Hepatocellular carcinoma on cirrhosis complicated with tumoral thrombi extended to the right atrium: Results in three cases treated with major hepatectomy and thrombectomy under hypothermic cardiocirculatory arrest and literature review

BACKGROUND: Hepatocellular carcinoma (HCC) with the presence of tumor thrombus in hepatic veins and vena cava, until the atrium (RATT), is correlated with poor prognosis and with risk of tricuspid valve occlusion, congestive heart failure, and pulmonary embolism. METHODS: Three patients with HCC on cirrhotic liver with RATT were studied. Operative technique, pre-operative and post-operative liver function tests, blood loss and transfusions, post-operative morbidity and mortality, and the overall survival and the disease free survival were analyzed. RESULTS: Mean operative time was 336 ± 66 min. Intra-operative blood loss was 926.6 ± 325.9 ml. No major complications occurred. The times of hospital stay were 10, 21, and 19 days, respectively. The survival times were 90, 161, and 40 days, and the disease-free survival times were 30, 141, and 30 days, respectively. CONCLUSIONS: The complete removal of HCC with RATT may be achieved with cardiopulmonary by-pass (CPB) and total hepatic vascular exclusion (THVE). Adding the hypothermic cardiocirculatory arrest (HCCA) to the use of CPB allowed us to have minimal blood loss and hemostasis of the resectional plane. So the use of CPB and HCCA should be considered a good therapeutic alternative to the normothermic CPB with THVE

Radiofrequency on the liver remnant after liver resection to reach the haemostasis not otherwise achievable with conventional techniques

AbstractINTRODUCTIONDuring liver resection, in same case of inflamed, steatotic or neo-vascularized liver parenchyma, reaching of haemostasis on the liver resection surface could be very difficult for the surgeon because of the presence of fragile tissue that does not allows the proper placement of stitches, and the conventional method fail.PRESENTATION OF CASEThe authors describe a novel technique in which, after a formal liver resection, liver haemostasis is achieved using radiofrequency energy on the resected surface. A patient affected by a hystiocytic sarcoma localized on the VI-V and IVa segments was scheduled for liver resection. During the resection a diffuse bleeding from the resected surface started with little success obtained with conventional method. So we decided to use the coagulative necrosis generated by the radiofrequency, using a cool type cluster needle, hand-piece with 3 needle, bending 2 needles in a way resembling a “fork”, to reach a complete and definitive haemostasis.DISCUSSIONHaemostasis remains a critical issue in liver surgery not only for the catastrophic effect of haemorrhage but also because it is correlated to complications rate and to survival. The coagulative necrosis generated by the radiofrequency could be used to facilitate the creation of a necrotic plane to be transacted.CONCLUSIONThe use of the radiofrequency energy, delivered through needles, is suggested when the conventional techniques fail to reach a proper haemostasis after a liver resection or, to consider its use, prior to resect the liver in presence of fragile parenchyma

Parenchymal-Sparing Surgery for the Surgical Treatment of Multiple Colorectal Liver Metastases Is a Safer Approach than Major Hepatectomy Not Impairing Patients' Prognosis: A Bi-Institutional Propensity Score-Matched Analysis

Background: The performance of parenchymal-sparing hepatectomy (PSH) versus major hepatectomy (MH) in patients with multiple colorectal liver metastases (CLM) is a matter that is yet debated. We investigated the outcome of patients with multiple CLM undergoing PSH instead of MH. Methods: Databases at 2 institutions were reviewed. A propensity score-matched analysis was applied. Among 554 patients, 110 undergoing PSH and 110 undergoing MH were matched. They were similar in baseline characteristics, comorbidity, and tumor features. Primary outcomes were short- and long-term outcomes. Results: Morbidity was significantly higher in the MH group, while mortality was not significantly different. There were no differences in free-margins width, but a trend of increased survival was seen in the PSH group with a median advantage of 6 months over the MH group. Among the prognostic factors, the T status (hazard ratio [HR] 2.6; p = 0.001), the N status (HR 2.9; p = 0.001), the timing of CLM diagnosis (HR 2.1; p = 0.002), the tumor number (HR 2.0; p = 0.001), the tumor size (HR 2.2; p = 0.015), and the neo-adjuvant chemotherapy (HR 1.7; p = 0.023) were found to be statistically and independently significant for survival. Conclusions: PSH conveys advantage over MH in terms of decreased postoperative morbidity, and a trend of survival benefit. PSH should be considered a suitable alternative to MH whenever it is technically feasible

Outcomes of robotic liver resections for colorectal liver metastases. A multi-institutional analysis of minimally invasive ultrasound-guided robotic surgery

Background Current evidence supporting robotics to perform minimally invasive liver resection is based on single center case series reporting surgical outcomes in heterogeneous groups of patients. On the contrary, relatively scarce data specifically focusing on secondary hepatic malignancies is available. The objective of this study is to assess short- and long-term outcomes following liver resection for colorectal liver metastasis on a multi-institutional series of patients. Methods All consecutive patients undergoing robotic surgery for colorectal liver metastasis at three different tertiary hospitals over a 10-year time frame were included in this analysis. All patients received ultrasound-guided liver resection according to tumor location following the principle of parenchymal sparing surgery. Perioperative, clinicopathologic and oncological outcomes were assessed. Results A total of 59 patients underwent liver resection. There were 7 cases of conversion to open surgery. The postoperative complication rate was 27%, 5% being the rate of major morbidity. Overall, the mean postoperative hospital stay was 6 days and no mortality occurred. R0 resection was achieved for 92% of lesions. At a mean follow-up of 19 months, the 1-year and 3-year DFS was 83.5% and 41.9%, while the 1-year and 3-year OS was 90.4% and 66.1%, respectively. Conclusions Robotic liver surgery does not impair surgical outcome and oncological results in patients with liver metastases from colorectal cancer

Robotic versus open distal pancreatectomy: a multi‐institutional matched comparison analysis

Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study we compared Robotic Distal Pancreatectomy (RDP) versus open (ODP) in terms of CR-POPF development, and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC)

Robotic versus open distal pancreatectomy: a multi-institutional matched comparison analysis

Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study we compared Robotic Distal Pancreatectomy (RDP) versus open (ODP) in terms of CR-POPF development, and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC)