
<b>Unquestionable indications for Surgical Resection are either solitary metastases or metastases limited to one liver lobe, since surgical resection provides the best long-time results. </b>  Sometimes surgeons will operate on one side of the liver, and then wait for recovery to operate on the other side.

For non-resectable liver metastases other treatments must be explored [RFA, microwave, conventional chemotherapy]. 

Where conventional systemic chemotherapy is chosen, but is ineffective, there are alternative methods of delivering the chemotherapy agent that maximizes tumor exposure to it. 

<b>Because of the mainly arterial supply of liver metastases, the different procedures of regional chemotherapy:

intra arterial infusion 
isolated liver perfusion 
embolization
chemoembolisation 
and/or 
radioisotope embolization

can provide the tumor/s in the liver with high drug concentrations without provoking systemic side effects.</b> These procedures do not prevent the appearance of extra-hepatic recurrence or metastases. 

<b>Hepatic Arterial Infusion [HAI] </b>has been used for many years to treat liver tumors (primary or secondary) if no extrahepatic tumor exists, when no resection is feasible, and when no active systemic chemotherapy is available. Liver toxicity and extrahepatic progression are the two main limiting factors that can possibly be reduced using new protocols and combinations with systemic chemotherapy. 

<b>Isolated hepatic perfusion (IHP)</b> is a regional treatment technique that delivers high dose chemotherapy, biologic agents, and hyperthermia via a completely isolated vascular recirculating perfusion circuit as a means of regionally treating liver tumors. [What this means is the two blood vessels feeding the liver, and the vein leaving the liver are hooked up to a heart-lung machine. The chemotherapy and other agent[s] are injected into the liver circulation, but do NOT get into the rest of the body's circulation. <b>The liver's blood circulation is ISOLATED from the rest of the body.</b> After perfusing the liver for an hour with the high concentration chemotherapy agent[s], the liver is given a 'washout' and then reconnected to the systemic circulation. This allows higher concentration of toxic chemicals to be given to the liver, and spares the rest of the body the side effects.] 

<b>HAI and isolated liver perfusion are two active locoregional treatments which can be combined with surgical resection and/or systemic chemotherapy for downgrading of unresectable tumors, for treatment of unresectable chemotherapy resistant tumors, and for palliation of severe disease. </b>Responses obtained by drugs delivered as continuous infusion into the hepatic artery have been kept lower because often the drugs' rapid uptake and detoxification by liver cells results in relatively low systemic drug levels. To improve opportunities for chemotherapy, the technique of 1-hour recirculating perfusion of the vascularly isolated liver (isolated hepatic perfusion, IHP) was developed. If leakage to the systemic circulation is negligible--and the compounds used do not readily cause hepatotoxicity--<b>IHP allows usage of drug doses that would be fatal if delivered systemically.</b> Observation for leakage of perfusate must be carried out. 

<b>Complications</b> Death within 30 days of perfusion due to multiple organ failure. These patients had more than 50% of liver volume occupied by cancer. In patients with massive liver tumour, there is a significant risk of developing multiple organ failure. Deaths also occurred from necrotizing pancreatitis and hepatic arterial thrombosis-both deaths were related directly to the hepatic arterial catheter. All surviving patients can develop reversible hepato- and renal toxicity. Postoperative bleeding or coagulopathies can develop. The most frequent side effects were mild to moderate chemical hepatitis and reversible bone marrow suppression. It may be difficult to distinguish between toxicity from the drug regimen and that from the perfusion procedure itself. 

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