History of liver surgery

Minimally Invasive Robotic Techniques for Hepatocellular Carcinoma Resection: How I Do It

The adoption of minimally invasive techniques for hepatocellular resection has progressively increased in North America. Cumulative evidence has demonstrated improved surgical outcomes in patients who undergo minimally invasive hepatectomy. In this review, the authors' approach and methodology to minimally invasive robotic liver resection for hepatocellular carcinoma is discussed.

Significance of lymph node metastasis in the survival of stage IV colorectal cancer by hematogenous metastasis

Purpose

Although lymph node (LN) metastasis is an important prognostic marker of colorectal cancer (CRC), the effect of LN metastasis on the survival of stage IV CRC is debated yet.

Methods

LN status and survivals as well as clinicopathological features of synchronous stage IV CRC patients, operated for 8 years, were analyzed. Patients with hematogenous metastases were included only but those with peritoneal seeding or preoperative adjuvant therapy were not included.

Results

Total 850 patients were enrolled and 77 (9.1%) were without LN metastases (N0M1). N0M1 patients were older and have favorable pathological features including lower CEA than patients with LN metastasis (N + M1). The pathologically poor features accumulated with N stage progression within N + M1. N0M1 had better 5-year overall survival (OS) and disease free survival than N + M1. And 5-year OS's within N + M1 group were stratified and different according to N stage progression, although the effect of N stage progression is different according to curative resection or not. When compared with stage III, 5-year OS of N0M1 with curative resection was comparable to that of anyTN2aM0 and was better than anyTN2bM1.

Conclusion

LN metastasis is a significant prognostic factor in stage IV by hematogenous metastasis, too. N stage progression accumulates pathologically poor prognostic factors. However, the effect on survival of each N stage progression differs depending on curative resection or not of the hematogenous metastases.

Caprio and Merola: Latin American Contribution to the Development of Liver Surgery

Regarding the history of liver surgery, Latin American pioneers have only occasionally been mentioned in the Anglo-Saxon literature. One of such rare cases was Uruguayan surgeon Gerardo Caprio, who in 1931 published a report about a resection of the left lobe of the liver. This was done during an uneventful period in the development of ideas on this surgical technique, following the remarkable advances made in the last quarter of the 19th Century. The anatomic and liver manipulation concepts used by Caprio had been developed by Merola in reports dating back to 1916 and 1920, which revealed well-grounded disagreements with the most renowned anatomists of the time. This paper discusses Merola and Caprio's academic profile by analyzing their publications, the knowledge base and experience that led the latter to perform such liver resection, and the surgical principles applied to it, which would only be formally adopted worldwide 20 years later.

Vascular inflow control during hemi-hepatectomy: a comparison between intrahepatic pedicle ligation and extrahepatic vascular ligation

BACKGROUND

Intrahepatic pedicle ligation (IPL) is an alternative to extrahepatic portal dissection (EPD). Although IPL has been well described, concern has arisen over a possible association with increased complication rates.

METHODS

Patients who underwent hemi-hepatectomy during January 1995 to December 2010 were reviewed and the inflow control technique (IPL versus EPD) documented. Patient, tumour, treatment and outcome variables were compared.

RESULTS

  A total of 798 patients underwent hemi-hepatectomy, 568 (71.2%) of the right and 230 (28.8%) of the left liver. In univariate analysis, factors associated with the choice of IPL included surgeon, right hepatectomy, preoperative portal vein embolization, diagnosis of colorectal cancer liver metastasis, and smaller tumour size (P < 0.011). In multivariate analysis, right hepatectomy [versus left: hazard ratio (HR) 3.878, 95% confidence interval (CI) 1.15-13.14; P = 0.029] and smaller tumour size (median of 4.5 cm versus 5.5 cm: HR 0.72, 95% CI 0.59-0.88; P = 0.002) were associated with IPL. Pringle manoeuvre time was longer in IPL procedures (40 min versus 29 min; P < 0.001). Complication rates (49.8% in IPL versus 48.4% in EPD; P = 0.706) were similar in both groups, as was the severity of complications; 17.6% of EPD and 22.3% of IPL patients experienced complications of grade ≥3 (P = 0.225).

CONCLUSIONS

Patients with small tumours undergoing right hepatectomy were more likely to undergo IPL. In selected patients, IPL was not associated with an increased complication rate and thus it should be considered a safe approach.

