Hepatic bisegmentectomy 7-8 for a colorectal metastasis

Color Doppler Intraoperative Ultrasonography Evaluation of Hepatic Hemodynamics for Laparoscopic Parenchyma-Sparing Liver Resections

BACKGROUND

Tumors involving the hepatic veins at the hepatocaval confluence often require major or extended hepatectomies. Color Doppler intraoperative ultrasonography (CD-IOUS) evaluation of liver hemodynamics to assess congestion in the veno-occlusive parenchyma provides real-time information helpful in parenchyma-sparing surgery (PSS). This study evaluated the feasibility of CD-IOUS in patients undergoing laparoscopic liver resections for such tumors and its capacity to allow PSS.

METHODS

Consecutive patients undergoing laparoscopic liver resection for tumors at the hepatocaval confluence requiring resection of at least one hepatic vein between January 2010 and August 2020 were included. Patients were divided in 3 groups: (A) patients not assessed with CD-IOUS because it would not change the scheduled operation; patients assessed with CD-IOUS and treated with (B) PSS and (C) no-PSS. Portal blood flow in the veno-occlusive parenchyma was assessed using CD-IOUS at baseline and after clamping the concerned hepatic vein.

RESULTS

The study included 43 out of 47 patients with tumors at the hepatocaval confluence. There were 19 patients in group A. Among patients assessed with CD-IOUS, the resection of 26 hepatic veins was planned: 25 were resected, and 1 was spared. Group B included 22 patients treated with PSS, whereas group C included 2 patients with resection of all veno-occlusive parenchyma. No postoperative mortality or major morbidity was observed. The median length of hospital stay was 5 days.

CONCLUSIONS

Selected patients with tumors involving the hepatocaval confluence can be safely approached using laparoscopy. CD-IOUS evaluation of the veno-occlusive area can increase the success rate of PSS.

Bisegmentectomy 7-8 for Small-for-Size Remanant Liver for Cirrhotic Patients Under Right Hemi-hepatectomy With Hepatocellular Carcinoma: A Case-Matched Comparative Study

Aim: To compare the short- and long-term treatment outcomes of bisegmentectomy 7-8 vs. right hepatectomy for patients with hepatocellular carcinoma and cirrhosis. Methods: Thirty six cirrhotic HCC patients with infiltration of right hepatic vein in segments 7-8 underwent bisegmentectomy 7-8 for small-for-size remanant liver under right hemi-hepatectomy. Its outcome was compared with a case-matched control group of cirrhotic HCC patients who underwent right hemi-hepatectomy during the study period. Results: The study group consisted of 36 patients and the control group 36 patients selected from 1,526 patients matched with age, tumor size, tumor location, and Pugh-Child staging. There were no significant differences between the two groups in operative parameters and in perioperative main complications which included hemorrhage, bile leakage, ascites, pleural effusion, and liver failure. The overall morbidity rate and morbidity rate classified according to Clavien's classification were similar. There was no in-hospital mortality or 90 day post-operative mortality. The mean follow-up was 30 and 32 months for the study group and control group, respectively. The disease free survival rate (DFS) for the study group was just significantly better than the control group. The median DFS was 24 months for the study group and 8 months for the control group (P = 0.049). Meanwhile, the median cumulative overall survival was 35 months for the study group and 27 months for the control group (P = 0.494). Conclusion: Bisegmentectomy 7-8 was safe and feasible for selected cirrhosis patients, and did not increase the perioperative risk and inferior long-term overall survival outcomes. It extended the indications for liver resection in patients with borderline volumes of future liver remnant for HCC cirrhotic liver.

Feasibility of Right Upper Transversal Hepatectomy in the Absence of an Inferior Right Hepatic Vein: New Insights regarding This Complex Procedure

Background

Right upper transversal hepatectomy (RUTH) is defined as the removal of liver segments 7, 8, and 4A with ligature of the right and middle hepatic veins and is considered one of the most complex techniques of parenchymal-sparing hepatectomies. This procedure can be performed, without venous reconstruction, if collateral veins are present communicating within remnant liver segments to a large inferior right hepatic vein and/or to the left hepatic vein. This venous network could maintain outflow from the inferior right segments (S5, S6) to the left liver when a RUTH is performed, even in the absence of an inferior right hepatic vein. The aim of this study is to present our experience with RUTH without venous reconstruction in patients with and without the presence of an inferior right hepatic vein (IRHV).

Methods

Patients submitted to RUTH for treatment of liver metastases were selected from our database. The presence of an IRHV, clinical and surgical characteristics of the patients, immediate outcomes, viability of liver segments 5 and 6, and long-term survival were analyzed.

Results

RUTH was successfully performed in four patients. In two patients, IRHV was not present, but intrahepatic communicating veins between proximal right and middle hepatic veins and left hepatic vein were present. No venous reconstructions were performed. Mild congestion of the inferior right segments occurred in the patients where there was no IRHV but no immediate, early, or late complications were observed.

Conclusions

RUTH is feasible and can be performed even in the absence of an IRHV, without venous reconstruction. Some degree of congestion of the right inferior liver segments might occur when an IRHV is absent, yet this is not clinically significant when communicating veins are present. Maximum parenchyma preservation might prevent postoperative liver failure and allow repeated resections in case of hepatic recurrence.

Parenchymal-sparing liver surgery in patients with colorectal carcinoma liver metastases

Liver resection is the treatment of choice for patients with colorectal liver metastases (CLM). However, major resections are often required to achieve R0 resection, which are associated with substantial rates of morbidity and mortality. Maximizing the amount of residual liver gained increasing significance in modern liver surgery due to the high incidence of chemotherapy-associated parenchymal injury. This fact, along with the progressive expansion of resectability criteria, has led to the development of a surgical philosophy known as "parenchymal-sparing liver surgery" (PSLS). This philosophy includes a variety of resection strategies, either performed alone or in combination with ablative therapies. A profound knowledge of liver anatomy and expert intraoperative ultrasound skills are required to perform PSLS appropriately and safely. There is a clear trend toward PSLS in hepatobiliary centers worldwide as current evidence indicates that tumor biology is the most important predictor of intrahepatic recurrence and survival, rather than the extent of a negative resection margin. Tumor removal avoiding the unnecessary sacrifice of functional parenchyma has been associated with less surgical stress, fewer postoperative complications, uncompromised cancer-related outcomes and higher feasibility of future resections. The increasing evidence supporting PSLS prompts its consideration as the gold-standard surgical approach for CLM.

Inferior Right Hepatic Vein: A Useful Anatomic Variation for Isolated Resection of Segment VIII

Anatomical resection of segment VIII (SVIII) is one of the most difficult hepatectomies to perform. Although it is the best choice of surgical treatment for tumors located at SVIII, its feasibility can be compromised when the right hepatic vein (RHV) must be resected en bloc with SVIII. Herein we describe a case of a cirrhotic patient that was submitted to segmentectomy VIII in bloc with the main trunk of the RHV, due to hepatocellular carcinoma. The resection could only be performed because a well developed inferior right hepatic vein (IRHV) was present. Anatomical variations of the liver vascularization should be used by liver surgeons to improve surgical results.