Background: Post-operative complications affect the long-term survival and quality of life in patients undergoing liver resection (LR). No model has yet been validated to predict 90-day severe morbidity and mortality after LR. Methods: Patients planned LR was prospectively recruited. Pre-operative clinical and laboratory data including liver stiffness (LS), and intra-operative parameters were analyzed to determine predictors of morbidity and mortality. Nomograms were developed using independent predictors in the study (training) cohort and validated using an external cohort by testing the Goodness of fit in calibration plots. Results: The most common indications in 418 LRs performed were colorectal metastases [35.6%], hepatocellular carcinoma [25.4%] and benign liver tumors [14.3%] with 39.2% of patients undergoing major LR. Post-operative severe morbidity and mortality rates were 20.8% and 2.2%, respectively. Independent predictors of severe morbidity were age [Odds ratio (OR):1.02, p=0.06], LS [OR:1.23, p=0.04], number of resected segments [OR:1.28, p=0.004], and operative time [OR:1.01, p=0.01]. Independent predictors of mortality were diabetes mellitus [OR:6.6, p=0.04], tumor size ≥51 mm [OR:4.8, p=0.08], LS ≥22 kPa [OR:7.0, p=0.04], and operative time ≥6 hours [OR:6.1, p=0.05]. Nomogram for severe morbidity had an excellent Goodness of fit in the study cohort (p=0.64) and an external validation cohort (p=0.70). Goodness of fit for mortality nomogram in both the study cohort (p=0.80) and the external cohort (p=0.60). Conclusion: In the era of personalized medicine, proposed nomograms would enable surgeons to adapt surgical strategy in patients undergoing LR according to their clinical profile and the center's expertise.

Background: Extended hepatectomy offers the only possibility of cure to patients with large or multifocal hepatic cancers. Post-hepatectomy de novo portal hypertension is a known risk factor of post-operative liver failure (PHLF). Intra-operatively pharmacological (somatostatin infusion) and surgical (splenic artery ligation) management of post hepatectomy portal hypertension have already been described. Objectives: We present here 3 cases where major hepatectomy was followed by intra- or post-operative creation of a porto-caval shunt in order to avoid de novo portal hypertension and subsequently PHLF. To our knowledge, no other similar cases have been reported in the literature. Case reports: In one case, the porto-caval shunt was performed intra-operatively after discovering a high portal pressure and porto-caval gradient at the end of the surgery. In the other 2 cases the shunt was performed post-operatively as a rescue procedure to treat a portal thrombosis related to portal hypertension. In all cases the porto-caval shunt managed to reduce the portal pressure and subsequently the porto-caval gradient and no post-hepatectomy liver failure occurred. Conclusion: In the event of de novo portal hypertension after major hepatectomy and in case of fail of peri-operative pharmacological treatment or splenic artery ligation, a porto-caval shunt may be a salvage manoeuvre to avoid post-operative liver failure.

Background: Incidence of severe morbidity after major hepatectomy (MH) has remained significantly high despite considerable improvement in mortality rates over last two decades. No risk model is currently available to identify those patients at higher risk of major complications after MH. Methods: Patients undergoing MH for various hepatobiliary diseases were prospectively recruited. Pre-operative clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were analyzed to identify independent risk factors for major complications, defined as >Grade II complications according to Clavien-Dindo grade of surgical complications during the 90-day post-operative period. A nomogram was built with only pre-operative predictors and validated by Heat map plot. Results: Complications observed after 164 MHs (56.7% men, median age-62 years) were Grade I (12.8%), Grade II (39%), Grade IIIa (9.8%), Grade IIIb (17.1%), Grade IVa (0.6%), Grade IVb (0%) and Grade V (2.4%). Three pre-operative parameters namely, patient's age, ICG-R15, and extent of liver resection (3-6 segments), were identified and internally validated as independent predictors in 49 patients (29.9%) who developed severe morbidity. A nomogram built with these three factors had a good discriminatory performance with area under receiver operating curve of 0.76 and an excellent Goodness-of-fit in Heat map plot. Conclusions: This novel and simple nomogram accurately predicts major post-operative complications in a patient undergoing MH and enables personalized pre-operative planning in patients at risk.

