Combined liver and inferior vena cava resection for hepatic malignancy

OBJECTIVE: The experience from a single center, in combined liver and inferior vena cava (IVC) resection for liver tumors, is presented. METHODS: Twelve patients underwent a combined liver resection with IVC replacement. The median age was 45 years (range 35-67 years). Resections were carried out for hepatocellular carcinoma (n = 4), colorectal metastases (n = 6), and cholangiocarcinoma (n = 2). Liver resections included eight right lobectomies and four left trisegmentectomies. The IVC was reconstructed with ringed Gore-Tex tube graft. RESULTS: No perioperative deaths were reported. The median operative blood transfusion requirement was 2 units (range 0-12 units) and the median operative time was 5 hr. Median hospital stay was 10 days (range 8-25 days). Three patients had evidence of postoperative liver failure, resolved with supportive management. Two patients developed bile leaks, resolved conservatively. With a median follow up of 24 months, all vascular reconstructions were patent and no evidence of graft infection was documented. CONCLUSIONS: Aggressive surgical management of liver tumors, offer the only hope for cure or palliation. We suggest that liver resection with vena cava replacement may be performed safely, with acceptable morbidity, by specialized surgical teams.     

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms.

AIMS: Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals. METHODS: Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour. RESULTS: There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases. CONCLUSION: In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life. Copyright Harcourt Publishers Limited.     

射频消融辅助肝切除术在巨大肝脏肿瘤治疗中的应用

目的:比较射频消融辅助肝切除术与嵌夹结扎法在巨大肝脏肿瘤切除中的有效性及安全性。方法:共31例诊断为巨大肝脏肿瘤的患者纳入回顾性研究,其中15例采用射频消融辅助肝切除术（RF-LR组）,16例采用传统的嵌夹结扎法（CC-LR组）。比较两组间出血量、输血情况、手术时间、术后并发症发生情况及生存率。结果:两组患者术前评估未见明显差异。CC-LR组患者中位术中出血量（1 000 ml vs 600 ml,P=0.005）及需输血患者例数（13例 vs 6例,P=0.029）较RF-LR组显著升高,但两组间手术时间、肝门阻断、术后并发症发生情况、围手术期死亡例数并无统计学差异。RF-LR组术后1年、2年、3年总体生存率分别为80.0%、70.0%、35.0%,与CC-LR组患者（76.9%、61.5%、38.5%）比较未见统计学差异（P>0.05）。结论:射频消融辅助肝切除术能有效减少巨大肝脏肿瘤患者术中出血量及输血患者例数,尤其对合并肝硬化患者适用,且与嵌夹结扎法具有相似的长期生存率。     

Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients.

BACKGROUND: This study documents patient outcomes with one department's approach to performing partial hepatectomy. METHODS: 101 consecutive patients underwent: preoperative dehydration; intraoperative CVP <5 cm H(2)O and selective continuous vascular occlusion. Outcome variables: pathology; type of hepatic resection; intraoperative blood loss and transfusion rate; 30 day morbidity and mortality; disease free and long term survival. Perioperative liver function was assessed by serial blood sampling. RESULTS: Of 101 resections: 90% malignant disease; 59% major resections and 35% synchronous procedures. Median estimated blood loss was 400 mL (mean 512 mL, range 50-3000 mL) with postoperative transfusions in 4%. Thirty day morbidity was 20% with no deaths. Median time to local recurrence after colorectal liver metastases resection was 17.1 months with 3 year survival of 51%. Distinct perioperative changes in hepatic function were seen. CONCLUSION: Selective continuous vascular occlusion and perioperative fluid restriction result in minimal blood loss, low morbidity and zero mortality in patients undergoing partial hepatectomy.     

Radiofrequency assisted liver resection: analysis of 604 consecutive cases

Background

Intraoperative blood loss is an important factor contributing to morbidity and mortality in liver surgery. To address this we developed a bipolar radiofrequency (RF) device, the Habib 4X, used specifically for hepatic parenchymal transection. The aim of this study was to prospectively assess the peri-operative data using this technique.

