Hepatocellular carcinoma (HCC) is usually associated with liver cirrhosis and is the principal cause of death among patients with cirrhosis.¹ Apart from liver transplantation that may cure both conditions, treatment of HCC and cirrhosis is complex because of the need to be oncologically radical but simultaneously conservative. In this sense, hepatectomy is considered an invasive approach and has a marginal role in the treatment of HCC.^2,3 According to the Barcelona Clinic Liver Cancer (BCLC) classification,⁴ hepatic resection should be performed only in patients with small single tumors without signs of portal hypertension or hyperbilirubinemia. Patients with multiple, large, or vascular invasive HCC should receive palliation or no treatment. However, surgical morbidity and mortality may approach 0% in expert hands,^5-7 and liver resection could offer effective treatment to patients with multiple, large, or vascular invasive HCC.^8-11

A surgical approach based on ultrasound-guided hepatectomy might minimize the need for major resection, whose rates of morbidity and mortality are not negligible. Right hepatectomy (RH) is traditionally performed in cases of vascular invasion of the right hepatic vein with multiple tumors in the right posterior section, and/or of the right posterior portal branch (P6-7) with tumor in contact with right anterior portal branch (P5-8). We herein describe an alternative approach to RH consisting in ultrasound-guided systematic extended right posterior hepatic sectionectomy (SERPS).Among 207 consecutive patients who underwent hepatectomies, 21 (10%) underwent SERPS. Median age was 67 years (range, 48-79). There were 13 men and 8 women. Ten (48%) patients had hepatocellular carcinoma; 11 (52%) had colorectal liver metastases. Median tumor number was 2 (range, 1-15); median tumor size was 4.5 cm (range, 2.5-20). Ten (48%) patients had cirrhosis, 8 (38%) had steatosis, and 3 (16%) had normal liver. Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS.In-hospital and 90-days mortality were nil. Major and minor morbidity occurred in 3 (14%) and 2 (9.5%) patients, respectively. No patients were reoperated because of complications. Blood transfusions were given to 2 (9.5%) patients. After a median follow-up of 21 months, no local recurrence was observed.IOUS-guided SERPS is feasible, safe, and effective. It should be applied whenever possible as alternative resection to RH to maximize liver parenchymal sparing.

We describe a new ultrasound guided conservative procedure for patients with liver tumors invading the middle hepatic vein (MHV) at its caval confluence. Morbidity and mortality for major hepatectomies are not negligible. However, when tumors invade the MHV at the caval confluence, major surgery is usually recommended. Patients included in this study were those with tumors invading the MHV at its hepato-caval confluence (within 4 cm). Minimum follow-up was established at 6-months from surgery. Among 284 consecutive hepatectomies, 17 (6%) met the inclusion criteria. Partial sparing of segments 4, 5, and 8 was established intraoperatively, based on color-Doppler IOUS findings (NCT00600522 on ClinicalTrials.gov). In all the 17 patients at least one of the color-Doppler IOUS criteria was disclosed, and limited resections of just segments 4sup and 8 were always feasible. The MHV tract involved was always resected. Seven patients had single tumor removed and 10 multiple: total number of resected tumors was 58 (median: 2; range: 1-18). There were no postoperative mortality and major morbidity. Overall morbidity occurred in 3 (18%) patients. Median blood loss was 250 (range: 50-1000). One patient (6%) received blood transfusion. No local recurrences were observed (median follow-up: 26 months). IOUS assistance systematically allows conservative resection of liver tumor invading the MHV at caval confluence. This drastically limits the need for larger resections, and further broadens the role of IOUS in optimizing the surgical strategy.

Metabolomics, the research area studying chemical processes involving metabolites, finds its utility in inflammasome biomarker discovery, thus representing a novel approach for cardiometabolic syndrome pathogeny acknowledgements. Metabolite biomarkers discovery is expected to improve the disease evolution and outcome. The activation of abundantly expressed NLRP3 inflammasome represents the background process of the diabetes mellitus disturbances like hyperglycemia and insulin resistance, as well as for myocardial cell death and fibrosis, all of them being features characteristic for cardiometabolic syndrome. Many molecules like troponins, brain natriuretic protein (BNP), ST2/IL-33, C-reactive protein (CRP), TNF, IL-1β, and IL-18 cytokines have been already examined as molecular markers for diagnosing or predicting different cardiac disturbances like myocardial infarction, heart failure, or myocarditis. In addition, metabolomics research comes with new findings arguing that NLRP3 inflammasome becomes a promising molecular tool to use for clinical and therapeutical management providing new targets for therapies in cardiometabolic syndrome. Inflammasome markers analyses, along with other molecular or genetic biomarkers, will result in a better understanding of cardiometabolic syndrome pathogenesis and therapeutic targets. Screening, diagnostic, and prognostic biomarkers resulted from inflammasome biomarker research will become standard of care in cardiometabolic syndrome management, their utility becoming the first magnitude.

BackgroundPreliminary reports led to discordant conclusions concerning the use of contrast-enhanced intraoperative ultrasonography (CE-IOUS) during surgery for colorectal liver metastases (CLM). The aim of this study was to evaluate the impact of CE-IOUS in patients undergoing surgery for CLM using an advanced preoperative imaging work-up, and well-established reference standards.Materials and methodsForty-seven consecutive patients underwent liver resection using IOUS and CE-IOUS for CLM. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI) within 2 weeks prior to surgery. CE-IOUS was performed by injecting intravenously 4.8ml of sulphur-hexafluoride microbubbles (SonoVue, Bracco, Italy). Reference standards were histology, and 6-month imaging follow-up.ResultsIOUS discovered 43 additional lesions in 20 patients. CE-IOUS found 10 additional lesions not seen at IOUS in four patients, and confirmed all the IOUS findings. Fourteen CLM in 10 patients appeared within 6 months after surgery. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were, respectively: 66%, 0%, 98%, 0% and 65% for CT+MRI; 88%, 100%, 100%, 8%, 88% for IOUS and 93%, 100%, 100%, 13%, 93% for IOUS+CE-IOUS. In nine patients CE-IOUS afforded better definition of tumour margins thus helping in resection guidance.ConclusionsCE-IOUS improves IOUS findings both for detection and for resection guidance. The combination of IOUS and CE-IOUS should be considered routinely in patients operated for CLM