[Primary liver tumors. Preoperative conditioning of the liver and perioperative management in extended liver resection]

Abstract

Background: Chronic liver parenchymal diseases as well as cholestasis are established risk factors for liver failure after partial hepatectomy. As hepatocellular (HCC) and cholangiocellular (CCC) carcinoma often require extended resection due to the often considerable size of tumors - in an often priorly damaged liver - surgery for these entities is usually demanding. Due to the lack of potent systemic treatment for primary liver tumors, surgery remains the only potentially curative treatment option for CCC and most HCC; therefore, perioperative risk factors for liver failure should be reduced as far as possible.

Objectives: In this study measures for reducing the risk of liver failure after extended liver resections were analyzed.

Methods: This analysis was based on a selective literature search in the Pubmed databank.

Results: Medical measures can be used to lower the degree of steatosis or the inflammatory reaction of ischemia/reperfusion injury. In particular, biliary decompression should be achieved in obstructive jaundice prior to liver surgery, e.g. for hilar cholangiocarcinoma, as cholestasis impairs liver regeneration. Moreover, the future liver remnant volume after extended liver resection can be increased by embolization (PVE) or ligation of major branches of the portal vein. Similar results as for PVE regarding liver hypertrophy have been reported from unilateral selective internal radiotherapy (SIRT) although this effect appears prolonged and less impressive than after PVE. In addition, two-stage concepts for liver surgery, which are also based on the regenerative potential of the liver, may lower the complication rate and increase patient safety by increasing liver volume. However, conventional two-stage procedures harbor the risk of disease progression during the time lapse to the second step which contraindicates complete resection in 20-30 % of patients. In contrast to this, a complete tumor resection is possible in nearly all patients treated by the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure but long-term results regarding tumor recurrence rate are scarce due to the limited experience with this novel technique.

Conclusion: The perioperative risks of extended liver resection can be lowered by technical and medical measures.