Acute Liver Failure following Hepatic Resection: Incidence, Presentation, Prevention and Management in ICU

The incidence of liver failure following liver resection has been reported to be between 8–32%, depending on the number of segments resected, the health of the patient and the incidence of hepatic ischaemic/reperfusion injury. This article outlines the evidence surrounding classification, prevention and management of this condition.

Perioperative management of liver resection surgery

Advances in liver resection surgery have lead to reductions in both mortality and morbidity. However morbidity remains high so effective multidisciplinary teamwork is essential to optimise the perioperative care of this patient group. In this article we review the current literature on the perioperative management of patients undergoing liver resection surgery.

History of hepatic surgery

This article describes the development of hepatic surgery from old anecdotes to spectacular progress achieved during the last 25 years. The door to this evolution was opened by anatomists who paved the way for a few courageous hepatic surgeons, who performed pioneering work between 1960 to 1980. Then, hepatic surgery and transplantation became widely accepted for the treatment of many diseases. Surgery on the liver has become safer with low postoperative mortality as a result of the creation of centers of excellence offering multidisciplinary expertise and technical innovation.

Liver resection for benign hepatic lesions: a retrospective analysis of 827 consecutive cases

AIM

To analyze the operative and perioperative factors associated with hepatectomy of benign hepatic lesions.

METHODS

A total of 827 consecutive cases of benign hepatic lesion undergoing hepatectomy from January 1986 to December 2005 in the Chinese PLA General Hospital were investigated retrospectively according to their medical documentation.

RESULTS

The effect of operative and perioperative factors on the outcome of patients were analyzed. Of the 827 cases undergoing hepatectomy for more than 3 liver segments accounted for 22.1%, 316 (38.21%) required transfusion of blood products during operation. The average operating time was 220.59 +/- 109.13 min, the average hospital stay after operation was 13.55 +/- 9.38 d. Child-Pugh A accounted for 98.13%. The postoperative complication rate was 13.54% and the in-hospital mortality rate was 0.24%. Multivariate analysis showed that operating time (P = 0.004, OR = 1.003) and albumin value (P = 0.040, OR = 0.938) were the independent predictors of morbidity and indicated that operating time, blood transfusion, complication rate, and LOS had a trend to decrease.

CONCLUSION

Hepatectomy for benign hepatic lesions can be performed safely with a low morbidity and mortality, provided that it is carried out with optimized perioperative management and an innovative surgical technique.

The clinical significance of hepatic parenchymal metastasis in patients with primary epithelial ovarian cancer

OBJECTIVE

The objective of this study was to determine the clinical significance of hepatic parenchymal metastasis on survival in patients with advanced epithelial ovarian cancer.

METHODS

We conducted a retrospective review of ovarian cancer patients with stages IIIc and IV hepatic parenchymal metastasis who were treated at the National Cancer Center in Korea between January 2001 and January 2008. Hepatic metastases were divided into unresectable, hematogenous parenchymal metastasis and resectable, parenchymal metastasis from peritoneal seeding.

RESULTS

One hundred twenty patients were identified, 113 of whom were included in the study. The stage IIIc group included 97 patients, and the group with stage IV disease and hepatic parenchymal metastasis included 16 patients. Of the 16 patients with hepatic parenchymal metastasis, 2 patients had unresectable, hematogenous parenchymal metastasis with a poor prognosis compared to the patients with resectable, hepatic parenchymal metastasis from peritoneal seeding. Fourteen patients with hepatic parenchymal metastases from peritoneal seeding underwent complete resection without complications as follows: wedge resection (n=7), segmentectomy (n=5), and hemi-hepatectomy (n=2). Age, tumor grade, histology, serum CA-125 level, and the rate of optimal debulking were similar in patients with stage IIIc disease and patients with stage IV disease who had resectable, hepatic parenchymal metastasis from peritoneal seeding. The 5-year progression free survival rate and the 5-year overall survival rate for patients with stage IIIc disease and patients with stage IV disease and hepatic parenchymal metastasis from peritoneal seeding were 25 and 23% (p=0.8063), and 55 and 51% (p=0.5671), respectively.

CONCLUSION

Our findings suggest that complete hepatic resection should be attempted for patients with hepatic parenchymal metastasis from peritoneal seeding.

