Extended Left Hepatectomy Research Articles

Reconstruction of middle hepatic vein using a rotating left hepatic vein flap.

S A m t n i i t t v d A f o c t S d v a v T s d t r c t i a f M L f he middle hepatic vein (MHV) drains the central part f the liver, including approximately two-thirds of the ight paramedian sector. In patients with a very thick HV, the MHV may drain an even larger part of the ight liver, including the caudal part of the right lateral ector. After a left hemihepatectomy including the HV (extended left hepatectomy), a considerable part f the remnant right liver becomes congested and may radually shrink postoperatively. This surgical proceure is sometimes used for the treatment of liver metasases from colorectal cancer, such as for patients in hom the tumor has invaded the confluence of the HV and left hepatic vein (LHV). Because the right iver constitutes 60% to 70% of the total liver parenhyma, most patients with normal liver function can olerate an extended left hepatectomy, even if most of he right paramedian sector becomes congested. When he possibility of future multiple liver resections or a epeat liver resection for an intrahepatic recurrence inolving the right hepatic vein is considered, reconstrucion of the MHV so as to preserve as much of the reaining liver function as possible becomes highly esirable. Repeat liver resections requiring the sacrifice f the right hepatic vein cannot be performed if the HV is not reconstructed during the first hepatectomy. n extended left hepatectomy sacrificing the MHV may e risky in patients with liver cirrhosis or other liver iseases. To reconstruct the MHV in this setting, we have deeloped a simple new technique for venous reconstrucion in which an LHV flap is rotated to reconstruct the HV after performing an extended left lobectomy or

Surgical treatment for the giant hepatic carcinomas occupying the central part of the liver

To evaluate the techniques and the effects of surgical resection of giant hepatic carcinomas which occupied the central part of the liver. A retrospective study was carried out of hepatectomies performed for central giant hepatic carcinomas. The hepatic tumors included in this study were hepatocellular carcinomas, cholangiocarcinomas and hepatic metastases which situated in the central part of the liver (segment IV, V, VIII, I) with a diameter of larger than 10 cm and involved hepatocaval confluence, retrohepatic inferior vena cava (IVC) as well as hepatic portal. A total of 40 central giant hepatic carcinomas were successfully resected, with a mean diameter of 13.6 cm (range 10.5-19.0 cm). The types of the hepatectomies conducted were as follows: extended mid-hepatectomy in 9 cases, atypical mid-hepatectomy in 13 cases, extended left hepatectomy in 13 cases, total caudatectomy plus extended left hepatectomy in 3 cases and extended right hepatectomy in 2 cases. The mean operation time was 197 min (range 90 - 380 min) and the mean intraoperative blood lose 1,596 ml (range 300-11,000 ml), with operative mortality and morbidity being 0 and 20%, respectively. The postoperative 1, 3 and 5 year survival rates for the patients were 88%, 56% and 28%, respectively. The hepatic carcinomas of central type, when larger than 10 cm in diameter, frequently involves all the hepatic portal, hepatocaval confluence and retrohepatic IVC. Surgical resection of this kind of tumor, though sophisticated in technique, is safe and effective and, therefore, the first choice of the treatments.

Preoperative portal vein embolization: is it useful?

Portal vein embolization (PVE) before hepatectomy is aimed to induce an atrophy of the embolized lobe to be resected, with a compensatory hypertrophy of the counterlobe to be preserved. To answer the question "Is it useful?," we reviewed the clinical outcome in 161 patients undergoing major hepatectomy after PVE for various hepatobiliary tumors. All the patients tolerated PVE well, and hepatic functional data returned to the baseline levels within a week. The left liver volume increased by a median of 8% (range 2%-14%) after the right PVE. The 20 patients undergoing right hepatectomy for hepatocellular carcinoma had a mean indocyanine green retention rate at 15 min of 16% (SD 4%), and the 24 patients with liver metastases underwent right hepatectomy with additional left liver resection. Hepatectomy procedures comprised right or extended right hepatectomy (n=105), left or extended left hepatectomy (n=13), hepatopancreato duodenectomy (n=12), and less extensive hepatectomies (n=31). As a whole, the operative morbidity and mortality rates were 19% and 1.2%, respectively. Hepatopancreato duodenectomy carried no operative mortality. The cumulative 5-year survival rates were 44% in patients with hepatocellular carcinoma and 60% in patients with metastatic tumor. PVE is useful for performing extensive hepatectomy in patients with mild hepatic dysfunction, in those with bilobar tumors, or in those undergoing hepatopancreato duodenectomy.

Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?

To evaluate the perioperative outcomes and long-term survival of extended hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis. Hepatic resection is a well-established treatment for HCC in cirrhotic patients with preserved liver function and limited disease. However, the role of extended hepatic resection (more than four segments) for HCC in cirrhotic patients has not been elucidated. Between 1993 and 2000, 45 consecutive patients with histologically confirmed cirrhosis underwent right or left extended hepatectomy for HCC (group A). Perioperative outcomes and long-term survival of these patients were compared with 161 patients with HCC and cirrhosis who underwent hepatic resection of a lesser extent in the same period (group B). All clinicopathologic and follow-up data were collected prospectively. Group A patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than group B. However, the two groups were similar in overall morbidity and hospital mortality. There were no significant differences in the incidence of liver failure or other complications. The resection margin width was similar between the two groups. Despite significantly larger tumor size in group A compared with group B, long-term survival was comparable between the two groups. Extended hepatic resection for HCC can be performed in selected cirrhotic patients with acceptable morbidity, mortality, and long-term survival that are comparable to those of lesser hepatic resection. Extended hepatectomy for large HCC extending from one lobe to the other or central HCC critically related to the hepatic veins is justifiable in cirrhotic patients with preserved liver function and adequate liver remnant.

Surgical Treatment of Hilar Bile Duct Carcinoma: Experience With 25 Consecutive Hepatectomies

To evaluate our recent surgical policy regarding hilar bile duct carcinoma, we evaluated 62 cases treated between 1976 and 1993, and 25 cases treated between 1994 and 2000. In the late period we used percutaneous transhepatic portal vein embolization (PTPE) before extended right hepatectomy; S4a + S5 + S1 hepatectomy for elderly patients and those with poor liver function; and routine total caudate lobectomy including the paracaval portion and resection of the inferior portion of the medial segment (S4a). Sixty-five (74.7%) of the 87 patients underwent hepatectomy: 40 in the early period and 25 in the late period. Bile duct resection alone was performed in 22 patients, all in the early period. Resection was curative in 54.8% in the early period and 88.0% in the late period. The 3- and 5-year survival rates in the early period were 27.1% and 20.2%, respectively, as compared to 59.9% and 49.9% in the late period. Analysis of the 25 hepatectomies in the late period revealed improved survival times compared to patients treated by PTPE with extended right hepatectomy. No complications occurred after extended left hepatectomy or S4a + S5 + S1 hepatectomy, but four patients (16%) who underwent extended right hepatectomy plus PTPE died postoperatively. Our policy has resulted in improved outcome in patients with hilar bile duct carcinoma. ( J Gastrointest Surg 2002;6:617–624.)

Surgical management of benign tumors of the liver.

