The detection and management of complications following the treatment of liver metastases

Whilst once considered as incurable systemic disease, treatment options for liver metastases have increased over the last 30 years and safety has improved dramatically, such that for a selected group of patients the hope of cure can now be offered with radical treatment and low morbidity interventions can be offered which prolong survival, even in patients with more widely disseminated disease. Advances have been made in selection and surgical technique for liver resection and several adjuncts to resection now exist in the form of portal vein embolization, thermal ablation and targeted drug or radiotherapy delivery options. A natural consequence of these developments has been the delivery of services within fewer specialist units, with the result that later complications of therapy may present to local hospitals, rather than directly to the specialist centres. This article will describe the current common liver directed therapies and outline the presentation and management of their complications.     

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

Aim The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection. Method A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained. Results Four hundred and twenty‐four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection. Conclusion Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.     

外科治疗转移性肝癌值得关注的若干问题

转移性肝癌在当今已不再被认为是毫无治疗希望的晚期癌症,其中部分病人可行肝切除术或辅助性综合治疗并能获得满意的治疗效果及5年存活率。为此,需要医生改变观念并与病人沟通为之共同努力,需要多学科合作采取最佳方案及组合。无论何种办法,如能手术切除才是最佳选择,选择手术时要权衡手术的安全性及有效性,否则会事与愿违。     

Oncologic aspects of the decision-making process for surgical approach for colorectal liver metastases progressing during chemotherapy

Colorectal cancer represents the third most diagnosed malignancy in the world. The liver is the main site of metastatic disease, affected in 30% of patients with newly diagnosed disease. Complete resection is considered the only potentially curative treatment for colorectal liver metastasis (CRLM), with a 5-year survival rate ranging from 35% to 58%. However, up to 80% of patients have initially unresectable disease, due to extrahepatic disease or bilobar multiple liver nodules. The availability of increasingly effective systemic chemotherapy has contributed to converting patients with initially unresectable liver metastases to resectable disease, improving long-term outcomes, and accessing tumor biology. In recent years, response to preoperative systemic chemotherapy before liver resection has been established as a major prognostic factor. Some studies have demonstrated that patients with regression of hepatic metastases while on chemotherapy have improved outcomes when compared to patients with stabilization or progression of the disease. Even if disease progression during chemotherapy represents an independent negative prognostic factor, some patients may still benefit from surgery, given the role of this modality as the main treatment with curative intent for patients with CRLM. In selected cases, based on size, the number of lesions, and tumor markers, surgery may be offered despite the less favorable prognosis and as an option for non-chemo responders.     

Associating liver partition and portal vein ligation for staged hepatectomy for extensive alveolar echinococcosis:First case report in the literature

Alveolar echinococcosis(AE) is a zoonotic disease that is caused by Echinococcus multilocularis that affects liver and a variety of organs and tissues. It differs from other echinococcal disease because it shows tumor like behavior in the affected organ and tissues. The treatment of choice is concomitant medical therapy and resection with negative margins. Nevertheless, resection with the intent of negative margins(R0) may lead to serious complications such as liver failure. In the present case report, we used Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy(ALPPS) procedure, which was defined in 2012 by Schnitzbauer et al, in a 28-year-old male patient to avoid complications of major liver resection in order to treat alveolar echinococcosis. Until now, we have not encountered any study using ALPPS procedure for the treatment of alveolar echinococcosis. In the present case report we aimed to show that ALPPS procedure can be safely performed for marginnegative resection of primary or recurrent AE that shows a tumor like behavior. It is our opinion that this procedure should be performed in centers that have expertise and sufficient technical capacity to perform liver transplantation and advanced liver surgery.     

原发性肝癌切除术后复发的肝移植治疗

目的总结原发性肝癌切除术后复发行肝移植治疗的经验。方法2002年8月至2004年11月上海交通大学医学院附属瑞金医院对4例肝癌切除术后复发病例（其中1例合并急性肝功能衰竭）行同种异体肝移植治疗。结果3例移植术后已分别无瘤存活17个月、12个月和27个月至今。1例术后第3天死于多器官功能衰竭。结论对原发性肝癌切除术后复发病例的肝移植治疗，小肝癌切除后复发肿瘤仍符合Milan标准者有着良好的预后；个别合并门静脉癌栓者预后较好；合并急性肝功能衰竭者应相当谨慎。     

