Total Hepatic Vascular Exclusion Research Articles

Extreme In Situ Liver Surgery Under Total Vascular Exclusion with Right Hepatic Vein and Inferior Vena Cava Grafts for an Intrahepatic Cholangiocarcinoma

In this multimedia article, we demonstrate an extreme in situ liver surgery under total vascular exclusion with right hepatic vein and inferior vena cava grafts for an intrahepatic cholangiocarcinoma in a centre with experience in highly complex hepatobiliary surgery and liver transplantation. This surgical approach after neoadjuvant chemotherapy provides an opportunity for surgical salvage in patients with large tumors invading the hepatocaval confluence. This patient was considered unresectable at another hospital and referred to our unit. We performed an accurate preoperative assessment with new generation 3D modelling to plan the type of vascular reconstruction that would allow adequate hepatic venous outflow and the volume of the future liver remnant sufficient to avoid postoperative liver failure. For hemodynamic management of the patient, we performed a total hepatic vascular exclusion with veno-venous bypass without intraoperative adverse events. We used a cryopreserved carotid artery graft after previously planning the most appropriate diameter and length for right hepatic vein reconstruction. The inferior vena cava was reconstructed with gore-tex graft. During the hospital stay there were no postoperative complications. The patient is free of disease. We conclude that patients with advanced malignant liver disease should always be referred to highly specialized liver surgery centers to assess the most appropriate oncological management and the possibility of surgical resectability.

Left hepatectomy with suprahepatic inferior vena cava resection and reconstruction under veno-arterial extracorporeal membrane oxygenation for intrahepatic cholangiocarcinoma: a case report

BackgroundCurative surgery is the most effective treatment for intrahepatic cholangiocarcinoma (ICC). When an ICC involves the suprahepatic inferior vena cava (IVC), hepatectomy with suprahepatic IVC resection and reconstruction is challenging. For reconstruction of the suprahepatic IVC, total hepatic vascular exclusion (THVE), veno-venous bypass, and/or in situ hypothermic portal perfusion are required, but mortality and morbidity remain high.Case presentationWe present a 73-year-old woman with mass-forming ICC which invaded the suprahepatic IVC and middle hepatic vein. Left hepatectomy, suprahepatic IVC resection, and reconstruction with an artificial graft were successfully performed during veno-arterial extracorporeal membrane oxygenation (V-A ECMO) to maintain blood pressure. While clamping the IVC diagonally, the right hepatic vein confluence could be preserved. No congestion in the right liver was seen; therefore, there was no requirement for the Pringle maneuver or THVE during reconstruction. No morbidity or mortality was seen after surgery.ConclusionsHepatectomy with suprahepatic IVC resection and reconstruction under V-A ECMO can be performed safely. When an ICC invades the suprahepatic IVC, V-A ECMO during resection and reconstruction of the suprahepatic IVC with an artificial graft is recommended as one of the options.

Conversion resection for patients with hepatocellular carcinoma and inferior vena cava tumor thrombus: a consecutive case series

Conversion resection for patients with hepatocellular carcinoma and inferior vena cava tumor thrombus: a consecutive case series

Transmediastinal, intrapericardial inferior vena cava approach based on anatomical landmarks for hepatectomy using total hepatic vascular exclusion.

Total hepatic vascular exclusion (THVE) is an essential technique to control hemorrhage during surgical treatment of advanced liver tumors or injury. However, surgeons often have difficulty securing the intrapericardial inferior vena cava (IVC) because few reports have described the anatomy around the supra-diaphragmatic IVC or the techniques and surgical outcomes for this procedure. This study presents our safe and feasible intrapericardial IVC approach, which is based on anatomical landmarks, and reports the surgical outcomes of this procedure. We performed THVE using our technique for hepatectomy, accompanied by resection of the hepatic vein confluence or tumor thrombectomy of the supra-hepatic IVC, in five patients between August 2011 and March 2018. The mean operative time was 568min (range: 240-820min). The mean THVE time was 10min (range: 5-15min), with a mean blood loss of 1882mL (range: 1010-3100mL). Postoperatively, one patient was classified as Clavien-Dindo grade II due to medication for tachycardia, and two patients were classified as grade IIIa due to drainage of bile and pleural effusion, including one patient with tachycardia. The mean postoperative hospital stay was 26days (range: 18-34days). No patient exhibited decreased cardiac function during surgery or postoperatively, and no patient experienced thoracotomy or phrenic nerve paralysis. Anatomical landmarks are important to ensure a safe approach to the intrapericardial IVC. Incising the pericardium does not lead to serious problems. The transmediastinal, intrapericardial IVC approach for THVE is a feasible method to secure the supra-diaphragmatic intrapericardial IVC.

