International Perspectives on Advanced Liver Surgery

At the invitation of Paul Berk and the Editorial Board, we are pleased to present in this edition of Seminars in Liver Disease a remarkable collection of articles that demonstrate what is possible in liver surgery in our era. An international perspective is essential, because some of the most dramatic advances in liver surgery have come from outside the United States. While European and American contributions to advance liver surgery have been many, the current explosion of innovation comes to us from the Far East, driven by the enormous incidence of hepatitis B and the advanced technologies implemented by leading medical centers across Asia. The largest liver transplant center in the world today is in Korea. In China, a country with an unimaginable burden of liver disease, an extremely high level of liver surgery is practiced at the leading medical centers.

The first article in this collection, entitled “Precision in Liver Surgery,” is contributed by Jiahong Dong and colleagues, who lead a team in Beijing that performs over 700 hepatic resections each year. Such a volume supported by high quality imaging and finely tuned perioperative services permits rigorous application of protocol-driven care throughout the process with a high level of predictability of outcomes. The dissemination of expert liver surgery in the United States has been limited by the decentralized nature of health care delivery and the relative lack of volume that fosters predictability through protocolized care. Morbidity and surgical outcomes vary widely, and using volume as a surrogate for expertise demonstrates the variation in mortality associated with liver surgery.[1] [2] [3] Furthermore, the surgical expertise required to perform many of the advanced procedures described in this edition is not uniformly available across the surgical specialties that are called upon to treat liver diseases, ranging from general and laparoscopic surgeons to surgical oncologists and transplant surgeons.

In parallel with the varying training of surgeons, a comparable lack of understanding exists in the gastroenterology, hepatology, and medical oncology communities regarding what is possible and what should be expected in the surgical treatment of liver diseases. Underlying this issue is the lack of uniform, high-quality imaging of the liver that is needed for decision making and surgical planning across medical centers in the United States, as well as liver-focused specialists in anesthesia, interventional radiology, and interventional gastroenterology necessary as collaborators to provide the best possible outcomes. In the contribution by Gebhart Wagener, safe evaluation of the liver surgery candidate and perioperative care practices are outlined. Thomas Ward, Joshua Weintraub, and David Madoff present a broad overview of the impact of image-guided interventions both as supportive and definitive therapies for the management of liver lesions. The growing role of minimal access techniques for complex liver surgery is subsequently reviewed with an eye toward both promise and caution by Cheguevara Afaneh and Michael Kluger.

The final five contributions assess the management of the four principal disease entities for which surgery is the primary mode of definitive treatment: benign liver tumors, cholangiocarcinoma, hepatic metastases from colorectal cancer, and resection and transplantation for hepatocellular carcinoma. Laurence Chiche and Jean-Philippe Adam from France present a thorough review of the management of benign tumors from the surgical perspective, in which nonoperative management and safe, minimally invasive surgical procedures figure prominently. Operative management of cholangiocarcinoma, a disease in which complex procedures determine the difference between palliation and cure, is critical in understanding the role of recent advances in liver surgery and is described by Ser Yee Lee (Singapore) and Daniel Cherqui (France). The surgery of colorectal metastases is described by Gilles Mentha and colleagues from Switzerland and highlights the synergy between improvements in chemotherapy and surgical techniques to bring about cure. Finally, Tiffany Cho Lam Wong and Chung Mau Lo from Hong Kong, and Truman Earl and William Chapman from the United States, highlight two very different perspectives on the role of resection and liver transplantation as curative therapies for hepatocellular carcinoma (HCC). In Asia, the combination of the high prevalence of HCC and a relatively restricted supply of organs mandates aggressive use of surgical resection with a sparing application of liver transplantation. In the United States, the relative availability of organs and the fewer cases of HCC shift the balance toward increased use of transplantation. This pragmatic observation does not address the effectiveness of each, and the most difficult debate concerns the role of transplantation in the treatment of a localized HCC in well-compensated cirrhosis.

In conclusion, the clearly presented and beautifully illustrated contributions in this “surgical” edition of Seminars should provide cause for excitement at what has been achieved in the current era of liver surgery and what will be possible in the coming years as expertise proliferates and supportive technology continues to advance.

• References

• 1 Farges O, Goutte N, Bendersky N, Falissard B , Group AC-FHS. Incidence and risks of liver resection: an all-inclusive French nationwide study. Annals of surgery 2012; 256: 697-704 ; discussion 704–705
• 2 Glasgow RE, Showstack JA, Katz PP, Corvera CU, Warren RS, Mulvihill SJ. The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma. Archives of surgery 1999; 134: 30-35
• 3 Nathan H, Cameron JL, Choti MA, Schulick RD, Pawlik TM. The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. Journal of the American College of Surgeons 2009; 208: 528-538