Transversal Hepatectomies. A New Parenchyma-sparing Procedures for Deep-located Hepatic Tumors

Abstract

Purpose: Deep-located liver tumors involving hepatic veins (HV) at the caval confluence or main Glissonean pedicles (Gp) generally required a major hepatectomy (MH). A strict IOUS-guidance policy opened a scenario to parenchyma-sparing procedures as alternative to MH: among them the transversal hepatectomies (TH) were described. Herein, we ought to systematize the procedure grouping it in different types, and to analyze the surgical outcome, oncological suitability, and salvageability. Method: All consecutive patients undergoing hepatectomy for liver tumors between January 2005 and August 2020 were reviewed. THs were classified as follows: a) upper-TH (UTH); resection of the postero-superior segments with at least one HV and preservation of the antero-inferior ones, upon confirmation and preservation of accessory and/or communicating veins; b) Rollercoaster resections (RCR): THs with tumor vessel detachment from at least one HV, with or without exposure of 1st/2nd order Gp; c) lower-TH (LTH), amputation of the distal portion of at least one HV with tumor-vessel detachment from 1st/2nd order Gp. Morbidity, mortality, local recurrences, and salvageability in case of relapse were considered. Results: A total of 44 THs were performed: 30 (68%) UTH, 12 (27%) RCR and 2 (5%) LTH. In UTH, 2 (7%) patients received resection of all the 3 HVs: namely total-UTH. Type of tumor were as follows: 25 (57%) patients with CLM, 7 (16%) intrahepatic cholangiocarcinoma, and 12 (27%) HCC. In 17 (41%) other resections were associated (median 2; range 1-7). Median preserved liver volume resulted 67% (range 60-74%) in UTH, 66% (range 55-74%) in RCR, and 65% (range 64-66%) in LTH. Mortality was nil, and overall morbidity was 31%. Local recurrence occurred in 6 (14%) patients: 5 with CLMs and 1 with HCC. Three out of 6 patients with liver-only recurrence received redo surgery. Unresectability in the remaining patients was due to technical issues. Conclusion: THs offer a new perspective in a parenchyma-sparing fashion for managing complex tumor presentation otherwise demanding major tissue removal or unresectability. Safety, adequate local control, and salvageability are further pillars of this approach herein systematized.