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Major Hepatectomy (major + hepatectomy)

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Medical Sciences	100%

Selected Abstracts

Role of hepatectomy in the management of bile duct injuries

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2001
C. H. Wakefield
Background: Laparoscopic cholecystectomy is associated with bile duct injuries of a more severe nature than open cholecystectomy. This study examined the emerging role of hepatectomy in the management of major iatrogenic bile duct injuries in the laparoscopic era. Methods: This was a retrospective cohort study of patients referred to a tertiary hepatobiliary unit with bile duct injuries over a 16-year period until April 2000. Data are expressed as median (range). Results: Eighty-eight patients (34 men, 54 women) were referred during this interval; their median age was 55 (19,83) years. Injuries resulted from 50 laparoscopic cholecystectomies and 35 open cholecystectomies, with three occurring during gastroduodenal procedures. Laparoscopic surgery was associated with injuries of greater severity than open cholecystectomy: Bismuth type I,II, 32 per cent versus 69 per cent for the open operation; type III,IV, 66 per cent versus 31 per cent for the open procedure (P = 0·02, ,2 test). After referral 73 patients underwent definitive surgical interventions: 57 hepaticojejunostomies, 11 revisions of hepaticojejunostomy, two orthotopic liver transplants and three right hepatectomies. Two patients had subsequent hepatectomy following initial hepaticojejunostomy. Four of the five hepatectomies were for the management of injuries perpetrated at laparoscopic cholecystectomy. Criteria necessitating hepatectomy were liver atrophy on computed tomography (80 versus 11 per cent; P = 0·0001, ,2 test) and a greater incidence of angiographically proven vascular injury (40 versus 6 per cent; P = 0·006, ,2 test); in addition, type III,IV injuries were more frequent (60 versus 42 per cent) in the hepatectomy group. There were no procedure-related deaths. The overall postoperative morbidity rate was 13 per cent. Median hospital stay was 10 days. Conclusion: Major hepatectomy allows the successful and safe repair of cholecystectomy-related bile duct injuries complicated by concomitant vascular injury, unilateral lobar atrophy and destruction of the biliary confluence. © 2001 British Journal of Surgery Society Ltd [source]

Major hepatectomy in patients with synchronous colorectal liver metastases: whether or not a contraindication to simultaneous colorectal and liver resection?

COLORECTAL DISEASE, Issue 3 2007
E. Jovine
Abstract Objective, Synchronous hepatic lesions account for 15,25% of newly diagnosed colorectal cancer and its optimal timing to surgery is not completely defined, but simultaneous colorectal and liver resection is recently gaining acceptance, at least in patients with a right colonic primary and liver metastases that need a minor hepatectomy to be fully resected. Method, From September 2002 to December 2004, 16 patients underwent simultaneous resection as treatment of synchronous colorectal liver resection; in 10 patients (62.5%) a major hepatectomy was performed. Results, The mean duration of intervention was 322.5 ± 59.5 min, operative mortality and morbidity rates was 0% and 25% respectively; the hospitalization was 14.4 (range 8,60) days on average. Mean follow-up was 14 months and actuarial survival was 76.5% at 1 year and 63.5% at 2 years. Conclusion, We concluded that simultaneous colonic and liver resection should be undertaken in selected patients with synchronous colorectal liver resection regardless of the extent of hepatectomy; major liver resection, in fact, seems capable of providing better oncological results, allowing resection of liver micrometastases that, in almost one-third of the patients, are located in the same liver lobe of macroscopic lesions, without increased morbidity rates. [source]

Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

HPB, Issue 4 2008
I. DI CARLO
Abstract Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120,480 min. The average blood loss was 325 ml (range 50,600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia,reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery. [source]

Resection and reconstruction of retrohepatic vena cava without venous graft during major hepatectomies

JOURNAL OF SURGICAL ONCOLOGY, Issue 1 2007
Marcel Autran C. Machado MD
Abstract Background Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft. Methods Parenchymal transection is performed from anterior surface of the liver down to the anterior or left lateral surface of the IVC using combination of two techniques reported elsewhere. IVC is clamped above and below the tumor and the liver in continuity with an invaded segment of IVC is removed en bloc. A transverse anastomosis of IVC is performed starting with running suture on the posterior wall followed by the anterior wall. Results This approach has been successfully employed in eight consecutive patients with IVC involvement. The procedures performed were 5 right hepatectomies, 1 right posterior sectionectomy, 1 right trisectionectomy, and 1 left trisectionectomy. Two patients needed total vascular exclusion (TVE) for 11 and 10 min, respectively. Blood transfusion was necessary in three patients. Pathologic surgical margins were free in all cases. No postoperative mortality was observed. Conclusion This technique of IVC reconstruction precludes the use of graft and minimizes the use of TVE decreasing ischemic damage to the remnant liver. J. Surg. Oncol. 2007;96:73,76. © 2007 Wiley-Liss, Inc. [source]

