ALCOLIZZAZIONE ASSOCIATA ALLA LEGATURA PORTALE: UNA TECNICA EFFICACE PER INCREMENTARE LA RIGENERAZIONE EPATICA

INTRODUZIONE E OBIETTIVO: L\u2019occlusione della vena porta mediante legatura (PVL) o embolizzazione (PVE) \ue8 utilizzata nella pratica clinica per favorire la rigenerazione epatica nei pazienti con volume di fegato residuo (FLRV) all\u2019intervento programmato inadeguato. Alcuni Autori hanno descritto un pi\uf9 elevato tasso di rigenerazione epatica nei pazienti sottoposti a PVE rispetto alla PVL, come conseguenza della formazione in questi ultimi di collaterali porto-portali tra il segmento 4 e i segmenti 5 e 8. L\u2019obiettivo dello studio era di paragonare il tasso di rigenerazione epatica dopo legatura portale con (gruppo Alc+) e senza (gruppo Alc-) la simultanea iniezione intra-portale di alcool. PAZIENTI E METODI: 42 pazienti affetti da metastasi colorettali sottoposti tra 01/2004 e 06/2014 a PVL preoperatoria sono stati analizzati. A partire dal 09/2011 la legatura portale destra \ue8 stata preceduta dall\u2019iniezione intraportale di alcool puro. IL FLRV \ue8 stato calcolato sulla base degli esami TC. Due radiologi hanno rivisto le immagini delle TC post-PVL al fine di identificare la presenza di cavernomi e ricanalizzazioni del flusso nel ramo portale occluso. La rigenerazione epatica \ue8 stata valutata in termini di Incremento Volumetrico (VI) calcolato con la seguente formula: [(FLRVpost PVL% \u2013 FLRVpre PVL%)/FLRVpre PVL%]. RISULTATI: I pazienti del gruppo Alc+ (n=23) e Alc- (n=19) erano simili in termini di et\ue0, sesso, diabete, FLRV pre-PVL e per la somministrazione di chemioterapia. Il tasso di ricanalizzazione portale (63.1% vs. 4.3%, p<0.001) e la presenza di cavernomi (36.8% vs. 8.7%, p=0.055) dopo PVL erano significativamente superiori nei pazienti del gruppo Alc-. Il FLRV post-PVL (43.3\ub114.3% vs. 34.6\ub16.4%, p=0.013) e l\u2019incremento volumetrico VI (0.44\ub10.24 vs. 0.28\ub10.20, p=0.029) erano significativamente superiori nel gruppo Alc+. All\u2019analisi univariata il sesso maschile (0.23\ub1024 vs.0.40\ub10.19, p=0.005) e la PVL senza alcolizzazione (0.35\ub10.24 vs. 0.26\ub10.20, p=0.035) sono risultati negativamente correlati con il valore di VI. L\u2019analisi multivariata ha mostrato che il sesso maschile (B= 120.149, p=0.035) e l\u2019iniezione intraportale di alcool (B=0.143 p=0.041) correlavano significativamente con il valore di VI [F(1,40)=5.200, p=0.010]. CONCLUSIONI: L\u2019iniezione di alcool prima della legatura portale incrementa significativamente la rigenerazione del FLRV, riducendo la ricanalizzazione del flusso nel ramo portale occlusoBACKGROUND AND AIM: Portal vein occlusion by ligation (PVL) or embolization (PVE) is routinely performed to increase inadequate future liver remnant volume (FLRV) . The higher liver regeneration rate observed after PVE than after PVL may be due to the formation in the latter of intrahepatic porto-portal collaterals between the portal branches of segment 4 and the branches of the adjacent right segments 5 and 8. The aim of the study was to compare liver regeneration rate following portal vein ligation (PVL) with (Alc+) and without (Alc-) simultaneous intraportal alcohol injection METHODS: Forty-two patients with colorectal liver metastases who underwent PVL between January 2004 and June 2014 were analyzed. Beginning in September 2011, absolute alcohol was injected prior to right PVL. Future liver remnant volume (FLRV) was assessed by CT-scan. CT-scans were reviewed to assess recanalization and/or cavernous transformation of the occluded portal vein. Liver regeneration was assessed as Volumetric Increase (VI) [(FLRVpost% \u2013 FLRVpre%)/FLRVpre%]. RESULTS: The Alc+ (n=23) and Alc- (n=19) groups were similar in age, sex, diabetes, pre-PVL FLRV and administration of chemotherapy. The rate of recanalization of the occluded portal vein was significantly higher (63.1% vs. 4.3%, p<0.001) and the rate of cavernous transformation higher (36.8% vs. 8.7%, p=0.055) in the Alc- than in the Alc+ group. Post-PVL FLRV (43.3\ub114.3% vs. 34.6\ub16.4%, p=0.013) and VI (0.44\ub10.24 vs. 0.28\ub10.20, p=0.029) were significantly higher in the Alc+ group. Univariate analysis showed that male sex (0.23\ub1024 vs.0.40\ub10.19, p=0.005) and PVL without alcohol injection (0.35\ub10.24 vs. 0.26\ub10.20, p=0.035) were negatively correlated with VI. Multiple regression analysis showed that male sex (B= 120.149, p=0.035) and alcohol injection (B=0.143 p=0.041) significantly predicted VI [F(1,40)=5.200, p=0.010]. CONCLUSIONS: Alcohol injection prior to PVL significantly increased regeneration rate of the future liver remnant, reducing recanalization of the occluded portal vein

