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  • Broelsch, Christoph E
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  • 1
    Article
    Article
    Prognostic impact of intrahepatic lymphatic and microvascular involvement in cases of colorectal liver metastases (2009)
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    Language: English
    In: International Journal of Colorectal Disease, 2009, Vol.24(7), pp.845-850
    Description: Byline: Maximilian Bockhorn (1), Georgios Sotiropoulos (1), Jan Neuhaus (1), George Sgourakis (1), Sien-Yi Sheu (2), Ernesto Molmenti (1), Christian Fingas (1), Tanja Trarbach (3), Andreja Frilling (1), Christoph E. Broelsch (1) Keywords: Liver metastases; Resection; Lymphatic vessel infiltration; Vascular invasion Abstract: Objective The purpose of this study was to evaluate the effect of intrahepatic microvascular and lymphatic infiltration on survival in cases of colorectal liver metastases. Materials and methods Prospectively collected data of 331 patients were analyzed for microvascular invasion (V), lymphatic infiltration (L), and resection margins (R) with respect to overall and disease-free survival. Results One-, 3-, and 5-year overall survival rates for R0 resected patients were 89%, 64%, and 39%, respectively. The corresponding survival rates for R1 resected patients were 83%, 42%, and 24% (p〈0.001). The sole presence of microvascular invasion (V1) or lymphatic infiltration (L1) was not associated with a diminished overall survival (p〉0.05). However, patients with a combination of L1V1 had a significantly worse overall survival of 68%, 20%, and 0% when compared to L0V0 patients. This difference was not influenced by the status of the resection margin. No other parameter investigated was found to be of predictive value. Conclusions The presence of combined lymphatic and vascular invasion (L1V1) constitutes a predictor of poor overall and disease-free survival. This subgroup of patients might benefit from adjuvant strategies such as chemotherapeutic treatment. Author Affiliation: (1) Department of General-, Visceral- and Thoracic Surgery, University Hospital Hamburg Eppendorf, 20246, Hamburg, Germany (2) Department of Pathology and Neuropathology, University Hospital Essen, Essen, Germany (3) Department of Oncology, University Hospital Essen, Essen, Germany Article History: Registration Date: 29/01/2009 Accepted Date: 29/01/2009 Online Date: 25/02/2009
    Keywords: Liver metastases ; Resection ; Lymphatic vessel infiltration ; Vascular invasion
    ISSN: 0179-1958
    E-ISSN: 1432-1262
    DOI: 10.1007/s00384-009-0674-6
    URL: View full text in Springer (Subscribers only)
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  • 2
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    Article
    Computer-Assisted Surgical Planning in Adult-to-Adult Live Donor Liver Transplantation: How Much Does it Help? A Single Center Experience (2012)
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    In: Transplantation Journal, 2012, Vol.94(11), pp.1138-1144
    Description: BACKGROUND: Preoperative imaging and donor selection are cardinal components of adult-to-adult live donor liver transplantation (ALDLT). The purpose of this study was to evaluate our three-dimensional (3D) computed tomography image-derived computer-assisted surgical planning (3D CASP) in ALDLT. METHODS: Eighty-three consecutive ALDLTs (71 right and 12 left) were planned with 3D CASP. Graft, remnant, and total liver volume compliance were calculated and compared with actual intraoperative values. Computed risk analysis encompassing territorial liver mapping, functional (safely drained) volumes, and outflow congestion volumes in grafts and remnants allowed for the individualized management of the middle hepatic vein (MHV). RESULTS: Graft volume compliance was 13.5%±4.4%. Three small-for-size (SFS) grafts with lethal SFS syndrome (SFSS) had nonsignificant volume compliance with maximal graft volume-body weight ratios of less than 0.83. Seven SFS grafts with reversible or absent SFSS showed maximal graft volume-body weight ratios of 0.9 to 1.16. Significant differences were identified for (a) virtual graft and remnant congestion volumes of risky versus nonrisky MHV types (49%±6% and 34%±7% vs. 29%±8% and 33%±12%, P〈0.001 and P〈0.02, respectively) and (b) virtual mean functional versus surgical volumes of grafts (527±119 vs. 963±176 mL, P〈0.0001) and remnants (419±182 vs. 640±213 mL, P〈0.001). CONCLUSIONS: CASP allowed for (a) prevention of SFSS in extremely small grafts by predicting donor liver plasticity and (b) individualized MHV management for both donors and recipients based on functional graft/remnant volume analysis.
