Two-Stage Liver Surgery



Fig. 13.1
Indication of two-stage hepatectomy for colorectal liver metastases at Paul Brousse Hospital. (a) When the multinodular tumors are distributed unilobar and thought to be unresectable because of small future liver remnant (FLR), portal vein embolization (PVE) followed by one-stage hepatectomy is performed. (b) When the multinodular tumors are distributed bilobar but the largest tumor size is ≤30 mm and the tumor number in the FLR ≤3, standard one-stage hepatectomy with simultaneous local ablation therapy is performed. (c) When the multinodular tumors are distributed bilobar, the largest tumor size is >30 mm and the tumor number in the FLR >3, two-stage hepatectomy (TSH) is performed




Table 13.1
Demographics of studies of two-stage hepatectomy for colorectal liver metastases in the literature




































































































































































Study
Year
Country
Study periods
Total No. of surgically treated pts. for CLM
No. of pts. planned for TSH
Percentage of pts. planned for TSH (%)

Lygidakis et al.
2004
Greece
1991–2003
NR
62
NR

Garcea et al.
2004
UK
2001–2003
446
11
3

Pamecha et al.
2008
UK
1999–2005
280
14
5

Homayounfar et al.
2009
Germany
2005–2007
NR
24
NR

Tsai et al.
2010
USA
1994–2008
720
45
6

Karoui et al.
2010
France
2000–2008
NR
33
NR

Tsim et al.
2011
UK
2003–2006
131
38
29

Brouquet et al.
2011
USA
2002–2010
890
65
7

Narita et al.
2011
France
1996–2009
753
80
11

Stella et al.
2012
France
1995–2009
1042
56
5

Bowers et al.
2012
UK
2004–2010
NR
33
NR

Tanaka et al.
2012
Japan
2003–2011
232
24
10

Turrini et al.
2012
France
2000–2010
NR
48
NR

Muratore et al.
2012
Italy
1997–2009
653
47
7

Cardona et al.
2014
USA
2000–2009
1188
40
3

Giuliante et al.
2014
Italy
2002–2011
NR
130
NR

Faitot et al.
2015
France
2004–2010
NR
50
NR

Imai et al.
2015
France
2000–2012
845
125
15


When multiple publications were identified from the same institutions, only the most recent publication was included. CLM colorectal liver metastases, TSH two-stage hepatectomy, NR not reported




Concomitant Extrahepatic Disease


Previous studies reported the rate of concomitant extrahepatic disease to be ranged from 0 to 33% in patients who were planned for TSH (Table 13.2). At Paul Brousse Hospital, the presence of extrahepatic metastases is not considered a contraindication for hepatectomy if these are limited and resectable. When limited extrahepatic disease is located in the abdominal cavity (i.e. pedicular lymph node or peritoneal metastases), resection is performed at the time of first-stage hepatectomy. When extrahepatic disease is located outside the abdomen (such as lung metastasis), resection is usually performed 2–3 months after the second-stage hepatectomy, provided that the disease remains controlled by chemotherapy. In our recent study (2000–2012), concomitant extrahepatic disease was observed in 26% of the patients who were planned for TSH [12]. Among them, resection of concomitant extrahepatic disease was consequently achieved in 42%. Remaining concomitant extrahepatic disease was not resected mainly because of disease recurrence after second-stage hepatectomy or in cases of TSH failure. In our treatment strategy, the presence of extrahepatic disease was neither a predictive factor of TSH failure nor a prognostic factor of survival after TSH (unpublished data). What is crucial however, is to envisage resection of concomitant extrahepatic disease when the disease is controlled by chemotherapy.


