Central Bisectionectomy Research Articles

Standardization of Laparoscopic Central Bisectionectomy by Extrahepatic Glissonean Pedicle Isolation and HV Root - At First One-way Resection Based on Laennec's Capsule

Standardization of Laparoscopic Central Bisectionectomy by Extrahepatic Glissonean Pedicle Isolation and HV Root - At First One-way Resection Based on Laennec's Capsule

Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes.

PurposeUnplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion.MethodsWe retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed.ResultsOf the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion.ConclusionUnplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions.

Laparoscopic Central Bisectionectomy and Right Anterior Sectionectomy Using Two Retraction Methods: Technical Aspects with Video.

Laparoscopic central bisectionectomy and right anterior sectionectomy for centrally located tumors are technically demanding surgeries. Here, we introduce our laparoscopic technique and present the associated perioperative outcomes relative to an open approach. From April 2014 to November 2017, 26 patients underwent central bisectionectomy or right anterior sectionectomy. A total of 17 patients underwent the laparoscopic approach and nine underwent an open approach. We used a perihilar Glissonian approach to determine each anatomical resection plane and employed a rubber band self-retraction technique to ensure proper exposure of the two resection planes. Detailed descriptions, illustrations, video, and perioperative outcomes of the approach are presented. Among patients who underwent the laparoscopic approach, there were no cases of conversion to open surgery. The mean operative times for the laparoscopic and open groups were similar (333 ± 76 vs. 305 ± 62min, respectively, p = 0.345). Intraoperative blood loss (535 ± 443 vs. 966 ± 650, p = 0.056) and postoperative complications (1 vs. 3, p = 0.065) were slightly less in the laparoscopic group, but the difference was not statistically significant. Surgical margins of both approaches were comparable (0.8 ± 0.6 vs. 0.7 ± 0.2cm, p = 0.671). The length of hospital stay after surgery was significantly shorter in the laparoscopic group (8.8 ± 2.6 vs. 17.1 ± 12.7days, p = 0.015). The laparoscopic approach for central bisectionectomy and right anterior sectionectomy described in this study is feasible and safe with respect to short-term perioperative outcomes and may provide several benefits commonly attributed to minimally invasive surgery in selected patients.

The anatomical characteristics of patients with posterior bile duct stricture after a liver resection including anterior section

Introduction: When deciding to proceed with anterior sectionectomy or central bisectionectomy, the posterior duct anatomy must be carefully reviewed due to the high variation rate of the duct. Additional procedures or posterior sectionectomy may be needed if injury occurs leading to posterior bile duct stricture. Method: We reviewed the clinical data of patients who received liver resections including the anterior section such as anterior sectionectomy and central bisectionectomy from July of 2009 to September of 2018. We reviewed the type of bile duct anatomy according to the Bismuth classification and the right hepatic duct length was measured if the classification was type A. We excluded patients without MRI and patients who underwent hepaticojejunostomy. We divided patients into 4 groups according to the bile duct anatomy and risk factor analysis for right posterior bile duct stricture. Result: A total of 69 patients received central bisectionectomy or anterior sectionectomy. The type A bile duct was most common (n=42, 60.9%) and type B was the second most type (n=12, 17.4%). Five patient (7.2%) need PTBD or ERCP procedures due to biliary stricture and occurs in only type A. The length of right hepatic duct (RHD) was related to biliary stricture (AUC=0.889) and the sensitivity was 0.8 and specificity was 0.889 when the length of RHD is 12mm. In multivariate analysis, the RHD more than 12mm was significant (OR: 47.068, 1.469 – 1508, P=0.029). The median time to biliary stricture was postoperative 34 day (5-81) and the stricture was managed with ENBD and PTBD and successfully resolved. Conclusion: The RHD more than 12mm was the risk factor of the posterior biliary stricture in anterior or central bisectionectomy.

Prospective multicenter study for robotic anatomical major liver resection : Can robotic beginners safely perform ?