Methods

Between 2001 and 2010, 604 consecutive patients underwent liver resections with the RF assisted technique. Clinico-pathological and outcome data were collected and analysed.

Results

There were 206 major and 398 minor hepatectomies. Median intraoperative blood loss was 155 (range 0–4300) ml, with a 12.6% rate of transfusion. There were 142 patients (23.5%) with postoperative complications; none had bleeding from the resection margin. Only one patient developed liver failure and the mortality rate was 1.8%.

Conclusions

RF assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss, low blood transfusion requirements, and reduced mortality and morbidity rates.     

Intensity-modulated radiotherapy following null-margin resection is associated with improved survival in the treatment of intrahepatic cholangiocarcinoma

Background

The current study is the first to examine the effectiveness and toxicity of postoperative intensity-modulated radiotherapy (IMRT) in the treatment of intrahepatic cholangiocarcinoma (ICC) abutting the vasculature. Specifically, we aim to assess the role of IMRT in patients with ICC undergoing null-margin (no real resection margin) resection.

Methods

Thirty-eight patients with ICC adherent to major blood vessels were included in this retrospective study. Null-margin resection was performed on all patients; 14 patients were further treated with IMRT. The median radiation dose delivered was 56.8 Gy (range, 50-60 Gy). The primary endpoints were overall survival (OS) and disease-free survival (DFS).

Results

At a median follow-up of 24.6 months, the median OS and DFS of all patients (n=38) were 17.7 months (95% CI, 13.2-22.2) and 9.9 months (95% CI, 2.8-17.0), respectively. Median OS was 21.8 months (95% CI, 15.5-28.1) among the 14 patients in the postoperative IMRT group and 15.0 months (95% CI, 9.2-20.9) among the 24 patients in the surgery-only group (P=0.049). Median DFS was 12.5 months (95% CI, 6.8-18.2) in the postoperative IMRT group and 5.5 months (95% CI, 0.7-12.3) in the surgery-only group (P=0.081). IMRT was well-tolerated. Acute toxicity included one case of Grade 3 leukopenia; late toxicity included one case of asymptomatic duodenal ulcer discovered through endoscopy.

Conclusions

The study results suggest that postoperative IMRT is a safe and effective treatment option following null-margin resections of ICC. Larger prospective and randomized trials are necessary to establish postoperative IMRT as a standard practice for the treatment of ICC adherent to major hepatic vessels.     

Combined liver and lung metastasectomy through an exclusive transthoracic approach

BACKGROUND: In a very selected group of patients, resection of metachronous liver and lung metastases, prolongs survival despite the aggressive nature of these lesions. We present here our experience with metastasectomy in patients with metachronous liver and lung metastases in whom, an exclusive transthoracic approach was performed. METHODS: Between 2002 and 2005, five patients with metachronous colorectal liver and right-lung metastases, underwent an exclusive transthoracic approach. There were three men and two women, with a median age of 68 years (range, 55-76 years). Liver resections performed included segmentectomy of segments VII, VIII, or both. Previous operations include colon resection, adhesiolysis, or ventral hernia repair were performed in all patients. RESULTS: No mortality was documented. Morbidity included pleural effusion (n = 2) and post-operative pneumonia (n = 1) which responded to conservative management. Median hospital stay was 8 days (range 5-12 days). With a median follow-up of 26 months all patients are alive without recurrent disease. CONCLUSION: An aggressive surgical approach should be undertaken for CRC metastases. An exclusive transthoracic approach is feasible for combined lung and subdiaphragmatic liver metastasectomy in selected cases with previous abdominal surgery.     

Tissue preserving hepatectomy by a vessel sealing device

BACKGROUND: The intraoperative blood loss and the biliary leak constitute the major causes of postoperative morbidity following liver resection. We describe a new technique for liver parenchyma transection using the Atlas modification of the ligasure vessel sealing system. The gradual closure of the instrument may cause crushing of the hepatic tissue and heat sealing of the vessels and bile ducts at the same time. MATERIALS AND METHODS: Ten cirrhotic patients (group A) underwent minor liver resections due to hepatocellular carcinoma (HCC). In four of these patients a bisegmentectomy was carried out, whereas in the remaining six the resection involved one segment. In addition, twelve patients with localized metastatic liver disease (group B) underwent tissue preserving hepatectomy also. Six of these patients underwent a bisegmentectomy and six had a local resection involving one segment. RESULTS: The blood loss in the first group varied from 120 to 350 ml, whereas in the second group varied from 80 to 280 ml. No postoperative biliary leakage was mentioned. CONCLUSION: This alternative technique of dividing the hepatic parenchyma seems to be simple and efficacious in preventing significant blood loss and bile leak in minor liver resections.     

