https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.20703

AASLD position paper : the management of acute liver failure

No consensus on the indications for surgical resection of colorectal liver metastases exists. This systematic review has been undertaken to assess the published evidence for its efficacy and safety and to identify prognostic factors. Studies were identified by computerised and hand searches of the literature, scanning references and contacting investigators. The outcome measures were overall survival, disease-free survival, postoperative morbidity and mortality, quality of life and cost effectiveness, and a qualitative summary of the trends across all studies was produced. Only 30 of 529 independent studies met all the eligibility criteria for the review, and data on 30-day mortality and morbidity only were included from a further nine studies. The best available evidence came from prospective case series, but only two studies reported outcomes for all patients undergoing surgery. The remainder reported outcomes for selected groups of patients: those undergoing hepatic resection or those undergoing curative resection. Postoperative mortality rates were generally low (median 2.8%). The majority of studies described only serious postoperative morbidity, the most common being bile leak and associated perihepatic abscess. Approximately 30% of patients remained alive 5 years after resection and around two-thirds of these are disease free. The quality of the majority of published papers was poor and ascertaining the benefits of surgical resection of colorectal hepatic metastases is difficult in the absence of randomised trials. However, it is clear that there is group of patients with liver metastases who may become long-term disease- free survivors following hepatic resection. Such survival is rare in apparently comparable patients who do not have surgical treatment. Further work is needed to more accurately define this group of patients and to determine whether the addition of adjuvant treatments results in improved survival.

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Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies.

Objective
To assess feasibility, risks, and patient outcomes in the treatment of colorectal metastases with two-stage hepatectomy.

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Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors.

OBJECTIVE: The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. SUMMARY BACKGROUND DATA: The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient. METHODS: From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-to-recipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient. RESULTS: Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the original graft at a median follow-up of 6.5 months (range, 5-10 months). CONCLUSIONS: When performed by a team with experience in hepatectomy and transplantation, LDLT, using an extended right lobe graft, can achieve superior results. The technique extends the success of LDLT from pediatric recipients to adult recipients and opens a new donor pool for adults to receive a timely graft of adequate function.

Adult-to-adult living donor liver transplantation using extended right lobe grafts.

Liver resection has been recognized as the treatment of choice for patients with colorectal liver metastases (CLM), offering long-term survival and the only hope for cure.1–3 However, hepatectomy can be performed only in approximately 10% to 20% of patients with CLM.4 In the majority of cases, liver surgery is contraindicated due to too small future remnant liver (FRL).5–7 During the last years, new multidisciplinary therapies have been proposed to increase safely the resectability rate in patients with initially nonresectable CLM. They include portal vein embolization (PVE),8–10 systemic or arterial hepatic neoadjuvant chemotherapy,11,12 transarterial neoadjuvant immunochemotherapy,13 and local tumoral destruction.14,15 However, these adjuvant therapies do not allow to achieve a curative resection in all patients and particularly in patients with multiple bilobar CLM (MBCLM). In these patients, the resection of MBCLM would result in a too small FRL. A 2-stage hepatectomy procedure (TSHP) without PVE was advocated to treat patients with unresectable multiple metastases.16 However, after resection of MBCLM, high mortality (9%–15%) was reported.16,17 Liver failure due to insufficient functional volume of the FRL is the main cause of postoperative mortality. Preoperative PVE has been proposed to induce compensatory hypertrophy of the FRL.8,9 Some successful cases undergoing right hepatectomy and simultaneous left hemiliver wedge resections after PVE have been reported in patients with MBCLM.18 However, growth of metastatic nodules in the FRL after PVE can be more rapid than that of the nontumoral remnant hepatic parenchyma.19 Therefore, metastases located in the FRL should be ideally resected before PVE in a first-stage hepatectomy; a major hepatic resection can then be performed, after PVE, in a second-stage hepatectomy. Therefore, a new strategy design has been developed to treat patients with initially unresectable MBCLM. Our preliminary results were previously reported.20

The present study reports feasibility, surgical outcome, recurrence rate, and long-term survival of patients presenting initially unresectable MBCLM undergoing a TSHP combined with PVE.

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A Two-Stage Hepatectomy Procedure Combined With Portal Vein Embolization to Achieve Curative Resection for Initially Unresectable Multiple and Bilobar Colorectal Liver Metastases

OBJECTIVE: The authors report on the experience of orthotopic liver transplantation in fulminant hepatitis at Paul Brousse Hospital. SUMMARY BACKGROUND DATA: Liver transplantation is a breakthrough in the treatment of patients with fulminant hepatitis. However, the indications, the timing for transplantation, the type of transplantation, and the use of ABO incompatible grafts in this setting still are debated. METHODS: Transplantation was indicated in patients with confusion or coma and factor V less than 20%, younger than 30 years of age, and confusion or coma and factor V less than 30% older than 30 years of age. RESULTS: Among 139 patients who met the aforementioned criteria for transplantation, 1 recovered, 22 died before transplantation, and 116 underwent transplants with a 1-year survival of 68%. Survival was 83% in patients with grade 1 and 2 comas at transplantation versus 56% (p < 0.001) in those with grade 3 comas; it was 51% versus 81% (p < 0.001) in those transplanted with high risk (ABO-incompatible, split, or steatotic) and low-risk grafts, respectively. In a multivariate analysis, steatotic and partial grafts were predictive of poorer patient survival, and ABO incompatibility was predictive of poorer graft survival. CONCLUSIONS: Orthotopic liver transplantation is an effective treatment in fulminant hepatitis. Use of high-risk grafts permitted transplantation of 83% of patients, but was responsible for higher mortality.

Orthotopic liver transplantation in fulminant and subfulminant hepatitis. The Paul Brousse experience.

ObjectiveThe authors evaluate the results of cryosurgery in malignant liver tumors.Summary Background DataThe outcome of primary or secondary liver tumors is poor when resection can not be achieved. Encouraging results of cryosurgery have been reported in unresectable liver tumors, but this trea

Place of cryosurgery in the treatment of malignant liver tumors.

Objective The authors objective is to report their recent experience with split-liver transplantation, focusing on the results and the impact on organ shortage. Background Data There is an insufficient number of organs for liver transplantation. Split-liver transplantation is a method to increase the number of grafts, but the procedure is slow to gain wide acceptance because of its complexity and the poor results reported in previous series. Methods During the year 1995, the authors split 20 of 83 transplantable livers allocated to the authors' center, generating 40 grafts: 23 were transplanted locally and 17 were given to partner centers. During the same period, the authors accepted four split-liver grafts proposed to them by other centers. Overall, 27 split-liver transplantations were done in the authors' unit, accounting for 30% of the 90 transplants performed in 1995. Results One-year patient and graft survival rates for split-liver transplantation were 79.4% and 78.5%, respectively. Arterial and biliary complications rates were 15% and 22%, respectively, with none leading to graft loss. Primary nonfunction occurred in one case (4%). By splitting 24 of 87 transplantable livers (4 of which were in partner units), a total of 111 transplantations were performed, increasing graft availability by 28%. Conclusions Split-liver transplantation is achieving graft and patient survival rates similar to that of whole liver transplantation despite a higher incidence of complications, which could become less frequent as experience is gained with this procedure. A wider acceptance of split-liver transplantation could markedly increase the supply of liver grafts.

Marc Johann

Papers

Orthotopic liver transplantation in fulminant and subfulminant hepatitis. The Paul Brousse experience.

Place of cryosurgery in the treatment of malignant liver tumors.

Split-liver Transplantation: The Paul Brousse Policy