Extreme Hepatic Surgery and Other Strategies (eBook)

Eduardo de Santibañes MD, PhD, Full Professor of Surgery at University of Buenos Aires (2005-2013) and Full Professor and Head of the Surgery Department (Hospital Italiano, 2008-2012). Chairman of the General Surgery Service since 2005, one of the most active Surgical services of Latin America, having performed over 7,400 procedures in 2013. Chairman of the Liver Transplant Unit of the Hospital Italiano since 1985. Former Chairman of the World Congress of the Hepato Pancreato Biliary Association; Argentine Academy of Surgery, Argentine Association of Surgery, Argentine Liver Transplant Society and the Argentine Chapter of the International Hepato Pancreato Biliary Association. Honorary Member of the American Surgical Association, German Surgical Society, European Surgical Association, among others. Victoria Ardiles MD, PhD, General Surgeon (University of Buenos Aires), Laparoscopic Surgeon (Argentine Association of Surgery) and HPB surgeon (Hospital Italiano de Buenos Aires). Professor of Surgery at University of Buenos Aires and Associated Professor and Coordinator of the Surgery Department of the University School of Medicine, Hospital Italiano. Associated staff of the General Surgery Service, member of the Liver Transplant Unit and General coordinator of the Department of Surgery, Hospital Italiano de Buenos Aires. Martin de Santibañes Surgeon at Liver Transplantation and HPB Unit, Hospital Italiano de Buenos Aires. Assistant Professor Hospital Italiano de Buenos Aires School of Medicine. General Surgery Residency Co-Director, Hospital Italiano de Buenos Aires. Fernando Alvarez MD. Fellowship of HPB Surgery and Liver Transplant at the Italian Hospital of Buenos Aires (2013-2014). Received the "Eduardo F. Beláustegui Award" from the Argentine Surgical Association (2008) and the “Annual Award" from the Argentine Academy of Surgery (2014). Virginia Cano Busnelli MD with Residency training at Italian Hospital of Buenos Aires.

Foreword 6
Preface 8
Contents 10
Contributors 13
Part I: Global Patient Evaluation and Oncological Assessment 18
1: Liver Surgical Anatomy 19
Introduction 19
Classical Surgical Anatomy of the Liver 19
Functional (Vascular) Anatomy 20
Alternative Representations 24
A More Independent Look at the Anatomies of the Liver 27
Surgical Anatomy and Anatomical Surgery of the Structures and Planes in the Liver 28
The Hilar Plate 28
Approaches to the Portal Pedicles 30
Arantius’ Ligament 31
Approaches to the Hepatic Veins 31
Segment 1 32
Segment 8 33
References 33
2: Resectability Assessment with Diagnostic Imaging 35
Introduction 35
Selection of Patients 35
Assessment of Resectability Based on Imaging 36
Imaging 37
Ultrasound 37
CT 38
MRI 40
FGD-PET 42
References 44
3: Preoperative Evaluation of Liver Function 47
Introduction 47
Definition of Liver Function 48
Passive Liver Function Tests 48
Aminotransaminases 48
Bilirubin 48
Albumin and Coagulation Factor Synthesis 48
Ammonia Elimination and Urea Production 49
Hyaluronic Acid Clearance 49
Clinical Grading Systems 49
Child–Pugh Score 49
MELD (Model for End-Stage Liver Disease) Score 50
Volumetric Measurements: the Gold Standard 50
Standardized CT Volumetry 51
Body Weight Ratio 51
Dynamic Quantitative Liver Tests 51
Indocyanine Green Clearance Test 52
Galactose Elimination Capacity (GEC) Test 52
Lidocaine Clearance (MEGX) Test 53
Scintigraphic Liver Function Tests 53
99mTc-GSA Scintigraphy 53
HBS with IDA Derivates 55
Other Modalities for Assessment of Liver Function 58
Bioenergetic Tests 58
