: A total of 336 patients were analyzed. One hundred fifteen patients (33 %) had thoracoabdominal approach, but only 39 (12 %) had major or extended resections. The median tumor number was 1 (range 1-33), while the median tumor size was 3.6 cm (range 1.1-28). Of those, 94 (29 %) had postoperative complications, of which 6 % were graded as major (Dindo III-IV). The 90-days mortality was 2 %. The MELD, APRI, and CPT scores were not found to be statistically significant for complications, while combining BIL and CHE we defined four classes of risk. The association of BIL >1 mg/dl (>17.1 µmol/l) and CHE ≤ 5,900 U/l was the best to detect complications (OR = 4.45; P = 0.007). CONCLUSIONS: This study shows that our selection criteria that count mainly on two commonly available, and inexpensive parameters, BIL and CHE, lead to identify patients potentially at risk of postoperative complications after hepatic resection for HCC. REGISTRATION NUMBER: NCT02056041 ( http://www.clinicaltrials.gov).

Hepatic vein-sparing hepatectomy for multiple colorectal liver metastases at the caval confluence.

BACKGROUND: Two-stage hepatectomies generally are selected for patients with multiple bilobar colorectal liver metastases (CLMs) involving the hepatic veins (HV) at the caval confluence to reduce the risk of postoperative hepatic failure due to insufficient remnant liver.1 (,) 2 The use of IOUS based on well-established criteria offers alternative technical solutions to the staged resections.3 (,) 4 This report describes a sophisticated IOUS-guided parenchyma-sparing procedure. METHODS: A 57-year-old woman with multiple CLMs underwent surgery. One of these CLMs was located in segments 8 to 4 sup involving the middle hepatic vein (MHV) at the caval confluence. A second CLM was between dorsal segment 8 and the paracaval portion of segment 1 involving the right hepatic vein (RHV) at the caval confluence. Neither the inferior RHV nor the communicating veins were evident at preoperative imaging. The left hemiliver represented 27 % of the total liver volume, and segments 2 and 3 represented 16 %. RESULTS: After a J-shaped thoracophrenolaparotomy, liver exploration with IOUS showed tumoral invasion of MHV and RHV at their caval confluence for one third of their circumference. No communicating veins were intraoperatively evident. A partial resection of segments 7, 8, and 4 superior and 1-paracaval sparing both RHV and MHV was performed. The latter were partially resected, and vessel wall reconstruction was obtained by direct running suture. No congested area or vascular thrombosis occurred, and the postoperative course was uneventful. No local recurrence had occurred after 6 months of follow-up evaluation. CONCLUSIONS: The video shows an HV-sparing IOUS-guided hepatectomy as an alternative to conventional staged surgery. This policy represents a safe and effective alternative to major resection performed immediately or in a staged perspective.