A new technique of hepatectomy using an occlusion balloon catheter for the hepatic vein

Liver tumor ablation: percutaneous and open approaches

The global incidence of liver cancer is greater than a million cases a year. Surgical resection where applicable is still the standard of care for these patients. Various liver-directed regional therapies have been developed in an effort to treat the vast majority of unresectable liver tumors. This article reviews the principles behind various ablation therapies currently available for malignant liver tumors and their outcomes.

Liver resection without total vascular exclusion: hazardous or beneficial? An analysis of our experience

OBJECTIVE

To evaluate retrospectively the safety and radicality of liver resection performed without total vascular exclusion (TVE).

SUMMARY BACKGROUND DATA

TVE is recommended for safe liver surgery, at least in the case of resection of the paracaval portion of the liver. However, it has some drawbacks because of its invasiveness.

METHODS

The authors retrospectively evaluated 329 of 471 consecutive patients who underwent liver resection from October 1994 to October 1999. All of these patients had tumors involving segments 1, 7, or 8 or the cranial portion of segment 4, or underwent major hepatectomies that required exposure of the inferior vena cava (IVC), the main trunks of the hepatic veins, or both. Sixty-four patients underwent resection that included segment 1, with or without the reconstruction of the IVC, the hepatic vein, or both.

RESULTS

Three hundred twenty-four of 329 procedures were done under intermittent warm ischemia; no clamping methods were used in 6. TVE was never needed. There were no postoperative 30-day deaths. The complication rate was 25.5%, and only 2.1% had major complications. Only 13 (3.9%) patients required whole blood transfusion. Part of the wall of the IVC was resected in six patients, and the hepatic veins were reconstructed in four. Surgical clearance was achieved in all patients undergoing surgery for a tumor.

CONCLUSIONS

These results show that liver surgery performed without TVE is safe and effective even in aggressive procedures for liver tumors involving the cavohepatic junction. Therefore, TVE should be further restricted to exceptional patients.

Hepatic outflow occlusion in laparoscopic hepatectomy

BACKGROUND

The application of laparoscopic techniques to major hepatic resection has been limited by the risk of hepatic vein laceration leading to massive bleeding or gas embolism. A balloon catheter has therefore been designed to occlude hepatic vein flow during experimental laparoscopic hepatectomy.

METHODS

The procedure was attempted in 8 pigs weighing around 50 kg and submitted to laparoscopic left hemihepatectomy. A specially designed balloon catheter was inserted via the femoral vein and advanced into the retrohepatic segment of inferior vena cava (IVC). After inflation of the balloon with 17 ml contrast, angiography confirmed complete occlusion of this segment, while a central rigid channel allowed passage of blood from IVC to right atrium. Haemodynamic studies were performed during resection of the left and left paramedial lobes of the liver, which was completed laparoscopically using ultrasonic coagulating shears and vascular linear staplers.

RESULTS

Inflation of the balloon reduced mean arterial pressure to 75-79% and central venous pressure to 29-42% of baseline values, while cardiac output also fell (to 69-73% of basal). IVC blood flow decreased to 58% and hepatic venous flow to only 16% of pre-inflation values. Left hemihepatectomy was successfully achieved by the laparoscopic route in all 8 animals with a mean balloon inflation time of 30 min and blood loss of 166 ml. Haemodynamic indices returned to normal after deflation of the balloon at the end of the resection.

DISCUSSION

This preliminary study shows that hepatic venous outflow can be occluded by this special balloon catheter and that animals can tolerate the associated haemodynamic disturbance. Similar techniques in man might permit major hepatectomy to be safely achieved by a laparoscopic approach.

Total vascular exclusion for liver resections: pros and cons

Dramatic improvements in morbidity and mortality rates following liver resections have been reported in the past decade. Consequently, the indications for hepatectomy are becoming more liberal. Many techniques of liver resection with or without vascular clamping have been reported with excellent clinical results. Total vascular exclusion (TVE) of the liver during parenchymal transection has been advocated susceptible to increase the resectability of tumors that might not be safely approached by other techniques. Cirrhotic livers are probably more vulnerable to ischemic injury related to TVE than normal livers. The indications and technical and metabolic aspects of the technique are reviewed.

Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study

OBJECTIVE

To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blood loss.

SUMMARY BACKGROUND DATA

Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during surgery remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but there is a potential harmful effect on the metabolic function of hepatocytes. There has been no prospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes.

METHODS

From July 1995 to February 1997, we studied 100 consecutive patients who underwent hepatectomy for liver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp-free interval (n = 50), or liver transection without the Pringle maneuver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection area was calculated. Routine liver biochemistry, arterial ketone body ratio (AKBR), and the indocyanine green (ICG) clearance test were done.

RESULTS

The two groups were comparable in terms of preoperative liver function and in the proportion of patients having major hepatectomy. The Pringle maneuver resulted in less blood loss per square centimeter of transection area (12 mL/cm2 vs. 22 mL/cm2, p = 0.0001), a shorter transection time per square centimeter of transection area (2 min/cm2 vs. 2.8 min/cm2, p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the early postoperative period, and, in cirrhotic patients, higher serum transferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on postoperative day 8 were equal for the two groups.

CONCLUSION

Performing the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postoperative period. This is probably because there was less hemodynamic disturbance induced by the bleeding.

Hepatic resections in normothermic ischemia

BACKGROUND

Reduction of operative blood transfusions is a primary goal in resective surgery of the liver. Temporary vascular inflow occlusion is an effective method to decrease hemorrhage during hepatic resection. This study was performed to assess the impact of normothermic ischemia on intraoperative bleeding and outcome after hepatic resection.

METHODS

Sixty-one hepatic resections were performed by using pedicle clamping alone or associated with total vascular exclusion of the liver. The mean duration of normothermic ischemia was 40 +/- 18 minutes (range, 7 to 98 minutes). Major resections were performed in 32 cases (52.5%).

RESULTS

Operative mortality was nil. Major complications occurred in 11.5% of cases. Twenty-five patients (41%) received intraoperative blood transfusions; mean +/- SD of transfused blood units was 2.4 +/- 1.3. Twelve major resections (37.5%) did not require any transfusion. Postoperative changes in liver function test results were moderate and transient.

CONCLUSIONS

The results of this study confirm the benefit of vascular occlusion techniques in reducing intraoperative bleeding and postoperative complications. The routine use of these techniques during hepatic resections, if applied properly and with the necessary precautions, is not associated with severe adverse effects on liver function.

Advances in hepatic resection and results for hepatocellular carcinoma

The mortality and morbidity of hepatic resection for hepatocellular carcinoma (HCC) have decreased in recent years because of the various advances in hepatic resection. Various improvements are evident in dissecting apparatus, liver hepatic inflow clamp, cold hepatic perfusion technique, intraoperative ultrasonography, accurate assessment of hepatic function, autologous blood transfusion, and so on. Five-year survival after hepatic resection for HCC was reported at 26-59% in Eastern as well as Western series. The prognostic factors were portal invasion, multiplicity, serum alpha-fetoprotein level, tumor size, associated cirrhosis, age, alcohol abuse, histologic classification, DNA ploidy, and surgical margin. Segmental or lobar hepatic resection brought about better survival, especially in stage I and II patients. Effective adjuvant therapy should improve the diagnosis.