Thomas M. van Gulik Bücher

Owing to both improved preoperative assessment and the use of established surgical techniques, liver resection can today be performed with low morbidity and minimal mortality. But no matter which technique is applied in liver resection, the most difficult event to manage is postresectional liver failure. All peri-operative efforts should therefore be directed to the prevention of this potentially lethal complication. This publication presents some of the current techniques of liver resection and the management of the most common complications associated with the procedures. The first part deals with the question of how much remnant liver is enough for a safe resection and describes appropriate techniques for optimal preservation. Then, several procedures for transection of the liver parenchyma and for clamping of the afferent vessels at the hepatic pedicle are presented, mainly aiming at limiting blood loss during resection. Bile leakage and its prevention after liver resection are considered last, followed by a discussion of indications for laparoscopic liver resection.

The incidental finding of benign hepatobiliary lesions has markedly increased due to the widespread use of abdominal imaging: most benign liver tumors are asymptomatic and often coincident when detected during the work-up of abdominal complaints. Since a correct diagnosis is crucial for further management, both physicians and surgeons should be familiar with the hierarchy of diagnostic methods and the indications for resection. The publication at hand summarizes a series of international expert discussions that focus on the management of benign hepatobiliary lesions: Liver cysts and hemangiomas, for instance, usually do not require specific treatment as they rarely become complicated. Resection, on the other hand, is indicated in congenital bile duct cysts and cystadenoma because of the risk of malignant transformation. Also addressed is the difficulty to diagnostically differentiate between focal nodular hyperplasia and hepatocellular adenoma. This distinction is important in view of the risk of bleeding and the malignant potential of hepatocellular adenoma. Moreover, the recent molecular approach to a subclassification of hepatocellular adenoma is introduced. This publication is intended for physicians, surgeons and hepatologists who want to stay abreast of recent opinions in the management of benign liver tumors.

While considerable progress has been made in both surgical treatment of liver metastases and neoadjuvant or postoperative chemotherapy, decision making has become more complex. The definition of accurate measures is very difficult because there exists no consensus regarding pre- or postoperative predictors of survival in patients undergoing liver resection: Even though PET is well established in the diagnosis of colorectal cancer and its metastases, it is unclear whether a combination of imaging modalities will be of additional value. Neoadjuvant strategies are very efficient in downsizing metastasis, but they at the same time reduce functional liver reserve due to chemotherapy-induced liver injury. The advantages and disadvantages of the ‘liver first’ approach are likewise discussed, as are controversial issues in the use of portal vein embolization and radiofrequency ablation versus resection. Even though the main focus of this publication is on colorectal liver metastases, other primary cancers also receive some attention: Papers on resection of liver metastases combined with primary cancers conclude the discussions. This collection of papers provides valuable information on the many issues connected with the management of liver metastases, both colorectal and non-colorectal. Surgeons confronted with the question as to the best treatment strategy will find it a very helpful aid in their decision process.

One of the most significant prognostic factors determining postoperative mortality and morbidity after liver resection is the volume of operative blood loss. In the past decade, the results of liver resection have greatly improved, largely owing to advances in surgical techniques. This publication discusses the various components that have contributed to this improvement, making it possible to perform safe liver resections even in patients requiring complex operations or patients with compromised blood coagulation. These include the testing and treatment of possible hemostatic abnormalities contributing to preoperative optimization of patients; The advancement of traditional surgical techniques; the availability of several new sophisticated devices, among them surgical staplers or tools based on local coagulation using radiofrequency technology; or the use of topical hemostatic agents to deal with bile or blood oozing from the cut surface of the liver after completion of the resection. Providing the most up-to-date information available on the topic, this publication will be of great value for those interested in the subject.