Background: Invasive hepatic venous pressure gradient (HVPG) measurement is the gold standard test to assess portal hypertension. The aim was to develop a model predictive of clinically significant portal hypertension (HVPG≥10mmHg) using pre-operative noninvasive makers. Methods: 161 patients [66% men, median age of 63 years] who have been planned for liver resection/transplantation were enrolled prospectively and preoperative liver stiffness measurement (LSM), liver function test, and intraoperative HVPG were performed. Results: Median LSM, and HVPG were 9.5kPa, and 5mmHg respectively. No underlying liver disease (F0/1), chronic liver disease (F2/3), and cirrhosis (F4) were found in 32.9%, 32.9% and 34.2% patients respectively. The study cohort was randomly divided into training [n=106] and validation [n=55] sets. Independent predictors of HVPG≥10mmHg in the training set, LSM [p< 0.01, OR=1.1], total bilirubin [p=0.04, OR=0.9], alkaline phosphatase [p=0.02, OR=1], and international normalized ratio [p< 0.01, OR=41.4], were used to develop a probability score model called HVPG10score. Area under receiver operating curve in the training and internal validation sets were 0.91 [95%CI:0.83-0.98] and 0.93 [95%CI:0.86-0.99] respectively with a cutoff of 0.15. HVPG10score was calculated by multiplying the probability by 100. In the overall cohort, HVPG10score of 15 would predict the individual risk of HVPG≥10mmHg with 83% accuracy, 90% sensitivity, 81% specificity and 96% negative predictive value. Conclusions: HVPG10score is an easy-to-use noninvasive continuous scale tool to predict HVPG≥10mmHg. A score < 15 would accurately rule out the need for esophageal varices screening and risk of decompensation in >95% chronic liver disease patients.

Introduction: Preoperative oral immunonutrition (POI) has been proven to reduce postoperative complications and length of hospital stay (LOS) in gastrointestinal surgery. The aim of this trial was to investigate the impact of POI in patients undergoing liver resection (LR) for cancer. Method: In this randomized placebo-controlled double-blind phase IV trial, between 2013 and 2018, 399 non-cirrhotic patients undergoing LR for cancer were randomly assigned to POI (n=199) or an isocaloric supplement (IS) (n=200) for 7 days before surgery. The primary end-point was the overall 30-day morbidity (ITT analysis). Secondary end-points were 30-day infectious and non-infectious morbidity, length of antibiotic treatment (LAT), LOS and compliance to treatment. Results: 82% of patients underwent open LR and 48% were major resections. In the POI and IS groups respectively, adherence to treatment initiation was 91% and 90% (p=0.289) and treatment discontinuation was observed in 83% and 80% of patients (p = 0.22). The 30-day morbidity rate (Clavien-Dindo ≥ 2) was 44.7% and 44.9% (odds ratio 0.20; 90% CI -8.33–7.87; p = 0.954) in the POI and in the IS groups respectively. Infectious and non-infectious complications occurred in 21% vs. 18 % (p= 0.498) and 38% vs. 39% (p= 0.7) of patients. LOS was 12±11 vs. 11±10 days (p= 0.803) and LAT was 2.7 vs. 2.5 days (p= 0.598) in the POI and in the IS groups respectively. Conclusion: In non-cirrhotic patients undergoing liver resection for cancer preoperative oral immunonutrition failed to reduce post-operative morbidity in this trial and cannot be recommended.

Background: Post-hepatectomy liver failure (PHLF) is a rare but serious complication after liver resection (LR) and a leading cause of mortality. The aim of the present study was to define preoperative predictors of PHLF and propose a predictive nomogram to be utilized in preoperative planning. Methods: Consecutive patients planned for LR from October 2014 to August 2016 were prospectively recruited. Clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were collected at inclusion and until three months after LR. PHLF was defined by 50-50 criteria and/or postoperative peak total bilirubin >7mg/dL. Results: Four hundred and eighteen LRs were performed in 244 men and 174 women whose median age was 62 years. PHLF was observed in 19 patients (4.6%) after major LR in 17 and minor LR in two. Mortality rate in patients developing PHLF was 21.1% while mortality rate in the entire cohort of 418 patients was 2.2%. Independent predictors of PHLF were diabetes mellitus (odds ratio (OR): 6.6; 95% confidence interval (CI):1.1-39.3), pre-operative chemotherapy cycles ≥8 (OR: 4.1; CI:0.8-20.9), tumor size ≥51mm (OR: 4.8; CI:0.9-26.1), platelet count < 150,000/mL (OR: 8.7; CI:1.3-56.8), ICG-R15 (OR: 10.4; CI:1.9-58.1) and number of resected liver segments ≥3 (OR: 12.9; CI:1.3-125.4). Nomogram built with these six factors had area under receiver operating characteristic curve of 0.92 and goodness-of-fit of p=0.44. Conclusion: Predictive nomogram incorporating ICG-R15 would improve the safety of LR by enabling surgeons to identify high-risk patients and adapt the surgical strategy in them.