Introduction: The robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. However, robotic liver resection had not generalized, so far. Thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by a prospective multicenter study. Method: From July 2017 to December 2018, five surgeons who were the novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed 46 cases of robotic major anatomical liver resection. Perioperative patient’s clinical data and surgical data including detailed procedure time were prospectively collected. All operations were performed identical procedures for dissection and hemostasis and were a totally robotic approach. Result: Twenty-two cases of left hemihepatectomy, 1 extended left hemihepatectomy, 14 right hemihepatectomy, 2 right anterior sectionectomy, 6 right posterior sectionectomy, and one central bisectionectomy were performed. The most common indications were hepatocellular carcinoma for 21 cases following intrahepatic cholangiocarcinoma for 7 cases, liver metastases for 3 cases. Surgical resection margins for all tumor cases were negative. Total average operation time was 378.58 ± 124.31 (190∼696) minutes and estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, minimal to 2600mL). Overall complications were developed in 16 cases (34.8%). In terms of severe (Clavien-Dindo classification, more than III) surgical complications, there were 3 cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous transhepatic biliary drainage. Only one case out of 46 cases was converted to the conventional open left hemihepatectomy because of bleeding. Transfusion was done in 2 patients (4.3%) and Pringle maneuver was applied in 16 (34.8%). Mean hospital stay was 7.3 days. Conclusion: Robotic anatomic major liver resection might be safely performed even by robotic beginners but experienced open liver surgeons.

Major hepatectomy with hepatic artery resection and microscopic reconstruction for advanced biliary tract cancer

Introduction: Advanced biliary tract cancer sometimes invades right hepatic artery and needs right lobectomy for curative resection, however, remnant liver volume is not sufficient and disables us to perform curative resection. Major hepatectomy with hepatic artery resection and microscopic reconstruction is still a challenging surgical procedure even now. Our surgical procedures and outcomes for these advanced biliary tract cancer were showed in this study. Method: Between 2011 and 2018, major hepatectomy with hepatic artery resection and microscopic reconstruction was performed for perihilar cholangiocarcinoma (n=5), intrahepatic cholangiocarcinoma (n=1) and gallbladder carcinoma (n=1). Operative procedure was selected according to tumor location and remnant liver volume measured by liver 3D reconstruction. Arterial reconstruction was performed microscopically under the help of plastic surgeons. Postoperatively, arterial flow was checked by Doppler US twice in a day. Result: Operative procedures were indicated as below; extended left hepatectomy (n=4), hepatopancreaticoduodenectomy (HPD, n=2) and central bisectionectomy (n=1). As a proximal artery, we selected end-to-end anastomosis of right hepatic artery (n=3), right gastroepiploic artery (RGEA, n=3) and gastroduodenal artery (n=1). Median operation time was 775 (range: 580-865) min and median intraoperative blood loss was 600 (range: 225-1,820) ml. Combined vascular resection (hepatic artery and portal vein) was carried out in four patients. There was no complication related to arterial reconstruction such as postoperative bleeding or obstruction of arterial reconstruction. Cancer negative at surgical margin (R0) was obtained in four patients. Two patients are still alive without recurrence, three patients however died within one year. Especially one patient of perihilar cholangiocarcinoma was alive more than five years after surgery. Conclusion: We could perform major hepatectomy with hepatic artery resection and microscopic reconstruction in advanced biliary tract cancers safely. R0 resection might be preferable for perihilar chorangiocarcinoma to obtain good prognosis.

