Major hepatectomy with simultaneous pancreatectomy.

I read with interest the article “Major Hepatectomy with Simultaneous Pancreatectomy for Advanced Hepatobiliary Cancer” by D’Angelica and colleagues. In their article, the authors submitted 17 patients to combined major hepatectomy with pancreatectomy (MHP), reporting considerable morbidity and mortality (mainly because of liver failure), but also unexpectedly good survival. It was interesting that mortality occurred only in patients in whom liver resection was associated with pancreaticoduodenectomy (PD). When hepatectomy was associated with resection of the tail of the pancreas, or was not concomitant to pancreatic resection (the latter operation being performed at a different time), no perioperative deaths occurred. There seems to be a relationship between severity of complications and type of pancreatic resection associated with hepatectomy, PD being the procedure carrying the highest risk. Hepatectomy and simultaneous pancreatectomy are performed in sizable numbers in Japan, with similar morbidity and mortality, although some authors report no mortality in fairly large series. Major complications, possibly leading to death after MHP, are liver failure and anastomotic leakage. Insulin in the portal blood is an important hepatotrophic factor. It has potential to enhance mitochondria in hepatocytes and is necessary for liver regeneration after hepatectomy. Loss of pancreatic parenchyma may lead to decreased insulin production and impaired liver regeneration. It is not surprising that simultaneous hepatectomy and PD are associated with higher complication rates. Indeed, a study by Nagino and colleagues identified four variables independently associated with liver failure after extensive hepatic resection for biliary tumors: presence of cholangitis, abnormal oral glucose tolerance test, abnormal indocyanine green disappearance rate, and concomitant PD. To reduce the high rate of liver failure, the majority of Eastern authors use preoperative portal vein embolization (PVE), with the rationale of inducing liver hypertrophy before the pancreatic resection and the associated reduction of insulin production. Nimura and colleagues report a reduction in mortality after introduction of preoperative PVE in patients submitted to MHP. Regarding the high incidence of anastomotic leakage, Noie and colleagues suggest complete external drainage of pancreatic juice by means of a small-bore catheter cannulating the main pancreatic duct in high-risk patients, followed by second-stage pancreaticojejunostomy; they reported no postoperative mortality. The series by D’Angelica and colleagues is by far the largest ever reporting combined hepatectomy and pancreatectomy in Western patients, although also Doty and colleagues submitted 5 patients to pylorus-preserving pancreaticoduodenectomy and simultaneous liver resection for gallbladder cancer between 1996 and 1999.