Caveats to this approach, and

for the initial combined resection-ablation strategy, are that for conventional thermal tumor ablation, lesions should be less than 4 cm. If bilobar disease is present, then ablation should not TWS119 nmr compromise inflow or outflow tracts as a consequence of hepatic swelling, as this may compromise future liver resection. Utilization of intra-operative ultrasound is employed both for targeting TTA, avoiding treatment failure, and protecting vital intrahepatic structures. Use of ablation for management of synchronous CRHM during primary tumor resection may limit the morbidity when compared to simultaneous colorectal and liver resections, although both can be performed Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical safely in selected patients (46). It is worth noting that in the setting of CRHM, the need for resection of the primary tumor in the absence of over bleeding or obstruction may not be necessary and could delay more pressing issues including the management of CRHM or extrahepatic disease (47,48). Bilobar CRHM with the ability to render an appropriate volume of liver free

of disease, upon which the future hepatic remnant can be based This is perhaps the most common clinical scenario in which ablation complements resection. Any staged treatment plan Inhibitors,research,lifescience,medical will ultimately require that after planned interventions, a portion of liver remains with uncompromised inflow and outflow, ideally completely clear of disease. Although not the focus of this review, portal vein embolization (PVE) has enabled the hepatic surgeon to offer staged approaches to a greater number of CRHM patients through the optimization of Inhibitors,research,lifescience,medical future liver remnant volume (49,50). Consider the patient with right hepatic lobe dominant disease and an isolated CRHM in segment III. The authors would advocate Inhibitors,research,lifescience,medical that this patient should proceed to undergo a partial left hepatic lobectomy (laparoscopic approach preferred) and thermal tumor ablation

of any lesion at risk of crossing the main portal scissurae as defined by the middle hepatic vein. Subsequently, the right portal vein is embolized to induce left liver hypertrophy in anticipation of a right formal hepatectomy. In a patient with more extensive, bilobar CRHM in segments II/III, IV, VIII (dome), and VI lesion, several approaches are Thiamine-diphosphate kinase possible. The optimal strategy would be based on the relationship of the tumors to major vascular and biliary structures, in addition to optimizing liver remnant volume. One approach would be to perform a formal left hemi-hepatectomy (clearing II/III and IV-A) and non-anatomic resections of the segment VIII and segment VI lesions. Another approach, again depending on proximity to vital intrahepatic structures, would be to use thermal ablation for the segment VIII lesion and resect the others as previously proposed.