**6. Repeat resections**

160 Liver Tumors

The principles are the same for the three techniques, which differ only in the extent to which liver is mobilized from its vascular connections, hylum and caval vein. Generally, a veno-venous bypass is used to avoid venous congestion during prolonged caval and portal crossclamping and a hypothermic preservation solution is instilled through the portal vein (Fortner et al. 1978). In a study population about liver resection under TVE, Azoulay et al. concluded that standard TVE of any duration with hypothermic perfusion of the liver, in this issue in-situ procedure, was associated with a better tolerance to ischemia. Furthermore, compared with TVE ≥ 60 minutes, it was associated with better post-operative liver and renal functions and lower morbidity (Azoulay et al. 2005). The main indications of the three techniques are tumours that involve vascular structures of the hylum, venous confluence or inferior vena cava (IVC), or are in close proximity to them. The technique can be used for benign, primary or metastatic tumours. The decision about what technique to use depends on the tumour location and its relationship with the three hepatic veins and caval vein. It is important to notice that the ex-situ technique is losing support due to its high morbidity and mortality. The location of the lesion or lesions in or near the suprahepatic IVC represents a true challenge due to the impossibility of using conventional resection techniques. Furthermore, optimal perioperative anaesthetic management is crucial in this setting, and the anaesthesia team

The involvement of the inferior vena cava does not necessarily preclude resection (Figure 5). Liver resection with reconstruction of the IVC can be performed in selected cases. The resected IVC may then be replaced with an autogenous vein graft or a prosthetic material. The mortality rate of resection IVC is 4.5-25% and morbidity up to 40% (Azoulay et al. 2005). The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative approaches is considered (Hemming et al. 2004).

In conclusion, liver resections, due to the adoption of several advanced techniques, such as vascular exclusion, veno-venous bypass, hypothermic perfusion of the liver (in-situ, antesitu or ex-situ), have become more common and, when IVC is involved, resection of the vein

Fig. 5. Huge liver metastasis in a 64 year old patient with colon cancer. First surgery was an extended right hepatectomy plus Sg 1 segmentectomy, after PVE of right and Sg 4 portal

should be familiar with the hepatic transplant procedure.

veins. A left hemicolectomy was performed 7 weeks later.

is no longer considered a contraindication.

The first large series of liver resections for secondary tumours was reported in 1978 (Foster 1978). By improvement in surgical techniques, peri-operative patient's care and management of complications, the morbidity and mortality associated with liver resection were reduced. This has been a very important factor to increase the aggressiveness of the surgical approach.

Fig. 6. LiverMet database, with permission.

Liver recurrence of CRC is common (Figure 6) but only 5-27% of the patients are candidates for potentially curative repeated hepatectomy. About 70% of recurrences will be observed within the first 12 months after resection and 92% will be apparent within 24 months (Langenhoff et al. 2009). In medically fit patients, repeat hepatectomy has emerged as a safe and effective procedure under the same criteria of selection of the first hepatectomy. Although the prognostic variables provide rough indicators of prognosis, they should not be used as absolute contraindications to surgery. The multidisciplinary team should plan the strategy individually. Each new re-hepatectomy needs a particular and specific evaluation: disease-free interval, number of metastases, quality of life, general health condition, resectable extrahepatic disease, assessment of residual liver volume, etc. by the multidisciplinary team (Figure 7).

Fig. 7. A 63 year old patient with right hepatectomy plus Sg 4a resection; 24 months later a recurrence involving the only hepatic vein (left hepatic vein) appeared. Tumour was removed and the left hepatic vein was reimplanted in the caval vein using graft prosthesis (less than 60 minutes of total vascular exclusion).

Liver recurrence of CRC is common (Figure 6) but only 5-27% of the patients are candidates for potentially curative repeated hepatectomy. About 70% of recurrences will be observed within the first 12 months after resection and 92% will be apparent within 24 months (Langenhoff et al. 2009). In medically fit patients, repeat hepatectomy has emerged as a safe and effective procedure under the same criteria of selection of the first hepatectomy. Although the prognostic variables provide rough indicators of prognosis, they should not be used as absolute contraindications to surgery. The multidisciplinary team should plan the strategy individually. Each new re-hepatectomy needs a particular and specific evaluation: disease-free interval, number of metastases, quality of life, general health condition, resectable extrahepatic disease, assessment of residual liver volume, etc. by the

Fig. 7. A 63 year old patient with right hepatectomy plus Sg 4a resection; 24 months later a recurrence involving the only hepatic vein (left hepatic vein) appeared. Tumour was removed and the left hepatic vein was reimplanted in the caval vein using graft prosthesis

(less than 60 minutes of total vascular exclusion).

multidisciplinary team (Figure 7).

The LiverMet Survey includes 12448 liver resections of which 14.5% are repeated hepatectomies (Figure 8, Table 2). Patients likely to benefit of this approach represent a small and highly selected group. Maybe, an accurate genetic, immunohistochemical and histological profile of the patient's tumour will be able to conclude who will benefit from this aggressive treatment.

Fig. 8. LiverMet Survey: number of hepatectomies.


Table 2. Repeat hepatectomies series and survival rates.

Recurrence after repeat hepatectomy has been reported in 60–80% of patients (Smith & McCall 2009). A few have resectable disease limited to the liver and may be candidates for a third or even fourth hepatic resection. In our group there are two patients with five hepatectomies. Reports of large repeated hepatectomy series show that 9-30% of patients who underwent a second hepatectomy for colorectal liver metastases had a third resection (Fong et al 1999; Söreide et al. 2008; Yamamoto et al. 1999; Petrowsky et al. 2002) and 4% of them had a fourth resection (Adam et al. 2003; Yamamoto et al. 1999). The safety of multiple repeated hepatic resections has been demonstrated in recent reports, and long-term survivors have been documented (Adam et al. 2003; Nordlinger et al, 1994; Yamamoto et al. 1999; Petroswsky et al. 2002). LiverMet Survey published the largest series (n = 251) of third hepatectomies for recurrent CRC liver metastases with a survival benefit of 29% at 5 years. Adam et al. published a large series of patients who underwent a third liver resection with zero mortality and a morbidity rate of 5%, not significantly different from those who have had only one or two liver resections. In addition, patients with a third liver resection had a survival benefit of 32–38% at 5 years (Adam et al. 2003; Yamamoto et al. 1999). Major hepatectomy is possible in a minority of these patients, who represent a small and highly selected group (Petrowsky et al. 2002).
