Gian Luca Grazi
Professor of Surgery
HepatoBiliaryPancreatic Surgery, AUO Careggi, Florence, Italy
Liver metastases
Parenchyma sparing surgery
2
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Antonio Lius: Di un adenoma del fegato. In: Gazzetta delle Cliniche, vol. 23, iss. 15, pp. 225-230, 1886
3
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
4
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Hjortsjo CH, Cells Tissues Organs, 1950:11(4),599–615
Photograph of a corrosion preparation
from the right side and somewhat from the dorsal
5
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Schematic drawing of the corrosion preparation with the main
parts, portions, segments and segments fissures
Hjortsjo CH, Cells Tissues Organs, 1950:11(4),599–615
6
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Lortat-Jacob JL, La Presse Médicale, April 16th, 1952;60(26):549-551
7
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Cunningham JD, Arch Surg. 1994;129(10):1050-6
Characteristics of Patients in the Prospective and Pilot Studies
8
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Kokudo N, Am J Surg. 2001;181(2):153-9
Background: Although systematic anatomical hepatic resection has been reported to improve patient
survival in hepatocellular carcinoma, principles of hepatectomy procedure have not been clearly
demonstrated in secondary hepatic malignancy.
The purpose of the present study was to determine whether selection of surgical procedures for liver
resection is associated with the pattern of tumor recurrence or patient survival.
9
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Kokudo N, Am J Surg. 2001;181(2):153-9
Operative morbidity and mortality
after liver resection
Kaplan-Meier estimates of overall survival after hepatic resection for
metastatic colorectal cancer according to surgical procedures.
There was no significant difference in patient survival between anatomical
(solid line, n = 96) and nonanatomical (dashed line, n = 78) group.
10
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Kokudo N, Am J Surg. 2001;181(2):153-9
Studies mentioning the effect of
surgical procedure on patient survival
11
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Kokudo N, Am J Surg. 2001;181(2):153-9
 There was not a significant difference in patient survival according to surgical procedure
employed for colorectal metastases.
 From the subset analysis in unilobar single or double tumors, anatomical major
hepatectomy was unnecessary in 80.4% of the cases if the tumors were resectable by
nonanatomical limited resection.
 Ninety percent of the ipsilateral recurrence, which could have been avoided if the first
operation was anatomical hemihepatectomy, could undergo second hepatectomy with
relatively favorable outcome.
 To minimize surgical stress and operative risk, nonanatomical limited liver resection
should be a basic surgical procedure for colorectal metastases.
 When technically unavoidable, anatomical major hepatectomy can be selected based on
the tumor size, location, or number of the tumors.
12
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Stewart GD,Eur J Surg Oncol. 2004;30:370-6
13
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Stewart GD,Eur J Surg Oncol. 2004;30:370-6
 Operative techniques are improving and now lesions which were once thought to be
irresectable can be approached safely, e.g. central hepatic lesions adjacent to the hilar
plate (5-year survival of 45%).7
 Extrahepatic disease is no longer an absolute contraindication to liver resection for
colorectal metastases, having been successfully resected along with liver metastases (5-
year survival rate of 29%).
 Chemotherapy has allowed 15% of patients initially deemed to have irresectable disease
to be down-staged to allow successful liver resection to take place.
 Potential use of adjuvant ablative techniques, such as radiofrequency ablation (RFA), in
addition to surgical resection, has also extended the indications for hepatic resection.
14
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
15
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi
• Non-anatomic resections pertain to wedge resections
or partial segmentectomies
• Parenchymal-sparing indicates only that functional
parenchyma has been preserved in some way
Parechymal-sparing vs Non anatomical resections
16
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Single Metastasis?
17
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Mise Y, Ann Surg. 2016;263:146-52
18
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Mise Y, Ann Surg. 2016;263:146-52
Patient selection
19
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Mise Y, Ann Surg. 2016;263:146-52
Time trend of surgical procedure
20
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Long-term survival in patients with liver-only recurrence after parenchymal-
sparing hepatectomy (PSH) and non-PSH.
OS (line) and RFS (dotted line) from initial hepatectomy.
Mise Y, Ann Surg. 2016;263:146-52
21
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
 The key finding of this study is that PSH significantly improves survival in case of liver recurrence.
