Declan Dunne

Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases†

The evidence surrounding optimal follow‐up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.

Randomized clinical trial of prehabilitation before planned liver resection

Patients with low fitness as assessed by cardiopulmonary exercise testing (CPET) have higher mortality and morbidity after surgery. Preoperative exercise intervention, or prehabilitation, has been suggested as a method to improve CPET values and outcomes. This trial sought to assess the capacity of a 4‐week supervised exercise programme to improve fitness before liver resection for colorectal liver metastasis.

Enhanced recovery in the resection of colorectal liver metastases.

There is limited evidence for the use of enhanced recovery after surgery (ERAS) in patients undergoing hepatectomy, and the impact of the evolution of ERAS over time has not been examined. This study sought to evaluate the effect of an evolving ERAS program in patients undergoing hepatectomy for colorectal liver metastases (CRLM).

Microwave ablation of ex vivo human liver and colorectal liver metastases with a novel 14.5 GHz generator

Purpose: This study assessed the relationship between time, power and ablation size using a novel high-frequency 14.5 GHz microwave applicator in ex vivo human hepatic parenchyma and colorectal liver metastases. Previous examination has demonstrated structurally normal but non-viable cells within the ablation zone. This study aimed to further investigate how ablation affects these cells, and to confirm non-viability. Materials and methods: Ablations were performed in ex vivo human hepatic parenchyma and tumour for a variety of time (10–180 s) and power (10–50 W) settings. Histological examination was performed to assess cellular anatomy, whilst enzyme histochemistry was used to confirm cellular non-viability. Transmission electron microscopy was used to investigate the subcellular structural effects of ablation within these fixed cells. Preliminary proteomic analysis was also performed to explore the mechanism of microwave cell death. Results: Increasing time and power settings led to a predictable and reproducible increase in size of ablation. At 50 W and 180 s application, a maximum ablation diameter of 38.8 mm (±1.3) was produced. Ablations were produced rapidly, and at all time and power settings ablations remained spherical (longest:shortest diameter <1.2). Routine histological analysis using haematoxylin-eosin (H&E) confirmed well preserved cellular anatomy despite ablation. Transmission electron microscopy demonstrated marked subcellular damage. Enzyme histochemistry showed complete absence of viability in ablated tissue. Conclusions: Large spherical ablation zones can be rapidly and reproducibly achieved in ex vivo human hepatic parenchyma and colorectal liver metastases using a 14.5 GHz microwave generator. Despite well preserved cellular appearance, ablated tissue is non-viable.

Cardiopulmonary exercise testing before liver surgery

Cardiopulmonary exercise testing (CPET) assessed “poorer” fitness correlates with poorer outcomes in blinded studies. Whether this correlation will persist when CPET is utilized to stratify care as part of a multi‐modal enhanced recovery after surgery (ERAS) program is unclear. This study examined whether CPET variables were associated with postoperative morbidity in patients undergoing hepatectomy within an ERAS program.

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BACKGROUND Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma. METHODS A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded. RESULTS Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively. CONCLUSIONS Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

The role of hepatectomy in the management of metastatic gastric adenocarcinoma: A systematic review

BACKGROUND Gastric cancer has a high mortality, with many patients presenting with advanced disease. Many patients who undergo curative gastrectomy will subsequently develop metastatic disease. Hepatectomy has an established place in treating metastases from a variety of cancers but its role in gastric cancer is not clear. This review sought to systematically appraise the literature to establish the role of hepatectomy in treating gastric cancer metastases. METHOD Medline and EMBASE were searched for all papers publishing data on survival of patients with metastatic gastric adenocarcinoma who underwent hepatectomy. RESULTS Seventeen studies with 438 patients were included. There were no randomised controlled trials. Perioperative mortality was 2%, with morbidity between 17 and 60%. Patients with solitary metastases appeared to have better survival. Other favourable survival characteristics included unilobar disease, and metachronous presentation. No advantage was demonstrated with either adjuvant or neoadjuvant chemotherapy. DISCUSSION Few patients with hepatic metastases from gastric cancer are suitable for hepatectomy, but for those suitable there appears to be survival benefit. Patients with synchronous, multiple or bilobar metastases have worse survival. CONCLUSION The evidence supporting the role of hepatectomy in the treatment of hepatic metastases from gastric cancer is weak. However in a selected group there appears to be a survival advantage; patients with solitary metastases had better survival outcomes than those with multiple metastases and metachronous presentation was associated with a better prognosis than synchronous presentation. Hepatectomy should be considered in these patients in the setting of a randomised trial.

A systematic review of the role of hepatectomy in the management of metastatic renal cell carcinoma.

AIM This review sought to systematically appraise the literature to establish the role of hepatectomy in treating renal cell carcinoma hepatic metastases. METHOD Medline and EMBASE were systematically searched for papers reporting survival of patients who underwent hepatectomy for metastatic renal cell carcinoma. RESULTS Six studies containing 140 patients were included. There were no randomised controlled trials. Perioperative mortality was 4.3%, with reported morbidity between 13 and 30%. Patients with metachronous presentation, and a greater time interval between resection of primary tumour and development of metachronous metastases, appeared to have better survival. There was no difference in survival between patients with solitary and multiple metastases. CONCLUSION Few patients with hepatic metastases from renal cell carcinoma are suitable for hepatectomy as metastatic disease is usually widespread. Selected patients may experience a survival benefit, but identifying these patients remains difficult.

Biopsy is not appropriate for incidentally detected liver lesions.

Patel and colleagues’ recommendations on liver biopsy for incidentally detected liver lesions are worrying.1 We see up to 10 such newly detected lesions each week in our cancer network hepatobiliary multidisciplinary team. By using high quality computed tomography, magnetic resonance imaging with hepatocyte specific contrast agents, and contrast ultrasound scanning, it has been more than five years since we have …

Optimal perioperative care in peri-hilar cholangiocarcinoma resection

SummarySurgical resection remains the only proven curative treatment for peri-hilar cholangiocarcinoma. Despite recent advances in liver surgery techniques and perioperative care, resection for peri-hilar cholangiocarcinoma remains associated with significant morbidity and mortality. Considerable variation in the perioperative management of these patients exists. Optimal perioperative management has the potential to deliver improved outcomes. This article seeks to summarize the evidence underpinning best practice in the perioperative care of patients undergoing resection of peri-hilar cholangiocarcinoma. The authors also seek to identify areas where research efforts and future clinical trials should be targeted.