Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients.

OBJECTIVES: Current clinical studies report the results of laparoscopic resection of hepatocellular carcinoma (HCC) obtained in small cohorts of patients. Because France was involved in the very early development of laparoscopic surgery, the present study was conducted in order to report the results of a large, multicentre experience. METHODS: A total of 351 patients underwent laparoscopic liver resection for HCC during the period from 1998 to 2010 in nine French tertiary centres. Patient characteristics, postoperative mortality and morbidity, and longterm survival were retrospectively reviewed. RESULTS: Overall, 85% of the study patients had underlying liver disease. Types of resection included wedge resection (41%), left lateral sectionectomy (27%), segmentectomy (24%), and major hepatectomy (11%). Median operative time was 180 min. Conversion to laparotomy occurred in 13% of surgeries and intraoperative blood transfusion was necessary in 5% of patients. The overall morbidity rate was 22%. The 30-day postoperative mortality rate was 2%. Negative resection (R0) margins were achieved in 92% of patients. Rates of overall and progression-free survival at 1, 3 and 5 years were 90.3%, 70.1% and 65.9%, and 85.2%, 55.9% and 40.4%, respectively. CONCLUSIONS: This multicentre, large-cohort study confirms that laparoscopic liver resection for HCC is a safe and efficient approach to treatment and can be proposed as a first-line treatment in patients with resectable HCC.

Concomitant extrahepatic disease in patients with colorectal liver metastases: when is there a place for surgery?

OBJECTIVE: To evaluate the impact of the location of extrahepatic disease (EHD) on survival and to determine patient outcome in a consecutive series of patients with both intrahepatic and extrahepatic colorectal metastases treated by an oncosurgical approach, combining repeat surgery and chemotherapy. BACKGROUND: Although recognized as poor prognostic factor, concomitant EHD is no more considered an absolute contraindication to surgery in patients with colorectal liver metastases (CLM). However, the impact of the location of EHD on survival and the benefit in patient outcome is still diversely appreciated. METHODS: From 840 patients resected for CLM between 1990 and 2006, 186(22%) also had resectable EHD. Sequential surgery was routinely combined with perioperative chemotherapy. Survival was compared with that of patients without EHD, prognostic factors were identified, and a predictive model was designed to better select surgical candidates. RESULTS: Patients resected for CLM with concomitant EHD experienced a lower 5-year survival than those without EHD (28% vs 55%, P < 0.001). Five poor prognostic factors were identified at multivariate analysis: EHD-location other than lung metastases (5-year survival: 23% vs 33%, P = 0.02), EHD concomitant to CLM recurrence (14% vs 34%, P < 0.001), carcinoembryonic antigen level at least 10 ng/mL (16% vs 37%, P=0.02), at least 6 CLM(9% vs 32%, P = 0.02), and right colon cancer (P = 0.02). Five-year survival ranged from 64% (0 factors) to 0% (>3 factors). In the EHD group, patients with an EHD-recurrence experienced better outcomes when resected than those treated by chemotherapy alone (5-year survival: 38% vs 21%, P = 0.05). CONCLUSION: Although sequential surgery is warranted for patients with 5 or less CLM with isolated lung metastases, low carcinoembryonic antigen levels,and no right colon primary tumor, it should be questioned in the presence of more than 3 of these prognostic factors.

Long-term outcomes after hepatic resection for colorectal metastases in young patients.