 This survival benefit is due to a higher likelihood to undergo salvage hepatectomy for recurrence
compared with a non-PSH approach.
 In addition, non-PSH was found to be the only risk factor preventing salvage liver resection.
 Repeat hepatectomy has previously been shown to be the optimal treatment for recurrent CLM, which
is confirmed by our survival subanalysis.
 Because liver-only recurrence in this good prognosis group can be expected to occur in 1 out of 5
patients and be even higher for tumors with high risk features such as large or multiple tumors, PSH
should be the standard of care in patients with CLM to improve salvageability.
Mise Y, Ann Surg. 2016;263:146-52
Conclusions
22
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Bilateral Metastasis?
23
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Gold JS, Ann Surg 2008;247: 109–117
24
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Trends over time in treatment-related variables in 443 operations
performed to resect bilateral colorectal cancer metastases to the liver
Gold JS, Ann Surg 2008;247: 109–117
25
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Gold JS, Ann Surg 2008;247: 109–117
 Resection of bilateral liver metastases from colorectal cancer can be performed safely at
a specialist center.
 Resection offers prolonged survival and reasonable control of disease within the liver,
although most of the patients recur distantly.
 Patient comorbidity and complex procedures independently predict morbidity after
resection.
 Variables independently associated with oncologic outcome are predominantly related to
tumor biology.
 The increased use of parenchymal-sparing surgery seems to be associated with
improved mortality without any detriment in oncologic outcome.
 Good risk patients should be considered for hepatic resection if all diseases can
technically be removed.
 Parenchymal-sparing techniques should be given preference in hepatic resection for
bilateral metastatic colorectal cancer.
26
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Hosokawa I, Surgery 2017;162:223-32
Overall survival (OS) of patients with liver-only
recurrence who underwent parenchyma-preserving
hepatectomy (PH) and those who underwent right
hepatectomy (RH) for a solitary small colorectal liver
metastasis (CLM)
27
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Hypothesis
28
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi
Paget’s “seed and soil” hypothesis posits that tumorigenic cells (seed) travel
throughout the blood or lymphatic system to arrive at a host organ (soil).
If “seed and soil” alone explain the phenomenon of metastasis, and one
believes that cancer cells will not navigate the hepatic lobule to then find
themselves circulating along hepatic venous outflow tracts, an argument
can be made for anatomic resection along portal blood supply.
Therefore, surgeons who prefer anatomic segmentectomies tend to argue
that they decrease local recurrence risk.
Proponents of more aggressive anatomic resections, such as right
hepatectomy for multifocal disease, have argued that preferential right-sided
liver perfusion from the portal vein governs tumor spread, mandating the
removal of the right lobe in cases of right-side-dominant disease
Rengers T, Surgery. 2023:S0039-6060(23)00121-6
29
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
Rengers T, Surgery. 2023:S0039-6060(23)00121-6
30
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi
Rengers T, Surgery. 2023:S0039-6060(23)00121-6
31
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi
Moris D, J Gastrointest Surg (2017) 21:1076–1085
Oncologic outcomes following parenchymal-sparing or anatomic resection
32
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi
 The oft-absent points in personalized medicine of actual origin and behavior of a patient’s
specific metastasis will remain unanswered until we can agree on whether hepatic lobules,
immune surveillance, or some combination of the two govern the position of the offending
lesions.
 Only then can we have closure about which technique is best for which patient.
 Until that time, the decision to perform non-anatomic versus anatomic resection for CRLM
requires multidisciplinary discussion and careful consideration of both short and long-term
disease course projections.
 When possible, it is the author’s preference to pursue parenchymal preservation.
 Anatomic resections are reserved for those lesions located at or near a dominant portal
pedicle, wherein concern for biliary injury renders ablation inappropriate.
