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Liver-Sparing Surgery Associated With Higher Survival Rates in Cancer Patients

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Key Points

  • Over the 19-year study period, the percentage of major hepatectomies performed decreased from 66% to 36%, and there was a noticeable decrease in 90-day mortality, overall complications, transfusions, and liver dysfunction.
  • The mortality risk for major hepatectomies remained constant throughout the study period, suggesting that the shift toward hepatic parenchymal preservation may be responsible for the decrease in overall mortality.
  • Many higher-risk patients who weren’t operated on historically because of the high complication rate associated with major hepatectomy may now have a chance at successful liver surgery.

According to researchers at Memorial Sloan Kettering Cancer Center (MSKCC), hepatic parenchymal preservation, in which a surgeon removes less than a lobe of the liver in a patient undergoing an operation for liver cancer, is associated with lower mortality and complication rates. Their study results were published in an article by Kingham et al in the Journal of the American College of Surgeons.

Surgical Methods

Historically, the most common surgical method of treatment for liver cancer was major hepatectomy, in which a lobe is removed in order to remove the tumor. The 5-year survival rate of selected patients who undergo a complete resection is as high as 50%, yet many people aren't operated on because of the high complication rate, blood loss, and liver dysfunction associated with a major hepatectomy.

However, over the past 20 years, liver operations have become safer and more effective, due to advances in surgical and anesthetic techniques and operating room devices, improvements in perioperative patient care, and a much wider availability of surgeons who are trained in liver surgery techniques.

When a patient has a single tumor, or tumors confined to one side of the liver, hepatic parenchymal preservation is far better for the patient than the traditional approach of removing large sections of the liver. This preservation procedure involves removing less than a lobe of the liver, without compromising principles of cancer surgery. It places less physical stress on the body, gives patients a quicker recovery time, and preserves the option to have another operation if the cancer recurs.

“The majority of patients with metastatic colorectal cancer are never sent to a liver surgeon, because of the impression that a liver operation is too dangerous and patient outcomes are poor,” according to T. Peter Kingham, MD, FACS, lead study author and Surgeon at MSKCC. “But we've shown that it's possible to do safe liver resection, so patients should be considered for hepatic parenchymal preservation.”

Study Details

The aim of this retrospective study was to investigate the correlation between surgical methods, mortality, and complication rates over the last 19 years. Dr. Kingham and colleagues at MSKCC analyzed hospital records of all patients who underwent liver resection for a malignant diagnosis from 1993 to 2012 at their cancer center.

There were 3,875 patients who underwent 4,152 resections for cancer entered into the MSKCC database. The most common diagnosis was metastatic colorectal cancer. The researchers divided the patients into three equal groups according to time period: early (1993–1999), middle (2000–2006), and late (2007–2012).

They then looked at what percentage of cases in each era were major vs minor hepatectomies (major resection was defined as removal of three or more segments of the liver). They then compared outcomes in terms of surgical morbidity and mortality rates between the three time periods.

Over the study period, the 90-day mortality rate decreased from 5% to 1.6%. Overall complications dropped from 53% to 20%. The percentage of major hepatectomies decreased from 66% to 36%. The transfusion rate decreased from 51% to 21%, and liver dysfunction for all cases decreased from 3% to 1%.

The mortality risk for major hepatectomies remained the same in all three time periods. “This change in approach to resection appears to be largely responsible for the decrease in overall mortality, given that the mortality rate associated with major liver resections remained constant over the entire study period,” Dr. Kingham said.

In addition, the researchers found that abdominal infections were the most common complication of liver surgical procedures.

Researchers conclude that encouraging parenchymal preservation and preventing abdominal infections are critical for continued improvement of liver procedure outcomes.

New Option for Patients With Liver Cancer

“The biggest takeaway from our study is that parenchymal preservation should be applied to all patients undergoing liver operations for malignancies, because the data show that the mortality rate and complication rate, the blood loss, the requirement for blood transfusions, time in the hospital, all of these things which we are all trying to improve on, are all lessened,” Dr. Kingham said. “That is an important message because parenchymal preservation is not always done. While it may be technically easier to remove more liver in some cases, it is worth considering a technically more challenging approach to remove less liver. In the end, there is a real difference in a patient's mortality risk. The more segments of liver that you take out, the higher the risk to the patient.”

“We hope our study findings interest more physicians who advise patients with liver cancers to send their patient to be evaluated by a liver surgeon, particularly high-risk patients, who previously may not have been considered for a liver operation at all,” Dr. Kingham concluded.

Dr. Kingham is the corresponding author for the Journal of the American College of Surgeons article.

This study was supported by the National Institutes of Health and the National Cancer Institute.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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