Metastases of gastric cancer into the liver – the authors’ own experience and literature review

Introduction. Synchronous metastases of gastric cancer to the liver occur in 3–14% of patients with this cancer, and metachronous lesions in 37% of patients after radical gastrectomy. Liver resections due to metastases of gastric carcinomas represent only 5–9% of resections due to metastases other than colorectal cancer. Until recently, patients with gastric carcinoma metastases to the liver were classified in the IV stage of cancer and the therapy was limited to chemotherapy or palliative treatment only.Material and methods. The paper presents a current review of literature and the authors’ own experience with liver resection due to gastric cancer metastases into this organ. During 34 months, 488 patients with liver metastases were treated in the Department of General, Transplant and Liver Surgery, of the Medical University of Warsaw, in whom 426 surgical procedures were performed (87.3%). The types of surgical procedures are as follows: minor liver resections in 204 patients (47.9%), hemihepatectomies in 102 patients (23.9%), thermoablations in 86 patients (20.2%) and laparotomies in 34 patients (8.0%). Among patients treated for liver metastases there were 4 patients with metastases from gastric cancer (0.8%), which constituted 1% of patients operated on, but 6.8% of patients with liver metastases from organs other than colorectal cancer. The postoperative course and direct results in all patients operated because of gastric cancer metastasesinto the liver were very good.Conclusions. In some patients (single metachronous metastasis, no extrahepatic lesions, no peritoneal lesions, with subsequent chemotherapy) liver resection due to metastases from gastric cancer provides a chance for a longer survival

Long-Term Effects of Pedicle Clamping during Major Hepatectomy for Colorectal Liver Metastases

The use of the Pringle maneuver (PM) varies widely among surgical departments. Its use depends on the operator and type of liver resection. The aim of this study was to determine the impact of the PM on patient outcomes when undergoing major liver resections. This retrospective study comprised 179 colorectal liver metastasis patients from two liver centers from Leeds and Warsaw. Only right or right extended hepatectomies with negative oncological margins were included. The primary outcome measure was the 5-year overall survival (OS). The PM was applied during 60 (33.5%) major hepatectomies included in the study and was associated with a higher peak 3-day postoperative bilirubin concentration (p = 0.002), yet not with the peak 3-day alanine aminotransferase activity (p = 0.415). The 5-year OS after liver resections with the PM and without the PM were 55.0% and 33.4%, respectively (p = 0.019). Following stratification by the Tumor Burden Score, after resections with the use of the PM, superior survival was particularly found in the subgroup of patients at intermediate risk of recurrence (p = 0.004). However, the use of the PM had no significant effect on the 5-year overall survival following adjustment for the confounding effect of the carcinoembryonic antigen concentration (p = 0.265). The use of the PM had no negative effects on the long-term outcomes in patients undergoing major, oncologically radical liver resections for colorectal metastases

Przesuwanie granicy wieku i zmniejszanie liczby przeciwwskazań do resekcji wątroby u obciążonych onkologicznych chorych — opis przypadku