13C-Methacetin Breath Test, LiMAx 58
Assessment of Liver Function Using Magnetic Resonance Imaging 59
Discussion 60
References 62
4: Imaging-Based Preoperative Planning 69
Introduction 69
Oncological Resectability 69
Imaging Techniques 69
Ultrasound 69
Intraoperative Ultrasound 70
Computed Tomography 70
MRI 70
FDG-PET-CT 71
Imaging-Based Assessment of Oncological Resectability in a Multimodal Treatment Setting 71
Impact of Preoperative Chemotherapy on the Diagnostic Performance of Liver Imaging 71
Radiological Assessment of the Oncological Response to Preoperative Chemotherapy 71
Preoperative Radiological Assessment of Pathologic Response 72
Complete Radiologic Response or the Disappeared Liver Metastasis 74
Functional Resectability 75
Assessment of the Functional Liver Remnant 75
Volumetric Assessment of the Liver 75
Enzymatic Liver Function Testing 75
Imaging-Based Liver Function Testing 76
Computer-Assisted Virtual Resection Planning in the 3D Liver Model 76
References 77
5: Choosing the Best Strategy 81
Introduction 81
Patient Selection 82
General Evaluation 82
Local Evaluation 83
Choosing the Best Strategy 84
Imaging Considerations 85
Chemotherapy Considerations 85
Surgical Considerations 86
References 89
Part II: Non-operative Multimodal Therapies 92
6: Conversion and Neoadjuvant Therapies 93
Introduction 93
Chemotherapeutic Agents: Overview and Toxicity 94
Molecular Targeted Agents: Overview and Toxicity 100
Criteria to Define Resectability in Colorectal Liver Metastases 106
Response Imaging Evaluation in Colorectal Liver Metastases 108
Disappearing Liver Metastases and Tumor Response 110
Neoadjuvant Chemotherapy and Resectable Colorectal Liver Metastases 112
Conversion Chemotherapy in Unresectable Colorectal Liver Metastases 116
Adjuvant Chemotherapy in Colorectal Liver Metastases 121
Liver Recurrence and Chemotherapy 122
References 123
7: Portal Vein Embolization 133
The Future Liver Remnant and the Rationale for Portal Vein Embolization 133
Surgical Strategy and Preoperative Assessment of FLR 133
Evaluation of Candidates for Portal Vein Embolization 133
Preoperative Assessment of FLR 136
Techniques of Portal Vein Embolization 138
Accessing the Portal Vein 138
Agents Used for Embolization and the Technique 138
Embolization of Segment 4 Portal Vein Branches 139
Measuring Effect and Outcome After Portal Vein Embolization 140
Degree of Hypertrophy 140
Kinetic Growth Rate 140
Salvage Options After PVE Failure 140
Complications After PVE 141
Oncologic Impact of PVE and Effect of Chemotherapy 142
Alternatives to Portal Vein Embolization and Additional Techniques to Induce Liver Hypertrophy 142
Associating Liver Partition and Portal Vein Ligation 142
Portal Vein Ligation 142
Summary 143
References 143
8: Intra-Arterial Chemotherapy 145
Introduction 145
Rationale for Intra-Arterial Chemotherapy 146
Hepatic Arterial Infusion (HAI) Pump Therapy 146
Technical Considerations 146
Alternative Modes of Intra-Arterial Chemotherapy 148
Outcomes in Unresectable Disease 149
Outcomes as Adjuvant Therapy Following Hepatic Resection 151
Complications 152
References 153
9: Radioembolization 157
Introduction 157
Principles and Technique of Radioembolization 157
Indications, Contraindications, and Patient Selection 163
Efficacy and Clinical Results 164
Radioembolization as First-Line Treatment 164
Radioembolization as Second-Line Treatment 165
Radioembolization as Salvage Treatment 165
Side-Effects and Complications 166
Follow-Up and Response Assessment 167
References 168
Part III: Surgical Strategies 170
