Detailed liver-specific imaging prior to pre-operative chemotherapy for colorectal liver metastases reduces intra-hepatic recurrence and the need for a repeat hepatectomy

AbstractBackgroundNeoadjuvant chemotherapy for colorectal liver metastases (CRLM) reduces the accuracy of liver imaging which may understage patients pre-operatively. Retrospective review of a prospective database to determine whether liver-specific magnetic resonance imaging (MRI) prior to pre-operative chemotherapy affects intra-hepatic recurrence and long-term outcome after hepatectomy.Patients and methodsBetween 2003 and 2009, 242 patients with CRLM underwent a hepatectomy after ≥3 cycles of oxaliplatin or irinotecan-based chemotherapy. All had a liver-specific MRI immediately pre-operatively. The outcome of patients who had a liver-specific MRI prior to chemotherapy (PCI group, n= 92) was compared with those who did not (non-PCI group, n= 150).ResultsA liver-specific MRI pre-chemotherapy changed the staging in 56% of patients. At a median (range) follow-up of 55 (6–94) months, there was a higher incidence of intra-hepatic recurrence at a new site in the non-PCI group (65% vs. 48% in the PCI group, P= 0.041) and an increased rate of recurrence in patients with the same number of lesions pre- and post-chemotherapy [hazard ratio (HR) 2.02, 1:10–3.37, P= 0.024]. The non-PCI group underwent more repeat hepatectomies than the PCI group (24.7% vs. 13%, P= 0.034), achieving similar long-term survival.ConclusionsA liver-specific MRI prior to chemotherapy reduces intra-hepatic recurrence and avoids a repeat hepatectomy

Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy

AbstractBackgroundControl of hepatic inflow is a key manoeuvre during right hepatectomy and has traditionally been achieved by extrahepatic dissection of the component right portal inflow structures at the hepatic hilum. An alternative technique is the anterior intrahepatic approach (AIA), in which the Glissonian sheath is isolated within the substance of the liver during parenchymal transection and secured using an endovascular stapling device. This study evaluates the intrahepatic, extra-Glissonian technique in comparison with classical extrahepatic dissection (EHD) in right hepatectomy.MethodsA retrospective case-controlled study referring to a 20-year period identified 342 consecutive patients who underwent right hepatectomy for colorectal liver metastases from a prospectively compiled database. The AIA to right hepatectomy was used in 182 of these patients and the extrahepatic approach in 160. The two groups were matched for age, gender, stage of primary tumour and number and size of metastases. Outcome measures included safety factors (bleeding, bile duct injury and gun failure), operative duration, oncological margin, morbidity and mortality.ResultsThere were no significant differences between the two groups in terms of operative duration (240min vs. 260min) or postoperative change in haemoglobin (1.3g/dl vs. 1.4g/dl). The AIA was associated with lower operative blood loss (355ml vs. 425ml; P≤ 0.001), a reduced rate of significant morbidity (14.6% vs. 23.1%; P= 0.005), better R0 resection rates (93% vs. 89%; P= 0.014) and a lower 90-day mortality rate (3% vs. 7%; P= 0.046). There was one minor bile leak in each group, two clinically significant bile leaks requiring endoscopic retrograde cholangiopancreatography and stenting in the extrahepatic group, and a further persistent bile leak requiring biliary reconstruction in each group. In two instances the endovascular stapler misfired. Both cases were dealt with at the time of surgery with no further sequelae. The length of hospital stay was equivalent in the two groups (8 days vs. 9 days).ConclusionsIn selected patients, intrahepatic, extra-Glissonian stapled right hepatectomy is feasible, safe and avoids the need for EHD. The anterior approach to right hepatectomy may achieve outcomes at least as good as those associated with the classical extrahepatic approach

Open liver resection for colorectal metastases: better short- and long-term outcomes in patients potentially suitable for laparoscopic liver resection

AbstractBackgroundThere is no prospective randomized data comparing laparoscopic to open hepatectomy. This study compared short- and long-term outcomes in patients undergoing hepatectomy for colorectal metastases (CRM), who were suitable for either laparoscopic or open surgery.MethodsData were prospectively collected from consecutive patients undergoing hepatic resection of CRM at a single centre (1987–2007). Patients who were suitable for laparoscopic resection (Group 1) were compared with patients whose tumour characteristics would best be considered for open resection (Group 2).ResultsOut of 1152 hepatectomies, 266 (23.1%) were deemed suitable for a laparoscopic approach. The median (IQR) number of metastases was greater in Group 2 [2(1–20) vs. 1(1–10), P < 0.001], as was the mean (SD) tumour size [5.3(3.6)cm vs. 3.3(1.2)cm, P < 0.001]. The median (IQR) operation time [210 (70)min vs. 240 (90)min, P < 0.001] and blood loss [270 (265)ml vs. 355 (320)ml, P < 0.001] were less in Group 1. There was no difference in length of stay, morbidity or mortality. Patients in Group 2 had a higher R1 resection rate (14.9%) compared with Group 1 (4.5%, P < 0.001) and lower 5-year survival (37.8% vs. 44.2%, P= 0.005).DiscussionCurrent criteria for laparoscopic hepatectomy selects patients who have more straight-forward surgery, with less risk of an involved resection margin and better long-term survival, compared with patients unsuited to a laparoscopic approach. Clearly defined criteria for laparoscopic hepatectomy are essential to allow meaningful analysis of outcomes and the results of unrandomized series of laparoscopic hepatectomies must be interpreted with caution

A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy?

AbstractBackgroundDespite a growing body of evidence reporting the deleterious mechanical and oncological complications of biopsy of hepatic malignancy, a small but significant number of patients undergo the procedure prior to specialist surgical referral. Biopsy has been shown to result in poorer longterm survival following resection and advances in modern imaging modalities provide equivalent, or better, diagnostic accuracy.MethodsThe literature relating to needle-tract seeding of primary and secondary liver cancers was reviewed. MEDLINE, EMBASE and the Cochrane Library were searched for case reports and series relating to the oncological complications of biopsy of liver malignancies. Current non-invasive diagnostic modalities are reviewed and their diagnostic accuracy presented.ResultsBiopsy of malignant liver lesions has been shown to result in poorer longterm survival following resection and does not confer any diagnostic advantage over a combination of non-invasive imaging techniques and serum tumour markers.ConclusionsGiven that chemotherapeutic advances now often permit downstaging and subsequent resection of ‘unresectable’ disease, the time has come to abandon biopsy of solid lesions outside the setting of a specialist multi-disciplinary team meeting (MDT)