    Keywords: Donors ; Computed Tomography ; Hepatic Vein ; Mapping ; Imaging ; Plasticity (Functional) ; Computed Tomography ; Donors ; Mapping ; Plasticity (Functional) ; Hepatic Vein ; Imaging ; Transplantation;
    ISSN: 0041-1337
    E-ISSN: 15346080
    DOI: 10.1097/TP.0b013e31826e5970
    URL: View record at Wolters Kluwer Health Ovid Technologies
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  • 3
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    Article
    Hepatic Venous Drainage: How Much Can We Learn From Imaging Studies? Anatomic-Functional Classification Derived From Three-Dimensional Computed Tomography Reconstructions (2010)
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    In: Transplantation, 2010, Vol.89(12), pp.1518-1525
    Description: BACKGROUND.: The knowledge of “venous dominance” is essential to prevent serious venous congestion in live donor liver transplantation and extended liver resections. AIMS.: The purpose of our study was to delineate our proposed anatomic-functional classification of hepatic venous drainage. METHODS.: One hundred forty consecutive live liver donor candidates underwent three-dimensional computed tomography reconstructions and three-dimensional virtual hepatectomies. Five different venous dominance types were defined on drainage volumes or territories. “Risky” configurations were identified and classified. RESULTS.: The right hepatic vein (RHV) was dominant for the entire liver and right hemiliver (RHH) in most (83.5%) cases irrespective of the presence of inferior (accessory) hepatic veins (IHVs). The middle hepatic vein (MHV) was dominant for the total liver (TL) in 15.5% of cases and for the RHH in 27% of cases. The left hepatic vein was almost always (92%) dominant for the left hemiliver. When associated with a large IHV drainage volume, a RHV/IHV complex dominant for the TL led to a RHH dominant MHV (mean 59.5%RHH) if the IHV was not reconstructed. CONCLUSIONS.: Our proposed anatomic-functional classification provides a valuable insight into hepatic vein dominance patterns. RHH venous drainage patterns at “high risk” for venous congestion include (1) a dominant MHV for the TL and (2) a dominant RHV/IHV complex with a large IHV drainage volume.
    Keywords: Hepatic Veins -- Pathology ; Image Processing, Computer-Assisted -- Methods ; Liver -- Blood Supply ; Liver Transplantation -- Methods ; Tomography, X-Ray Computed -- Methods;
    ISSN: 0041-1337
    E-ISSN: 15346080
    DOI: 10.1097/TP.0b013e3181dd6bac
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  • 4
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    Article
    The “carving” liver partitioning technique for graft hepatectomy in live donor liver transplantation: A single-center experience (2013)
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    Language: English
    In: Surgery, February 2013, Vol.153(2), pp.189-199
    Description: In adult live donor liver transplantation, postoperative venous congestion of graft and remnant livers can lead to life-threatening complications. The purpose of this study was to evaluate the safety and benefits of our 3-dimensional, computed tomographic, computer-assisted donor hepatectomy using the “carving” partitioning technique. Eighty-three consecutive adult live donor liver transplantations were performed based on data obtained from individualized preoperative 3-dimensional, computed tomographic reconstructions and virtual graft hepatectomies. There were 71 right and 12 left grafts. Small grafts (graft volume body weight ratio, 〈1.0) were used in 20 cases. We observed no clinically important differences in postoperative function between right and left grafts. Four recipients developed lethal small-for-size syndrome. Reversible small-for-size syndrome was observed in a right graft recipient and in 2 right graft donors. Preoperative 3-dimensional, computed tomographic, computer-assisted planning using virtual liver partitioning allowed for: (1) an individualized carving technique based on specific donor anatomic characteristics, (2) donor safety based on individualized patterns of venous outflow, and (3) optimized drainage of the medial area of the graft based on the preferential inclusion of the middle hepatic vein.
