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Postoperative early recurrence after hepatic resection for hepatocellular carcinoma (HCC) poses a challenge to surgeons, and the effect of a surgical margin is still controversial. This study aimed to identify an ideal margin to prevent early recurrence. A total of 226 consecutive patients who underwent primary curative hepatic resection for solitary and primary HCC were enrolled. The definition of early recurrence was determined using the minimum P value approach. Logistic regression analysis was used to identify the risk factors of early recurrence. The receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off of the surgical margin and early recurrence. Recurrence within 8 months induced the poorest overall survival (P = 2×10−15). ROC analysis showed that the optimal cut-off value of the surgical margin was 7 mm. The risk factors of early recurrence (≤ 8-month recurrence) were preoperative alpha-fetoprotein levels ≥ 100 ng/ml (Odds ratio [OR] 4.92 [2.28–10.77], P 7-mm margin is important to prevent early recurrence. Patients with HCC and alpha-fetoprotein levels > 100 ng/ml, non-capsule formation, or microvascular invasion may have a survival benefit from a ≥ 7-mm margin.

Assessing the risk of significant macrosteatosis in donors is crucial before considering hepatic graft procurement. We aimed to build a model to predict significant macrosteatosis based on noninvasive methods. From January 2012 to December 2018, liver attenuation indices and liver-to-spleen (L/S) ratio were measured in 639 brain-dead donors by local radiologists. Quantity and quality of steatosis were evaluated by an expert pathologist, blinded for attenuation indices measurement. Macrosteatosis ≥ 30% was found in 33 donors (5.2%). Body weight, body mass index (BMI), abdominal perimeters, history of alcohol abuse, L/S ratio, and liver parenchyma attenuation were associated with macrosteatosis ≥ 30%. The L/S ratio, BMI, and a history of alcohol abuse remained independent predictors in multivariate analysis and were used to build a predictive model (C-index: 0.77). The optimal cutoff to predict macrosteatosis ≥ 60% was 0.85. Our model, including L/S ratio, BMI, and history of alcohol, might be helpful to refine indication for liver biopsy before donation after brain death. External validation is required.

Postoperative early recurrence after hepatic resection for hepatocellular carcinoma (HCC) poses a challenge to surgeons, and the effect of a surgical margin is still controversial. This study aimed to identify an ideal margin to prevent early recurrence.A total of 226 consecutive patients who underwent primary curative hepatic resection for solitary and primary HCC were enrolled. The definition of early recurrence was determined using the minimum P value approach. Logistic regression analysis was used to identify the risk factors of early recurrence. The receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off of the surgical margin and early recurrence.Recurrence within 8 months induced the poorest overall survival (P = 2×10A7-mm margin is important to prevent early recurrence. Patients with HCC and alpha-fetoprotein levels100 ng/ml, non-capsule formation, or microvascular invasion may have a survival benefit from a ≥ 7-mm margin.

Vascular complications following liver transplantation (LT) may result from technical deficiencies. Intraoperative diagnosis remains challenging but can prevent serious delayed complications. Intraoperative Doppler ultrasonography (IOUS) represents the gold standard for imaging, although it requires radiological skills. Contrast-enhanced ultrasonography has been reported during postoperative assessments, but never intraoperatively (CE-IOUS). The aim of this study was to assess the feasibility of routine CE-IOUS, to evaluate its impact on surgical strategy and its usefulness. All 553 whole LTs performed in our tertiary centre between 01/2010 and 12/2014 were reviewed. We compared perioperative outcomes and long-term survival in IOUS (n = 370) versus CE-IOUS (n = 103) groups. Secondarily, the seven cases where the two imaging findings conflicted (CE+ Group) were matched 1:2 and compared with an exclusively IOUS procedure (CE− Group, n = 14) to assess the consequences of a specific CE-guided strategy. CE-IOUS assessments were successful in 100% of cases, without any adverse effects. Vascular complications and patient/graft survival rates were identical in the IOUS and CE-IOUS groups (p = 0.65, 0.95 and 0.86, respectively). CE-IOUS confirmed IOUS findings in 93% of cases (n = 96) and led to the realization of an additional procedure (median arcuate ligament lysis) and six conservative strategies despite poor arterial (n = 5) or venous flow (n = 1) under Doppler analysis. The CE+ and CE− groups presented statistically identical perioperative and long-term outcomes. This study demonstrated the feasibility of CE-IOUS during whole LT. However, we failed to demonstrate any advantages of CE-IOUS over IOUS. Therefore, IOUS currently remains the gold-standard imaging technique for the intraoperative assessment of vascular patency.