Resection of hepatic and pulmonary metastases in patients with colorectal cancer.

The resection of liver and lung metastases is now regarded as valid therapy, although the surgical procedure of both metastatic sites has not been clearly defined. Nine consecutive patients who underwent resection of both liver and lung metastases from colorectal cancer (5 Dukes' stage B, 3 C, 1 D) between 1986 and 1999 were studied retrospectively. A total of 19 resections were performed: 8 hepatectomies, 2 liver wedge resections, and 9 lung lobectomies. No operative or hospital deaths occurred, and mean postoperative hospital stay per procedure was 12 days. Mean survival after resection of the primary colorectal tumor was 66.3 (range: 26-96) months. The median interval was 24.2 (range: 2-39) months from resection of the liver metastasis and 30.4 (range: 3-45) months from resection of the lung metastasis. At the last follow-up, 6 patients were still alive, 4 of whom were free of recurrence 59, 69, 74, and 76 months, respectively, after resections. Three patients died with metastases. Aggressive treatment of liver and lung secondaries from colorectal cancer was performed without hospital mortality and acceptable morbidity. Longer survival times warrant the use of this alternative therapy for selected patients. In association with new effective chemotherapies, it will be possible to select patients who will benefit from surgery.     

Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK.

OBJECTIVE: To review the outcome of patients operated for hilar cholangiocarcinoma and analyse prognostic variables. PATIENTS AND METHODS: A prospectively collected database on patients with hilar cholangiocarcinoma, between 1992 and 2003, and relevant clinical notes were reviewed retrospectively. A total of 174 patients, 96 male, median age 63 years (27-86), were referred. Jaundice was the initial presentation in 167. RESULTS: ERCP was the initial interventional investigation at the referring centre in 150, of which only 30 were stented successfully. PTC and decompression was carried out on 120. In 17, combined PTC and ERCP were required for placement of stents. Seventy-two underwent laparotomy at which 27 had locally advanced disease. Forty-five had potentially curative resections. Extra hepatic bile duct resection was done in 14 patients of which four were R0 resections. Thirty-one had bile duct resection including partial hepatectomy with 19 R0 resections (P=0.042). Post-operative complications developed in 19 patients, and there were 4 30 day mortalities [hepatic insufficiency:/sepsis (n=3), thrombosis of the reconstructed portal vein (n=1)]. Among the patients with R0 resections, the cumulative survival rates at 1, 3, and 5 year; was 83, 58, 41%, respectively, and in those with R1 resections were 71, 24, 24%, respectively, (P=0.021). Overall survival was shorter in patients with positive perineural invasion (P=0.066: NS). There was no significant difference in survival between the node positive and negative group. Median survival of patients who underwent liver resection was longer than those with bile duct resection only (30 vs 24 months P=0.43: NS). CONCLUSIONS: ERCP was associated with a high failure rate in achieving pre-operative biliary decompression which was subsequently achieved by PTC. Clear histological margins were associated with improved survival and were better achieved by liver resection as compared to extra hepatic bile duct resection. Positive level I lymph nodes did not adversely impact survival.     

