1. Innovations in HCC surgery
Pr Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse, Villejuif

2. Disclosures
• Fees from Bayer, BMS, Johnson&Johnson
• Consultant for Nanobiotix and MID
• Academic collaboration with EchoSens,
Fluoptics and IntraSense

3. Surgery for HCC
Must be feasible Must be useful
Must continue to improve

4. Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?

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. 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. 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. 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. 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. Portal Hypertension is an indirect
method to assess of liver parenchyma

12. 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..

13. Same portal hypertension and nodule
But different location…
Easy lap’ Segmentectomy 3Hard lap’ Segmentectomy 8

14. The location of HCC is determinant…
LiverSP by SIGHT

15. Pathological liver classified as cirrhotic
« Soft » cirrhosis post HBV « Hard » cirrhosis post HCV

16. In absence of right large tumor
Direct and global liver parenchyma
evaluation by physical measurement
Elastometry for Stifness and CAP for Steatosis

17. Liver Stiffness and Posthepatectomy complications
Cescon et al, Ann Surg 2012 Wong et al, Ann Surg 2013
>16 kPa 12 kPa

18. 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

19. Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?

20. 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…

21. Fantastic tools… for publication

23. 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

24. Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)
2007
Margin : 1 cm vs 2 cm

25. 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

26. 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

28. Improved anatomical resection in all tumoral type
Improved Recurrence Free Survival in HCC

29. Golse, Cottin, Vibert et al.
Pessaux et al.
From virtual to real…
Open or Lap

30. Innovative Methods
To evaluate feasibility of surgery ?
To perform a useful surgery ?
To improve surgical gesture ?

31. 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%)

32. 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

33. Intra Operative Portal Pressure ?
28 mm Hg…10 mm Hg

34. 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…

35. 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

36. Fluorescent Guided Liver Surgery
Ishizawa. Cancer 2009 Ishizawa. Surg Endos 2016Ishizawa. Ann Surg Onc 2010

37. • Indocyanine Green Dye (ICG) – Intravenous injection
• Passive hepatocytes captation and active biliary secretion
• Decrease of the ICG secretion  Decrease of liver function

38. 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

39. Camera Vert D’indo

40. 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

41. With the courtesy of T. Ishizawa and M. Terasawa

42. Intraoperative Pathological Data
Macroscopic Scale and,
in a very next future, at
Microscopic scale…

43. 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….