Middle Hepatic Vein Resection Research Articles

Pathological complete response following neoadjuvant chemotherapy for locally advanced intrahepatic cholangiocarcinoma

BackgroundIntrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer. Cases when found are often advanced with vascular invasion, and radical resection is often difficult. Despite curative resection, the postoperative recurrence rate of patients with histological lymph node metastasis is high, and their prognosis is poor. Therefore, there is an urgent need to establish multidisciplinary treatment that combines chemotherapy and surgical resection. The efficacy of neoadjuvant chemotherapy (NAC) for locally advanced ICC is unclear. In this report, a case of locally advanced ICC in which pathological complete response (pCR) was achieved after NAC is described.Case presentationA 79-year-old woman was admitted to a local hospital with appetite loss. Computed tomography showed a 100 × 90 mm low-contrast tumor in the left hepatic lobe and segment 1 with invasion to the inferior vena cava (IVC), and several lymph nodes along the left gastric artery and lesser curvature were enlarged. Therefore, she was treated with a combined chemotherapy regimen of gemcitabine and cisplatin. After four courses, the tumor size decreased to 30 × 60 mm without invasion to the IVC. Left hepatectomy extending to segment 1 with bile duct resection combined with middle hepatic vein resection (H1234-B-MHV), dissection of regional lymph nodes and pyloroplasty were performed. After radical resection, pCR was achieved. She is alive with no evidence of disease, 2 years after surgery.ConclusionsIn this case, a patient with locally advanced ICC achieved pCR to NAC. NAC may be effective for ICC. Patients who achieve pCR may have a better prognosis.

Volumetric Remodeling of the Left Liver After Right Hepatectomy: Analysis of Factors Predicting Degree of Hypertrophy and Post-hepatectomy Liver Failure

BackgroundThis study investigated the volumetric remodeling of the left liver after right hepatectomy looking for factors predicting the degree of hypertrophy and severe post-hepatectomy liver failure (PHLF). MethodsIn a cohort of 121 right hepatectomies, we performed CT volumetrics study of the future left liver remnant (FLR) preoperatively and postoperatively. Factors influencing FLR degree of hypertrophy and severe PHLF were identified by multivariate analysis. ResultsAfter right hepatectomy, the mean degree of hypertrophy and kinetic growth rate of the left liver remnant were 25% and 3%/day respectively. The mean liver volume recovery rate was 77%. Liver remodeling volume was distributed for 79% on segments 2 and 3 and 21% on the segment 4 (p<0.001). Women showed a greater hypertrophy of segments 2 and 3 compared with men (p=0.002). The degree of hypertrophy of segment 4 was lower in case of middle hepatic vein resection (p=0.004). Left liver remnant kinetic growth rate was associated with the standardized future liver remnant (sFLR) (p<0.001) and a two-stage hepatectomy (p=0.023). Severe PHLF were predicted by intraoperative transfusion (p=0.009), biliary tumors (p=0.013), and male gender (p=0.022). ConclusionsVolumetric remodeling of the left liver after right hepatectomy is not uniform and is mainly influenced by gender and sacrifice of middle hepatic vein. Male gender, intraoperative transfusion, and biliary tumors increase the risk of postoperative liver failure after right hepatectomy.

Laparoscopic surgical technique for left intrahepatic cholangiocarcinoma with lymph node metastasis after conversion therapy (with video).

Intrahepatic cholangiocarcinoma (ICC) with lymph node metastasis has a poor clinical prognosis. Comprehensive surgical treatment based on surgery is critical for improving the prognosis. Conversion therapy provides an opportunity for radical surgery in such patients but also increases the difficulty of surgery. The technical barrier to laparoscopic lymph node dissection is determining the extent of regional lymph node dissection after conversion therapy and formulating a suitable procedure to ensure the quality of lymph node dissection and oncological safety. One patient with initially unresectable left ICC underwent successful conversion therapy at another hospital. Then, we performed laparoscopic left hemihepatectomy with middle hepatic vein resection and regional lymph node dissection. Specific surgical techniques are used to reduce injury and bleeding, ultimately reducing the incidence of complications and promoting rapid recovery of patients. No postoperative complications were noted. The patient recovered well; no tumor recurrence was observed during the follow-up. Preoperatively planned regional lymph node dissection provides a reference for exploring the standard laparoscopic surgical treatment of ICC. Procedural regional lymph node dissection and artery protection techniques ensure quality and oncological safety in lymph node dissection. When selecting appropriate cases, as long as the laparoscopic surgical technique is mastered, laparoscopic surgery is safe and feasible with faster postoperative recovery and less trauma for left ICC.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes.

