Safe perioperative management of major hepatectomy in a patient with portal hypertension after elimination of hepatitis C: a case report

Background The administration of direct-acting antiviral agents in patients with liver cirrhosis and hepatitis C has been shown to improve liver function and long-term prognosis after sustained virological response (SVR) is achieved. However, in patients with portal hypertension (PH) at the time of SVR, PH may persist despite improvement in liver function. Case presentation An 82-year-old woman with liver cirrhosis due to hepatitis C was treated with direct-acting antiviral agents and achieved SVR. During follow-up, computed tomography revealed a low-density tumor in the left lateral region of the liver with dilation of the left intrahepatic bile duct. Considering the patient’s advanced age and PH persistence with a mild decrease in liver reserve function after SVR, preoperative percutaneous transhepatic portal embolization (PTPE) and partial splenic embolization (PSE) were performed concomitantly. Laparoscopic left hemihepatectomy was performed 8 days after the PTPE and PSE. The patient was discharged 8 days after surgery without any postoperative complications. Conclusions Laparoscopic left hemihepatectomy after preoperative management of PH was performed safely in a patient after the elimination of hepatitis C.

Rescue partial ALPPS for left hemihepatectomy with reconstruction of the middle hepatic vein

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70 with an intrahepatic cholangiocarcinoma (ICC) in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization (PVE). The FLR volume increased to 71.3%, however, the non-congestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue ALPPS (Associating Liver Partition and Portal vein occlusion for Staged hepatectomy) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie’s line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

Left-side vs. right-side hepatectomy for hilar cholangiocarcinoma: a meta-analysis

Goals We aim to draw a conclusion which type of hepatectomy could be the priority for hilar cholangiocarcinoma patients. Background Surgery is established as only potentially curative treatment for hilar cholangiocarcinoma. However, whether hepatectomy should be preferred to the left-side hepatectomy, which includes left hemihepatectomy, extended left hemihepatectomy, and left trisectionectomy, or right-side hepatectomy, which represents right hemihepatectomy, extended right hemihepatectomy, and right trisectionectomy, is debated. In this meta-analysis, we evaluated and compared the efficacy and safety of left-side hepatectomy and right-side hepatectomy in patients with hilar cholangiocarcinoma. Study We systematically retrieved the MEDLINE, PubMed, and Cochrane library and related bibliography up to February 2020. The primary outcome is overall survival, and the secondary outcome includes 1-, 3-, and 5-year survival rates, morbidity, mortality, R0 resection rate, and operation time. Based on heterogeneity, fixed-effects model or random-effects models were established through meta-analysis. Results Eleven studies (11 cohort studies, totally 1031 patients) were involved in this study. The overall survival of patients who underwent left-side hepatectomy was comparable to that of patients who underwent right-side hepatectomy (hazard ratio, 1.27 [95% confidence interval, 0.98–1.63]). And there was no significant difference observed in 1-year (relative risk, 1.01 [95% CI, 0.89–1.15]), 3-year (relative risk, 0.94 [95% confidence interval, 0.80–1.11]), and 5-year survival (relative risk, 0.82 [95% confidence interval, 0.67–1.01]) rates between the left-side hepatectomy group and the right-side hepatectomy group. Comparing with the right-side hepatectomy cluster, the hilar cholangiocarcinoma patients in the left-side hepatectomy cluster presented better overall postoperative morbidity (relative risk, 0.82 [95% confidence interval, 0.71–0.96]) and major postoperative morbidity (relative risk, 0.73 [95% confidence interval, 0.56–0.95]). The post-hepatectomy liver failure rate (relative risk, 0.22 [95% confidence interval, 0.09–0.56]) and procedure-related mortality (relative risk, 0.41 [95% confidence interval, 0.23–0.70]) in the left-side hepatectomy group were better than those of the right-side hepatectomy group. Besides, the R0 resection rate was similar between the left-side hepatectomy group and the right-side hepatectomy group (relative risk, 0.95 [95% confidence interval, 0.87–1.03]). And the operation time for the left-side hepatectomy was significantly longer than that for the right-side hepatectomy (mean difference, 38.68 [95% confidence interval, 7.41–69.95]). Conclusion Through meta-analysis, we explored the comparable long-term outcomes and better short-term outcomes in the left-side hepatectomy group as is compared to the right-side hepatectomy group of hilar cholangiocarcinoma patients. In this study, the evidence obtained might indicate that the choice of left-side hepatectomy or right-side hepatectomy depends on the site of hilar cholangiocarcinoma in every patient.