Benign tumors of the liver are increasingly being diagnosed and continue to represent a management challenge. These lesions constitute a substantial component of hepatic neoplasms evaluated and resected at a tertiary referral center. We reviewed our experience with resection of benign liver lesions to clarify the safety and effectiveness of this treatment. Between January 1996 and January 2000, 28 patients with benign hepatic lesions were identified from a cohort of 140 hepatic resection patients. Demographic characteristics, operative management, morbidity, mortality and follow-up were retrospectively analyzed. The mean age in our patients was 35 +/- 14, with 24/28 (86%) patients being female. Seven of the 24 woman (29%) at presentation were either pregnant or immediate postpartum. A history of OCP use was noted in 14/24 (58%) female patients. The most common presenting symptom was abdominal pain in 12/28 (43%). Resection for an undiagnosed mass occurred in 11/28 (39%) patients. The distribution of pathology was hemangioma 10/28 (35.7%), adenoma 8/28 (28.6%), hepatic cyst 5/28 (17.9%), hamartoma 2/28 (7.1%), and FNH 3/28 (10.7%). Average size of the tumor was 7.4 +/- 3.9 (range 2.5-15 cm) with a mean of 1.4 +/- 0.8 lesions (range 1-3) per patient. Tumors were evenly distributed between the right and left side while eight patients (29%) had bilobar tumors. Enucleation rather than anatomic resection was performed in 18/28 (64%) patients, with a mean blood loss of 457 +/- 532 cc (range 50-2200 cc). Blood transfusion was required in only 3/28 (10%) patients, while total vascular isolation was used in only a single patient undergoing an extended left hepatectomy. Mean length of stay was 6.8 +/- 3.2 d (range 3-14 d). Three complications (10.7%) were encountered: pulmonary embolus, ileus and non-operative bile leak. There were no mortalities in this series. Recurrence of tumor occurred in only one patient with a giant hepatic cyst managed laparoscopically. In our institution, the management of clinically relevant benign tumors of the liver comprises a significant proportion of our resectional practice (20%). Our data suggests that both enucleation and anatomically based resections can be performed safely with minimal blood loss and transfusion requirements. Resection of symptomatic lesions was highly effective in treating abdominal pain due to these benign tumors. We advocate resection of non-resolving hepatic adenomas, symptomatic lesions, or when malignancy cannot be excluded.

A new technique for resecting ‘unresectable’ liver tumors

Background/Purpose: Liver tumors that surround the three major hepatic veins traditionally have been considered unresectable. This report describes an extended atypical left hepatectomy technique for tumors around the major hepatic veins. Methods: Three children with tumors surrounding the 3 hepatic veins underwent intraoperative evaluation for extended atypical left hepatectomy. The left hepatic artery, left branch of the portal vein, and the 3 hepatic veins are occluded with vascular clamps. Perfusion of the remaining liver is through the right hepatic artery and portal vein into the retrohepatic vena cava via the retro hepatic veins. If the liver remains soft and does not become mottled, division of the 3 hepatic veins and resection of the tumor are carried out. Results: Extended atypical left hepatectomy was successful in 2 children. Bile leak occurred in 1 instance and healed spontaneously. Both patients had transiently elevated serum bilirubin and transaminase levels and an elevated prothrombin time for 2 weeks. Both survived after treatment with chemotherapy. In the third child the liver became tense and mottled, and the procedure was abandoned. Conclusions: Successful extended atypical left hepatectomy depends on the ability of the retro hepatic veins to adequately drain blood into the vena cava after interruption (clamping) of the main hepatic veins. If the liver becomes mottled and tense the procedure must be abandoned and the patient should be considered for hepatic transplantation. J Pediatr Surg 35:1294-1299. Copyright © 2000 by W.B. Saunders Company.

Extended left hepatectomy (left hepatic trisegmentectomy) in childhood

Background/Purpose: Extended left hepatectomy, also referred to as left hepatic trisegmentectomy, in which segments II, III, IV, V, and VIII are excised, is rarely performed in children. Experience with 7 such resections is reported to describe the anatomy, technique, indications, and outcomes of the operation.Methods: The medical records of all pediatric patients treated at our institution over the last 15 years who underwent extended left hepatectomy were reviewed. Demographic information as well as operative, pathological, and follow-up data were analyzed.Results: Seven patients underwent extended left hepatectomy over this period. There were 5 boys and 2 girls ranging in age between 4 months and 9 years with a median age of 3.1 years. Follow-up ranged from 8 months to 5 years with a median of 3.5 years. Diagnoses included hepatoblastoma (HB, n = 3), focal nodular hyperplasia (FNH, n = 1), leiomyosarcoma (LMS, n = 1), hepatocellular carcinoma (HCC, n = 1), and metastatic neuroblastoma (NB, n = 1). All surgical margins were grossly negative. Median operative blood loss was 13 mL/kg (range, 5 to 32 mL/kg), and mean hospital stay was 9 days (range, 7 to 12 days). No major intra- or postoperative complications were encountered, and there was no perioperative mortality. The 3 HB patients, 1 FNH patient, 1 LMS patient, and 1 NB patient are without evidence of disease, whereas the 1 child with HCC died of recurrent and distant disease. The 6 surviving children have normal hepatic function.Conclusion: Although technically challenging and rarely performed, extended resection of the left hepatic lobe is feasible in children and can yield curative results with minimal morbidity.