Laparoscopic Liver Resection: Experience of 436 Cases in One Center

BackgroundTo report experience of laparoscopic liver resection (LLR) in one center. MethodsWe retrospectively reviewed 436 consecutive LLRs in 411 patients between December 2010 and December 2016. On the basis of the 2008 Louisville Statement, we divided the 436 cases into two groups: Simple Group (n = 203) and Difficult Group (n = 233). ResultsThe indications were HCC (n = 194), colorectal cancer liver metastasis (n = 156), benign tumors (n = 62), hepatolithiasis (n = 2), and other malignant lesions (n = 22). The median tumor size was 24 mm (range 3 to 130). Procedures of LLR included wedge resection (n = 230), one segmentectomy (n = 8), two segmentectomies (n = 12), left lateral sectionectomy (n = 75), right hepatectomy (n = 52), left hepatectomy (n = 31), extended right hepatectomy (n = 2), extended left hepatectomy (n = 5), central bisectionectomy (n = 3), right posterior sectionectomy (n = 12), and right anterior sectionectomy (n = 6). The median operative time was 228 min (range 9–843) and median blood loss was 150 ml (range 2–3500). Twenty-five cases required blood transfusion (5.7%). Conversion to open surgery was required in six cases (1.4%). The mean length of stay was 6.4±2.9 days. Overall complication rate was 9.4% and major complication rate was 5%. One patient died of liver failure on the thirtieth postoperative day after a right hepatectomy. We had higher median blood loss (200 vs. 100 ml; p < 0.001), higher transfusion rate (8.2 vs. 2.9%; p = 0.020), longer median operative time (297 vs. 164 min; p < 0.001), higher conversion rate (2.6 vs. 0%; p = 0.021), higher complication rate (14.2 vs. 3.9%; p < 0.001), and longer mean postoperative hospital stay (6.8±2.9 vs. 5.9±3.0 days; p < 0.001) in the Difficult Group. ConclusionsLaparoscopic liver resection is safe for selected patients in the Difficult Group. On the basis of the 2008 Louisville Statement, selection criteria of LLR are helpful to predict the difficulty of the operation and the postoperative outcomes of LLR.

Surgical Outcomes for Perihilar Cholangiocarcinoma with Vascular Invasion

PurposeTo investigate short- and long-term surgical outcomes for patients with perihilar cholangiocarcinoma and vascular invasion. MethodsData from 249 patients who underwent perihilar cholangiocarcinoma surgery between 2000 and 2016 were retrospectively analyzed. Patient evaluations included short-term surgical outcomes following vascular resection and long-term outcomes in cases with histopathological vascular invasion. ResultsMortality was 3.6% overall; 16% for hepatic artery resections, 5.4% for portal vein resections, and 1.7% in the absence of vascular resection (p = 0.029). No between-group differences were observed in the incidence of Clavien–Dindo grade ≥ 3 complications. The factors related to perioperative mortality were hepatic artery resection (odds ratio [OR] = 25.5), right trisectionectomy (OR = 13.0), and central bisectionectomy (OR = 13.8). Multivariate analysis for overall survival identified several prognostic factors: carcinoembryonic antigen level ≥ 5 ng/mL (hazard ratio [HR] = 1.68), poor differentiation (HR = 2.39), distant metastasis (HR = 1.97), and R1 invasive resection (HR = 2.13). Five-year overall survival for patients with portal vein invasion and M0R0/1cis was 35.6%, significantly worse than the 53.4% for patients with no portal vein invasion and M0R/1cis but better than the 0% for patients with portal vein invasion and M1 or R1. Those with hepatic arterial invasion and M0R0/1cis were 24.7%, significantly worse than the 53.4% for patients with no hepatic arterial invasion and M0R0/1cis but significantly better than the 0% for patients with hepatic arterial invasion and M1 or R1. ConclusionShort-term outcomes for patients with perihilar cholangiocarcinoma and undergoing vascular resection were poor compared to those without vascular resection. Long-term survival in R0M0 disease was more favorable; aggressive surgery is recommended.

