Liver Metastases [antikvár]

Introduction Martin A. Adson 1 I have framed the introduction to this text by looking backward to two personal events: my surgical introduction to the liver and my more recent retirement from it. These benchmarks gave focus to my reading, placed progress in frames of time, and offer some historical perspective. The value of reflection about the treatment of liver metastases forty years ago may be questioned by readers who now study liver metastases at the molecular level; but it is not good to be isolated from the past, and others who intervene grossly with new instruments may find understanding in surgical memory. These reflections are personal, but less personal than metastatic cancer which must be treated in the context of personal relationships - with patients and colleagues. My surgical training was completed in 1955 but was incomplete 'liver-wise' because most of my teachers had little need and less inclination to trespass on the liver. However, my mentor, Dr. John McMaster Waugh, often took out things that others left behind. In 1963, a year after his untimely death, his personal experience with resection of hepatic metastases from a variety of visceral cancers was published. Operative mortality was 4% and 20% of his 25 patients lived for five or more years. Despite that favourable report, such efforts did not become the conventional wisdom of that day, because such operations were not convenient and in ordinary hands their risk was unacceptable. Nevertheless, John Waugh had established an institutional precedent and obligation to patients referred for management of metastatic tumours of the liver. I found myself in a lonely gap between institutional and personal obligation. John Waugh was no longer here; I had been surgically and metaphysically close to him; and none of my colleagues seemed to be much interested in the liver. I had shared only a small part of my mentor's surgical experience with the liver (which on no day involved resection of the huge tumours that I was then asked to see). Also, at that time, like most young surgeons, I did not feel ordinary and was extraordinarily reluctant to leave in place a tumour that might reasonably be taken out when nothing else useful might be done. That attitude was reinforced by close association with surgical pathologists whose expert interpretation of frozen sections was clinically enhanced by frequent visits with surgeons in the operating room. I recall asking Drs. David Dahlin and Malcolm Dockerty for help with a surgical judgement when they said simply: 'If you leave that in, don't you think it will grow?' That whimsical remark was offered within a very special relationship. I had studied surgical pathology with both of them and we all knew that their knowledge and experience was just one aspect of surgical judgment. That was particularly true when surgeons and surgical pathologists were dealing with a 'new' clinico-pathological entity for which the benefits of surgical treatment were unknown. Surgically inviting hepatic metastases, once clinically obscure, were made newly visible by evolving diagnostic technology, newly vulnerable to changing surgical attitudes, and more often referred after discovery during another surgeon's operation. Most surgeons removed small superficial lesions safely. However, the reported risk of removing larger lesions was formidable; and the unreported risk of this endeavour was unacceptable. In this circumstance, a so-called general surgeon had to decide whether to become a liver surgeon or not. In the early 1960s, that transition involved two major concerns: one strategic (what should be done), and the other tactical (what could be done). It was difficult to make a case for the removal of any l