Two-Stage Hepatectomy: A Planned Strategy to Treat Irresectable Liver Tumors

Abstract

ObjectiveTo assess feasibility, risks, and patient outcomes in the treatment of colorectal metastases with two-stage hepatectomy. Summary Background DataSome patients with multiple hepatic colorectal metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization, or combined with a locally destructive technique. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. In selected patients with irresectable multiple metastases not amenable to a single hepatectomy procedure, two-stage hepatectomy might offer a chance of long-term remission. MethodsOf consecutive patients with conventionally irresectable colorectal metastases treated by chemotherapy, 16 of 398 (4%) became eligible for curative two-stage hepatectomy combined with chemotherapy and adjuvant nonsurgical interventions as indicated. ResultsTwo-stage hepatectomy was feasible in 13 of 16 patients (81%). There were no surgical deaths. The postoperative death rate (2 months or less) was 0% for the first-stage procedure and 15% for the second-stage one. Postoperative complication rates were 31% and 45%, respectively, with only one complication leading to reoperation. The 3-year survival rate was 35%, with four patients (31%) disease-free at 7, 22, 36, and 54 months. Median survival was 31 months from the second hepatectomy and 44 months from the diagnosis of metastases. ConclusionsTwo-stage hepatectomy combined with chemotherapy may allow a long-term remission in selected patients with irresectable multiple metastases and increases the proportion of patients with resectable disease.Liver resection is the only treatment known to provide long-term survival and the possibility of cure in patients with liver metastases. [1][2][3][4][5][6] However, at the time of diagnosis, most patients have irresectable tumors. Systemic chemotherapy, the current standard treatment, offers these patients a limited benefit, with median survivals not exceeding 12 to 18 months. [7][8][9][10] We combine chemotherapy with other therapeutic modalities and offer resection to patients who respond in such a way that surgery again becomes an option.In patients whose initially irresectable metastases are downstaged by neoadjuvant chemotherapy, one-stage resection provides a survival rate similar to that of patients undergoing primary resection. 11 We have also shown that cryosurgery and portal embolization can increase the resectability rate in patients with colorectal metastases. 12,13 In patients with intrahepatic multinodular diffusion of tumor, however, even with these techniques, it is not always possible to perform a resection that would be curative. An incomplete resection is not indicated because there is no significant survival benefit compared with patients who do not undergo surgery.14 We proposed to modify this practice by using a strategy whose overall intention is cu...

Evolution and revolution of laparoscopic liver resection in Japan

“…However, LLR can still be performed safely if the surgeon understands the pharmacological profile of the chemotherapeutic agents, chooses appropriate surgical instruments, and perform the proper surgical maneuvers 100. A study of the utility of two‐stage hepatectomy for bilobar multiple liver metastases as proactive curative surgical treatment for unresectable liver metastases101 found that two‐stage LLR drastically reduced development of intra‐abdominal adhesions after first‐stage liver resection and thus simplified second‐stage liver resection, which is considered technically difficult, thereby achieving long‐term outcomes comparable to those for open two‐stage hepatectomy 102, 103…”

Experimental evaluation of liver regeneration patterns and liver function following ALPPS

“…Previous studies have indicated that the size of the FLR should be at least 25 per cent of total liver volume1 or a ratio greater than 0·5 between FLR and bodyweight2 3. Various strategies such as portal vein embolization (PVE)4 and two‐stage hepatectomy5 have been developed to increase FLR and enable surgical therapy in patients otherwise deemed unresectable.…”

Adjuvant interleukin-12 gene therapy for the management of colorectal liver metastases

“…However, the resectability rate does not exceed 25%, being limited by the multiplicity of LM. 1 The results obtained with other therapies, such as systemic or hepatic arterial chemotherapy, radiotherapy, or immunotherapy, still remain disappointing. Therefore, novel therapeutic strategies are needed, of which gene therapy still represents an attractive approach.…”