Background: Treatment by salvage liver transplantation (LT) for early hepatocellular carcinoma (HCC) is known to be associated with good Results. However, the prognostic factors of OS with LT are not clearly investigated, especially for patients beyond Milan criteria at the time of liver resection. The purpose of this study aimed to evaluate the outcomes of such patients after LT. Methods: Data from 602 consecutive patients who underwent LT for HCC between 1994 and 2017 at a single center institution, were retrospectively reviewed. Patients were divided into two groups whether they underwent liver resection or not (R group, n=74 and NR group, n=528). Univariate and multivariate analyses were performed to assess survival outcome. Results: The 3 and 5-year overall survival (OS) rates between the R and NR groups were not significantly different (88.0% and 77.8 % versus. 91.4% and 83.1 %, respectively, P=0.719). The 3 and 5-year disease-free survival (DFS) rates between the two groups were also not significantly different (79.0% and 68.7 % versus. 86.2% and 82.9 %, P=0.082). Multivariate analysis identified tumor size >5 cm at the time of liver resection (P=0.014) and HCC beyond Milan criteria at the time of recurrence (P=0.042) as independently associated to work OS. When the number of risk factors was considered, patients who had 2 factors had significantly poorer OS (5-year OS; 33.3%) and DFS (5-year DFS; 0%) compared to patients with no or 1 factor (5-year OS; 88.5%, P=0.001 and 5-year DFS;79.2%, P=0.001, and 5-year OS; 72.5%, P=0.033 and 5-year DFS;60.6%, P=0.001, respectively). Conclusions: LT for patients who underwent liver resection for HCC seems to be acceptable, even when we including HCC beyond Milan criteria. Large HCC at the time of liver resection and HCC recurrence beyond Milan criteria are however associated to a poor prognosis and has high rate of recurrence.

Background: Living donor liver transplantation (LDLT) is limited by donor risk and has little penetration in the Western word. The use of minimally invasive donor hepatectomy (MIDH) may reduce its impact on quality of life and increase its acceptability. Few data from European Centers are currently available. Materials and Methods: From 2013 to 2019, 38 of 886 (4.2%) liver transplantations were LDLT. MIDH was used in all living donors including 22 (58%) full left, 9 (24%) right and 7 (18%) left lateral hepatectomies. Results: Donors characteristics: median age 37 (20-59), median BMI 25 (17-34). A pure laparoscopic technique was used in 17 cases (45%): all left laterals, 8 (36.6%) full left and 2 (22%) right. In the remaining ones, a hybrid procedure was used including laparoscopic mobilization and hilar dissection followed by a short mid-line incision (8-12 cm). Median operative time was 412 minutes (300-659). Pringle maneuver was used in 18 cases (47%). Estimated blood loss was 400 cc (150-900). No donor needed transfusion. No emergency conversion was required. 28 donors (72%) had no 90-day complications. 10 (18%) had complications including Clavien I-II in 8 cases (18%) and Clavien III in 2 (8%), including one fluid collection and one biloma both drained percutaneously. One late bleeding peptic ulcer occurred 10 months after surgery and was treated medically without transfusion. Median peak bilirubin was 23 μmol/L for left sided grafts and 59 for right sided grafts (p<0.05). Median hospital stay was 7.5 days (4-19). Conclusion: This experience confirms the safety of MIDH in an experienced transplantation and lap liver center. In contrast with Asian studies where LDLT is largely dominant, pure laparoscopy was possible in all left lateral grafts but only in a minority of full grafts reflecting the impact of LDLT activity, learning curve and the priority on donor safety.

