Abstract
Aims: Venous drainage pathways that develop in the liver due to the tumor compression of the hepatic veins have been rarely described. The aim of this study was to describe these pathways in patients with tumor obstruction of hepatic veins confluence, according to the extent of obstruction and the presence of accessory veins, and the relevance in the setting of liver resection. Methods: Between 2009 and 2013, 32 patients with compression of at least one main hepatic vein undergoing liver resection were retrospectively selected from a prospective database. Preoperative CT-scans were re-assessed for the extent of hepatic vein compression, presence of accessory veins and collateral veins (both intra hepatic end subcapsular). A 2:1 matched control group was used for comparison of intra operative outcomes. Results: The right hepatic vein was involved in 23 (77%) patients. Two hepatic veins were obstructed in 12 (38%) patients, and all three in 4 (12%). Intra hepatic collaterals were observed in 66% of the patients, mostly between segments 3/4b and 5/4b. Sub-capsular collaterals were observed in 31% of the patients. A right inferior hepatic vein was present in 25% of the patients. Patients with right hepatic vein compression and with an accessory right hepatic vein developed less collateral pathways than patients without (3/7 (43%) vs. 15/16 (94%), p = 0.017). Caudate veins were never observed. There was a significant increase in blood losses (700 mL vs 500 mL, p = 0.0096) and transfusion requirements (transfusion rate 56% versus 13%, p < 0.0001), whereas there was no difference regarding pedicular clamping and operative time. Inferior vena cava clamping was necessary in 11 patients (34%). Conclusions: The development of collateral pathways depends on the type and number of hepatic veins involved and of pre-existing accessory veins. The presence of collateral veins increases blood losses and transfusion rate during liver resection.
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