Intrahepatic cholangiocarcinoma with a tumor thrombus extending from the inferior vena cava to the right atrium: a case report

BackgroundVascular invasion involving a tumor thrombus in the inferior vena cava and/or right atrium is an unfavorable prognostic factor after intrahepatic cholangiocarcinoma resection. We report an intrahepatic cholangiocarcinoma case with a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium.Case presentationA 58-year-old man with epigastralgia was referred to our hospital after an emergent transcatheter arterial embolization was done following the radiological diagnosis of a ruptured hepatic tumor. The serum concentrations of carcinoembryonic antigen, carbohydrate 19-9, duke pancreatic monoclonal antigen type 2, and cytokeratin-19 fragments were elevated; meanwhile those of alfa-fetoprotein and des-γ-carboxy prothrombin were within normal ranges. A contrast-enhanced computed tomography scan showed a heterogeneously enhanced tumor, 13 cm in diameter, in the left lobe of the liver, enlarged lymph nodes along the lesser curvature of the stomach, and a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. We performed a left hemihepatectomy and tumor thrombectomy under total hepatic vascular exclusion to reduce the risk of sudden death. After dissection of the liver parenchyma along the left side of the middle hepatic vein, except for the left hepatic vein, the inferior vena cava just below the right atrium could be clamped by pulling down the left lobe of the liver toward the caudal side. The thrombus could be removed by incising the inferior vena cava under total hepatic vascular exclusion. Microscopic examination showed a tubular adenocarcinoma. Immunohistochemical staining was positive for cytokeratin-7, cytokeratin-19, and epithelial membrane antigen, but negative for arginase-1, glypican-3, and hepatocyte. The patient was pathologically diagnosed with an intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava. Adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered for 1 year. The patient remained in good health without cancer recurrence for over 4 years after the operation.ConclusionAn aggressive surgical approach may be indicated for intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava and/or right atrium to avoid the risk of impending death.

Resection of recurrent hepatocellular carcinoma with thrombi in the inferior vena cava, right atrium, and phrenic vein: a report of three cases

BackgroundPrognosis for patients with advanced hepatocellular carcinoma with a tumor thrombus in the inferior vena cava or right atrium is extremely poor due to cancer progression, pulmonary embolism, and congestion of the circulatory system caused by right heart failure. Surgical resection of the tumor thrombi may potentially yield better results than non-surgical treatments through prevention of sudden death. However, the benefits of surgical resection in patients with hepatocellular carcinoma and a tumor thrombus extending to the inferior vena cava, right atrium, and potentially in the phrenic vein are unclear. Here, we report three such cases.Case presentationOf the total 136 patients who underwent hepatectomies for hepatocellular carcinoma in our institution, three patients with prior hepatectomies and recurrent hepatocellular carcinoma had tumor thrombi in the inferior vena cava, right atrium, and phrenic vein. Surgical resections were performed, as there was a possibility of sudden death, despite the risk of leaving residual tumor. For all patients, we performed resection of the tumor thrombi in the inferior vena cava and right atrium and combined diaphragm resection. Surgical resection was performed using the total hepatic vascular exclusion technique in all cases. Additional passive veno-venous bypass was also performed in two cases, in which complete tumor resections could not be achieved. The microscopic surgical margins of the combined resected diaphragms were positive in all cases. Progression-free survival was 20.2, 3.8, and 9.5 months for case 1, 2, and 3, respectively. The respective overall postoperative survival was 98.0, 38.9, and 30.9 months. The patients died due to liver cirrhosis, acute heart failure, and hepatocellular carcinoma, respectively. Sudden death did not occur for any of the patients.ConclusionSurgical resections may extend prognosis for patients with recurrent hepatocellular carcinoma with tumor thrombi in the inferior vena cava, right atrium, and phrenic vein, although the indications should be considered carefully.

Hepatic Vascular Exclusion Minimizes Hemorrhage During Isolated Caudate Lobectomy

Objectives Isolated caudate lobectomy is a challenging operation for hepatobiliary surgeons. Unexpected massive hemorrhage is one of the major concerns for successful operation. Addressing the issue of bleeding control and prophylaxis during isolated caudate lobectomy is necessary. Our aim was to summarize the application of hepatic vascular exclusion in the operation to decrease blood loss. Methods Twenty-six cases of isolated caudate lobectomy were reviewed. Different hepatic vascular exclusion and its outcome were analyzed. Results All the operations were accomplished successfully with satisfactory average blood loss (325.38 mL) and without major postoperative complications. Hepatic vascular exclusion was used in nearly four-fifths of the cases. Pringle maneuver, portal vein exclusion, total hepatic vascular exclusion, selective total hepatic vascular exclusion, and selective regional total hepatic vascular exclusion were applied selectively. Conclusions Hepatic vascular exclusion decreased possible blood loss effectively during isolated caudate lobectomy. Full mobilization of the liver facilitates hepatic vascular exclusion. Certain precautionary measures and effective remedies are necessary for unexpected bleeding. Isolated caudate lobectomy should be carried out by experienced hepatobiliary surgeons.

Treatment of hepatocellular carcinoma with hepatic vein tumor thrombosis protruding into the inferior vena cava by conversion surgery following chemotherapy with regorafenib: a case report

Regorafenib is an oral multikinase inhibitor affecting angiogenesis, oncogenesis, metastasis, and tumor immunity. As a systemic treatment, it has been shown to provide survival benefits in hepatocellular carcinoma (HCC) patients progressing on sorafenib treatment. We report herein a case of HCC with hepatic vein tumor thrombosis protruding into the inferior vena cava (IVC-HVTT) which was successfully treated by surgery following second-line chemotherapy with regorafenib. A 79-year-old man with chronic hepatitis was diagnosed with HCC. Computed tomography revealed a solitary tumor in segments 7 and 8 and an IVC-HVTT from the right hepatic vein. Since IVC-HVTT removal is a difficult procedure, the tumor was diagnosed as unresectable, and administration of sorafenib was started. Five weeks later, the lesion had increased in size by 15.3%; subsequently, regorafenib was given as second-line therapy for 12 months. After shrinkage of the IVC-HVTT, the patient was referred to our hospital for surgery. One month after the cessation of regorafenib, an extended resection of segment 8 and total removal of the IVC-HVTT was successfully performed without using total hepatic vascular exclusion. There were no serious postoperative complications. Additionally, there has been no recurrence for about 2 years since the initial therapy.

Current role of trisectionectomy for hepatopancreatobiliary malignancies.

BackgroundTrisectionectomy is a treatment option in extensive liver malignancy, including colorectal liver metastases (CRLM). However, the reported experience of this procedure is limited. Therefore, we present our experience with right hepatic trisectionectomy (RHT) for CRLM as an example and discuss the changing role of trisectionectomy in the context of modern treatment alternatives based on a literature review.MethodsBetween January 1993 and December 2014 all patients undergoing RHT at a single center in the UK for CRLM were included. Patient and tumor characteristics were reviewed and a multivariate analysis was done. Based on a literature review the role of trisectionectomy in the treatment of HPB malignancies was discussed.ResultsA total of 211 patients undergoing RHT were included. Overall perioperative morbidity was 40.3%. Overall 90‐day mortality was 7.6% but reduced to 2.8% over time. Multivariate analysis identified additional organ resection (P = .040) and blood transfusion (P = .028) as independent risk factors for morbidity. Multiple tumors, total hepatic vascular exclusion, and R1 resection were independent risk factors for significantly decreased disease‐free and disease‐specific survival. Further surgery for recurrence after RHT significantly prolonged survival compared with palliative chemotherapy only.ConclusionWith the further development of surgical and multimodal treatment strategies in CRLM the indications for trisectionectomy are decreasing. Having being formerly associated with high rates of perioperative morbidity and mortality, this single‐center experience clearly shows that these concomitant risks decrease with experience, liberal use of portal vein embolization and improved patient selection. Trisectionectomy remains relevant in selected patients.

Retrohepatic vena cava lesion: which we cannot forget?

Vascular lesions are the leading cause of death after abdominal trauma. Among them, the inferior vena cava (IVC) lesion, especially its retrohepatic portion, is one of the most severe, rare, and complicated treatment. The difficult access and delicate anatomical relationships do not favor hemostasis. The etiology of the lesion is variable, resulting from penetrating trauma (transection and/or laceration), blunt or, more rarely, iatrogenic causes. After the initial approach of the polytraumatized patient, the identification of vascular damage must be early, so that surgical treatment of those patients presenting severe hypovolemic shock can be successful. Therapeutic options include tamponade of the lesion through adequate hepatic packaging, digital compression, or repair of the lesions after exposure of the retrohepatic area. In injuries that have not been controlled with tamponade, the total hepatic vascular exclusion is the treatment of choice. In extreme cases, the atriocaval shunt can be performed; however, compared with the vascular isolation technique, the latter showed a better survival rate. Besides, conservative treatment in selected cases of traumatic lesions of retrograde hepatic IVC is feasible and a priority because of the high mortality intrinsic to the surgical procedure. In this sense, the present review reinforces the need for continuous clinical and surgical improvement to obtain outcomes with a better prognosis, especially in retrohepatic vena cava lesions.

Comparative study on selective hepatic vascular exclsion and total hepatic vascular exclusion for hepatic trauma with major hepatic vein injury

Objective To compare the effect of selective hepatic vascular exclsion (SHVE) and total hepatic vascular exclusion (THVE) in the treatment of hepatic trauma with major hepatic vein injury. Methods A retrospective case control study was conducted to analyze the clinical data of 42 patients with hepatic trauma accompanied by hepatic vein injury admitted to multiple centers from April 2000 to December 2017. There were 30 males and 12 females, aged 14-65 years [(40.2±18.8)years]. Blood flow exclusion was operated through HVE in 22 patients (SHVE group) and through THVE in 20 patients (THVE group). SHVE group included 22 patients (16 males and six females), aged (40.1±19.4)years. There were 10 patients with grade IV and 12 with grade V according to American Association of Traumatic Surgery (AAST) classification of liver injury. In terms of the hepatic vein injury, there were 13 patients with type I, eight with type III, and one with type IV. THVE group included 20 patients (14 males and six females), aged (39.9±18.2)years. There were nine patients with grade IV and 11 with grade V according to AAST classification of liver injury. In terms of the hepatic vein injury, there were 11 patients with type I, seven with type III, and two with type IV. The operation approach, operation time, hepatic warm ischemia time, blocking time of hepatic vein blood flow, amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, intraoperative infusion, total blood transfusion, length of ICU stay after operation, length of hospital stay after operation, function of liver and kidney after operation, incidence of complications and mortality were compared between the two groups. Results There were no significant differences in the amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, perioperative blood transfusion, surgical procedure, and postoperative liver and kidney function between the two groups (P>0.05). The THVE group had significantly longer operation time, hepatic warm ischemia time, hepatic venous blood flow blocking time, postoperative ICU time and postoperative hospital stay than the SHVE group (P<0.05). The amount of infusion in the SHVE group was less than that in the THVE group (P<0.05). The incidence of complications in SHVE group was 27% (6/22), lower than that in THVE group [60% (12/20)] (P<0.05). The mortality of SHVE group was 14% (3/22), lower than that of THVE group [45% (9/20)](P<0.05). Conclusions SHVE and THVE can effectively control bleeding in the treatment of hepatic trauma with main hepatic vein injury. SHVE has more advantages over THVE in shortening operation time, warm ischemia time of liver, blocking time of hepatic vein blood flow, ICU stay after operation, hospital stay after operation and reducing intraoperative infusion volume, and can reduce the incidence of complications and mortality. Key words: Digestive system diseases; Liver; Hepatic veins; Hepatic vascular exclusion