    Keywords: Universities And Colleges -- Methods ; Liver Transplantation -- Methods;
    ISSN: 0039-6060
    E-ISSN: 1532-7361
    DOI: 10.1016/j.surg.2012.06.027
    URL: View record in ScienceDirect (Access to full text may be restricted)
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  • 5
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    Article
    “Anatomical” versus “Territorial” Belonging of the Middle Hepatic Vein: Virtual Imaging and Clinical Repercussions (2011)
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    Language: English
    In: Journal of Surgical Research, 2011, Vol.166(1), pp.146-155
    Description: Venous drainage patterns are of vital importance in live donor liver transplantation. The purpose of this study was to delineate “anatomical-topographical” and “territorial-physiologic” patterns of the middle hepatic vein (MHV) in a 3-D liver model as determined by the Pringle line and its drainage volume of the right and left hemilivers. One hundred thirty-seven consecutive live donor candidates were evaluated by 3-D CT reconstructions and virtual hepatectomies. Based on right (R) and left (L), anatomical (A) and territorial (T) belonging patterns of the MHV, each individual was assigned to one of four possible types: type I:A –T ; type II:A –T ; type III:A –T ; type IV:A –T . Couinaud's anatomical MHV variants A–C were subsequently included in our combined anatomical/territorial MHV belonging classification. The MHV showed a significant predominance of right “anatomical” (59.1%) and left “territorial” belonging patterns (65.7%). The paradoxical combinations A –T (type III) and A –T (type IV) were encountered in 36.5% and 11.7% of cases, respectively. The constellations Couinaud's A-belonging type IV and Couinaud's C-belonging type IV were predictive of right hemiliver venous congestion. (1) Almost half of all livers in our series had paradoxical “anatomical”/“territorial” MHV belonging patterns that placed them at risk for right and left hepatectomies. (2) The proposed combined “anatomical”/“territorial” MHV belonging types (I–IV) provide useful preoperative information. (3) Combined types III and IV as well as Couinaud's A–IV, and Couinaud's C–IV should be considered particularly risky for venous congestion in right hemiliver grafts and in extended left hepatectomies.
    Keywords: Liver Surgery ; Living Donor Liver Transplantation ; Liver Anatomy ; 3-D Reconstruction ; 3-D CT ; Liver Imaging ; Liver Venous Drainage ; Hepatic Vein Anatomy ; Hepatic Vein Dominance ; Hepatic Vein Classification
    ISSN: 0022-4804
    E-ISSN: 1095-8673
    DOI: 10.1016/j.jss.2009.07.042
    Source: ScienceDirect Journals (Elsevier)
    URL: View record in ScienceDirect (Access to full text may be restricted)
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  • 6
    Article
    Article
    Risk of venous congestion in live donors of extended right liver graft (2015)
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    Language: English
    In: World journal of gastroenterology, 21 May 2015, Vol.21(19), pp.6008-17
    Description: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV). There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-body-weight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cut-off- RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV. MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV 〈 30% and non-SFS-remnants with RV/TLV ≥ 30% showed no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR 〈 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P 〈 0.009. Six SFS-remnants with RV/TLV 〈 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P 〈 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations. MHV procurement should consider individual remnant congestive- and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.
