Dong K. Kim

Major Hepatic Resection Using Vascular Isolation and Hypothermic Perfusion

The technique and results of 29 major hepatic resections using the method of complete vascular isolation and hypothermic perfusion of the liver are reported. The method enables the surgeon to perform otherwise difficult or impossible resections through chilled bloodless hepatic parenchyma. Major intrahepatic vascular structures can thus be recognized and controlled readily under clear vision. Direct neoplastic involvement of, or tumor thrombi in the portal vein, hepatic vein or vena cava, can be successfully dealt with by appropriate surgical measures. The operative mortality was 10.3% for this series which included many tumors previously deemed unresectable. The technical detail and intraoperative physiologic monitoring crucial to success in the use of the method are described. It is hoped that with the widened scope of resectability afforded by this technique, and the use of adjuvant chemotherapy, the currently experienced low cure rates for hepatic cancer can be improved.

Regional pancreatectomy: en bloc pancreatic, portal vein and lymph node resection.

Eighteen patients are reported who have had a regional pancreatectomy. The pancreatic segment of portal vein was excised with en bloc total pancreatectomy and regional lymph node dissection in all 18. Venous repair was by end-to-end anastomosis without a graft. Five of the 18 also had various arterial resections and reconstructions. Sixteen of the 18 had been explored and deemed nonresectable elsewhere. This operation has doubled the resectability rate in this institution. The 30-day operative mortality rate was 16.6%. Acurarial survival is 62% at one year compared with 36% one year survival rate for patients undergoing pancreaticoduodenectomy for less advanced cancer in previous years. A more valid comparison would be between those who had a palliative procedure since most patients in the present series were initially considered unresectable. One year survival for these patients was 22%. The quality of life was good for most patients.

Major hepatic resection for neoplasia: personal experience in 108 patients.

One hundred eight patients have undergone major hepatic resection by the senior author during the eight year period April 1970 to April 1978. Primary liver cancer was present in 36; metastatic colorectal cancer in 25, miscellaneous metastatic cancers in 15, hepatoblastoma in 5, gallbladder cancer in 4, and bile duct cancer in 3. Benign tumors, principally giant hemangioma, were resected in 20 additional patients. The 30 day operative mortality rate was 9% overall. Prior to 1975, 41 of the resections were done using the vascular isolation perfusion technique. The operative mortality rate of 17% for this technique is a reflection of early experience and the advanced stage of disease of many patients. The operative mortality for the standard resection has been only 4%. Subphrenic abscess has developed in only 13% of patients during the past three years. Postoperative hospitalization has been shortened, being a median of 13 days. The resectability rate for malignant disease was 33%. Forty-six per cent of the resections were performed with curative intent. Fifty-four per cent were palliative, performed in individuals with regional spread or distant metastasis. After curative surgery, three year survival was 88% for individuals with primary liver cancer and 72% with metastatic colorectal cancer. After palliative resection, the rates were 31 and 0%, respectively. The three year survival rate is 46% overall, being 81% for the curative resection group and 18% for the palliative group. Tumor markers proved useful in monitoring patients after hepatic resection.

The seventies evolution in liver surgery for cancer.

During the past decade, one of the major changes in the field of oncology has been in the surgical approach to primary and secondary cancer of the liver. As a result of data and experience gained in liver transplantation programs and with the application of vascular surgical principles, resectability rates have been increased. The present rate of 32% has been achieved with an overall 30‐day operative mortality rate of 9%. More sophisticated intraoperative and postoperative supports have been essential in achieving these results. The median operating time is now 4′3/4 hours in length. Complications are minimal. The median postoperative hospital stay is now 13 days.

Surgical management of carcinoma of the junction of the main hepatic ducts.

Twenty-six patients are reviewed who had primary carcinomas involving the junction of the hepatic ducts. The majority had had an initial procedure of palliative biliary diversion elsewhere and were referred for further treatment. In three cases, en bloc resection of the tumor with total hepatectomy and orthotopic liver transplantation were performed. All tumor growth was encompassed in each case, but within 4 months all succumbed as a result of allograft rejection. Auxitiary (heterotopic) liver transplantation was performed in another patient because of recurrent disease after previous left hepatic resection in continuity with a hilar duct lesion. Five patients underwent hepatic lobectomy with en bloc resection of the hepatic duct junction.When adequate tumor excision was not feasible, biliary diversion could provide good palliation in some instances for extended periods of time. This is demonstrated by one patient who lived for 4 years and 4 months after the initial operation. In the meantime, the patient underwent 6 subsequent procedures of dilating of constricted bile ducts and tube cannulation of the biliary tree. Biliary diversion was achieved in 4 cases by intrahepatic cholangiojejunostomy. One of these patients, who is on chemotherapy, is asymptomatic one year after surgery.

Tumor vascularity as a prognostic factor for hepatic tumors.

The prognostic and therapeutic significance of tumor vascularity was studied in 36 patients with hepatoma or metastatic colon cancer in the liver. All patients had nonresectable tumor and were treated by hepatic artery ligation and hepatic arterial infusion chemotherapy. Chemotherapy consisted of methotrexate, actinomycin-D, 5-fluorouracil and cyclophosphamide. Hepatic tumors were categorized into Grades I to III in the order of increasing vascularity as determined by preoperative hepatic angiography. Tumor vascularity of 15 patients with hepatoma was Grade III in 11 (73%) and Grade II in 4 (27%). No patient with hepatoma had a Grade I tumor. The median survival of patients was 10 and 6 months for Grade III and II hepatomas, respectively, after hepatic artery ligation, and 18 and 8.5 months for Grade III and II, respectively, from the time of diagnosis of hepatoma. Tumor vascularity of 21 patients with metastatic colon cancer was as follows: Grade III in 3 (14%); Grade II in 10 (48%); and Grade I in 8 (38%). The median survival was 11, 10.5 and 4 months for Grades III, II and I, respectively, after hepatic artery ligation, and 17, 14.5 and 7.2 months for Grades III, II and I, respectively, from the time of diagnosis of hepatic metastases of colon cancer. The results indicate that the more vascular the hepatic tumor on angiogram, the better the prognosis following hepatic artery ligation and infusional chemotherapy.

Vagotomy-pyloroplasty for prevention of gastric ulcer in pig liver transplantation

Morphophysiological similarities of the livers of the pig and human make the pig an ideal model for the study of liver transplantation. Frequent gastric ulcers after transplantation, however, are troublesome. Although vagotomy-pyloroplasty prevents pig gastric ulcer very effectively [4], peculiarities of the pig anatomy hinder its application. The present communication reports a simple method for vagotomy and its results in pig liver transplantation.