Extended left hepatectomy.

Extended left hepatectomy (resection of Couinaud segments II, III, IV, V, and VIII of the liver) has only slowly been appreciated as a viable resectional technique for large, strategically placed, left-sided and central hepatic lesions that extend to involve the right anterior sectoral portal pedicular structures. We report on the preoperative, intraoperative, and postoperative findings of 51 patients undergoing extended left hepatectomy at Memorial Sloan-Kettering from 1992 to 1998. Median age was 58 years (range 1-85), with 28 males and 23 females. Altogether 34 patients had metastatic hepatic malignancies, 14 had primary hepatic malignancies, and 3 had benign hepatic lesions. Median postoperative length of stay was 10 days (range 6-52). Postoperative morbidity and mortality were 53% and 8%, respectively. Multivariate analysis of multiple preoperative variables disclosed that only the largest hepatic lesion of >8 cm (p = 0.033) was an independent predictor of a positive microscopic margin or tumor within one high power field. No preoperative, intraoperative, or postoperative variables were independent predictors of postoperative morbidity or mortality. Utilization of extended left hepatectomy allows resection of critically positioned hepatic lesions previously thought unresectable. It can be performed relatively safely, although it is not without somewhat increased postoperative morbidity and mortality compared to lesser anatomic hepatic resections. Patient selection, as dictated by factors associated with adequate tumor clearance (tumor size and proximity to the right sectoral portal pedicular structures), may be important for determining appropriate candidates for this aggressive resectional technique.

Endoscopic management of major bile leaks complicating hepatic resections for hepatocellular carcinoma

Nine patients with postoperative biliary leaks are presented. These were selected from 128 adult patients with hepatocellular carcinoma who underwent hepatic resections at our hospital between March 1990 and July 1995. Types of hepatic resections as defined by Couinaud7 included nonanatomic resection (40), anatomic resection of 3 or less segments (25), left lateral segmentectomy (6), right or left hepatectomy (41), extended hepatectomy (12), and trisegmentectomy (4). Of the 9 patients (7%) who developed bile leaks postoperatively, there were 7 men and 2 women with median age of 49 years (range 35 to 71 years) (Table 1). Types of resections in these patients were right hepatectomy (2), left hepatectomy (2), left extended hepatectomy (2), right extended hepatectomy (1), right hepatectomy with caudate lobe excision (1), and nonanatomic resection (1). One patient who presented with obstructive jaundice from a left lobe tumor invading the common hepatic duct required reconstruction of the common hepatic duct in addition to left hepatectomy. The incidence of bile leaks after extended hepatectomy was significantly higher (4 in 16 vs. 5 in 112, p = 0.01, Fisher’s exact test). The median tumor size was 8 cm (range 3 to 10 cm). Resection margins were free of tumor in all patients. All 9 patients except 1 had cirrhosis confirmed at laparotomy. ERCP was performed at a median of 19 days (range 11 to 80 days) from surgery. The indications for referral were recurrent infected bilomas in 5 patients, high output fistula (greater than 500 mL daily from subhepatic drains) in 2 patients and nonhealing fistula beyond 2 weeks in 2 patients. Radiologic-guided percutaneous aspirations and pigtail catheter drainage (median 3 sessions, range 1 to 5 sessions) were required in patients with infected bilomas prior to ERCP. The volume of aspirates from bilomas varied from 100 mL to 1.5 L. At ERCP in 1 patient with a previous Billroth II gastrectomy, the papilla could not be accessed because of a redundant afferent limb. He was managed conservatively and his bilocutaneous fistula was healed 2 months later. In another patient, deep cannulation of common bile duct was not achieved. Percutaneous transhepatic biliary drainage was not attempted because of a coagulopathy. She subsequently died of sepsis and liver failure. ERCP was successful in 7 patients. Endoscopic sphincterotomy was performed in 2 patients in whom deep cannulation of the bile duct had been difficult. Bile leaks were demonstrated in all patients to be at or proximal to the liver hilum at segmental branches of intrahepatic ducts. In 5 patients without associated strictures, 10F stents were inserted across the sphincter with the proximal ends of the stents near the site of leakage (Figure 1). A nasobiliary drain was initially placed in 1 patient and subsequently changed to a stent following drying of the fistula. After stent insertion, a significant reduction in fistula output was noted in all patients. Fistulas healed in a median of 11 days (range 9 to 47 days). The effect of stenting was best appreciated in patients with high fistula output. The output often fell from 1.5 L to 300 mL on the day after stenting. Two patients had associated strictures with proximal fistulation, one at a reconstructed common hepatic duct and the other from a segment II duct. In the patient with a common hepatic duct stricture, a stent was inserted across an anastomotic stricture proximal to the site of leakage after balloon dilation of the stricture. Distal migration below the stricture occurred twice leading to recollection of bilomas. Longer stents were placed on two occasions. The fistula took 31 days to heal, 18 days from the last stent placement. In the other patient with a tight segmental II duct stricture following right trisegmentectomy, a nasobiliary drain was initially placed. This subsequently became dislodged. At a second ERCP, the stricture was found to be resistant to balloon dilation and a 6.5F stent was inserted across the stricture. Because of the poor bile duct drainage, healing of fistula was slow. The patient was left with a persistent discharge sinus that finally healed after 110 days. Stents were removed in all cases from 6 to 8 weeks after fistula healing. The duration of follow-up in these patients ranged from 2 to 69 months. No median-term complication was noted. Two patients had died of tumor recurrence, one at 2 and the other at 4 months from surgery.