Transhepatic lactate gradient in relation to liver ischemia/reperfusion injury during major hepatectomies

LIVER TRANSPLANTATION, Issue 12 2006
Kassiani Theodoraki
Hepatectomies performed under selective hepatic vascular exclusion are associated with a series of events culminating in ischemia/reperfusion injury, a state that shares common characteristics with situations known to result in global or regional hyperlactatemia. Accordingly, we sought to determine whether lactate is released by the liver during hepatic resections performed under blood flow deprivation and what relation this has to a possible systemic hyperlactatemic state. After ethical approval, 14 consecutive patients with resectable liver tumors subjected to hepatectomy under inflow and outflow occlusion of the liver were studied. Lactate concentrations were assessed in simultaneously drawn arterial, portal venous, and hepatic venous blood before liver dissection and 50 minutes postreperfusion. Moreover, the transhepatic lactate gradient (hepatic vein , portal vein) was calculated to see if there was net production or consumption of lactate. Before hepatic dissection, the transhepatic lactate gradient was negative, suggesting consumption by the liver. Fifty minutes after reperfusion, this gradient became significantly positive, demonstrating release of lactate by the liver (0.12 ± 0.31 vs. ,0.38 ± 0.30 mmol/L, P < 0.05). The magnitude of lactate release correlated with systemic arterial lactate levels at the same time point (r2 = 0.63, P < 0.001). A weaker but significant correlation was demonstrated between the transhepatic lactate gradient postreperfusion and systemic arterial lactate levels 24 hours postoperatively (r2 = 0.41, P = 0.013). A strong correlation between the transhepatic lactate gradient postreperfusion and peak postoperative aspartate aminotransferase values was also demonstrated (r2 = 0.73, P < 0.001). The liver becomes a net producer of lactate in hepatectomies performed under blood flow deprivation. This lactate release can explain some of the systemic hyperlactatemia seen in this context and relates to the extent of ischemia/reperfusion injury. Liver Transpl 12:1825-1831, 2006. © 2006 AASLD. [source]

The small remnant liver after major liver resection: How common and how relevant?

LIVER TRANSPLANTATION, Issue 9 2003
Cengizhan Yigitler
The maximum extent of hepatic resection compatible with a safe postoperative outcome is unknown. The study goal was to determine the incidence and impact of a small remnant liver volume after major liver resection in patients with normal liver parenchyma. Among 265 major hepatectomies performed at our institution (1998 to 2000), 138 patients with normal liver and a remnant liver volume (RLV) systematically calculated from the ratio of RLV to functional liver volume (FLV) were studied. Patients were divided into five groups based on RLV-FLV ratio from ,30% to ,60%. Kinetics of postoperative liver function tests were correlated with RLV. Postoperative complications were stratified by RLV-FLV ratios. Ninety patients (65%) underwent resection of up to four Couinaud segments. The RLV-FLV ratio was ,60% in 94 patients (68%) including only 13 (9%) with RLV-FLV ,30%. There was no linear correlation between the number of resected segments and the RLV-FLV. Postoperative serum bilirubin but not prothrombin time correlated with extent of resection. The incidence of complications including liver failure was not different among groups. Analysis of the four groups with a RLV-FLV ratio <60% showed a trend toward more complications and a longer intensive care unit stay in patients with the smallest RLVs. After major hepatectomy in patients with normal livers, the proportion of patients with a small remnant liver is low and not directly related to the number of segments resected. Although the rate of postoperative complications, including liver failure, did not directly correlate with the volume of remaining liver, the postoperative course was more difficult for patients with smaller remnants. Therefore preoperative portal vein embolization should be considered in patients who will undergo extended liver resection who have (1) injured liver or (2) normal liver when the planned procedure will be complex or when the anticipated RLV-FLV will be <30%. (Liver Transpl 2003;9:S18-S25.) [source]

