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Guido Torzilli Editor Ultrasound-Guided Liver Surgery An Atlas Ultrasound-Guided Liver Surgery Guido Torzilli Editor Ultrasound-Guided Liver Surgery An Atlas 123 Editor Guido Torzilli Department of Hepatobiliary Surgery Humanitas Research Hospital—IRCCS University of Milan, School of Medicine Rozzano, Milano Italy ISBN 978-88-470-5509-4 DOI 10.1007/978-88-470-5510-0 ISBN 978-88-470-5510-0 (eBook) Springer Milan Heidelberg New York Dordrecht London Library of Congress Control Number: 2013954559  Springer-Verlag Italia 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To my family, to my Masters, and to all the colleagues who feel a passion for what they do for the benefit of their patients Foreword Liver resection had been carried out since before World War II. However, Ichio Honjo and Lortat-Jacob’s successful right liver resection by ways of controlled method after the war established the era of right liver resection, left liver resection and left lobe resection (S2+S3 resection) from the 1950s to the 1970s. Then came the end of the 1970s, and the introduction of intraoperative ultrasound had suddenly enabled detection of small tumors within the liver which until then was not possible to locate from the surface of the liver either palpatively or visually. Stereo visualization of the positional relationship of the vessels and the tumors, and identification of tumor thrombus in the vessels and intrahepatic metastases were realized. Radical resections of deeply situated tumors were made possible, segmentectomy/subsegmentectomy with the use of intraoperative ultrasound-guided puncture technique was introduced, and the liver can now be transected while exposing the main hepatic vein running between the segments within the liver. All these are the fruits brought about by the technological advancement of intraoperative ultrasound during 1980s up to 2010. Doctor Guido Torzilli first came to visit me at the beginning of 1990s when I was holding a position of professorship at the Shinshu University. He had been an avid learner from the beginning, with a stern, uncompromising and reliable characteristic that I had no reservations in offering Dr. Torzilli the position of research assistant, when I moved to the University of Tokyo in 1994. At the end of his one-year study, he submitted a thesis and was awarded a doctorate from the University of Tokyo. He has always been a skillful surgeon and a prolific writer who does not hesitate to share his knowledge through publishing his works, and today, he is one of the few surgeons in Europe with reliable intraoperative ultrasound technique, whose surgical accomplishments are much acknowledged around the world. Dr. Torzilli is also respected for his dedication in organizing European School of Surgical Ultrasound meetings every year since 2006. Doctor Torzilli’s new book Ultrasound-guided Liver Surgery covers every issue about intraoperative ultrasound in hepatobiliary surgery, from basic information on ultrasound, guidance on liver scanning vii viii Foreword procedure, liver evaluation according to its anatomical characteristics, intraoperative diagnosis and staging, contrast-enhanced ultrasonography, planning up of the surgical strategy, liver transplantation, laparoscopic ultrasound, intraoperative radiofrequency ablation, to ultrasound guidance in robotic surgery. This book is worth being owned by surgeons who wish to newly acquire what has now become the essential technique for a successful hepatobiliary surgery, and by the veterans to update their knowledge. Masatoshi Makuuchi, MD, PhD Professor Emeritus of the University of Tokyo President of the Japanese Red Cross Medical Center Foreword In 1988, ultrasound was already an established diagnostic tool for abdominal diseases and was per se anyway a revolutionary advancement for a medical community used to consider the liver, the spleen, the pancreas, and the pelvic organs as a sort of unexplored world, ‘‘hic sunt leones’’, like it was named in the ancient maps. Still nowadays I feel emotion when I put the probe on the abdomen of a patient often solving, by doing this, his diagnostic problem. However, it was at that time that new applications of ultrasound started to be established too, such as guided punctures of organs, tumors, and collections. That year in November, while I was running a course on interventional ultrasound, GuidoTorzilli, who was getting the MD degree, came to visit me and wished to join my course. Although I was initially skeptical, his passion and willingness convinced me to accept his application: it was well-founded trust. Once gotten the MD degree, in a span of a few months he developed enough skill to become consultant in ultrasound in my hospital. For some years I had been investigating the possibility to treat small liver tumor with percutaneous ethanol injection (PEI) [1]. Indeed, if it was possible to disclose a lesion, puncture it, and sample the tissue in real time, why should it have been unfeasible to inject something able to induce toxicity in it? The field of investigation was fascinating and potentially enormous. Was that therapeutic efficacy equal for primary or metastastic liver tumors? Was an eventual different therapeutic efficacy depending on the origin of the primary tumor? How much necrosis would have been achievable? Which morbidity? Guido was passionate too in that clinical research, and we wrote together the first report about 3-year survival of cirrhotic patients with hepatocellular carcinoma (HCC) and treated with PEI [2]. Data were surprising, with survival after PEI similar to results obtained with surgery: with that contribution a debate started about the role of surgery and ablation for liver tumors, which is still open. However, Guido, despite his great interest for these new applications, had a dream: becoming a surgeon and specifically a hepato-biliary surgeon. Although disappointed, anyway I supported his design and I asked Professor Makuuchi to accept him in his Department as a visiting doctor: by that, the interventional ultrasound community was losing a ix x Foreword potentially valuable member. However, we got in touch, having the chance to follow his training. Meanwhile, many studies on PEI were published and the comparison with surgery became a source of deep discussions in the international meetings. In the mid 1990s, PEI started to be progressively substituted by thermal ablation [3]. This new tool demonstrated the ability to destroy a tumor in a few minutes, hence justifying randomized trials versus surgery for early HCC, which showed long-term outcome as similar despite the lower invasivity, and the limited costs of ablation. Moreover, at least for the tumors in a very early stage, we were able to prove that ablation could be somehow ‘‘surgical,’’ justifying its affirmation as the gold standard approach for these particular subsets of patients [4]. However, although proud of that, the doubt that surgical results were biased by an inadequate way of facing the problem, with too extensive and risky hepatectomies, started growing in my mind. That idea found its confirmation some years ago, when I had the chance again to share working experience with Guido, at the Humanitas Research Hospital in Milan. Accurate patient selection, ‘‘radiological’’ knowledge of the preoperative imaging, the absolute mastery of intraoperative ultrasound resulting in targeted resection of the liver, with low morbidty and mortality, although often referred to patients presenting high complexities, convinced me that surgery could play still a great role. As the French are used to saying: ‘‘Chapeau!’’ We share now the knowledge that ablation should be limited to small lesions and surgery offered to patients with more complex diseases, provided that the surgical team offers adequate expertise—expertise in which ultrasound plays a fundamental role and for which the need for an adequate training has to be accounted. From this perspective, this book is certainly unique, and for the richness of images and details about new techniques, it seems to me, although I am not a surgeon, a must-have for those who wish to get into the world of a new and modern concept of liver surgery guided by ultrasound. Tito Livraghi, MD Member Emeritus of the Italian Society of Ultrasound Member Emeritus of the Italian Society of Radiology Former Director Department of Radiology Hospital of Vimercate Vimercate, Milan Italy Foreword xi References 1. Livraghi T, Festi D, Monti F et al (1986) US-guided percutaneous alcohol injection of small hepatic and abdominal tumors. Radiology 161(2):309–312 2. Livraghi T, Bolondi L, Lazzaroni S et al (1992) Percutaneous ethanol injection in the treatment of hepatocellular carcinoma in cirrhosis. A study on 207 patients. Cancer 69(4):925–929 3. Livraghi T, Goldberg SN, Lazzaroni S et al (1999) Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. Radiology 210(3):655–661 4. Livraghi T, Meloni F, Di Stasi M et al (2008) Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice? Hepatology 47(1): 82–89