Laparoscopic liver resections.

The authors present the rationale of the laparoscopic approach to liver surgery, showing the technique of fully endoscopic and endoscopic-assisted formal and wedge hepatic resections and the early results of their experience. From 1993 to 1997, 38 liver resections have been attempted through the laparoscopic or the laparoscopic assisted approach. Out of these 38 resections, 5 were wedge resections, 11 were segmentectomies, 10 were left formal hepatectomies, 1 was an extended left hepatectomy, 5 were bisegmentectomies, 5 were right formal hepatectomies, and 1 was an extended right hepatectomy. In two cases, one segmentectomy and one bisegmentectomy, the procedures were converted to open surgery. Wedge, segmental, and left liver resections were usually performed through a fully endoscopic approach, whereas right liver resections were accomplished by a video-assisted approach. In all but six cases, the resections were attempted for malignancy. There were no intra-operative deaths. One patient died on postoperative day-1 because of liver failure and severe coagulopathy. The early results are comparable to those of conventional surgery, with the benefits derived from minimal access surgery. Laparoscopic liver resections are technically feasible with an acceptable morbidity and mortality rate, but extensive experience in conventional liver surgery, advanced laparoscopic surgery, and the availability of all requested technology are indispensable prerequisites.

Improved liver function due to decompression of the hepatic veins after extended left hepatectomy

Extended left hepatectomy was performed on a patient with hepatocellular carcinoma in the median segment of the liver. The impaired hepatic venous outflow demonstrated by preoperative duplex Doppler ultrasonography improved after surgery due to decompression of the hepatic veins, and liver function improved. A certain volume of hepatic venous outflow may be necessary to maintain liver function and allow compensatory hypertrophy after partial hepatectomy.

Whiplash amnesia

Aim: To assess the utility of the perioperative use of direct oral anticoagulants for patients with hepatocellular carcinoma (HCC) with cancer-associated thrombosis. Case Report: An 83-year-old woman was admitted with a solitary HCC (10-cm diameter), as well as with multiple sites of venous thromboembolism and macroscopic portal vein tumor thrombosis. She had appropriate liver function without viral hepatitis, triple-positive tumor markers, and secondary polycythemia. Edoxaban at 30 mg was initiated 10 days before surgery to remove HCC. Complete remission of the pulmonary embolism and stability of the deep vein thrombosis and massive superior mesenteric vein thrombosis were recognized preoperatively. An extended left hepatectomy was successfully performed. To avoid hemorrhage complications, we used intravenous administration of nafamostat mesylate for 2 days, thereafter we restarted edoxaban. Superior mesenteric vein thrombosis resolved 5 months after surgery. Conclusion: Perioperative oral administration of edoxaban was useful in multidisciplinary treatment for a patient with advanced HCC with cancer-associated thrombosis.