Liver resection for cancer: is it worth the risk?

techniques. Those who have persisted in their attempts to do so testify to the tenacity required. Current reports from a number of well-organized groups and institutions justify their efforts. Extent of resection, including satisfactory margins and lymph node harvest, are comparable to that with open procedures for similar-stage disease. Early follow-up data suggest that survival will be equivalent. A major concern has been the apparent increase in the number of local abdominal wall (incisional) recurrences. As the learning curve flattens, this seems to be less of a problem. A great deal of publicity has been generated about this, and many attempts to explain pathogenesis have resulted. It is shown to occur more frequently in patients with extensive local disease. It can be reduced by selection of patients with early disease and by meticulous surgical technique, both in gaining access to and in removing disease. The use of cytotoxic agents at the port site and for peritoneal lavage and fascial closure of the port sites may decrease its incidence. Patients so treated should be part of a prospective, randomized, multicenter trial. This is the only evidence that will quiet all naysayers.7,8 What Works and What Doesn’t Despite the ability of some to provide the benefits of laparoscopic surgery effectively to patients with cancer, barriers to widespread application exist, the most significant of which is cost. Newman and Traverso10 define the value of a surgical procedure as being directly proportional to appropriateness and quality, and inversely so to cost. Standard definition of these terms is possible only when the procedure matures. Only the experience with laparoscopic cholecystectomy permits reasonable estimation of its value under these terms. It is “at a level of maturity . . . to fine tune the procedure.”10 Laparoscopic appendectomy may be of value in women with pelvic peritonitis. Laparoscopic hernia repair is difficult to justify in its present state. Laparoscopic antireflux surgery is problematic because of poor definition of appropriateness and outcome. Short-stay savings are canceled out by operating room costs. Laparoscopic colon surgery for malignancy cannot be evaluated because of the lack of adequate follow-up.10 Laparoscopic staging procedures are useful if resection for cure can be shown to be

unlikely and a reasonable alternative is available. Laparoscopic palliation is valuable in case of symptomatic, locally advanced disease. The role of laparoscopy in the curative treatment of intraabdominal malignancy is yet to be established. Short-term studies carried out in tertiary care institutions show promise but point out the difficulty of the procedure, the training necessary to achieve acceptable results, and the time needed to assess all the factors involved. F. JOHN COTTONE, MD Department of Surgery St. Francis Medical Center Trenton, New Jersey

References 1. SAGES position statement on advanced laparoscopic training. Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons, March 1997. 2. Verification by the American College of Surgeons for the use of emerging technologies. Board of Regents of the American College of Surgeons, February 1998. 3. Bailey RW, Fowler DL, Roslyn JJ. Credentialing in laparoscopic surgery: a guideline for practical use. Surg Endosc 1999;13(suppl 1):S22. 4. Geis P, Kim C, Gillian K. Surgeon rationale for use of preceptoring in minimally invasive surgery: experiences and outcomes. Surg Endosc 1999;13(suppl 1):S-37. 5. van Dijkum EL, Dewit L, van Delden O, et al. The efficacy of laparoscopic staging in patients with upper gastrointestinal tumors. Cancer 1997;79:1315–1319. 6. Finch MD, John TG, Garden OJ, Allen PL, Paterson-Brown S. Laparoscopic ultrasonography for staging gastroesophageal cancer. Surgery 1996;121:10 –17. 7. Krasna MJ. Advances in staging of esophageal cancer. Chest 1998; 113:107S–111S. 8. Bessler M. Tumor implantation at laparoscopy: is it a real problem? Surg Endosc 1998;12:1288 –1289. 9. Lacy AM, Delgado S, Garcia-Valdecasas JC, Castells A, et al. Port site metastases and recurrence after laparoscopic colectomy: a randomized trial. Surg Endosc 1998;12:1039 –1042. 10. Newman RM, Traverso LW. Cost-effective minimally invasive surgery: what procedures make sense? World J Surg 1999;23:415– 421.

Surgical Oncology

Liver Resection for Cancer: Is It Worth the Risk? Guest Reviewer: Frederick L. Greene, MD HEPATIC RESECTION FOR HEPATOCELLULAR CARCINOMA IN THE MODERN ERA WITH SPECIAL REFERENCE TO REMNANT LIVER VOLUME.

Shirabe K, Shimada M, Gion T, et al. J Am Coll Surg 1999;188:304 –309.

To assess the factors leading to liver failure after hepatic resection.

Objective

Second Department of Surgery, Kyushu University, Fukuoka, Japan.

Setting

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Design

Participants

Retrospective clinical review.

Eighty patients with hepatitis B or C who underwent resection for hepatocellular cancer.

Methods

A review of 80 patients having resection of at least a lobe of the liver showed that 7 patients (8.8%) died of liver failure within 6 months. In patients who had , 250 ml/m2 of liver volume (based on CT analysis) liver failure developed in 7 (38%) of 20 patients. In patients with . 250 ml/m2 of liver volume remaining, 0 of 27 patients developed liver failure.