    Keywords: Liver Volume ; Living Donor Liver Transplantation ; Remnant Volume ; Small-for-Size ; Small-for-Size Syndrome ; Living Donors ; Hepatectomy -- Adverse Effects ; Hepatic Veins -- Surgery ; Hyperemia -- Etiology ; Liver -- Surgery ; Liver Transplantation -- Adverse Effects
    ISSN: 10079327
    E-ISSN: 2219-2840
    DOI: 10.3748/wjg.v21.i19.6008
    URL: View this record in MEDLINE/PubMed
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  • 7
    Article
    Article
    "Anatomical" versus "territorial" belonging of the middle hepatic vein: virtual imaging and clinical repercussions (2011)
    Details
    Language: English
    In: The Journal of surgical research, March 2011, Vol.166(1), pp.146-55
    Description: Venous drainage patterns are of vital importance in live donor liver transplantation. The purpose of this study was to delineate "anatomical-topographical" and "territorial-physiologic" patterns of the middle hepatic vein (MHV) in a 3-D liver model as determined by the Pringle line and its drainage volume of the right and left hemilivers. One hundred thirty-seven consecutive live donor candidates were evaluated by 3-D CT reconstructions and virtual hepatectomies. Based on right (R) and left (L), anatomical (A) and territorial (T) belonging patterns of the MHV, each individual was assigned to one of four possible types: type I:A(R)-T(R); type II:A(L)-T(L); type III:A(R)-T(L); type IV:A(L)-T(R). Couinaud's anatomical MHV variants A-C were subsequently included in our combined anatomical/territorial MHV belonging classification. The MHV showed a significant predominance of right "anatomical" (59.1%) and left "territorial" belonging patterns (65.7%). The paradoxical combinations A(R)-T(L) (type III) and A(L)-T(R) (type IV) were encountered in 36.5% and 11.7% of cases, respectively. The constellations Couinaud's A-belonging type IV and Couinaud's C-belonging type IV were predictive of right hemiliver venous congestion. (1) Almost half of all livers in our series had paradoxical "anatomical"/"territorial" MHV belonging patterns that placed them at risk for right and left hepatectomies. (2) The proposed combined "anatomical"/"territorial" MHV belonging types (I-IV) provide useful preoperative information. (3) Combined types III and IV as well as Couinaud's A-IV, and Couinaud's C-IV should be considered particularly risky for venous congestion in right hemiliver grafts and in extended left hepatectomies.
    Keywords: Hepatic Veins ; Living Donors ; Hepatectomy -- Methods ; Liver Transplantation -- Methods
    ISSN: 00224804
    E-ISSN: 1095-8673
    DOI: 10.1016/j.jss.2009.07.042
    Source: MEDLINE/PubMed (U.S. National Library of Medicine)
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  • 8
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    Article
    Multicentric evaluation of a clinical and prognostic scoring system predictive of survival after resection of intrahepatic cholangiocarcinomas (2010)
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    In: Liver International, August 2010, Vol.30(7), pp.996-1002
    Description: To develop a clinical and prognostic scoring system predictive of survival after resection of intrahepatic cholangiocarcinomas (ICC). Two hundred and one consecutive ICC patients (83 from Essen, Germany, 54 from New York, USA and 64 from Chiba, Japan). The scoring systems were developed utilizing the data set from Essen University and then applied to the data sets from Mount Sinai Medical Center and Chiba University for validation. Eighteen potential prognostic factors were evaluated. Statistical analysis included multivariable regression analyses with the Cox proportional hazard model, power analysis, internal validation with structural equation modelling bootstrapping and external validation. The prognostic scoring model was based mainly in pathological and demographical variables, whereas the clinical scoring model was based mainly in radiological and demographical variables. Gender (=0.0086), UICC stage (=0.0140) and R‐class (=0.0016) were predictive of survival for the prognostic scoring model, while gender (=0.0023), CA 19‐9 levels (=0.0153) and macrovascular invasion (=0.0067) were predictive of survival for the clinical scoring model. Prognostic points were assigned as follows: female:male=1:2 points, UICC (I–II):UICC (III–IV)=1:2 points and R0:R1=1:2 points. Clinical points were allocated as follows: female:male=1:2 points, CA 19‐9 (〈100 U/ml):CA 19‐9 (≥100 U/ml)=1:2 points and no macrovascular invasion:macrovascular invasion=1:2 points. Prognostic groups with 3–4, 5 and 6 points (=0.000001) and clinical groups with 3–4 and 5–6 points (=0.0103) achieved statistically significant difference. We propose a clinical and prognostic scoring system predictive of long‐term survival after surgical resections for ICC.
