Occlusion of hepatic blood inflow for complex central liver resections in cirrhotic patients: a randomized comparison of hemihepatic and total hepatic occlusion techniques

BACKGROUND: Intermittent occlusion of hepatic blood inflow by means of a hemihepatic or total hepatic occlusion technique is essential for reducing operative blood loss. Central liver resection to preserve more functioning liver parenchyma is mandatory for centrally located liver tumors in patients with cirrhosis, but it requires a longer overall hepatic ischemic time because of a wide transection plane. No controlled comparison has been performed for the 2 techniques in these operations. HYPOTHESIS: Hemihepatic inflow occlusion may be beneficial in cirrhotic patients who undergo complex central hepatectomy with a wide liver transection plane. DESIGN: A prospective, randomized study. SETTING: University hospital and tertiary referral center. PATIENTS: During liver parenchymal transection, 58 cirrhotic patients who underwent complex central liver resections with a wide transection plane were prospectively randomized into 2 groups. In the group undergoing total hepatic inflow clamping (group T; n = 28), occlusion of hepatic blood inflow was performed for 15 minutes with declamping for 5 minutes. In the group undergoing selective clamping of ipsilateral blood inflow (group H; n = 30), clamping was performed for 30 minutes with declamping for 5 minutes. INTERVENTION: Comparison of patient backgrounds, operative procedures, and early postoperative results. MAIN OUTCOME MEASURES: Operative blood loss, need for blood transfusion, and postoperative morbidity. RESULTS: The patients' backgrounds, operative procedures, and area of liver transection plane were not significantly different between the 2 groups. In all patients, the liver transection areas were greater than 60 cm(2) and overall liver ischemic times were greater than 60 minutes. The amount of operative blood loss and incidence of blood transfusion were significantly greater in group T because of greater blood loss during declamping. Overall liver ischemic and total operative times, postoperative morbidity, and postoperative changes in liver enzyme levels were not significantly different between groups. No in-hospital deaths occurred in either group. CONCLUSIONS: Intermittent hemihepatic and total occlusion of hepatic blood inflow are safe in cirrhotic patients with an overall ischemic time of greater than 60 minutes. However, for complex liver resections with an estimated liver transection plane of greater than 60 cm(2), hemihepatic occlusion of blood inflow, if feasible, may be recommended in cirrhotic patients to reduce operative blood loss and the incidence of blood transfusion under our defined occlusion time.     

Trends in morbidity and mortality of hepatic resection for malignancy. A matched comparative analysis.

OBJECTIVE: The authors define more clearly the trends in morbidity and mortality after hepatic resection for malignant disease in matched patient groups during two discrete time periods. SUMMARY BACKGROUND DATA: Recent reports have shown improvement in operative morbidity and mortality associated with hepatic resection; however, results often included resections for benign disease and trauma. Furthermore, specific factors contributing to the improvement in operative risks between the last two decades have not been defined. METHODS: A retrospective matched comparative analysis was conducted of patients with primary and metastatic hepatic malignancy resected with curative intent between two periods (1976 to 1980 and 1986 to 1990). Eighty-one patients met our inclusion criteria in the early period; this group was matched with 81 patients from the latter period by the following four parameters: age, gender, type of malignant disease, and extent of resection. Records of these two patient groups were abstracted for clinical presentation, co-morbid factors, operative techniques, and perioperative morbidity and mortality. RESULTS: The authors found a significant decrease in operative morbidity, median perioperative transfusion, and length of hospital stay in the latter period (1986 to 1990). The incidence of postoperative subphrenic abscess and intra-abdominal hemorrhage was significantly lower during this period. Operative mortality rate was similar for both periods, 4.9% and 1.2%, respectively (p > 0.05). CONCLUSION: Hepatic resection for malignant disease currently can be performed with a low morbidity and mortality in the hands of trained and experienced hepatic surgeons; operative risks of hepatic resection should not deter its application in the treatment of primary and metastatic malignant disease of the liver.     