Iron chelation prevents lung injury after major hepatectomy

HEPATOLOGY RESEARCH, Issue 8 2010
Konstantinos Kalimeris
Aim:, Oxidative stress has been implicated in lung injury following ischemia/reperfusion and resection of the liver. We tested whether alleviating oxidative stress with iron chelation could improve lung injury after extended hepatectomy. Methods:, Twelve adult female pigs subjected to liver ischemia for 150 min, 65,70% hepatectomy and reperfusion of the remnant liver for 24 h were randomized to a desferrioxamine (DF) group (n = 6) which received i.v. desferrioxamine to a total dose of 100 mg/kg during both ischemia and reperfusion, and a control (C) group (n = 6). We recorded hemodynamic and respiratory parameters, plasma interleukin-6 and malondialdehyde levels, as well as liver malondialdehyde and protein carbonyls content. Total non-heme iron was measured in lung and liver. Pulmonary tissue was evaluated histologically for its nitrotyrosine and protein carbonyls content and for superoxide dismutase (SOD) and platelet-activating factor acetylhydrolase (PAF-AcH) activities. Results:, Reperfusion of the remnant liver resulted in gradual deterioration of gas-exchange and pulmonary vascular abnormalities. Iron chelation significantly decreased the oxidative markers in plasma, liver and the lung and lowered activities of pulmonary SOD and PAF-AcH. The improved liver function was followed by improved arterial oxygenation and pulmonary vascular resistance. DF also improved alveolar collapse and inflammatory cell infiltration, while serum interleukin-6 increased. Conclusion:, In an experimental pig model that combines liver resection with prolonged ischemia, iron chelation during reperfusion of the remnant liver is associated with improvement of several parameters of oxidative stress, lung injury and arterial oxygenation. [source]

Thrombotic complications following liver resection for colorectal metastases are preventable

HPB, Issue 5 2008
G. Morris-Stiff
Background. Surgery for colorectal liver metastases (CRLM) can be expected to be associated with a significant rate of thromboembolic complications due to the performance of long-duration oncologic resections in patients aged 60 years. Aims. To determine the prevalence of clinically significant thrombotic complications, including deep venous thrombosis (DVT) and pulmonary embolus (PE), in a contemporary series of patients undergoing resection of CRLM with standard prophylaxis. Material and methods. A prospectively maintained database identified patients undergoing resection of CRLM from January 2000 to March 2007 and highlighted those developing thromboembolic complications. In addition, the radiology department database was reviewed to ensure that clinically suspicious thromboses had been confirmed radiologically by ultrasound in the case of DVT or computed tomography for PEs. Results. During the period of the study, 523 patients (336 M and 187 F) with a mean age of 65 years underwent resection. A major hepatectomy was performed in 59.9%. One or more complications were seen in 45.1% (n=236) of patients. Thrombotic complications were seen in 11 (2.1%) patients: DVT alone (n=4) and PE (n=7). Eight of 11 thrombotic complications occurred in patients undergoing major hepatectomy, 4 of which were trisectionectomies. Patients were anti-coagulated and there were no mortalities. Conclusions. The symptomatic thromboembolic complication rate was lower in this cohort than may be expected in patients undergoing non-hepatic abdominal surgery. It is uncertain whether this is due entirely to effective prophylaxis or to a combination of treatment and a natural anti-coagulant state following hepatic resection. [source]

Preoperative biliary drainage before resection for cholangiocarcinoma (Pro)

HPB, Issue 2 2008
Y. NIMURA
Abstract Three types of preoperative biliary drainage (BD): percutaneous transhepatic (PTBD), endoscopic (EBD), and endoscopic nasobiliary (ENBD) can be indicated before resection of cholangiocarcinoma. However, three randomized controlled trials (RCTs) have revealed that preoperative PTBD does not improve perioperative results. Other RCTs have revealed that preoperative EBD for malignant obstructive jaundice has no demonstrable benefit and after EBD for hilar cholangiocarcinoma there are highly developed infectious complications. Most patients with distal cholangiocarcinoma undergo pancreatoduodenectomy (PD) without preoperative BD. However, no RCTs have been performed to clarify the safety of major hepatectomy without preoperative BD for cholestatic patients with hilar cholangiocarcinoma. Furthermore, preoperative intrahepatic segmental cholangitis is a prognostic factor in the outcome of major hepatectomy for biliary cancer. Preoperative BD has another purpose in the preoperative management of patients with hilar cholangiocarcinoma. Selective cholangiography via ENBD and/or PTBD catheters provides precise information about the complicated segmental anatomy of the intrahepatic bile ducts and extent of cancer along the separated segmental bile ducts, which contributes toward designing a type of resective procedure. RCTs in biliary cancer patients undergoing major hepatectomy have revealed that bile replacement during external biliary drainage and perioperative synbiotic treatment can prevent postoperative infectious complications. Although preoperative EBD increases the risk of cholangitis, major hepatectomy combined with preoperative biliary drainage, preferably PTBD and/or ENBD, followed by portal vein embolization has been established as a safer management strategy for perihilar cholangiocarcinoma. [source]

Preoperative optimization of the liver for resection in patients with hilar cholangiocarcinoma

HPB, Issue 4 2005
Jacques Belghiti
Optimal preoperative preparation is required to reduce operative risk of major hepatectomy in jaundiced patients. The role of percutaneous preoperative biliary drainage (PTBD) is, apart from assessment of intraductal extent of the tumour, to allow contralateral hypertrophy if portal vein embolization (PVE) is performed. The increased use of PTBD over a 10-year period was associated with increased resectability rate in this study, while PTBD-related complications decreased. Efficient hypertrophy of the future liver remnant (FLR) requires biliary drainage to reduce the risk of postoperative liver dysfunction. Preoperative staging laparoscopy avoided unnecessary surgical exploration in 20% of patients previously considered resectable. [source]

The small remnant liver after major liver resection: How common and how relevant?

