Risk Factors of Positive Resection Margin in Laparoscopic and Open Liver Surgery for Colorectal Liver Metastases: A New Perspective in the Perioperative Assessment

Abstract

Objective: To assess the risk factors associated with R1 resection in patients undergoing OLS and LLS for CRLMs. Background: The clinical impact of R1 resection in liver surgery for CRLMs has been continuously appraised, but R1 risk factors have not been clearly defined yet. Methods: A cohort study of patients who underwent OLS and LLS for CRLMs in 9 European high-volume referral centers was performed. A multivariate analysis and the receiver operating characteristic curves were used to investigate the risk factors for R1 resection. A model predicting the likelihood of R1 resection was developed. Results: Overall, 3387 consecutive liver resections for CRLMs were included. OLS was performed in 1792 cases whereas LLS in 1595; the R1 resection rate was 14% and 14.2%, respectively. The risk factors for R1 resection were: the type of resection (nonanatomic and anatomic/nonanatomic), the number of nodules and the size of tumor. In the LLS group only, blood loss was a risk factor, whereas the Pringle maneuver had a protective effect. The predictive size of tumor for R1 resection was >45 mm in OLS and >30 mm in LLS, > 2 lesions was significative in both groups and blood loss >350 cc in LLS. The model was able to predict R1 resection in OLS (area under curve 0.712; 95% confidence interval 0.665–0.739) and in LLS (area under curve 0.724; 95% confidence interval 0.671–0.745). Conclusions: The study describes the risk factors for R1 resection after liver surgery for CRLMs, which may be used to plan better the perioperative strategies to reduce the incidence of R1 resection during OLS and LLS.

Indocyanine Green Fluorescence Navigation in Liver Surgery

“…2,3 The cornerstone for a successful oncologic liver surgery relies on obtaining a R0 resection margin and preserving a proper healthy liver parenchyma to achieve better short-and long-term outcomes. 4,5 To achieve these goals, the application of intraoperative navigation tools has been required as a part of the progressive developments in liver surgery. In fact, the need of the real time visualization of precise liver anatomy, in particular during minimally invasive surgery (MIS), has encouraged the implementation of such instruments, potentially helpful for a proper and safe liver transection.…”

Evaluation of accuracy of laparoscopic liver mono‐segmentectomy using the Glissonian approach with indocyanine green fluorescence negative staining by comparing estimated and actual resection volumes: A single‐center retrospective cohort study

“…We showed that LLMS with ICG negative staining technique may ensure the complete curability of liver tumors, although some evidence showed positive resection margins (R1) in 6% of cases 23 . In contrast, Benedetti et al 24 reported that R1 resection was independent of the method of liver transection (open vs laparoscopy) as they showed R1 incidence of around 14% in both open resection and LLR. In our study, total R1 incidence of LLMS was 5.4%.…”

Outcome of major hepatectomy in cirrhotic patients; does surgical approach matter? A propensity score matched analysis

“…However, these studies mainly focused on minor liver resections without considering major hepatectomies 17 . Furthermore, Pringle's maneuver was used more and for longer time during mjLLR, which could be related to the necessity of avoiding oozing during LLR proceedings 23 . As previously reported, although Pringle's Maneuver tended to reduce blood loss, it is interesting that this aspect was more noticeable when performing mjLLR than mjOLR.…”

“…Based on the result of the survey, all procedures were performed with curative intent aiming for R0 resection, thus no debulking procedures were included. Surgical technique was comparable among all the participating centers and the laparoscopic approach for major liver resections has been previously described by many authors of our group 22,23 . Klatskin tumors and the need for vascular or biliary reconstruction were the main contraindications for LLR in cirrhotic patients.…”