Perioperative parenteral tranexamic acid in liver tumor resection: a prospective randomized trial toward a "blood transfusion"-free hepatectomy

OBJECTIVE: To examine the feasibility of a real "blood transfusion"-free hepatectomy in a large group of patients with liver tumors. SUMMARY BACKGROUND DATA: Bleeding control and blood transfusion remains problematic in liver resection. A real "blood transfusion"-free hepatectomy in a large group of patients has rarely been reported. The impact of tranexamic acid (TA), an antifibrinolytic agent, on blood transfusion in liver resection is unknown. METHODS: A prospective double-blind randomized trial was performed on elective liver tumor resections. In group A, TA 500 mg was intravenously administered just before operation followed by 250 mg, every 6 hours, for 3 days. In group B, only placebo was given. The patients' background, blood transfusion rates, and early postoperative results in the 2 groups were compared. Factors that influenced blood requirement were analyzed. RESULTS: There were 108 hepatectomies in group A and 106 hepatectomies in group B. The patients' backgrounds, operative procedures, and hepatectomy extent did not significantly differ between the 2 groups. Although the differences of the operative morbidity and postoperative stay were not significant, a significantly lower amount of operative blood loss, lower blood transfusion rate, shorter operative time, and lower hospital costs were found in group A patients. No patient in group A received blood transfusion. No hospital mortality occurred in either group. Tumor size and use of TA were independent factors that influenced blood transfusion. CONCLUSIONS: Perioperative parenteral use of TA reduced the amount of operative blood loss and the need for blood transfusion in elective liver tumor resection. A real "blood transfusion"-free hepatectomy may be feasible with the assistance of parenteral TA.     

Bloodless liver resection using radiofrequency energy

BACKGROUND: Liver surgery carries the risk of intraoperative bleeding. In order to avoid bleeding, transection of the liver can be performed after coagulating the parenchyma by using monoplolar or bipolar radiofrequency energy. METHODS: 236 consecutive patients underwent liver resection with the radiofrequency-assisted technique using either a monopolar or a bipolar device. Data were collected prospectively to assess the outcome including, intraoperative blood loss, blood transfusion requirement, morbidity and mortality rates. RESULTS: There were 41 major hepatectomies and 195 minor resections. Overall mean intraoperative blood loss was 157 +/- 240 ml, while mean blood loss during liver transection was 90 +/- 105 ml. 10 patients (4%) received blood transfusion. 50 patients (21%) developed postoperative complications including 5 bile leaks (2%). The mortality rate was 2.1%. No patient was reoperated for postoperative haemorrhage or bile leak. The mean postoperative stay was 11 +/- 10 days. CONCLUSION: The radiofrequency-assisted liver resection technique offers hepatobiliary surgeons an additional method for performing liver resections with minimal blood loss, low transfusion requirement, and low morbidity and mortality rates.     

Perioperative predictors of morbidity following hepatic resection for neoplasm. A multivariate analysis of a single surgeon experience with 105 patients.

OBJECTIVE: Factors that predict mortality or morbidity risk in consecutive hepatic resections for neoplasm were examined, with controlled variables of surgical technique and experience. SUMMARY BACKGROUND DATA: Hepatic resection has become the therapy of choice for the management of metastatic or primary neoplasms of the liver. Although mortality for this procedure has steadily decreased, associated morbidity remains high. METHODS: One hundred five patients undergoing hepatic resection for malignancy over a 4-year period by a single surgeon to identify preoperative, intraoperative, or postoperative predictors of morbid outcomes were studied. Variables were analyzed using multiple regression in a stepwise, logistic model. RESULTS: Sixty-day hospital mortality was 2.8%, with morbidity occurring in 33%. A significant preoperative predictor of morbidity was serum bilirubin (p > 0.005). Notably, preoperative renal function, or medical illness, did not increase morbid risk. Operative variables increasing risk included extent of resection, blood loss, and operative time (p > 0.005). CONCLUSIONS: Complex hepatic resection can be performed with low mortality, and serum bilirubin is the single most powerful predictor of postoperative complication.     

Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements

BACKGROUND: Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series. METHODS: Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates. RESULTS: There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days. CONCLUSION: The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.     

