Integrative Concepts for Liver Surgery

Abstract

<b><i>Background:</i></b> Surgery is the standard treatment for primary tumors and metastases. Due to improvements in surgical outcomes as well as the efficacy of systemic treatments, the role of surgery has changed in recent years. <b><i>Summary:</i></b> Liver surgery has become safe and efficient, with resectability being increased by multimodality concepts as well as staged liver resections and orthotopic liver transplantation. These concepts may be applied to primary liver tumors but also to selected patients with liver metastases from various diseases. In addition, even debulking surgery may be indicated for selected patients with endocrine metastases. While patient selection for liver resections was limited to clinical parameters in the past, histological and molecular characteristics have become increasingly important. Moreover, the response to regional or systemic chemotherapy has been demonstrated to be strong for a beneficial course of the disease even in advanced diseases. <b><i>Key-Messages:</i></b> Due to the variety of available treatment options, optimal patient selection is crucial. Besides liver surgery, staged concepts as well as liver transplantation are curative tools for many patients.

Patient-centered developments in colon- and rectal cancer with a multidisciplinary international team: From translational research to national guidelines

“…We were the first worldwide to perform “split time liver resections” in case of far advanced CRLM. TSH and ALPPS later followed our first report in 1993 (see in[ 13 , 23 , 24 ]) and is now routinely practiced in surgical liver units[ 9 , 45 , 46 , 65 , 66 ]. We have observed several patients who live > 5 years after this exceptional surgical treatment with added chemotherapy.…”

“…Chemoembolization, in Germany promoted by a surgical friend, Professor Schultheis KH, is still standard in nonresectable liver tumors nonresponsive to the low concentration systemic i.v. chemotherapy, and applied as rescue therapy in CRLM[ 9 ].…”

“…Our reconstruction experiment in ILP confirmed this hypothesis. Individual response, besides K-ras status and SMAD status is now also a prognosticator for the benefit of downstaging/resection, ALPPS or orthotopic liver transplantation in CRLM[ 9 , 64 , 67 ] . To our knowledge, up to now there is no test to individually select effective chemotherapeutic drugs for systemic chemotherapy, but research is ongoing[ 68 , 69 ].…”

“…One patient, received his second resection of a segment I metastasis by Link KH together with the top specialist for segment I resections from China, Professor Peng SY from the Department for Liver and Transplantation Surgery at Zhejiang University, Hangzhou, China, on occasion of his participation in an ICRCC-congress in Wiesbaden, and the patient remained tumor free for the rest of his life exceeding 5 years. Split time resection thus was the precursor of TSH (Two Stage Hepatectomy) and ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy), both of which have become the treatment of choice in specialized surgical liver units[ 9 , 45 , 46 ].…”

“…The lethal fate of patients with metastasis, e.g. , to the liver[ 8 , 9 ] or to the peritoneum[ 10 , 11 ] has been stepwise diminished, but not abolished. In the late 1980’s surgery was the only treatment of choice for patients with primary colon- and rectal tumors in Germany.…”