Outcomes of major laparoscopic liver resection for hepatocellular carcinoma

BackgroundTo compare the surgical outcomes of major laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC). MethodsWe retrospectively reviewed the medical records of 177 patients who underwent major liver resection for HCC between January 2004 and June 2015. We divided the 177 patients into two groups according to the type of procedure: major LLR (LLR group; n = 67) and major OLR (OLR group; n = 110). ResultsProcedures in the LLR group were right hepatectomy (30 patients), right posterior sectionectomy (28), left hepatectomy (11), right anterior sectionectomy (6), extended right hepatectomy (6), and central bisectionectomy (2). Tumor size was greater in the OLR group than in the LLR group (6.3 ± 3.8 vs 4.1 ± 2.4 cm; P = 0.016). The mean indocyanine green retention rate at 15 min (P = 0.698) and serum α-fetoprotein (P = 0.186) were similar in both groups. The mean operation time was longer in the LLR group (416.6 ± 166.9 vs 332.5 ± 105.4 min; P = 0.002). Blood loss (P = 0.319), transfusion rate (P = 0.260), and R0 rate (P = 0.255) were similar in both groups. Hospital stay was shorter (11.3 ± 8.3 vs. 18 ± 21.4 days; P = 0.007) and the complication rate was lower (20.5% vs. 38.7%; P = 0.005) in the LLR group. The 5-year overall survival (77.3% vs 60.2%; P = 0.087) and disease-free survival (50.8% vs 40.1%; P = 0.139) rates were comparable in both groups. ConclusionMajor LLR of HCC is feasible and oncologically safe when performed by experienced surgeons. Further refinements of the surgical technique are needed to reduce operation time.

The Pitfalls of Left Trisectionectomy or Central Bisectionectomy for Biliary Cancer: Anatomical Classification Based on the Ventral Branches of Segment VI Portal Vein Relative to the Right Hepatic Vein

BackgroundsSome patients have P6a running on the ventral side (Ventral-P6a), relative to the right hepatic vein (RHV). Study DesignForty-one patients who underwent left trisectionectomy or central bisectionectomy for biliary cancer were enrolled. We compared the anatomical features using 3D images and surgical outcomes between patients with Ventral-P6a (n = 17) and those with P6a running on the dorsal side relative to the RHV (Dorsal-P6a; n = 25). Moreover, the liver volume by hand-tracing 2D axial images was compared to the volume calculated using the 3D images. ResultsThe frequency of complete exposure of RHV on the transection plane was less in Ventral-P6a (12 vs. 76%; p < 0.001), and the frequency of supraportal type of right posterior hepatic artery (RPHA, 29 vs. 4%, p = 0.020), the presence of inferior RHV (47 vs. 12%, p = 0.011), and the angle between the transection plane of segment VI and VII (S6–S7angle, 29.0° vs. 4.9°; p < 0.001) were greater in Ventral-P6a than in Dorsal-P6a. In Dorsal-P6a, the volume of posterior section calculated using 2D images was greater than that calculated using 3D images (404 vs. 370 mL; p = 0.004). The incidence of daily diuretic administration in Dorsal-P6a was greater than in Ventral-P6a (88 vs. 54%, p = 0.035). Conclusion and RelevanceIn Ventral-P6a, the complete exposure of RHV was rare in left trisectionectomy or central bisectionectomy. Surgeons should preoperatively recognize the course of RPHA, the presence of inferior RHV, and the S6–S7angle. In Dorsal-P6a, the volume of posterior section, which tended to be overestimated using 2D images, was smaller than that in Ventral-P6a.

Clinicopathological Features and Prognosis of Hepatic Epithelioid Hemangioendothelioma After Liver Resection and Transplantation.

