Left Superior Hepatectomy and Segment 6 Resection for Colorectal Cancer Metastasis Invading the Left Hepatic Vein: An Actual Parenchyma Preserving Technique

Abstract

Introduction: Hepatic metastasis is the most common form of distant spread of colorectal cancer (CRC) with about 50% occurrence rate. Liver resection (LR) with R0 margins is the only curative treatment and is believed to have improved the long-term out-come of these patients. Because of a chemotherapeutic injury to the liver, preservation of as much parenchymal volume as possible to minimize the risk of liver failure is the most important issue in these group of patients.Our present report describes a parenchyma preserving technique with left superior hepatectomy and segment 6 resection in a case. Case Report: A 64- year- old woman presented to our instution with a colorectal liver metastasis. PET-CT scan showed solitary liver lesions in segment 2-4a and 6. A left superior hepatectomy (segment 2 and 4a) and segment 6 resection was performed with glissonian approach and clemp-crush technique. Left hepatic vein was ligated without blocking the venous and biliary drainage of segment 4b and segment 3. Pathological examination of the specimen showed tumor-free margins (R0 resection). Discussion: Developments in imaging modalities provide an improved visualization of hepatic segmental anatomy and also provide volumetric calculation on the liver. This allows a successful planning for segmental liver resections with a minimum risk of postoperative liver failure. Factors that were considered contraindications for the surgery, such as number of metastases, tumor size, synchronous metastases and the presence of extrahepatic disease, must be evaluated as prognostic factors and must not prevent these patients opportunity of being treated. The main consideration is to achieve a complete R0 resection. A 1cm-R0 surgical margin width has been considered to avoid local intrahepatic recurrence and optimize long-term survival after hepatic resection for colorectal cancer metastases but tumor biology is a more important predictor for intrahepatic recurrence rather than milimetres. Conclusion: Preservation of as much parenchymal volume as possible in order to minimize the risk of liver failure is required in liver resections with chemotherapeutic liver injury. Drainage of the remaining liver segments into the retrohepatic vena cava via the retrohepatic veins and communicating veins between adjacent hepatic veins may allow adequate liver outflow and remaining functional liver parenchyma in selected cases with hepatic vein invasion.