Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension

Background & Aims: Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) >−10 mmHg is not encouraged. Here, we reap praised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres. Methods: This was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified. Results: In total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients at 3 months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively. Conclusions: Patients with cirrhosis, HCC and HVPG >−10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome

És possible expandir les indicacions de la cirurgia en el tractament de l’hepatocarcinoma?

[cat] Actualment, l'únic tractament potencialment curatiu per a l’hepatocarcinoma és la cirurgia, ja sigui la resecció o el trasplantament hepàtics. La resecció hepàtica presenta principalment dues limitacions, un nombre elevat de recidives tumorals i, associada a una hipertensió portal (CSPH), una elevada morbimortalitat. El trasplantament hepàtic ofereix millors resultats oncològics i tracta també la cirrosi hepàtica, però a expenses d’una llista d'espera per accedir al tractament i els nombrosos inconvenients que s’hi relacionen. S'han produït importants canvis en el tractament dels pacients cirròtics amb un hepatocarcinoma, en part gràcies a un refinament de la tècnica quirúrgica. Encara no s'ha aconseguit un clar consens sobre les noves indicacions de la cirurgia. Tesi en format compendi d’articles: 1. Article 1: Azoulay D, Rams E, Casellas-Robert M, Salloum C, Lladó L, Nadler R, Busquets J, Caula-Freixa C, Mils K, Lopez-Ben S, Figueres J, Lim C. clinically significant portail hypertension. JHEP Rep. 2021;3(1):100190. 2. Article 2: Casellas-Robert M, Lím C, Lopez-Ben S, Lladó L, Salloum C, Codina- Font J, Comes-Cufí M, Rams E, Figueres J, Azoulay D. with and without portal hypertension: A multicentre study. World J Surg. 2020;44(11):3915–22. 3. Article 3: Lim C, Goumard C, Caselles-Robert M, Lopez-Ben S, Lladó L, Busquets J, Salloum C, Albiol-Quer MT, Castro-Gutiérrez E, Rosmorduc O, Feray C, Rams E, Figueres J, Scatton O, Azoulay D. Impact oncological outcomes i intent-to-treat survival de ressection margin per transplantable hepatocellular carcinoma en all-comers i patients s cirrhosis: A multicenter study. World J Surg. 2020;44(6):1966–74. En els 3 casos es tracta d'estudis multicèntric retrospectius. En el primer cas de pacients amb un hepatocarcinoma i CSPH intervinguts on s'analitzen els factors predictors d'una descompensació hepàtica postoperatòria la possibilitat d'aconseguir uns resultats de llibre de text, en el segon estudi es valoren els efectes de la laparoscòpia sobre els resultats quirúrgics dels pacients amb una hepatocarcinoma amb i sense CSPH i en el tercer cas, com afecten els marges quirúrgics en la cirurgia d’un hepatocarcinoma en la recidiva tumoral, la supervivència i la trasplantabilitat de la recidiva . Conclusions: 1. L'hepatocarcinoma en el pacient cirròtic amb CSPH pot ser ressecat quirúrgicament amb taxes acceptables de morbiditat, mortalitat i descompensació hepàtica postoperatòria. Aquests resultats es poden aconseguir en pacients seleccionats amb una funció hepàtica preservada, bon estat general i un romanent hepàtic suficient. 2. És possible aconseguir uns resultats de llibre de text a la cirurgia de l'hepatocarcinoma en el pacient cirròtic amb CSPH. L'únic factor que es correlaciona amb uns resultats de llibre de text és l'abordatge laparoscòpic de la cirurgia. 3. L'abordatge laparoscòpic és factible en pacients seleccionats amb hepatocarcinoma i CSPH, encara que a costa d'un augment significatiu de les complicacions postoperatòries i una estada hospitalària més llarga comparativament amb els pacients sense hipertensió portal. 4. Els marges propers després d'una hepatectomia pel tractament d'un hepatocarcinoma es troben associats amb una taxa de recidiva tumoral més elevada i una menor supervivència lliure de malaltia en els pacients amb hepatocarcinomes inicialment trasplantables. Tot i això, la transplantabilitat de la recidiva i la supervivència global no es veu afectada.[eng] Currently, the only potentially curative treatment for hepatocellular carcinoma (HCC) is surgery, either liver resection or transplantation. Hepatic resection mainly presents two limitations, a high number of tumor recurrences and, associated with portal hypertension (CSPH), a high morbidity and mortality. Liver transplantation offers better oncological results and treats liver cirrhosis, but at the expense of a waiting list to access the treatment and the many disadvantages associated with it. Major changes have occurred in the treatment of cirrhotic patients with hepatocarcinoma, in part thanks to a refinement of surgical technique. A clear consensus has not yet been reached on the new indications for surgery. Thesis as a collection of articles. In all 3 cases, these are retrospective multicentric studies. In the first study we evaluated surgical resections in patients with HCC and CSPH to detect predictive factors of postoperative liver decompensation and analyzed the possibility of achieving textbook outcomes. In the second study, we evaluated the effects of laparoscopy on the surgical outcomes for patients with HCC and with or without CSPH. In the third study, we evaluated how surgical margins after liver resection for HCC affected tumor recurrence, survival, and translatability of the recurrence. Conclusions: 1. HCC in the cirrhotic patient with CSPH can be surgically resected with acceptable rates of morbidity, mortality, and postoperative liver decompensation. These results can be achieved in selected patients with preserved liver function, good general condition and sufficient liver remnant. 2. It is possible to achieve textbook results in HCC surgery in the cirrhotic patient with CSPH. The only factor that correlates with textbook results is the laparoscopic approach to surgery. 3. The laparoscopic approach is feasible in selected patients with HCC and CSPH, although at the cost of a significant increase in postoperative complications and a longer hospital stay compared to patients without portal hypertension. 4. Narrow margins after hepatectomy for the treatment of HCC are associated with a higher rate of tumor recurrence and shorter disease-free survival in patients with initially transplantable HCC. However, recurrence, translatability of the recurrence and overall survival are not affected