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Background: We report the case of a 79-year-old patient with voluminous cholangiocarcinoma that was located in the left liver extended to segment V. A left extended hepatectomy is planned, under temporary porto-caval shunt (TPCS) and Liver Cooling (LC) Methods: The patient was operated on 5 days before from left portal vein ligation. The first step is preparing for TPCS: the right suprahepatic and the trunk of the main and left suprahepatic veins are controlled and the liver is fully mobilized to expose and control the infra and suprahepatic inferior vena cava with a tape. The pedicle is prepared dissecting the portal vein independently from the artery and bile duct. Results: The second step is to realize porto-caval shunt: the graft is sutures between the inferior vena cava and the main trunk of the portal vein. The film reports step by step this operative procedure, until the cannulation of the portal vein. The third step starts with the extended left hepatectomy. The transaction is realized using conventional bipolar electrocautery and ultrasonic dissection. The mains segmental pedicles were controlled using ligation, in particular the pedicle of segment VIII that must be preserved. Conclusion: Liver is rewarmed, cannula is removed. The interest of this film is: i) the realisation of the venous shunt using a vascular graft and ii) the major hepatic resection, which can be managed safely, taking the time to attentively perform a meticulous haemostasis, thanks to the temporary portacaval shunt.

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Outcomes of surgery for hepatocellular carcinoma with tumor thrombus in the inferior vena cava or right atrium.

The prognosis of hepatocellular carcinoma (HCC) patients with tumor thrombus (TT) in the inferior vena cava (IVC) or right atrium (RA) is extremely poor. We reviewed the recent surgical treatments and outcomes of this form of advanced HCC. TT is classified into three types according to its anatomic location relative to the heart: the inferior hepatic type (type I), where the TT is in the IVC below the diaphragm; the superior hepatic type (type II), where the TT is in the IVC above the diaphragm, but still outside the RA; and the intracardiac type (type III), where the TT is above the diaphragm and has entered the RA. Type I can be treated relatively easily by standard radical hepatectomy. For type II, the intrathoracic IVC is approached via the abdominal cavity and an incision in the diaphragm with total hepatic vascular exclusion (THVE). For type III, hepatectomy plus thrombectomy is generally performed under cardiopulmonary bypass. If the TT is only just inside the RA, THVE can be performed by mobilizing the liver caudally. The median overall survival of HCC patients with TT in the IVC or RA, who undergo curative resection, is 19.0-30.8months. As postoperative recurrence is likely to develop, even after curative surgery, effective postoperative adjuvant chemotherapy is required.

Rescue strategy for advanced liver malignancy with retrohepatic inferior vena cava thrombi: experience to promote surgical oncological benefit

BackgroundThe prognosis of advanced liver malignancy with inferior vena cava (IVC) thrombi is poor. Many therapeutic policies are challenging for long-term prognosis. We performed the modified effective technique of transdiaphragmatic intrapericardial IVC isolation for curative resection of IVC tumors and prolonged survival time.MethodsBetween 2003 and 2015, 10 patients, sustained liver malignancy with IVC thrombi, underwent surgical intervention. Liver resection with thrombectomy under total hepatic vascular exclusion via the transdiaphragmatic intrapericardial IVC isolation method was performed for these 10 patients. The first 4 patients underwent retrohepatic IVC resection in order to complete resection, and the other 6 patients preserved the retrohepatic IVC. The last 3 patients received preoperative locoregional therapies, and all 10 patients received postoperative adjuvant chemotherapies immediately.ResultsAll 10 patients underwent gross en bloc tumor resections with thrombectomy with R0 resection. There was no surgical mortality. Shortening of operation time and reduction of both intraoperative blood loss and hospital stay were demonstrated in the last 6 patients with preserving the retrohepatic IVC. However, similar time to recurrence and survival time were noted in the first 7 patients. The last 3 patients, who had received preoperative locoregional therapies, have better disease-free survival time.ConclusionSimplified surgical procedure combined with preoperative locoregional therapies and rapid postoperative adjuvant treatment may provide a greater advantage for these patients.