Introduction: Liver transplantation (LT) has become a consensual treatment for hepatocellular carcinoma (HCC) in human immunodeficiency virus (HIV)-carriers. However, high drop-out rates raise questions to the role of alternative treatments. Our aim was to address the Results of resection in this setting and to compare them against survival after LT in an intention-to-treat analysis. Patients and Methods: Records from all patients with HIV and HCC listed for LT (liver transplant candidates = LTc+) or resection (LR+) between 2000 and 2017 at our tertiary centre were analysed and compared for overall survival (OS) and disease-free survival (DFS). Result: The LTc+ group (n=43) presented with higher MELD scores and more advanced portal hypertension and HCC stages than the LR+ group (n=15), with no differences in epidemiological or co-infection rates. One-, 3- and 5-year intention-to-treat survival rates were: 81%, 60% and 44%, versus 86%, 58% and 58% in the LTc+ and LR+ groups, respectively (p=0.746). Eleven patients dropped out (in all cases before LT). After LT, OS was 81%, 68% and 59% (no difference versus the LR+ group; p=0.844). There tended to be better DFS after LT, reaching 78%, 68% and 56% versus 53%, 33% and 33% in the LR+ group (p=0.062). Time-to-recurrence was significantly longer in the LT+ group (p=0.001). Conclusion: This was the largest series of resections for HCC in HIV+ patients and the first intention-to-treat analysis. Although LT and resection do not always concern the same population, they enable equivalent survival. At the price of a high recurrence rate, resection could be integrated in the global armoury of liver surgeons.

Background: Invasive measurement of hepatic venous pressure gradient(HVPG) is needed to diagnose clinical significant portal hypertension(CSPH) preoperatively in hepatectomy. Effectiveness of liver stiffness measurement(LSM) in predicting persistent posthepatectomy hepatic decompensation(PHD), an important complication of CSPH was investigated. Methods: Consecutive patients with resectable hepatocellular carcinoma(HCC)were recruited prospectively. LSM of non-tumoral liver was measured using FibroScan® preoperatively and HVPG was measured peroperatively. HVPG≥10mmHg was defined as CSPH. PHD was defined as the presence of atleast one of the following unresolved ascites, jaundice, and/or encephalopathy beyond 3 months following hepatectomy. Results: Study included 106 hepatectomies for HCC in Child-Pugh A/B patients(84 men and 22 women; median age:67.5years) including right hepatectomy(20.8%), central hepatectomy(1.9%), left hepatectomy(8.5%), bisegmentectomy(14.1%), unisegmentectomy(28.3%) and partial hepatectomy(26.4%). Nine patients(8.5%) developed PHD. Bootstrapped multivariate logistic regression identified LSM(P=0.001) as the only preoperative predictor of PHD. Area under ROC curve for LSM and HVPG was 0.807(95%CI=0.506-0.907) and 0.712(95%CI=0.646-0.917) respectively. LSM≥12kPa had 85.7% sensitivity and 66.7% specificity. HVPG≥10mmHg had 28.6% sensitivity and 96.3% specificity. Conclusion: In patients undergoing hepatectomy for HCC, LSM is an effective test to predict PHD pre-operatively when compared to HVPG.

L’impact des évènements indésirables (EI), lors d’un prélèvement de greffon hépatique sont inconnus. Les objectifs de ce travail étaient d’identifier leurs facteurs favorisants et d’en évaluer l’impact.

Introduction: Historically, patients with liver metastases from uterine neoplasms have been treated with palliative intent. Surgery is proving to have an increasing role, but there are few studies in this setting, usually analyzing endometrium with others gynecological tumors. We report on a retrospective series of patients with liver metastases from uterine primaries that underwent hepatic resection at a reference center. Methods: We retrospective analyzed 11 patients who underwent hepatic resection of endometrial cancer metastases in our institution. Data related to the primary tumor, hepatic and extrahepatic metastases and patient follow-up were collected. All patients were treated in a multidisciplinary context. Results: During the last 35 years we resect 11 patients with metastases from endometrium. The median age was 56.4y (43-70). All presented with metachronous metastases, with a median interval between the surgery of the primary tumor and the metastases diagnosis of 53 months (12-150). Some presented with extrahepatic metastases, they were controlled more then 6 months before liver surgery by resection or radiation therapy or they were resected with the liver surgery. A complete resection (R0) was achieved in 10 patients (90.9%). The median survival was 3.4 years, and the overall survival at 5 years was 50%. On univariate analysis extra hepatic disease (controlled before or resected with) was not a predictor of survival. Conclusions: The survivals are surprisingly good in many cases, even if they appear with an extra hepatic metastase. We should consider surgery especially in those patients with an interval free of disease more than 12 months.

Background: Hepatectomy remains the standard treatment for large hepatocellular carcinoma (LHCC) >= 5cm. Fibrosis may constitute a contraindication for resection because of high risk of post-hepatectomy liver failure, but its impact on patient outcome and cancer recurrence remains ill defined. Our aim was to compare predictors of survival in patients with and without cirrhosis following hepatectomy for LHCC. Methods: The data on consecutive patients undergoing hepatectomy for LHCC in two tertiary centres between 2012 and 2016 were reviewed. The outcomes of cirrhotic (F4) and non-cirrhotic (F0-F3) patients were compared. Patients with perioperative medical (sorafenib) or radiological (transarterial chemoembotization, radiofrequency) treatments were excluded. Results: Sixty patients were included. Preoperative and intraoperative features were identical between both groups. Cirrhotics (n=15) presented more satellite nodules on specimens (73% vs. 44%; P=0.073) but better differentiated lesions than non-cirrhotics (P=0.041). The median overall survival of cirrhotics was 34 vs. 29 months for non-cirrhotics (P=0.8), and their diseasefree survival was 14 versus 18 months (P=0.9). Fibrosis stage did not impact overall (P=0.2) nor disease-free survivals (P=0.6). Conclusion: Hepatectomy for LHCC in cirrhotics can achieve acceptable oncological results when compared to non-cirrhotic patients. Curative resection of LHCC should be attempted if liver function is acceptable, whatever the fibrosis stage. (C) 2017 Elsevier Masson SAS. All rights reserved.

Introduction: The proportion of old people has risen over the past 50 years. Nevertheless such population presents an increased rate of comorbities; this can negatively impact on postoperative course after elective surgery. Liver surgery has gained an important role in the treatment of liver tumors over the last 20 years, however overall morbidity and mortality rate are estimated at 22.6% and 2.6% respectively. The aim of this study is to evaluate the impact of liver surgery in elderly patients in order to identify patient that can benefit from liver resection. Methods: We reviewed our prospective database of liver resections between April 2012 and December 2016. All patients aged ≥ 65 years were collected. Patients were divided into 4 groups according to their age: group 1 (65-69yrs), 2 (70-74yrs), 3 (75-79yrs), 4 (≥80yrs). Preoperative, intraoperative and postoperative data were analyzed. Results: Four-hundred four patients underwent liver resection in the study period. Laparoscopic approach was used in 13.1% of the patients, while 37.6% of the patients underwent major hepatectomy. Liver cirrhosis was present in 21% of the patients. Median hospital stay was 9 days. Overall morbidity (Clavien-Dindo ≥3a) was 15.8%, liver-related 12%, while extra-hepatic complications were 7.2%. Ninety-days mortality was 3.2%. Patient's age did not negatively impact on morbidity and mortality. At multivariate analysis major hepatectomy, increased preoperative bilirubin and pedicle clamping >60' were predictive factors of postoperative morbidity while intraoperative transfusions, insulin-dependent diabetes and cirrhosis were predictive of 90-days mortality. Conclusions: Liver resection is safe and feasible in selected elderly patients.