Factors associated with and impact of open conversion on the outcomes of minimally invasive left lateral sectionectomies: An international multicenter study

Background: Despite the rapid advances that minimally invasive liver resection has gained in recent decades, open conversion is still inevitable in some circumstances. In this study, we aimed to determine the risk factors for open conversion after minimally invasive left lateral sectionectomy, and its impact on perioperative outcomes.Methods: This is a post hoc analysis of 2,445 of 2,678 patients who underwent minimally invasive left lateral sectionectomy at 45 international centers between 2004 and 2020. Factors related to open conversion were analyzed via univariate and multivariate analyses. One-to-one propensity score matching was used to analyze outcomes after open conversion versus non-converted cases.Results: The open conversion rate was 69/2,445 (2.8%). On multivariate analyses, male gender (3.6% vs 1.8%, P = .011), presence of clinically significant portal hypertension (6.1% vs 2.6%, P = .009), and larger tumor size (50 mm vs 32 mm, P < .001) were identified as independent factors associated with open conversion. The most common reason for conversion was bleeding in 27/69 (39.1%) of cases. After propensity score matching (65 open conversion vs 65 completed via minimally invasive liver resection), the open conversion group was associated with increased operation time, blood transfusion rate, blood loss, and postoperative stay compared with cases completed via the minimally invasive approach.Conclusion: Male sex, portal hypertension, and larger tumor size were predictive factors of open conversion after minimally invasive left lateral sectionectomy. Open conversion was associated with inferior perioperative outcomes compared with non-converted cases. (C) 2022 Elsevier Inc. All rights reserved

Impact of liver cirrhosis, severity of cirrhosis and portal hypertension on the difficulty of laparoscopic and robotic minor liver resections for primary liver malignancies in the anterolateral segments

Introduction: We performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies.Methods: This was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021.Results: 1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss &gt;500 mls (p = 0.001), blood transfusion (p &lt; 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer post-operative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p &lt; 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss &gt;500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025).Conclusion: The presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR