Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database

Strategies to treat primary unresectable colorectal liver metastases

The liver is the most common site of metastases in patients with colorectal cancer (CRC), and hepatic metastases are responsible for fatalities in at least two thirds of patients with colorectal malignancy. However, the only available treatment associated with long-term survival in patients with CRC metastases is liver resection. While recent studies have shown that liver resection achieves a 5-year overall survival from 37% to 58%, only 10% to 20% of patients with colorectal liver metastases are eligible for resection. Pharmacologic developments and conceptual advances in chemotherapy, regional treatment, and aggressive surgical strategies have ultimately changed the current treatment of patients with primary unresectable liver metastases caused by CRC. Patients who were treated by only palliative chemotherapy a few years ago presently have a variety of strategies available to render their disease surgically resectable with the potential for long-term survival. These advances are the result of a strong collaboration between medical oncologists and surgeons. The development of new chemotherapy protocols that offer the potential for curative surgery with optimum timing within the natural history of this metastatic disease is a shared therapeutic challenge.

Safety and hemostatic effect of recombinant activated factor VII in cirrhotic patients undergoing partial hepatectomy: a multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Coagulopathy caused by cirrhosis may contribute to excessive bleeding during hepatectomy. We evaluated the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in cirrhotic patients undergoing partial hepatectomy.

METHODS

Patients were randomized to rFVIIa 50 or 100 mug/kg or placebo, administered intravenously 10 minutes before surgery and every second hour during surgery. The primary efficacy end points were the proportion of patients receiving red blood cell (RBC) transfusions and the amount of RBCs transfused. The RBC transfusion trigger was blood loss of 500 mL. Safety end points included thromboembolic and adverse events.

RESULTS

No statistically significant effect of rFVIIa treatment on efficacy end points was observed. Serious and thromboembolic adverse events occurred at similar incidences in the study groups.

CONCLUSIONS

Using blood loss as a transfusion trigger, the efficacy of rFVIIa in reducing the requirement for RBC transfusion was not established in this study. No safety concerns were identified.

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.

How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies

OBJECTIVE

To identify the most efficient parenchyma transection technique for liver resection using a prospective randomized protocol.

SUMMARY BACKGROUND DATA

Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle maneuver). Only limited data are currently available on the best transection technique.

METHODS

A randomized controlled trial was performed in noncirrhotic and noncholestatic patients undergoing liver resection comparing the clamp crushing technique with Pringle maneuver versus CUSA versus Hydrojet versus dissecting sealer without Pringle maneuver (25 patients each group). Primary endpoints were intraoperative blood loss, resection time, and postoperative liver injury. Secondary end points included the use of inflow occlusion, postoperative complications, and costs.

RESULTS

The clamp crushing technique had the highest transection velocity (3.9 +/- 0.3 cm/min) and lowest blood loss (1.5 +/- 0.3 mL/cm) compared with CUSA (2.3 +/- 0.2 cm/min and 4 +/- 0.7 mL/cm), Hydrojet (2.4 +/- 0.3 cm/min and 3.5 +/- 0.5 mL/cm), and dissecting sealer (2.5 +/- 0.3 cm/min and 3.4 +/- 0.4 mL/cm) (velocity: P = 0.001; blood loss: P = 0.003). Clamp crushing technique was associated with the lowest need for postoperative blood transfusions. The degree of postoperative reperfusion injury and complications were not significantly different among the groups. The clamp crushing technique proved to be most cost-efficient device and had a cost-saving potential of 600 to 2400 per case.

CONCLUSIONS

The clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device.

Factors associated with early recurrence after resection for hepatocellular carcinoma and outcomes

BACKGROUND

Early recurrence (ER) (<1 year) after liver resection is one of the most important factors that impact the prognosis of patients with hepatocellular carcinoma (HCC). We sought to determine factors associated with ER of HCC and examine the outcomes thereafter.

STUDY DESIGN

From March 2001 to June 2003, 56 patients underwent hepatic resection for HCC at University of Toronto and were prospectively followed with median followup of 24 months. Patients with ER were compared with those who remained disease free for more than 1 year. Patient characteristics, tumor stage, and operative procedures were evaluated for their prognostic significance by univariate and multivariable analysis. Time to recurrence and time to death were analyzed using Kaplan-Meier survival curves and compared using log-rank analysis.

RESULTS

The initial procedure in all patients was surgical hepatectomy. ER occurred in 21 patients (38%), 31 (55%) remained disease free for more than 1 year, and 4 (7%) were omitted from evaluation because of early (<30 days) death. Median survival after initial hepatic resection for those with ER was 27 months, and 2-year survival was 54%. There were no deaths in the group that remained disease free for more than 1 year (100% 2-year survival, p < 0.05). By multivariate analysis, vascular invasion and positive microscopic margins were significant predictors when all 4 variables were considered in the model (p < 0.05). After ER, 11 of 21 patients (52%) underwent additional therapy with significant improvement in median survival (33 months) compared with those not eligible for conventional therapy (18 months, p = 0.05).

CONCLUSIONS

ER after liver resection for HCC is the leading cause of death during the first 2 years after potentially curative resection. ER will develop in approximately 75% of patients with either vascular invasion or positive margins. For patients with these predictive factors additional treatment might be advised.

Extending the frontiers of surgical therapy for hepatic colorectal metastases: is there a limit?

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival, and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of patients with disease limited to the liver, which consequently translates into only 5% to 10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort directed towards the following areas, (1) refining prognostic factors that would improve patient selection, (2) advancements in surgical technique such as, use of intraoperative ultrasonography, controlling hemorrhage through use of vascular clamping techniques supplemented with low central venous pressure anesthesia, availability of novel devices for parenchymal transection, and controlled anatomic hepatectomy with Glissonian technique, and (3) novel approaches to permit curative hepatic resection such as, preoperative portal vein embolization for hypertrophy of future liver remnant and staged hepatic resection. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

Low preoperative platelet counts predict a high mortality after partial hepatectomy in patients with hepatocellular carcinoma

AIM: To assess the validity of our selection criteria for hepatectomy procedures based on indocyanine green disappearance rate (KICG), and to unveil the factors affecting posthepatectomy mortality in patients with hepatocellular carcinoma (HCC).

METHODS: A retrospective analysis of 198 consecutive patients with HCC who underwent partial hepatectomies in the past 14 years was conducted. The selection criteria for hepatectomy procedures during the study period were KICG ≥ 0.12 for hemihepatectomy, KICG ≥ 0.10 for bisegm-entectomy, KICG ≥ 0.08 for monosegmentectomy, and KICG ≥ 0.06 for nonanatomic hepatectomy. The hepatectomies were categorized into three types: major hepatectomy (hemihepatectomy or a more extensive procedure), bisegmentectomy, and limited hepatectomy. Univariate (Fisher’s exact test) and multivariate (the logistic regression model) analyses were used.

RESULTS: Postoperative mortality was 5% after major hepatectomy, 3% after bisegmentectomy, and 3% after limited hepatectomy. The three percentages were comparable (P = 0.876). The platelet count of ≤ 10104/mL was the strongest independent factor for postoperative mortality on univariate (P = 0.001) and multivariate (risk ratio, 12.5; P = 0.029) analyses. No patient with a platelet count of >7.3104/mL died of postoperative morbidity, whereas 25% (6/24 patients) of patients with a platelet count of ≤ 7.3104/mL died (P<0.001).

CONCLUSION: The selection criteria for hepatectomy procedures based on KICG are generally considered valid, because of the acceptable morbidity and mortality with these criteria. The preoperative platelet count independently affects morbidity and mortality after hepatectomy, suggesting that a combination of KICG and platelet count would further reduce postoperative mortality.