The optimal management of the open abdomen (OA) after liver transplantation (LT) is unclear. The negative pressure wound therapy (NPWT) has been shown to be safe and can increase the chance for early fascial closure in trauma or septic patients. However, little data are available on the specific setting of LT. We aimed to report our experience of OA after LT, marked by the recent use of NPWT. All patients with postponed wall closure after LT, from 2002 to 2014, in a single institution were included and retrospectively analyzed. Our management of OA after LT has shifted from skin-only closure (SOC) followed by abdominal wall reconstruction at a distance to the use of NPWT with early fascial closure. Of the 1559 LTs performed during the study period, immediate abdominal wall closure at the end of transplantation could not be achieved in 46 (2.9%) patients. Of them, SOC was performed in 22 (47.8%) patients, whereas vacuum-assisted closure (VAC) therapy was used in 24 (52.1%) patients. The comprehensive complication indexes (CCI) were similar [CCI: 66 (0–100) in the SOC group vs. 56 (0–100) in the VAC group; p = 0.55]. No evisceration or fistula occurred in both groups. One (4.2%) postoperative bleeding case was reported in the VAC group. Early fascial closure was achieved within a median of 5.5 days (1–12) for the 24 patients (100%) of the VAC group. In four of them, a biological mesh was necessary. Only nine patients (52.9%) of the survivors in the SOC group underwent abdominal reconstruction. The NPWT in patients with OA after LT enables early fascial closure with limited morbidity provided a specific attention is given to the risk of bleeding. These results support the use of NPWT as the first option in OA patients after LT.

The specific definition of central hepatectomy (CH) (i.e., resection of segments 4-5-8 ± 1) is not uniformly used, resulting in conflicting comparisons with the more commonly performed extended hepatectomy (EH). The study aimed to compare, using propensity score matching (PSM) analysis, the incidence of postoperative complications between CH and EH for centrally located liver tumors (CLLT). All consecutive CH and EH procedures for CLLT performed from 1980 to 2011 were retrospectively reviewed. Independent predictors of postoperative complications were identified. CH was compared to EH after PSM. The study population consisted of 373 patients, 44 (11.8 %) of whom underwent CH and 329 (88.2 %) of whom underwent EH. Before PSM, the overall 90-day mortality was 7.2 % (27 patients) without a group difference (2 (4.5 %) for CH vs. 25 (7.6 %) for EH, p = 0.756). The CH and EH groups had similar postoperative morbidity rates (43.2 vs. 55.3 %; p = 0.108). Blood transfusion was the only independent predictor of postoperative complications (Hazard Ratio: 1.73; 95 % confidence interval: 1.11–2.68; p = 0.014). After PSM, 43 CH patients were matched with 43 EH patients. No group difference was observed for the postoperative mortality, morbidity, or duration of hospital stay. A higher number of EH patients (30.2 vs. 9.3 %, p = 0.028) presented with more than one postoperative complication. CH and EH yield similar mortality and morbidity. For CLLT, CH may be an attractive procedure with the advantage of sparing the liver parenchyma compared with EH.