Early results after radiofrequency-assisted liver resection

AIMS AND BACKGROUND: Intraoperative blood loss during liver resection remains a major concern due to its association with higher postoperative complications and shorter long-term survival. The aim of this study was to assess the feasibility and safety of a novel concept for liver resection using a radiofrequency energy-assisted technique. METHODS: From January 2001 to July 2002, 42 patients were operated on using radiofrequency energy-assisted liver resection. Radiofrequency energy was applied along the resection edge to create a 'zone of desiccation' prior to resection with a scalpel. RESULTS: Median resection time was 50 mins (range, 30-110). The median blood loss during resection was 30 mL (range, 15-992). Mean preoperative and postoperative hemoglobin values were 13.7 g/dL (SD +/- 1.6) and 11.8 g/dL (SD +/- 1.4), respectively. No blood transfusion was registered, nor was any mortality observed. There were 3 postoperative complications, one subphrenic abscess, one chest infection and one biliary leak from a hepatico-jejunostomy. Median postoperative stay was 8 days (range, 5-86). CONCLUSIONS: Liver resection assisted by radiofrequency energy is feasible, easy and safe. This novel technique offers a new method for 'transfusion-free' resection without the need for sutures, ties, staples, tissue glue or admission to an intensive care unit.     

The renal sequelae of a novel triphasic approach to blood loss reduction during hepatic resection.

AIMS: To report our novel triphasic approach to minimising blood loss during hepatic resection and the renal sequelae. METHODS: Fifty consecutive patients (median age 63.3 years, range 37-86) underwent hepatic resection. Triphasic approach consisted of: pre-operative bowel preparation with no supplementary fluids; intraoperative intravenous fluid restriction with low central venous pressure (<5 cmH2O) and continuous selective occlusion of the left or right portal structures and corresponding hepatic vein/s. The following variables were analysed: blood loss; transfusion requirements; perioperative renal function; perioperative morbidity and mortality. RESULTS: Median estimated blood loss was 330 mL (range 50-1200). No patient was transfused intraoperatively, with two patients transfused post-operatively. Median intraoperative urine output prior to hepatic re-perfusion was 28.4 mL/h (range 13.3-40.0) with no patient developing renal impairment. Morbidity occurred in 22% of patients with no documented hepatic failure. There was zero 30-day mortality. CONCLUSIONS: Pre-operative dehydration and intraoperative fluid restriction combined with continuous selective vascular occlusion minimizes blood loss during hepatic resection with no consequent detriment to renal function.     

Liver resections in over‐75‐year‐old patients: Surgical hazard or current practice?

OBJECTIVES: To assess the safety of hepatic resections in the very old patient by comparing the outcome in patients younger and older than 75 years. METHODS: Thirty-two resections in 31 patients > or =75 years (Over-75 Group) were compared with 164 resections in 162 patients <75 years (Control Group). Indications for resection, concomitant diseases, previous abdominal surgery, type of resection, associated surgical procedures, use/length of portal clamping, intra-operative blood losses and transfusions, and length of operation were preliminarily compared. The outcome was evaluated in terms of post-operative mortality, morbidity, transfusions, and postoperative hospitalization. RESULTS: Mean age was 76.0 +/- 2.3 years (range 75-83) in the Over-75 Group and 58.4 +/- 10.7 years (range 23-74) in the Control Group. The over-75 group included more hepatomas (43.8% vs. 26.8%, P = 0.09), chronic liver disease (31.3% vs. 28.7%, P = 0.03) and concomitant diseases (62.5% vs. 32.9%, P = 0.002). The two groups were comparable (P = n.s.) when evaluated for all other variables. The 30-day mortality rate was 3.6% in the Control Group and none in the Over-75 Group. Postoperative surgical complications occurred in 37 patients (22.6%) in the Control Group and 1 patient (3.1%) in the Over-75 Group, with statistically significant differences (P = 0.01), and incidence of medical complications was 13.4% in the Control Group and 3.1% in the Over-75 Group. Median postoperative hospitalization and transfusions were not statistically different. CONCLUSIONS: Hepatic resections in over-75-year-old patients are not a surgical hazard and may be carried out relatively safely as long as an accurate selection of the patient is performed.     

