Vascular reconstruction combined with liver resection for malignant tumours (Br J Surg 2013; 100: 1764-1775).

TLDR: It is shown here that combining this type of surgery with another major intra-abdominal procedure is associated with an increased risk of death, and there is increasing consensus that such complex procedures should be performed only in very high-volume experienced centres and that they should probably not be combined with other intra-ABdominal surgical procedures.

Abstract: This study reports on one of the largest single-centre series on vascular resection and reconstruction combined with liver resection for malignant liver tumours. The long time span of the study, its retrospective nature and the heterogeneity of the tumours decrease the strength of this report, yet this is compensated for by the large number of procedures performed in an internationally well recognized hepatopancreatobiliary unit. The authors demonstrate that it is technically feasible to perform major hepatic resections combined with vascular resections and subsequent reconstruction. For the two most common tumours in this study, colorectal cancer metastases and cholangiocarcinomas, this was associated with acceptable long-term oncological outcomes. The authors detail the intraoperative approach regarding vascular occlusions, in situ perfusion and venovenous bypass shunts, as well as their policy for prevention and detection of thrombosis of vessels in the postoperative phase. Early diagnosis of vessel occlusion is a prerequisite for undertaking this type of surgery safely, and requires a dedicated multidisciplinary team and setting. The mortality rate in this series was 14 per cent, whereas mean intensive care stay was around 14 days, both indicators of the significant nature of this type of surgery. Although reports from Asia1 suggest that liver resection combined with vascular resection and reconstruction can be performed with mortality rates as low as 2 per cent, similar series from Europe2 have not been able to reproduce this and mortality may be well in excess of 10 per cent. Azoulay and colleagues show here that combining this type of surgery with another major intra-abdominal procedure is associated with an increased risk of death. There is now increasing consensus (associating liver partition with portal vein ligation for staged hepatectomy, 10th Congress of the European–African Hepato-Pancreato-Biliary Association, Belgrade, Serbia, May 2013) that such complex procedures should be performed only in very high-volume experienced centres and that they should probably not be combined with other intra-abdominal surgical procedures.