Electrolytic ablation as an adjunct to liver resection: Safety and efficacy in patients

Background: Electrolytic ablation is a relatively new method for the local destruction of colorectal liver metastases. Experimental work in animal models has shown this method to be safe and efficacious. However, before proceeding to clinical trials it was necessary to confirm these findings in a pilot study of five patients. Methods: Five patients with colorectal liver metastases were studied prospectively. Each patient underwent a potentially curative liver resection. One of the metastases to be removed was treated using electrolysis before resection. Each patient was monitored closely during and after electrolysis to determine any morbidity associated with the treatment. Once resected, the metastases were examined histologically for completeness of ablation. Results: All patients tolerated the electrolysis well; there were no deaths or complications related to the treatment. Histological examination of the resected metastases which had been treated electrolytically showed complete tissue destruction with no viable malignant cells remaining at the site of treatment. Discussion: This pilot study of electrolytic ablation of liver metastases in five patients showed the treatment to be well tolerated and safe. Additionally, it demonstrated total destruction of the malignant tissue at the site of electrolysis. Based on these encouraging results, clinical trials can now begin.     

Malignant liver tumours

Malignant liver tumours can be primary or secondary. The most common primary malignant liver tumours are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC), while the colorectal and neuroendocrine liver metastases account for the majority of secondary tumours.HCC tends to arise in patients with cirrhosis secondary to hepatitis or alcohol. Diagnosis is usually made on a raised α-fetoprotein and CT and MRI. Treatment options include hepatic resection, transplantation, percutaneous ablation and transarterial chemo-embolization. Treatment is dependent on the Child’s status of the patient, extent of liver disease and the presence of metastatic disease.IHC accounts for 10% of cholangiocarcinomas. Risk factors include primary sclerosing cholangitis and choledochal cysts. Liver resection offers the only chance for cure in these patients.Secondary liver tumours account for 95% of hepatic malignancies, the most common being colorectal liver metastases (CRLM). CRLM are detected during surveillance following surgery for the primary tumour. Liver resection is potentially curative, and more patients are being subjected to liver resection following down-staging of the disease with neoadjuvant chemotherapy.Surgery offers a potential cure for liver tumours. Recent medical advances have made treatment of malignant liver tumours safer and potentially curative.     

Liver transplantation for primary and metastatic liver cancers

Liver transplantation for hepatic malignancies has emerged as a well‐documented and proven treatment modality. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, 15% of all liver transplants performed are for hepatocellular carcinoma (HCC). There is no controversy about the fact that liver transplantation for HCC in the adult population yields good results for patients whose tumour masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumours can be reliably selected to benefit from the procedure. In patients with small HCC at an early stage and preserved liver function, liver resection provides an alternative to transplant. Liver resection may offer similar survival results to orthotopic liver transplantation (OLT) in the short term, and does not carry the long‐term effects of immunosuppression; however, long‐term and disease‐free survival favours liver transplantation. Very promising results have been obtained for cholangiocarcinoma treated by aggressive combination therapies, including chemo‐ and radiotherapy followed by OLT. Survival rate in these selected patients can approach that of patients with cholestatic liver disease, and the role of transplantation now requires re‐evaluation. Similarly, hepatoblastoma is an excellent indication in paediatric patients with unresectable or recurrent tumours. Epithelioid hemangioendothelioma is also an appropriate indication for liver transplantation, even in the presence of extrahepatic metastases, unlike angiosarcoma which is associated with a very poor survival and considered as a contraindication. And finally for metastatic liver disease from neuroendocrine tumours, liver transplantation can result in long‐term survival and even cure in well selected patients. Conversely, the value of transplantation for colorectal liver metastases (currently a contraindication) requires further evaluation by well‐designed trials.     

Quelle stratégie thérapeutique devant un cancer du rectum avec métastases hépatiques synchrones ?

