The necessity of hepatic vein reconstruction after resection of cranial part of the liver and major hepatic veins in cirrhotic patients

First Robotic Hepatectomy With Middle Hepatic Vein Reconstruction Using ePTFE Graft for Hepatic Adenoma: A Case Report

Surgical resection remains the best choice for the treatment of liver tumors. Hepatectomy combined with artificial vascular reconstruction has been proven as an alternative to treating tumors involving the main hepatic veins. As the cutting-edge surgical technique, robotic liver surgery is a novel procedure expanding the field of minimally invasive approaches, especially in complex reconstruction. This study reports, for the first time, on a robotic hepatectomy with middle hepatic vein (MHV) reconstruction using an expanded polytetrafluoroethylene (ePTFE) graft for a patient with hepatic adenoma. The tumor, which was located in segment 8, was adjacent to the MHV. Robot-assisted resection of segment 4 and partial segment 8, and MHV reconstruction using a ePTFE graft were performed. During the post-operative examination and follow-up, the blood flow of the ePTFE graft was patent, and liver function recovered well. Thus, robotic hepatectomy with MHV reconstruction is a safe, minimally invasive, and precise surgery that may provide a novel approach for patients with liver tumors that are invading or adjacent to the main hepatic veins.

Concomitant Hepatectomy and Atrial Thrombectomy under Cardiopulmonary Bypass versus Staged Hepatectomy in the Treatment for Hepatocellular Carcinoma with Large Right Atrial Tumor Thrombi

(1) Background: Hepatocellular carcinoma (HCC) with a large right atrium tumor thrombus (RATT) is a rare and critical presentation. Emergency hepatectomy and thrombectomy under cardiopulmonary bypass (CPB) is life-saving and potentially curative. The aim of this study is to propose an appropriate approach for this condition. (2) Methods: In period A (1998 to 2010, n = 7), hepatectomy and thrombectomy were concomitantly performed, and staged hepatectomy was performed in period B (2011 to 2018, n = 17). (3) Results: The median overall survival time (MOST) in the published studies was 14 months. Moreover, the blood loss, blood transfusion rate, length of ICU stays, and hospital costs were significantly reduced in period B. The MOSTs of patients in period A (n = 6) and period B (n = 17) were 14 vs. 18 months (p = 0.099). The median disease-free survival times (MDFTs) in period A (n = 6) and period B (n = 15) were 8 vs. 14 months (p = 0.073), while the MOSTs in period A and period B were 14 vs. 24 months (p = 0.040). (4) Conclusions: Emergency thrombectomy under CPB and staged hepatectomy 4–6 weeks later may be an appropriate approach for HCC with large RATT. However, the optimal waiting interval requires further investigation.

Left renal vein graft and in situ hepatic perfusion in hepatectomy for complete tumor invasion of hepatic veins: hemodynamic optimization and surgical technique

Purpose

Assessing hepatic vein reconstruction using a left renal vein graft and in situ hypothermic liver perfusion in an extended liver resection.

Methods

Patients included in this study were those with liver tumors undergoing curative surgery with resection and reconstruction of hepatic veins. Hepatic vein was reconstructed using a left renal vein graft. We describe the technical aspects of liver resection and vascular reconstruction, the key aspects of hemodynamic management, and the use of in situ hypothermic liver preservations during liver transection (prior to and during vascular clamping).

Results

The right hepatic vein was reconstructed with a median left renal venal graft length of 4.5 cm (IQR, 3.1–5.2). Creatinine levels remained within normal limits in the immediate postoperative phase and during follow-up. Median blood loss was 500 ml (IQR, 300–1500) and in situ perfusion with cold ischemia was 67 min (IQR, 60.5–77.5). The grafts remained patent during the follow-up with no signs of thrombosis. No major postoperative complications were observed.

Conclusion

Left renal vein graft for the reconstruction of a hepatic vein and in situ hypothermic liver perfusion are feasible during extended liver resection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02451-6.

Validation of Functional Assessment for Liver Resection Considering Venous Occlusive Area after Extended Hepatectomy

BACKGROUND

Previous studies demonstrated that liver function in a veno-occlusive region is approximately 40% of that in a non-veno-occlusive region after hepatectomy with excision of major hepatic vein. We validated the preoperative assessment of future remnant liver (FRL) function based on 40% decreased function of the veno-occlusive region.

METHODS

Sixty patients who underwent hepatectomy with excision of major hepatic vein were analyzed. The FRL functions of the veno-occlusive and non-veno-occlusive regions were calculated with 99mTc-galactosyl human serum albumin scintigraphy single-proton emission computed tomography fusion system and SYNAPSE VINCENT® preoperatively. Risk assessment for hepatectomy was evaluated based on indocyanine green retention at 15 min, and patients with insufficient FRL function were described as marginal.

RESULTS

The median volume and function of the veno-occlusive region per whole liver were 111 ml and 11.0%, respectively. When the function of the veno-occlusive region was presumed as 0%, 40%, and 100%, the FRL function was 62.5%, 68.4%, and 75.0% and 21, 15, and 7 patients were classified as marginal, respectively. When the function of the veno-occlusive region was presumed as 40%, the posthepatectomy liver failure (PHLF) rate of marginal patients was significantly higher than that of safe patients (46.7% vs 8.9%, P = 0.002). Multivariable analysis indicated that marginal FRL function based on 40% decreased function of the veno-occlusive region was the only independent risk factor for PHLF (odds ratio 8.97, P = 0.002) after extended hepatectomy.

CONCLUSION

Assessment of preoperative FRL function based on 40% decreased function of the veno-occlusive region may have high validity.

Two-stage hepatectomy aiming for the development of intrahepatic venous collaterals for multiple colorectal liver metastases

Background

Aggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures.

Case presentation

A 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy.

Conclusions

Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.

Liver resection for hepatocellular carcinoma in patients with hematological malignancies

Background

Improvements in antimetabolite drugs have prolonged the survival of patient with hematological malignancies. However, these drugs may have hepatotoxic side effects and may induce acute liver failure, chronic liver fibrosis, cirrhosis, or even hepatocellular carcinoma (HCC). Although liver resection remains a curative option for HCC, its role in HCC with hematological malignancies has never been fully explored.

Methods

A retrospective review of 1725 patients who underwent curative liver resection for newly diagnosed HCC between 1994 and 2016 was conducted. Among these patients, 16 had a history of hematological malignancies (HM group). Their hematological malignancies were well-controlled at the time of liver resection. The clinicopathological characteristics of the HM group, along with their short- and long-term outcomes after liver resection, were compared with those of the other 1709 patients without hematological malignancy (non-HM group).

Results

All HM group patients were seropositive for hepatitis marker surface for hepatitis B and C. No significant differences were observed in any background characteristics between the two groups. The postoperative complication rate and 90-day mortality in the HM and non-HM groups were 25 and 20.4%, P = 0.754, and 0 and 0.6%, P = 1.000, respectively. The 5-year disease-free and overall survival rates for the HM and non-HM groups were 42.3 and 35.1%, P = 0.552, and 69.5 and 56.9%, P = 0.192, respectively.

Conclusions

Hepatitis markers should be examined during chemotherapy for hematological malignancies. Regular liver imaging studies are recommended for seropositive cases. When HCC occurs secondary to a well-controlled hematological malignancy, liver resection is suggested in selected patients.

Management consensus guideline for hepatocellular carcinoma: 2016 updated by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality in Taiwan. To help clinical physicians to manage patients with HCC, the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan produced the management consensus guideline for HCC.

METHODS

The recommendations focus on nine important issues on management of HCC, including surveillance, diagnosis, staging, surgery, local ablation, transarterial chemoembolization/transarterial radioembolization/hepatic arterial infusion chemotherapy, systemic therapy, radiotherapy, and prevention.

RESULTS

The consensus statements were discussed, debated and got consensus in each expert team. And then the statements were sent to all of the experts for further discussion and refinement. Finally, all of the experts were invited to vote for the statements, including the level of evidence and recommendation.

CONCLUSION

With the development of the management consensus guideline, HCC patients could benefit from the optimal therapeutic modality.