Rengers T, Surgery. 2023:S0039-6060(23)00121-6
TAKE HOME MESSAGE
Parenchyma sparing surgery
Gian Luca Grazi
Professor of Surgery – HepatoBiliaryPancreatic Surgery AOU Careggi
gianluca.grazi@unifi.it
Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
www.chirurgiadelfegato.it

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Liver metastases - Parenchyma sparing surgery.pptx

  • 1. Gian Luca Grazi Professor of Surgery HepatoBiliaryPancreatic Surgery, AUO Careggi, Florence, Italy Liver metastases Parenchyma sparing surgery
  • 2. 2 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Antonio Lius: Di un adenoma del fegato. In: Gazzetta delle Cliniche, vol. 23, iss. 15, pp. 225-230, 1886
  • 3. 3 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
  • 4. 4 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Hjortsjo CH, Cells Tissues Organs, 1950:11(4),599–615 Photograph of a corrosion preparation from the right side and somewhat from the dorsal
  • 5. 5 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Schematic drawing of the corrosion preparation with the main parts, portions, segments and segments fissures Hjortsjo CH, Cells Tissues Organs, 1950:11(4),599–615
  • 6. 6 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Lortat-Jacob JL, La Presse Médicale, April 16th, 1952;60(26):549-551
  • 7. 7 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Cunningham JD, Arch Surg. 1994;129(10):1050-6 Characteristics of Patients in the Prospective and Pilot Studies
  • 8. 8 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Kokudo N, Am J Surg. 2001;181(2):153-9 Background: Although systematic anatomical hepatic resection has been reported to improve patient survival in hepatocellular carcinoma, principles of hepatectomy procedure have not been clearly demonstrated in secondary hepatic malignancy. The purpose of the present study was to determine whether selection of surgical procedures for liver resection is associated with the pattern of tumor recurrence or patient survival.
  • 9. 9 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Kokudo N, Am J Surg. 2001;181(2):153-9 Operative morbidity and mortality after liver resection Kaplan-Meier estimates of overall survival after hepatic resection for metastatic colorectal cancer according to surgical procedures. There was no significant difference in patient survival between anatomical (solid line, n = 96) and nonanatomical (dashed line, n = 78) group.
  • 10. 10 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Kokudo N, Am J Surg. 2001;181(2):153-9 Studies mentioning the effect of surgical procedure on patient survival
  • 11. 11 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Kokudo N, Am J Surg. 2001;181(2):153-9  There was not a significant difference in patient survival according to surgical procedure employed for colorectal metastases.  From the subset analysis in unilobar single or double tumors, anatomical major hepatectomy was unnecessary in 80.4% of the cases if the tumors were resectable by nonanatomical limited resection.  Ninety percent of the ipsilateral recurrence, which could have been avoided if the first operation was anatomical hemihepatectomy, could undergo second hepatectomy with relatively favorable outcome.  To minimize surgical stress and operative risk, nonanatomical limited liver resection should be a basic surgical procedure for colorectal metastases.  When technically unavoidable, anatomical major hepatectomy can be selected based on the tumor size, location, or number of the tumors.
  • 12. 12 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Stewart GD,Eur J Surg Oncol. 2004;30:370-6
  • 13. 13 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Stewart GD,Eur J Surg Oncol. 2004;30:370-6  Operative techniques are improving and now lesions which were once thought to be irresectable can be approached safely, e.g. central hepatic lesions adjacent to the hilar plate (5-year survival of 45%).7  Extrahepatic disease is no longer an absolute contraindication to liver resection for colorectal metastases, having been successfully resected along with liver metastases (5- year survival rate of 29%).  Chemotherapy has allowed 15% of patients initially deemed to have irresectable disease to be down-staged to allow successful liver resection to take place.  Potential use of adjuvant ablative techniques, such as radiofrequency ablation (RFA), in addition to surgical resection, has also extended the indications for hepatic resection.
  • 14. 14 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy
  • 15. 15 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi • Non-anatomic resections pertain to wedge resections or partial segmentectomies • Parenchymal-sparing indicates only that functional parenchyma has been preserved in some way Parechymal-sparing vs Non anatomical resections
  • 16. 16 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Single Metastasis?