Background: Incidence of serious complications after MH has remained high despite considerable improvement in mortality rates over last two decades and it has significant negative impact on post-operative survival and quality of life in patients undergoing MH. No risk model is currently available to identify those patients at higher risk of major complications after MH. Methods: Prospective recruitment of patients undergoing MH for various indications was performed. Pre-operative clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were analyzed to identify independent risk factors for major complications, defined as >Grade II complications according to Clavien-Dindo classification during the 90-day post-operative period. A nomogram was built with only pre-operative predictors and validated by Heat map plot. Results: Complications observed after 164 MHs (56.7% men, median age-62 years) were Grade I (12.8%), Grade II (39%), Grade IIIa (9.8%), Grade IIIb (17.1%), Grade IVa (0.6%), Grade IVb (0%) and Grade V (2.4%) with 49 patients (29.9%) developing major complications. Three pre-operative parameters: patient's age, ICG-R15, and extent of liver resection, were identified and internally validated by bootstrap as independent predictors of major complications after MH. A nomogram (Figure1) built with these three factors demonstrated a good discriminatory performance with area under receiver operating curve of 0.76 and an excellent Goodness-of-fit in Heat map plot. Conclusions: This novel and simple nomogram accurately predicts major complications in a patient undergoing MH. This allows pre-operative identification of patients at risk and may influence decision making for surgical intervention.

Background: Resection of breast cancer liver metastases (BCLM) combined with systemic treatment is increasingly accepted but not offered as therapeutic option. New evidence of the additional value of surgery in these patients is scarce while prognoses without surgery remains poor. Patients and methods: For this case matched analysis, all nationally registered patients with BCLM confined to the liver in the Netherlands (systemic group; N=523) were selected and compared with patients who received systemic treatment and underwent hepatectomy (resection group; N= 139) at a hepatobiliary centre in France. Matching was based on age, decade when diagnosed, interval to metastases, maximum metastases size, single or multiple tumours, chemotherapy, hormonal or targeted therapy after diagnosis. Based on published guidelines, palliative systemic treatment strategies are similar in both European countries. Results: Between 1983 and 2013, 3894 patients were screened for inclusion. Overall median follow-up was 80 months (95% CI 70-90 months). The median, 3- and 5-year overall survival of the whole population was 19 months, 29% and 19%, respectively. The resection and systemic group had median survival of 73 vs. 13 months (P < 0.001), respectively. Three and 5-year survival was 18% and 10% for the systemic group and 75% and 54% for the resection group, respectively. After matching, the resection group had a median overall survival of 82 months with a 3-and 5-year overall survival of 81% and 69%, respectively, compared with a median overall survival of 31 months in the systemic group with a 3and 5-year overall survival of 32% and 24%, respectively (HR 0.28, 95% CI 0.15-0.52; P < 0.001). Conclusions: For patients with BCLM, liver resection combined with systemic treatment results in improved overall survival compared to systemic treatment alone. Liver resection should be considered in selected cases. (C) 2018 Elsevier Ltd. All rights reserved.

Le traitement chirurgical est le traitement de référence des volumineux carcinomes hépatocellulaires (VCHC) ≥ 5 cm. La fibrose peut constituer une contre-indication à la résection en raison du surrisque d’insuffisance hépatique postopératoire mais son impact sur les suites postopératoires et la récidive demeure mal défini. Notre objectif était donc de comparer les facteurs pronostiques de survie chez les patients cirrhotiques ou non, après hépatectomie pour VCHC. Les données des patients réséqués pour VCHC entre 2012 et 2016 dans deux centres de référence ont été analysées. Les résultats obtenus chez les patients cirrhotiques (fibrose F4) et non cirrhotiques (F0–F3) ont été comparés. Les patients ayant reçu un traitement médical (sorafénib) ou radiologique (chimioembolisation intra-artérielle, radiofréquence) ont été exclus. Soixante patients ont été inclus. Les données préopératoires et peropératoires étaient identiques entre les deux groupes. Les patients cirrhotiques (n = 15) étaient plus souvent porteurs de nodules satellites à l’anatomopathologie définitive (73 % vs 44 % ; p = 0,073) mais leurs tumeurs étaient mieux différenciées que celles des patients non-cirrhotiques (p = 0,041). La survie médiane des patients cirrhotiques était de 34 mois vs 29 mois chez les non-cirrhotiques (p = 0,8) et la survie sans récidive était respectivement de 14 mois vs 18 mois (p = 0,9). Le degré de fibrose n’avait pas d’impact sur la survie globale (p = 0,2) ou la survie sans récidive (p = 0,6). Le traitement chirurgical des VCHC chez les patients cirrhotiques permet d’obtenir des résultats oncologiques satisfaisants et comparables à ceux obtenus chez les patients non-cirrhotiques. Le traitement curatif des VCHC doit donc être envisagé, sous réserve d’une fonction hépatique conservée, quel que soit le degré de fibrose. Hepatectomy remains the standard treatment for large hepatocellular carcinoma (LHCC) ≥ 5 cm. Fibrosis may constitute a contraindication for resection because of high risk of post-hepatectomy liver failure, but its impact on patient outcome and cancer recurrence remains ill defined. Our aim was to compare predictors of survival in patients with and without cirrhosis following hepatectomy for LHCC. The data on consecutive patients undergoing hepatectomy for LHCC in two tertiary centres between 2012 and 2016 were reviewed. The outcomes of cirrhotic (F4) and non-cirrhotic (F0–F3) patients were compared. Patients with perioperative medical (sorafénib) or radiological (transarterial chemoembolization, radiofrequency) treatments were excluded. Sixty patients were included. Preoperative and intraoperative features were identical between both groups. Cirrhotics (n = 15) presented more satellite nodules on specimens (73% vs 44%; P = 0.073) but better differentiated lesions than non-cirrhotics (P = 0.041). The median overall survival of cirrhotics was 34 vs 29 months for non-cirrhotics (P = 0.8), and their disease-free survival was 14 versus 18 months (P = 0.9). Fibrosis stage did not impact overall (P = 0.2) nor disease-free survivals (P = 0.6). Hepatectomy for LHCC in cirrhotics can achieve acceptable oncological results when compared to non-cirrhotic patients. Curative resection of LHCC should be attempted if liver function is acceptable, whatever the fibrosis stage.

