title: Minor-but-Complex Liver Resection: An Alternative to Major Resections for Colorectal Liver Metastases Involving the Hepato-Caval Confluence.
abstract: Major hepatectomy (MH) is often considered the only possible approach for colorectal liver metastasis (CRLM) at the hepato-caval confluence (CC), but it is associated with high morbidity and mortality. With the aim to reduce MH, we developed the "minor-but-complex" (MbC) technique, which consists in the resection of less than 3 adjacent liver segments with exposure of the CC and preservation of hepatic outflow until spontaneous maturation of peripheral intrahepatic shunts between main hepatic veins. We have evaluated applicability and outcome of MbC resections for the treatment of CRLM involving the CC. In this retrospective cohort study, all consecutive liver resections (LR) performed for CRLM located in segments 1, 7, 8, or 4a were classified as MINOR - removal of <3 adjacent segments; MbC - removal of <3 adjacent segments with CC exposure; and MH - removal of ≥ 3 adjacent segments. The rate of avoided MH was obtained by the difference between the rate of potentially MH (PMH) plus potentially inoperable cases and the rate of the MH performed. Taking into account that postoperative mortality is mainly related to the amount of resected liver, MbC was compared with minor resections for safety, complexity, and outcome. Of the 59 LR analyzed, 29 (49.1%) were deemed PMH and 4 (6.8%) potentially inoperable. Eventually, MH was performed only in 8 (13.5%) with a decrease rate of 42.4%. Minor LR was performed in 23 (39.0%) and MbC LR in 28 (47.5%) patients. Among MbC cases, 32.1% had previous liver treatments, 39.3% required vascular reconstruction (no reconstructed vessel thrombosis occurred before maturation of peripheral intrahepatic shunts between main hepatic veins), and 7.1% had grade IIIb-IV complications, their median hospital stay was 9 days and 90-day mortality was 0%. After a median follow-up of 22.2 months, oncological results were comparable with those of minor resections. MbC hepatectomy lowers the need for MH and allows for the resection of potentially inoperable patients without negative impact on safety and survival.
authors.affiliation: From the General Surgery Unit (LU, MP, RB, AM, VP, PB); Oncology Unit (GM, CV); Hepatology Unit (PC); Anaesthesiology and Intensive Care Unit (FF, GL, CL, AP); Radiology Unit (PB, AL); Infectious Disease Unit (CT); Pathology Unit (MC); Azienda Ospedaliero-Universitaria Pisana, Ospedale Nuovo Santa Chiara, Cisanello, Pisa, Italy.
authors.forename: Lucio
authors.initials: L
authors.lastname: Urbani
authors.forename: Gianluca
authors.initials: G
authors.lastname: Masi
authors.forename: Marco
authors.initials: M
authors.lastname: Puccini
authors.forename: Piero
authors.initials: P
authors.lastname: Colombatto
authors.forename: Caterina
authors.initials: C
authors.lastname: Vivaldi
authors.forename: Riccardo
authors.initials: R
authors.lastname: Balestri
authors.forename: Antonio
authors.initials: A
authors.lastname: Marioni
authors.forename: Valerio
authors.initials: V
authors.lastname: Prosperi
authors.forename: Francesco
authors.initials: F
authors.lastname: Forfori
authors.forename: Gabriella
authors.initials: G
authors.lastname: Licitra
authors.forename: Chiara
authors.initials: C
authors.lastname: Leoni
authors.forename: Adriana
authors.initials: A
authors.lastname: Paolicchi
authors.forename: Piero
authors.initials: P
authors.lastname: Boraschi
authors.forename: Alessandro
authors.initials: A
authors.lastname: Lunardi
authors.forename: Carlo
authors.initials: C
authors.lastname: Tascini
authors.forename: Maura
authors.initials: M
authors.lastname: Castagna
authors.forename: Piero
authors.initials: P
authors.lastname: Buccianti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000473:pathology* / Q000628:therapy; D003131:Combined Modality Therapy; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008099:Liver / Q000098:blood supply / Q000473:pathology; D008113:Liver Neoplasms / Q000556:secondary* / Q000601:surgery* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies