FREQUENCY, TECHNICAL, ASPECTS, RESULTS, A ND INDICATIONS OF MAJOR HEPATECTOMY AFTER PROLONGED INTRAARTERIAL HEPATIC CHEMOTHERAPY FOR INITIALLY UNRESECTABLE HEPATIC-TUMORS

Background: Major hepatectomy after prolonged intra-arterial hepatic c hemotherapy (IAHC) is extremely rare, because IAHC usually fails to re duce the tumor volume sufficiently or obtain a long duration of respon se, or both, and because it impairs hepatic function. The present repo rt was done to study the frequency, feasibility and the results of hep atectomy following IAHC. Study design: This retrospective study consis ted of 14 patients treated with at least six courses of IAHC (mean of 17.6, median of 13, range of six to 48 courses) for hepatic tumors: co lorectal metastases (n = 9), apudoma metastases (n = 3), and hepatobla stoma (n = 1). Systemic chemotherapy was associated in eight cases dur ing (n = 5), or after (n = 3) IAHC. Initially, multiple hepatic tumors were unresectable in ten cases. They eventually became resecable, but were associated with extensive extrahepatic sites of involvement in f our cases. All patients underwent curative major hepactectomy after a careful and specific morphologic and functional hepatic assessment. Ri ght portal vein embolization was performed preoperatively upon three p atients, resulting in 38, 44 and 77 percent hypertrophy of the left lo be before hepatectomy. Hepatectomy was also performed upon three patie nts with hepatic arterial thrombosis induced by IAHC, after a careful workup of the neoarteriovascularization of the liver. Results. These 1 4 cases only represented 5.8 percent of the 239 patients in whom a cat heter was inserted for IAHC, and 4.2 percent of the 335 patients who h ad hepatectomy for carcinoma. Postoperatively, there was no mortality and no clinical hepatic insufficiency. However, ten complications occu rred in eight patients (three of them resulted in reoperation). Histol ogic examination revealed substantial modifications of the hepatic par enchyma because of IAHC. Results concerning survival were very encoura ging: five of the nine patients with metastases of the colon and rectu m are free of disease, with a mean follow-up period of 36 months after the beginning of IAHC. Conclusions: The decision to perform a major h epatectomy after prolonged IAHC is difficult and must be based on an o utput morphologic assessment with computed tomographic portography and a careful evaluation of functional liver impairment because of IAHC ( the therapeutic strategy proposed by Makuuchi for hepatectomy in patie nts with cirrhosis, based on indocyanine green clearence and volume to resect, is very useful for this purpose). Hepatectomy is technically difficult to perform following IAHC because of a flabby parenchyma and unusually high pressure in the small central hepatic veins. This draw -back is circumvented by using techniques: such as preoperative hypert rophy of the future remaining liver, a transparenchymatous approach of vasculobiliary structures, and intermittent clamping of the hepatic p edicle or vascular isolation of the liver. Postoperative complications occurred more frequently than after major, hepatectomy in other clini cal settings (p < 0.05). However, as this therapeutic approach greatly increases survival, it should not be neglected by clinicians, althoug indications for its use are very rare.