Hepatocellular carcinoma (HCC), although generally associated with cirrhosis, can also develop in a noncirrhotic liver. To study HCCs in noncirrhotic liver, their surgical management and prognosis, 68 patients with partial hepatectomy for this disease were analyzed. The liver, in all cases, appeared normal macroscopically at laparotomy, but in 13 cases (19%) it presented some slight histologic modifications, such as steatosis or portal fibrosis. Five patients had a fibrolamellar carcinoma. The mean diameter of the tumors was 8.8 cm. Sixteen patients (23.5%) were treated preoperatively by embolization or chemoembolization. Surgical procedures consisted in a major hepatectomy (three segments or more) in 72% of the cases. Operative mortality and morbidity were, respectively, 2.9% and 19.0%. The 1-, 3-, 5-, and 10-year survivals and the survivals without recurrence were 74%, 52%, 40%, and 26% and 69%, 43%, 33%, and 19%, respectively. Recurrence, which was in most cases intrahepatic, occurred in 39 of the 66 survivors (59%) and was treated by rehepatectomy in 12 cases, providing long survivals. These data justify extensive, aggressive surgery for HCCs in noncirrhotic liver and show the need for long-term follow-up to defect late recurrence, as surgery for recurrent disease prolongs survival.

During the past 25 years, 213 patients with hilar cancer have been treated in this unit. One hundred seventy-eight patients had some form of surgical intervention and 35 were unfit for any surgery. The preoperative and peroperative assessment of the 178 patients having surgery was directed toward identifying tumors which might be suitable for potentially curative resection. On this basis, 18 patients (10.1%) had tumor resection and the remaining 160 patients had a palliative procedure. When possible, some form of surgical bypass procedure was performed to achieve palliation (96 patients) but when this was either impossible or contraindicated, an intubation and drainage procedure was performed (64 patients). There was no operative mortality among the 18 patients having surgical resection (10 having local resection and 8 having hepatic resection). There was a complete disappearance of jaundice in all patients and the mean survival was 53 months with a mean duration of well-being of 39 months. Among the 96 patients having surgical bypass, the operative mortality rate was 7%, and 20% of these patients had a postoperative complication. There was a complete relief of jaundice in more than 75% of these patients. The average survival time was 9 months with a duration of well-being of 8 months. Among the 64 patients having intubation and drainage, the operative mortality rate was 30%, and 26% of these patients had postoperative complications. Less than half of these patients experienced a complete relief of jaundice. Although the average survival time was 7 months, the duration of well-being was usually only 2–4 months. We conclude that surgical resection offers the best possibility of prolonged survival and the best quality of life for suitable patients with hilar cancer. The majority of patients are, however, suitable only for a palliative procedure and the best palliation is achieved by a surgical bypass procedure.

Operative ultrasound was evaluated in 77 patients submitted for surgery of primary liver tumors over a 3-year period. Preoperative ultrasonography, computed tomography, and selective hepatic arteriography were performed in all patients before 79 surgical interventions. Peroperative ultrasonography provided additional information to that obtained from preoperative investigations in 26 cases (33%). This information modified the intended surgical procedure in 21 cases and, in 10 patients, subsegmental resection was facilitated by ultrasonically guided cannulation of the portal venous branch.

Individualization of the segment as the functional anatomical unit of the liver permits the performance of surgical segmentectomies. These segmental resections are “reglees” because the plane of cleavage of the hepatic parenchyma follows the anatomical scissurae. From the technical point of view, liver segmentectomies are characterized by an exclusive transparenchymatous approach to the vascular pedicles of the segment to be removed. We have performed this type of surgery in 22 patients with no mortality. These operations are indicated in: (1) some benign tumors; (2) some liver trauma; (3) biliary operations above the hilus, where anterior resection of segment IV can be necessary; and (4) carcinomas of the gallbladder discovered histologically after cholecystectomy. Liver segmentectomies can also be indicated for malignant tumors when the liver is cirrhotic, or when an extended resection is likely to expose the patient to the risk of liver failure. Indeed, one of the main advantages of liver segmentectomies is that they permit an economical but safe surgical resection of the hepatic parenchyma.