Rectal cancer with synchronous liver metastases includes a wide variety of clinical presentations. In patients with rectal cancer and synchronous liver metastases, treatment strategy depends on the site and the extent of rectal cancer, the extent of liver metastases and the presence of extra-hepatic disease. In the majority of patients, liver metastases are unresectable and in this setting, the primary goal of treatment strategy is to prolong survival and to preserve quality of life. Most of these patients are treated with systemic chemotherapy and local treatment including radiotherapy or surgical resection is indicated in patients presenting with symptoms or complications related to the primary tumor. In patients with resectable liver metastases, a curative approach to the disease including resection of rectal cancer and liver metastases should be proposed. In this setting, a large number of treatment options can be discussed especially regarding the use of preoperative treatments (radiotherapy, radiochemotherapy or chemotherapy) and the design of surgical strategy (simultaneous resection of rectal cancer and liver metastases or staged resection). Treatment strategy should aim at conciliating optimal treatment for all tumor sites. Accurate pretreatment workup contributes to identify the most advanced tumor site that should be treated first without compromising optimal treatment of the other site. None standard treatment approach can be define for all patients presenting with rectal cancer and synchronous liver metastases because this entity includes a wide variety of clinical presentation and a large number of treatment options are available. Treatment strategy should be discussed during multidisciplinary meeting at diagnosis.     

Bile duct complications after liver transplantation

Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.     

Cryoablation, Percutaneous Alcohol Injection, and Radiofrequency Ablation for Treatment of Neuroendocrine Liver Metastases

Neuroendocrine liver metastases are associated with slow clinical progression, prolonged patient survival, and symptoms of hormone oversecretion. Although surgical resection is the gold standard of treatment, most of the patients are not candidates for resection, and the 5-year survival of patients with neuroendocrine liver metastases is 11% to 40%. Cryotherapy, percutaneous alcohol injection, and radiofrequency thermal ablation are among the alternative regional treatment options available for these patients. The current role of these treatment options for neuroendocrine liver tumors are discussed in this review. Cryosurgery is the classic technique for local tumor destruction, mostly performed with open surgery. There has been limited experience with percutaneous alcohol injection for neuroendocrine liver metastasis. Radiofrequency thermal ablation is a relatively new modality that can be performed percutaneously or laparoscopically, and encouraging results have been obtained with it for treatment of neuroendocrine liver metastases.     

Clinical Implications of Advances in the Basic Science of Liver Repair and Regeneration

Recent advances in our understanding of the basic mechanisms that control liver regeneration and repair will produce the next generation of therapies for human liver disease. Insights gained from large-scale genetic analysis are producing a new framework within which to plan interventions. Identification of specific molecules that drive regeneration will increase the options for live-donor liver transplantation, and help treat patients with small-for-size syndrome or large tumors who would otherwise have inadequate residual mass after resection. In a complementary fashion, breakthroughs in the ability to manipulate various cell types to adopt the hepatocyte or cholangiocyte phenotype promise to revolutionize therapy for acute liver failure and metabolic liver disease. Finally, elucidating the complex interactions of liver cells with each other and various matrix components during the response to injury is essential for fabricating a liver replacement device. This focused review will discuss how a variety of important scientific advances are likely to impact the treatment of specific types of liver disease.     

肝内胆管癌多学科综合治疗优化选择

肝内胆管癌（ICC）作为第二常见的肝脏恶性肿瘤，虽然R0根治性切除是首选的可治愈方法，但ICC诊断时仅12%～40%病人可获得手术根治的机会，手术后5年存活率也仅为25%～40%。通过辅助化疗和区域治疗降期后可使部分晚期ICC病人获得行根治性手术或肝移植的机会。靶向药物和免疫治疗作为有益的补充，对于有基因突变作用靶点的选择性病人可能会延长生存期。以肝胆外科为主，包含影像科、病理科、肿瘤化疗科、放疗科和介入科的多学科诊疗团队，通过多学科讨论模式，结合病人具体病情，采取个体化、综合化的治疗手段，才能使ICC病人获得最优化的治疗选择。     

Management of liver trauma with implications for the rural surgeon

Background: The majority of patients with liver trauma can be managed conservatively. However, the unstable patient requires emergency laparotomy to control bleeding. Controversy exists regarding the primary surgical management of these injuries. This is of particular relevance for the isolated rural general surgeon. Methods: The literature was reviewed by searching MEDLINE databases from 1966 to the present time. The majority of the evidence presented is level 3, with interpretations and recommendations based on the experience of the senior authors. Results: In the majority of patients, conservative management remains the mainstay of treatment. However, haemodynamic ­instability requires urgent laparotomy. Perihepatic packing should be used to arrest bleeding. Primary anatomical resection is rarely indicated, especially in non‐specialist centres. Conclusion: In the remote rural setting, severe liver trauma remains a daunting condition for the general surgeon to manage. Primary surgical treatment should be perihepatic packing, stabilization and urgent transfer; there is no place for primary anatomical resection outside specialist units.     