10: Anesthetic Management 171
Introduction 171
Anatomy and Hepatic Physiology 171
Anatomic and Physiological Characteristics of the Liver with Surgical and Anaesthetic Relevance 172
Hepatic Endothelium and Influence on Central Venous Pressure 173
Surgical Manoeuvres that Diminish Intraoperative Bleeding 174
Pringle Manoeuvre (PM) 174
Total Vascular Exclusion (TVE) 175
Anaesthetic Technique 176
Relationship Between Central Venous Pressure (CVP) and Intraoperative Haemorrhage 177
Other Causes that Can Influence Intraoperative Bleeding 178
Patients with Preoperative Morbility 178
Other Strategies to Diminish Bleeding 178
Hepatic Injury due to Ischemia: Pre Conditioning 180
Post-operative Analgesia and Fast Track Technique 181
Ex-Situ, Ex-Vivo Hepatic Resection 183
Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy—ALPPS 183
Final Considerations 184
References 184
11: Intraoperative Evaluation of Resectability 188
Introduction 188
Surgical Technique 189
Incision 189
IOUS Intraoperative Staging 191
Mobilization 192
Tumor–Vessel Detachment 194
Flow Analyses 195
New Operations 197
Systematic Extended Right Posterior Sectionectomy 197
Eligibility Criteria 197
Procedure 198
Minimesohepatectomy 199
Eligibility Criteria 199
Procedure 199
Upper Transversal Hepatectomy (UTH) 199
Eligibility Criteria 200
Procedure 200
Liver Tunnel 201
Eligibility Criteria 201
Procedure 202
References 203
12: Vascular Control in Major Hepatic Resections 205
Introduction 205
Anatomical Fundaments for Vascular Control in Liver Surgery 205
Inflow–Outflow–Parenchyma 206
Types of Vascular Control 206
Portal Triad Clamping 207
Total- and Selective Hepatic Vascular Exclusion 208
Selective or Total Hepatic Vascular Exclusion Combined with Cold Perfusion 208
Infrahepatic Inferior Vena Cava Clamping 209
Anesthesiological- and Pharmacological Interventions 210
Laparoscopic Surgery 210
Conclusion/Summary 210
References 211
13: Two-Stage Liver Surgery 213
Introduction and Development of TSH 213
Indication of TSH for CLM 214
Concomitant Extrahepatic Disease 214
Surgical Procedures of TSH 216
First-Stage Hepatectomy 216
Portal Vein Ligation/Embolization 217
Second-Stage Hepatectomy 217
Concomitant Use of Local Ablation Therapy 217
Primary Tumor Resection in Case of Synchronous Presentation 218
Chemotherapy 218
Preoperative Chemotherapy 218
Interval Chemotherapy 218
Postoperative Chemotherapy 219
Drawbacks of TSH 219
Short-Term Outcome 221
Long-Term Outcome 221
Prognostic Factors of Survival After TSH 222
Future Perspective of TSH 223
References 223
14: Two-Stage Liver Surgery with Portal Vein Occlusion 226
The Evolution of Staged Liver Surgery 226
Indications and Limitations 231
The Three Elements of Two-Stage Hepatectomy 233
Portal Vein Occlusion (PVO) 234
Chemotherapy (Systemic, Intra-arterial) 235
Surgery 235
How Far Can We Go? Failing Liver Regeneration and Small-for-Size Syndrome 236
Outlook 237
References 237
15: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) 240
Introduction 240
Patient Selection and Preoperative Evaluation 241
Surgical Technique 242
Classical Technique 243
First Stage 243
Second Stage 244
Proposed Technical Variations 245
Hypertrophic Efficacy 247
Interval Management and Timing of Second Stage 248
Short and Long-Term Outcomes 249
Postoperative Complications 250
Oncological Results 252
Benefits, Drawbacks, and Future Perspectives 253
References 254
16: Parenchymal-Sparing Liver Resections 257
Introduction 257
Surgical Principles of Parenchymal-­Sparing Liver Resection 257
Oncological Principles of Parenchymal Sparing Liver Resection 258