Impact of pedicle clamping in pediatric liver resection

BACKGROUND: Vascular clamping techniques are commonly used but so far the impact on pediatric liver surgery has not been investigated. The purpose of this study was to analyze pedicle clamping during pediatric liver resection in terms of hepato-cellular injury and blood loss. METHODS: Sixty-seven children undergoing liver resection were analyzed retrospectively. Vascular clamping was used in 28 cases (PC group), in 39 the resection was performed without clamping (NPC group). Major hepatectomies (resection of more than three segments) were carried out in 88%, minor hepatectomies (resection of three and less segments) in 12% of patients. Twenty-six children underwent extended liver resection. Patient data, liver function tests (LFTs) and blood loss were analyzed statistically. RESULTS: There were no significant differences in patient preoperative and postoperative data and LFTs between the groups. Within the NPC group the amount of administered fresh frozen plasma (FFP) in total and per kilogram (FFP/kg) was significantly higher (p=0.023 and 0.028) than in the PC group. For patients with extended liver resection, operation times were significantly longer (p=0.016) in the group without vascular clamping (NPCext). In the NPCext group significantly more children required packed red cells, FFP and FFP/kg. LFTs showed no significant differences in all children regardless of vascular clamping. CONCLUSIONS: For children undergoing liver resection, vascular clamping offers a blood saving surgical technique. Postoperative LFTs were not statistically different, regardless of vascular clamping. Pedicle clamping proved to be a safe method, not associated with an increase in perioperative complications.     

The extent of resection influences outcome following hepatectomy for colorectal liver metastases.

BACKGROUND: The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. METHODS: All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. RESULTS: One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group(p = 0.012). There was a significant difference between the groups in terms of median operating time (p < 0.0001, Kruskal-Wallis test), operative blood loss (p = 0.006, Kruskal-Wallis test) and post-operative stay ( p = 0.036, Kruskal-Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection (p = 0.050. Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p = 0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival (p = 0.662, Pearson chi-square test). CONCLUSION: Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.     

Liver resection using bipolar InLine multichannel radiofrequency device: Impact on intra- and peri-operative outcomes

Aims

Liver resection is indicated for several primary and secondary liver lesions. We follow up our earlier experience with the use of InLine Multichannel Radiofrequency Device (ILMRD, Resect Medical Inc., Fremont, CA) a device that produces coagulative necrosis along the transection plane.

Methods

The records of 68 consecutive patients who underwent liver resection for primary and metastatic liver tumors from August 2000 to December 2008 were reviewed. Data analyzed include demographic data as well as complexity of liver resection, intra-operative blood loss, use of portal triad clamping and transfusion of blood. Postoperative outcomes measured were morbidity, hospital and ICU length of stay.

Results

The median estimated blood loss was 150 mL in the ILMRD group compared to 400 mL in the non-ILMRD group (p < 0.0001). Median length of stay was decreased in the ILMRD group by a day (7 vs. 8 p < 0.003). There was a significant decrease in frequency of parenchymal clamp time (57% vs 84%, p < 0.001) and median total portal triad clamp time (2.5 vs 30 min p < 0.0001). We also noted a significant decrease in the median portal triad clamp time (0 vs 25 min, p < 0.001) used during the parenchymal transection phase. Furthermore, use of the ILMRD device allowed us to perform more complex hepatic resections.

Conclusion

Use of ILMRD to perform radiofrequency-assisted hepatic resection was associated with a significant decrease in intra-operative blood loss and earlier discharge from the hospital despite increasing complexity of resections and decreased use of portal triad clamping.     

Multimodal treatment of malignant sacrococcygeal germ cell tumors: a prospective analysis of 66 patients of the German cooperative protocols MAKEI 83/86 and 89.

