Palliative liver resections

Major liver resections have become so much more commonly performed over the past two decades, owing in large part to numerous technical advances that have reduced the morbidity and mortality associated with the procedure. This progress has altered the risk–benefit analysis for liver resections; the envelope has expanded and operations that were previously placed ‘‘outside the envelope’’ are now inside. This concept has pushed some to question whether survival is prolonged by debulking liver tumors, an operation that has been imprecisely labeled ‘‘palliative liver resection. ’’ The term ‘‘palliate’’ as defined in medical dictionaries means ‘‘to reduce symptoms of a disease. ’’ Therefore, the truest sense of the phrase, ‘‘palliative liver resection’’ refers to a very infrequent operation, because most patients with liver tumors have few symptoms that can be palliated effectively by a liver resection. Palliative liver operations are indeed occasionally performed but are generally procedures such as a bypass for unresectable biliary obstruction, debulking of biochemically active neuroendocrine tumors in the liver, or, on rare occasions, hepatic artery ligation for hemoperitoneum from rupture of an unsuspected hepatocellular carcinoma. Despite the misconceptions associated with the phrase ‘‘palliative liver resection,’’ it is important to determine when to perform liver resections that have a low probability of cure. In other words, the question that is relevant to a large number of patients and surgeons is: ‘‘What is the minimum chance for cure for which we should offer a liver resection? ’’ Is it a 15% chance of 5-year survival? A 10% chance? A 5% chance? This is a difficult question. Not surprisingly, a patient will give a different answer to this question than will a surgeon. As a matter of fact, it is surprising to oncologists what patients will knowingly subject themselves to in order to achieve a very slight benefit in survival. Patients are typically willing to endure more morbidity than we as physicians think is ‘‘warranted. ’’ In a standard gamble, patients are all too often willing to accept a substantial risk of instant painless death to avoid cancer recurrence and death from cancer. For example, as many as 50% of patients with breast cancer will accept the toxic effects of chemotherapy for an incremental benefit of an additional 1% survival advantage after 5 years [1,2]. Of course, this means that 50% of patients would not accept such treatment. Nearly everyone would accept toxic chemotherapy for an additional 10% survival advantage. So what is an appropriate cutoff? 1%? 5%? 10%? More to the point, what is the cutoff for a patient considering a major liver resection? Many surgeons have struggled with this question during conversations with patients and family members concerning a patient’s suitability for liver resection. We should remember that the decision will always involve an analysis of both the risks and the benefits. From a safety standpoint, centers with expertise and large volumes of liver surgery can perform the operation more safely, and for this reason these centers are justified in being more aggressive in giving patients with a low probability of cure the benefit of the doubt with a liver resection. Data obtained from a Surveillance, Epidemiology, and End Results (SEER)–Medicare–linked database demonstrate that 30-day operative mortality after liver resections declines with increasing hospital volume, a finding that is not surprising [3]. So, when weighing risks versus benefits, centers with more experience have lower risks, and therefore can theoretically justify offering liver resections to patients with lower statistical probabilities of benefit. How do we determine the chance of benefit? For patients who undergo resection of colorectal carcinoma liver metastases, factors that influence outcome after resection