Surgical resection of recurrent extrahepatic hepatocellular carcinoma with tumor thrombus extending into the right atrium under cardiopulmonary bypass: a case report and review of the literature.

BackgroundRecurrent hepatocellular carcinoma accompanied by a right atrial tumor thrombus is rare. No standard treatment modality has been established. Surgical treatment may be the only curative treatment; however, surgery has been considered high risk. We herein describe a patient who underwent resection of a recurrent right atrial tumor thrombus under normothermic cardiopulmonary bypass on a beating heart.Case presentationA 60-year-old man underwent a right hepatectomy for hepatocellular carcinoma with diaphragm invasion. During the preoperative cardiac screening, he was diagnosed with an old myocardial infarction with triple-vessel coronary disease. Percutaneous coronary intervention was performed for the left anterior descending artery and left circumflex coronary artery. High-grade stenosis remained in his right coronary artery. Nine months later, computed tomography showed recurrent hepatocellular carcinoma in the diaphragm and a tumor thrombus extending from the suprahepatic inferior vena cava into the right atrium. Surgical resection of the recurrent tumor was performed through a right subcostal incision with xiphoid extension and median sternotomy. The recurrent tumor was incised with the diaphragm and pericardium. Intraoperative ultrasonography revealed that the tumor thrombus was free from right atrium wall invasion and that the right atrium could be clamped just proximal to the tumor thrombus. The right atrium, infrahepatic vena cava, left and middle hepatic veins, and hepatoduodenal ligament were encircled. Cardiopulmonary bypass was performed to prevent ischemic heart disease caused by intraoperative hypotension. Total hepatic vascular exclusion was then performed under normothermic cardiopulmonary bypass on heart beating. The inferior vena cava wall was incised. The tumor thrombus with the diaphragmatic recurrent tumor was resected en bloc. The patient had a favorable clinical course without any complications.ConclusionThe recurrent hepatocellular carcinoma in the diaphragm and the right atrial tumor thrombus were safely resected using normothermic cardiopulmonary bypass on heart beating.

Application of liver visualization technologies in hilar tumor resection at the second hepatic portal area

To discuss the application of liver visualization technology in complex liver tumor resection at the second hepatic portal area. Clinical data of 80 cases who received surgery at the second hepatic portal area from August 2014 to September 2015 in the Third Department of Hepatic Surgery of Eastern Hepatobiliary Surgery Hospital were analyzed retrospectively. There were 58 male and 22 female patients aged from 21 to 70 years with median age of 52 years. Median maximum diameter of tumor was 7.6 cm (3.0 to 17.0 cm). Before surgery, liver dimensional graphics produced by liver visualization technology were taken on all patients to observe the relationship between intrahepatic vasculars and the liver tumor, and to calculate the intended resection range and the remaining liver volume in order to make a proper surgery plan. Suitable hepatic vascular occlusion was applied in the tumor resection. Intrahepatic vessel shape and variation, surgical operation, surgical operation time, manner and time of hepatic vascular occlusion, blood loss, liver resection volume, postoperative complications were observed. There were 23 patients who changed surgery plan after liver visualization technology.There were 44 cases with single main hepatic vein compressed by tumors, 32 cases with 2 main hepatic veins, 4 cases with 3 main hepatic veins compressed by tumors.And there were 58 cases with both hepatic vein and inferior vena cava compressed by tumor. Hepatic segments 6 and 7 was removed in 12 cases, 14 cases, hepatic segments 4, 5 and 8 were removed in 8 cases.Right hepatectomy was carried out in 9 patients and left hepatectomy was carried out in 8 patients. Right trisectionectomy was carried out in 3 patients and left trisectionectomy was applied in 5 patients.Local hepatectomy was performed in 12 patients. Nine patients received associating liver partition and portal vein ligation for staged hepatectomy. Four patients underwent total hepatic vascular exclusion, while 16 patients underwent selective hepatic vascular exclusion. The median surgical time was 132 minutes(80 to 240 minutes). Median blood loss volume was 580 ml(100-5 000 ml). Median volume of hepatic resection was 750 ml(30 to 2 000 ml). One patient needed secondary surgery to stop bleeding as a result of postoperative abdominal bleeding.Complication of postoperative bile leakage occurred in 14 cases.Five patients had pleural effusion requiring invasive therapy.Four patients had ascites requiring invasive therapy. Besides, 5 patients had incisive infection while 2 patients were found with pulmonary infection after surgery and two patients occurred biliary obstruction. There was no death case occurred a result of surgery. Using liver visualization technology to make surgical operation plan can improve surgical safety of the second hepatic portal area and optimize the operation plan. It can also reduce the risk of blood loss and postoperative complications such as liver failure.

