Safe Hepatic Resection Research Articles

Reoperation for Colorectal Carcinoma

In the management of the patient with intra-abdominal recurrence of colorectal carcinoma, surgery remains the primary mode of therapy when cure or significant palliation is anticipated. Appreciation of the importance of close follow-up after primary resection coupled with improved diagnostic modalities has allowed the surgeon not only to detect earlier recurrence but also to select the patients most likely to benefit from resection of recurrent disease. Improved surgical techniques with resultant decreases in the rates of morbidity and mortality have allowed safe hepatic resection of metastatic disease. In selected patients, this procedure produces 5-year survival rates approaching 50%. Although a clear consensus has not been reached, most studies agree that positive prognostic indicators include absence of extrahepatic disease, a small number of intrahepatic lesions, a low CEA level, and a better Dukes stage of the primary. Likewise, in the patient with recurrent disease locally, surgery provides the only means of cure and also plays a significant role in palliation. Aggressive resection with generous surgical margins in patients with contained disease may yield 5-year survival rates approaching 35%. In patients with unresectable disease and even in those with carcinomatosis, palliation can be obtained by surgical therapy. Judgment is necessary in treating these patients both preoperatively and intraoperatively. Surgical intervention for obstruction, perforation, or other anatomic or physiological compromise is often indicated and can improve the quality of life of the patient with intra-abdominal recurrence.

Liver resection using a water jet.

The water-jet method has been used during hepatic resection. The instrument cuts the hepatic tissue with the high pressure of the fine water flow, while the exposed elastic intrahepatic vessels are spared injury. A comparative study on the water-jet method with the previously employed conventional methods was undertaken. Hepatic resections were performed on 35 patients using the water-jet method. Cirrhosis of the liver was associated with 10 of the 24 patients with hepatocellular carcinoma. An ordinary saline solution was used as the jet, which was projected at a pressure of between 12 kg/cm2 and 20 kg/cm2 through a 0.15/mm-diameter nozzle. A higher jet pressure was needed to cut the fibrotic hepatic parenchyma. In the case of normal liver, the intrahepatic vessels of more than 0.2 mm were well preserved. In most of the cases, the loss of blood when cutting the hepatic parenchyma can be easily reduced with a jet pressure of 15-16 kg/cm2, thus preserving the fine vessels more than 0.2 mm in diameter without injury. When the same pressure was applied in the cutting of a cirrhotic liver, it took much longer time compared to that of a non-cirrhotic normal liver parenchyma. The cut surface was smooth compared to that after using CUSA, although its disadvantages lie in the formation of air bubbles, which obscure the operative field. The controlled projection of a jet of water under optimal pressure may ensure a safe hepatic resection of both normal and cirrhotic livers. Furthermore, because of its uncomplicated form, a wide range of applications can be expected, while the lower cost will also expedite its large-scale use for economic reasons.