  • 17. 17 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Mise Y, Ann Surg. 2016;263:146-52
  • 18. 18 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Mise Y, Ann Surg. 2016;263:146-52 Patient selection
  • 19. 19 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Mise Y, Ann Surg. 2016;263:146-52 Time trend of surgical procedure
  • 20. 20 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Long-term survival in patients with liver-only recurrence after parenchymal- sparing hepatectomy (PSH) and non-PSH. OS (line) and RFS (dotted line) from initial hepatectomy. Mise Y, Ann Surg. 2016;263:146-52
  • 21. 21 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy  The key finding of this study is that PSH significantly improves survival in case of liver recurrence.  This survival benefit is due to a higher likelihood to undergo salvage hepatectomy for recurrence compared with a non-PSH approach.  In addition, non-PSH was found to be the only risk factor preventing salvage liver resection.  Repeat hepatectomy has previously been shown to be the optimal treatment for recurrent CLM, which is confirmed by our survival subanalysis.  Because liver-only recurrence in this good prognosis group can be expected to occur in 1 out of 5 patients and be even higher for tumors with high risk features such as large or multiple tumors, PSH should be the standard of care in patients with CLM to improve salvageability. Mise Y, Ann Surg. 2016;263:146-52 Conclusions
  • 22. 22 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Bilateral Metastasis?
  • 23. 23 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Gold JS, Ann Surg 2008;247: 109–117
  • 24. 24 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Trends over time in treatment-related variables in 443 operations performed to resect bilateral colorectal cancer metastases to the liver Gold JS, Ann Surg 2008;247: 109–117
  • 25. 25 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Gold JS, Ann Surg 2008;247: 109–117  Resection of bilateral liver metastases from colorectal cancer can be performed safely at a specialist center.  Resection offers prolonged survival and reasonable control of disease within the liver, although most of the patients recur distantly.  Patient comorbidity and complex procedures independently predict morbidity after resection.  Variables independently associated with oncologic outcome are predominantly related to tumor biology.  The increased use of parenchymal-sparing surgery seems to be associated with improved mortality without any detriment in oncologic outcome.  Good risk patients should be considered for hepatic resection if all diseases can technically be removed.  Parenchymal-sparing techniques should be given preference in hepatic resection for bilateral metastatic colorectal cancer.
  • 26. 26 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Hosokawa I, Surgery 2017;162:223-32 Overall survival (OS) of patients with liver-only recurrence who underwent parenchyma-preserving hepatectomy (PH) and those who underwent right hepatectomy (RH) for a solitary small colorectal liver metastasis (CLM)
  • 27. 27 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Hypothesis
  • 28. 28 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi Paget’s “seed and soil” hypothesis posits that tumorigenic cells (seed) travel throughout the blood or lymphatic system to arrive at a host organ (soil). If “seed and soil” alone explain the phenomenon of metastasis, and one believes that cancer cells will not navigate the hepatic lobule to then find themselves circulating along hepatic venous outflow tracts, an argument can be made for anatomic resection along portal blood supply. Therefore, surgeons who prefer anatomic segmentectomies tend to argue that they decrease local recurrence risk. Proponents of more aggressive anatomic resections, such as right hepatectomy for multifocal disease, have argued that preferential right-sided liver perfusion from the portal vein governs tumor spread, mandating the removal of the right lobe in cases of right-side-dominant disease Rengers T, Surgery. 2023:S0039-6060(23)00121-6
  • 29. 29 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy Rengers T, Surgery. 2023:S0039-6060(23)00121-6
  • 30. 30 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi Rengers T, Surgery. 2023:S0039-6060(23)00121-6
  • 31. 31 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi Moris D, J Gastrointest Surg (2017) 21:1076–1085 Oncologic outcomes following parenchymal-sparing or anatomic resection
  • 32. 32 Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi  The oft-absent points in personalized medicine of actual origin and behavior of a patient’s specific metastasis will remain unanswered until we can agree on whether hepatic lobules, immune surveillance, or some combination of the two govern the position of the offending lesions.  Only then can we have closure about which technique is best for which patient.  Until that time, the decision to perform non-anatomic versus anatomic resection for CRLM requires multidisciplinary discussion and careful consideration of both short and long-term disease course projections.  When possible, it is the author’s preference to pursue parenchymal preservation.  Anatomic resections are reserved for those lesions located at or near a dominant portal pedicle, wherein concern for biliary injury renders ablation inappropriate. Rengers T, Surgery. 2023:S0039-6060(23)00121-6 TAKE HOME MESSAGE
  • 33. Parenchyma sparing surgery Gian Luca Grazi Professor of Surgery – HepatoBiliaryPancreatic Surgery AOU Careggi [email protected] Liver mets - Parenchyma sparing surgery - Gian Luca Grazi – HepatoBiliaryPancreatic Surgery, AOU Careggi, Florence, Italy www.chirurgiadelfegato.it