BACKGROUND: Long-term outcomes after hepatectomy for colorectal liver metastases in relatively young patients are still unknown. The aim of the current study was to evaluate long-term outcomes in patients < or = 40 years old, and to compare them with patients >40 years old. METHODS: All consecutive patients who underwent hepatectomy for colorectal liver metastases at the authors' hospital between 1990 and 2006 were included in the study. Patients < or = 40 years old were compared with all other patients treated during the same period. Overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS) rates were determined, and prognostic factors were identified. RESULTS: In total, 806 patients underwent hepatectomy for colorectal liver metastases, of whom 56 (7%) were aged < or = 40 years. Among the young patients, more colorectal liver metastases were present at diagnosis, and they were more often diagnosed synchronous with the primary tumor. Five-year OS was 33% in young patients, compared with 51% in older patients (P = .12). Five-year PFS was 2% in young patients, compared with 16% in older patients (P < .001). DFS rates were comparable between the groups (17% vs 23%, P = .10). At multivariate analysis, age < or = 40 years was identified as an independent predictor of poor PFS. CONCLUSIONS: In young patients, colorectal liver metastases seem to be more aggressive, with a trend toward lower OS, more disease recurrences, and a significantly shorter PFS after hepatectomy. However, DFS rates were comparable between young and older patients, owing to an aggressive multimodality treatment approach, consisting of chemotherapy and repeat surgery. Therefore, physicians should recognize the poor outcome of colorectal liver metastases in young patients and should consider an aggressive approach to diagnosis and early treatment.

One hundred liver resections: improved outcome in a tertiary care center in Lebanon.

BACKGROUND: Recent reports highlight the reduced mortality and morbidity rates of liver resection in the last decades. The authors report on the surgical techniques and perioperative management that have yielded a low mortality and morbidity rates. METHODS: One hundred consecutive liver resections carried out from 1997 to 2005 were reviewed. Data were collected retrospectively. RESULTS: The indications for liver resection were malignant tumors in 73%. Major liver resection was performed in 52%. Overall, 42.5% of liver resections were performed without vascular clamping and 57% of liver resections were performed without blood transfusions. There was no intraoperative death and the overall mortality rate was 1%. The major complications rate was 28% and was related to the extent of resection. The mean length of hospital stay was 12 days. CONCLUSION: The current series shows that with accurate preoperative evaluation, standardization of the surgical technique, appropriate use of vascular clamping method, and vigilant postoperative monitoring, an in-hospital mortality of 1% was achieved in a series where more than 50% of patients underwent a major hepatectomy.

Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience.

BACKGROUND: Liver tumors with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach, with its high surgical risks and poor long-term prognosis, was precluded until the development of neoadjuvant chemotherapy, portal vein embolization, reinforced vascular prostheses, and technical advances in liver transplantation. METHODS: We reviewed 22 cases of hepatectomy with retrohepatic IVC resection and reconstruction. The patients had a median age of 51.5 years (range, 32.8-75.3 years). Indications for resection were: liver metastases (n = 9), cholangiocarcinoma (n = 8), hepatocellular carcinoma (n = 2), other cancers (n = 3). The liver resections carried out included 18 first, 3 second, and one third hepatectomy. Segment 1 (caudate lobe) was included in the specimen in 19 cases (86%). Resection concerned 1 to 6 liver segments (median = 5.0). Vascular control was achieved by vascular exclusion of the liver preserving the caval flow (n = 1), standard vascular exclusion of the liver (n = 12), in situ cold perfusion of the liver (n = 9). Ex situ surgery was not necessary in any case. Venovenous bypass was used in 12 cases. The IVC was reconstructed with a ringed Gore-Tex tube graft (n = 10), primarily (n = 8), or by caval plasty (n = 4). A main hepatic vein was reimplanted in 6 cases: into the native IVC (n = 4) or into a Gore-Tex tube graft (n = 2). RESULTS: One patient died (4.5%) due to catheter infection, 7 days after in situ cold perfusion with replacement of the vena cava. Eight patients (36%) had no complications and 14 patients (64%) had 23 complications. In all but 1 case, the complications were transient and successfully controlled. The patients stayed in intensive care for 3.3 +/- 2.0 days and in the hospital for 17.7 +/- 7.8 days. All vascular reconstructions were patent at last follow-up. With median follow-up of 19 months, 10 patients died of tumor recurrence and eleven were alive with (n = 5) or without (n = 6) disease. Actuarial 1-, 3-, and 5-year survival rates were 81.8%, 38.3%, and 38.3%, respectively. CONCLUSIONS: IVC resection and reconstruction combined with liver resection can be safely performed in selected patients. The lack of alternative treatments and the spontaneous poor prognosis justify this approach, provided that surgery is carried out at a center specialized in both liver surgery and liver transplantation. The development of adjuvant chemotherapy regimens is required to improve the long-term results of this salvage surgery.