A prospective evaluation of ultrasonic dissector plus harmonic scalpel in liver resection

Several techniques have been described for safe dissection of the liver parenchyma. The aim of this study was to evaluate the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector and the harmonic scalpel, during hepatic resection. One hundred consecutive patients who underwent liver resection between January and December 2004 were enclosed in the study. Patients requiring concomitant colic resection or biliary-enteric anastomosis were excluded from the study. Operative variables (type of procedure, operating time, Pringle time, blood losses, transfusions, and histological tumor exposure at the transection surface), hospital stay, and complications were recorded. The extent of hepatic resection was a minor resection in 31 and major in 69 cases. Median blood loss was 500 mL (range, 100-2000 mL) and the Pringle maneuver was used in 58 patients. Median operative time was 367 minutes (range, 150-660 minutes). Hepatic resection was performed in 32 cirrhotic livers. Surgical complications included one postoperative hemorrhage and two bile leaks. The overall morbidity and mortality rate was 14 and 1 per cent, respectively. In conclusion, the combined use of these electronic devices allows liver resection to be safely performed, even in cirrhotic patients, with the advantage of reducing surgical complications. A prospective randomized trial is needed to clarify the clinical benefits of liver resections performed combining these two devices.     

One thousand fifty-six hepatectomies without mortality in 8 years

BACKGROUND: Despite improvements in diagnostic and surgical techniques, operative mortality associated with liver resection is still greater than 2% in most of the recent studies. HYPOTHESIS: By refining preoperative and postoperative care and surgical skills, liver resection mortality can be decreased to zero. DESIGN: Retrospective cohort study to analyze postoperative morbidity and mortality in 1056 consecutive hepatectomies performed at a single medical center during 8 years. SETTING: Tertiary referral center. PATIENTS: A total of 915 patients who underwent 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign diseases. MAIN OUTCOME MEASURES: Operative mortality and morbidity rates. RESULTS: No operative mortality occurred. Major complications, as defined by postoperative radiologic or surgical intervention, occurred in 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary malignancy, and 5% of living donor liver transplantation donors. Using multiple logistic regression, independent risk factors associated with major complications were operative blood loss of 1000 mL or greater for hepatocellular carcinoma and total bilirubin level of 1.0 mg/dL or greater (>or=17 micro mol/L) and operative time greater than 6 hours for other liver malignancy. No independent factors associated with major complications were identified for biliary malignancy or for living donor liver transplantation donors among the variables investigated in this study. CONCLUSIONS: Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.     

Radiofrequency-Assisted Liver Resection in Patients With Hepatocellular Carcinoma and Cirrhosis: Preliminary Results

Radiofrequency (RF)-assisted liver resection has been shown to allow virtually bloodless procedures without the need for vascular exclusion maneuvers. The aim of this study was to evaluate the safety and feasibility of RF-assisted liver resection in cirrhotic patients with hepatocellular carcinoma (HCC) and, moreover, to assess whether the RF-assisted procedure influenced the outcomes in terms of morbidity and mortality. This retrospective study included 39 cirrhotic patients who underwent RF-assisted liver resection for HCC between September 2001 and March 2006. In this period, we performed 17 monosegmentectomies, 16 bisegmentectomies, 4 trisegmentectomies, and 2 right hepatectomies. We never performed vascular exclusion maneuvers. Blood transfusion was necessary in 3 cases. One patient died postoperatively because of untreatable hepatorenal syndrome. The morbidity rate was 23%. Among patients without postoperative morbidity (n = 30), the 4-year survival rate was 61% versus 23% in patients who experienced postoperative morbidity (n = 9; P < .05). The 4-year disease-free survival rate was 40% in patients without postoperative morbidity versus 10% in patients who experienced postoperative morbidity (P = .05). Tumor dimension, number of lesions, and Child-Pugh class at surgery did not seem to significantly influence the 4-year overall survival (P > .05). In conclusion, RF-assisted liver resection was a safe, feasible procedure associated with low morbidity and hospital mortality rates even in cases of liver cirrhosis. It is, in our opinion, highly recommended for patients with HCC not suitable for liver transplantation.     

