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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 Echo...
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 predictive
factor of mortality
Cuccheti et al. Liver Transp...
Mortality of Liver Resection for HCC
Authors Period N 90 days Mortality Parenchyma
Greco et al. 2001-2005 129 4.1% Abnorma...
Our patients are in metastable equilibrium
Clinical Ascitis and/or Jaundice and/or
Encephalopathy at 3 months po.
Liver De...
When I plan a treatment to Mister
Durand, I think to Mister Dupond…
Who will be more beneficiated of
liver transplantation...
De Novo recurrence
Postop. Courses
Local recurrence
Extra-hepatic Disease
Utility of liver resection ?
Response in the can...
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...
Same portal hypertension and nodule
But different location…
Easy lap’ Segmentectomy 3Hard 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 Stif...
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(%)
L...
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 Disease
Utility of liver resection ?
Response in the can...
Fantastic tools… for publication
0
10
20
30
40
50
60
70
80
<100 100-1000 >1000
Ratesofmicrovascularinvasion
251/743
70/116
42/62
%
Rates of microvascular i...
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...
3 cm HCC deeply
located in segment 8
MELD 10 – FE 12 kPa
Local destruction Segmentectomy 8
AFP > 100 ng/mlAFP < 100 ng/ml
...
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 cirrhosis
on post-operative liver failure : A Propensity Score Ana...
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....
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 pts
New Device n...
75% Hepatectomy in Pig with or without Portal Flow Modulation from POD-0 to POD3
Lower Bilirubin at PO3 and POD5 and Highe...
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
• Decre...
26 patients (20 HCC – 6 Colorectal LM) : intraoperative exploration with ICG cam
Only to detect subcapsular lesion / No cl...
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
Intrao...
With the courtesy of T. Ishizawa and M. Terasawa
Intraoperative Pathological Data
Macroscopic Scale and,
in a very next future, at
Microscopic scale…
Conclusions
• Fibroscan is important tools to select patient
• Tumoral biology should impact surgical strategy
• Virtual H...
Innovations in liver surgery for Hepatocellular Carcinoma
Innovations in liver surgery for Hepatocellular Carcinoma
Innovations in liver surgery for Hepatocellular Carcinoma
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Innovations in liver surgery for Hepatocellular Carcinoma

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Plenary conference in International Liver Cancer Assocation (ILCA) congress in Korea

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Innovations in liver surgery for Hepatocellular Carcinoma

  1. 1. Innovations in HCC surgery Pr Eric Vibert, MD, PhD Centre Hépato-Biliaire, Hop. Paul Brousse, Villejuif
  2. 2. Disclosures • Fees from Bayer, BMS, Johnson&Johnson • Consultant for Nanobiotix and MID • Academic collaboration with EchoSens, Fluoptics and IntraSense
  3. 3. Surgery for HCC Must be feasible Must be useful Must continue to improve
  4. 4. Innovative Methods To evaluate feasibility of surgery ? To perform a useful surgery ? To improve surgical gesture ?
  5. 5. Feasibility of Liver Surgery ? MELD < 10 MELD < 12 Independant predictive factor of mortality Cuccheti et al. Liver Transpl 2006Farges et al. Ann Surg 2012 Bruix et al. Gastroenterology 1996
  6. 6. Mortality of Liver Resection for HCC Authors Period N 90 days Mortality Parenchyma Greco et al. 2001-2005 129 4.1% Abnormal Liver Rosaye et al 2005-2011 2342 3.5% Abnormal Liver Zhong et al 2000-2007 908 3.1% Abnormal Liver Vigano et al 2000-2012 192 2.1% Abnormal Liver Donadon et al 2004-2013 336 2% Abnormal Liver French HPB Registry 2012-2016 343 4.7% Abnormal liver Kim et al 2005-2010 454 0.7% Healthy Liver Zhou 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)
  7. 7. Our patients are in metastable equilibrium Clinical Ascitis and/or Jaundice and/or Encephalopathy at 3 months po. Liver Decompensation Metastable Child A/B
  8. 8. When I plan a treatment to Mister Durand, I think to Mister Dupond… Who will be more beneficiated of liver transplantation relatively to resection ? Risk and Interest of oncologic hepatectomy ? VS
  9. 9. De Novo recurrence Postop. Courses Local recurrence Extra-hepatic Disease Utility of liver resection ? Response in the cancer… Feasibility of liver resection ? Response in the liver…
  10. 10. Portal Hypertension is an indirect method to assess of liver parenchyma
  11. 11. 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 hypertension To decrease impact of portal hypertension Ishizawa et al. Gastroenterology 20..
  12. 12. Same portal hypertension and nodule But different location… Easy lap’ Segmentectomy 3Hard lap’ Segmentectomy 8
  13. 13. The location of HCC is determinant… LiverSP by SIGHT
  14. 14. Pathological liver classified as cirrhotic « Soft » cirrhosis post HBV « Hard » cirrhosis post HCV
  15. 15. In absence of right large tumor Direct and global liver parenchyma evaluation by physical measurement Elastometry for Stifness and CAP for Steatosis
  16. 16. Liver Stiffness and Posthepatectomy complications Cescon et al, Ann Surg 2012 Wong et al, Ann Surg 2013 >16 kPa 12 kPa
  17. 17. 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 HCC HVPG was measured intra-operatively Rajakunnu et al., Vibert. Surgery 2017
  18. 18. Innovative Methods To evaluate feasibility of surgery ? To perform a useful surgery ? To improve surgical gesture ?
  19. 19. De Novo recurrence Postop. Courses Local recurrence Extra-hepatic Disease Utility of liver resection ? Response in the cancer… Feasibility of liver resection ? Response in the liver…
  20. 20. Fantastic tools… for publication
  21. 21. 0 10 20 30 40 50 60 70 80 <100 100-1000 >1000 Ratesofmicrovascularinvasion 251/743 70/116 42/62 % 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
  22. 22. Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15) 2007 Margin : 1 cm vs 2 cm
  23. 23. 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
  24. 24. 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
  25. 25. Improved anatomical resection in all tumoral type Improved Recurrence Free Survival in HCC
  26. 26. Golse, Cottin, Vibert et al. Pessaux et al. From virtual to real… Open or Lap
  27. 27. Innovative Methods To evaluate feasibility of surgery ? To perform a useful surgery ? To improve surgical gesture ?
  28. 28. Impact of laparoscopic liver resection in patients with cirrhosis on 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 2016 6 French HPB Centers 343 Hepatectomies in F3/F4 89 pts by Lap (26%)
  29. 29. 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
  30. 30. Intra Operative Portal Pressure ? 28 mm Hg…10 mm Hg
  31. 31. Intraoperative Portal Flow modulation MODHEP-1 : Phase I/II in Human (Hop. Paul Brousse – Villejuif), n=4 pts New Device now tested to improve it 1. Splenic Artery Ligation 2. Portal Caval Shunt (8 mm Goretex) Today… Tomorrow…
  32. 32. 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
  33. 33. Fluorescent Guided Liver Surgery Ishizawa. Cancer 2009 Ishizawa. Surg Endos 2016Ishizawa. Ann Surg Onc 2010
  34. 34. • Indocyanine Green Dye (ICG) – Intravenous injection • Passive hepatocytes captation and active biliary secretion • Decrease of the ICG secretion  Decrease of liver function
  35. 35. 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
  36. 36. Camera Vert D’indo
  37. 37. 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
  38. 38. With the courtesy of T. Ishizawa and M. Terasawa
  39. 39. Intraoperative Pathological Data Macroscopic Scale and, in a very next future, at Microscopic scale…
  40. 40. 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….

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