Conclusions

In patients with associated viral markers and hepatocellular cancer, the postoperative volume of remaining liver is an important determinant in the development of postoperative liver failure.

REVIEWER COMMENTS. This study by Shirabe et al from Japan is important because it takes into account modern concepts of anesthesia, blood replacement, and critical care support in patients who currently have had major hepatic resection for carcinoma of the liver. These experts in the area of hepatic resection have identified factors that may be responsible for postoperative liver failure in their patient population. They have carefully analyzed this population and have come to the conclusion that volume of remaining liver, especially in those patients having major right lobectomy, is an indicator of risk for postoperative hepatic failure. Many other parameters are studied and include demographic data as well as laboratory functions. None of these parameters had a significant effect on the development of postoperative hepatic failure. They did discover that patients with diabetes mellitus and smaller remnant liver volumes are more at risk than patients without diabetes. This paper should serve as a benchmark for further studies in this area.

PERIOPERATIVE OUTCOMES OF MAJOR HEPATIC RESECTIONS UNDER LOW PRESSURE: ANESTHESIA BLOOD LOSS, BLOOD TRANSFUSION, AND THE RISK OF POSTOPERATIVE RENAL DYSFUNCTION.

Melendez J, Arslan V, Fischer M, et al. J Am Coll Surg 1998;187:620 – 625.

Objective

Setting

Hepatobiliary service of the Memorial Sloan-Kettering Cancer Center (MSKCC).

Design

A clinical review of the prospective database of the MSKCC hepatobiliary service with linkage to the blood-bank database.

Participants

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To assess renal complications in patients undergoing liver resection utilizing low central venous pressure (LCVP) combined with extra hepatic control of venous outflow.

Patients undergoing major liver resections utilizing LCVP techniques.

Methods

Four hundred ninety-six patients had liver resection using LCVP techniques; 0 intraoperative deaths and a mortality rate of 3.8% were noted. Blood transfusion was avoided in 67% of patients during the perioperative period. There was no finding of renal failure in the postoperative evaluation.

Conclusions

With a lowered CVP technique, transected hepatic veins could be more easily controlled, with an associated reduction in blood loss. Renal function was preserved using this technique. CURRENT SURGERY

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REVIEWER COMMENTS. Melendez et al have been proponents of performing hepatic resection using anesthetic techniques, which allow for the creation of LCVP in combination with extrahepatic control of venous outflow. In their significant experience on the Hepatobiliary Surgical Service, they have reported 496 liver resections using these techniques and have shown that blood loss is minimized and that renal function is preserved. The important message in this paper is that experience with significant hepatic resections probably is the greatest predictor of outcome. The addition of LCVP may facilitate the hepatic dissection, especially in the area of the major hepatic veins. Other techniques, which include in-flow occlusion and vascular isolation, have shown similar results when blood loss has been measured and mortality and morbidity have been assessed. This paper also describes some of the other problems associated with major hepatic resection, including the occurrence of air emboli. They do admit that embolization may increase under LCVP anesthesia. The authors make their most important conclusion in recommending that the surgeon and anesthesiologist work closely in the management of these very complex cases. The most important parameter for major hepatic resection is an efficient operation done by an expert operating team. A STUDY OF PROGNOSTIC FACTORS FOR HEPATIC RESECTION FOR COLORECTAL METASTASES.

Taylor M, Forster J, Langer B, et al. Am J Surg 1997;173:467– 471. To assess a group of patients having hepatic resection for metastatic colorectal cancer in terms of short- and long-term survival.

Objective

Hepato-Pancreatic-Biliary Service, University of Toronto, Canada.

Setting

Chart review.

Design

One hundred twenty-three patients who had liver resection for colorectal metastases between August 1977 and June 1993.

Participants

The authors reviewed the charts of 123 patients who had hepatic resection for metastases. Solitary lesions were found in 77, single lesions with satellites in 15, and multiple lesions in 31. Synchronous metastases were found in 40 patients and metachronous lesions in 83. Formal lobectomies were performed in 51 patients and extended lobectomies were necessary in 21 patients.

Methods

Postoperative complications occurred in 28% of patients. There were no operative or postoperative deaths. Overall actuarial 5-year survival was 34%. Patients with single lesions had a 5-year survival of 47%, compared with 16% for those with single lesions and satellite nodules and 17% for those with multiple lesions. Finding synchronous or metachronous lesions had no effect on survival.