BACKGROUND Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor. We present a single-center study on hepatic EHE cases treated by hepatic resection (HR) or liver transplantation (LT). MATERIAL AND METHODS Six HR patients with hepatic EHE were identified during 5 years from 2010 to 2014; EHE represented 0.13% (6 of 4572) of all primary liver tumors. Two LT recipients were also identified during 12 years from 2003 to 2014, who represented 0.06% (2 of 3576) of all adult LT patients. RESULTS Mean age of the patients was 42.3±11.2 years and 7 were female. Preoperative diagnoses based on imaging studies were suspected liver metastasis or EHE; thus, all patients underwent liver biopsy. The extent of HR, which was determined by the location and size of tumors, consisted of right hepatectomy in two patients, right anterior sectionectomy in one, right posterior sectionectomy in one, central bisectionectomy plus partial hepatectomy in one, and right trisectionectomy plus partial hepatectomy in one. All patients recovered uneventfully from surgery. The disease-free survival rate was 83.3% at 1 year and 44.4% at 3 years in HR patients, but all patients are alive to date. Two patients underwent living-donor LT because they had multiple tumors scattered throughout the liver. Of these, one patient died from tumor recurrence at 9 months and the other is alive after 5 years without recurrence. CONCLUSIONS Hepatic EHE is often misdiagnosed as a metastatic tumor. This disease has malignant potential; thus, it requires aggressive treatment including HR, non-surgical treatment, and LT.

Central bisectionectomy for hepatocellular carcinoma in a patient with indocyanine green excretory defect associated with reduced expression of the liver transporter.

BackgroundIndocyanine green (ICG) excretory defect is a dye excretory disorder, and it is characterized by the selective impairment of plasma ICG clearance with normal liver histology. The pathophysiology involves selective loss of active transporters for ICG in the hepatic cell membrane. Several cases of hepatectomy in patients with ICG excretory defect have been reported, but the expression of hepatic transporters involved in ICG excretory defect has not been examined in these cases.Case presentationAn 81-year-old man who was hepatitis B and C virus negative was admitted to our hospital with a diagnosis of HCC. Abdominal computed tomography revealed an 8-cm-diameter tumor in hepatic segments 4 and 8. The retention rate of ICG at 15 min (ICGR15), which has been used to evaluate hepatic functional reserve, was markedly elevated (79.1 %), whereas other liver function test results, were normal. Therefore, we diagnosed the patient with HCC with an ICG excretory defect, and considered major hepatectomy. Central bisectionectomy was performed, and the postoperative course was uneventful. Microscopic examination of the resected specimen showed moderately differentiated HCC. Immunohistochemical staining and polymerase chain reaction analysis of a non-neoplastic site of the resected specimen showed very few expression of the organic anion-transporting polypeptide 1B3 (OATP1B3), which is usually expressed on the basolateral membrane of human hepatocytes and mediates the uptake of ICG.ConclusionsIn this case, we present a case of hepatectomy for HCC in a patient with ICG excretory defect, which may be attributable to a congenital disorder of OATP1B3 expression; however, an ICG excretory defect did not seem to have any effect on the short-term prognosis after hepatectomy.

Clinical feasibility of laparoscopic central bisectionectomy

Introduction: Laparoscopic central bisectionectomy (LCB) for centrally located tumor has been rarely attempted. It is come from a technical difficulty due to two different surgical plane and extensive parenchymal transection area resulting long operative time. Methods: From April 2014 to August 2015, four of 9 patients underwent central bisectionectomy were performed by the laparoscopic procedure. Initial perioperative outcomes of the laparoscopic group and open group were compared. The patient was placed supine in a reverse Trendelenburg position with right elevation. Four trocars were used and a rubber band self-retraction technique was applied for the two different resectional planes respectively. Results: There were no conversions to open surgery in the laparoscopic group. The mean operative time in the laparoscopic group was longer (395 ± 57 vs. 288 ± 23 min, respectively, p = 0.007). Intraoperative blood loss was less in the laparoscopic group (1100 ± 336 vs. 960 ± 288 ml, p = 0.522). There was no difference in the surgical margin (0.45 ± 0.5 vs. 0.64 ± 0.22 cm, p = 0.470). The length of stay after surgery was shorter in the laparoscopic group (8.7 ± 1.2 vs. 12.6 ± 4.4 days, p = 0.141). There was no difference in the rate of postoperative complications between the two groups (1 vs. 1 cases). Conclusion: LCB is still demanding procedure with long operative time. However, this procedure is feasible and safe in regard to short-term perioperative outcomes. LCB may provide several benefits commonly attributed to minimally invasive surgery in selected patients.

