Strategies and techniques to increase resectability rate for liver tumors.

Liver tumour resectability rate may be increased if a tumour shrinkage is obtained using preoperative chemotherapy for liver metastasis from colon-rectal cancer and with chemo-embolization for hepatocellular carcinoma. Multiple and bi-lobar metastasis have been considered for a long time a contraindication for liver resection but nowadays they can be resected, at time, by means of planned subsequent resections (so called “staged”) that included minor resections (mostly wedge) and/or thermal ablations first, followed by delayed major resections. These latter may be preceded by a portal branch embolization in order to obtain a compensatory hypertrophy of the part of the liver to be left especially when this looks small (<20%) or there is some degree of parenchymal damage such as steathosis, fibrosis or cirrhosis. Re-resection is an option that should be considered each time a resectable recurrence of a liver tumour develops. In fact disease free and survival rates after a re-resection are comparable to those after the first resection provided that there are not extra-hepatic disease. Among the techniques that have allowed to increase liver tumour resectability rate there are some difficult hepatectomies such as extended hepatectomies or tri-segmentectomies, central-hepatectomies or meso-hepatectomies and some segmentectomies. These latter have been considered and classified as “minor” hepatectomies but they actually may result more difficult to perform compared to the major ones as segment VIII or caudate lobe resection. This is due to the difficult isolation of the corresponding glissonean pedicles, to the extension and deepness of the resection area that may allow the increase of blood loss and biliary leakages. Furthermore vital structures such as vena cava, hepatic veins, portal vein and its branches, biliary ducts and artery can be resected and reconstructed. Resection and reconstruction of vascular structures are at present made possible thanks to the experience gained with liver transplantation. Knowledge of liver tolerance to ischemia and the techniques to control blood in and out-flow are others key factors for resections that entail vascular reconstructions. These techniques have allowed to resects lesions once considered un-resectable such as those near the cavo-hepatic junction or those infiltrating the portal bifurcation.