PURPOSE: To evaluate a multimodal approach including surgery and cisplatinum chemotherapy for treatment of children with malignant sacrococcygeal germ cell tumors (GCT) and to compare adjuvant and neoadjuvant strategies in advanced tumors. PATIENTS AND METHODS: Between 1983 and 1995, 71 patients with malignant sacrococcygeal GCT were prospectively enrolled onto the German protocols for nontesticular GCT Maligne Keimzelltumoren 83/86 and 89. Five patients who received no chemotherapy (n = 2) or nonplatinum chemotherapy (n = 2) or who did not undergo tumor resection (n = 1) were excluded from this analysis. Among the 66 patients analyzed were 14 boys and 52 girls. The median age was 17.4 months (range, 7 months to 119 months). Median follow-up was 79 months (range, 4 months to 145 months). RESULTS: Fifty-two patients presented with locally advanced stage T2 tumors, and 30 patients had distant metastases at diagnosis. Patients received a median of eight cycles (range, four to nine cycles) of cisplatinum-based chemotherapy. Thirty-five patients underwent tumor resection at diagnosis and received adjuvant cisplatinum-based chemotherapy (group A). Thirty-one patients received up-front chemotherapy followed by delayed tumor resection (group B). Group B included more metastatic tumors than group A (group B, 19 of 31 patients; group A, 11 of 35 patients, P =.01). Preoperative chemotherapy facilitated complete tumor resections (group B, 20 of 31 patients; group A, five of 35 patients, P <.001) and avoided second-look surgery. Metastases at diagnosis and completeness of the first attempt of tumor resection were significant prognostic predictors; however, metastases were not predictive for patients treated with up-front chemotherapy. At 5 years follow-up, event-free survival was 0.76 +/- 0.05 (50 of 66 patients), and overall survival was 0.81 +/- 0.05 (54 of 66 patients). Four patients died as a result of therapy-related complications, and eight patients died of their tumors. Patients with locally advanced and metastatic tumors (T2b M1) fared better with neoadjuvant treatment [overall survival: 0.83 +/- 0.09 (16 of 19 patients) versus 0.45 +/- 0.15 (five of 11 patients), P =.01]. CONCLUSION: Even locally advanced and metastatic sacrococcygeal GCT can be successfully treated with up-front cisplatinum-based chemotherapy followed by delayed but complete tumor resection.     

Survival with dacarbazine and fotemustine in newly diagnosed glioblastoma multiforme

A total of 55 patients with histologically proven glioblastoma multiforme (total gross resection: n=24, subtotal resection: n=20, stereotactic biopsy: n=11) were treated with the combination of dacarbazine (D) (200 mg m(-2)) and fotemustine (F) (100 mg m(-2)) and concomitant radiotherapy (2 Gy day(-1), 5 days per week using limited fields up to 60 Gy) to assess efficacy and toxicity of this regimen. Survival (median survival, 12-, 18- and 24-month survival rates) and time to progression (median time to progression (TTP), 6-month progression-free survival) were analysed by Kaplan-Meier's method. A total of 268 (range 1-8, median: 5) cycles were administered. Median survival is 14.5+ (range: 0.5-40+) months, and the 12-, 18- and 24-month survival rates are 58, 29 and 23%, respectively. Median TTP from the start of D/F therapy is 9.5+ (range: 0.5-33+) months. The 6-month progression-free survival is 54%. Partial remissions were observed in 3.6%. Main toxicity was thrombocytopenia. Five patients were excluded from further D/F application, four patients because of prolonged thrombocytopenia NCI-CTC grades 3 and 4 and one patient because of whole body erythrodermia. One patient died because of septic fever during thrombocytopenia and leukopenia NCI-CTC grade 4 after the first cycle. No other toxicities of NCI-CTC grade 3 or 4 occurred. The treatment is feasible in a complete outpatient setting and the results of the D/F regimen justify further investigations with these compounds.     

Use of transportal balloon catheter occlusion of the portal triad in prevention of bleeding during liver resection

BACKGROUND: Operative blood loss is among the most important factors determining the prognosis of patients undergoing hepatic resection. The best method for preventing bleeding is preliminary selective vascular occlusion of lobar, sectoral, or segmental portal triads, although not always technically feasible. METHOD: Transportal occlusion of the portal triad with a balloon catheter was used in 35 hepatectomies for various tumors. RESULTS: In 27 out of 35 resections, there was absence or minimal bleeding from afferent vessels (portal vein, hepatic artery). In the remaining eight cases, there was significant bleeding from the hepatic artery. In these cases, transportal occlusion of portal triad was combined with a temporary interruption of the hepatic artery after the dissection of the hepatoduodenal ligament. The average intraoperative blood loss was 350-1,500 ml. CONCLUSION: The use of a balloon catheter occlusion of the portal triad during liver resection is often technically feasible. It facilitates temporary occlusion of hardly accessible portal veins in the hepatic hilus without their prior exposure and minimizes bleeding.