Parenchyma-Sparing Hepatectomy with Vascular Reconstruction Techniques for Resection of Colorectal Liver Metastases with Major Vascular Invasion.

BackgroundResectability of colorectal liver metastasis (CRLM) depends on major vascular involvement and is affected by chemotherapy-induced liver injury. Parenchyma-sparing with combined resection and reconstruction of involved vessels may expand the indications and safety of hepatectomy.MethodsOf 92 patients who underwent hepatectomy for CRLM, 15 underwent major vascular resection and reconstruction. The reconstructed vessels were the portal vein (PV) in five cases, the major hepatic vein (HV) in nine cases, and the inferior vena cava in six cases.ResultsAll PV reconstructions were direct anastomoses. The HV was reconstructed with an autologous inferior mesenteric venous patch or an external iliac vein interposition graft. Total hepatic vascular exclusion was performed for six patients. Of nine patients with HV reconstruction, three had tumors involving all three major HVs, in whom the left HV was reconstructed as an only vein after extended right hepatectomy. In another six patients, multiple bilobar tumors or tumors in the liver that had chemotherapy-induced injury involved one or two HVs. Parenchyma-sparing by reconstruction of the HV was performed to secure the residual liver function. The patients with vascular reconstruction had an operative time of 462 ± 111 min and a blood loss of 1278 ± 528 mL. No complication classified as Clavien–Dindo 3 or more developed. The median hospital stay was 17 days (range 8–26 days). The cumulative 5-year survival rate for all the patients was 54.6 %, with no significant difference according to vascular reconstruction.ConclusionParenchyma-sparing hepatectomy combined with vascular reconstruction is a useful option to avoid major hepatectomy among various procedures for resection of CRLM with major vascular invasion.

Short-term Total Hepatic Vascular Exclusion in Difficult Caudate Lobe Dissection in Living-donor Liver Transplantation Recipients

BackgroundRecipient hepatectomy can be complicated by severe bleeding during caudate lobe dissection in living-donor liver transplantation (LDLT), especially when the inferior vena cava is encased or with dense adhesions from prior interventions. Total hepatic vascular exclusion (TVE) including total hepatic inflow (Pringle maneuver) and occlusion of supra- and infra-hepatic inferior vena cava during the partial hepatectomy has been studied well, but it has not been mentioned regarding recipient hepatectomy in LDLT. The aim of this study is to evaluate hemodynamic impact and surgical outcome by using the technique of TVE in LDLT. MethodsFrom April 2010 to June 2010, 30 consecutive LDLT recipients at Kaohsiung Chang Gung Memorial Hospital with TVE (TVE group, n = 14) or without TVE (non-TVE group, n = 16) for the caudate lobe dissection were analyzed retrospectively. ResultsThe TVE group had a mean decrease in systolic blood pressure and cardiac index of 21% and 41% during caudate dissection in recipient hepatectomy, respectively. The TVE group had shorter time for caudate mobilization and less blood loss compared with the non-TVE group (3904 mL vs. 5650 mL, P = .461). Two patients in the non-TVE group were shifted to TVE as a salvage procedure to control bleeding. Three patients in the non-TVE group underwent relaparotomy for homeostasis. ConclusionsShort-term TVE is a technically feasible procedure and should be considered during recipient hepatectomy with difficult caudate lobe dissection in LDLT to create a bloodless surgical field. Most patients tolerated the TVE without hemodynamic impact under anesthetic management.

Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection.

To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC). Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8 (2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage. Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra- to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technical modifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication (i.e., Clavien-Dindo grade of III or more). The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.