Table 13.2
Perioperative features at first-stage hepatectomy











































































































































































































 
Concomitant extrahepatic disease (%)
Preoperative chemotherapy (%)
Simultaneous resection of primary tumor (%)
Major resection (%)
Concomitant use of local ablation therapy (%)
Intraoperative PVE/PVL (%)
Morbidity (%)
Mortality (%)

Lygidakis et al.
NR
NR
100
0
100
100
11
0

Garcea et al.
0
100
0
28
0
NR
NR
0

Pamecha et al.
0
100
0
14
0
0
0
0

Homayounfar et al.
4
75
0
0
29.2
100
13
0

Tsai et al.
7
71
49
25
23
73
26
4

Karoui et al.
12
61
100
0
15
52
21
0

Tsim et al.
0
97
0
NR
0
0
11
0

Brouquet et al.
0
100
29
3
3
0
25
0

Narita et al.
14
84
31
0
32
4
14
0

Stella et al.
6
96
49
4
76
61
37
0

Bowers et al.
0
85
31
23
9
3
23
0

Tanaka et al.
33
100
NR
5
0
86
29
0

Turrini et al.
0
100
37
0
67
0
10
0

Muratore et al.
26
79
0
4
0
23
19
0

Cardona et al.
0
100
100
2
9
9
14
0

Giuliante et al.
26
87
55
3
4
52
17
0

Faitot et al.
10
90
NR
NR
38
88
18a

2

Imai et al.
26
98
30
2
10
76
14a

1


aMajor complication (Clavien ≥ III)

PVE portal vein embolization, PVL portal vein ligation, NR not reported


Surgical Procedures of TSH



First-Stage Hepatectomy


At Paul Brousse Hospital, during the first-stage hepatectomy, either the most invaded hemiliver (usually the right) is resected, or, in most cases, the less-invaded liver lobe (FLR) is cleared of its metastases [10, 12, 13]. In the literature, limited hepatectomy (<3 segments) was mainly performed during first-stage hepatectomy (Fig. 13.2). Clearance is generally obtained by non-anatomical resection (Fig. 13.2a), and local ablation therapy such as cryotherapy and radiofrequency ablation (RFA), is only used in combination with hepatectomy for the treatment of unresectable tumors deeply located in the FLR with the purpose of sparing liver parenchyma of the FLR. Portal vein ligation (PVL)/PVE is routinely performed intraoperatively during the first-stage. Previous studies reported that stimulation of liver hypertrophy could also accelerate intrahepatic tumor progression after PVE [14–17]. From this aspect, what is essential during first-stage hepatectomy is that all tumors in the FLR should be removed to avoid tumor regrowth, leading to the failure to proceed to second-stage procedure.

A331430_1_En_13_Fig2_HTML.jpg


Fig. 13.2
Procedure of two-stage hepatectomy. (a) During the first-stage hepatectomy, in most cases, the less-invaded liver lobe is cleared of its metastases, usually by non-anatomical resection. (b) Ligation of right portal vein. (c) Embolization by dehydrated ethanol. For the safety of second-stage hepatectomy, portal vein ligation and embolization is routinely performed during first-stage hepatectomy


Portal Vein Ligation/Embolization


At Paul Brousse Hospital, for the safety of second-stage hepatectomy, PVE using dehydrated ethanol in combination with ligation is routinely performed during first-stage hepatectomy (about 82%) (Fig. 13.2b, c) [12]. If PVL/PVE is not performed during first-stage, percutaneous PVE is added after first-stage (about 18%). The volume of FLR is evaluated by volumetric computed tomography (CT) analysis 4–6 weeks later. Whether PVL/PVE is performed during or after first-stage hepatectomy seems to depend on institutions (Tables 13.2 and 13.3).


Table 13.3
Perioperative features at second-stage hepatectomy































































































 
Interval duration (days)
Interval PVE (%)
Interval chemotherapy (%)
Major hepate ctomy (≥3 segments) (%)
Concomitant use of local ablation therapy (%)
Morbidity (%)
Mortality (%)

Lygidakis et al.
40
0
100
77
0
11
3

Garcea et al.
150
NR
0
78
0
33
0

Pamecha et al.
210
35.7
100
73
0
27
0

Homayounfar et al.
42
0
0
73
11
58
5

Tsai et al.
135
4
62
80
17
26
6

Karoui et al.
111
15
76
92
4
32
4

Tsim et al.
NR
95
13
NR
0
33
0

Brouquet et al.
32
70
19
85
0
49
0

Narita et al.

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Nov 6, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Two-Stage Liver Surgery

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