Novel in-line multielectrode radiofrequency ablation considerably reduces blood loss during liver resection in an animal model

INTRODUCTION: Liver resection is widely used in the treatment of primary and secondary liver tumours. One of several important factors associated with mortality both in cirrhotic and non-cirrhotic patients after liver resection is operative blood loss. We evaluated the use of a prototype radiofrequency ablation probe to treat the transection plane prior to liver resection in the sheep model. METHODS: In-line radiofrequency ablation (RFA) was performed on the liver using a prototype device consisting of 11 electrodes mounted on a 8-cm base. The RITA 1500 generator was used for power delivery. Ultrasonic aspirator (UA) and clamp resection were performed on the liver of sheep with and without in-line RFA. The blood loss was measured by weighing swabs. RESULTS: A total of 26 liver resections were performed. The mean (SD) blood loss with UA resection was 0.032 g (0.011) versus 0.005 (0.005) g without and with prior in-line RFA, respectively (P = 0.001). The mean (SD) blood loss with clamp resection was 0.087 (0.10) g versus 0.01 (0.008) without and with in-line RFA, respectively (P = 0.155). CONCLUSION: In-line RFA makes liver resection easier with minimal blood loss and may make cirrhotic liver resection easier with minimal blood loss. This is likely to improve the operative safety of liver resection.     

Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma--a single center experience

BACKGROUND: Hilar resection, especially in combination with liver resection, results in substantial morbidity and mortality, which clearly influences the overall outcome. In the present study, patients who underwent resection of a proximal bile duct tumor were analyzed with the aim of identifying risk factors for morbidity and mortality. METHODS: Between 1983 and 1998, 112 consecutive patients underwent a local resection, which in 32 patients was combined with a hemihepatectomy (11 extended resections). Eighty-four percent of the patients underwent preoperative (endoscopic) drainage. For evaluation of different treatment strategies during the study, the period was divided in three 5-year intervals. RESULTS: Postoperative complications occurred in 65% of the patients. The overall hospital mortality was 15% for local resections and 25% for hemi-hepatectomies. There was a significantly lower morbidity and no mortality after hilar resection during the last 5 years. A higher Bismuth classification showed significant correlation with postoperative morbidity. Extended liver resections and vascular resections and a preoperative albumin level below 35 g/L were found to be significant predictors of increased mortality in univariate analysis. CONCLUSIONS: The overall morbidity and mortality rate in this series is higher than most recently published series. More (extended) liver resections resulted in an increased rate of microscopic tumor-free resections, at the cost of higher hospital morbidity and mortality. Improved preoperative work-ups will result in a selection of patients who might benefit from these extensive resections.     

Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade

OBJECTIVE: To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome. METHODS: Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed. RESULTS: Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality. CONCLUSIONS: Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.     

Current treatment of hepatocellular carcinoma. Analysis of a series of 123 cases over a 5-year period

We analyze a 123-cases experience over a 5-year period in the treatment of hepatocellular carcinoma (HCC). Liver resection, transplantation and hyperthermic ablation of the tumor were used according to the indication and patient selection. Systemic chemotherapy followed resection in 18 cases and hyperthermic ablation in 5 cases. Chemo-embolisation was performed in patients to be transplanted and in other two patients with tumor destruction. A number of 86 liver resections were performed in 84 patients (2 re- resections in 1 patient, subsequently transplanted) - 43 on normal liver and 41 on cirrhotic liver. Postoperative mortality was 4.7% in non-cirrhotic and 4.9% in cirrhotic patients. Survival in non-cirrhotic patients was 77% at 1 year, 65% at 2 years, and constant - 45% at 3 and 4 years, whereas in cirrhotic patients it was 60%, 56%, 56% and 36% (Kaplan-Meyer actuarial survival rates). Nine patients underwent liver transplantation (4 OLTs, 3 living donor LT, 1 split LT and 1 "domino" LT); postoperative mortality was 11% (1 patient). At present five patients are alive and well. One patient died by peritoneal carcinomatosis at 10 months; another patient died at 6 months by severe cholestatic recurrent C virus hepatitis and one patient was discharged with permanent severe neurologic disturbances. In 31 patients hyperthermic ablation of the tumor was used with zero mortality. Actuarial survival rates were 75% at one year and 67% at 2 years. In conclusion, in non-cirrhotic patients with HCC resection is the treatment of choice. In cirrhotic patients limited resections should be preferred and liver transplantation is the best solution in selected cases; local ablative methods may be used for some unresectable tumors. The role of adjuvant chemotherapy has to be determined in future comparative studies.     

Liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND: Although liver resection is now a safe procedure, its role for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial. METHODS: This study compared the results of liver resection for HCC in patients with cirrhosis over two time intervals. One hundred and sixty-one patients had resection during period 1 (1991-1996) and 265 in period 2 (1997-2002). Early and long-term results after liver resection in the two periods were compared, and clinicopathological characteristics that influenced survival were identified. RESULTS: Tumour size was smaller, indocyanine green retention rate was higher, patients were older and a greater proportion of patients were asymptomatic in period 2 than period 1. Operative blood loss, need for blood transfusion, operative mortality rate, postoperative hospital stay and total hospital costs were significantly reduced in period 2. The 5-year disease-free survival rates were 28.2 and 33.9 per cent in periods 1 and 2 respectively (P = 0.042), and 5-year overall survival rates were 45.9 and 61.2 per cent (P < 0.001). Multivariate analysis identified serum alpha-fetoprotein level, need for blood transfusion and Union Internacional Contra la Cancrum tumour node metastasis stage as independent determinants of disease-free and overall survival. CONCLUSION: The results of liver resection for HCC in patients with cirrhosis improved over time. Liver resection remains a good treatment option in selected patients with HCC arising from a cirrhotic liver.     

Repeat liver resection for hepatocellular carcinoma

BACKGROUND: Although hepatectomy has been accepted as a therapeutic option for the primary tumor of hepatocellular carcinoma (HCC), what role the second liver resection will play in the clinical care of patients with intrahepatic recurrence of HCC after the initial resection has not been well evaluated. STUDY DESIGN: In a retrospective review of the 6-year period between January 1991 and December 1996, records were examined of 94 patients who underwent curative liver resection for HCC. Of these, 57 patients had isolated recurrent disease to the liver; 12 of the 57 patients underwent repeat surgical resection and 45 patients received nonsurgical ablative therapy. Clinical data for these patients were reviewed for operative morbidity and mortality, survival, disease-free survival, and pattern of failure. RESULTS: There were no perioperative deaths during repeat liver resections for recurrent HCC. Operative morbidity in the second resection was comparable to the initial resection. The disease-free survival rate after the second hepatectomy was 31% at 2 years, significantly lower than that after initial hepatectomy (62%) (p = 0.009). The overall survival rate after the second hepatectomy was 90% at 2 years, in contrast to 70% after nonsurgical ablative treatment for recurrent HCC (p = 0.253). CONCLUSIONS: Although the second liver resection for recurrent HCC can be performed safely and may improve survival, the disease-free survival rate after such resection therapy is low. This likelihood of further recurrences encourages studies for the selection of patients who may benefit from repeat liver resection.     

Laparoscopic liver resections: a feasibility study in 30 patients

OBJECTIVE: To assess the feasibility and safety of laparoscopic liver resections. SUMMARY BACKGROUND DATA: The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. METHODS: A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. RESULTS: From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. CONCLUSION: Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.     

No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach.

BACKGROUND: Low resectability rates and significant morbidity and mortality rates often make surgery for hepatocellular carcinomas (HCCs) unfeasible. HYPOTHESIS: Our policy for surgical treatment of cirrhotic and noncirrhotic patients with HCC is adequate and safe. DESIGN: Prospective validation cohort study. SETTING: University hospital. PATIENTS: One hundred seven consecutive patients with HCCs. Associated cirrhosis was present in 64 (59.8%), and only 7 (6.5%) had normal livers. INTERVENTIONS: The presence of ascites, serum bilirubin level, and indocyanine green retention rate at 15 minutes were considered when selecting patients for surgery. Preoperative recovery of liver function was achieved with portal venous branch embolization, liver volumetry, bed rest, and control of serum aminotransferase levels. The surgical techniques mainly involved bloodless dissection using intraoperative ultrasonography and intermittent warm ischemia. The main perioperative care regimen was fresh frozen plasma infusion and strict limitation of blood transfusion. MAIN OUTCOME MEASURES: The 30-day postoperative mortality and morbidity rates. RESULTS: All the patients underwent surgery (37 major resections, 45 segmentectomies, and 25 limited resections), with no 30-day postoperative mortality, overall morbidity of 26.2%, and no major complications. Multiple logistic regression analysis revealed that only the type of operation was associated with a significantly higher morbidity risk (P = .05). CONCLUSION: With high resectability, low morbidity, and no mortality, our policy represents a solution to the drawbacks of surgical resection for treatment of HCCs, especially in patients with associated liver cirrhosis.     