Prediction of posthepatectomy hepatic functional reserve by serum hyaluronate

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 5 2009
S. Yachida
Background: Serum hyaluronate can be used as an index of hepatic sinusoidal endothelial cell function and hepatic fibrosis. This study was designed to clarify the clinical significance of the serum hyaluronate level as a parameter of functional reserve. Methods: The study included 283 patients undergoing hepatectomy. Liver function parameters were examined before surgery and compared with outcomes. Patients were retrospectively grouped according to the presence or absence of postoperative hepatic dysfunction. Results: Preoperative serum hyaluronate levels were significantly raised in parallel with the degree of severity of the underlying chronic liver disease. Regression analysis revealed serum hyaluronate level to be an independent predictor of portal hypertension. In 131 patients undergoing major hepatectomy, preoperative hyaluronate levels were significantly higher in patients with poor outcome. Multivariable logistic regression analysis demonstrated serum hyaluronate and total bilirubin levels to be independent variables associated with postoperative hepatic dysfunction. Patients with high indocyanine green retention rate at 15 min (over 15 per cent) showed significantly higher morbidity and mortality rates when their serum hyaluronate levels were over 180 ng/ml. Conclusion: Serum hyaluronate is a simple clinical marker for portal venous pressure and a reliable auxiliary parameter of hepatic functional reserve in combination with other liver function tests. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]

Improved operative and survival outcomes of surgical treatment for hilar cholangiocarcinoma

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 12 2006
C. L. Liu
Background: The aim of the present study was to assess whether an aggressive surgical approach in the management of patients with hilar cholangiocarcinoma was associated with improved operative and survival outcomes. Methods: Eighty-two patients with hilar cholangiocarcinoma treated between 1989 and 1998 (period 1), and 60 patients treated between 1999 and 2004 (period 2), were evaluated. Modifications to management in period 2 primarily included percutaneous biliary drainage instead of endoscopic drainage for relief of obstructive jaundice, preoperative right portal vein embolization before right-sided hepatectomy, routine total caudate lobectomy and radical lymphadenectomy during surgical resection of the tumour. Results: The surgical resection rate was significantly higher in period 2 than in period 1 (45 versus 16 per cent; P < 0·001). All patients in period 2 underwent major hepatectomy with concomitant caudate lobectomy. The operative morbidity and hospital mortality rates decreased significantly in period 2 compared with period 1, with significantly better survival outcomes. In multivariate analysis, resection of the tumour in period 2 and operative blood loss of 1·5 litres or less were the significant independent factors associated with improved survival. Conclusion: An aggressive surgical approach was associated with improved operative and survival outcomes for patients with hilar cholangiocarcinoma. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]

Liver regeneration after major hepatectomy for biliary cancer

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 8 2001
Dr M. Nagino
Background: The aim of this study was to evaluate serial changes in liver volume after major hepatectomy for biliary cancer and to elucidate clinical factors influencing liver regeneration. Methods: , Serial changes in liver volume were determined, using computed tomography, in 81 patients with biliary cancer who underwent right hepatic lobectomy or more extensive liver resection with or without portal vein resection and/or pancreatoduodenectomy. Possible factors influencing liver regeneration were evaluated by univariate and multivariate analyses. Results: The remnant mean(s.d.) liver volume was 41(8) per cent straight after hepatectomy. This increased rapidly to 59(9) per cent within 2 weeks, then increased more slowly, finally reaching a plateau at 74(12) per cent about 1 year after hepatectomy. The regeneration rate within the first 2 weeks was 16(8) cm3/day and was not related to the extent of posthepatectomy liver dysfunction. On multivariate analysis, the extent of liver resection (P < 0·001), body surface area (P = 0·02), combined portal vein resection (P = 0·024) and preoperative portal vein embolization (P = 0·047) were significantly associated with the liver regeneration rate within the first 2 weeks. In addition, body surface area (P < 0·001) and liver function expressed as plasma clearance rate of indocyanine green (P = 0·01) were significant determinants of final liver volume 1 year after hepatectomy. Conclusion: The liver regenerates rapidly in the first 2 weeks after major hepatectomy for biliary cancer. This early regeneration is influenced by four clinical factors. Thereafter, liver regeneration progresses slowly and stops when the liver is three-quarters of its original volume, approximately 6 months to 1 year after hepatectomy. © 2001 British Journal of Surgery Society Ltd [source]

Major hepatectomy in patients with synchronous colorectal liver metastases: whether or not a contraindication to simultaneous colorectal and liver resection?