Biological treatment for liver tumor and new potential biomarkers

The search for effective and efficacious therapy for liver tumor was started many years ago and is still ongoing. Despite all of the surgical advances, much work needs to be done to improve understanding of the biology of the tumor and its treatment. The rules of hepatic surgery are changing because of two recent major trends: (1) technical simplification, and (2) the endeavor to treat an increasing number of patients. T lymphocytes are potent cellular effectors of the immune system and possess a memory that responds to rechallenge by the same antigen. Being more specific and less toxic than chemotherapy, tumor infusion could be an ideal adjuvant therapy for patients with primary and secondary liver malignancies. Moreover, tumor cell vaccines have demonstrated efficacy in terms of minimal residual disease and are being investigated, but the requirement for an adequate supple of autologos tumor may limit the general applicability of these approaches. Various studies have demonstrated the aberrant expression of germ-cell proteins called cancer-testis (CT) antigens in liver neoplastic cells. Their selective normal-tissue expression makes them ideal antigens for immune targeting of malignant disease. Specific expression of CT antigens also suggests their application as tumor markers to detect circulating hepatocellular carcinoma (HCC) cells, as an adjuvant diagnostic tool, and as indicators for recurrence and prognosis. Biological therapy is now generating more clinical trials. More studies need to be performed and further experiments need to be done, although currently this seems a valid pathway for the treatment of liver cancer. Cytoreduction treatment of liver tumor and the vaccine might be the future of the treatment of primary and secondary liver tumor.

Live donor liver transplantation

With ever-increasing demand for liver replacement, supply of organs is the limiting factor and a significant number of patients die while waiting. Live donor liver transplantation has emerged as an important option for many patients, particularly small pediatric patients and those adults that are disadvantaged by the current deceased donor allocation system. Ideally there would be no need to subject perfectly healthy people in the prime of their lives to a potentially life-threatening operation to procure transplantable organs. Donor safety is imperative and cannot be compromised regardless of the implication for the intended recipient. The evolution of split liver transplantation is the basis upon which live donor transplantation has become possible. The live donor procedures are considerably more complex than whole organ decreased donor transplantation and there are unique considerations involved in the assessment of any specific recipient and donor. Donor selection and evaluation have become highly specialized. The critical issue of size matching is determined by both the actual size of the donor graft and the recipient as well as the degree of recipient portal hypertension. The outcomes after live donor liver transplantation have been at least comparable to those of deceased donor transplantation. Nevertheless, all efforts should be made to improve deceased donor donation so as to minimize the need for live donors. Transplant physicians, particularly surgeons, must take responsibility for regulating and overseeing these procedures.

OncoSurge: a strategy for long-term survival in metastatic colorectal cancer

OncoSurge is a combined modality strategy for the management of colorectal cancer with hepatic metastases. It has emerged as a result of new and expanded patient selection criteria for resectability of metastases, coupled with more effective neoadjuvant and postoperative chemotherapy. By bringing together these developments in surgery and medical oncology, the new approach promises to increase significantly the resectability rate and long-term survival in colorectal cancer patients with liver metastases. Surgery for colorectal liver metastases should now be considered across a range of clinical circumstances that would historically have been contraindications to resection. These contraindications include multiple or bilobar metastases, large tumour size, a Dukes stage C or poorly differentiated primary tumour, synchronous detection of metastases with the primary tumour, disease in elderly patients, or a resection margin of less than 1 cm. None of these criteria should necessarily exclude a patient from resection, because although they may be associated with a less favourable prognosis they do not exclude the possibility of long-term survival. Non-resectable extrahepatic disease and portal lymph node involvement, however, remain contraindications to resection in most circumstances. Retrospective studies of neoadjuvant therapy have indicated that a regimen based on low dose oxaliplatin, 5-fluorourucil (5-FU) and leucovorin increased the overall resectability rate of patients presenting with hepatic colorectal metastases from 20% to 30%, with 13.6% of patients with unresectable metastases becoming eligible for curative resection. More recently, studies using more potent oxaliplatin-based regimens have reported significantly higher resectability rates of at least 40%, with 5-year survival of 50% reported in one large study among patients whose liver metastases were resected after initial neoadjuvant therapy for unresectable tumours. Following resection, postoperative therapy based on a combination of hepatic artery infusion (HAI) and systemic chemotherapy reduces hepatic recurrence and increases survival, but more potent systemic therapy is required to reduce the rate of extrahepatic recurrence. Studies are now in progress combining HAI with oxaliplatin-based systemic therapy to address this issue. By combining a more inclusive approach to surgery with more effective neoadjuvant and postoperative chemotherapy, the OncoSurge treatment model is likely to increase significantly the number of patients with hepatic colorectal metastases who can be treated with curative intent, and thus has the potential to improve overall patient survival.