A decade of experience with transthoracic and transhiatal esophagectomy

BACKGROUND: Morbidity and mortality remain significant for transthoracic (TT) and transhiatal (TH) esophagectomy. We report a case-specific approach employing either resection to minimize perioperative morbidity and mortality. METHODS: All primary esophageal resections performed for benign and malignant esophageal disease were reviewed over a 10-year period. The operative approach was tailored to the location and extent of disease and the physiologic reserve of the patient. RESULTS: In all, 115 patients underwent esophagectomy for benign (25) and malignant (90) disease. Fifty-six TT and 59 TH resections were performed. Four emergent TT cases did not have reconstruction. There was 1 hospital mortality. Perioperative transfusion was avoided in 65 patients. Respiratory complications occurred in 15. Three patients had a cervical anastomotic leak requiring open wound drainage. No association between resection type and complication was evident. CONCLUSIONS: The judicious use of both TT and TH esophagectomy resulted in an operative mortality of less than 1%, reduced operative blood loss, and a relatively low rate of perioperative complications.     

MICROWAVE TISSUE COAGULATOR IN LIVER RESECTION FOR CIRRHOTIC PATIENTS

The use of the microwave tissue coagulator was studied on 20 consecutive elective hepatic resections carried out for symptomatic hepatocellular carcinoma with liver cirrhosis. The mean operative blood loss (excluding one patient with hepatic vein injury) was 1132 mL. Five patients required no blood transfusion. The average time taken to coagulate the anticipated liver transection plane was less than 15 min. Apart from the complications similar to those occurring in hepatic resections for cirrhotic patients, higher incidences of intra-abdominal sepsis (20%), sympathetic pleural effusion in the absence of chest or intra-abdominal sepsis (20%), and persistent fever lasting more than 1 week (40%) were encountered. It was considered that these complications were related to the coagulated tissue present in the liver remnants (mean depth of tissue coagulation = 3.8 mm) and concluded that although the hospital mortality rate of 10% and the mean operative blood loss of 1132 mL were acceptably low, microwave liver surgery carried a high morbidity rate which is a drawback in major hepatic resectional surgery.     

Hepatic resection for breast cancer metastases

INTRODUCTION: Hepatic resection is an established modality of treatment for colorectal cancer metastases. Resection of breast cancer liver metastases remains controversial, but has been shown to be an effective treatment in selected cases. This study reports the outcome of 8 patients with liver metastases from breast cancer. PATIENTS & METHODS: 8 patients with liver metastases from previously treated breast cancer were referred for hepatic resection between September 1996 and December 2002. Six were eligible for liver resection. The mean age was 45.8 years. The resections performed included 1 segmentectomy and 5 hemihepatectomies of which one was an extended hemihepatectomy. One patient had a repeat hepatectomy 44 months after the first resection. RESULTS: There were no postoperative deaths or major morbidity. The resectability rate was 75%. Follow-up periods range from 6 to 70 months with a median survival of 31 months following resection. There have been 2 deaths, one died of recurrence in the residual liver at 6 months and one died disease-free from a stroke. Of the remaining 4 patients, 1 has had a further liver resection at 44 months following which she is alive and ''disease-free'' at 70 months. The one patient with peritoneal recurrence is alive 49 months after her liver resection with 2 patients remaining disease-free. CONCLUSION: Hepatic resection for breast cancer liver metastases is a safe procedure with low morbidity and mortality.