A case of extrahepatic bile duct resection with central bisectionectomy in patient with early onset localized primary sclerosing cholangitis

A case of extrahepatic bile duct resection with central bisectionectomy in patient with early onset localized primary sclerosing cholangitis

Robotic extrahepatic Glissonean pedicle approach for anatomic liver resection in the right liver: techniques and perioperative outcomes.

The Glissonean pedicle approach is one of the most popular methods of anatomic liver surgery. Liver surgeons have attempted to reproduce this method laparoscopically. In this study, we introduce our technique of the extrahepatic Glissonean approach for anatomic liver resections, using a robotic system, and report on short-term perioperative outcomes. From December 2008 to July 2014, 10 patients underwent robotic anatomic liver resection in the right liver. The procedure is as follows: (1) mobilization of the liver and isolation and clamping of a selected Glissonean pedicle; (2) transection of the liver parenchyma using a rubber band retraction technique; (3) division of the Glissonean pedicle after full exposure, followed by completion of parenchymal transection. The median age of the patients was 52.50 (range 28-59) years, and seven were male. All patients had hepatocellular carcinoma. The types of resections performed were as follows: segmentectomy 6 (n=1), segmentectomy of 4b+5 ventral segments (n=2), right posterior sectionectomy (n=3), extended right hepatectomy (n=1), extended right posterior sectionectomy (n=2), and central bisectionectomy (n=1). Only one case was converted to open surgery due to severe tumor adhesions on the diaphragm. The median operative time was 555min (range 413-848), and the median estimated blood loss was 225ml (range 30-700), with no perioperative transfusions. The overall complication rate was 70% (grade I, 5; grade II, 1; grade III, 1; grade IV, 0). The median length of hospital stay postsurgery was 7days (range 6-11). Robotic surgery allowed for successful anatomic liver resections via an extrahepatic Glissonean pedicle approach in the right liver and can be safely performed in selected patients.

Risk Factors and Managements of Bile Leakage After Hepatectomy.

BackgroundThe purpose of this study was to retrospectively determine the risk factors and evaluate the management of bile leakage.MethodsThree hundred and thirty-four patients who underwent hepatectomy for Child classification grade A liver disease, without biliary reconstruction and laparoscopic procedures, between 2003 and 2013 were included. Risk factors were identified using multivariate analysis.ResultsBile leakage was observed in 30 (9.0 %) patients. Multivariate analysis demonstrated that type of hepatectomy (segmentectomy 1, medial sectionectomy, anterior sectionectomy, or central bisectionectomy) and operating time was independent risk factors for bile leakage. Among 30 patients with confirmed bile leakage, central type leakage that was in communication with the biliary tree occurred in 23 (76.7 %) patients and peripheral type, which was not in communication with the biliary tree, in 7 (23.3 %) patients. Ten patients were treated with only drainage. Endoscopic or percutaneous transhepatic procedures were performed in 15 cases with central type leakage. Ablation treatment using ethanol or minocycline was mainly performed for peripheral type leakage. Four cases with central type leakage had strictures of the right hepatic duct. Two of them were treated with ablation treatment, portal vein embolization, or fistulojejunostomy. Median duration from diagnosis to end of therapy was 77 days (11–323) in central type and 44 days (6–123) in peripheral type leakage, respectively.ConclusionsComplex hepatectomy and operating time are independent risk factors for postoperative bile leakage. Biliary exploration should be performed as soon as possible after diagnosis, because most bile leakage is the central type. Central type of bile leakage is sometimes refractory to therapy, needing various treatments and requiring a long time for recovery.

Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer.

Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD. Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r. The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery. While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.