    Keywords: Cholangiocarcinoma ; Cholangiocellular Carcinoma ; Primary Liver Tumours ; Surgical Therapy ; Survival Score ; Tumour Recurrence
    ISSN: 1478-3223
    E-ISSN: 1478-3231
    DOI: 10.1111/j.1478-3231.2010.02203.x
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  • 9
    Article
    Article
    Major liver resections in the elderly—is an aggressive approach justified? (2009)
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    Language: English
    In: International Journal of Colorectal Disease, 2009, Vol.24(1), pp.83-86
    Description: Byline: Maximilian Bockhorn (1,2), Georgios C. Sotiropoulos (1), George Sgourakis (1), Jan P. Neuhaus (1), Ernesto P. Molmenti (1), Hauke Lang (1), Andreja Frilling (1), Christoph E. Broelsch (1) Keywords: Liver resection; Colorectal liver metastases; Elderly; Survival Abstract: Background and aims As the mean life expectancy rises, the incidence of patients 75 years of age and older who present with colorectal liver metastases continues to increase. The purpose of our study was to evaluate the outcome of major hepatic resections in the elderly population. Patient and methods From April 1998 to December 2006, 572 consecutive patients with colorectal liver metastases were treated at our Institution. Of these, 59 were 75 years or older. There was an intent to proceed with major liver resections in all cases. Data were analyzed according to diagnosis, comorbidities, extent of liver resection, postoperative complications, overall survival, and disease-free survival. Results Surgical treatment included right hepatectomies (n=8), left hepatectomies (n=4), and sectionectomies (more than three segments n=33). Fourteen (n=14) patients received an explorative laparotomy alone. Morbidity and hospital mortality were 10% and 3%, respectively. Overall survival of 1, 3, and 5 years was 90%, 64%, and 33%, respectively. The corresponding disease-free survival was 74%, 42%, and 32%. Resection margin (R class) was the only predictor of survival by both uni- and multivariate analyses. Conclusion Hepatic resections can be performed safely in selected patients 75 years of age or older. Author Affiliation: (1) Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany (2) Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany Article History: Registration Date: 15/08/2008 Accepted Date: 15/08/2008 Online Date: 03/09/2008
    Keywords: Liver resection ; Colorectal liver metastases ; Elderly ; Survival
    ISSN: 0179-1958
    E-ISSN: 1432-1262
    DOI: 10.1007/s00384-008-0571-4
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  • 10
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    Article
    R0 Liver Resections for Primary Malignant Liver Tumors in the Noncirrhotic Liver: A Diagnosis-Related Analysis (2009)
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    Language: English
    In: Digestive Diseases and Sciences, 2009, Vol.54(4), pp.887-894
    Description: Background Primary liver cancer constitutes an increasingly malignancy in the Western world and one of the leading causes of cancer-related deaths worldwide. The purpose of this study was to evaluate and compare long-term outcomes after R0 resections in noncirrhotic livers for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Methods Between April 1998 and May 2006 a total of 102 patients with either ICC ( n  = 41, group 1) or HCC ( n  = 61, group 2) in the absence of cirrhosis underwent curative liver resection in our department. Demographic characteristics, operative details, perioperative complications, pathologic findings, tumor recurrence and survival were analyzed. Results Gender ( P  = 0.007), extent of liver resection ( P  = 0.036), additional surgical procedures ( P  〈 0.001) and operative morbidity ( P  = 0.018) differed among the two groups. Following resection, after a median follow-up of 28 months, the calculated 5-year survival was 44% and 40% for ICC and HCC, respectively ( P  = 0.38). The corresponding recurrence-free survival was 25% for both ICC and HCC ( P  = 0.66). UICC stage was found to predict overall and recurrence-free survival in both types of tumors. Multifocality in the case of ICC, and tumor differentiation and vascular invasion in the case of HCC, were predictive factors for overall and recurrence-free survival, respectively. In multivariable analyses, vascular invasion for HCC was predictive for overall and recurrence-free survival, whereas in the case of ICC significant differences were detected in the recurrence analysis for multifocality and UICC stage. Conclusions R0 resections for both ICC and HCC result to similar long-term outcomes, which are characterized by good overall and acceptable recurrence-free survival rates.
    Keywords: R0 resection ; Intrahepatic cholagiocarcinoma ; Intrahepatic cholangiocellular carcinoma ; Hepatocellular carcinoma ; Patient outcome ; Tumor recurrence
    ISSN: 0163-2116
    E-ISSN: 1573-2568
    DOI: 10.1007/s10620-008-0408-6
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