Backgrounds/AimsMiddle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy.MethodsPatients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation.ResultsA total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52).ConclusionsResection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.

Role of middle hepatic vein resection in standard right or left hepatectomy on post hepatectomy outcomes

Middle hepatic vein (MHV) is preserved in standard right or left hepatectomy in order to maintain the venous outflow of the remnant liver. Resection of MHV can cause venous parenchymal congestion, reflux of blood flow into portal vein, avoiding the regeneration of liver. The aim of this study was to evaluate if preservation or not of the MHV will influence post-surgical outcomes including post hepatectomy liver failure (PHLF) in standard right or left hepatectomy. A retrospective analysis was carried out using a prospectively maintained database. A total of 144 patients underwent standard right or left hepatectomy (Brisbane 2000 nomenclature) between January 2015 and March 2019 were included. Anatomical remnant liver volumes were measured retrospectively using Hermes software. A right hepatectomy was performed in the 79% of the cases and a left one in the 21%. MHV was resected in 13 patients (10%) in addition to standard right or left hepatectomy. Median remnant liver volume in the MHV resected group was significantly more (p = 0.006). In the multivariable analysis, resection of the MHV did not influence in the occurrence of PHLF (p = 0.518). Similarly, there was no significant difference in the serum bilirubin, INR, ALT, creatinine levels on post op days 1, 3, 5, 10, and no significant difference in Grade IIIa or more complications, and 90-day mortality rates. Resection of the MHV as a part of standard right or left hepatectomy in liver resection surgery did not have a negative impact on the post-operative outcomes in patients with adequate remnant liver volume.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes

Purpose: Middle hepatic vein (MHV) is preserved in standard right or left hepatectomy to maintain the venous outflow of the remnant liver. The aim of this study is to evaluate if resection of MHV will influence post-resection outcomes in standard right or left hepatectomy.

Parenchymal-Sparing Hepatectomies for Colorectal Liver Metastases

Introduction: Parenchymal-sparing hepatectomies (PSH) have been performed widely for the patients of colorectal liver metastases (CLM) to preserve much liver parenchyma and allow for future re-resection. Herein, we divide PSH into 3 types of hepatectomies,ⅰ)limited anatomical resection,ⅱ)tumor-vessel detachment resection, andⅲ)tumor enucleation locating at the deep part of liver parenchyma from the parenchymal slit. In this presentation, we show each case, and evaluate the feasibility. Case1: In this case, the tumor was located at the boundary of S1 and S4. The tumor was 2cm in size, and involving the main trunk of middle hepatic vein (MHV). To preserve lateral section and left hepatic vein, we selected anatomical S1/S4 resection concomitant with MHV resection. Case2: The second patient had a tumor in S7, which was adjacent to the right hepatic vein (RHV). To preserve the venous return from the posterior section, we performed partial resection by detaching the tumor from the RHV. Case3: The last patient had multiple CLMs in bilateral lobe. Most tumors were located in the shallow part of liver parenchyma and dissected by partial resections. However, one tumor in S8 was located at the deep part of liver. Hence, we made parenchymal slit and enucleated the tumor. Results: We archived R0 resection in all cases. Postoperative mortality and morbidity were nil. Conclusions: PSH can be classified into 3 types. All types of PSH are feasible and can be performed safely.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes

Successful use of the left portal vein as graft for middle hepatic vein reconstruction in left hemihepatectomy: preliminary experience on six cases

BackgroundThe purpose of this research was to assess the feasibility of reconstructing the middle hepatic vein (MHV) with resected left portal vein during left hemihepatectomy.MethodsFrom January 2014 to January 2018, six patients received left hemihepatectomy combined with MHV reconstruction using the resected left portal vein in West China Hospital. We reviewed the clinical data including patient details, surgical technique, graft patency, and operative results.ResultsAll six patients underwent left hemihepatectomy for liver tumors located at left hepatocaval confluence. In these patients, MHV was resected due to tumor invading and reconstructed using the resected left portal vein as graft. The mean operating time was 316 min. Two patients developed complications: one experienced bile leakage and one experienced pleural effusion. No patient developed vascular graft complications. All the grafts remained unobstructed, and no local tumor recurrence occurred during the observation period of 13–41 months.ConclusionsOur results indicated that the left portal vein was a safe graft for hepatic vein reconstruction. In addition, left hemihepatectomy combined with middle hepatic vein resection and reconstruction using the left portal vein can be performed safely to treat liver tumors located at hepatocaval confluence.

The Liver Tunnel

This prospective intention-to-treat validation study evaluated the liver tunnel (LT) technique for patients having ≥1 deep centrally located liver tumor, with or without middle hepatic vein (MHV) invasion. Conservative surgery has been proposed for patients with deep liver tumors having complex relationships. LT is one such novel technique. Eligible patients were prospectively enrolled for LT. LT relies on tumor-vessel detachment, and the presence of communicating veins if MHV resection is necessary. Twenty consecutive patients met the inclusion criteria: 17 had colorectal liver metastases, 1 had hepatocellular carcinoma, 1 had mass-forming cholangiocarcinoma, and 1 had mixed hepatocellular carcinoma-mass-forming cholangiocarcinoma. Nineteen patients underwent LT. The MHV was resected in 6 patients, always sparing segments 4i and 5. Overall, 180 lesions were removed (median 7; range 1-37): 79 lesions were included in the LT specimen (median 3; range 1-13). There was no in-hospital 90-day mortality. Overall morbidity occurred in 10 (50%) patients: major in 2 (10%). All complications were managed conservatively. After a median 15-month follow-up (range 6-48), 2 instances of cut-edge local recurrences were observed. This study shows that LT is technically feasible and safe. Further studies are needed for standardizing its use.

Left hepatectomy is associated with enhanced liver regeneration after resection for colorectal liver metastases

Objective: Hepatectomy remains the only curative treatment for patients with colorectal liver metastases (CRLM). Depending on tumor location, right or left hepatectomy may be indicated. As the implications of resection type on liver regeneration have not been well-studied, we aimed to examine them in the present study. Methods: Liver regeneration rates of patients who underwent hepatectomy for CRLM between 2003 and 2015 were assessed. The early and late regeneration indexes were defined as the relative increase in liver volume (RLV) within 2[(RLV2m − RLVp)/RLVp] and 7 months [(RLV7m − RLVp)/RLVp] from surgery. The right (RH) and left (LH) hepatectomy (both formal and extended) groups were compared with respect to liver regeneration; multivariable analysis was then performed. Results: Preoperative chemotherapy details and volumetric data were available for 69 patients. The RH group consisted of 51 patients (73.9%); the LH group included 18 (26.1%). Baseline characteristics and frequency of middle hepatic vein resection were similar across both groups; however, resected liver volume was significantly greater in the RH group [Right: 52.3% (IQR: 45.3–58.8) vs. Left: 21.8% (IQR: 16.2–28.0), p ;< 0.001].On univariable analysis, the RH group exhibited higher early [44.4% (20.7%–64.0%) vs. 7.4 (−3.8%–19.0%);p = 0.001] and late regeneration rate[66.0% (37.6%–92.0%) vs. 13.0 (−7.0%–23.6%); p < 0.001]. However, after adjusting for potential confounders – portal vein embolization, resected volume, and bevacizumab – this effect reversed for both the early (23.7% increase for LH vs RH; p = 0.062) and late (52.1% increase for LH vs RH; p = 0.001) regeneration indexes. Liver failure occurred exclusively in the RH group (n = 6). Conclusion: Left hepatectomy was associated with greater regeneration than right hepatectomy after adjusting for potential confounders on multivariable analysis. This finding should be confirmed in future studies.

