FREQUENCY, TECHNICAL ASPECTS, RESULTS, AND 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 results of hepate ctomy following IAHC. STUDY DESIGN: This retrospective study consisted 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: color ectal metastases (n=9), apudoma metastases (n=4), and hepatoblastoma ( n=1). Systemic chemotherapy was associated in eight cases during (n=5) or after (n=3) IAHC. Initially, multiple hepatic tumors were unresect able in ten cases. They eventually became resectable, but were associa ted with extensive extrahepatic sites of involvement in four cases. Al l patients underwent curative major hepatectomy after a careful and sp ecific morphologic and functional hepatic assessment. Right portal vei n embolization was performed preoperatively upon three patients, resul ting in 38, 44, and 77 percent hypertrophy of the left lobe before hep atectomy. Hepatectomy was also performed upon three patients with hepa tic arterial thrombosis induced by IAHC, after a careful workup of the neoarteriovascularization of the liver. RESULTS: These 14 cases only represented 5.8 percent of the 239 patients in whom a catheter was ins erted for IAHC, and 4.2 percent of the 335 patients who had hepatectom y for carcinoma. Postoperatively, there was no mortality and no clinic al hepatic insufficiency. However, ten complications occurred in eight patients (three of them resulted in reoperation). Histologic examinat ion revealed substantial modifications of the hepatic parenchyma becau se of IAHC. Results concerning survival were very encouraging: five of the nine patients with metastases of the colon and rectum are free of disease, with a mean follow-up period of 36 months after the beginnin g of IAHC. CONCLUSIONS: The decision to perform a major hepatectomy af ter prolonged IAHC is difficult and must be based on an output morphol ogic assessment with computed tomographic portography and a careful ev aluation of functional liver impairment because of IAHC (the therapeut ic strategy proposed by Makuuchi for hepatectomy in patients with cirr hosis, based on indocyanine green clearance and volume to resect, is v ery useful for this purpose). Hepatectomy is technically difficult to perform following IAHC because of a flabby parenchyma and unusually hi gh pressure in the small central hepatic veins. This drawback is circu mvented by using techniques, such as preoperative hypertrophy of the f uture remaining liver, a transparenchymatous approach of vasculobiliar y structures, and intermittent clamping of the hepatic pedicle or vasc ular isolation of the liver. Postoperative complications occurred more frequently than after major hepatectomy in other clinical settings (p <0.05). However, as this therapeutic approach greatly increases surviv al, it should not be neglected by clinicians, although indications for its use are very rare.