Left-side vs. right-side hepatectomy for Hilar Cholangiocarcinoma: A meta-analysis

Goals: We aim to draw a conclusion which type of hepatectomy could be the priority for hilar cholangiocarcinoma patients.Background: Surgery is established as only potentially curative treatment for hilar cholangiocarcinoma. However, whether hepatectomy should be preferred to the left-side hepatectomy, which includes left hemihepatectomy, extended left hemihepatectomy and left trisectionectomy, or right-side hepatectomy, which represents right hemihepatectomy, extended right hemihepatectomy and right trisectionectomy, is debated. In this meta-analysis, we evaluated and compared the efficacy and safety of left-side hepatectomy and right-side hepatectomy in patients with hilar cholangiocarcinoma.Study: We systematically retrieved the MEDLINE, PubMed and Cochrane library and related bibliography up to February 2020. The primary outcome is overall survival, and secondary outcomes include 1-, 3-, and 5-Year survival rates, morbidity, mortality, R0 resection rate and operation time. Based on heterogeneity, fixed-effects model or random-effects models were established through meta-analysis.Results: Eleven studies (11 cohort studies, totally 1031 patients) were involved in this study. The overall survival of patients underwent left-side hepatectomy was comparable to that of patients underwent right-side hepatectomy (hazard ratio, 1.27 [95% confidence interval, 0.98-1.63]). And there was no significant difference observed in 1-year (relative risk, 1.01 [95% CI, 0.89-1.15]), 3-year (relative risk, 0.94 [95% confidence interval, 0.80-1.11]), and 5-year survival (relative risk, 0.82 [95% confidence interval, 0.67-1.01]) rates between left-side hepatectomy group and the right-side hepatectomy group. Comparing with right-side hepatectomy cluster, the hilar cholangiocarcinoma patients in left-side hepatectomy cluster presented better overall postoperative morbidity (relative risk, 0.82 [95% confidence interval, 0.71-0.96]) and major postoperative morbidity (relative risk, 0.73 [95% confidence interval, 0.56-0.95]). The post-hepatectomy liver failure rate (relative risk, 0.22 [95% confidence interval, 0.09-0.56]) and procedure-related mortality (relative risk, 0.41 [95% confidence interval, 0.23-0.70]) in left-side hepatectomy group was better than that of right-side hepatectomy group. Besides, the R0 resection rate was similar between left-side hepatectomy group and right-side hepatectomy group (relative risk, 0.95 [95% confidence interval, 0.87-1.03]). And the operation time for left-side hepatectomy were significantly longer than those for right-side hepatectomy (mean difference, 38.68 [95% confidence interval, 7.41-69.95]).Conclusion: Through meta-analysis, we explored the comparable long-term outcomes and better short-term outcomes in left-side hepatectomy group as is compared to right-side hepatectomy group of hilar cholangiocarcinoma patients. In this study, the evidence obtained might indicate that the choice of left-side hepatectomy or right-side hepatectomy had better depend on the site of hilar cholangiocarcinoma in every patient.

Left-Side vs. Right-Side Hepatectomy for Hilar Cholangiocarcinoma: A Meta-Analysis

Goals: We aim to draw a conclusion which side of hepatectomy could be the priority for hilar cholangiocarcinoma patients.Background: Surgery is established as only potentially curative treatment for hilar cholangiocarcinoma. However, whether hepatectomy should be preferred to the left-side hepatectomy, which contains left hemihepatectomy, extended left hemihepatectomy and left trisectionectomy, or right-side hepatectomy, which represents right hemihepatectomy, extended right hemihepatectomy and right trisectionectomy, is debated. In this meta-analysis, we evaluated and compared the efficacy and safety of left-side hepatectomy and right-side hepatectomy in patients with hilar cholangiocarcinoma.Study: We systematically retrieved the MEDLINE, PubMed and Cochrane library and related bibliography up to February 2020. The primary outcome is overall survival, and secondary outcomes include 1-, 3-, and 5-Year survival rates, morbidity, mortality, R0 resection rate and operation time. Based on heterogeneity, fixed-effects model or random-effects models were established through meta-analysis.Results: Eleven studies (11 cohort studies, totally 1031 patients) were involved in this study. The overall survival of patients underwent left-side hepatectomy was comparable to that of patients underwent right-side hepatectomy (hazard ratio, 1.27 [95% confidence interval, 0.98-1.63]). And there was no significant difference observed in 1-year (relative risk, 1.01 [95% CI, 0.89-1.15]), 3-year (relative risk, 0.94 [95% confidence interval, 0.80-1.11]), and 5-year survival (relative risk, 0.82 [95% confidence interval, 0.67-1.01]) rates between left-side hepatectomy group and the right-side hepatectomy group. Comparing with right-side hepatectomy cluster, the hilar cholangiocarcinoma patients in left-side hepatectomy cluster presented better overall postoperative morbidity (relative risk, 0.82 [95% confidence interval, 0.71-0.96]) and major postoperative morbidity (relative risk, 0.73 [95% confidence interval, 0.56-0.95]). The post-hepatectomy liver failure rate (relative risk, 0.22 [95% confidence interval, 0.09-0.56]) and procedure-related mortality (relative risk, 0.41 [95% confidence interval, 0.23-0.70]) in left-side hepatectomy group was better than that of right-side hepatectomy group. Besides, the R0 resection rate was similar between left-side hepatectomy group and right-side hepatectomy group (relative risk, 0.95 [95% confidence interval, 0.87-1.03]). And the operation time for left-side hepatectomy were significantly longer than those for right-side hepatectomy (mean difference, 38.68 [95% confidence interval, 7.41-69.95]).Conclusion: Through meta-analysis, we explored the comparable long-term outcomes and better short-term outcomes in left-side hepatectomy group as is compared to right-side hepatectomy group of hilar cholangiocarcinoma patients. In this study, the evidence obtained might indicate that the choice of left-side hepatectomy or right-side hepatectomy had better depend on the specific situation of every patients of hilar cholangiocarcinoma.