Liver resections are performed in increasing numbers due to oncological indications. Thus, the indications for surgical treatment of liver tumors are constantly expanding. Advanced age and other comorbidities often exclude this group of patients from treatment by liver resection. Patient C.S. (80 y.a., height 166 cm, weight 97 kg, ASA = 4) with risk factors was admitted for resection of metastatic lesions (adenocarcinoma) of the cecum to the liver. The patient was diagnosed with hypertension, atherosclerosis, stable coronary heart disease, type 2 diabetes, chronic renal failure (eGFR = 37), obesity, degenerative spinal lesions, sigmoid colon diverticulitis, dystonic tremor of the head. Previously operated upon and had amputation of the uterus with appendages (2005), cholecystectomy, right hemicolectomy (2012) complicated by respiratory failure with the need for ventilation seven days post-surgery. Prior to surgery, the patient had imaging tests such as ultrasound, CT and MRI scans of the abdomen, which confirmed a 55mm metastatic tumor in the seventh segment of the liver. The results were analyzed during a radiological and surgical consultation in order to prepare the safest available surgical access and the scope of the planned resection. A cardiac echocardiography was performed and the patient had a cardio-, neuro- and anesthetic consultation. The patient was fully informed about the high risk of complications and possible operational failure. During surgery a right hemihepatectomy was performed. The resected lobe weighed 712 g. Blood loss was < 500 ml, 2 units RBC and 2 units FFP were transfused. The surgery and the postoperative period proceeded without serious complications. The only problem was a short-lived biliary fistula, which healed spontaneously. Age and comorbid conditions are often a contraindication for surgery, but with proper medical support, the opportunity to interact with other professionals and thorough preparation of the patient and the team of surgeons, the risk of failure can be significantly minimized. A modern, personalized, multidisciplinary approach towards each patient can expand indications and reduce contraindications for hepatic resection.Resekcje wątroby ze wskazań onkologicznych są coraz częściej wykonywaną operacją. Wskazania do leczenia operacyjnego nowotworów wątroby stale są rozszerzane, wciąż jednak zaawansowany wiek pacjenta oraz inne towarzyszące choroby często wykluczają tę grupę chorych z leczenia resekcją wątroby. Chora C.S. (lat 80, wzrost 166 cm, masa ciała 97 kg, ASA = 4) obciążona internistycznie została zakwalifikowana do resekcji zmiany przerzutowej gruczolakoraka kątnicy do wątroby. W wywiadzie nadciśnienie tętnicze, uogólniona miażdżyca, stabilna choroba niedokrwienna serca, cukrzyca typu 2, przewlekła niewydolność nerek (eGFR = 37), otyłość, stany zwyrodnieniowe kręgosłupa, uchyłkowatość esicy, drżenie dystoniczne głowy. Stan po amputacji macicy z przydatkami (2005), po cholecystektomii, po hemikolektomii prawostronnej (2012) powikłanej niewydolnością oddechową z koniecznością wentylacji 7 dni od operacji. Wykonano USG, TK i MR jamy brzusznej, które potwierdzały guz przerzutowy o średnicy 55 mm w VII segmencie wątroby. Wyniki tych badań były dokładnie omówione na konsylium radiologiczno-chirurgicznym w celu zaplanowania najbezpieczniejszego dostępu i zakresu planowanej resekcji. Wykonano echokardiografię serca i konsultowano chorą kardiologicznie, neurologicznie oraz anestezjologicznie. Pacjentka była w pełni poinformowana o wysokim ryzyku powikłań i ewentualnego niepowodzenia operacji. Podczas operacji wykonano hemihepatektomię prawostronną. Resekowana część wątroby ważyła 712 g. Utrata krwi w czasie operacji < 500 ml, przetoczono 2 j. KKCz oraz 2 j. FFP. Chora zniosła zabieg operacyjny i okres pooperacyjny bez powikłań. Jedynym problemem była krótkotrwała przetoka żółciowa, która zagoiła się samoistnie. Wiek i choroby towarzyszące często stanowią przeciwwskazanie do leczenia operacyjnego, jednak przy odpowiednim zapleczu medycznym, możliwości współpracy z innymi specjalistami oraz dokładnym przygotowaniem chorego i zespołu przeprowadzającego operację ryzyko niepowodzenia znacznie spada. Zatem nowoczesne, indywidualne, wielospecjalistyczne podejście do chorego pozwala rozszerzać wskazania i zmniejszać przeciwwskazania do resekcji wątroby

Liver transplantation in metastatic liver tumors

As transplant medicine has evolved in recent decades so too have the indications for liver transplantation (LT). Active or suspected malignancy has stopped being considered as a contraindication for organ transplantation, and nowadays LT plays a major role in the treatment strategies of liver malignancy, specially primary, but also metastatic. It offers excellent long-term outcomes for certain patients with neuroendocrine tumors liver metastases (NETLMs) and carefully selected patients with colorectal cancer liver metastases (CRLMs), who undergo neoadjuvant chemotherapy. Optimal patient selection has become the key issue to achieve the best possible outcomes and to deal with the alleviating shortage of organs. The recent tendency to incorporate markers of tumor biology into selection criteria, rather than simply focusing on tumor size and number, has led to further extension of indications for LT in patients with liver ma­lignancy. This review article focuses on the current place of liver transplantation in the treatment strategy for patients with metastatic/secondary liver tumors

The influence of fluid therapy on short- and long-term outcomes in patients undergoing liver resection for malignant indications

Although fluid therapy in hepatic surgery affects the postoperative course and morbidity, there is a paucity of unequivocal guidelines in the literature as to which of three fluid strategies to use: liberal, restrictive or goal-directed. We performed a review of literature regarding fluid management strategies in major abdominal procedures, focusing on hepatic sur­gery. The quantity and quality of fluids infused perioperatively is often dependent on the preference of the physician, institutional experience and practices. A liberal fluid regimen carries the risk of impaired wound healing and prolonged ileus, furthermore in liver surgery it may increase blood loss. Restrictive fluid therapy is the mainstay of the anesthetic management in hepatic resections, keeping the central venous pressure low controls outflow from the liver and results in a decrease in intraoperative blood loss. In recent years, goal-directed fluid therapy ( GDFT), as a component of enhanced recovery pathways after surgery (ERAS) programs, has gained in popularity. It is based on the concept of hemodynamic optimization in order to ensure optimal tissue perfusion and oxygen delivery. Furthermore, a fluid infusion strategy should be individualized in terms of the unique pathophysiology of the patient (e.g. cirrhosis) and the specific requirements of the surgical technique (laparoscopic procedures). Controversy regarding often contradictory data, leaves the clinician at a loss as to which fluid strategy will best serve the patient. Therefore, it is imperative to design and conduct clinical trials in a homogenous group of patients to define the optimal type and amount of fluid for patients undergoing hepatic surgery

