Hpb Surgery: Udine Meets The Experts

Press Release

Udine, 1 October 2015 – Liver resection with curative intent or transplantation: this is the choice faced by the hepatologist and the surgeon in the case of a patient affected with liver cancer. ‘Under certain conditions, the new surgical techniques permit operating on tumours of the liver even in highly advanced cases and cases once considered inoperable. At the same time, a “collateral effect” of improvements in clinical and pharmacological liver transplant management has been to extend the range of indications for this procedure,’ explains Andrea Risaliti, Director of the Department of Surgery and the Liver, Kidney and Pancreas Transplantation Unit of the University Hospital of Udine and Chairman of the‘HPB Surgery: Udine Meets the Experts’international conference now underway in Udine. Organised by the General Surgery and Transplantation Centre of the University Hospital of Udine and promoted by Fondazione Internazionale Menarini, the conference welcomes the participation of several of the world’s top sector experts.

‘In patients affected by malignant hepatic tumours, curative resection of the liver is still the preferred option,’ continues Risaliti.

‘Unfortunately, at diagnosis, many patients present multiple lesions or damage so extensive as to preclude resection. The main limitation to surgical intervention is the risk of acute post-operative liver failure due to low remnant liver volume. But technical advances in recent years have expanded the potentially resectable pool of patients.One innovative technique which now permits operating on tumours of the liver previously judged inoperable is ALPPS(Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), an approach involving partitioning of the liver and ligation of the portal vein to permit hepatectomy in two stages. This is the new frontier in advanced liver surgery and can be carried out only at centres specialised in hepatobiliary surgery and transplantation.’
In recent years, the treatment opportunities offered by traditional, consolidated liver resection surgery have been augmented by liver transplantation, which permits removing the entire liver and with it, all the secondary intrahepatic localizations. 
Historically, Friuli Venezia Giulia is one of the regions highest in the Italian rankings for donor procurement. Data derived from observation of liver transplants performed in Udine show success rates higher than international standards: an 84% as opposed to 81% survival rate at one year, 76% as opposed to 74% at three years, 74% as opposed to 69% at five years. Even more impressive are the figures for liver transplants in HIV-positive patients, for which Udine is the first pilot centre in Italy, with survival rates of 80% at one year and 63% at 5 years, as compared to the 50% survival rate for the other seven centres in Italy.  
‘Recourse to transplantation, however, is still debated, especially due to the high risk of tumour recurrence,’ warns Risaliti. ‘What is more, although prediction of the survival rate has recently become more accurate and precise, the centres are not yet in agreement concerning what should constitute an “acceptable” rate when evaluating the probability of recovery against organ availability.’ 
Retrospective statistical analysis of transplanted patients has revealed several candidate assessment factors which are favourably linked to long-term survival after surgery:

• age less than 55 years
• primitive tumour localised in the gastroenteric tract (portal drainage area)
• good management of the syndrome and/or response to therapy (stabilisation of the disease) with medical treatment in the pre-transplant phase (chemotherapy and/or somatostatin analogue therapy)
• low-grade neuroendocrine tumours
• lack of need to conduct the transplant and other complex surgical procedures in the same period.

‘In conclusion, for each single condition we must conduct careful cost-benefit evaluation, above all to correctly weigh the various options against current organ availability. It is thus recommended to use the resection technique, whenever possible, reserving transplant as an option in the case of liver tumours which are not resectable because of diffuse localization or the advanced stage of the disease.’ comments Risaliti.
Surgical resection is often a viable option in treatment of secondary liver tumours and today represents a valid and irreplaceable support in radical and palliative oncological treatment of hepatic metastases from primitive colorectal carcinoma. In the future, transplantation could also play a greater role in this context, as is already the case in Norway; an honoured guest at the conference is one of the world’s foremost experts on liver replacement in cases of colorectal liver metastases, Prof. Aksel Foss, who will illustrate the most significant world case studies in this field. 

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