Percutaneous management of hepatic abscess: a perspective by interventional radiologists

Techniques for treating hepatic abscess have evolved rapidly during the past decade. For many years, the traditional treatment was surgical drainage. The development of modern imaging modalities, such as CT and US, has not only made the diagnosis more certain, but has also introduced a variety of percutaneous treatment options. Pyogenic hepatic abscess is now accepted as a medical/radiologic disease requiring surgical intervention only for correctable offending causes or for failed radiologic evacuation. Drainage via an indwelling catheter has been the traditional method of percutaneous treatment. However, indwelling catheters have disadvantages, including patient discomfort, the nuisance of catheter maintenance, and postprocedural complications. The technique of simple aspiration and intracavitary antibiotics as advocated by McFadzian et al, with excellent results confirmed by Giorgio et al, is a promising alternative to prolonged catheter drainage, and may be the biggest advancement in the management of hepatic abscess in 80 years. Surgeons have recently accepted radiologic drainage; now we need to see if interventional radiologists and surgeons will accept evacuation without indwelling catheter drainage. The role of interventional techniques for nonpyogenic hepatic abscesses will vary considerably. Mortality will still occur in the pyogenic varieties but should be related to underlying disease rather than the abscess itself.

One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery

A technique of hepatic resection is described and the results of 150 resections are reviewed. Hepatic transection was performed, under intermittent portal inflow occlusion, using ultrasonic aspiration to skeletonize portal branches and venous tributaries. Control of venous haemorrhage during resection was optimized by argon beam coagulation and lowering central venous pressure to between 0 and 4 cmH2O by extradural blockade and systemic nitroglycerine infusion. One patient with jaundice died in hospital, giving a mortality rate of 0.7 per cent. There were no deaths in patients without jaundice and cirrhosis. Fifteen patients (10.0 per cent) had significant complications, nine medical and six surgical, including three bile leaks (2.0 per cent). Mean blood loss was 814 ml for the whole study but only 434 ml in the last 4 years. During this latter period mean blood transfusion in hospital was 0.5 units and mean postoperative haemoglobin value fell by 0.7 g per 100 ml. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

The safety of elective liver resection in a special unit

The benefit of hepatic surgery for benign or malignant conditions is a balance between peri-operative morbidity/mortality and long-term potential for cure or palliation. The aim of this retrospective study was to illustrate that the safety of liver resection is a function of the frequently of performance of the procedure. Between 1973 and 1992, 327 elective liver resections were performed. The indication for surgery was malignant tumour in 275 cases of which 170 (62%) and 105 (38%) were for metastatic and primary disease, respectively, and non-malignant conditions in 52 cases. The series included the complete spectrum of hepatectomies. There were nine deaths (2.7%). Mortality was 8% (3/38) before 1985, 3.4% (3/89) between 1985-88 and 1.5% (3/200) between 1989-92. In non-jaundiced/non-cirrhotic patients, mortality was 1.4% (4/270). Morbidity, defined as the incidence of at least one major complication, occurred in 87 patients (26.6%) with a re-operation rate of 6.4%. During the same time periods, the morbidity rate was 42, 35 and 20%, respectively, and the median blood transfusion requirement and postoperative stay progressively decreased to 2 units and 9 days, respectively. In conclusion, as experience was gained, the need for blood transfusion diminished, morbidity and mortality improved and the hospital stay shortened.

Surgical anatomy of hepatic transplantation

Hepatic transplantation was pioneered by the work of Starzl and colleagues, first at the University of Colorado and later at the University of Pittsburgh. With the meeting of the National Institutes of Health (NIH) Consensus Development Conference in June of 1983, and their conclusion that liver transplantation was no longer experimental, orthotopic liver transplantation entered the "modern era." The release of cyclosporine by the US Food and Drug Administration (FDA) to transplant centers around the country, at the end of 1983, allowed for significant expansion of hepatic transplantation programs. Hepatic transplantation remains, however, the most difficult and complex of all solid organ transplants. A thorough grounding in the anatomic variations of hepatic segmental, arterial, venous, and ductal anatomy is only the first step in the successful completion of this challenging procedure.