Progress of liver resection for hepatocellular carcinoma in Taiwan

Taiwan is a well-known endemic area of hepatitis B. Hepatocellular carcinoma (HCC) has consistently been the first or second highest cause of cancer death over the past 20 years. This review article describes the progress of liver resection for HCC in Taiwan in the past half century. The mortality rate for HCC resection was 15-30% in Taiwan in the 1970s. The rate decreased to 8-12% in the early 1990s, and it declined to <1-3% recently. The development of new operative instruments, and surgical techniques, increased knowledge of liver anatomy and pathophysiology after hepatectomy, and more precise patient selection have contributed to this improvement. The use of intermittent hepatic inflow blood occlusion, a restrictive blood transfusion policy and intraoperative ultrasonography, have also led to substantial improvements in resectability and safety for HCC resection in Taiwan. Advances in non-operative modalities for HCC treatment have also helped to improve long-term outcomes of HCC resection. Technical innovations have allowed the application of complex procedures such as mesohepatectomy, unroofing hepatectomy, major portal vein thrombectomy, hepatic vein reconstruction in resection of the cranial part with preservation of the caudal part of the liver, and inferior vena cava and right atrium tumor thrombectomy under cardiopulmonary bypass. In selected patients, including patients with end-stage renal failure, renal graft recipients, patients with portal hypertension, hypersplenic thrombocytopenia and/or associated gastroesophageal varices, octogenarian, ruptured HCC, recurrent HCC and metastatic HCC can also be resected with satisfactory survival benefits. We conclude that the results of liver resection for HCC in Taiwan are improving. The indications for HCC resection continue extending with lower the surgical risks and increasing the long-term survival rate.

Partial Hepatectomy with Middle Hepatic Vein Reconstruction Using a Left Inferior Vena Cava Graft

Duplicated inferior vena cava (IVC) is a rare congenital anomaly. We describe the utility of a new graft from the left IVC in a patient with duplicated IVC for reconstructing the middle hepatic vein (MHV) after partial hepatectomy with MHV resection. A 67-year-old woman with hepatitis C was found to have a liver tumor. Magnetic resonance imaging confirmed that the tumor, which was attached to the MHV, was hepatocellular carcinoma. Central bisectionectomy (S4, S5, and S8 resection) could not be tolerated because of poor liver function and a low future liver remnant volume. Therefore, partial hepatectomy with MHV resection was performed. The left IVC was harvested as a venous graft and was substituted for the resected MHV. She recovered uneventfully and was discharged on postoperative day 12. To the best of our knowledge, this is the first report of using the left IVC as a venous graft. The left IVC is a good candidate graft for the MHV or for portal vein reconstruction because of its length, diameter, and easy harvesting (it did not require an extra incision) in a patient with duplicated IVC.

Hepatic tumors: a continuous challenge to achieve further improvements

Bucharest (Romania) hosted this year's annual meeting of the International Association of Surgeons, Gastroenterologists and Oncologists. The president of the Congress was Irinel Popescu of the University of Bucharest (Romania) and the meeting was held under the auspices of the International Association of Surgeons, Gastroenterologists and Oncologists president Masatoshi Makuuchi (Japanese Red Cross Medical Center, Tokyo, Japan) and its general secretary, Nicolas J Lygidakis (Athens Medical Center, Greece). The organizing committee of the Congress has made considerable efforts to promote the globalization of medical knowledge and to maintain the values of Médecins Sans Frontières. The Congress was a model of scientific professionalism, and was attended by more than 850 delegates. Approximately 250 specialists from 43 countries on five continents described their most recent advances, providing the delegates with an intense and very rich program. The program included symposia, video presentations, free papers and poster presentations. This article highlights the newest and most original results concerning the treatment of liver tumors, particularly in cirrhotic patients.

New developments in the treatment of hepatic tumors

The International Association of Surgeons, Gastroenterologists and Oncologists (IASGO) hosted their annual world congress under the auspices of president Masatoshi Makuuchi from Japan and the general secretary Nicolas J Lygidakis. This year the congress was held in Tokyo, and the president was Wataru Kimura of Yamagata University. It is common knowledge that a major triple disaster struck Japan in March 2011. It was thought, for a time, that the congress would not take place, but the great courage and determination of the hosts allowed the conference to continue as scheduled. This congress was one of the most interesting hosted by the IASGO, evidenced by the presence of 909 participants from 59 countries, including invited speakers from Europe, America, Africa and Asia. The congress provided an opportunity to exchange knowledge of new techniques, methods of diagnosis and therapy. The program included symposiums, video presentations, free papers and poster presentations. This manuscript highlights presentations of the newest and most original material concerning the treatment of liver tumors, especially hepatocellular carcinoma.