Aggressive Hemihepatectomy Combined with Resection and Reconstruction of Middle Hepatic Vein for Intrahepatic Cholangiocarcinoma.

Major hepatectomy for intrahepatic cholangiocarcinoma (ICC) sometimes involves resection of major hepatic veins, which might result in the future liver remnant (FLR) congestion. The necessity and efficacy of resection and reconstruction of the middle hepatic vein (MHV) during right or left hemihepatectomy for resection of ICC remains unclear. Between 1995 and 2013, 68 patients underwent right (n=24) or left hemihepatectomy (n=44) for primary ICC, with (n=27) or without (n=41) resection of MHV. If the noncongested FLR volume was <40% of the total liver volume, reconstruction of major hepatic veins was considered. No significant differences between the groups were observed for patients with or without resection of MHV in the pathologic findings, including negative surgical margins (81 vs. 85%, P=0.67) and overall survival (5-year survival rate: 18.3 vs. 33.4%, P=0.26). In five patients who underwent venous resection and reconstruction, the noncongested FLR increased from 37 to 74% after reconstruction (P<0.01); this noncongested FLR was almost similar to the patients without venous resection (72%). Three patients undergoing venous resection without reconstruction developed postoperative hepatic failure (grade A in 2 and grade B in 1; International study group of liver surgery definition); however, there was no surgical mortality. Aggressive hemihepatectomy for ICC with venous resection in the FLR resulted in acceptable long-term outcome with no mortality when considering hepatic venous reconstruction based on our criterion.

Reply to Norihiro Kokudo et al. Regional liver function is not “zero” in the congestive area after hepatectomy with middle hepatic vein resection

Reply to Norihiro Kokudo et al. Regional liver function is not “zero” in the congestive area after hepatectomy with middle hepatic vein resection

An extended dysfunctional area in the congestive area of the remnant liver after hemi‐hepatectomy with middle hepatic vein resection for liver cancers evaluated on the gadoxetic acid disodium‐enhanced magnetic resonance imaging

The aim of the present study was to evaluate the liver function in the congestive area of the remnant liver after hemi-hepatectomy with middle hepatic vein (MHV) resection for liver cancers. From November 2009 through December 2012, 18 patients underwent hemi-hepatectomy including the MHV for liver cancers. Post-hepatectomy, the volume of the congestive area, which appeared as a hyper-intense area on T2-weighted images and dysfunctional area, which appeared as a low intensity area on hepatobiliary phase images in the remnant liver was evaluated in all patients by gadoxetic acid disodium-enhanced magnetic resonance imaging. Fifteen of 18 patients showed a congestive area, and 16 of 18 patients showed a dysfunctional area in the remnant liver. The dysfunctional rate (median 11%) was significantly larger than the congestive rate (median 5%, P = 0.0004). The dysfunctional rate was associated with tumor invasion to the root of the MHV, and no tumor invasion to the root of the MHV was identified as a significant predictor of a larger dysfunctional area (odds ratio 25.888, P = 0.0267) on multivariate analysis. Hemi-hepatectomy with MHV resection for liver cancers should be performed considering the dysfunctional area in the remnant liver, which is associated with tumor invasion to the root of the MHV.

