Revolution in liver surgery

Practical questions in liver metastases of colorectal cancer: general principles of treatment

Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.

[Selective use of vascular clamps in major hepatectomy]

OBJECTIVE

To report the results of a selective use of vascular occlusions in major hepatectomies according to the size and location of the hepatic lesion.

BACKGROUND

Total vascular exclusion (TVE) and portal triad clamping (PTC) ensure efficient hemostatic effect but lead to warm ischemia of the liver. Lobar vascular occlusion (LVO) avoids warm ischemia of the remnant liver but could result in increased blood loss.

PATIENTS AND METHODS

Sixty consecutive major hepatectomies were studied. TVE was applied in 22 patients with large lesions (= 10 cm) or lesions with connections to the major hepatic veins or inferior vena cava. PTC (n = 15) and LVO (n = 23) were applied in remaining cases.

RESULTS

Clamping method was efficient in 87%, 93% and 100% for LVO, PTC and TVE, respectively. Median blood transfusions were 0.3 and 2 units for LVO, PTC and TVE, respectively. Postoperative aminotransferase peak value was significantly lower after LVO than after PTC or TVE, while those peaks were not statistically different with these latter two methods. Postoperative prothrombin time fall value was identical in the three groups. Mortality was 3.3% (2/60) and was not influenced by the type of clamping, but both deaths and most complications occurred in patients with abnormal underlying liver parenchyma.

CONCLUSION

Provided that adequate techniques are used, the need for blood transfusions is more dependent on the characteristics of the resected tumor than on the type of clamping used. Total vascular exclusion does not create more ischemic injury to the liver than portal triad clamping and it should be recommended for the resection of large or strategically located tumors. Other tumors can be resected in more than 80% of the cases with LVO, thus avoiding ischemia to the remnant liver. With the control of hemorrhage, pathology of underlying liver parenchyma has emerged as the main prognostic factor in major liver resections.

Repeat hepatectomy for colorectal liver metastases

OBJECTIVE

The authors assess the long-term results of repeat hepatectomies for recurrent metastases of colorectal cancer and determine the factors that can predict survival.

SUMMARY BACKGROUND DATA

Safer techniques of hepatic resection have allowed surgeons to consider repeat hepatectomy for colorectal metastases in an increasing number of patients. However, higher operative bleeding and increased morbidity have been reported after repeat hepatectomies, and the long-term benefit of these procedures needs to be evaluated.

STUDY POPULATION

Sixty-four patients from a group of 243 patients resected for colorectal liver metastases were submitted to 83 repeat hepatectomies (64 second, 15 third, and 4 fourth hepatectomies). Combined extrahepatic surgery was performed in 21 (25%) of these 83 repeat hepatectomies.

RESULTS

There was no intraoperative or postoperative mortality. Operative bleeding was not significantly increased in repeat hepatectomies as compared to first resections. Morbidity and duration of hospital stay were comparable to first hepatectomies. Overall and disease-free survival after a second hepatectomy were 60% and 42%, respectively, at 3 years and 41% and 26%, respectively, at 5 years. Factors of prognostic value on univariate analysis included the curative nature of first and second hepatectomies (p = 0.04 and p = 0.002, respectively), an interval between the two procedures of more than 1 year (p = 0.003), the number of recurrent tumors (p = 0.002), serum carcinoembryonic antigen levels (p = 0.03), and the presence of extrahepatic disease (p = 0.03). Only the curative nature of the second hepatectomy and an interval of more than 1 year between the two procedures were independently related to survival on multivariate analysis.

CONCLUSIONS

Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies, with no mortality and comparable morbidity. Combined extrahepatic surgery can be required to achieve tumor eradication. Repeat hepatectomies appear worthwhile when potentially curative.

Primary treatment of hepatocellular carcinoma by arterial chemoembolization

Two hundred and ninety-one patients with hepatocellular carcinoma were treated by chemoembolization (CE), using ethiodized oil, doxorubicin, and a gelatin sponge. Patients with thrombosis of either the portal vein or a main branch were excluded. The mortality rate in the first 2 months after treatment was 7% in noncirrhotic patients, 2.8% in patients with class A cirrhosis, 8% in patients with class B cirrhosis, and 37% in patients with class C cirrhosis. The tumor diameter remained the same in 55.3% of patients, was reduced by up to 50% in 20% of the patients, was reduced by more than 50% in 7.3% of the patients, and almost completely disappeared in 1.8% of the patients. The diameter of the tumor increased in 15.6% of patients. Forty-three patients underwent a resection or transplantation after chemoembolization. Histologic examination of the specimens revealed significant necrosis of the tumor. The long-term survival rate at 2 years was 49% for class A cirrhotics, 29% for class B cirrhotics, and 9% for class C cirrhotics. Complications included cholecystitis (10%), vasculitis (14%), renal decompensation (13%), an increase in ascites (14%), and jaundice (12%). Chemoembolization is an effective and safe initial treatment for hepatocellular carcinoma. It is effective in producing tumor necrosis and reducing the size of the tumor. Improvement in survival was noted when patients who underwent chemoembolization were compared with an historical series of untreated patients, and resection and transplantation are kept as options.