Liver-directed therapies: surgical approaches, alone and in combination with other interventions

When feasible, surgical resection is typically the preferred therapeutic option in patients with both primary and secondary hepatic malignancies. Improved patient selection, preoperative management, and advances in perioperative care have had a considerable effect on short-term and long-term outcomes following hepatic resection. Parenchymal transection of the liver can be performed using many different techniques such as digitoclasia, clamp crushing, vessel sealing system, harmonic scalpel, water-jet, Cavitron Ultrasonic Surgical Aspirator, or radiofrequency dissecting sealer. At the time of surgery, one of the main factors that influences postoperative morbidity and mortality is blood loss. Different techniques are used to decrease blood loss, such as the Pringle maneuver, selective ligation of the right, left, or smaller branches of the portal system; extrahepatic dissection; isolation; and transection of the hepatic artery and portal vein and the total vascular exclusion. Liver resection is on occasion accompanied by a concomitant procedure. Given that colorectal liver metastasis is a common indication for liver resection, colon resection is one of the more common concurrent procedures, but also surgical management of other disease in the lung or pancreas may sometimes be indicated. A subset of patients with primary or secondary liver malignancies may also require the addition of an ablative therapy to treat the extent of disease in the liver. Moreover, occasionally, hepatic resection takes place following intra-arterial therapy administration to the liver. Although many of these patients may benefit from surgical therapy, a multidisciplinary team approach remains critical.