Liver-sparing surgery may increase survival in patients with liver cancer

A surgical approach in which less than one lobe of the liver is removed in a patient undergoing resection for liver cancer is associated with lower mortality and complication rates, according to new study results published in the Journal of the American College of Surgeons (2015; doi:10.1016/j.jamcollsurg.2014.12.026).

Historically, the most common surgical method of treatment for liver cancer was a major hepatectomy in which a lobe (hemi-liver) is removed in order to remove the tumor. The 5-year survival rate of selected patients who undergo a complete resection is as high as 50%, yet many people do not undergo the surgery because of its high complication rate, blood loss, and liver dysfunction associated with a major hepatectomy.

However, over the last 20 years surgery on the liver has become safer and more effective due to advances in surgical and anesthetic techniques and operating room devices; improvements in perioperative patient care; and a much wider availability of surgeons who are trained in liver surgery techniques.

When a patient has a single tumor, or tumors confined to one side of the liver, a surgical approach called hepatic parenchymal preservation is far better for the patient than the traditional approach of removing large sections of the liver. This preservation procedure involves removing less than a lobe of the liver without compromising principles of cancer surgery. It places less physical stress on the body, and gives patients a quicker recovery time and the option to have another operation if the cancer recurs.

"The majority of patients with metastatic colorectal cancer are never sent to a liver surgeon because of the impression that a liver operation is too dangerous and patient outcomes are poor," according to T. Peter Kingham, MD, FACS, lead study author and a surgeon at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, New York. "But we've shown that it's possible to do safe liver resection, so patients should be considered for hepatic parenchymal preservation."

A total of 3,875 patients underwent 4,152 resections for cancer and were entered into the MSKCC database. The most common diagnosis was metastatic colorectal cancer. The researchers divided the patients into three equal groups according to time period: early (1993 to 1999), middle (2000 to 2006), and late (2007 to 2012).

Over the study period, the 90-day mortality rate decreased from 5% to 1.6%. Overall complications dropped from 53% to 20%. The percentage of major hepatectomies decreased from 66% to 36%. The transfusion rate decreased from 51% to 21%, and liver dysfunction for all cases decreased from 3% to 1%.

"This change in approach to resection appears to be largely responsible for the decrease in overall mortality, given that the mortality rate associated with major liver resections remained constant over the entire study period," Kingham said.

The study authors concluded that encouraging parenchymal preservation and preventing abdominal infections are critical for continued improvement of liver procedure outcomes.

"The biggest takeaway from our study is that parenchymal preservation should be applied to all patients undergoing liver operations for malignancies because the data show that the mortality rate and complication rate, the blood loss, the requirement for blood transfusions, time in the hospital, all of these things which we are all trying to improve on, are all less," Kingham said.

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