Liver transplantation in primary liver tumors

As transplant medicine has evolved in recent decades so too have the indications for liver transplantation (LT). Active or suspected malignancy has stopped being considered as a contraindication for organ transplantation, and nowa­days LT plays a major role in the treatment strategies of liver tumors. It offers excellent long-term outcomes for certain patients with hepatocellular carcinoma (HCC) and carefully selected patients with cholangiocarcinoma (CCA), who undergo neoadjuvant chemoradiatotherapy. In certain clinical courses of rare primary liver tumors, hepatic epithelioid haemangio-endothelioma (HEHE) and hepatic adenoma (HA), liver transplantation is also considered the best treatment option. Optimal patient selection has become the key issue to achieve the best possible outcomes and to deal with the alleviating shortage of organs. The recent tendency to incorporate markers of tumor biology into selection criteria, rather than simply focusing on tumor size and number, has led to further extension of indications for LT in patients with liver malignancy. This review article focuses on the current place of liver transplantation in the treatment strategy for patients with primary liver tumors, mainly primary liver cancers

Liver transplantation in metastatic liver tumors

As transplant medicine has evolved in recent decades so too have the indications for liver transplantation (LT). Active or suspected malignancy has stopped being considered as a contraindication for organ transplantation, and nowadays LT plays a major role in the treatment strategies of liver malignancy, specially primary, but also metastatic. It offers excellent long-term outcomes for certain patients with neuroendocrine tumors liver metastases (NETLMs) and carefully selected patients with colorectal cancer liver metastases (CRLMs), who undergo neoadjuvant chemotherapy. Optimal patient selection has become the key issue to achieve the best possible outcomes and to deal with the alleviating shortage of organs. The recent tendency to incorporate markers of tumor biology into selection criteria, rather than simply focusing on tumor size and number, has led to further extension of indications for LT in patients with liver ma­lignancy. This review article focuses on the current place of liver transplantation in the treatment strategy for patients with metastatic/secondary liver tumors

Przerzuty raka żołądka do wątroby – doświadczenie własne i przegląd piśmiennictwa

Wstęp. Synchroniczne przerzuty raka żołądka do wątroby występują u 3–14% chorych na ten nowotwór, a ogniska metachroniczne – u 37% pacjentów, u których wykonano radykalną gastrektomię. Natomiast resekcje wątroby z powodu przerzutów raków żołądka stanowią zaledwie 5–9% resekcji z powodu przerzutów innych niż raka jelita grubego. Do niedawna chorych z przerzutami raka żołądka do wątroby zaliczano do IV stopnia zaawansowania choroby nowotworowej i terapię ograniczano wyłącznie do leczenia chemicznego lub paliatywnego. Materiał. W pracy przedstawiono aktualny przegląd piśmiennictwa i własne doświadczenie dotyczące resekcji wątroby z powodu przerzutów raka żołądka do tego narządu. W ciągu 34 miesięcy leczono w Klinice Chirurgii Ogólnej, Transplantacyjnej i Wątroby Warszawskiego Uniwersytetu Medycznego 488 chorych z przerzutami do wątroby, u których wykonano 426 zabiegów operacyjnych (87,3%). Rodzaje postępowania operacyjnego przedstawiają się następująco: resekcje wątroby mniejsze – u 204 chorych (47,9%), hemihepatektomie – u 102 chorych (23,9%), termoablacje – u 86 chorych (20,2%) i laparotomie – u 34 chorych (8,0%). Wśród osób leczonych z powodu przerzutów do wątroby było 4 chorych z przerzutami raka żołądka (0,8%), co stanowiło 1% chorych operowanych, ale 6,8% chorych z przerzutami do wątroby z innych narządów niż rak jelita grubego. Przebieg pooperacyjny i bezpośrednie wyniki u wszystkich chorych operowanych z powodu przerzutów raka żołądka do wątroby były bardzo dobre. Wnioski. U niektórych pacjentów (pojedynczy przerzut metachroniczny, bez zmian pozawątrobowych, bez zmian otrzewnowych, z następową chemioterapią) resekcja wątroby z powodu przerzutów raka żołądka daje szanse na dłuższe przeżycie

Liver transplantation in primary liver tumors

As transplant medicine has evolved in recent decades so too have the indications for liver transplantation (LT). Active or suspected malignancy has stopped being considered as a contraindication for organ transplantation, and nowa­days LT plays a major role in the treatment strategies of liver tumors. It offers excellent long-term outcomes for certain patients with hepatocellular carcinoma (HCC) and carefully selected patients with cholangiocarcinoma (CCA), who undergo neoadjuvant chemoradiatotherapy. In certain clinical courses of rare primary liver tumors, hepatic epithelioid haemangio-endothelioma (HEHE) and hepatic adenoma (HA), liver transplantation is also considered the best treatment option. Optimal patient selection has become the key issue to achieve the best possible outcomes and to deal with the alleviating shortage of organs. The recent tendency to incorporate markers of tumor biology into selection criteria, rather than simply focusing on tumor size and number, has led to further extension of indications for LT in patients with liver malignancy. This review article focuses on the current place of liver transplantation in the treatment strategy for patients with primary liver tumors, mainly primary liver cancers