Game-score predicts pathological and radiological response to chemotherapy in patients with colorectal liver metastases

Background: Genetic And Morphological Evaluation (GAME) score is the newest prognostic model for patient with colorectal liver metastases (CRLMs). Pathological and radiological responses to neoadjuvant chemotherapy (NAC) can stratify the prognosis of these patients. Aim of the present study is to evaluate the ability of GAME score to predict pathological and radiologic responses to NAC. Methods: Patients with CRLMs who underwent liver resection after NAC between January 2010 and December 2021 were divided into three groups according to GAME scores: low risk (LR, 0–1), moderate risk (MR, 2–3), and high risk (HR, ≥4). Correlations between groups with radiological and pathological features were analyzed. Results: In total, 448 of the 1054 liver resections for CRLMs were included. GAME scores were grouped as follows: LR: 80 (18%), MR: 228 (51%), and HR: 140 (31%). HR-GAME scores were associated with lower pathological response assessed by Tumor Regression Grade 4–5 (LR: 67.1%, MR: 74.9%, HR: 82.6%; p=0.010). Radiologic progressive disease was found in 10% of HR patients, which was significantly higher than in the other groups (LR: 3.8%, MR: 3.5%; p=0.011). These findings were confirmed at multivariable analysis. HR-GAME scores were also associated with higher rates of mucinous differentiation (LR: 3.8%, MR: 8.8%, HR: 13.1%; p=0.021), satellitosis (LR: 27%, MR: 40.4%, HR: 53%; p=0.001), vascular invasion (LR: 73.8%, MR: 81%, HR: 87.5%; p=0.011), and perineural invasion (LR: 8.8%, MR: 10.6%, HR: 19.7%; p=0.010). Conclusions: GAME score category should be considered during planning of therapeutic strategy of patients with CRLMs

Ultrasound liver map technique for laparoscopic liver resections: tips and tricks

Laparoscopic liver resection (LLR) is safer and more advantageous than open surgery regarding morbidity, blood loss, and length of hospital stay. Several radiological studies and liver surgical strategies confirmed that the anatomy of the liver is more complex than what Couinad described. Intraoperative ultrasound (IOUS) has become an indispensable tool to identify the “real anatomy” and to plan a tailored LLR because of wide sub-segmentary variability and lack of external indicators for small functional liver cores. We schematized our standard ultrasound guidance technique during anatomical and non-anatomical LLR as a four-step method called the Ultrasound Liver Map Technique: (1) Compose the three-dimensional mind map to study the relationships between lesions and surrounding vascular elements; (2) create a sketch on the Glissonian using cautery to help the surgeon recall the mind liver anatomy map; (3) check the section plane while proceeding with the transection; and (4) correct the direction of resection plan to ensure a healthy margin concerning the lesion and to point out the pedicle section correctly and not affected structures. Finally, IOUS-Doppler can be used to study the segmental portal flow to assess venous drainage of the remnant parenchyma, avoiding ischemia and increasing the possibility of performing parenchyma-sparing surgery

Recurrence after Curative Resection for Intrahepatic Cholangiocarcinoma: How to Predict the Chance of Repeat Hepatectomy?

(1) Background: Tumor recurrence after liver resection (LR) for intrahepatic cholangiocarcinoma (ICC) is common. Repeat liver resection (RLR) for recurrent ICC results in good survival outcomes in selected patients. The aim of this study was to investigate factors affecting the chance of resectability of recurrent ICC. (2) Methods: LR for ICC performed between January 2001 and December 2020 were retrospectively reviewed. Patients who had undergone first LR were considered for the study. Data on recurrences were analyzed. A logistic regression model was used for multivariable analysis of factors related to RLR rate. (3) Results: In total, 140 patients underwent LR for ICC. Major/extended hepatectomies were required in 105 (75%) cases. The 90-day mortality was 5.7%, Clavien–Dindo grade 3, 4 complications were 9.3%, N+ disease was observed in 32.5%, and the median OS was 38.3 months. Recurrence occurred in 91 patients (65%). The site of relapse was the liver in 53 patients (58.2%). RLR was performed in 21 (39.6%) patients. Factors that negatively affected RLR were time to recurrence ≤12 months (OR 7.4, 95% CI 1.68–33.16, p = 0.008) and major hepatectomy (OR 16.7, 95% CI 3.8–73.78, p p = 0.02). (4) Conclusions: Patients with ICC treated at first resection with major hepatectomy and those who recurred in ≤12 months had significantly lower probability to receive a second resection for recurrence