Conclusions

REVIEWER COMMENTS. Taylor et al reviewed the prognostic indicators before resection in treating metastatic colorectal cancer to the liver. Parameters that have been proposed as predictors of survival have included the number of liver metastases, the stage of the primary colorectal tumor, the timing of appearance of the metastatic disease, demographic data such as age and gender, the need for blood replacement during hepatic resection, as well as other parameters. The authors report a single-institution study of 123 consecutive patients who had undergone resection. Their findings are not unusual because previous studies have also shown that limited disease tends to predict a better overall survival. The lack of differentiation between synchronous and metachronous resection is surprising in that previous studies have shown a better long-term survival pattern in patients whose disease appears after the initial colorectal resection. The authors recognize the problems in reporting retrospective studies and agree that survival patterns can only be appropriately measured by prospective, randomized trials. However, they recommend the use of historical groups in which patients had not had resection. When these groups are compared with those having surgical resections, the survivorship tends to be superior in the operative groups. The authors agree that the number of metastatic lesions is the best preoperative predictor of long-term survival. At this time, the most effective use of the hepatic resection is in patients with single lesions with good hepatic reserve.

SUMMARY In order to answer whether liver resection for cancer is worth the risk, a variety of preoperative and postoperative indicators must be assessed. The papers reviewed here indicate that an expert team and close coordination beCURRENT SURGERY

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tween the surgeon and anesthesia support probably go further to indicate good results than any other parameters. In this era of improvement in hepatic transplantation, consideration must be given to patients with isolated primary malignancies of the liver who, in fact, may benefit from total hepatic removal and orthotopic hepatic transplantation.

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Langer et al in Toronto continue to support the concept of performing resection as a first-line treatment for primary hepatic cancer because of the significant organ shortage that affects transplant decisions. Survival patterns show that resection still offers the best long-term survival for patients with metastatic colorectal cancer. The important issue is to predict preoperatively which patients will benefit from these techniques. Generally, the number and location of metastases are important. The use of intraoperative ultrasound in conjunction with resection techniques is one of the important advances in this area and should be utilized liberally.2 The finding of new areas of metastases after resection offers little to the patient and represents a failure of preoperative assessment. Compared with major hepatic resection, newer techniques of cryotherapy3 and radiofrequency ablation4 of hepatic tumors should be considered in management of these patients. Operative ablation of hepatic lesions may offer a short-term benefit for these patients without the associated morbidity seen with major hepatic resection. The ultimate management of patients with malignant disease of the liver

will probably be a combination of resection and ablation to achieve control and possible cure of these processes. The “full service” hepatic surgical unit will need to have many techniques available that can be used under various circumstances. It will be necessary to assess these patients carefully and to develop prospective studies in which outcome and survival can be appropriately measured. FREDERICK L. GREENE, MD Carolinas Medical Center Charlotte, North Carolina

References 1. Philosophe B, Greig PD, Hemming AW, et al. Surgical management of hepatocellular carcinoma: resection or transplantation? J Gastrointest Surg 1998;2:21–27. 2. Jakimowicz JJ, Stultie¨ns G. Laparoscopic intraoperative sonography, colon Doppler and power flow application. Sem Lap Surg 1997;4: 110 –119. 3. Cuschieri A, Crosthwaite G, Shimi S, et al. Hepatic cryotherapy for liver tumors. Surg Endosc 1995;9:483– 489. 4. Buscarini L, Rossi S. Technology for radio frequency thermal ablation of liver tumors. Sem Lap Surg 1997;4:96 –101.

Thoracic

Current Approaches to Thoracic Aortic Aneurysms Guest Reviewer: Martin L. Dalton, MD PROSPECTIVE STUDY OF THE NATURAL HISTORY OF THORACIC AORTIC ANEURYSMS.

Juvonen T, Ergin M, Griepp R, et al. Ann Thorac Surg 1997;63:1533–1545.

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Objective

To better define the risk of thoracic aortic aneurysm rupture; a better understanding will enable the surgeon to recommend operative intervention more confidently to those patients who are likely to succumb to rupture of their aneurysm.

Design

A prospective natural history study of patients with descending thoracic or thoracoabdominal aneurysms who did not meet standard criteria for immediate surgical intervention and had at least 2 CT studies separated by a minimum interval of 3 months, at which time they would enter into the study. Patients with chronic thoracic aortic dissection were excluded.

Participants

Of 114 patients included in this analysis, 8 died of unrelated causes and 4 were excluded, leaving 102 patients for longitudinal analysis. There were 90 patients with descending thoracic aneurysms and 12 with thoracoabdominal aortic aneurysms.

Setting

Department of Cardiothoracic Surgery at Mount Sinai Medical Center, New York, New York.

Results

With a computer program that produced three-dimensional reconstruction of the entire aorta from serial sections of CT scans, an equation was devised that reliably predicts rupture of a thoracic aortic aneurysm. The variables included in this equation are age, pain, COPD, descending thoracic aortic diameter, and abdominal aortic diameter. With this calculation, the probability of rupture within 1 year can be calculated within 95% confidence limits. The absolute indications for operative treatment included: (1) the presence of pain or other symptoms suggestive of rapid expansion; (2) an absolute aortic diameter of more than 7 cm; (3) an increased rate of growth defined as an increase in diameter of 1 cm or more per year; or (4) marked irregularity of aneurysm CURRENT SURGERY

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