Innovations in liver surgery for Hepatocellular Carcinoma
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Transcript of Innovations in liver surgery for Hepatocellular Carcinoma
Innovations in HCC surgery
Pr Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse, Villejuif
Disclosures
• Fees from Bayer, BMS, Johnson&Johnson
• Consultant for Nanobiotix and MID
• Academic collaboration with EchoSens, Fluoptics and IntraSense
Surgery for HCC
Must be feasible Must be useful
Must continue to improve
Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?
Feasibility of Liver Surgery ?
MELD < 10
MELD < 12
Independant predictivefactor of mortality
Cuccheti et al. Liver Transpl 2006Farges et al. Ann Surg 2012 Bruix et al. Gastroenterology 1996
Mortality of Liver Resection for HCC
Authors Period N 90 days Mortality Parenchyma
Greco et al. 2001-2005 129 4.1% Abnormal LiverRosaye et al 2005-2011 2342 3.5% Abnormal LiverZhong et al 2000-2007 908 3.1% Abnormal LiverVigano et al 2000-2012 192 2.1% Abnormal Liver
Donadon et al 2004-2013 336 2% Abnormal LiverFrench HPB Registry 2012-2016 343 4.7% Abnormal liver
Kim et al 2005-2010 454 0.7% Healthy LiverZhou et al 2006-2009 124 0.5% Healthy Liver
Post-operative mortality in cirrhotic patient is inferior to 5%
3-months Mortality of Liver Transplantation : 9% (Adam et al. J Hep 2012)
Our patients are in metastable equilibrium
Clinical Ascitis and/or Jaundice and/or Encephalopathy at 3 months po.
Liver Decompensation
Metastable
Child A/B
When I plan a treatment to MisterDurand, I think to Mister Dupond…Who will be more beneficiated ofliver transplantation relatively toresection ?
Risk and Interest of oncologic hepatectomy ?
VS
De Novo recurrence
Postop. Courses
Local recurrence
Extra-hepatic DiseaseUtility of liver resection ?Response in the cancer…
Feasibility of liver resection ?Response in the liver…
Portal Hypertension is an indirect method to assess of liver parenchyma
2005-2011 : Cohort BRIDGE 8656 patients
70% No Surgery (n=6134 )
30% Surgery (n=2342 )70% Out BCLC Guidelines (n=1624)
30% In BCLC Guidelines (n=718 )
2% BCLC Guideline for Surg (n=123)
2015
Resection adapted to portal hypertensionTo decrease impact of portal hypertension
Ishizawa et al. Gastroenterology 20..
Same portal hypertension and nodule But different location…
Easy lap’ Segmentectomy 3 Hard lap’ Segmentectomy 8
The location of HCC is determinant…
LiverSP by SIGHT
Pathological liver classified as cirrhotic
« Soft » cirrhosis post HBV « Hard » cirrhosis post HCV
In absence of right large tumor
Direct and global liver parenchyma evaluation by physical measurement
Elastometry for Stifness and CAP for Steatosis
Liver Stiffness and Posthepatectomy complications
Cescon et al, Ann Surg 2012 Wong et al, Ann Surg 2013
>16 kPa 12 kPa
LSM was an independent Risk Factor of mortality and po. Liver decompensation
Parameter AUROC 95% CI Cut-off Se (%) Sp(%)
LSM
(kPa)0.80 0.64 - 0.97
12 86 67
15 43 82
22 43 93
HVPG
(mm Hg)0.71 0.497 – 0. 91 10 29 96
LSM was systematically measured preop. in 167 pts operated for HCCHVPG was measured intra-operatively
Rajakunnu et al., Vibert. Surgery 2017
Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?