Management of liver trauma.

BACKGROUND AND METHODS: Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience. RESULTS: Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak. CONCLUSION: Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.     

Hepatocellular cancer: Resection or transplantation

Surgery remains the treatment of choice for hepatocellular carcinoma (HCC). For HCC without underlying cirrhosis resection remains the mainstay treatment option. Prognosis depends on the stage of the tumor. Survival appears to be better for small (less than 5 cm) solitary tumors with negative resection margins and absence of vascular invasion. At present, liver transplantation does not have an established role in the treatment of HCC in a non-cirrhotic liver. Because of the high recurrence rate, it should not be considered for more advanced disease which is not amenable to resection. The surgical approach in cirrhotics depends not only on the stage of the tumor but also on the liver functional reserve. Tumor size, presence of multifocal disease, and vascular invasion determine the risk of HCC recurrence after resection, and the functional stability of the liver determines both resectability and outcome. In societies in which transplantation is not available, small tumors will be treated with liver resection. The outcome in patients with well preserved liver function is relatively good, at least in the medium term. However, recurrent tumor and progressive hepatic decompensation have significant adverse effects on long-term survival. Poor functional reserve may be associated with significant perioperative mortality and lower survival due to progressive liver failure. In our opinion, for small cirrhosis-related HCCs, liver transplantation offers better long-term prospects than resection. Therefore, if liver transplantation is available as an option it should be considered as the treatment of choice, particularly for younger patients with otherwise good life expectancy. Received for publication on June 9, 1997; accepted on July 3, 1997     

Inflammatory pseudotumor of the liver: Report of a case and review of the literature

Only 56 cases of inflammatory pseudotumor of the liver have been reported in the world literature since its first documentation in 1953. We report herein the case of a 68-year-old man incidentally found to have a lesion in the right lobe of the liver which closely resembled a neoplasm on imaging studies. Thus, partial hepatic resection was performed and histological examination of the resected specimen revealed a diagnosis of inflammatory pseudotumor. Surgical resection is the preferred treatment for inflammatory pseudotumor of the liver, especially in patients for whom a definite histologic diagnosis cannot be made preoperatively or by intraoperative frozen sections. In fact, most of the patients reported in the literature recovered uneventfully after local resection without any postoperative complications, as did our patient.     

Liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the commonest malignancies worldwide, and accounts for more than 1 million deaths annually. Identification of tumors early in the course of disease appears to be important for treatment, yet remains difficult to accomplish. Without treatment the prognosis is dismal with a median survival of 6-9 months. Partial hepatic resection is generally accepted as the treatment of choice for HCC with reported survival rates of up to 50% at 5 years. Unfortunately poor underlying liver function as well as tumor number or location preclude traditional hepatic resection in many cases. Total hepatectomy with transplantation (LT) has been advocated such cases, but the results have been variable. LT offers the advantage of radical tumor removal even in patients with multifocal disease or severe cirrhosis. Additionally, LT removes the possibility of metachronous lesions developing in the liver remnant and restores normal liver function. The critical limitation to advocating LT as primary oncotherapy in patients with HCC is the severe shortage of donor livers. Until organ availability improves, transplantation for HCC can only be offered to patients whose survival is predicted to be similar to that in patients transplanted for benign disease. This report reviews the current role and indications for liver transplantation as therapy for hepatocellular carcinoma.     

The principles of liver resection

Liver resection is now a well-established and routine treatment for malignant and some benign liver diseases. However, its associated mortality and morbidity should not be underestimated, especially as increasingly complex procedures in patients with increasing degrees of comorbidity are now being undertaken. A number of fundamental principles are important to consider, in terms of patient selection and perioperative care, as well as technical and anatomical tenets that, if adhered to, aid achievement of the best possible clinical outcomes for patients undergoing liver surgery. The introduction of modern technologies such as minimally invasive surgery and other techniques has made sound understanding of such principles all the more vital. This article will discuss many of these key underlying principles, illustrated with relevant surgical anatomy and how they pertain to modern techniques in liver resection.