Metabolic Disorders, Non-Alcoholic Fatty Liver Disease and Major Liver Resection: An Underestimated Perioperative Risk

IntroductionDespite increasing evidence of an association of metabolic syndrome and liver degeneration, little is known about the results of major hepatic resection in patients with metabolic disorders. Following the observation of some unexplained perioperative deaths following uncomplicated right hepatectomy in patients presenting metabolic disorders, we analyzed the perioperative mortality in such population. Material and MethodsA retrospective analysis of immediate outcome was performed of patients undergoing right hepatectomy and affected by two or more metabolic disorders (diabetes mellitus, hypertension, dyslipidemia, obesity/overweight) without any other known cause of liver disease from January 2001 to May 2010. ResultsAmong 151 patients undergoing right hepatectomy, 30 patients presented two or more metabolic disorders. Perioperative mortality in this group reached 30 % (nine patients). In patients presenting MS (≥3 disorders), mortality reached 54 %. Univariate analysis identified four criteria associated with poor prognosis: MS, perioperative bleeding ≥1,000 mL, middle hepatic vein resection and primary hepatic malignancy. At multivariate analysis, middle hepatic vein resection and underlying primary hepatic malignancy resulted as being related to mortality. ConclusionsPatients presenting with multiple metabolic disorders should be carefully evaluated before major liver resection, especially when the procedure is planned for hepatocellular carcinoma and when a middle hepatic vein resection is required.

Minimesohepatectomy for Colorectal Liver Metastasis Invading the Middle Hepatic Vein at the Hepatocaval Confluence

In case of liver tumors invading the middle hepatic vein (MHV) at the hepatocaval confluence (HC) major resection is recommended. We describe a new ultrasound-guided conservative operation for patients with colorectal liver metastasis (CLM) invading the MHV at the HC. The case of a 65-year-old woman with two CLMs is described. One CLM was in segments 4-superior (S4-superior) and 8-ventral (S8-ventral) with invasion of the MHV 2 cm from the HC, while the other was in segment 8-dorsal (cranial portion). J-shaped laparotomy and intraoperative ultrasonography (IOUS) were carried out. Anterior surface of the HC was exposed, and compression using the surgeon's fingertips was applied at the MHV. Once reversal flow in the peripheral portion of the MHV, and/or shunting collaterals with right or left hepatic vein, and/or hepatopetal flow in portal branches to right paramedian section (P5-8) and/or to segment 4-inferior (P4-inferior) were detected by color Doppler IOUS (CD-IOUS), partial resection of S4-superior and S8-ventral with vascular resection of MHV was performed. The disclosure of those three criteria by CD-IOUS enables the performance of minimesohepatectomy. No congestion of the remnant liver was found. Ninety-day mortality and morbidity were nil. The patient was discharged 8 days after surgery. At 11 months of follow-up the patient underwent percutaneous radiofrequency ablation for a new 15-mm CLM in segment-8-dorsal (caudal portion). Currently, the patient is alive and free of disease at 17 months after surgery. The use of CD-IOUS may allow conservative resection of liver tumors invading the MHV at the HC. This might limit the need for larger resections, and broadens the role of IOUS in optimizing surgical strategy.

Impaired volume regeneration of split livers with partial venous disruption: a latent problem in partial liver transplantation.

In living-donor and split-liver transplantations using a hemi-liver graft, it is practically impossible to maintain complete venous drainage in both the right and left livers, because the middle hepatic vein can be preserved only on the unilateral side. However, it is not clear whether partial venous disturbances affect postoperative liver volume regeneration. Living donors who underwent left-sided hepatectomy preserving the middle hepatic vein (group A, n=40) or left hepatectomy with middle hepatic vein resection (group B, n=37) were reviewed. Volume regeneration of the remnant right paramedian (segments V + VIII) and lateral (segments VI + VII) sectors and overall liver volume was assessed at 3 postoperative months by computed tomography. In group A, both sectors showed a proportional increase by 21.7% (P=0.991), whereas in group B the rate of increase of the right paramedian sector was less than that of the right lateral sector (13.3% vs. 36.5%, P<0.001). Comparisons of rate of increase for each sector between the groups indicated that interruption of the middle hepatic venous drainage impaired enlargement of the right paramedian sector and induced a compensatory hypertrophy of the right lateral sector. Overall liver mass restoration rate in group B was inferior to that in group A (78.9% vs. 85.0%, P=0.001). Split livers with partial outflow disturbances are associated with latent disadvantages in postoperative liver volume regeneration even if venous congestion is not evident. These results suggest a problem of regenerative capacity of right liver grafts.