Ultrasound Guidance to Parenchymal-Sparing Liver Resections 259
Laparoscopic Liver Resection 268
References 271
17: Combined Vascular Resections 273
Introduction 273
Portal Triad Resections 274
Hepatic Vein Resections 276
Vena Cava Resections 278
References 279
18: Ex-Vivo Liver Surgery 281
Introduction 281
Patient Selection 282
Operative Technique 284
Reference 287
19: The Role of Laparoscopy in Advanced Liver Disease 289
Introduction 289
Staging 289
Tumor Ablation 290
Laparoscopic Liver Resections (LLRs) 290
Surgical Technique 291
Results 294
References 295
20: Liver Transplantation for Unresectable Disease 297
Introduction 297
Liver Transplantation for Tumors: Historical Perspective 298
Liver Transplantation for Nonresectable CLM in Norway: The SECA Study 298
Further Developments 302
Patient Selection 303
Can the Access to Liver Grafts to CLM Patients Be Improved? 303
References 305
Part IV: Management of Concomitant Extrahepatic Disease 308
21: Lung Metastases 309
Introduction 309
Historical Note 309
Rationale for Resection of Pulmonary Metastases 310
Criteria for Pulmonary Metastasectomy 311
Imaging Requirements 311
Factors Influencing Outcome After Lung Metastasectomy in Colorectal Cancer 311
Surgical Aspects of Pulmonary Metastasectomy 313
Surgical Approach 313
Type of Resection 314
The Role of Lymph Node Dissection 315
The Role of Chemotherapy 316
Systemic Chemotherapy 316
Loco-Regional Therapy 316
Chemoembolization 316
Isolated Lung Perfusion 317
References 318
22: Nodal Involvement 323
Introduction 323
Anatomy 323
Hepatic Lymph 323
Drainage of Portal Lymphatic Vessels 324
Frequency and Pre- and Intra-­Operative Assessment of HPLN Involvement 326
Prognosis of CLM Patients with Metastatic HPLN and Distant LN, Particularly Para-Aortic LN (PALN) 329
Surgical Technique of HPLN Dissection 330
Reference 336
23: Peritoneal Metastases 338
Introduction 338
Mechanisms 338
Incidence 338
Diagnosis 339
Patients at Risk 340
Complete Cytoreductive Surgery Plus HIPEC—Objectives and Results 340
Principles and Objectives 340
Surgical Technique 341
Hyperthermic Intraperitoneal Chemotherapy 341
Short-Term Results 342
Long-Term Results 343
Prognostic Factors 343
Completeness of Resection 343
Extent of Peritoneal Disease 344
Others Prognostic Factors 345
Histological Findings and Response to Systemic Preoperative Chemotherapy 345
Indications 345
Perspectives 345
Standardization of the Procedures 345
New Drugs, New Combinations 345
To Treat earlier 346
References 347
24: Adjacent Organs Invasion: Multivisceral Resections 351
Introduction 351
Surgical Indications 351
Patient Work-Up 351
Radiological Assessment 352
Operative Procedure 353
Definitions 353
Preoperative Care 353
Surgical Aspects 353
Short-Term and Long-Term Outcomes 354
References 355
Part V: Miscellany 356
25: Postoperative Complications and Their Management 357
Introduction 357
Post HR Liver Insufficiency 358
Definition 358
Prevention 359
Treatment 361
Bile Leaks 361
Treatment 362
Prevention 363
Hemorrhage 363
Bleeding of the HR’s Surface 364
Coagulopathies 364
Prevention 365
Abdominal Collections 365
References 365
26: Improving Quality of Life in Patients with Unresectable Disease 366
Introduction 366
Interaction Between Surgery and Palliative Care in the Case of Planning a CLM Resection 367
Decision-Making and Communication 368
Degree of Response to Opioids and Analgesia–Side-Effects Balance 372
General Guidelines for the Use of Analgesic Opioids 372
Examples of Treatment in Particular Situations [19] 373
References 374
Index 375