De Novo recurrence
Postop. Courses
Local recurrence
Extra-hepatic DiseaseUtility of liver resection ?Response in the cancer…
Feasibility of liver resection ?Response in the liver…
Fantastic tools… for publication
0
10
20
30
40
50
60
70
80
<100 100-1000 >1000
Rat
es o
f m
icro
vasc
ula
r in
vasi
on
251/743
70/11642/62
%
Rates of microvascular invasion among the patients
who underwent hepatic resection or transplantation (n=921)
P<0.0001
P=0.33
Patients who underwent hepatic resection or liver transplantation from January 1994 to May 2016 in Paul Brousse Hospital
AFP (ng/ml) at preoperation
AFP to evaluated HCC aggressiveness
Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)
2007
Margin : 1 cm vs 2 cm
Surgical margin impact depend of preop. AFP rate
Median of Follow-up : 17 months
75%
45% 51%
55%
AFP > 100 : Margin > 1 cm is mandatoy AFP < 100 : Margin > 1 cm is not mandatoy
2012- 2016 : 334 pts operated for HCC in 4 HPB Centers in France
#ILCA_17 congress – Poster XX
3 cm HCC deeply
located in segment 8
MELD 10 – FE 12 kPa
Local destruction Segmentectomy 8
AFP > 100 ng/mlAFP < 100 ng/ml
Margin > 1 cmMargin < 1 cm
Improved anatomical resection in all tumoral type
Improved Recurrence Free Survival in HCC
Golse, Cottin, Vibert et al.
Pessaux et al.
From virtual to real…
Open or Lap
Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?
Impact of laparoscopic liver resection in patients with cirrhosison post-operative liver failure : A Propensity Score Analysis
M. Prodeau, S. Truant, E. Vibert, O. Farges, J.Y. Mabrut,
J. Hardwigsen, J.M. Régimbeau, G. Millet, O. Soubrane,
R. Adam, D. Cherqui, F.R. Pruvot, E. Boleslawski
The ACHBT French Hepatectomy Study Group
Oct 2012 – June 20166 French HPB Centers
343 Hepatectomies in F3/F4 89 pts by Lap (26%)
Incidence of Post-Operative Liver Failure
Matched-LAP Matched-OPEN
Age (years) 65.3 65.3
BMI (kg/m²) 26.9 26.9
MELD 8.6 8.5
Platelets (x 1000/mm3) 167 167
ICG (15 min) 15.2 % 15.0 %
HVPG (mmHg) 7.9 8.1
LS (kPa) 21.8 21.9
RLV (%) 88.6 87.6
16% in LAP and 32% in OPEN
OR 0.31 [0.12-0.78]; p<0.001
Intra Operative Portal Pressure ?
28 mm Hg…10 mm Hg
Intraoperative Portal Flow modulation
MODHEP-1 : Phase I/II in Human(Hop. Paul Brousse – Villejuif), n=4 ptsNew Device now tested to improve it
1. Splenic Artery Ligation
2. Portal Caval Shunt (8 mm Goretex)
Today… Tomorrow…
75% Hepatectomy in Pig with or without Portal Flow Modulation from POD-0 to POD3
Lower Bilirubin at PO3 and POD5 and Higher ki67 index at POD3
2017
Fluorescent Guided Liver Surgery
Ishizawa. Cancer 2009 Ishizawa. Surg Endos 2016Ishizawa. Ann Surg Onc 2010
• Indocyanine Green Dye (ICG) – Intravenous injection
• Passive hepatocytes captation and active biliary secretion
• Decrease of the ICG secretion Decrease of liver function
26 patients (20 HCC – 6 Colorectal LM) : intraoperative exploration with ICG cam
Only to detect subcapsular lesion / No clear data on clinical rentability
Cancer 2009
HCC : Fluorescent spot CRLM : Fluorescent ring
HCC : No functional
hepatocytes
Camera Vert D’indo
170 patients operated by laparotomy for HCC who had received ICG (0.5 mg/kg) at least 48 hours before liver surgery
Intraop. detection of 21 new spots in 19 patients 14 HCC (8.2%) and 7 False-Positive
Low specificity in severe cirrhosis
With the courtesy of T. Ishizawa and M. Terasawa
Intraoperative Pathological Data
Macroscopic Scale and,in a very next future, atMicroscopic scale…
Conclusions
• Fibroscan is important tools to select patient• Tumoral biology should impact surgical strategy• Virtual Hepatectomy increased surgical quality• Laparoscopy decreased by 2 the risk of POLF• Fluorescent guided liver surgery seems useful
And surgeons must come to ILCA….