Outcomes of central bisectionectomy for hepatocellular carcinoma

BackgroundCentral bisectionectomy (resection of Couinaud segments IV, V and VIII) for malignant or benign disease poses a technical challenge to the surgeon but if feasible, has significant benefits in terms of conserving liver volume and options for future intervention. This study reviews a cohort of patients who underwent this procedure; outlines the indications, optimal operative technique as well as both short‐ and long‐term outcomes. MethodsA retrospective review of a prospectively maintained database was performed. Pre‐operative clinicopathological data, operative details and post‐operative outcomes including overall and disease‐free survival were analysed. ResultsBetween 1989 and 2009, 21 patients underwent a central bisectionectomy. All procedures were performed for hepatocellular carcinoma (HCC). All patients underwent a R0 resection with a median resection margin of 5 mm (1–15 mm). The 1‐, 3‐ and 5‐year disease‐free survivals were 65%, 34.8% and 34.8%, and the corresponding overall survival rates were 90.5%, 66.8% and 66.8%, respectively. ConclusionThese data support the use of a central bisectionectomy in selected cases in the management of HCC. With the use of a meticulous operative technique and adherence to surgical oncological principles, satisfactory long‐term outcomes were achievable.

Salvage hepatectomy for perihilar malignancy treated initially with biliary self-expanding metallic stents

A salvage hepatectomy for an "inoperable" advanced perihilar tumor initially treated with a self-expanding metallic stent (SEMS) is challenging, and its safety and survival benefits remain unclear. The aim of this study was to report our experiences with this difficult resection. This study involved 10 consecutive patients with suspected perihilar cholangiocarcinoma who underwent SEMS placement at a local hospital and were referred to our clinic for possible resection as their last option. Their medical records were analyzed retrospectively. Tumor extent was first reevaluated using multidetector-row computed tomography. Of the 10 patients, 4 were diagnosed as inoperable owing to locally advanced tumors (n = 3) or poor physical condition (n = 1). In the remaining 6 patients, after additional biliary drainage, a salvage hepatectomy was performed, including a right hepatectomy with a caudate lobectomy in 5 patients and a central bisectionectomy with a caudate lobectomy in 1. A combined portal vein resection was required in 3 patients, and a combined pancreatoduodenectomy was performed in 2 patients. R0 resection was achieved in 5 patients, and all patients tolerated the resection. Three patients died of recurrence, and the remaining 3 were alive without recurrence at the time of publication, 1 of whom has survived >10 years. Pre-resection SEMS placement does not preclude a subsequent hepatectomy for patients with advanced perihilar tumors. Salvage hepatectomy, although technically demanding, is feasible and can revise the palliative scenario and benefit selected patients treated initially with an SEMS.

Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

Despite the accumulation of favorable results from laparoscopic liver resection (LLR), centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava (IVC) are still considered contraindications for LLR. We evaluated the feasibility and safety of LLR for centrally located tumors. Of the 182 patients who underwent LLR for benign or malignant tumors between September 2003 and June 2010, the clinical outcomes of 13 patients with tumors within 1 cm or less of the major vascular structures, including the hilum, major hepatic veins, and IVC, were retrospectively analyzed. The perioperative outcomes of the patients were compared with those of the 23 patients who underwent open liver resection for tumors with similar criteria in terms of location and size during the same period. Anatomic liver resection, including left and right hepatectomy, central bisectionectomy, right anterior and posterior sectionectomy, and extended S4 segementectomy, was performed in 10 patients. The remaining 3 patients underwent subsegmentectomy for tumors located in the Spiegel lobe of the caudate. There was no open conversion or postoperative mortality. Compared with the open group, the laparoscopic group showed similar rates of intraoperative transfusion, postoperative complications, and operative time. However, the laparoscopic group spent less time in the hospital postoperatively and had shorter resection margins. After a median follow-up of 34.3 months, there were no statistically significant differences between the 2 groups in reference to the overall survival rates and the disease-free survival rates. This study shows that LLR can be safely performed in selected patients with centrally located tumors close to the liver hilum, the major hepatic veins, or the IVC that were previously considered to be contraindications for LLR. Recent technical developments in the performance of laparoscopic major liver resection may have contributed to the successful application of LLR for centrally located tumors.