BACKGROUND:Indications for surgical resection of non-colorectal, non-neuroendocrine (NCNNE) liver metastases are unclear. This study analysed the influence of response to neoadjuvant chemotherapy and the presence of extrahepatic disease (EHD) on outcomes.METHODS:Patients who underwent hepatic resection for NCNNE liver metastases and who received neoadjuvant chemotherapy at a single centre between 1982 and 2016 were analysed retrospectively. Patients were classified as having no EHD, controlled EHD or non-controlled EHD.RESULTS:Hepatic resection was performed in 199 patients (81·2 per cent) after partial or complete response to chemotherapy or disease stabilization, and 46 patients (18·8 per cent) after tumour progression. Patients with progressive disease after chemotherapy had worse overall survival than those without (23 versus 50·4 per cent at 5 years; P = 0·004). Median survival was 63·6 (range 31·1-94·8) months for patients without EHD, 34·8 (19·2-49·2) months for those with controlled EHD and 7·2 (1·2-13·2) months for patients with non-controlled EHD (P = 0·004). In multivariable analysis, EHD (P = 0·004), response to chemotherapy (P = 0·004) and resection margins (P = 0·002) were all independent predictors of overall survival, regardless of primary tumour site.CONCLUSION:The prognosis of patients with NCNNE liver metastases is influenced by preoperative chemotherapy and resectability.

Introduction: Surgical margins in hepatocellular carcinoma (HCC) are required to remove potential satellite nodules and microvascular invasion. The aim of this study was to assess if preoperative tumors with high AFP (>100 ng/ml) required wider margins than tumors with low AFP. Methods: Between April 2012 and January 2016, all patients (n=397) who underwent a first hepatectomy without macroscopic remnant disease (R2) were analyzed in eHPBChir Group (5 centers). Preoperative prognostic factors for time to recurrence were analyzed in univariate and multivariate analysis. The impact of surgical margins (≥ 1 cm or not), in patients with AFP rate inferior or superior to 100 ng/ml on the time to recurrence (TTR) and the overall survival (OS) were studied. Results: Preoperative high AFP rate (> 100 ng/ml) was observed in 98/397 (25%) patients and resection margin < 1cm was retrieved in 247/397 (62%) patients. The comparison of low and high AFP patient groups was summarized in table 1. In multivariate analysis, the only prognostic factor for TTR was a combination of AFP > 100 ng/mL and resection margin < 1cm (HR=2.438; IC95% [1.709-3.478]; p< 0.001). In patients with high AFP rate, surgical margin highly impacted TTR contrary to patients with low AFP rate where surgical margin had no impact on TTR (graph 1). There is a trend for better OS according to AFP and margin that did not reach significance. Conclusion: Surgical margins ≥1 cm highly impacted recurrence in patients with AFP>100 but not in patients with AFP≤100.